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Background  Acute calculous cholecystitis (ACC) is the second most frequent surgical condition in emergency departments. The recommended treatment is the early laparoscopic cholecystectomy; however, the Tokyo Guidelines (TG) advocate for different initial treatments in some subgroups of patients without a strong evidence that all patients will benefit from them. There is no clear consensus in the literature about who is the unfit patient for surgical treatment. The primary aim of the study is to identify the risk factors for mortality in ACC and compare them with Tokyo Guidelines (TG) classification.    Methods  Retrospective unicentric cohort study of patients emergently admitted with and ACC during 1 January 2011 to 31 December 2016. The study comprised 963 patients. Primary outcome was the mortality after the diagnosis. A propensity score method was used to avoid confounding factors comparing surgical treatment and non-surgical treatment.    Results  The overall mortality was 3.6%. Mortality was associated with older age (68  +  IQR 27  vs.  83  +  IQR 5.5;  P  = 0.001) and higher Charlson Comorbidity Index (3.5  +  5.3  vs.  0 + 2;  P  = 0.001). A logistic regression model isolated four mortality risk factors (ACME): chronic obstructive pulmonary disease (OR 4.66 95% CI 1.7–12.8  P  = 0.001), dementia (OR 4.12; 95% CI 1.34–12.7,  P  = 0.001), age  >  80 years (OR 1.12: 95% CI 1.02–1.21,  P  = 0.001) and the need of preoperative vasoactive amines (OR 9.9: 95% CI 3.5–28.3,  P  = 0.001) which predicted the mortality in a 92% of the patients. The receiver operating characteristic curve yielded an area of 88% significantly higher that 68% ( P  = 0.003) from the TG classification. When comparing subgroups selected using propensity score matching with the same morbidity and severity of ACC, mortality was higher in the non-surgical treatment group. (26.2%  vs.  10.5%).    Conclusions  Mortality was higher in ACC patients treated with non-surgical treatment. ACME identifies high-risk patients. The validation to ACME with a prospective multicenter study population could allow us to create a new alternative guideline to TG for treating ACC.    Trial registration  Retrospectively registered and recorded in Clinical Trials.  NCT04744441

Mortality risk estimation in acute calculous cholecystitis: beyond the Tokyo Guidelines