Gall bladder perforation is a complication experienced by 2–11% of patients with acute cholecystitis.8,15
In the current study, the incidence of gall bladder perforation was 5.6% (33/585) among patients diagnosed with acute cholecystitis in the emergency department. The characteristics of our patients were older age with longer duration of signs and symptoms, high percentage of systemic diseases, right quadrant pain or tenderness, mild leucocytosis, and poor physical status. These clinical presentations were similar to those patients with acute cholecystitis without perforation. This condition may present a great challenge to emergency physicians due to possible delay in patient presentation to the emergency department, difficulty in recognition and diagnosis,16
and association with high morbidity and mortality.8,15,17
Emergency physicians should perform prompt imaging studies, including ultrasound or CT scan, upon suspicion of this uncommon disease.
With regard to the therapeutic intervention for gall bladder perforation, open cholecystectomy should be performed as quickly as possible if gallbladder perforation has developed.1,15
However, the operative mortality rate associated with this surgery is in the range of 8.6–23% according to the literature,1,2
and even up to 90% in some patients with delayed diagnosis or treatment.18
The application of ultrasound guided percutaneous transhepatic gallbladder drainage to treat acute cholecystitis with empyema was proposed by Radder in 1980.19
It is a simple, local, and less invasive procedure, which is mainly indicated in high risk patients with moribund condition, old age, or severe systemic disease unsuitable for open or laparoscopy cholecystectomy.19,20
By using percutaneous transhepatic gallbladder drainage, gallbladder decompression as well as improvement of local circulation and infection can be achieved.21
Currently, it is considered as a bridge before elective open cholecystectomy or an interval laparoscopic cholecystectomy for acute cholecystitis.5,6,22
In addition, percutaneous transhepatic gallbladder drainage can be used for cholangiography, which is very important for revealing the anatomy of biliary tract and further therapeutic suggestions.5,6
In recent years, based on the maturity of this technique, many studies indicate that percutaneous transhepatic gallbladder drainage can greatly reduce both the mortality and morbidity rate in high risk patients with acute cholecystitis.6,7,23
Felice et al
reported that 35 patients with gall bladder perforation, receiving either open cholecystectomy or percutaneous transhepatic gallbladder drainage, had a mortality rate of 8.6% and 22%, respectively.1
In other words, patients receiving percutaneous transhepatic gallbladder drainage seemed have poorer outcome than patients receiving open cholecystectomy. However, percutaneous transhepatic gallbladder drainage was used as a rescue treatment for the moribund patients who were unsuitable for open cholecystectomy in their study. In this study, overall mortality rate was high (24.2%), and no mortality was noted in the percutaneous transhepatic gallbladder drainage group. Our high mortality rate may be attributed to many factors, including the older age of the patients (mean age of 72.6 years), multiple comorbid systemic diseases, delayed emergency department visits and diagnosis, and poor physical status classification.
To the best of our knowledge, the current therapeutic interventions for gall bladder perforation are open cholecystectomy and percutaneous transhepatic gallbladder drainage with subsequent cholecystectomy. Other supportive care, including antibiotics and fluid supplementation for sepsis caused by biliary peritonitis, are mandatory. It remains a great challenge to determine the best choice among these procedures for improving survival and reducing hospital complications during the short stay in the emergency department. The clinical characteristics of our 33 study patients, including age, past systemic diseases, clinical symptoms and signs, and risk factors, were comparable with previous case series studies.3,4,24
No statistical significant difference in clinical characteristics was found between both groups, even when utilising the APACHE II score and the ASA classifications for preoperative risk assessment (table 1). We suggest percutaneous transhepatic gallbladder drainage is more beneficial in the initial treatment of gall bladder perforation, due to the higher survival rate. Additionally, fewer complications associated with acute renal failure and pneumonia during hospitalisation were found in patients who received percutaneous transhepatic gallbladder drainage (p<0.05, Fisher exact test). However, some disadvantages were noted, including a longer hospital stay in survival patients, subsequent elective open cholecystectomy, or endoscopic extraction with papillotomy for the removal of biliary stones in the percutaneous transhepatic gallbladder drainage group. The major complications of percutaneous transhepatic gallbladder drainage that occurred frequently included haemorrhage, hypotension due to sepsis or vasovagal reaction, pneumothorax, bile leakage, and puncture of intra‐abdominal organs.25
However, these can be avoided by a well experienced invasive radiologist, who can successfully achieve a 100% safety record.5
Minor complications included incorrect catheter positioning, catheter dislodgment, and colonisation of the gallbladder with new bacteria.25
Major complication rates were reported to range from 3–8%, with the incidence of minor complications ranging from 4–13%.26,27
In 17 patients receiving percutaneous transhepatic gallbladder drainage in this study, three patients suffered from catheter dislodgment with successful replacement later. Two patients had minor local bleeding with spontaneous resolution after conservative treatment. Overall, no major complication was detected, but minor complications occurred in five patients (29.4%).
This investigation has several limitations. First, data were collected from a retrospective chart review. Some clinical presentations or records may not have been documented completely. Second, due to retrospective analysis, both the diagnostic modalities and treatments of the gall bladder perforation cases could not be standardised. We could not strongly advocate that percutaneous transhepatic gallbladder drainage was absolutely superior to open cholecystectomy in treating gall bladder perforation. A randomised prospective trial would serve to prove which method is better. Third, in patient selection, patients whose gall bladder perforation developed during hospitalisation, but not in the emergency department, and patients with traumatic cause were excluded from our study. Further investigation is needed to delineate therapeutic strategies for these patients. Fourth, the emergency department diagnosis of gall bladder perforation may be false positive or false negative in some patients without surgical validation. This is an insuperable limitation of this study; however, we have made every effort to provide the correct diagnosis by clinical and image correlation.