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TYPE II GALL BLADDER PERFORATION: A MANAGEMENT CONUNDRUM OR A SURGICAL INDECISION?!
Marco M. Youssef
*, Mina N. Aziz, Ashraf Rasheed
General and Gastrointestinal Surgery, The Grange University Hospital, Cwmbran, Wales, United Kingdom
Background: Gall bladder perforation (GBP) complicates 2–11% of acute cholecystitis cases.
Aims: To evaluate the management and outcomes of GBP over nine years at a UK university hospital.
Methods: A retrospective study included all radiologically diagnosed GBP cases from June 2014 to June 2022. Cases were classified using Neimeier's classification. Demographics, Charlson comorbidity index, management, and outcomes were analyzed.
Results: Ninety-one patients (mean age 70.76±13.2, 56.04% male) were included. The overall mean hospital stay was 15.67 and overall mortality rate was 12.08%.
Type I GBP (acute free perforation, 8.69%) was male-dominated (7/8), and all underwent emergent surgical intervention (4 open cholecystectomy (OC), 2 laparoscopic cholecystectomy (LC), 1 laparoscopic subtotal cholecystectomy, 1 laparotomy + washout). There was one mortality in this group in an elderly frail patient.
Type II GBP (localized perforation, 79.12%) had varied management: 9/72 underwent cholecystectomy (0% mortality), 12/72 had radiological cholecystostomy (25% mortality), 17/72 underwent interventional radiology (IR) drainage (17.6% mortality), 1/72 had IR drainage and cholecystostomy and 33/72 were treated with antibiotics only (12.1% mortality).
Type III GBP (chronic perforation with fistula, 12.08%) included 6/11 cholecysto-cutaneous fistulas (treated with antibiotics ± incision and drainage ± IR drainage, 1/6 failed treatment and had cholecystectomy), 3/11 cholecysto-duodenal fistulas (two had laparotomy for gallstone ileus), and 2/11 cholecysto-colonic fistulas (one had attempted LC followed by interval OC). Overall mortality in type III was 0%.
Conclusion: Management of GBP is tailored according to perforation type, patients’ comorbidities, facilities availability and surgeons’ expertise. While the management of type I GBP seems clear, the optimal management of localized gallbladder perforation (Neimeier type II) has yet to be defined. Our intermediate follow up data suggests that percutaneous catheter drainage alone is safe in certain individuals, however, necessitates follow-up to identify candidates for further intervention. Type III GBP, often chronic and complex, requires tailored surgical approaches, particularly in cases with gallstone ileus or significant fistula formation.
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