Gallbladder Perforation Research Articles

Primary admission to a surgical service facilitates early cholecystectomy in acute cholecystitis but does not influence patient outcome

PurposeEarly cholecystectomy is recommended for acute calculous cholecystitis to reduce complications and lower health care costs. However, not all patients admitted to emergency services due to acute calculous cholecystitis are considered for surgery immediately. Our intention was therefore to evaluate patient management and outcome parameters following cholecystectomy depending on the type of emergency service patients are primarily admitted to.MethodsWe performed a retrospective analysis of all patients that were treated for acute cholecystitis at our hospital between 2014 and 2021. Only patients that underwent surgical treatment for acute calculous cholecystitis were included. Patients with cholecystectomies that were performed due to other medical conditions were not incorporated. Primary outcomes were the perioperative length of stay and postoperative complications. Perioperative antimicrobial management and disease deterioration according to Tokyo Guidelines from 2018 due to inhouse organization were assessed as secondary outcome parameters.ResultsOf 512 patients included in our final analysis, 334 patients were primarily admitted to a surgical emergency service (SAG) whereas 178 were initially treated in a medical service (MAG). The latency between admission and cholecystectomy was significantly prolonged in the MAG with a median time to surgery of 2 days (Q25 1, Q75 3.25, IQR 2.25) compared to the SAG with a median time to surgery of 1 day (Q25 1, Q75 2, IQR 1) (p < 0.001). The duration of surgery was comparable between both groups. Necrotizing cholecystitis (27.2% vs. 38.8%, p = 0.007) and pericholecystic abscess or gallbladder perforation (7.5% vs. 14.6% p = 0.010) were less frequently described in the SAG. In the SAG, 85.7% of CCEs were performed laparoscopically, 6.0% were converted to open, and 10.4% were performed as open surgery upfront. In the MAG, 80.9% were completed laparoscopically, while 7.2% were converted and 11.2% were performed via primary laparotomy (p = 0.743). Histologically gangrenous cholecystitis was confirmed in 38.0% of the specimen in the SAG compared to 47.8% in the MAG (p = 0.033). While the prolonged preoperative stay led to prolonged overall length of stay, the postoperative length of stay was similar at a median of 3 days in both groups.ConclusionsTo our knowledge, we present the largest single center cohort of acute calculous cholecystitis evaluating the perioperative management and outcome of patients admitted to either medical or surgical service prior to undergoing cholecystectomy. In patients that were primarily admitted to medical emergency services, we found disproportionately more gallbladder necrosis, perforation, and gangrene. Despite prolonged time intervals between admission and cholecystectomy in the MAG and advanced cases of cholecystitis, we did not record a prolonged procedure duration, conversion to open surgery, or complication rate. However, patients with acute calculous cholecystitis should either be primarily admitted to a surgical emergency service or at least a surgeon should be consulted at the time of diagnosis in order to avoid disease progression and unnecessary health care costs.

A retrospective study of diagnosis and management of gallbladder perforation: 10-year experience from a tertiary health care centre.

The aim of this study was to perform retrospective analysis of data collected from patients of gallbladder perforations for diagnosis, management and outcome. A retrospective analysis of data was carried out for 40 patients of gallbladder perforations from the hospital record of patients who were diagnosed preoperatively and intraoperatively as a case of gallbladder perforation over a period of 10 years and were managed in our surgery unit of a tertiary health care centre. Patients were included irrespective of sex except cases of trauma and patients of the paediatric age group. Among 40 patients, 26 were females and 14 were males. As per Anderson modification of Neimeier classification, 13 (32.5%) had type 1, 23 (57.5%) had type 2, and four (10%) patients had type 3 perforations and none of the patients had type 4 perforation. Twenty-three patients (57.5%) were found to have fundal perforation, followed by body in 11 patients (27.5%), three (7.5%) in Hartman's pouch while in three patients (7.5%), there were multiple perforations. All patients of type 1 Neimer classification were diagnosed clinically as cases of biliary peritonitis, whereas most cases of type 2 Neimer classification were diagnosed preoperatively by CECT abdomen 12/23 patients (52%) and ultrasound abdomen 10/23 (43.47%). All patients underwent surgery, and there were three mortalities. In our study, there was female predominance in patients having gallbladder perforation. Of the patients, 52.5% were diabetic and mean age was 55.9 years. CECT abdomen was the most useful modality for diagnosis of type 2 gallbladder perforations. Timely surgical intervention is mandatory for a better outcome of these cases.

Assessing incidence and risk factors of laparoscopic cholecystectomy complications in Jeddah: a retrospective study.

We aimed to identify the risk factors for postoperative complications (POCs) of LC at a tertiary institute in Jeddah, Western Saudi Arabia. This retrospective study was conducted between June 2021 and August 2021 among patients who underwent LC at a tertiary centre in Jeddah, Saudi Arabia. Records of 596 patients were reviewed, and 510 patients were included in the final analysis after applying the exclusion criteria. Data were collected from hospital medical records. χ 2 tests and independent t tests were used to analyse categorical and continuous variables, respectively. The Mann-Whitney U test was used for nonparametric data. Multivariate regression analysis was used to adjust the P values to determine the most strongly and independently associated risk factors. Our data showed that the overall incidence of intraoperative complications (IOCs) was 10.8%. The most common complications were gallbladder perforation (n=28, 5.5%), bile leakage (n=25, 4.9%), and bleeding (n=15, 2.9%). POCs occurred in 11% of the patients; the majority complained of abdominal pain (n=36, 6.9%), had elevated liver function tests (n=14, 2.7%), and retained stones (n=11, 2.2%). Acute cholecystitis, overweight, diabetes, and male sex were significant predictors of IOC, POC, and conversion to open cholecystectomy (P<0.05). LC complications have a multifactorial aetiology. Patient awareness of all possible IOCs is fundamental. The improved skill and experience of the surgical team can mitigate serious complications.

USE OF USG GUIDED PERCUTANEOUS CHOLECYSTOSTOMY IN ACUTE CHOLECYSTITIS AND GALL BLADDER PERFORATION

Background: Acute cholecystitis is dened as inammation of gall bladder it can be divided into calculous cholecystitis and acalculous cholecystitis, Gall bladder perforation. Acute cholecystitis not responding to antibiotics therapy requires intervention and intervention of choice being laparoscopic cholecystectomy however many patients will not be able to tolerate surgical stress. Thus, patient who are unt for surgery can be benetted with per percutaneous cholecystostomy. This study was a non-randomized Method: cohort study carried out in 15 patients who presented to our tertiary care center with clinical symptoms and signs of acute cholecystitis and gall bladder perforation. In present study Results: of total study patients 10 (66%) are male and 5(34%) females. In the study patient with acute cholecystitis are 12(80%) and type 2 Gall bladder perforation were 3(20%). Patient who underwent USG guided PCC 98% had signicant pain improvement measured by pain scale. Patient with USG guided PCC has 100 % improvement in blood parameters - TLC, RFT, LFT, thus patient who underwent medical 95 % management had increase hospital stay and 16% mortality. Patient who underwent emergency cholecystectomy 50% had more pain and morbidity Conclusion: Patients with USG-guided PCC have better morbidity compared to conservative management. As USG-guided PCC has less surgical stress, it is better compared to emergency cholecystectomy

Late presentation of isolated gallbladder perforation due to penetrating abdominal trauma. Case Report

Late presentation of isolated gallbladder perforation due to penetrating abdominal trauma. Case Report

Gallbladder perforation following peroral cholangioscopy‐guided lithotripsy: A case report

Peroral cholangioscopy-guided lithotripsy is highly effective in clearing difficult bile duct stones. It can cause adverse events, such as cholangitis and pancreatitis; however, gallbladder perforation is extremely rare. Herein, we describe the case of a 77-year-old woman who developed gallbladder perforation following peroral cholangioscopy -guided lithotripsy. She was referred to our hospital to treat multiple large bile duct stones. She underwent peroral cholangioscopy-guided lithotripsy because of conventional lithotripsy failure. After a cholangioscope was advanced into the bile duct, saline irrigation was used for visualization. Electronic hydraulic lithotripsy was performed, but it took time for fragmentation because the calculus was hard. The 2-h endoscopic procedure did not completely remove the stone, and treatment was discontinued after placing a biliary plastic stent and nasobiliary tube. After the endoscopic procedure, she started experiencing right hypochondrial pain, which worsened the next day. Computed tomography showed a gallbladder wall defect in the gallbladder fundus with pericholecystic fluid. She was diagnosed with gallbladder perforation and underwent emergency surgery. A perforation site was found at the gallbladder fundus. Open cholecystectomy, choledochotomy, and extraction of residual bile duct stones were performed. The patient was discharged 9 days post-surgery without any complications. The saline irrigation used for visualization may have caused a surge in intra-gallbladder pressure, resulting in gallbladder perforation. Therefore, endoscopists may need to conserve irrigation water during peroral cholangioscopy-guided lithotripsy.

Comparative study of dissection of Calot’s triangle and gallbladder using monopolar hook versus harmonic scalpel in laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy (LC) using surgical electrocautery is considered to be the gold standard procedure for the treatment of uncomplicated cholecystitis and cholelithiasis. The objective of the current study was to evaluate the effectiveness and safety of the Harmonic scalpel, an advanced laparoscopic technique when compared to electrocautery. Methods: From June, 2021 through December 2022, a total of 50 patients were randomly allocated to LC with a harmonic scalpel (group 2, 25 patients) or conventional monopolar electrocautery (group 1, 25 patients). The main outcome measures were gall bladder perforation during surgery (bile leakage), stone spillage, duration of surgery, hospital stay. Results: The 2 groups were comparable with respect to baseline patient characteristics. When compared to conventional monopolar electrocautery, Gall bladder perforation during surgery (bile leakage) 12% vs. 8%, stone spillage 4% vs. 8%, duration of surgery 52.13 min vs. 54.89 min, hospital stay 2.09 days vs. 2.04 days. Conclusions: LC using conventional monopolar electrocautery is as effective and safe as that with the harmonic scalpel, for treating uncomplicated cholecystitis and cholelithiasis.

Early Cholecystectomy versus Conservative Management in Mucocele Gall Bladder

Aim: To compare the early cholecystectomy versus conservative management in mucocele gall bladder. Study design: Retrospective study Place and duration of study: Department of General Surgery, Ward-2, JPMC/Jinnah Sindh Medical University, Karachi from 1st October 2020 to 30th September 2022. Methodology: One hundred patients suffering from cholelithiasis with mucocele gall bladder were included. The patients were divided into two groups on the basis of stone location. Group 1 was those where the stone was found on the base of common bile duct (CBD) and elective/early surgery was conducted for the cases of cholelithiasis. Group 2 was those where conservative/delayed surgical technique was applied due to stone location not in the CBD for treatment. While in each group there were 50 cases which were age and gender matched. The first priority for surgical option was through laparoscopic surgery. Results: The mean age of the patients was 45.2±3.3 years. Out of the total cases in group 1 the process of ERCP was conducted in 64% of the cases before laparoscopy. There were 1% and 10% cases which were shifted to open surgery from laparoscopic in group1 and 2 respectively. Consequently, the mean operative time and hospital duration was increased in group 2. Within the Group 2 cases the risk of sepsis, wound contamination and perforation of gall bladder was much higher than in the Group 1 by a value of 10%, 12% and 6% respectively. There was 1 case of mortality and 2 cases of pancreatitis in group 2. Conclusion: The early cholecystectomy is a much safer and efficient procedure on treatment of mucocele gall bladder cases verses conservative management. Keywords: Early cholecystectomy, Conservative management, Mucocele gall bladder

A Rare Complication of Typhoid Fever: Perforated Gallbladder in Children

Background: Gall bladder perforation is a rare complication in the pediatric age group secondary to enteric fever and a definitive diagnosis is necessary to deal with the management. Preoperative diagnosis of gallbladder perforation is challenging and demanding in most cases diagnosed intraoperatively. Our study aims to evaluate the pattern of presentation, investigation, and complication. Methods: A descriptive case series was carried out in our pediatric department of surgery at Liaquat University Hospital Hyderabad Sindh Pakistan from January 2016 to December 2021. Data were analyzed regarding age, clinical presentation, investigation, surgical procedure, site of perforation, complication, and outcome. Results: Eleven patients were managed in five years. The patient's ages ranged from 6 years to 12 years old child of 9.19 years was the mean age of presentation. The fundus and body was the commonest site of perforation and was diagnosed intraoperatively. The presenting feature was fever, abdominal pain with distension, vomiting, constipation, and a sign of peritonism. The gallbladder perforation was managed by cholecystectomy in 10 patients and partial in one due to difficult dissection. In our series, zero mortality, and all eleven patients were symptom-free in the postoperative outpatient department clinic. Conclusion: In Perforated gallbladder patients early and aggressive management improves mortality and morbidity but represents a special diagnostic and surgical challenge. Keywords: Typhoid Fever, Perforated Gallbladder, Acalculous Cholecystitis.

Gall bladder perforation: critical analysis of management at tertiary care centre

Background: Gall bladder perforation (GBP) is a rare complication of acute cholecystitis. Despite considerable advancements in diagnostic and therapeutic modalities, morbidity and mortality continues to be high, owing to delay in diagnosis and ill-defined treatment protocols. Methods: We reviewed demographic profile, diagnosis and management strategies employed in 28 patients at our centre from Jan 2018 till Jul 2020. Patients were classified based on Niemeier classification. Results: A total of 28 patients were identified but 3 excluded due to paucity of data. There were 21 patients of Niemeier type II perforation and 02 each of type I and III. Diagnosis of GBP was based on CECT in 18 patients. In patients with type II perforation, 03 underwent emergency laparoscopic cholecystectomy (LC) though one required conversion. Twelve patients were managed conservatively followed by interval cholecystectomy after mean duration of 14 weeks. Of these 08 successfully underwent LC and 03 were converted to open surgery. One patient underwent open radical cholecystectomy due to intraoperative suspicion of carcinoma. 06 patients of type II perforation underwent percutaneous drainage of collection followed by LC after mean duration of 23 weeks. Histopathology revealed chronic cholecystitis in 16 patients, acute cholecystitis in 05, carcinoma in 02 and xantho-granulomatous cholecystitis in one patient. Conclusions: CECT should be employed early for diagnosis in suspected cases and percutaneous intervention should be used in cases unresponsive to conservative measures alone. There are higher chances of success in performing LC after 14 weeks leading to better outcomes.

Comment on: intraoperative gallbladder perforation and risk of postoperative abscess with or without antibiotics: national cohort study of more than 108 000 cholecystectomies.

Comment on: intraoperative gallbladder perforation and risk of postoperative abscess with or without antibiotics: national cohort study of more than 108 000 cholecystectomies.

Laparoscopic versus open oncological extended re-resection for incidental gallbladder adenocarcinoma: we can do more than T1/2.

The laparoscopic and open approaches have comparable safety and oncological efficacy to treat early (T1b or T2) stage incidental gallbladder cancer (IGBC). However, their effects on T3 stage or above tumors unclear. Data of IGBC patients who underwent radical re-resection were retrospectively analyzed. Demographic characteristics, surgical variables, and tumor characteristics were evaluated for association with survival. We analyzed retrospectively 201 patients (72 men, 129 women; median age 63years; range, 36-85years). 84 underwent laparoscopic re-resection and 117 underwent open surgery. The 5-year OS post-resection was 74.7%, with a median survival of 74.52months. The median OS (73.92months vs. 77.04months, P = 0.67), and disease-free survival (72.60months vs. 71.09months, P = 0.18) were comparable between the laparoscopic re-resection and open surgery groups. The survival of patients with T1/T2 (median: 85.50months vs. 80.14months; P = 0.67) and T3 (median: 68.56months vs. 58.85months; P = 0.36) disease were comparable between the open re-resection and laparoscopic re-resection groups even after PS matching. Open surgery group lost significantly more blood, while laparoscopic surgery took longer. The postsurgical stay in the laparoscopic re-resection group was significantly shorter. Combined extrahepatic bile duct resection, gallbladder perforation, pT, pStage, histological grade, microscopic liver invasion, status of the resected margin, and adjuvant therapy comprised significant independent prognostic indicators for IGBC. Laparoscopic and open surgery can achieve similar short and long-term outcomes for T3 IGBC; however, careful surgical manipulation is necessary to avoid secondary injuries.

The clinical effect of a strategy called transcystic gallbladder-preserving cholecystolithotomy based on endoscopic retrograde cholangiopancreatography for cholecystolithiasis: A retrospective study from a single center.

Choledocholithiasis complicated with cholecystolithiasis is a common disease. This study explores a novel strategy, called ERCP-based transcystic gallbladder-preserving cholecystolithotomy, for the simultaneous removal of common bile duct stones and gallbladder stones. From December 2018 to June 2021, all patients with cholecystolithiasis and common bile duct stones who met the criteria for gallbladder preservation in our hospital were included in the study and prospectively followed up. We included 48 patients, including 20 patients with acute biliary pancreatitis. All patients successfully underwent ERCP to remove common bile duct stones. One patient had gallbladder perforation during gallbladder-preserving cholecystolithotomy. The guide wire successfully entered the gallbladder, and the transpapillary gallbladder metal-covered stent was successfully placed in 44 patients. The technical success rate was 91.67% (44/48). All stones were removed in 34 patients, for a clinical success rate of 77.27% (34/44). The total postoperative complication rate was 6.25% (3/48), with 2 cases of pancreatitis (4.17%) and 1 case of cholangitis (2.08%). Three patients were lost to follow-up. Among the 31 patients who were followed up for a mean of 27 months (6-40), 5 patients (16.13%) experienced gallstone recurrence. The recurrence rates at 12 months, 18 months, 24 months, 30 months and 36 months were 0%, 3.23%, 6.45%, 12.9%, and 16.13%, respectively. For patients with cholecystolithiasis and common bile duct stones, ERCP-based transcystic gallbladder-preserving cholecystolithotomy without gallbladder incision can preserve gallbladder structure, and this procedure is safe and feasible for the protection of gallbladder function.Clinical trial registration: The study was registered in the Chinese Clinical Trial Registry, and the registry number is ChiCTR1900028006.

Clinical experience in laparoscopic treatment of gallbladder perforation.

We herein present our clinical experience in laparoscopic surgery for gallbladder perforation (GBP). Retrospective analysis was performed on the clinical data of 44 patients who diagnosed with GBP from January 2015 to November 2020. The mean age of the 44 patients was 64.0 years and the female-to-male ratio was 20:24. The most common type of GBP was Type II, followed by Type I and Type III (31:9:4). 72.7% of the patients were diagnosed with GBP at the time of surgery. Laparoscopic surgery was performed for 38 (86.4%) patients, with a conversion rate of 13.2%. The mean length of hospital stays was 7.8 days. The mortality and morbidity rates were 2.3% and 11.4%, respectively. Pre-operative diagnosis of GBP is difficult. Laparoscopic surgery is safe, feasible and effective for patients with GBP.

Gall bladder perforation: a case-series &amp; proposal of the algorithm to a management plan.

Introduction: Gallbladder perforation (GBP) is a rare &amp; life-threatening complication of both benign &amp; malignant diseases of the gall bladder which requires aggressive supportive management and sepsis control in the initial phase. Follow by further evaluation to know the pathology of GBP and definitive surgical management. Hence, the aim of this study is the describing an algorithmic approach based on our case series. Material and Methods: A retrospective study of GBP patients between 2016 and 2020 in a tertiary care centre. Comparisons were made between xanthogranulomatous cholecystitis (XGC) vs. chronic cholecystitis (CC) &amp; benign vs. malignant disease. Results: 81 patients with GBP were included. The mean age was 54 years. Male: Female ratio was 1.13. Mortality was 3.7% (n=3). The most common clinical presentation was a combination of pain in the right upper quadrant of the abdomen &amp; fever with chills or rigours in 61(75.3%) cases. Surgery was performed in 62 patients (76.5%) out of which, open cholecystectomy 23 (37.7%) was the most common. 7 had the malignant disease in the final histopathology. The most common aetiology was XGC – 32 (51.61%). Conclusions: GBP is a complex problem, requiring multidisciplinary aggressive management in the initial phase followed by meticulous evaluation before definitive surgery.

Comparative evaluation of three laparoscopic cholecystectomy techniques in rabbit's model.

The aim of this randomized study was to compare the complications and perioperative outcome of three different techniques of laparoscopic cholecystectomy (LC). Changes in the liver function test after LC techniques were investigated. Also, we compared the degree of postoperative adhesions and histopathological changes of the liver bed. Thirty rabbits were divided into three groups: group A) Fundus-first technique by Hook dissecting instrument and Roeder Slipknot applied for cystic duct (CD) ligation; group B) conventional technique by Maryland dissecting forceps and electrothermal bipolar vessel sealing (EBVS) for CD seal; group C) conventional technique by EBVS for gallbladder (GB) dissection and CD seal. Group A presented a longer GB dissection time than groups B and C. GB perforation and bleeding from tissues adjacent to GB were similar among tested groups. Gamma-glutamyl transferase and alkaline phosphatase levels increased (p ≤ 0.05) on day 3 postoperatively in group A. By the 15th postoperative day, the enzymes returned to the preoperative values. Transient elevation of hepatic transaminases occurred after LC in all groups. Group A had a higher adherence score than groups B and C and was associated with the least predictable technique. LC can be performed using different techniques, although the use of EBVS is highly recommended.

Harmonic Scalpel versus Electrocautery and its Outcome in Laparoscopic Cholecystectomy: A Prospective Interventional Study

Introduction: Laparoscopic cholecystectomy can now be performed safely and effectively due to various surgical tools that have significantly reduced intraoperative and postoperative problems. The Harmonic® Scalpel (HS) is a superior option to more conventional Electrocautery (EC) because it reduces temperatures, smoke, and lateral tissue damage. The Harmonic® Scalpel also lowers the risk of injury due to minimal heat dispersion. Due to less trauma, there is a decrease in both moderate and severe bleeding. It is hypothesised that the HS might be a more cost-effective alternative to employing a variety of disposable tools, such as scissors, a clipper, an EC hook, and a grasper. Aim: To compare the effectiveness and safety of the HS compared to traditional EC in achieving complete dissection and haemostasis during laparoscopic cholecystectomies. Materials and Methods: A prospective interventional study was conducted with 300 patients diagnosed with chronic calculous cholecystitis, admitted to a tertiary care hospital under Department of General Surgery, from November 2020 to October 2022. Patients were allocated to two groups, and the outcomes of laparoscopic cholecystectomy were compared between the usage of a HS and EC in Calot’s triangle dissection and Gallbladder (GB) dissection from the GB fossa. Descriptive data were represented through frequencies and percentages. The means of the two groups were compared using t-test, and categorical variables were compared using chi-square test. Results: The mean age was 46.53±13.740 years in the HS group, while it was 45.3±13.961 years in the EC group. The average duration of dissection with a HS was 52.84±6.167 minutes and 56.79±5.582 minutes in the EC group (p-value 0.001). A total of 67 (44.7%) patients in the HS group had minimal or no bleeding, while it was 23 (15.3%) patients in the EC group. GB perforation occurred in 13 (8.7%) patients in the HS group and in 26 (17.3%) patients in the EC group. Liver injury occurred in 2 (1.3%) patients in the HS group and in 6 (4%) patients in the EC group. Postoperative nausea and vomiting were reported in 20 (13.3%) and 72 (48%) patients in the HS and EC groups, respectively, in the first 48 hours. All these associations were found to be statistically significant (p-value 0.001). Conclusion: The present study found that the HS offers a hassle-free dissection without much incidence of intraoperative bleeding or surrounding tissue damage.

Progression of acute acalculous cholecystitis to gallbladder perforation in a hospitalized old patient and managed by percutaneous drainage

Progression of acute acalculous cholecystitis to gallbladder perforation in a hospitalized old patient and managed by percutaneous drainage

Progression of acute acalculous cholecystitis to gallbladder perforation in a hospitalized old patient and managed by percutaneous drainage

Progression of acute acalculous cholecystitis to gallbladder perforation in a hospitalized old patient and managed by percutaneous drainage

Review Article on Prevention and Treatment of Gallstones

Cholecystitis (inflammation of the gallbladder) is mainly caused by gallbladder stones which are common with prevalence as high as 60 % to 70% in American Indians and 10% to 15% in white adults of developed countries and more prevalent in females. It is caused by high content of cholesterol or bilirubin in bile and gallbladder being unable to empty well. It causes no symptoms sometimes, but severe pain and if left untreated gallbladder perforation occurs leading to peritonitis/sepsis and even death in 5 – 50 % of cases. It can be mainly prevented by maintaining normal bodyweight, eating healthy foods mostly fruits and vegetables and doing regular exercises. Its common treatment for symptomatic cases is by three methods of cholecystectomy (surgical removal of gallbladder) out of which laparoscopic cholecystectomy is a standard and minimally invasive method and most people treated go home same day and soon return to normal activities