Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department

Abstract

Objectives: To investigate clinical features and outcomes in patients with acute cholecystitis with gall bladder perforation receiving open cholecystectomy or percutaneous transhepatic gall bladder drainage in the emergency department. Methods: From 1996 through 2005, 33 patients with non-traumatic gall bladder perforation, among 585 patients with acute cholecystitis, were enrolled. Patients were divided into two groups: open cholecystectomy in 16 patients and percutaneous transhepatic gall bladder drainage in 17 patients. Medical records, including demographic data, past history of systemic diseases or gallbladder stones, initial clinical presentations, laboratory data, physical status, therapeutic interventions, and outcomes, were analysed. Results: Mean patient age was 72.6 years (range 54-92 years). 28 patients (84.8%) were male. Median time of symptom onset before emergency department diagnosis was 5 days (range 0.5-30 days). Estimated incidence of gall bladder perforation was 5.6% (33/585). 27 patients (81.8%) had gallstones operatively or in image studies. All patients had either right upper quadrant pain/tenderness or epigastric pain/tenderness. Only 9 (27.3%) patients had positive Murphy's sign. Six patients in the percutaneous transhepatic gall bladder drainage group received further open cholecystectomy. Overall mortality was 24.2% (8/33). The direct cause of death was disease related sepsis in all patients. Patients receiving percutaneous transhepatic gall bladder drainage had a higher survival rate than those receiving open cholecystectomy (100% vs 50%, p,0.001). No differences in complications and length of hospital stay of survivors were observed between groups. Conclusions: In this study, we delineated clinical features of patients with gall bladder perforation. Better clinical outcome is observed for percutaneous transhepatic gall bladder drainage, and this is suggested as an initial therapeutic choice, especially in high risk patients who are likely to need surgery.T he choice of therapeutic modalities for acute cholecystitis includes both open cholecystectomy and percutaneous transhepatic gallbladder drainage. If left untreated, acute cholecystitis can progress to gall bladder perforation. During the past decades, open cholecystectomy has been used to treat acute cholecystitis with gallbladder perforation contributing to the mortality rate ranging from 8.6% to 23% in respective studies.1 2 Risk factors, including older age, increased disease severity, and comorbidities with multiple systemic diseases, were considered to account for the high mortality rate.3 4 In recent years, percutaneous transhepatic gallbladder drainage has been successfully adopted as an alternative or a bridge before elective cholecystectomy for acute cholecystitis, 5 and even used in high risk patients for a greatly improved outcome.5-7 A favourable outcome was also demonstrated in patients with a localised gall bladder perforation under percutaneous transhepatic gallbladder drainage treatment.8 To the best of our knowled...

A case of perforated gallbladder with liver abscess

“…Upon making the diagnosis, the decision for treatment is based mostly on the clinical features of the patient including patient's fitness for surgery at the time of diagnosis and the severity of the disease. Our patient underwent percutaneous gallbladder drainage (PTGBD) as it has been proven to be effective and relatively safe with lower risk of morbidity and mortality compared to emergency cholecystectomy [5]. By performing a percutaneous drainage prior to definitive surgery in fact provides the opportunity for optimization of a patient's condition including the comorbidity and the possibility of cholecystectomy via laparoscopic approach.…”

Successful non-operative management of spontaneous type II gallbladder perforation in a patient with Alzheimer's disease

“…It is divided into three categories according to Niemeier's classification: type I, acute perforation into the free peritoneal cavity; type II, subacute perforation with abscess formation; type III, chronic perforation with bilioenteric fistula formation 4. In the last decade, its incidence has been reported to range from 0.8% to 5.6% 3 5 6. Therapeutic options are an urgent laparotomy (or laparoscopy) or percutaneous gallbladder drainage.…”

“…A recent study showed that early laparoscopic cholecystectomy should be considered an optimal treatment for gallbladder perforation in selected patients 12. A non-operative strategy consisting of ultrasound-guided percutaneous gallbladder drainage has been used in a smaller group of patients with gallbladder perforation 3 11…”

Perforation as a cause of failure in the conservative treatment of acute cholecystitis: Is percutaneous cholecystostomy a sufficient treatment?

“…Conservative treatment, particularly preferred in cases with high risk of surgical morbidity and mortality, is a method involving the use of antibiotics or fl uid and electrolyte support without antibiotics, and despite conservative treatment, patients may develop complications and the gallbladder may progress to perforation [5,6]. In case of no clinical improvement during conservative treatment, PC or emergency surgery can be performed [7,8].…”