This study investigated the extent of gallbladder inflammation in patients undergoing emergency or urgent surgery for APC. Fifty patients with confirmed APC following intraoperative and histological diagnosis were compared to 150 randomly chosen cases undergoing LC for AC without perforation. Advanced gallbladder inflammation with empyematous and gangrenous cholecystitis was recorded significantly more often in the APC group compared to the control. Patients with APC were significantly older and had significantly higher CRP in comparison to the controls. Surgery lasted significantly longer; the rates of conversation, morbidity, and mortality were significantly higher in the APC group. ICU management was needed significantly more often in the APC group, and the overall LOS was significantly longer in the APC group compared to the group without perforation.
Gallbladder perforation in the setting of acute cholecystitis has been suggested in our recently published register study to be a risk factor for poor outcome in patients undergoing cholecystectomy for AC [1]. The outcomes of 5704 cases with APC undergoing emergency or urgent cholecystectomy were compared to those of 39,661 patients without perforation. The duration of surgery, the rates of conversation, morbidity, and mortality were significantly higher in patients with APC compared to those without APC. The results of the present study are in accordance with the results reported in the above study.
A great drawback to the register study by Jansen et al. which was clearly stated by the authors in the limitation section was the inability to characterize the extent of gallbladder inflammation because the register data used in their study did not contain histology findings. This shortcoming was investigated in the present study. Complicated cholecystitis defined as advanced gallbladder inflammation in the form of empyematous or gangrenous cholecystitis was confirmed in a significant portion of the APC group compared to the control group.
Advanced age > 65 years and elevated CRP were identified as risk factors for APC. These factors were further confirmed on multivariate analysis as independent risk factors for APC. These same factors have been previously described in connection with other forms of severe cholecystitis and therefore are not specific for APC [18, 19].
The significantly longer duration of surgery and higher rate of conversion to open surgery following attempted LC in the APC group in comparison to the group without perforation are de facto arguments for the surgical challenge associated with the management of patients with APC. Besides, the 8% rate of bile duct injury and 6% rate of postoperative intra-abdominal abscess formation in the APC group herald the severity of this entity. The mortality rate in this study was 8%. This rate is almost twice the reported rate by Jansen et al. [1] but comparable with the 9.5% rate of death reported in a retrospective analysis of 137 patients with APC by Ausania et al. in 2015 [20]. The heterogeneity in the reported risk of mortality in this and as well as in previous publications must be interpreted in context with the study population. Furthermore, the significantly higher rates of ICU management, as well as the significantly longer LOS, must be interpreted as indicators of the astringent nature of APC.
Another interesting finding in this study was the fact that four patients (8%) in the APC group underwent primary open cholecystectomy compared to none in the control group. These patients underwent explorative laparotomy for acute abdomen with peritonitis, and the diagnosis of APC was reached during surgery. Type I perforation with bilious peritonitis was evident during laparotomy in these patients. This finding should be interpreted as a further demonstration of the severe clinical nature of APC.
The retrospective study design and the small size of the study population must be stated as possible limitations to this study. Thus, further investigations with larger populations would be needed to further investigate the trends shown here. Besides, the results reported in this study might be secondary to the profound expertise in laparoscopic surgery in our department. Therefore, the results of this study might not be readily projected on other institutions. All cases included in this study were managed surgically. Interventional treatment like percutaneous cholecystostomy is not routinely performed in our center. Although the current literature on the role of percutaneous cholecystostomy is not conclusive [21,22,23,24,25], it remains speculative if the outcomes recorded in this study might have been altered by such an interventional management.
Surgeons and clinicians must be aware of the severe nature of APC with associated high risks of morbidity and mortality. The surgical management of such patients warrants profound expertise, and conversion from laparoscopic to open surgery should never be considered a failure. A vigilant postoperative care including the use of broadband antibiotics and close monitoring, e.g., in the ICU, should be considered in such cases.
Taken together, the results of this study confirm APC as a severe complication of AC with significantly higher rates of morbidity and mortality. Advanced gallbladder inflammation including empyematous and gangrenous cholecystitis was seen significantly more often in patients with APC compared to those without perforation. Thus, gallbladder perforation in APC must be secondary to advanced gallbladder inflammation.