Early laparoscopic cholecystectomy in acute gallbladder perforation - Single-centre experience.

Dear Sir,

We sincerely applaud the work done by Krishnamurthy et al., in which they report the single-centre experience for gallbladder perforation (GBP) management.[1] A revision of the available literature demonstrates an important lack of cohort studies, many still recommending an open cholecystectomy approach.[2] There is a need for updated studies evaluating treatment approach options, to suggest evidence-based algorithms, as the current guidelines do not specify GBP management.[3] The current study provides details of clinical presentation, comorbidities, pre-operative characteristics, surgical procedure, intra-operative findings, need for further interventions, and post-operative complications. Its results favour an early laparoscopic approach.

The treatment should be based on the type of GBP and patient condition.[2] Niemeier proposed a classification in which type 1 consists of a fistulous communication between the gallbladder and adjacent viscus; type 2 consists of a localised collection/abscess-walled off by adhesions; and type 3 includes generalised biliary peritonitis. However, Fletcher and Ravdin in 1951 referred to Niemeier's classification mistakenly switching type 1 and 3 causing many other authors to subsequently make the same mistake.[24] The current study's description suggests 13 patients with type 2 and 1 patient with type 3, although their results were three patients for type 1 and 12 patients for type 2.[1] Early diagnosis is crucial to reduce patient morbidity and mortality. However, readers should keep in mind, unless there are signs of cholangitis, a type 1 GBP can be delayed or scheduled by an advanced laparoscopic or hepato-pancreatico-biliary surgeon. In type 3 GBP (generalized biliary peritonitis), the patient will always need urgent surgical treatment, due to peritoneal irritation. Type 2 GBP management regarding time has not been clearly established, the reason why this study provides valuable data favouring an early laparoscopic approach with a safe view of Calot's triangle. However, authors should consider providing the specific periods between diagnosis and the first surgical treatment and specify the type of surgeon, to avoid a performance bias. Although the role of preoperative percutaneous drainage as an adjuvant treatment is still debated,[2] this option was not discussed in this study. Three patients were reported to have complications, requiring re-interventions. Two patients with endoscopic common bile duct stenting and one patient were surgically explored for cystic artery bleed secondary due to clip dislodgement, although the technique (laparoscopic vs. open) was not clearly stated.

The current study provides valuable data missing from the literature and will aid in guiding future treatment recommendations for GBP. We recommend author enlist the preoperative and operative diagnosis, patient comorbidities, clearly detail the number of days between diagnosis and each intervention, technique used in each intervention, complications, and total days of hospital stay when publishing studies regarding GBP. Characteristics such as the location of collection, of GBP, cystic duct management, and drain type may also provide useful data. Reporting and evaluating these parameters in subsequent studies will help with future meta-analyses.

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