INTRODUCTION
Acute perforated cholecystitis is a rare (approximately 2%) but dramatic presentation of biliary disease. When the gallbladder is perforated, patients can deteriorate within hours from localized right upper quadrant inflammation to generalized biliary peritonitis and septic shock. The mortality of elderly or comorbid patients, now exceeds 20%[1]. Emergency laparoscopic cholecystectomy is the unchallenged gold standard of care recommended from both Tokyo Guidelines and the World Society of Emergency Surgery (WSES)[2-5]. However, in the modern era of minimally invasive strategies, the question is no longer whether surgery is mandatory, but rather which patients can be stabilized with nonoperative treatments such as percutaneous transhepatic cholecystostomy (PTC) as an initial or even definitive intervention[6], as significant debate exists regarding the criteria for identifying high risk patients when surgery is needed[3]. In connection with the retrospective study of Mazarieb et al[7], recently published in the World Journal of Gastrointestinal Surgery, we prepared this editorial, performing a narrative literature review based on PubMed, EMBASE, and the Cochrane Library covering 2008-2024. We included English-language articles and prioritized randomized controlled trials, meta-analyses, and international guidelines.
Thus, the therapeutic spectrum of acute perforated cholecystitis has broadened. At one end, urgent laparoscopic cholecystectomy remains the gold standard for rapid control of the infection focus and is associated with favorable patient outcomes. At the other end lies image-guided percutaneous drainage, which provides immediate decompression and sepsis control. Among these two therapeutic modalities are other variants: Interval cholecystectomy following initial drainage, and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) for primary or definitive treatment[8,9]. According to the 2018 Tokyo Guidelines, gallbladder drainage is recommended for grade II acute cholecystitis in patients with Niemeier I and Niemeier II disease when early surgery is considered high risk[3]. Although perforated cases are not separately stratified, because of their low incidence, the principle is transferable: Hemodynamic instability or prohibitive risk warrants drainage first[3].
PTC VS EUS-GBD
For patients with septic shock, multiple comorbidities, and prohibitive anesthetic risk, PTC is a safe option. When a transhepatic catheter is inserted, the infected and perforated gallbladder is decompressed within minutes, often without general anesthesia. For many interventional radiologists, this is the preferred “damage control” maneuver when surgery is unsafe. An alternative method is the transperitoneal approach, with similar results[10]. A theoretical advantage of the transperitoneal approach over transhepatic puncture is its lower risk of hemoperitoneum[11]. The transhepatic route is however mostly recommended[12].
The rise of EUS-GBD challenges the primacy of PTC. EUS-GBD using lumen-apposing metal stents (LAMS) has become one of the treatments of choice for acute cholecystitis in fragile patients[10,13]. The WSES guidelines identify EUS-GBD with LAMS as a safe, effective and definitive alternative to PTC[14]. The DRAC-1 randomized controlled trial directly compared EUS-GBD with PTC in patients who suffered from acute cholecystitis. Following criteria for high- risk patients were defined: Age ≥ 80 years, American Society of Anesthesiologists (ASA) score ≥ III, Charlson Comorbidity Index (CCI) > 5, or Karnofsky performance status < 50. The study clearly favorizes EUS-GBD regarding lower rates of complications 30-days and 1-year after intervention, fewer redo procedures, reduced readmissions, reduced recurrence of cholecystitis and lower pain scores[9]. Multiple trials and meta-analyses have revealed superior outcomes for EUS-guided stent placement compared with percutaneous tubes in nonoperative treatments. These include fewer reinterventions, improved patient comfort, and no external catheter[8,9]. However, limited expertise and equipment availability hinder widespread adoption, leading to use of endoscopic options in a few experienced centers. When performed by experienced practitioners, EUS-GBD offers superior long-term palliation for patients who will never undergo surgery[15].
PTC VS EMERGENCY SURGERY
A meta-analysis by Huang et al[16] revealed that compared with emergency laparoscopic cholecystectomy performed < 7 days after PTC placement, delayed laparoscopic cholecystectomy > 7 days after PTC has the advantages of a shorter operative time, a lower conversion rate and less intraoperative blood loss. Elkeleny et al[17] suggested that for patients with grade II acute cholecystitis and higher perioperative risks, PTC can be beneficial for preventing life-threatening consequences. The findings of the study suggested a 2-month interval between percutaneous cholecystostomy and subsequent laparoscopic cholecystectomy. In contrast, evidence from a randomized study favored emergency surgical treatment. The CHOCOLATE trial, a landmark multicenter study in the Netherlands, compared percutaneous drainage with early laparoscopic cholecystectomy for high-risk patients with acute cholecystitis[18]. According to the trial, surgery yielded fewer major complications and fewer reinterventions than drainage did, despite the inclusion of multimorbid patients. The main conclusion is that surgery is superior to PTC, if possible[18]. According to WSES, the only absolute contraindications for emergency cholecystectomy are patient refusal or unsuitability for surgery. This conclusion appears to conflict with the meta-analysis by Huang et al[16], which suggested benefits for delayed cholecystectomy after PTC. Possible reasons include differences in patient selection, heterogeneity in study populations, and the CHOCOLATE trial’s focus on acute but not specifically perforated cholecystitis.
INDICATIONS FOR PTC CONSIDERING TYPE OF PERFORATION ACCORDING TO NIEMEIER
The value of PTC depends on the type of perforation. With respect to free perforation with generalized bile peritonitis (Niemeier type I), laparoscopic lavage and cholecystectomy remain the gold standard, provided that the patient can tolerate anesthesia. In cases of localized perforation with pericholecystic abscess (type II), PTC plus abscess drainage can stabilize the infection, allowing later elective surgery under better conditions. With respect to chronic fistulas (type III), drainage plays a minor role, except as bridging therapy[19].
Thus, PTC is considered a bridge rather than a definitive therapy[20]. A misconception that should be avoided is the idea of “tube and forget”. Patients left indefinitely with a catheter suffer from recurrent infections, drain dislodgement, and a poor quality of life. Observational data show high readmission rates and significant late mortality in “drainage only” cohorts. Conversely, when interval cholecystectomy is performed after stabilization, long-term outcomes improve significantly. After PTC placement, a strategy for interval reassessment should be documented: Either interval cholecystectomy within 4-8 weeks, or, in inoperable patients, conversion to internal stenting. Abdelhalim et al[10] explored the effect of interval cholecystectomy timing after PTC on postoperative outcomes. The time interval of 5-12 weeks between PTC and laparoscopic cholecystectomy was associated with a shorter in-hospital length of stay. This study also suggests the persistence of racial disparities among these patients. Ábrahám et al[21] reported in a retrospective study of 162 elderly patients with acute cholecystitis, who were treated between 2010 and 2020, that PTC was a definitive therapy for 42.18% of these patients. However, a very high post-PTC in hospital mortality of 40.91% was observed for grade III gallbladder inflammation; thus, PTC for this subgroup of patients was excluded. Complications of drainage often reflect poor catheter protocols, such as dislodgement, blockage, and bile leaks. Preventive measures are essential; for example, before PTC tube removal, cholangiography should be performed. International guidelines concerning the management of PTC tubes are necessary[12].
THERAPEUTIC ALGORITHM
Pesce et al[19] suggested a practical therapeutic algorithm for patients with acute cholecystitis. Laparoscopic cholecystectomy should be recommended in patients with moderate acute cholecystitis, a CCI ≥ 6, and an ASA-Performance Status ≥ 3, where conservative therapy failed. Patients with severe acute cholecystitis and high surgical risk should undergo percutaneous cholecystostomy within 48 hours. Once the infection is controlled, they should be thoroughly evaluated for interval laparoscopic cholecystectomy. The surgical treatment should follow at least six weeks after percutaneous cholecystostomy. In unsuitable candidates for surgery, such as those with a CCI ≥ 6 and an ASA-Performance Status ≥ 4, the percutaneous cholecystostomy tube should remain in place for at least three weeks. After radiographic controlling of biliary tree patency, the percutaneous cholecystostomy tube can be then removed[19].
In acute perforated cholecystitis after assessment of physiology and perforation type, a pragmatic management pathway could be as follows: For type I (free perforation), an urgent laparoscopic cholecystectomy with lavage and drainage should be performed. For type II (localized abscess), PTC ± abscess drainage/or EUS GBD with LAMS should be considered. An interval cholecystectomy should be planned as a definitive therapy. For type III (fistula) patients, a multidisciplinary consent is necessary; drainage may occasionally be considered as a definitive therapy in selected patients, although supporting evidence remains limited.
FUTURE PERSPECTIVES
Important research gaps on this topic include the following: First, gallbladder perforation-specific randomized data comparing surgery with PTC and EUS-GBD are absent because of the rarity of acute perforated cholecystitis. Second, the optimal timing of interval surgery after drainage is unclear; meta-analyses suggest flexible time frames, but prospective stratification by frailty/sarcopenia scores or biomarker recovery is needed. Third, determining the high- risk patients with acute cholecystitis for emergency cholecystectomy remains highly challenging. The Validation and Comparison of Scores for Prediction of Risk for Postoperative Major Morbidity after Cholecystectomy in Acute Calculous Cholecystitis study, endorsed by WSES is a prospective, multicenter, observational study recruiting patients with acute calculous cholecystitis scheduled for emergency cholecystectomy. Primary scope was to evaluate the predictive accuracy of the eCholeRisk morbidity score after surgery, comparing with other stratification tools, including Physiologic and Operative Severity Score for the Study of Mortality and Morbidity, modified Frailty Index, CCI, ASA score, Acute Physiology and Chronic Health Evaluation II Score and the acute cholecystitis classification of severity grading from Tokyo Guidelines[22]. The 1253 patients from 79 centers across 19 countries were enrolled. Among the various models the Physiologic and Operative Severity Score for the Study of Mortality and Morbidity score demonstrated the highest predictive value for adverse outcomes[22]. Thus, in emergency setting, predicting high operative risk remains still challenging.
CONCLUSION
PTC is reasonably considered a safe bridging option for immediate infection control in hemodynamically unstable patients. The true art lies in using PTC as a bridge before surgery: First stabilizing the patient, then guiding him with reduced risk to definitive therapy, whether interval cholecystectomy or internal endoscopic drainage in high-risk patients. Future studies should determine the criteria of high-risk patients with acute cholecystitis that benefit from non- surgical interventions.
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: Germany
Peer-review report’s classification
Scientific Quality: Grade B
Novelty: Grade C
Creativity or Innovation: Grade C
Scientific Significance: Grade B
P-Reviewer: Jiang X, PhD, China S-Editor: Zuo Q L-Editor: A P-Editor: Zhang L
