Spontaneous cholecystocutaneous fistula: an uncommon complication of acute cholecystitis

Gallbladder empyema: An atypical manifestation of acute cholecystitis

INTRODUCTION AND IMPORTANCE

Acute cholecystitis is responsible for 44 % of emergency admissions to the emergency services with multiple complications such as empyema a necesitatis (EN). EN has a close relation with cholecystitis when the perforation of the gallbladder (GB) can lead to the formation of a biliary fistula. Patients can be asymptomatic, with late consultations, thus being a diagnostic challenge. Different techniques are described for cholecystitis and secondary abscess, therefore, the choice of the appropriate procedure should be the best one to reduce the high associated morbidity.

CASE PRESENTATION

We present a case of an 89-year-old patient, admitted for a sensation of a mass in the right hypochondrium with abdominal pain. He was taken to the operating room, finding a vesicular plastron with piocholecyst and perforation into the abdominal wall with abscess and fasciitis. Subtotal cholecystectomy was performed laparoscopically and an open approach in the abdominal wall, drainage of the abscess and debridement, leaving a negative pressure system.

CLINICAL DISCUSSION

EN affects elder patients with high rates of morbidity, also GB empyema, which is related with its perforation and posterior fistulization, its external spontaneous perforation is much less frequent. Fistulas originated from the biliary tract are well described in the literature, with low incidence. They are related with improved diagnostic investigations and earlier implemented treatment by antibiotics and surgery.

CONCLUSION

Biliary EN represents a very unusual complication of acute cholecystitis, its atypical presentation represents a diagnostic challenge, with very few cases documented and high mortality rates. Its management represents a challenge for the general surgeon, finding different approaches and surgical behaviors to take.

Gallbladder perforation with fistulous communication

BACKGROUND

The management of gallbladder perforation (GBP) with fistulous communication (Neimeier type I) is controversial.

AIM

To recommend management options for GBP with fistulous communication.

METHODS

A systematic review of studies describing the management of Neimeier type I GBP was performed according to the PRISMA guidelines. The search strategy was conducted in Scopus, Web of Science, MEDLINE, and EMBASE (May 2022). Data extraction was obtained for patient characteristics, type of intervention, days of hospitalization (DoH), complications, and site of fistulous communication.

RESULTS

A total of 54 patients (61% female) from case reports, series, and cohorts were included. The most frequent fistulous communication occurred in the abdominal wall. Patients from case reports/series had a similar proportion of complications between open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) (28.6 vs 12.5; P = 0.569). Mortality was higher in OC (14.3 vs 0.0; P = 0.467) but this proportion was given by only one patient. DoH were higher in OC (mean 26.3 d vs 6.6 d). There was no clear association between higher rates of complications of a given intervention in cohorts, and no mortality was observed.

CONCLUSION

Surgeons must evaluate the advantages and disadvantages of the therapeutic options. OC and LC are adequate options for the surgical management of GBP, with no significant differences.