Hermilo Jeptef Angeles-Mr , Mrino Gri-Cmp , Rodrigo Enrique Elizondo-Om? ,Sntos Guzmán-López , Jvier Humerto Mrtinez-Grz , Alejndro Quirog-Grz , ,

a Universidad Autonoma de Nuevo Leon, School of Medicine, Human Anatomy Department, Monterrey, Nuevo León CP 64460, México

b Universidad Autonoma de Nuevo Leon, School of Medicine, Plataforma INVEST - KER Unito Mayo Clinic (KER Unit Mexico), Monterrey, Nuevo León, México

c General Surgery Division, Instituto Mexicano del Seguro Social, Monterrey, Nuevo León, México

To the Editor :

We sincerely applaud the work done by Gupta et al., in which they analyzed a single-center experience regarding gallbladder perforation (GBP) management [1] . Currently, there is a lack of cohort studies to adequately describe the approach strategies and management for this pathology, with international guidelines making ambiguous recommendations [ 2 , 3 ]. Their study stratified GBP types and provided details regarding clinical presentation, comorbidities,preoperative diagnosis, etiology, imaging techniques, and surgical approach. The study reported a high conversion rate when a laparoscopic approach was attempted for cholecystectomy.

GBP treatment should be based on the Niemeier classification(1934) [4] and patient condition. Type 1 consists of a fistulous communication between the gallbladder and adjacent viscus; type 2 includes a localized collection/abscess walled off by adhesions;and type 3 includes generalized biliary peritonitis [4] . However,Fletcher and Ravdin in 1951 referred to Niemeier’s classification mistakenly switching types 1 and 3 causing many other authors to subsequently make the same mistake [ 1 , 2 , 5 , 6 ]. The current study has this inaccuracy, although due to its clear description, its data can be interpreted correctly and are of valuable importance.

The ideal time of intervention for GBP has yet to be established.A review of GBP management could not establish a statistical difference between early ( < 7 days) versus late ( > 21 days) intervention [2] . Gupta et al. reported definite cholecystectomy at a mean interval of 57 days, although they discuss in their population, this is due to multiple factors such as culture, beliefs, education, and patients’ economic status, rather than by decision of the surgeons,as is the case in many low and middle-income countries. The specific mean time periods (days) between diagnosis and some of the procedures, such as percutaneous catheter drainage were not specified. Although the Tables summarized the prevalence of each type of procedure, these were not compared with patient outcomes and prevalence of complications, nor between preoperative and transoperative diagnosis. Due to some missing statistical analysis of interest, a definite conclusion on which approach has the most favorable outcome by type of GBP is open to interpretation by the reader using the parameters evaluated, and how it may relate to their resources and experience.

A laparoscopic approach was reported difficult with a high conversion rate. The authors reported an overall success rate of 8.7%(10/115) for type 2 GBP, although this could be considered higher in view it was only attempted in 27 patients. These results are consistent with that reported in the systematic review by Quiroga-Garza et al. [2] , as open cholecystectomy had the lowest number of complications and need of further interventions, but the longest hospital stay, although it included many studies from earlier years,before the laparoscopic boom. Krishnamurthy et al. [5] recently published a single-center experience in which they favor early laparoscopic approach as a safe and effective method.

Fistulous was diagnosed primarily trans-operatively being open cholecystectomy the most prevalent approach for this condition,making surgical planning difficult. Surgeons must consider their experience, training, and availability of resources to determine the best approach, considering the results of this study had no successful laparoscopic procedures in free and fistulous GBP. The organ or cavity with which the fistula connected was not described, which is of relevance, as this established the management [7] . A review of therapeutic options according to the organ/cavity of the fistulous path is needed.

The current study will help establish future recommendations for GBP management through meta-analysis, thanks to the valuable data it provides. We recommend publication regarding GBP which clearly state preoperative and operative diagnosis based on the original Niemeier’s classification, patient comorbidities, the time periods between diagnosis and each intervention, technique used in each intervention, complications, and days of hospital stay. Characteristics such as the location of collection, site of GBP, cystic duct management, and drain type may also provide useful data.

Acknowledgments

None.

CRediT authorship contribution statement

Hermilo Jeptef Angeles-Mar: Writing – original draft. Mariano Garcia-Campa: Writing – original draft. Rodrigo Enrique Elizondo-Oma?a: Supervision, Writing – review & editing.Santos Guzmán-López: Supervision, Writing – review & editing.Javier Humberto Martinez-Garza: Supervision, Writing – review& editing. Alejandro Quiroga-Garza: Supervision, Writing – review& editing.

Funding

None.

Ethical approval

Not needed.

Competing interest

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.