Surgical Endoscopy

, Volume 29, Issue 4, pp 955–960 | Cite as

Gallbladder perforation: morbidity, mortality and preoperative risk prediction

  • F. AusaniaEmail author
  • S. Guzman Suarez
  • H. Alvarez Garcia
  • P. Senra del Rio
  • E. Casal Nuñez



Gallbladder perforation (GBP) is a life threatening complication of acute cholecystitis occurring in approximately 2–11 % of patients. The aim of this study is to analyse all factors associated with morbidity and mortality and assess the accuracy of preoperative risk prediction scores.


Medical records of 1,033 patients who underwent cholecystectomy for acute cholecystitis in our centre between 2002 and 2012 were reviewed. Preoperative, intraoperative and postoperative relevant data were analysed with univariate and multivariate statistical methods to identify all factors associated with postoperative complications and mortality. Accuracy of ASA, POSSUM and APACHE II scores was also compared using receiver-operating characteristics methodology.


137 (12.4 %) patients with gallbladder perforation were identified. Morbidity and mortality rates were 57.7 and 9.5 %, respectively. At multivariate analysis, preoperative albumin (P = 0.007, OR 0.175), open surgery (P = 0.011, OR 37.78) and preoperative sepsis (P = 0.002, OR 51.647) were associated with complications, and preoperative sepsis was the only factor independently associated with hospital mortality (P = 0.007, OR 9.127). Both POSSUM and APACHE II scores were superior to ASA score in risk prediction.


Preoperative severe sepsis is the most important factor associated with postoperative morbidity and mortality following GBP, and it can be helpful to identify those patients needing the highest level of care possible.


Gallbladder perforation Acute cholecystitis Mortality 



Drs. Fabio Ausania, Silvia Guzman, Helena Alvarez, Paula Senra and Enrique Casal have no conflicts of interest or financial ties to disclose.


  1. 1.
    Isch J, Finneran JC, Nahrwold DL (1971) Perforation of the gall-bladder. Am J Gastroenterol 55:451–458PubMedGoogle Scholar
  2. 2.
    Bennet GL, Balthazar EJ (2003) Ultrasound and CT evaluation of emergent gallbladder pathology. Radiol Clin North Am 41:1203–1216CrossRefGoogle Scholar
  3. 3.
    Strohl EL, Diffenbaugh WG, Baker JH, Chemma MH (1962) Collective reviews: gangrene and perforation of the gallbladder. Int Abstr Surg 114:1–7Google Scholar
  4. 4.
    Doherty GM, Way LW (2003) Biliary Tract. In: Way LW, Doherty GM (eds) Current Surgical Diagnosis & Treatment, 11th edn. McGraw-Hill, New York, pp 595–624Google Scholar
  5. 5.
    Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ (2009) Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. 1992. Chest 136(5):e28PubMedGoogle Scholar
  6. 6.
    Saklad M (1941) Grading of patients for surgical procedures. Anesthesiology 2:281–284CrossRefGoogle Scholar
  7. 7.
    Copeland GP, Jones D, Walters M (1991) POSSUM: a scoring system for surgical audit. Br J Surg 78:355–360CrossRefPubMedGoogle Scholar
  8. 8.
    Knaus WA, Draper EA, Wagner DP (1985) APACHE II: a severity of disease classification system. Crit Care Med 13(10):818–829CrossRefPubMedGoogle Scholar
  9. 9.
    Niemeier OW (1934) Acute free perforation of the gallbladder. Ann Surg 99:922–924CrossRefPubMedCentralPubMedGoogle Scholar
  10. 10.
    Glenn F, Moore SW (1942) Gangrene and perforation of the wall of the gallbladder. A sequele of acute cholecystitis. Arch Surg 44:677–686CrossRefGoogle Scholar
  11. 11.
    Roslyn JJ, Thompson JE Jr, Darvin H, DenBesten L (1987) Risk factors for gallbladder perforation. Am J Gastroenterol 82:636–640PubMedGoogle Scholar
  12. 12.
    Date RS, Thrumurthy SG, Whiteside S, Umer MA, Pursnani KG, Ward JB, Mughal MM (2012) Gallbladder perforation: case series and systematic review. Int J Surg 10(2):63–68CrossRefPubMedGoogle Scholar
  13. 13.
    Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF (1999) Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg 134(1):36–42CrossRefPubMedGoogle Scholar
  14. 14.
    Fuhrman MP, Charney P, Mueller CM (2004) Hepatic proteins and nutrition assessment. J Am Diet Assoc 104:1258–1264CrossRefPubMedGoogle Scholar
  15. 15.
    Carlson GL (2003) Surgical management of intestinal failure. Proc Nutr Soc 62(3):711–718CrossRefPubMedGoogle Scholar
  16. 16.
    Boldt J (2010) Use of albumin: an update. Br J Anaesth 104(3):276–284CrossRefPubMedGoogle Scholar
  17. 17.
    Suter M, Meyer A (2001) A 10-year experience with the use of laparoscopic cholecystectomy for acute cholecystitis: is it safe? Surg Endosc 15(10):1187–1192CrossRefPubMedGoogle Scholar
  18. 18.
    Gupta H, Gupta PK, Schuller D, Fang X, Miller WJ, Modrykamien A, Wichman TO, Morrow LE (2013) Development and validation of a risk calculator for predicting postoperative pneumonia. Mayo Clin Proc 88(11):1241–1249CrossRefPubMedGoogle Scholar
  19. 19.
    Tzeng CW, Katz MH, Fleming JB, Lee JE, Pisters PW, Holmes HM, Varadhachary GR, Wolff RA, Abbruzzese JL, Vauthey JN, Aloia TA (2014) Morbidity and mortality after pancreaticoduodenectomy in patients with borderline resectable type C clinical classification. J Gastrointest Surg 18(1):146–156CrossRefPubMedGoogle Scholar
  20. 20.
    Cho SW, Tzeng CW, Johnston WC, Cassera MA, Newell PH, Hammill CW, Wolf RF, Aloia TA, Hansen PD (2014) Neoadjuvant radiation therapy and its impact on complications after pancreaticoduodenectomy for pancreatic cancer: analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). HPB (Oxford) 16(4):350–356CrossRefGoogle Scholar
  21. 21.
    Johnson RG, Arozullah AM, Neumayer L, Henderson WG, Hosokawa P, Khuri SF (2007) Multivariable predictors of postoperative respiratory failure after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg 204(6):1188–1198CrossRefPubMedGoogle Scholar
  22. 22.
    de Mestral C, Rotstein OD, Laupacis A, Hoch JS, Zagorski B, Alali AS, Nathens AB (2014) Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: a population-based propensity score analysis. Ann Surg 259(1):10–15CrossRefPubMedGoogle Scholar
  23. 23.
    Stefanidis D, Sirinek KR, Bingener J (2006) Gallbladder perforation: risk factors and outcome. J Surg Res 131(2):204–208CrossRefPubMedGoogle Scholar
  24. 24.
    Kim PN, Lee KS, Kim IY, Bae WK, Lee BH (1994) Gallbladder perforation: comparison of US findings with CT. Abdom Imaging. 19(3):239–242CrossRefPubMedGoogle Scholar
  25. 25.
    Tsai MJ, Chen JD, Tiu CM, Chou YH, Hu SC, Chang CY (2009) Can acute cholecystitis with gallbladder perforation be detected preoperatively by computed tomography in ED? Correlation with clinical data and computed tomography features. Am J Emerg Med 27(5):574–581CrossRefPubMedGoogle Scholar
  26. 26.
    Morris BS, Balpande PR, Morani AC, Chaudhary RK, Maheshwari M, Raut AA (2007) The CT appearances of gallbladder perforation. Br J Radiol 80(959):898–901CrossRefPubMedGoogle Scholar
  27. 27.
    Bedirli A, Sakrak O, Sözüer EM, Kerek M, Güler I (2001) Factors effecting the complications in the natural history of acute cholecystitis. Hepatogastroenterology. 48(41):1275–1278PubMedGoogle Scholar
  28. 28.
    Williams NF, Scobie TK (1976) Perforation of the gallbladder: analysis of 19 cases. Can Med Assoc J 115(12):1223–1225PubMedCentralPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • F. Ausania
    • 1
    Email author
  • S. Guzman Suarez
    • 1
  • H. Alvarez Garcia
    • 1
  • P. Senra del Rio
    • 1
  • E. Casal Nuñez
    • 1
  1. 1.HPB Unit, Department of SurgeryHospital XeralVigoSpain

Personalised recommendations