Gallbladder Perforation: A 23-Year Study of 100 Patients and Evolving Management Strategies

Gallbladder perforation (GBP) is an uncommon but clinically significant complication of gallstone disease, characterized by heterogeneous presentation, diagnostic ambiguity, and variable management strategies. Despite advances in imaging and surgical techniques, optimal treatment pathways remain ill-defined, particularly in distinguishing patients requiring urgent intervention from those suitable for conservative or delayed management.

A retrospective analysis was conducted of 100 patients diagnosed with GBP at a single tertiary care center over a 23-year period (2002-2025). Clinical presentation, comorbidity profile, imaging findings, perforation subtype, management strategies, and outcomes were systematically evaluated. Patients were classified according to the modified Niemeier classification. Temporal trends in diagnosis, intervention, and surgical approach were analyzed to assess evolving management patterns. Data were analyzed descriptively to identify clinically meaningful patterns.

The cohort comprised 100 patients with a mean age of 61.1 years and a male predominance. Type II perforation was the most common subtype (62%), followed by Type III (34%) and combined Type II and III (4%), with no cases of Type I perforation observed. Preoperative diagnosis was achieved in 49% of cases, predominantly in Type II perforations, whereas Type III perforations were largely diagnosed intraoperatively. Imaging accuracy improved substantially in the later years of the study. Percutaneous drainage was required in 11% of patients and was employed selectively in those with persistent sepsis or significant collections. The majority of patients were managed with initial conservative treatment followed by interval surgery. A progressive shift toward laparoscopic surgery was observed over time, with improved feasibility and outcomes in delayed settings. Type III perforations were associated with increased operative complexity and a higher requirement for additional procedures. Occult malignancy was identified in 2% of patients.

GBP represents a spectrum of diseases requiring individualized, physiology-driven management. Most Type II perforations can be managed conservatively with selective intervention, while delayed surgery facilitates safer and more effective minimally invasive treatment. Type III perforation, although technically demanding, can often be managed electively in stable patients. These findings support a tailored approach that prioritizes sepsis control, appropriate patient selection, and optimal timing of surgery over routine early escalation.