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Gross A, Hong H, Hossain MS, Chang JH, Wehrle CJ, Sahai S, Quick J, Izda A, Said S, Naffouje S, Walsh RM, Augustin T. Clinical and patient-reported outcomes following subtotal cholecystectomy: 10-year single-institution experience. Surgery 2025; 179:108805. [PMID: 39358120 DOI: 10.1016/j.surg.2024.07.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/30/2024] [Accepted: 07/30/2024] [Indexed: 10/04/2024]
Abstract
OBJECTIVE Subtotal cholecystectomy provides a safe, bail-out alternative for difficult gallbladders. However, long-term outcomes comparing fenestrating and reconstituting subtotal cholecystectomy subtypes remain underexplored. METHODS This retrospective cohort included patients who underwent subtotal cholecystectomy between 2010 and 2020 within a single hospital system. Subtotal cholecystectomy was identified by parsing operative notes for keywords. Demographic and clinical variables were collected by manual review. Patient-reported outcomes were collected via phone using an abbreviated Gastrointestinal Quality-of-Life Index. RESULTS We identified 218 subtotal cholecystectomies, with 113 (51.8%) fenestrating subtotal cholecystectomy and 105 (48.2%) reconstituting subtotal cholecystectomy and a median follow-up of 63 months (interquartile range 27-106). Rates of bile duct injury (0.9% vs 1.0%; P > .99), bile leak (10.6% vs 9.5%; P > .99), and 30-day readmission (7.6% vs 8.0%; P > .99) did not differ between fenestrating and reconstituting subtotal cholecystectomy. For fenestrating subtotal cholecystectomy, the postoperative bile leak rate decreased fourfold when cystic duct closure was achieved (6.0% vs 24.1%; P = .012). Subtotal cholecystectomies completed laparoscopically had fewer postoperative bile leaks (2.9% vs 16.8%; P = .001), fewer wound complications (4.8% vs 13.3%; P = .035), and decreased length of stay (7.00 ± 9.07 vs 10.15 ± 13.50 days; P < .001) compared with open operations. The survey response rate was 38.9% (n = 51/131); 47 patients (92.2%) did not report recurrent biliary pain or postprandial nausea or vomiting, but 19 patients (37.2%) reported dietary restriction. Long-term completion cholecystectomy rate was 0.9%. CONCLUSION Given no notable difference in postoperative or quality of life outcomes between subtotal cholecystectomy subtypes, consideration of technique depends on intraoperative conditions. Cystic duct closure during fenestrating subtotal cholecystectomy and laparoscopic completion of subtotal cholecystectomy are associated with improved postoperative outcomes.
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Affiliation(s)
- Abby Gross
- Department of General Surgery/Hepato-Pancreato-Biliary Surgery, Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Cleveland, OH. https://twitter.com/AbbyRGrossMD
| | - Hanna Hong
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH
| | - Mir Shanaz Hossain
- Department of General Surgery/Hepato-Pancreato-Biliary Surgery, Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Cleveland, OH
| | - Jenny H Chang
- Department of General Surgery/Hepato-Pancreato-Biliary Surgery, Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Cleveland, OH
| | - Chase J Wehrle
- Department of General Surgery/Hepato-Pancreato-Biliary Surgery, Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Cleveland, OH. https://twitter.com/ChaseWehrle
| | | | - Joseph Quick
- Department of General Surgery/Hepato-Pancreato-Biliary Surgery, Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Cleveland, OH
| | - Aleksander Izda
- Department of General Surgery/Hepato-Pancreato-Biliary Surgery, Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Cleveland, OH
| | - Sayf Said
- Department of General Surgery/Hepato-Pancreato-Biliary Surgery, Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Cleveland, OH
| | - Samer Naffouje
- Department of General Surgery/Hepato-Pancreato-Biliary Surgery, Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Cleveland, OH
| | - R Matthew Walsh
- Department of General Surgery/Hepato-Pancreato-Biliary Surgery, Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Cleveland, OH
| | - Toms Augustin
- Department of General Surgery/Hepato-Pancreato-Biliary Surgery, Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Cleveland, OH.
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Badve SB, Turcotte J, Brennan JC, Klune J, Feather CB, Rehrig S, Kulkarni SS. Comparison of Long-Term Outcomes Between Conversion to Open and Laparoscopic Subtotal Cholecystectomy in the Difficult Gallbladder: A Single-Center Retrospective Study. Am Surg 2025:31348251318380. [PMID: 39894760 DOI: 10.1177/00031348251318380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2025]
Abstract
BACKGROUND A difficult laparoscopic cholecystectomy (LC) confers an increased risk of bile duct injury. Traditionally, surgeons convert to open cholecystectomy (OC) as a bailout procedure for safer dissection. Laparoscopic subtotal cholecystectomy (LSC) has recently gained favor with comparable short-term complication rates, but differences in long-term outcomes remain unknown. We sought to compare long-term biliary outcomes between OC and LSC. STUDY DESIGN We performed a single-center retrospective cohort study of adults who underwent non-elective LC converted to OC or LSC due to difficult dissection from 1/1/2015 to 12/31/2019. The primary outcome was a composite measure of postoperative biliary events, and we used time-to-event analysis to compare the 2 groups. We evaluated secondary outcomes using Chi-squared or independent t-tests as appropriate. RESULTS Of 1089 patients who underwent non-elective LC, 68 (6%) underwent a bailout procedure (30 OC vs 38 LSC). There were no differences in demographics or comorbidities between the groups. Most patients (84%) had acute cholecystitis. Average follow-up times were 40 ∓ 29 months in OC and 54 ∓ 21 months in LSC. Biliary events occurred in 13 total patients (19%) with OC most commonly suffering bile leak (17%) and LSC most commonly having choledocholithiasis (11%). Kaplan-Meier analysis demonstrated no significant difference in biliary events between the groups (P = 0.71). Secondary outcomes were all similar between groups, except LSC had a shorter length of stay (2.9 ∓ 2.3 vs 5.1 ∓ 3.6 days, P = 0.002). CONCLUSIONS OC and LSC demonstrated comparable long-term biliary outcomes. In a difficult LC, surgeons may perform either bailout procedure to safely manage the gallbladder.
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Affiliation(s)
| | | | - Jane C Brennan
- Department of Surgery, Luminis Health, Annapolis, MD, USA
| | - John Klune
- Department of Surgery, Luminis Health, Annapolis, MD, USA
| | | | - Scott Rehrig
- Department of Surgery, Luminis Health, Annapolis, MD, USA
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Motter SB, de Figueiredo SMP, Marcolin P, Trindade BO, Brandao GR, Moffett JM. Fenestrating vs reconstituting laparoscopic subtotal cholecystectomy: a systematic review and meta-analysis. Surg Endosc 2024; 38:7475-7485. [PMID: 39266763 DOI: 10.1007/s00464-024-11225-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Accepted: 08/22/2024] [Indexed: 09/14/2024]
Abstract
INTRODUCTION Laparoscopic cholecystectomy is one of the most frequently performed procedures by general surgeons. Strategies for minimizing bile duct injuries including use of the critical view of safety method, as outlined by the SAGES Safe Cholecystectomy Program, are not always possible. Subtotal cholecystectomy has emerged as a safe "bail-out" maneuver to avoid iatrogenic bile duct injury in these difficult cases. Strasberg and colleagues defined two main types of subtotal cholecystectomies: reconstituting and fenestrating. As there is a paucity of studies comparing the two subtypes of laparoscopic subtotal cholecystectomy (LSC), we performed a systematic review and meta-analysis comparing the reconstituting and fenestrating techniques for managing the difficult gallbladder. METHODS A search of PubMed, Embase, and Cochrane databases was conducted to identify prospective and retrospective studies comparing fenestrating and reconstituting LSC. The outcomes of interest were bile leak, reoperation, readmissions, completion cholecystectomy, postoperative ERCP, and retained CBD stones. RESULTS We screened 2855 studies and included 13 studies with a total population of 985 patients. Among them, 330 patients (33.5%) underwent reconstituting LSC and 655 patients (55.5%) underwent fenestrating LSC. Twelve studies were retrospective, and one was prospective. Notably, reconstituting STC was associated with decreased incidence of bile leak (OR 0.29; CI 95% 0.16-0.55; p = 0.0002; I2 = 36%). We also noted increased rates of postoperative ERCP with fenestrating STC in sensitivity analysis (OR 0.32; CI 95% 0.16-0.64; p = 0.001; I2 = 31%). In addition, there was no difference between the two techniques regarding the rates of completion of cholecystectomy, reoperation, readmission, and retained CBD stones. CONCLUSIONS Fenestrating LSC leads to a higher incidence of postoperative bile leakage. In addition, our sensitivity analysis revealed that the fenestrating technique is associated with a higher incidence of postoperative ERCP. Further randomized trials and studies with longer-term follow-up are still necessary to better understand these techniques in the difficult gallbladder cases.
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Affiliation(s)
- Sarah Bueno Motter
- Medical School, Universidade Federal de Ciências da Saúde de Porto Alegre, Rua Sarmento Leite, 245, Centro Histórico, Porto Alegre, 90050-170, Brazil.
| | | | - Patrícia Marcolin
- Medical School, Universidade Federal da Fronteira Sul, Passo Fundo, Brazil
| | - Bruna Oliveira Trindade
- Medical School, Universidade Federal de Ciências da Saúde de Porto Alegre, Rua Sarmento Leite, 245, Centro Histórico, Porto Alegre, 90050-170, Brazil
| | - Gabriela R Brandao
- Medical School, Universidade Federal de Ciências da Saúde de Porto Alegre, Rua Sarmento Leite, 245, Centro Histórico, Porto Alegre, 90050-170, Brazil
| | - Jennifer M Moffett
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX, USA
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Murry J, Babineau H. Management of the Difficult Gallbladder. Surg Clin North Am 2024; 104:1217-1227. [PMID: 39448123 DOI: 10.1016/j.suc.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2024]
Abstract
Cholecystectomies are very common in general surgery practice. A small percentage of these will present with factors that pose operative difficulty. The surgeon should have a high index of suspicion based on preoperative factors of patients that may present an operative challenge and have necessary equipment available and the surgical skill to provide the best surgical outcome for the patient if a total cholecystectomy is unable to be performed.
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Affiliation(s)
- Jason Murry
- Department of Surgery, UT Tyler School of Medicine, 1020 East Idel Street, Tyler, TX 75701, USA.
| | - Hugh Babineau
- Department of Surgery, UT Tyler School of Medicine, 1100 East Lake Suite 150, Tyler, TX 75701, USA
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Ugarte C, Ugarte R, Gallagher S, Park S, Kagan O, Murphy R, Matsushima K, Inaba K, Martin MJ, Schellenberg M. Bail Out Procedures in Acute Cholecystitis: Risk Factors and Optimal Approach. Am Surg 2024:31348241304008. [PMID: 39608319 DOI: 10.1177/00031348241304008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2024]
Abstract
BACKGROUND For difficult cholecystectomies, bail out procedures (BOP) are performed to mitigate risk of patient harm. OBJECTIVE This study sought to identify risk factors for BOP for acute cholecystitis and to compare outcomes by type of BOP performed. Methods: Patients with acute cholecystitis who underwent cholecystectomy were included (2020-2022). Demographics, clinical data, and outcomes were collected. Primary outcome was <30-day complication rate. Groups were defined by surgery performed: BOP vs Laparoscopic Complete Cholecystectomy (LCC). BOPs were defined as any deviation from laparoscopic complete cholecystectomy. Univariate analyses compared outcomes between groups. Multivariable analysis identified independent factors associated with BOP. Subgroup analysis compared outcomes of laparoscopic BOP vs open BOP. RESULTS Of 728 patients, 659 (91%) underwent LCC and 69 (9%) underwent BOP: 34 (49%) laparoscopic BOP and 35 (51%) open BOP. Independent predictors of BOP included admission total bilirubin >0.2 mg/dL (OR 5.80, P = .017), >7 days of symptoms at time of cholecystectomy (OR 1.96, P = .019), and arrival heart rate >100 bpm (OR 1.82, P = .032). On subgroup analysis, laparoscopic vs open BOP demonstrated no difference in operative time (P = .536) and overall (P = .733) or gallbladder-related complications (P = .364), including bile leaks (P = .090). Laparoscopic BOP was associated with shorter postoperative lengths of stay (P = .005). CONCLUSION The risk factors for BOP identified in this study may help inform patient consent and operative planning. Laparoscopic BOP incurred equivalent complications to open BOP but with shorter hospital stays, challenging conventional dogma that conversion to open is the optimal approach for complicated acute cholecystitis.
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Affiliation(s)
- Chaiss Ugarte
- Division of Acute Care Surgery, Los Angeles General Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Ramsey Ugarte
- Division of Acute Care Surgery, Harbor UCLA Medical Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Shea Gallagher
- Division of Acute Care Surgery, Los Angeles General Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Stephen Park
- Division of Acute Care Surgery, Los Angeles General Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Odeya Kagan
- Division of Acute Care Surgery, Los Angeles General Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Ryan Murphy
- Division of Acute Care Surgery, Los Angeles General Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Los Angeles General Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Division of Acute Care Surgery, Los Angeles General Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Matthew J Martin
- Division of Acute Care Surgery, Los Angeles General Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Morgan Schellenberg
- Division of Acute Care Surgery, Los Angeles General Medical Center, University of Southern California, Los Angeles, CA, USA
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Aloraini A, Alanezi T, AlShahwan N. Subtotal laparoscopic cholecystectomy versus open total cholecystectomy for the difficult gallbladder: A systematic review and meta-analysis. Curr Probl Surg 2024; 61:101607. [PMID: 39477670 DOI: 10.1016/j.cpsurg.2024.101607] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Revised: 08/04/2024] [Accepted: 08/18/2024] [Indexed: 01/05/2025]
Affiliation(s)
- Abdullah Aloraini
- Division of General Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Tariq Alanezi
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.
| | - Nawaf AlShahwan
- Trauma and Acute Care Surgery Unit, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Blitzkow ACB, Freitas ACTD, Coelho JCU, Campos ACL, Costa MARD, Buffara-Junior VA, Matias JEF. CRITICAL VIEW OF SAFETY: A PROSPECTIVE SURGICAL AND PHOTOGRAPHIC ANALYSIS IN LAPAROSCOPIC CHOLECYSTECTOMY - DOES IT HELP TO PREVENT IATROGENIC LESIONS? ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2024; 37:e1827. [PMID: 39475862 PMCID: PMC11506944 DOI: 10.1590/0102-6720202400034e1827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 05/08/2024] [Indexed: 11/02/2024]
Abstract
BACKGROUND The incidence of biliary duct injuries remains higher in laparoscopic cholecystectomy (LC) in comparison to open surgery. The Critical View of Safety (CVS) was introduced by Strasberg as a strategy for reducing this catastrophic complication. AIM: The aim of this study was to evaluate how often an adequate CVS is achieved during LC, the determining factors for its success, and the associated surgical outcomes. METHODS This is a prospective study. CVS photographs of all patients who underwent LC by the same surgeon between 2020 and 2023 were taken. Success in achieving CVS was analyzed by the surgeon herself and posteriorly by hepatobiliary specialists. Patients were classified into two groups: CVS achieved and CVS not achieved. Finally, multivariable logistic regression was used to examine the association between preoperatory factors and surgical complications. RESULTS Three hundred and nine consecutive patients were submitted to LC. There were 73.5% elective CL and 26.5% acute cholecystitis. The age ranged from 14 to 87 years, and 76.8% were female. The median body mass index was 26.7. Previous abdominal surgeries were present in 64%, and 26% were obese. The CVS was achieved in 79.9% of the patients, and there were no surgical complications in this group. The factors associated with nonachievement were acute cholecystitis (p=0.007), male sex (p=0.014), and previous surgeries (p=0.021). Three patients needed a subtotal cholecystectomy due to severe inflammation. There was no statistical correlation between the identification of CVS and surgical complications. CONCLUSIONS The CVS is achieved in most patients. Acute cholecystitis, male sex, and previous abdominal operations are associated with difficulties in obtaining CVS.
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Affiliation(s)
| | | | | | | | | | - Victor Assad Buffara-Junior
- Hospital Santa Cruz - Rede D'or, Department of Surgery - Curitiba, Paraná (PR), Brazil
- Pilar Hospital, Department of Surgery - Curitiba (PR), Brazil
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8
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Aloraini A, Alburakan A, Alhelal FS, Alabdi G, Elmutawi H, Alzahrani NS, Alkhalife S, Alanezi T. Bailout for the Difficult Gallbladder: Subtotal vs. Open Cholecystectomy-A Retrospective Tertiary Care Center Experience. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1642. [PMID: 39459429 PMCID: PMC11509598 DOI: 10.3390/medicina60101642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2024] [Revised: 09/22/2024] [Accepted: 10/05/2024] [Indexed: 10/28/2024]
Abstract
Background and Objectives: A difficult gallbladder anatomy augments the risk of bile duct injuries (BDIs) and other complications during a laparoscopic cholecystectomy. This study compares the outcomes of a laparoscopic subtotal cholecystectomy (LSTC) and open total cholecystectomy (OTC) for difficult cholecystectomies. Materials and Methods: This retrospective analysis of gallbladder procedures (LSTC or OTC) from 2016 to 2023 examined patient demographics, surgical details, and postoperative results. The primary outcome was the incidence of a BDI. Secondary outcomes included operative duration, blood loss, and postoperative complications. Results: Seventy-one patients were included in the study. Of them, 59.2% (n = 42) underwent an LSTC and 44.6% (n = 29) underwent an OTC. The LSTC cohort was more likely to have a day-surgery case with a same-day discharge (33.3% vs. 0%, p = 0.009), less blood loss (71.4 ± 82.26 vs. 184.8 ± 234.86, p = 0.009), and a shorter operative duration (187.86 ± 68.74 vs. 258.62 ± 134.52 min, p = 0.008). Furthermore, BDI was significantly lower in the LSTC group (2.4% vs. 17.2%, p = 0.045). However, there were no significant differences between the two groups concerning intraoperative drain placement, peri-cholecystic fluid collection, bile leak, and other complications (p > 0.05). Conclusions: LSTC is a safe and effective alternative to OTC for challenging gallbladder cases. Further studies with larger sample sizes and longer follow-up periods as well as different study designs are warranted.
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Affiliation(s)
- Abdullah Aloraini
- Division of General Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia;
| | - Ahmed Alburakan
- Trauma and Acute Care Surgery Unit, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia;
| | - Fatimah Saad Alhelal
- College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia; (F.S.A.); (G.A.); (H.E.); (N.S.A.); (S.A.)
| | - Ghada Alabdi
- College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia; (F.S.A.); (G.A.); (H.E.); (N.S.A.); (S.A.)
| | - Hend Elmutawi
- College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia; (F.S.A.); (G.A.); (H.E.); (N.S.A.); (S.A.)
| | - Najd Saeed Alzahrani
- College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia; (F.S.A.); (G.A.); (H.E.); (N.S.A.); (S.A.)
| | - Sarah Alkhalife
- College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia; (F.S.A.); (G.A.); (H.E.); (N.S.A.); (S.A.)
| | - Tariq Alanezi
- Division of General Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia;
- College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia; (F.S.A.); (G.A.); (H.E.); (N.S.A.); (S.A.)
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9
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Ravendran K, Elmoraly A, Thomas CS, Job ML, Vahab AA, Khanom S, Kam C. Fenestrating Versus Reconstituting Subtotal Cholecystectomy: Systematic Review and Meta-Analysis on Bile Leak, Bile Duct Injury, and Outcomes. Cureus 2024; 16:e72769. [PMID: 39483541 PMCID: PMC11526809 DOI: 10.7759/cureus.72769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2024] [Indexed: 11/03/2024] Open
Abstract
Symptoms of gallstone disease are the most common reason for cholecystectomy. Fenestration reduces the likelihood of severe inflammation or scarring after normal treatments are used, and it also enhances control over bile outflow. The goal of reconstituted cholecystectomy is to lessen symptoms like pain and jaundice without undergoing the high-risk procedures associated with more invasive procedures. The reconstituted and fenestrated procedures were assessed by a meta-analysis and systematic review. Of the five studies, 189 (34.2%) had a reconstituted subtotal cholecystectomy, and 363 (65.8%) had a fenestrated subtotal cholecystectomy, which had populations from the United States of America, the United Kingdom, Japan, and Turkey. Two individuals from three trials had bile duct injury, according to three studies. Whereas the fenestrated group reported no bile injury from 236 individuals (0%), the reconstituted group reported two bile duct injuries from 100 patients (2%). The incidence was found to be lower in the fenestrated group (OR 10.81; CI 95% 1.03-113.65; p = 0.39; I2 = 0%) than in the reconstituted group. Four studies revealed 92 cases of bile leaks: 19 out of 155 cases (12.3%) were reconstituted, and 73 out of 351 cases (20.8%) were fenestrated. Between the two groups, there was a significant difference in bile leakage (OR 0.72; CI 95% 0.23-2.32; p = 0.03; I2 = 66%). Two studies reported the establishment of fistulas following surgery in 58 patients in the reconstituted group (5.2%) and 120 patients in the fenestrated group (2.5%) (p = 0.56, I2 = 0%, and OR 0.65; CI 95% 0.12-3.38); however, there was no statistically significant difference between the groups. Following a fenestrated partial cholecystectomy, postoperative bile leakage, fistula development, wound infection, and retained stones are more prevalent. Additionally, we saw that the fenestrated method was being used more frequently for post-operative endoscopic retrograde cholangiopancreatography (ERCP). The subtotal cholecystectomy technique used should be chosen according to the surgeon's comfort level and experience with the various techniques and intraoperative findings, even if the reconstituted procedure could be preferred when feasible. To completely understand the role of each method in the general surgeon's toolkit for treating complex gallbladder (GB) patients, longer-term follow-up studies are still necessary.
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Affiliation(s)
- Kapilraj Ravendran
- Surgery, Royal National Orthopaedic Hospital, Brighton and Hove, GBR
- Doctor, Gradscape, London, GBR
| | - Ahmed Elmoraly
- General Medicine, East Sussex Healthcare NHS Trust, Hastings, GBR
| | - Christo S Thomas
- Surgery, Medical University of Varna, Varna, BGR
- Medicine, Gradscape, London, GBR
| | - Mridhu L Job
- Surgery, Medical University of Varna, Varna, BGR
- Medicine, Gradscape, London, GBR
| | - Afrah A Vahab
- Surgery, Medical University Sofia, Sofia, BGR
- Medicine, Gradscape, London, GBR
| | - Shafali Khanom
- Endocrinology, Medical University of Sofia, Sofia, BGR
- Medicine, Gradscape, London, GBR
| | - Chloe Kam
- Surgery, Medical University Sofia, Sofia, BGR
- Medicine, Gradscape, London, GBR
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10
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Barnes A, Viscomi B, Gorham JK. Surgical Management of the Horrible Gallbladder. Adv Surg 2024; 58:143-160. [PMID: 39089774 DOI: 10.1016/j.yasu.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Laparoscopic cholecystectomy is one of the most frequently performed operations by general surgeons, with up to 1 million cholecystectomies performed annually in the United States alone. Despite familiarity, common bile duct injury occurs in no less than 0.2% of cholecystectomies, with significant associated morbidity. Understanding biliary anatomy, surgical techniques, pitfalls, and bailout maneuvers is critical to optimizing outcomes when encountering the horrible gallbladder. This article describes normal and aberrant biliary anatomy, complicated cholelithiasis, ways to recognize cholecystitis, and considerations of surgical approach.
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Affiliation(s)
- Andrew Barnes
- Department of General Surgery, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Brian Viscomi
- Department of General Surgery, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Jessica Koller Gorham
- Department of General Surgery, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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11
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Cherng N, Achebe I, Winkie M, Thomann J, Then E, Marya NB. Approaches to Cholecystitis: Surgical, Endoscopic, and Percutaneous Management. J Intensive Care Med 2024:8850666241267262. [PMID: 39094604 DOI: 10.1177/08850666241267262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Acute cholecystitis (AC) is associated with significant morbidity and mortality. Minimally invasive laparoscopic cholecystectomy remains the gold standard of treatment. Therapeutic endoscopy for management of AC continues to emerge as a favorable alternative to percutaneous gallbladder drainage in patients with prohibitive operative risk. Endoscopic management of AC includes transpapillary and transmural stenting. When patient-specific factors prevent both surgical and endoscopic treatment, percutaneous cholecystostomy tube (PCT) placement is an option. Early studies show PCT to have worse outcomes when compared against all other described treatment options for the management of AC.
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Affiliation(s)
- Nicole Cherng
- Department of Surgery, UMass Chan Medical School, Worcester, MA, USA
| | - Ikechukwu Achebe
- Division of Gastroenterology, UMass Chan Medical School, Worcester, MA, USA
| | - Mason Winkie
- Department of Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Julie Thomann
- Department of Surgery, UMass Chan Medical School, Worcester, MA, USA
| | - Eric Then
- Division of Gastroenterology, UMass Chan Medical School, Worcester, MA, USA
| | - Neil B Marya
- Division of Gastroenterology, UMass Chan Medical School, Worcester, MA, USA
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12
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Bhandarkar SD, Kalikar VR, Patankar A, Patankar R. The use of indocyanine green and near-infrared imaging in laparoscopic completion cholecystectomy for the management of stump cholecystitis: A case series. J Minim Access Surg 2024; 20:253-257. [PMID: 37843171 PMCID: PMC11354946 DOI: 10.4103/jmas.jmas_98_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/24/2023] [Accepted: 07/15/2023] [Indexed: 10/17/2023] Open
Abstract
INTRODUCTION Stump cholecystitis is managed by performing a completion cholecystectomy, which can be done either laparoscopically or by an open method. The use of indocyanine green (ICG) is known to improve the identification of the biliary tree anatomy, facilitating Calot's triangle dissection and shortening surgery, thereby reducing the risk of bile duct injuries and making laparoscopic cholecystectomy safer. PATIENTS AND METHODS A retrospective analysis was performed of prospectively collected data from 15 patients at our institution from March 2016 to March 2021. Magnetic resonance cholangiopancreatography was performed in all 15 cases, showing remnant gall bladder in all cases with calculi within. Four cases had a dilated common bile duct (CBD) with CBD calculi. Endoscopic retrograde cholangiopancreatography (ERCP) and stone removal followed by CBD stenting were performed in the four patients with CBD calculi. These four cases were scheduled for surgery 4 weeks post-ERCP. All 15 patients underwent laparoscopic completion cholecystectomy. The mean operating time was 80 min. RESULTS The post-operative period of all cases was uneventful, and the patients were discharged on post-operative day 2 or day 3. All patients remained asymptomatic during 1-5 years of follow-up. CONCLUSION Laparoscopic completion cholecystectomy was performed safely in cases of stump cholecystitis and resulted in symptom relief during short-term follow-up. The use of ICG and near-infrared imaging in such cases helps identify the biliary anatomy, may contribute to the safety of laparoscopic completion cholecystectomy and might reduce the duration of surgery.
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Affiliation(s)
| | | | - Advait Patankar
- Department of Surgery, Zen Multispeciality Hospital, Chembur, Mumbai, Maharashtra, India
| | - Roy Patankar
- Department of Surgery, Zen Multispeciality Hospital, Chembur, Mumbai, Maharashtra, India
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Ravendran K, Elmoraly A, Kagiosi E, Henry CS, Joseph JM, Kam C. Converting From Laparoscopic Cholecystectomy to Open Cholecystectomy: A Systematic Review of Its Advantages and Reasoning. Cureus 2024; 16:e64694. [PMID: 39156274 PMCID: PMC11327417 DOI: 10.7759/cureus.64694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2024] [Indexed: 08/20/2024] Open
Abstract
Cholecystectomy is the standard treatment for symptomatic cholelithiasis and asymptomatic impending biliary obstruction, which is typically carried out laparoscopically. However, difficult gallbladders, due to distorted anatomy or increased risk of bleeding, can necessitate conversion to open surgery. This systematic review evaluates the advantages, disadvantages, complications, and outcomes of laparoscopic versus converted open cholecystectomy. We screened articles published from 2011 to 2024 by utilizing advanced filters of PubMed, Cochrane, and Scholar databases. Exclusion criteria included non-English language articles, duplicates, and animal studies. After analyzing relevant articles, 31 articles were included in this study. The total number of participants who underwent laparoscopic procedures was 28,054, of which 5,847 were converted from laparoscopic to open procedures. Conversions were primarily due to bleeding, adhesions, and obscured anatomy, with bile leakage being the most common short-term complication. Converted cases showed higher rates of long-term complications, increased hospital stays, and higher morbidity and mortality. Laparoscopic cholecystectomy remains safe and effective, but identifying high-risk patients for conversion is important. Preoperative identification of high-risk patients and recognizing predictive factors for conversion can enhance surgical outcomes and cost-effectiveness. While laparoscopic cholecystectomy is generally preferred, timely conversion to open surgery is essential for patient safety.
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Affiliation(s)
- Kapilraj Ravendran
- General Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, GBR
- Medicine, Gradscape, London, GBR
| | - Ahmed Elmoraly
- General Surgery, East Sussex Healthcare NHS Trust, Hastings, GBR
| | - Eirini Kagiosi
- Medicine and Surgery, Medical University of Sofia, Sofia, BGR
- General Surgery, Gradscape, London, GBR
| | - Casey S Henry
- Surgery, Medical University of Sofia, Sofia, BGR
- Surgery, Gradscape, London, GBR
| | - Jenisa M Joseph
- Surgery, Medical University of Sofia, Sofia, BGR
- Surgery, Gradscape, London, GBR
| | - Chloe Kam
- Surgery, Medical University of Sofia, Sofia, BGR
- Medicine, Gradscape, London, GBR
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14
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Booyse K, Lindemann J, Calitz M, Bernon M, Jonas E, Kloppers C. Laparoscopic subtotal cholecystectomy outcomes across a low-and middle-income country metropolitan health service. World J Surg 2024; 48:1323-1330. [PMID: 38581358 DOI: 10.1002/wjs.12180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/26/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Laparoscopic subtotal cholecystectomy (LSC) is a safe alternative for difficult cholecystectomies to prevent bile duct injury and open conversion. The primary aim was to detail the use and outcomes on LSCs. METHODS Retrospective analysis of a prospectively maintained database of laparoscopic cholecystectomy (LC). Relative clinical factors, outcomes, and 30-day follow-up between LSC and LC were compared using univariate and multivariate analyses. RESULTS Six hundred and twenty four cholecystectomies were performed and 53 (8.5%) required LSC. 81.8% were fenestrating LSC. Male sex was significantly overrepresented in the LSC group (p < 0.01) and patients requiring LSC were significantly older (p < 0.01). Same admission cholecystectomy was associated with a higher risk of LSC (p < 0.01). Patients with a history of previous surgery, preoperative ERCP, or percutaneous cholecystostomy had an increased risk of undergoing LSC (p < 0.01). A necrotic gallbladder was the most significant predictor of the need for a LSC (p < 0.001). A contracted gallbladder, extensive adhesions, gallbladder empyema, and severe inflammation were significant predictors of difficulty (all p < 0.01). Postoperative complications occurred in 26.4% of LSC patients. There were ten (18.9%) Clavien-Dindo Grade III complications, 5.7% required ERCPs, and 9.4% required relook laparotomies. Significantly, more patients in the LSC group developed bile leaks (n = 8, 15%) (p < 0.001). There were two readmissions within 30 days, one mortality, and no BDIs occurred in the LSC cohort. CONCLUSION LSC provides a feasible surgical option that should be utilized in complex cholecystitis.
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Affiliation(s)
- Karien Booyse
- Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa
| | - Jessica Lindemann
- Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa
- Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Mariska Calitz
- Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa
| | - Marc Bernon
- Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa
| | - Eduard Jonas
- Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa
| | - Christo Kloppers
- Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa
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Deng SX, Sharma BT, Ebeye T, Samman A, Zulfiqar A, Greene B, Tsang ME, Jayaraman S. Laparoscopic subtotal cholecystectomy for the difficult gallbladder: Evolution of technique at a single teaching hospital. Surgery 2024; 175:955-962. [PMID: 38326217 DOI: 10.1016/j.surg.2023.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 12/02/2023] [Accepted: 12/07/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND We have developed an algorithmic approach to laparoscopic cholecystectomy, including subtotal cholecystectomy, as a bailout strategy when the Critical View of Safety cannot be safely achieved due to significant inflammation and fibrosis of the hepatocystic triangle. METHODS This is a retrospective cohort study comparing postoperative outcomes in patients with severe cholecystitis who underwent laparoscopic cholecystectomy or laparoscopic subtotal cholecystectomy at St. Joseph's Health Centre from May 2016 to July 2021, as well as against a historical cohort. We further stratified laparoscopic subtotal cholecystectomy cases based on fenestrating or reconstituting subtype. RESULTS The cohort included a total of 105 patients who underwent laparoscopic cholecystectomy and 31 patients who underwent laparoscopic subtotal cholecystectomy. Bile leaks (25.8% vs 1.0%, relative risk 3.5, 95% confidence interval 3.5-208.4) were more common in the laparoscopic subtotal cholecystectomy group. Postoperative endoscopic retrograde cholangiopancreatography (22.6% vs 3.8%, relative risk 5.9, 95% confidence interval 1.9-18.9) and biliary stent insertion (19.4% vs 1.0%, relative risk 20.3, 95% confidence interval 2.5-162.5) were also more common in the laparoscopic subtotal cholecystectomy group. Bile leaks in laparoscopic subtotal cholecystectomy were only documented in the fenestration subtype, most of which were successfully managed with endoscopic retrograde cholangiopancreatography and biliary stenting. Compared to our previous study of laparoscopic cholecystectomy and subtotal cholecystectomy for severe cholecystitis between 2010 and 2016, there has been a decrease in postoperative laparoscopic cholecystectomy complications, subtotal cholecystectomy cases, and no bile duct injuries. CONCLUSION Following our algorithmic approach to safe laparoscopic cholecystectomy has helped to prevent bile duct injury. Laparoscopic cholecystectomy remains the gold standard for the management of severe cholecystitis; however, in extreme cases, laparoscopic subtotal cholecystectomy is a safe bailout strategy with manageable morbidity.
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Affiliation(s)
- Shirley X Deng
- Division of General Surgery, University of Toronto, Toronto, ON Canada
| | - Bree T Sharma
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Tega Ebeye
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Anas Samman
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Amna Zulfiqar
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Brittany Greene
- Division of General Surgery, University of Toronto, Toronto, ON Canada; HPB Service, St. Joseph's Health Centre, Unity Health, Toronto, ON, Canada
| | - Melanie E Tsang
- Division of General Surgery, University of Toronto, Toronto, ON Canada; HPB Service, St. Joseph's Health Centre, Unity Health, Toronto, ON, Canada
| | - Shiva Jayaraman
- Division of General Surgery, University of Toronto, Toronto, ON Canada; HPB Service, St. Joseph's Health Centre, Unity Health, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, Unity Health Toronto, ON, Canada.
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16
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Fasting MH, Strønen E, Glomsaker T, Søvik TT, Fyhn TJ, Mala T. Perioperative strategies for patients undergoing subtotal cholecystectomy: a single-center retrospective review of 102 procedures. Scand J Gastroenterol 2024; 59:456-460. [PMID: 38053273 DOI: 10.1080/00365521.2023.2289352] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 11/25/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Calculous gall bladder disease is often handled by laparoscopic cholecystectomy. In cases where a safe dissection of the hepatocystic triangle cannot be carried out, a subtotal cholecystectomy (STC) may be performed. The perioperative management of patients undergoing STC is characterized by limited evidence. This large single-center series explores some of the perioperative aspects and outcomes after STC. MATERIALS AND METHODS The study population includes all patients who underwent STC at Oslo University Hospital (Ullevål and Aker Hospitals) from 01.01.2014 to 30.09.2020. A STC was defined as a cholecystectomy where there was a failure to control the cystic duct during surgery. Study variables included demographic data, comorbidities, previous biliopancreatic disease, indication for surgery, perioperative information, subsequent interventions and outcome data. RESULTS During the study period, 2376 cholecystectomies were performed, and 102 (4.3%) were categorized as STC. Of all patients with STC, 48 (47.1%) had an intra- or postoperative ERCP during the index hospital admission. The indication for ERCP was bile leak in 37 (42.6%) of the cases. The bile leak resolution rate was 60.0 % in intraoperative ERCP vs 95.7% in postoperative ERCP. Among the STC patients, there were no injuries to the central bile ducts. Later, one patient has undergone a remnant cholecystectomy, following fenestrating STC. CONCLUSION STC was a safe bailout strategy for dissection in the hepatocystic triangle in difficult cholecystectomies. Intraoperative ERCP increased procedure time and was associated with a lower rate of leak resolution, as compared to postoperative ERCP.
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Affiliation(s)
- Magnus Hølmo Fasting
- Department of Gastrointestinal Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Erlend Strønen
- Department of Gastrointestinal Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Tom Glomsaker
- Department of Gastrointestinal Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Torgeir Thorson Søvik
- Department of Gastrointestinal Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Thomas Johan Fyhn
- Department of Gastrointestinal Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Tom Mala
- Department of Gastrointestinal Surgery, Oslo University Hospital Ullevål, Oslo, Norway
- University of Oslo, Institute of Clinical Medicine, Oslo, Norway
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Koo SS, Krishnan RJ, Ishikawa K, Matsunaga M, Ahn HJ, Murayama KM, Kitamura RK. Subtotal vs total cholecystectomy for difficult gallbladders: A systematic review and meta-analysis. Am J Surg 2024; 229:145-150. [PMID: 38168604 PMCID: PMC11529787 DOI: 10.1016/j.amjsurg.2023.12.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/14/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION With severely inflamed gallbladders, laparoscopic cholecystectomy can be difficult and may require procedures like subtotal cholecystectomy (SC). Few studies exist comparing SC and total cholecystectomy (TC) in the setting of severe biliary inflammation. This meta-analysis aims to compare SC and TC for difficult gallbladders. METHODS Medline-OVID, Embase-OVID, and Cinahl were searched including only studies comparing SC to TC for difficult gallbladders. Primary outcome was CBD injury. Secondary outcomes included bile leak, duodenal injury, retained stone, bleeding, intraabdominal collection, wound infection, reoperation, and mortality. RESULTS Ten studies were included. Compared to TC, SC significantly lowered the risk for CBD injury (0 % vs. 1.6 %, RR 0.30, 95%CI 0.10-0.87) but increased risk of bile leaks (RR 3.5, 95%CI 1.79-6.84), postoperative ERCP (RR 2.86, 95%CI 1.53-5.35), intraabdominal collections (RR 2.55, 95%CI 1.32-4.93), and reoperation (RR 2.92, 95%CI 1.14-7.47). CONCLUSION SC is a reasonable alternative to difficult gallbladders that may decrease the risk of CBD injuries. Knowing both approaches is crucial to manage the difficult gallbladder while minimizing harm. Further studies are needed to understand the value of SC for difficult cholecystectomy.
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Affiliation(s)
- Sylvia Sj Koo
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, 96813, USA; Department of Surgery, The Queen's Medical Center, Honolulu, HI, 96813, USA.
| | - Rohin J Krishnan
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, 96813, USA
| | - Kyle Ishikawa
- Department of Quantitative Health Sciences, University of Hawai'i, John A. Burns School of Medicine, Honolulu, HI, 96813, USA
| | - Masako Matsunaga
- Department of Quantitative Health Sciences, University of Hawai'i, John A. Burns School of Medicine, Honolulu, HI, 96813, USA
| | - Hyeong Jun Ahn
- Department of Quantitative Health Sciences, University of Hawai'i, John A. Burns School of Medicine, Honolulu, HI, 96813, USA
| | - Kenric M Murayama
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, 96813, USA; Department of Surgery, The Queen's Medical Center, Honolulu, HI, 96813, USA
| | - Riley K Kitamura
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, 96813, USA; Department of Surgery, The Queen's Medical Center, Honolulu, HI, 96813, USA
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18
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Thomas C, Wintrip D, Horgan L, Brown J. Outcomes of laparoscopic subtotal cholecystectomy: a comparative analysis of fenestrating and reconstituting approaches in 170 cases. Surg Endosc 2024; 38:1484-1490. [PMID: 38233627 DOI: 10.1007/s00464-023-10652-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/17/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Laparoscopic subtotal cholecystectomy (LSC) is a recognised alternative to laparoscopic cholecystectomy (LC) when it is unsafe to achieve the "critical view of safety". Although LSC reduces the risk of bile duct injury, it is associated with increased morbidity, primarily due to bile leak. LSC can be classified as fenestrating (F-LSC) or reconstituting (R-LSC), with the latter being more complex. The objective of this study was to evaluate the two LSC techniques, their complications, and overall outcomes. METHODS We conducted a retrospective analysis of all adult patients who underwent LSC between January 2015 and December 2021 using our electronic database. Data collected included patient demographics, prior acute biliary presentations, operative details/techniques, length of stay (LOS), 30-day complications, 30-day mortality, readmissions, and follow-up investigations/procedures. Descriptive statistics, Chi-squared tests, and relative risk were employed for data analysis. RESULTS In the study period, LSC was performed on 170 patients, showing an increasing trend over time. Most procedures (76%) were performed in the acute setting, and 37.1% of patients had a history of previous acute biliary presentations. Fenestrating LSC was the most performed technique (115 [67.6%] vs. 55 [32.4%]). Complications occurred in 80 (47.1%) patients; 60 patients (35.3%) had a bile leak. 16 patients (9.4%) required reoperation, and readmission was observed in 14 patients (8.2%). F-LSC was associated with more complications [p = 0.03 RR 2.46 (95% CI 1.5-4)], more bile leaks [p < 0.01, RR 2.1 (95% CI 1.2-3.7)], greater need for rescue postoperative endoscopic retrograde cholangiopancreatography (ERCP) [p < 0.01, RR 3.8 (95% CI 1.4-10.2)], and longer LOS (6 vs. 4 days p < 0.01). CONCLUSION Although LSC is seen as a safe alternative to open conversion, our findings demonstrate a high morbidity, including reoperation/reintervention, readmissions, and complications, associated with LSC especially with F-LSC. We suggest that if LSC is performed, the reconstituted technique should be chosen, if feasible.
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Affiliation(s)
- Christophe Thomas
- General Surgery Department, North Tyneside General Hospital, Northumbria Healthcare NHS Foundation Trust, Rake Ln, Tyne and Wear, North Shields, NE29 8NH, England.
| | - Dorothy Wintrip
- General Surgery Department, North Tyneside General Hospital, Northumbria Healthcare NHS Foundation Trust, Rake Ln, Tyne and Wear, North Shields, NE29 8NH, England
| | - Liam Horgan
- General Surgery Department, North Tyneside General Hospital, Northumbria Healthcare NHS Foundation Trust, Rake Ln, Tyne and Wear, North Shields, NE29 8NH, England
| | - James Brown
- General Surgery Department, North Tyneside General Hospital, Northumbria Healthcare NHS Foundation Trust, Rake Ln, Tyne and Wear, North Shields, NE29 8NH, England
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Al-Azzawi M, Abouelazayem M, Parmar C, Singhal R, Amr B, Martinino A, Atıcı SD, Mahawar K. A systematic review on laparoscopic subtotal cholecystectomy for difficult gallbladders: a lifesaving bailout or an incomplete operation? Ann R Coll Surg Engl 2024; 106:205-212. [PMID: 37365939 PMCID: PMC10904265 DOI: 10.1308/rcsann.2023.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 06/28/2023] Open
Abstract
INTRODUCTION Laparoscopic subtotal cholecystectomy (LSTC) is a bailout procedure that is undertaken when it is not safe to proceed with a laparoscopic total cholecystectomy owing to dense adhesions in Calot's triangle. The main aim of this review was to investigate the early (≤30 days) and late (>30 days) morbidity and mortality of LSTC. METHODS A literature search of the PubMed® (MEDLINE®), Google Scholar™ and Embase® databases was conducted to identify all studies on LSTC published between 1985 and December 2020. A systematic review was then performed. RESULTS Overall, 45 studies involving 2,166 subtotal cholecystectomy patients (51% female) were identified for inclusion in the review. The mean patient age was 55 years (standard deviation: 15 years). Just over half (53%) of the patients had an elective procedure. The conversion rate was 6.2% (n=135). The most common indication was acute cholecystitis (49%). Different techniques were used, with the majority having a closed cystic duct/gallbladder stump (71%). The most common closure technique was intracorporeal suturing (53%), followed by endoloop closure (15%). Four patients (0.18%) died within thirty days of surgery. Morbidity within 30 days included bile duct injury (0.23%), bile leak (18%) and intra-abdominal collection (4%). Reoperation was reported in 23 patients (1.2%), most commonly for unresolving intra-abdominal collections and failed endoscopic retrograde cholangiopancreatography to control bile leak. Long-term follow-up was reported in 30 studies, the median follow-up duration being 22 months. Late morbidity included incisional hernias (6%), symptomatic gallstones (4%) and common bile duct stones (2%), with 2% of cases requiring completion of cholecystectomy. CONCLUSIONS LSTC is an acceptable alternative in patients with a "difficult" Calot's triangle.
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Affiliation(s)
| | - M Abouelazayem
- St George’s University Hospitals NHS Foundation Trust, UK
| | - C Parmar
- Whittington Health NHS Trust, UK
| | - R Singhal
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - B Amr
- University Hospitals Plymouth NHS Trust, UK
| | | | - SD Atıcı
- Izmir Tepecik Training and Research Hospital, Turkey
| | - K Mahawar
- South Tyneside and Sunderland NHS Foundation Trust, UK
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Hajibandeh S, Hajibandeh S, Parente A, Laing RW, Bartlett D, Athwal TS, Sutcliffe RP. Meta-analysis of fenestrating versus reconstituting subtotal cholecystectomy in the management of difficult gallbladder. HPB (Oxford) 2024; 26:8-20. [PMID: 37739875 DOI: 10.1016/j.hpb.2023.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/07/2023] [Accepted: 09/04/2023] [Indexed: 09/24/2023]
Abstract
AIMS To evaluate comparative outcomes of fenestrating and reconstituting subtotal cholecystectomy (STC) in patients with difficult gallbladder. METHODS A systematic search of electronic data sources and bibliographic reference lists were conducted. All comparative studies reporting outcomes of laparoscopic fenestrating and reconstituting STC were included and their risk of bias were assessed using ROBINS-I tool. RESULTS Seven comparative studies were included enrolling 590 patients undergoing laparoscopic STC using either fenestrating (n = 353) or reconstituting (n = 237) approaches. Although fenestrating STC was associated with a significantly higher rate of bile leak (OR: 2.47, p = 0.007) compared to reconstituting STC, both approaches were comparable in terms of resolution of bile leak without (RD: -0.02, p = 0.86) or with (OR: 1.84, p = 0.40) postoperative ERCP. Moreover, there was no significant difference in development of bile duct injury (RD: -0.02, p = 0.16), need for postoperative ERCP (OR: 1.36, p = 0.49), wound infection (RD: 0.03, p = 0.27), re-operation (OR: 0.95, p = 0.95), gallbladder remnant cholecystitis (OR: 0.21, p = 0.09) or need for completion cholecystectomy (RD: 0.01, p = 0.59) between two groups. CONCLUSIONS Fenestrating STC is associated with a higher risk of bile leak than the reconstructing technique. This issue can be mitigated by routine use of drains, delayed drain removal, and in selected cases endoscopic therapy. We encourage the fenestrating approach considering trends in improved short- and long-term outcomes.
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Affiliation(s)
- Shahin Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom.
| | - Shahab Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Alessandro Parente
- Division of Hepatobiliary and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Richard W Laing
- Department of Hepatobiliary and Pancreatic Surgery, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - David Bartlett
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Tejinderjit S Athwal
- Department of Hepatobiliary and Pancreatic Surgery, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Robert P Sutcliffe
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
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21
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Grossman H, Holder KG, Freedle C, Dhanasekara CS, Dissanaike S. Comparing Outcomes of Sub-Total Cholecystectomy Versus Open Cholecystectomy as Bailout Procedures for the Difficult Gallbladder. Am Surg 2023; 89:5372-5378. [PMID: 36573574 DOI: 10.1177/00031348221148345] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Although laparoscopic cholecystectomy is one of the most common operations performed, there is no consensus on the best surgical approach when inflammation obscures hepatocystic anatomy in severe cholecystitis. Traditionally, this situation triggered conversion to open cholecystectomy (COC); however, in recent decades, alternative approaches have been described. We compared outcomes of bailout procedures for severe cholecystitis, primarily focusing on COC versus laparoscopic subtotal cholecystectomy (LSTC). STUDY DESIGN Retrospective review comparing outcomes of intended laparoscopic cholecystectomy cases that were converted to bailout procedures between 2015-2020 at a single institution. Bailout procedures were categorized into LSTC and COC groups. Demographics, clinical presentation, time to surgery, operative indications, operative duration, and post-operative outcomes were compared using independent sample t-tests with Welch-Satterthwaite correction or Wilcoxon rank-sum tests (continuous variables) or Fisher's exact/χ2 tests. A P-value of less than .05 was considered significant. RESULTS Final analysis included 158 subjects: 55 LSTC and 99 COC. Patient demographics and clinical presentations were similar between groups. LSTC had shorter operative time, fewer ICU admissions, and shorter length of stay than COC (P < .05). There were 9 (9.2%) cases of ileus, 4 (4.0%) cases of post-operative bleeding, and 2 (2.0%) cases of bile duct injury in COC. There was 1 (1.8%) case of ileus, 1 (1.8%) case of post-operative bleeding, and no bile duct injury in LSTC. CONCLUSION LSTC was associated with fewer complications than COC, which had higher rates of biliary injury, bleeding, ileus, ICU admission, and longer hospital stay.
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Affiliation(s)
- Holly Grossman
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Katherine G Holder
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Caroline Freedle
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Department of Surgery, University of Oklahoma College of Medicine, Oklahoma City, OK, USA
| | | | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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22
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Ibrahim R, Abdalkoddus M, Mownah OA, Chanthu A, Yao L, Aroori S. Safety profile and outcomes of intraoperative ultrasound-guided remnant cholecystectomy. Ann R Coll Surg Engl 2023; 105:528-531. [PMID: 36748801 PMCID: PMC10313443 DOI: 10.1308/rcsann.2022.0142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Subtotal cholecystectomy (STC) is a safe approach in difficult cholecystectomies to prevent bile duct and vascular injury. However, the gallbladder remnant can become symptomatic, necessitating further surgical intervention. This study evaluates the safety profile and perioperative outcomes of remnant cholecystectomy (RC) performed under intraoperative ultrasound guidance. METHODS We retrospectively reviewed the records of all patients that underwent RC under intraoperative ultrasound guidance in 2009 and 2019. Pre-, intra- and postoperative details of patients who underwent RC were obtained from patients' electronic and paper copy records. RESULTS Ninety-seven patients underwent STC during the study period. Of this cohort, 16 patients (16.5%) presented with symptomatic gallbladder remnant over a median follow-up period of 14 months (interquartile range [IQR] 2-26). The median age was 64 years (IQR 54-69) with an equal male-to-female distribution. The median body mass index was 31kg/m2 (IQR 28-33). Twelve of 16 patients (75%) then proceeded to elective RC. Intraoperative ultrasound was used in all cases to identify the location of the remnant gallbladder and biliary anatomy. The median operative time was 88min (IQR 80-96), with 67% completed laparoscopically. No patients suffered bile duct injury. The median hospital stay was 3 days (IQR 1-5). During the follow-up period, eight patients (67%) reported symptom resolution. CONCLUSIONS RC is a safe operation that can be performed laparoscopically even after previous open subtotal cholecystectomy. We recommend the routine use of intraoperative ultrasound as an adjunct for identifying remnant gallbladder and biliary anatomy in all patients.
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Affiliation(s)
| | | | - OA Mownah
- University Hospitals Plymouth NHS Trust, UK
| | - A Chanthu
- University Hospitals Plymouth NHS Trust, UK
| | - L Yao
- University Hospitals Plymouth NHS Trust, UK
| | - S Aroori
- University Hospitals Plymouth NHS Trust, UK
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23
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Ibrahim R, Abdalkoddus M, Mahendran B, Mownah OA, Nawara H, Aroori S. Subtotal cholecystectomy: is it a safe option for difficult gall bladders? Ann R Coll Surg Engl 2023; 105:455-460. [PMID: 34821508 PMCID: PMC10149244 DOI: 10.1308/rcsann.2021.0291] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Subtotal cholecystectomy (STC) is an alternative to total cholecystectomy (TC) in patients with severe inflammation/adhesions around the hepatocystic triangle. This study aimed to evaluate the safety profile of STC. METHODS We retrospectively reviewed all patients who had STC at our unit between February 2009 and August 2019. STC was divided into two types, reconstituting (R-STC) and fenestrating (F-STC), depending on whether the gall bladder remnant was closed or left open. Patients who had cholecystectomy for gall bladder malignancy or as part of another operation were excluded from the study. RESULTS A total of 5,664 patients underwent cholecystectomy during the study period. Of these, 97 (1.7%) underwent STC. The laparoscopic to open conversion rate was high at 48.8% (47 cases), as was the overall postoperative complication rate (45.4%, 44 cases). No patient suffered iatrogenic bile duct injury. Nineteen patients (19.6%) suffered postoperative bile leak. This was significantly higher in patients who had STC in the acute setting (41% vs 13% for elective STC cases; p=0.04). There was no significant difference in rate of bile leak or other complications between R-STC and F-STC types. The 90-day readmission rate was 8.2% (8 cases). No mortalities were recorded within 90 days post STC. CONCLUSIONS STC seems to be an effective technique to avoid bile duct injury in difficult cholecystectomy cases. However, the perioperative morbidity associated with STC is relatively high. Surgeons should be aware of the risks of STC and take appropriate steps to minimise them.
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Affiliation(s)
- R Ibrahim
- University Hospitals Plymouth NHS Trust, UK
| | | | | | - OA Mownah
- University Hospitals Plymouth NHS Trust, UK
| | - H Nawara
- University Hospitals Plymouth NHS Trust, UK
| | - S Aroori
- University Hospitals Plymouth NHS Trust, UK
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24
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Ramírez-Giraldo C, Torres-Cuellar A, Van-Londoño I. State of the art in subtotal cholecystectomy: An overview. Front Surg 2023; 10:1142579. [PMID: 37151864 PMCID: PMC10162495 DOI: 10.3389/fsurg.2023.1142579] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/31/2023] [Indexed: 05/09/2023] Open
Abstract
Introduction Subtotal cholecystectomy is a type of surgical bail-out procedure indicated when facing difficult laparoscopic cholecystectomy due to not reaching the critical view of safety, inadequate identification of the anatomical structures involved and/or risk of injury. Materials and methods A comprehensive search on PubMed were performed using the following Mesh terms: Subtotal cholecystectomy and Partial cholecystectomy. The PubMed databases were used to search for English-language reports related to Subtotal cholecystectomy between January 1, 1987, the date of the first published laparoscopic cholecystectomy, through January 2023. 41 studies were included. Results Subtotal cholecystectomy's incidence oscillates between 4.00% and 9.38%. Strasberg et al., divided subtotal cholecystectomies in "fenestrating" and "reconstituting" types based on if the remaining portion of the gallbladder was left open or closed. Subtotal cholecystectomy can sometimes be a challenging procedure and is associated to a high rate of complications such as biliary fistula, retained gallstones, subhepatic or subphrenic collections, among others. Conslusion Subtotal cholecystectomy is a safe alternative when facing difficult cholecystectomy in which the critical view of safety is not reached in order to avoid complications. A classification system should be implemented in surgical descriptions to compare the different surgical techniques employed. In order to avoid bile leakage and cholecystitis of the remnant gallbladder, the surgical technique must be performed skillfully. There is still a current lack of information on alternative techniques such as omental plugging or falciform patch in order to judge their utility. There needs to be further research on long-term complications such as malignancy of the remnant gallbladder.
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Affiliation(s)
- Camilo Ramírez-Giraldo
- General Surgery Department, Hospital Universitario Mayor – Méderi, Bogotá, Colombia
- Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Andrés Torres-Cuellar
- Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Isabella Van-Londoño
- Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
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25
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The artery first technique: re-examining the critical view of safety during laparoscopic cholecystectomy. Surg Endosc 2023:10.1007/s00464-023-09912-z. [PMID: 36792783 DOI: 10.1007/s00464-023-09912-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/28/2023] [Indexed: 02/17/2023]
Abstract
INTRODUCTION Significant discrepancies exist between surgeon-documented and actual rates of critical view of safety (CVS) achievement on retrospective review following laparoscopic cholecystectomy. This discrepancy may be due to surgeon utilisation of the artery first technique (AFT), an exception to the CVS first described by Strasberg et al. The present study aims to characterise the use of the AFT, hypothesising it is used as an adjunct in difficult dissections to maximise exposure of the hepato-cystic triangle ensuring safe cholecystectomy. METHODS Prospective digital recording of the operative procedure of patients' undergoing laparoscopic cholecystectomy were undertaken at Christchurch Public Hospital, New Zealand and North Shore Private Hospital, Sydney, Australia. Videos were uploaded to Touch Surgery™ Enterprise. Difficulty was graded, annotated and indications for the AFT quantified using a standardised protocol. RESULTS A total of 275 annotated procedures were included in this study. The AFT was employed in 54 (20%) patients; in 13 (24%) patients for bleeding, in 35 (65%) patients where windows one and two were visible, and in 6 (11%) patients no windows were visible within the hepato-cystic triangle. There were significant differences in utilisation across operative grade and by seniority of operator (p < 0.005). CONCLUSIONS The data presented here demonstrate the AFT is frequently used, particularly with Grade 3 cholecystectomy. However, more data are needed to confirm the utility and safety of this approach. Analysis of the AFT shows that to understand and improve safety in laparoscopic cholecystectomy appreciating how the operation was undertaken and not just that the CVS was achieved is crucial.
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26
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Review of the Literature on Partial Resections of the Gallbladder, 1898-2022: The Outline of the Conception of Subtotal Cholecystectomy and a Suggestion to Use the Terms 'Subtotal Open-Tract Cholecystectomy' and 'Subtotal Closed-Tract Cholecystectomy'. J Clin Med 2023; 12:jcm12031230. [PMID: 36769878 PMCID: PMC9917859 DOI: 10.3390/jcm12031230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/29/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Abstract
Current descriptions of the history of subtotal cholecystectomy require more details and accuracy. This study presented a narrative review of the articles on partial resections of the gallbladder published between 1898 and 2022. The Scale for the Assessment of Narrative Review Articles items guided the style and content of this paper. The systematic literature search yielded 165 publications. Of them, 27 were published between 1898 and 1984. The evolution of the partial resections of the gallbladder began in the last decade of the 19th century when Kehr and Mayo performed them. The technique of partial resection of the gallbladder leaving the hepatic wall in situ was well known in the 3rd and 4th decades of the 20th century. In 1931, Estes emphasised the term 'partial cholecystectomy'. In 1947, Morse and Barb introduced the term 'subtotal cholecystectomy'. Madding and Farrow popularised it in 1955-1959. Bornman and Terblanche revitalised it in 1985. This term became dominant in 2014. From a subtotal cholecystectomy technical execution perspective, it is either a single-stage (when it includes only the resectional component) or two-stage (when it also entails closure of the remnant of the gallbladder or cystic duct) operation. Recent papers on classifications of partial resections of the gallbladder indicate the extent of gallbladder resection. Subtotal cholecystectomy is an umbrella term for incomplete cholecystectomies. 'Subtotal open-tract cholecystectomy' and 'subtotal closed-tract cholecystectomy' are terms that characterise the type of completion of subtotal cholecystectomy.
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27
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Song J, Chen J, Zheng S. Lateral dorsal infundibular approach: an alternative option for the safe completion of difficult laparoscopic cholecystectomy. BMC Surg 2022; 22:439. [PMID: 36567315 PMCID: PMC9790120 DOI: 10.1186/s12893-022-01894-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 12/22/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Difficult laparoscopic cholecystectomy (LC) due to acute cholecystitis (AC) increases the risk of bile duct injuries and postoperative complications. Here, we added the lateral dorsal infundibular approach as an initial surgical maneuver during LC to improve outcomes. METHODS We describe the detailed technical procedure of the lateral dorsal infundibular approach in patients with AC resulting in difficult LC. This technique was developed after nearly 10 years of experience in laparoscopic surgery, and has been routinely used in the past 5 years. We also retrospectively analyzed the perioperative data for 469 patients with difficult LC. RESULTS A total of 469 patients with AC received difficult LC between July 2016 and June 2021, of which 438 (93.4%) performed a lateral dorsal infundibular approach. Sixty-four patients (13.6%) had variations of the hepatic bile duct and cystic duct according to preoperative magnetic resonance cholangiopancreatography, 438 patients (93.4%) received elective surgery, 31 (6.6%) received emergency surgery, and 10 (2.1%) underwent conversion. There was no postoperative bile leaks and no bile duct injuries in the described technique. CONCLUSION During difficult LC, the critical view of safety can be gradually achieved by changing the surgical approach to achieve cholecystectomy.
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Affiliation(s)
- Juxian Song
- Department of Hepatobiliary Surgery, The 925Th Hospital of the Chinese People’s Liberation Army, Guiyang, 550009 China
| | - Jian Chen
- Institute of Hepatobiliary Surgery, First Affiliated Hospital, Army Military Medical University, Shapingba District, Gaotanyan Main Street 29, Chongqing, 400038 China
| | - Shuguo Zheng
- Institute of Hepatobiliary Surgery, First Affiliated Hospital, Army Military Medical University, Shapingba District, Gaotanyan Main Street 29, Chongqing, 400038 China
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28
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Deng SX, Greene B, Tsang ME, Jayaraman S. Thinking Your Way Through a Difficult Laparoscopic Cholecystectomy: Technique for High-Quality Subtotal Cholecystectomy. J Am Coll Surg 2022; 235:e8-e16. [PMID: 36102500 DOI: 10.1097/xcs.0000000000000392] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Laparoscopic subtotal cholecystectomy (LSC) is a bailout strategy to prevent bile duct injury in difficult gallbladder cases. It is associated with acceptable morbidity that is readily managed with postoperative interventions. Here we share our techniques for LSC. We begin with landmarking, which includes the line of safety, a theoretical line the sulcus of Rouvière and the junction of the cystic and hilar plates. If the fundus can be grasped, then the gallbladder is dissected off the cystic plate using the top-around approach. The gallbladder is then amputated, creating a short cuff of proximal gallbladder. This cuff can be left patent (2A) or cinched close with an ENDOLOOP (Ethicon) if it is small, ideally less than 1 cm (1A). If the fundus cannot be grasped, then an inverted T incision is made on the anterior gallbladder wall. The longitudinal incision is extended toward the fundus, and the transverse incision is extended superiorly along the cystic plate edge. Two "bunny ears" are developed and ultimately resected to excise the anterior gallbladder wall at an oblique angle while leaving the posterior wall intact (2B). If the remaining cuff is small, then it can be sutured closed against the gallbladder back wall (1B). In the setting of extensive bowel adhesion to the anterior gallbladder, we perform a fundectomy, from which we extend two incisions along the cystic plate to open the gallbladder like a clamshell. Our paper describes and illustrates our St Joseph's Health Centre institutional LSC approach and subtype classification (1A, 1B, 2A, and 2B).
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Affiliation(s)
- Shirley X Deng
- From the Division of General Surgery, University of Toronto, Toronto, ON Canada (Deng, Greene, Tsang, Jayaraman)
| | - Brittany Greene
- From the Division of General Surgery, University of Toronto, Toronto, ON Canada (Deng, Greene, Tsang, Jayaraman)
- the HPB Service, St Joseph's Health Centre (Greene, Tsang, Jayaraman), Unity Health, Toronto, ON, Canada
| | - Melanie E Tsang
- From the Division of General Surgery, University of Toronto, Toronto, ON Canada (Deng, Greene, Tsang, Jayaraman)
- the HPB Service, St Joseph's Health Centre (Greene, Tsang, Jayaraman), Unity Health, Toronto, ON, Canada
| | - Shiva Jayaraman
- From the Division of General Surgery, University of Toronto, Toronto, ON Canada (Deng, Greene, Tsang, Jayaraman)
- the HPB Service, St Joseph's Health Centre (Greene, Tsang, Jayaraman), Unity Health, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute (Jayaraman), Unity Health, Toronto, ON, Canada
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Braschi C, Tung C, Tang A, Delgado C, Uribe L, Senekjian L, Keeley JA. Early Outcomes of Subtotal vs Total Cholecystectomy for Acute Cholecystitis. JAMA Surg 2022; 157:2796295. [PMID: 36103166 PMCID: PMC9475435 DOI: 10.1001/jamasurg.2022.3146] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/18/2022] [Indexed: 09/16/2023]
Abstract
This cohort study compares outcomes including hospital length of stay and 30-day rates of complications after nonelective subtotal cholecystectomy vs total cholecystectomy among patients with cholecystitis.
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Affiliation(s)
- Caitlyn Braschi
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Christine Tung
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Annie Tang
- Department of Surgery, UCSF-East Bay, San Francisco, California
| | - Cynthia Delgado
- Department of Surgery, Olive View-UCLA Medical Center, Los Angeles, California
| | - Lisandra Uribe
- Department of Surgery, Olive View-UCLA Medical Center, Los Angeles, California
| | - Lara Senekjian
- Department of Surgery, UCSF-East Bay, San Francisco, California
| | - Jessica A. Keeley
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
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30
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Kohga A, Suzuki K, Okumura T, Yamashita K, Isogaki J, Kawabe A, Muramatsu K, Kimura T. Presence of cystic duct stone is a risk for postoperative retained stones in patients with acute cholecystitis. Clin Imaging 2022; 89:55-60. [PMID: 35704962 DOI: 10.1016/j.clinimag.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/06/2022] [Accepted: 06/03/2022] [Indexed: 12/07/2022]
Abstract
PURPOSE Retained stones (RS) in the common bile duct (CBD) are one of the major problems after laparoscopic cholecystectomy and usually require endoscopic treatment. However, few reports have investigated risk factors for the development of RS in the CBD. METHODS A total of 325 patients with acute cholecystitis underwent laparoscopic cholecystectomy at our hospital between January 2013 and Jury 2021. Patient characteristics, including radiographic factors and perioperative outcomes, were reviewed, and perioperative factors predicting RS in the CBD were investigated. RESULTS RS in the CBD were developed in 34 patients. All 34 patients were treated endoscopically. ASA-PS class 3 or more (p = 0.029, odds ratio = 2.601), subtotal cholecystectomy performance (p = 0.004, odds ratio = 3.783) and the presence of cystic duct stones (p < 0.001, odds ratio = 11.759) were found by logistic regression analysis to be independent risk factors for developing RS in the CBD. Cystic duct stones were preoperatively detected in 60 patients. Of these, 21 cases were not detected on magnetic resonance cholangiopancreatography (MRCP) but on CT, while 15 cases were not detected on CT but on MRCP. CONCLUSIONS The presence of cystic duct stones on preoperative CT or MRCP is a crucial risk factor for developing RS in the CBD. Both CT and MRCP are useful to avoid overlooking cystic duct stones.
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Affiliation(s)
- Atsushi Kohga
- Division of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan.
| | - Kenji Suzuki
- Division of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
| | - Takuya Okumura
- Division of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
| | | | - Jun Isogaki
- Division of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
| | - Akihiro Kawabe
- Division of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
| | - Katsuaki Muramatsu
- Division of Radiology, Fujinomiya City General Hospital, Shizuoka, Japan
| | - Taizo Kimura
- Division of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
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31
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Loh AYH, Chean CS, Durkin D, Bhatt A, Athwal TS. Short and long term outcomes of laparoscopic fenestrating or reconstituting subtotal cholecystectomy versus laparoscopic total cholecystectomy in the management of acute cholecystitis. HPB (Oxford) 2022; 24:691-699. [PMID: 34696994 DOI: 10.1016/j.hpb.2021.09.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 08/17/2021] [Accepted: 09/09/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Strasberg proposed classifying subtotal cholecystectomy techniques into fenestrating (fSC) and reconstituting (rSC) subtypes. The aim of this study is to compare our outcomes of laparoscopic subtotal cholecystectomies of both subtypes against laparoscopic total cholecystectomy (TC) in difficult emergency laparoscopic cholecystectomies. METHODS Patients undergoing emergency laparoscopic cholecystectomy were identified over 2 years and all Nassar scale 3 and 4 cholecystectomies were included for analysis. RESULTS 108 fSC and 24 rSC were compared against 317 TC. Patients undergoing fSC and rSC were older and more likely to be male. fSC (128 min) and rSC (141 min) recorded longer median operative times than TC (109). Post-operative ERCP was more common after rSC (16.7%). Patients undergoing fSC (2 days) and rSC (3.5 days) had longer post-operative stays. Bile leaks were more likely in fSC (9.3%) and rSC (8.3%) compared to TC (1.9%), Long term morbidity was higher in the rSC group (12.5% vs 10%). And these were solely due to gallbladder remnant complications. CONCLUSION Laparoscopic fSC and rSC techniques are associated with a higher rate of bile leaks and rSC has more long term morbidty as compared to TC.
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Affiliation(s)
- Alex Y H Loh
- Royal Stoke University Hospital, Newcastle Road, ST4 6QG, Stoke-on-Trent, United Kingdom
| | - Chung Shen Chean
- Royal Stoke University Hospital, Newcastle Road, ST4 6QG, Stoke-on-Trent, United Kingdom
| | - Damien Durkin
- Royal Stoke University Hospital, Newcastle Road, ST4 6QG, Stoke-on-Trent, United Kingdom
| | - Anand Bhatt
- Royal Stoke University Hospital, Newcastle Road, ST4 6QG, Stoke-on-Trent, United Kingdom
| | - Tejinderjit S Athwal
- Royal Stoke University Hospital, Newcastle Road, ST4 6QG, Stoke-on-Trent, United Kingdom.
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Abstract
IMPORTANCE Gallbladder disease affects approximately 20 million people in the US. Acute cholecystitis is diagnosed in approximately 200 000 people in the US each year. OBSERVATIONS Gallstone-associated cystic duct obstruction is responsible for 90% to 95% of the cases of acute cholecystitis. Approximately 5% to 10% of patients with acute cholecystitis have acalculous cholecystitis, defined as acute inflammation of the gallbladder without gallstones, typically in the setting of severe critical illness. The typical presentation of acute cholecystitis consists of acute right upper quadrant pain, fever, and nausea that may be associated with eating and physical examination findings of right upper quadrant tenderness. Ultrasonography of the right upper quadrant has a sensitivity of approximately 81% and a specificity of approximately 83% for the diagnosis of acute cholecystitis. When an ultrasound result does not provide a definitive diagnosis, hepatobiliary scintigraphy (a nuclear medicine study that includes the intravenous injection of a radiotracer excreted in the bile) is the gold standard diagnostic test. Following diagnosis, early (performed within 1-3 days) vs late (performed after 3 days) laparoscopic cholecystectomy is associated with improved patient outcomes, including fewer composite postoperative complications (11.8% for early vs 34.4% for late), a shorter length of hospital stay (5.4 days vs 10.0 days), and lower hospital costs. During pregnancy, early laparoscopic cholecystectomy, compared with delayed operative management, is associated with a lower risk of maternal-fetal complications (1.6% for early vs 18.4% for delayed) and is recommended during all trimesters. In people older than 65 years of age, laparoscopic cholecystectomy is associated with lower mortality at 2-year follow-up (15.2%) compared with nonoperative management (29.3%). A percutaneous cholecystostomy tube, in which a drainage catheter is placed in the gallbladder lumen under image guidance, is an effective therapy for patients with an exceptionally high perioperative risk. However, percutaneous cholecystostomy tube placement in a randomized trial was associated with higher rates of postprocedural complications (65%) compared with laparoscopic cholecystectomy (12%). For patients with acalculous acute cholecystitis, percutaneous cholecystostomy tube should be reserved for patients who are severely ill at the time of diagnosis; all others should undergo a laparoscopic cholecystectomy. CONCLUSIONS AND RELEVANCE Acute cholecystitis, typically due to gallstone obstruction of the cystic duct, affects approximately 200 000 people in the US annually. In most patient populations, laparoscopic cholecystectomy, performed within 3 days of diagnosis, is the first-line therapy for acute cholecystitis.
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Affiliation(s)
- Jared R Gallaher
- Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill
| | - Anthony Charles
- Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill
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Yildirim AC, Zeren S, Ekici MF, Yaylak F, Algin MC, Arik O. Comparison of Fenestrating and Reconstituting Subtotal Cholecystectomy Techniques in Difficult Cholecystectomy. Cureus 2022; 14:e22441. [PMID: 35345702 PMCID: PMC8942168 DOI: 10.7759/cureus.22441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose Cholecystectomy is one of the most frequently performed surgeries. Although laparoscopy is considered the gold standard approach, it cannot prevent biliary injuries. Subtotal cholecystectomy has been performed mainly to prevent biliary injuries during difficult cholecystectomies. This study aimed to analyse our subtotal cholecystectomy results for difficult cholecystectomy cases and to evaluate the fenestrating and reconstituting techniques. Methods Retrospective data were collected and analysed statistically for cases that underwent subtotal cholecystectomy in a single referral centre between 2015 and 2020. Comparisons were made of the patients’ age, gender, preoperative American Society of Anaesthesiologists (ASA) score, comorbidities, surgical timing, surgical procedure choice, postoperative complications, and mortality. Results The number of patients who underwent subtotal cholecystectomy was 46; 30.4% underwent emergent surgery and 69.6% underwent elective surgery. Twelve patients had subtotal fenestrating cholecystectomy and 34 had subtotal reconstituting cholecystectomy. Wound issues were noted in 17.4% of the patients, while 10.9% had temporary biliary fistulas that resolved spontaneously. Reoperation was performed in one patient due to high-output biliary drainage. Patients with postoperative complications had significantly higher co-morbid conditions (p=0.000), but surgery timing (p=0.192) and type of subtotal cholecystectomy (p=0.409) had no statistically significant effect on complications. Mortality showed a statistically significant correlation with patient comorbidities, surgery timing, and the type of procedure (p<0.05). Postoperative complications showed a statistically significant correlation with mortality (p<0.05). Conclusion Subtotal cholecystectomy prevents major biliary complications after cholecystectomy. Yet, the frequency of postoperative complications after subtotal cholecystectomy is incontrovertible. Intraoperative characteristics and the surgeon’s expertise decide the optimal choice of the subtotal cholecystectomy technique.
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Watanabe Y, Mochidome N, Nakayama H, Gotoh Y, Setoguchi T, Sunami S, Yoneda R, Ochiai Y, Mizoguchi K, Yamamoto H, Ueki T. Intracholecystic papillary neoplasm associated with invasive carcinoma of the remnant gallbladder after subtotal cholecystectomy: a case report. Surg Case Rep 2022; 8:31. [PMID: 35187597 PMCID: PMC8859015 DOI: 10.1186/s40792-022-01388-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 02/16/2022] [Indexed: 11/30/2022] Open
Abstract
Background Intracholecystic papillary neoplasm (ICPN) of the gallbladder is a rare tumor and a relatively new concept. Therefore, the natural history and imaging characteristics of ICPN have not yet been fully documented. Moreover, cases who underwent curative resection for remnant gallbladder cancer, including ICPN with associated invasive carcinoma, have been rarely reported. We report a resected case of ICPN of the remnant gallbladder with associated invasive carcinoma for which we could observe a temporal change in imaging findings until malignant transformation. Case presentation A 79-year-old female patient with a surgical history of subtotal cholecystectomy for acute cholecystitis was an ambulatory patient of our institution because of postoperative surveillance for colon cancer. Ultrasonography and computed tomography incidentally detected a small nodule in the cystic remnant gallbladder. The nodule had increased in size 3 months later; thus, additional investigations were performed. Magnetic resonance imaging revealed a 10-mm enhanced nodule without evidence of extraluminal invasion. Diffusion-weighted magnetic resonance imaging revealed restricted diffusion of the lesion, and positron emission tomography revealed marked accumulation in the lesion. The lesion was diagnosed as suspicious for a malignant remnant gallbladder tumor. Therefore, remnant cholecystectomy with gallbladder bed resection was performed. Because preoperative endoscopic retrograde cholangiography revealed a relatively long intact cystic duct, extrahepatic bile duct resection was planned to be omitted. Intraoperatively, the hepatic and duodenal side bile duct where the cystic duct diverged was taped. Using these tapes, which permitted pulling the bile duct, the cystic duct located behind the bile duct could be safely exposed. The lesion was pathologically diagnosed as biliary morphologic ICPN with associated invasive carcinoma. Conclusions Because remnant cholecystectomy is an uncommon procedure and technically difficult, accurate preoperative investigation and surgical planning are important to prevent bile duct injury and omit extrahepatic bile duct resection. In the present case, intracystic change could be detected incidentally at an early stage because of previous remnant gallbladder producing (reconstituting) subtotal cholecystectomy and surveillance for other disease. This case suggests the existence of ICPN that can progress to invasive carcinoma during a short period.
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Affiliation(s)
- Yusuke Watanabe
- Department of Surgery, Hamanomachi Hospital, 3-3-1, Nagahama, Chuo-ku, Fukuoka, 810-8539, Japan.
| | - Naoki Mochidome
- Department of Surgery, Hamanomachi Hospital, 3-3-1, Nagahama, Chuo-ku, Fukuoka, 810-8539, Japan
| | - Hiromichi Nakayama
- Department of Surgery, Hamanomachi Hospital, 3-3-1, Nagahama, Chuo-ku, Fukuoka, 810-8539, Japan
| | - Yoshitaka Gotoh
- Department of Surgery, Hamanomachi Hospital, 3-3-1, Nagahama, Chuo-ku, Fukuoka, 810-8539, Japan
| | - Taro Setoguchi
- Department of Radiology, Hamanomachi Hospital, 3-3-1, Nagahama, Chuo-ku, Fukuoka, 810-8539, Japan
| | - Shunya Sunami
- Department of Radiology, Hamanomachi Hospital, 3-3-1, Nagahama, Chuo-ku, Fukuoka, 810-8539, Japan
| | - Reiko Yoneda
- Department of Pathology, Hamanomachi Hospital, 3-3-1, Nagahama, Chuo-ku, Fukuoka, 810-8539, Japan
| | - Yurina Ochiai
- Department of Surgery, Hamanomachi Hospital, 3-3-1, Nagahama, Chuo-ku, Fukuoka, 810-8539, Japan
| | - Kimihisa Mizoguchi
- Department of Surgery, Hamanomachi Hospital, 3-3-1, Nagahama, Chuo-ku, Fukuoka, 810-8539, Japan
| | - Hirofumi Yamamoto
- Department of Surgery, Hamanomachi Hospital, 3-3-1, Nagahama, Chuo-ku, Fukuoka, 810-8539, Japan
| | - Takashi Ueki
- Department of Surgery, Hamanomachi Hospital, 3-3-1, Nagahama, Chuo-ku, Fukuoka, 810-8539, Japan
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Morant T, Klier T, Nüssler NC. [Measures for preventing bile duct injuries during difficult cholecystectomies-Bail-out procedures]. Chirurg 2022; 93:548-553. [PMID: 35138419 DOI: 10.1007/s00104-022-01582-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Cholecystectomies can sometimes be very complex operations, which place high demands on the surgeon. OBJECTIVE Are there preoperative and intraoperative procedures available for reducing the risk of intraoperative bile duct injuries during a complex cholecystectomy? RESULTS The complexity of the operation should be estimated preoperatively. Extended diagnostic examinations, preoperative biliary stenting and the performance of the operation by an experienced surgeon may help to reduce the operative risk. In high-risk patients, postponing the cholecystectomy may be indicated. The timely intraoperative recognition of the impossibility to perform a regular cholecystectomy is of decisive importance. In this situation, so-called bail-out procedures, such as fundus-down cholecystectomy or subtotal cholecystectomy are warranted. Conversion from laparoscopic to open surgery is not always necessary. CONCLUSION Bail-out procedures are useful to reduce the risk of bile duct injuries during complex cholecystectomy and can enable a safe completion of the operation.
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Affiliation(s)
- Tanja Morant
- Klinik für Allgemein- und Viszeralchirurgie, München Klinik Neuperlach, München, Deutschland
| | - Thomas Klier
- Klinik für Allgemein- und Viszeralchirurgie, München Klinik Neuperlach, München, Deutschland
| | - Natascha C Nüssler
- Klinik für Allgemein- und Viszeralchirurgie, München Klinik Neuperlach, München, Deutschland. .,München Klinik Neuperlach, Oskar-Maria-Graf-Ring 51, 81737, München, Deutschland.
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Jenner DC, Klimovskij M, Nicholls M, Bates T. Occlusion of the cystic duct with cyanoacrylate glue at laparoscopic subtotal fenestrating cholecystectomy for a difficult gallbladder. Acta Chir Belg 2022; 122:23-28. [PMID: 33210557 DOI: 10.1080/00015458.2020.1846937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND Subtotal cholecystectomy is occasionally the management of choice in the patient with a hostile Calot's triangle but when it is not considered safe to close the cystic duct this often leads to a biliary fistula. In order to reduce this morbidity a novel strategy to seal the cystic duct with cyanoacrylate glue was introduced. The outcome of the two strategies have been compared. METHODS Patients who had a laparoscopic subtotal cholecystectomy where the cystic duct was left open, the Unsecured group, were compared with those where the duct orifice was occluded with cyanoacrylate glue, the Glued group. The outcome of the two strategies have been compared by duration of biliary drainage, whether a leak was shown on ERCP, time to removal of the drain, length of hospital stay, the re-operation and readmission rates. RESULTS In 78 cases of laparoscopic subtotal cholecystectomy it was considered unsafe to close the cystic duct. 36 patients were managed without closure of the cystic duct, the Unsecured group and bile drainage continued for more than 3 days in 9 cases (25%) compared with 3 of 42 cases (7%) treated with glue, the Glued group (NS). Postoperative ERCP demonstrated a leak more frequently in the Unsecured group (p < 0.02). The length of stay was reduced in the Glued group. (0.9 compared with 3.0 days, p < 0.01). CONCLUSION The results suggest that glue may be a safe option to occlude the cystic duct orifice and reduce hospital stay when this cannot safely be closed at subtotal cholecystectomy.
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Affiliation(s)
| | | | | | - Tom Bates
- Centre for Professional Practice, University of Kent, Kent, UK
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The effect of surgical strategy in difficult cholecystectomy cases on postoperative complications outcome: a value-based healthcare comparative study. Surg Endosc 2022; 36:5293-5302. [PMID: 35000001 DOI: 10.1007/s00464-021-08907-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/21/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND In patients undergoing laparoscopic cholecystectomy (LC) for complicated biliary disease, complication rates increase up to 30%. The aim of this study is to assess the effect of differences in surgical strategy comparing outcome data of two large volume hospitals. METHODS A prospective database was created for all the patients who underwent a LC in two large volume hospitals between January 2017 and December 2018. In cases of difficult cholecystectomy in clinic A, regular LC or conversion were surgical strategies. In clinic B, laparoscopic subtotal cholecystectomy was performed as an alternative in difficult cases. The difficulty of the cholecystectomy (score 1-4) and surgical strategy (regular LC, subtotal cholecystectomy, conversion) were scored. Postoperative complications, reinterventions, and ICU admission were assessed. For predicting adverse postoperative complication outcomes, uni- and multivariable analyses were used. RESULTS A total of 2104 patients underwent a LC in the study period of which 974 were from clinic A and 1130 were from clinic B. In total, 368 procedures (17%) were scored as a difficult cholecystectomy. In clinic A, more conversions were performed (4.4%) compared to clinic B (1.0%; p < 0.001). In clinic B, more subtotal laparoscopic cholecystectomies were performed (1.8%) compared to clinic A (0%; p = < 0.001). Overall complication rate was 8.2% for clinic A and 10.2% for clinic B (p = 0.121). Postoperative complication rates per group for regular LC, conversion, and subtotal cholecystectomy in difficult cholecystectomies were 45 (15%), 12 (24%), and 7 (35%; p = 0.035), respectively. The strongest predictor for Clavien-Dindo grade 3-5 complication was subtotal cholecystectomy. CONCLUSION Surgical strategy in case of a difficult cholecystectomy seems to have an important impact on postoperative complication outcome. The effect of a subtotal cholecystectomy on complications is of great concern.
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Patient and surgeon factors contributing to bailout cholecystectomies: a single-institutional retrospective analysis. Surg Endosc 2022; 36:6696-6704. [PMID: 34981223 DOI: 10.1007/s00464-021-08942-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/06/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomies continue to pose trouble for surgeons in the face of severe inflammation. In the advent of inability to perform an adequate dissection, a "bailout cholecystectomy" is advocated. Conversion to open or subtotal cholecystectomy is among the standard bailout procedures in such instances. METHODS We performed a retrospective single institution review from January 2016 to August 2019. All patients who underwent a cholecystectomy were included, while those with a concurrent operation, malignancy, planned as an open cholecystectomy, or performed by a low volume surgeon were excluded. Patient characteristics, operative reports, and outcomes were collected, as were surgeon characteristics such as years of experience, case volume, and bailout rate. Univariable and multivariable analysis were performed. RESULTS 2458 (92.6%) underwent laparoscopic total cholecystectomy (LTC) and 196 (7.4%) underwent a bailout cholecystectomy (BOC). BOC patients tended to be older (p < 0.001), male (p < 0.001), have a longer duration of symptoms (p < 0.001), and higher ASA class (p < 0.001). They also had more signs of biliary inflammation, as evidenced by increased leukocytosis (p < 0.001), tachycardia (p < 0.001), bilirubinemia (p = 0.003), common bile duct dilation (p < 0.001), and gallbladder wall thickening (p < 0.001). The BOC cohort also had increased rates of complications, including bile leak (16%, p < 0.001), retained stone (5.1%, p = 0.005), operative time (114 min vs 79 min, p < 0.001), and secondary interventions (22.7%, p < 0.001). Male gender (aOR = 2.8, p < 0.001), preoperative diagnosis of acute cholecystitis (aOR = 2.2, p = 0.032), right upper quadrant tenderness (aOR = 3.0, p = 0.008), Asian race (aOR = 2.7, p = 0.014), and intraoperative adhesions (aOR = 13.0, p < 0.001) were found to carry independent risk for BOC. Surgeon bailout rate ≥ 7% was also found to be an independent risk factor for conversion to BOC. CONCLUSIONS Male gender, signs of biliary inflammation (tachycardia, leukocytosis, dilated CBD, and diagnosis of acute cholecystitis), as well as surgeon bailout rate of 7% were independent risk factors for BOC.
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Acher AW, Rahnemai-Azar AA, Weber SM, Pawlik TM. Surgical Approach to Pancreas, Liver, Biliary Physiologic Impairment. THE IASGO TEXTBOOK OF MULTI-DISCIPLINARY MANAGEMENT OF HEPATO-PANCREATO-BILIARY DISEASES 2022:31-49. [DOI: 10.1007/978-981-19-0063-1_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Abstract
Laparoscopic cholecystectomy is a common operation; approximately 20 million Americans have gallstones, the most common indication. Surgeons who operate on the biliary tree must be familiar with the presentations and treatment options for acute and chronic biliary pathology. We focus on the difficult "bad" gallbladder. We explore the available evidence as to what to do when a gallbladder is too inflamed, too technically challenging, or a patient is too sick to undergo standard laparoscopic cholecystectomy. We discuss whether or not open cholecystectomy is a relevant tool and what can be done to manage common bile duct stones found unexpectedly intraoperatively.
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Affiliation(s)
- Miloš Buhavac
- Texas Tech University Health Sciences Center, Department of Surgery, 3601 4th Street, Lubbock, TX 79430, USA.
| | - Ali Elsaadi
- Texas Tech University Health Sciences Center, Department of Surgery, 3601 4th Street, Lubbock, TX 79430, USA
| | - Sharmila Dissanaike
- Texas Tech University Health Sciences Center, Department of Surgery, 3601 4th Street, Lubbock, TX 79430, USA
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Chávez-Villa M, Dominguez-Rosado I, Figueroa-Méndez R, De Los Santos-Pérez A, Mercado MA. Subtotal Cholecystectomy After Failed Critical View of Safety Is an Effective and Safe Bail Out Strategy. J Gastrointest Surg 2021; 25:2553-2561. [PMID: 33532977 DOI: 10.1007/s11605-021-04934-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 01/16/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Bile duct injury (BDI) is accompanied by significant morbidity and long-term impact in quality of life. Subtotal cholecystectomy (STC) is an alternative to prevent this outcome but is associated with other complications. The aim of this work is to demonstrate that BDI associated morbidity exceeds STC associated morbidity, underscoring STC as a reasonable bail out strategy. METHODS We compared 115 patients who underwent STC with 293 patients who were referred to our center with BDI type E1-E3 and underwent surgical repair. The groups were comparable because in both instances the surgeon had the opportunity to decide not to perform a total cholecystectomy once critical view of safety (CVS) was not achieved. RESULTS Bile leakage was found in 21% of the STC group with only one BDI (0.9%). More Accordion ≥ 4 were found in the STC group (10.4% vs 4.8%, p = 0.035); however, reoperations were more frequent in the BDI group (8.2% vs 0.9%, p = 0.006). No patient in the STC group required reintervention for completion cholecystectomy. After 3.8 years follow-up, 2.4% of patients had secondary biliary cirrhosis in the BDI group; none in the STC group. CONCLUSIONS Despite complications of STC, morbidity associated with BDI is much higher due to high long-term reoperation rate, in addition to secondary biliary cirrhosis. STC is a safe alternative that can prevent BDI if properly and timely performed in the context of difficult cholecystectomy.
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Affiliation(s)
- Mariana Chávez-Villa
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ismael Dominguez-Rosado
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
| | - Rodrigo Figueroa-Méndez
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Sección XVI, 14080, Tlalpan, Mexico City, México
| | - Aldair De Los Santos-Pérez
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Miguel Angel Mercado
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Toro A, Teodoro M, Khan M, Schembari E, Di Saverio S, Catena F, Di Carlo I. Subtotal cholecystectomy for difficult acute cholecystitis: how to finalize safely by laparoscopy-a systematic review. World J Emerg Surg 2021; 16:45. [PMID: 34496916 PMCID: PMC8424983 DOI: 10.1186/s13017-021-00392-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/28/2021] [Indexed: 01/11/2023] Open
Abstract
Background Aim of this study was to clarify the best laparoscopic subtotal cholecystectomy (LSTC) technique for finalizing a difficult cholecystectomy.
Patients and methods A review was performed (1987–2021) searching "difficulty cholecystectomy" AND/OR "subtotal cholecystectomy". The LSTC techniques considered were as follows: type A, leaving posterior wall attached to the liver and the remainder of the gallbladder stump open; type B, like type A but with the stump closed; type C, resection of both the anterior and posterior gallbladder walls and the stump closed; type D, like type C but with the stump open. Morbidity (including mortality) was analysed with Dindo–Clavien classification. Results Nineteen articles were included. Of the 13,340 patients screened, 678 (8.2%) had cholecystectomy finalized by LSTC: 346 patients (51.0%) had type A LSTC, 134 patients (19.8%) had type B LSTC, 198 patients (29.2%) had type C LSTC, and 198 patients (0%) had type D LSTC. Bile leakage was found in 83 patients (12.2%), and recorded in 58 patients (69.9%) treated by type A. Twenty-three patients (3.4%) developed a subhepatic collection, 19 of whom (82.6%) were treated by type A. Other complications were reported in 72 patients (10.6%). The Dindo–Clavien classification was four for grade I, 27 for grade II, 126 for grade IIIa, 18 for grade IIIb, zero for grade IV and three for grade V. Conclusion In the case of LSTC, closure of the gallbladder stump represents the best method to avoid complications. Careful exploration of the gallbladder stump is mandatory, washing the abdominal cavity and leaving drainage.
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Affiliation(s)
- Adriana Toro
- General Surgery, Augusta Hospital, Siracusa, Italy
| | | | - Mansoor Khan
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Elena Schembari
- Department of General Surgery, Whipps Cross University Hospital-Barts Health NHS Trust, London, UK
| | | | - Fausto Catena
- Emergency and Trauma Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies "G.F. Ingrassia", Cannizzaro Hospital, University of Catania, Via Messina 829, 95126, Catania, Italy.
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Lunevicius R, Haagsma JA. Subtotal Cholecystectomy: Results of a Single-Center, Registry-Based Retrospective Cohort Study of 180 Adults in 2011–2018. J Laparoendosc Adv Surg Tech A 2021; 31:1019-1033. [DOI: 10.1089/lap.2020.0713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Raimundas Lunevicius
- Department of General Surgery, Liverpool University Hospitals NHS Foundation Trust, School of Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Juanita A. Haagsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
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Falciform Patch for Laparoscopic Subtotal Cholecystectomy to Decrease Biliary Fistulas: A Technique Review. Ann Surg 2021; 273:e278-e279. [PMID: 33630433 DOI: 10.1097/sla.0000000000004827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Comment on "Falciform Patch for Laparoscopic Subtotal Cholecystectomy to Decrease Biliary Fistulas: A Technical Review". Ann Surg 2021; 273:e280. [PMID: 33651723 DOI: 10.1097/sla.0000000000004833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wang SY, Yeh CN, Jan YY, Chen MF. Management of Gallstones and Acute Cholecystitis in Patients with Liver Cirrhosis: What Should We Consider When Performing Surgery? Gut Liver 2021; 15:517-527. [PMID: 32921635 PMCID: PMC8283297 DOI: 10.5009/gnl20052] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 06/19/2020] [Accepted: 07/27/2020] [Indexed: 02/06/2023] Open
Abstract
Acute cholecystitis and several gallbladder stone-related conditions, such as impacted common bile duct stones, cholangitis, and biliary pancreatitis, are common medical conditions in daily practice. An early cholecystectomy or drainage procedure with delayed cholecystectomy is the current standard of treatment based on published clinical guidelines. Cirrhosis is not only a condition of chronically impaired hepatic function but also has systemic effects in patients. In cirrhotic individuals, several predisposing factors, including changes in the bile acid composition, increased nucleation of bile, and decreased motility of the gallbladder, contribute to the formation of biliary stones and the possibility of symptomatic cholelithiasis, which is an indication for surgical treatment. In addition to these predisposing factors for cholelithiasis, systemic effects and local anatomic consequences related to cirrhosis lead to anesthesiologic risks and perioperative complications in cirrhotic patients. Therefore, the treatment of the aforementioned biliary conditions in cirrhotic patients has become a challenging issue. In this review, we focus on cholecystectomy for cirrhotic patients and summarize the surgical indications, risk stratification, surgical procedures, and surgical outcomes specific to cirrhotic patients with symptomatic cholelithiasis.
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Affiliation(s)
- Shang Yu Wang
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chun Nan Yeh
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yi Yin Jan
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Miin Fu Chen
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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Tschuor C, Lyman WB, Passeri M, Salibi PN, Baimas-George M, Iannitti DA, Baker EH, Vrochides D, Martinie JB. Robotic-assisted completion cholecystectomy: A safe and effective approach to a challenging surgical scenario - A single center retrospective cohort study. Int J Med Robot 2021; 17:e2312. [PMID: 34261193 DOI: 10.1002/rcs.2312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/30/2021] [Accepted: 07/09/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Reoperation following a previous subtotal or aborted cholecystectomy presents a challenging surgical scenario that has traditionally required an open completion cholecystectomy. The aim of this study was to describe an institutional experience with a robotic-assisted approach to completion cholecystectomy. METHODS A database was retrospectively audited to identify all patients who underwent robotic-assisted cholecystectomy performed by two hepatopancreatobiliary surgeons at a single centre from 2010 to 2019. RESULTS Twenty six patients who underwent a robotic-assisted completion cholecystectomy were identified. Median operative time was 142 min (48-247 min) with a blood loss of 50 cc (0-500 cc). Minor complications (Clavien-Dindo ≤ II 90 days) occurred in three patients (11.5%) with no major complication or mortality reported. Median hospital length of stay was 1 day (0-6 days) with one patient readmitted. CONCLUSION This study represents to our knowledge the largest series of robotic-assisted completion cholecystectomies to date. The robotic approach appears to be a safe and effective procedure associated with a low morbidity and high success rate.
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Affiliation(s)
- Christoph Tschuor
- Division of HPB Surgery, Department of General Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA.,Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - William B Lyman
- Division of HPB Surgery, Department of General Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Michael Passeri
- Division of HPB Surgery, Department of General Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Patrick N Salibi
- Division of HPB Surgery, Department of General Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Maria Baimas-George
- Division of HPB Surgery, Department of General Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| | - David A Iannitti
- Division of HPB Surgery, Department of General Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Erin H Baker
- Division of HPB Surgery, Department of General Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of General Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| | - John B Martinie
- Division of HPB Surgery, Department of General Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
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de'Angelis N, Catena F, Memeo R, Coccolini F, Martínez-Pérez A, Romeo OM, De Simone B, Di Saverio S, Brustia R, Rhaiem R, Piardi T, Conticchio M, Marchegiani F, Beghdadi N, Abu-Zidan FM, Alikhanov R, Allard MA, Allievi N, Amaddeo G, Ansaloni L, Andersson R, Andolfi E, Azfar M, Bala M, Benkabbou A, Ben-Ishay O, Bianchi G, Biffl WL, Brunetti F, Carra MC, Casanova D, Celentano V, Ceresoli M, Chiara O, Cimbanassi S, Bini R, Coimbra R, Luigi de'Angelis G, Decembrino F, De Palma A, de Reuver PR, Domingo C, Cotsoglou C, Ferrero A, Fraga GP, Gaiani F, Gheza F, Gurrado A, Harrison E, Henriquez A, Hofmeyr S, Iadarola R, Kashuk JL, Kianmanesh R, Kirkpatrick AW, Kluger Y, Landi F, Langella S, Lapointe R, Le Roy B, Luciani A, Machado F, Maggi U, Maier RV, Mefire AC, Hiramatsu K, Ordoñez C, Patrizi F, Planells M, Peitzman AB, Pekolj J, Perdigao F, Pereira BM, Pessaux P, Pisano M, Puyana JC, Rizoli S, Portigliotti L, Romito R, Sakakushev B, Sanei B, Scatton O, Serradilla-Martin M, Schneck AS, Sissoko ML, Sobhani I, Ten Broek RP, Testini M, Valinas R, Veloudis G, Vitali GC, Weber D, Zorcolo L, Giuliante F, Gavriilidis P, Fuks D, Sommacale D. 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy. World J Emerg Surg 2021; 16:30. [PMID: 34112197 PMCID: PMC8190978 DOI: 10.1186/s13017-021-00369-w] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/18/2021] [Indexed: 12/16/2022] Open
Abstract
Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.
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Affiliation(s)
- Nicola de'Angelis
- Unit of Minimally Invasive and Robotic Digestive Surgery, General Regional Hospital "F. Miulli", Strada Prov. 127 Acquaviva - Santeramo Km. 4, 70021 Acquaviva delle Fonti BA, Bari, Italy. .,Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France.
| | - Fausto Catena
- Department of Emergency and Trauma Surgery of the University Hospital of Parma, Parma, Italy
| | - Riccardo Memeo
- Department of Hepato-Pancreatic-Biliary Surgery, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Department, Pisa University Hospital, Pisa, Italy
| | - Aleix Martínez-Pérez
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Oreste M Romeo
- Trauma, Burn, and Surgical Care Program, Bronson Methodist Hospital, Kalamazoo, Michigan, USA
| | - Belinda De Simone
- Service de Chirurgie Générale, Digestive, et Métabolique, Centre hospitalier de Poissy/Saint Germain en Laye, Saint Germain en Laye, France
| | - Salomone Di Saverio
- Department of Surgery, Cambridge University Hospital, NHS Foundation Trust, Cambridge, UK
| | - Raffaele Brustia
- Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Rami Rhaiem
- Department of HBP and Digestive Oncologic Surgery, Robert Debré University Hospital, Reims, France
| | - Tullio Piardi
- Department of HBP and Digestive Oncologic Surgery, Robert Debré University Hospital, Reims, France.,Department of Surgery, HPB Unit, Troyes Hospital, Troyes, France
| | - Maria Conticchio
- Department of Hepato-Pancreatic-Biliary Surgery, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Francesco Marchegiani
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Nassiba Beghdadi
- Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Ruslan Alikhanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Shosse Enthusiastov, 86, 111123, Moscow, Russia
| | | | - Niccolò Allievi
- 1st Surgical Unit, Department of Emergency, Papa Giovanni Hospital XXIII, Bergamo, Italy
| | - Giuliana Amaddeo
- Service d'Hepatologie, APHP, Henri Mondor University Hospital, Creteil, and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Luca Ansaloni
- General Surgery, San Matteo University Hospital, Pavia, Italy
| | | | - Enrico Andolfi
- Department of Surgery, Division of General Surgery, San Donato Hospital, 52100, Arezzo, Italy
| | - Mohammad Azfar
- Department of Surgery, Al Rahba Hospital, Abu Dhabi, UAE
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Amine Benkabbou
- Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco
| | - Offir Ben-Ishay
- Department of General Surgery, Rambam Healthcare Campus, Haifa, Israel
| | - Giorgio Bianchi
- Unit of Minimally Invasive and Robotic Digestive Surgery, General Regional Hospital "F. Miulli", Strada Prov. 127 Acquaviva - Santeramo Km. 4, 70021 Acquaviva delle Fonti BA, Bari, Italy
| | - Walter L Biffl
- Division of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Francesco Brunetti
- Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | | | - Daniel Casanova
- Hospital Universitario Marqués de Valdecilla, University of Cantabria, Santander, Spain
| | - Valerio Celentano
- Colorectal Unit, Chelsea and Westminster Hospital, NHS Foundation Trust, London, UK
| | - Marco Ceresoli
- Emergency and General Surgery Department, University of Milan Bicocca, Milan, Italy
| | - Osvaldo Chiara
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Roberto Bini
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Raul Coimbra
- Riverside University Health System Medical Center, Comparative Effectiveness and Clinical Outcomes Research Center - CECORC and Loma Linda University School of Medicine, Loma Linda, USA
| | - Gian Luigi de'Angelis
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesco Decembrino
- Gastroenterology and Endoscopy Unit, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Andrea De Palma
- General, Emergency and Trauma Department, Pisa University Hospital, Pisa, Italy
| | - Philip R de Reuver
- Department of Surgery, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - Carlos Domingo
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | | | - Alessandro Ferrero
- Department of General and Oncological Surgery, Azienda Ospedaliera Ordine Mauriziano "Umberto I", Turin, Italy
| | - Gustavo P Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP, Brazil
| | - Federica Gaiani
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Federico Gheza
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Gurrado
- Unit of General Surgery "V. Bonomo", Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Ewen Harrison
- Department of Clinical Surgery and Centre for Medical Informatics, Usher Institute, University of Edinburgh, Little France Crescent, Edinburgh, UK
| | | | - Stefan Hofmeyr
- Division of Surgery, Surgical Gastroenterology Unit, Tygerberg Academic Hospital, University of Stellenbosch Faculty of Medicine and Health Sciences, Stellenbosch, South Africa
| | - Roberta Iadarola
- Department of Emergency and Trauma Surgery of the University Hospital of Parma, Parma, Italy
| | - Jeffry L Kashuk
- Department of Surgery, Tel Aviv University, Sackler School of Medicine, Tel Aviv, Israel
| | - Reza Kianmanesh
- Department of HBP and Digestive Oncologic Surgery, Robert Debré University Hospital, Reims, France
| | - Andrew W Kirkpatrick
- Department of Surgery, Critical Care Medicine and the Regional Trauma Service, Foothills Medical Center, Calgari, Alberta, Canada
| | - Yoram Kluger
- Department of General Surgery, Rambam Healthcare Campus, Haifa, Israel
| | - Filippo Landi
- Department of HPB and Transplant Surgery, Hospital Clínic, Universidad de Barcelona, Barcelona, Spain
| | - Serena Langella
- Department of General and Oncological Surgery, Azienda Ospedaliera Ordine Mauriziano "Umberto I", Turin, Italy
| | - Real Lapointe
- Department of HBP Surgery and Liver Transplantation, Department of Surgery, Centre Hospitalier de l'Université de Montreal, Montreal, QC, Canada
| | - Bertrand Le Roy
- Department of Digestive Surgery, University Hospital of Saint-Etienne, Saint-Priest-en-Jarez, France
| | - Alain Luciani
- Unit of Radiology, Henri Mondor University Hospital (AP-HP), Creteil, and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Fernando Machado
- Department of Emergency Surgery, Hospital de Clínicas, School of Medicine UDELAR, Montevideo, Uruguay
| | - Umberto Maggi
- General Surgery and Liver Transplantation Unit, Fondazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Alain Chichom Mefire
- Department of Surgery and Obstetrics/Gynecologic, Regional Hospital, Limbe, Cameroon
| | - Kazuhiro Hiramatsu
- Department of General Surgery, Toyohashi Municipal Hospital, Toyohashi, Aichi, Japan
| | - Carlos Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundacion Valle del Lili, Universidad del Valle Cali, Cali, Colombia
| | - Franca Patrizi
- Unit of Gastroenterology and Endoscopy, Maggiore Hospital, Bologna, Italy
| | - Manuel Planells
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Andrew B Peitzman
- Department of Surgery, UPMC, University of Pittsburg, School of Medicine, Pittsburg, USA
| | - Juan Pekolj
- General Surgery, Liver Transplant Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Fabiano Perdigao
- Liver Transplant Unit, APHP, Unité de Chirurgie Hépatobiliaire et Transplantation hépatique, Hôpital Pitié Salpêtrière, Paris, France
| | - Bruno M Pereira
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP, Brazil
| | - Patrick Pessaux
- Hepatobiliary and Pancreatic Surgical Unit, Visceral and Digestive Surgery, IHU mix-surg, Institute for Minimally Invasive Image-Guided Surgery, University of Strasbourg, Strasbourg, France
| | - Michele Pisano
- 1st Surgical Unit, Department of Emergency, Papa Giovanni Hospital XXIII, Bergamo, Italy
| | - Juan Carlos Puyana
- Trauma & Acute Care Surgery - Global Health, University of Pittsburgh, Pittsburgh, USA
| | - Sandro Rizoli
- Trauma and Acute Care Service, St Michael's Hospital, Toronto, ON, Canada
| | - Luca Portigliotti
- Chirurgia Epato-Gastro-Pancreatica, Azienda Ospedaliera-Universitaria Maggiore della Carità, Novara, Italy
| | - Raffaele Romito
- Chirurgia Epato-Gastro-Pancreatica, Azienda Ospedaliera-Universitaria Maggiore della Carità, Novara, Italy
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Behnam Sanei
- Department of Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Olivier Scatton
- Liver Transplant Unit, APHP, Unité de Chirurgie Hépatobiliaire et Transplantation hépatique, Hôpital Pitié Salpêtrière, Paris, France
| | - Mario Serradilla-Martin
- Instituto de Investigación Sanitaria Aragón, Department of Surgery, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Anne-Sophie Schneck
- Digestive Surgery Unit, Centre Hospitalier Universitaire de Guadeloupe, Pointe-À-Pitre, Les Avymes, Guadeloupe, France
| | - Mohammed Lamine Sissoko
- Service de Chirurgie, Hôpital National Blaise Compaoré de Ouagadougou, Ouagadougou, Burkina Faso
| | - Iradj Sobhani
- Department of Gastroenterology and Digestive Endoscopy, Henri Mondor Hospital, AP-HP, Creteil, and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Richard P Ten Broek
- Department of Surgery, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - Mario Testini
- Unit of General Surgery "V. Bonomo", Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Roberto Valinas
- Department of Surgery "F", Faculty of Medicine, Clinic Hospital "Dr. Manuel Quintela", Montevideo, Uruguay
| | | | - Giulio Cesare Vitali
- Division of Transplantation, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Dieter Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Luigi Zorcolo
- Department of Surgery, Colorectal Surgery Unit, University of Cagliari, Cagliari, Italy
| | - Felice Giuliante
- Hepatobiliary Surgery Unit, Foundation "Policlinico Universitario A. Gemelli", IRCCS, Rome, Italy
| | - Paschalis Gavriilidis
- Division of Gastrointestinal and HBP Surgery, Imperial College HealthCare, NHS Trust, Hammersmith Hospital, London, UK
| | - David Fuks
- Institut Mutualiste Montsouris, Paris, France
| | - Daniele Sommacale
- Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
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Nzenwa IC, Mesri M, Lunevicius R. Risks associated with subtotal cholecystectomy and the factors influencing them: A systematic review and meta-analysis of 85 studies published between 1985 and 2020. Surgery 2021; 170:1014-1023. [PMID: 33926707 DOI: 10.1016/j.surg.2021.03.036] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/05/2021] [Accepted: 03/12/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Subtotal cholecystectomy is recognized as a rescue procedure performed in grossly suboptimal circumstances that would deem a total cholecystectomy too risky to execute. An earlier systematic review based on 30 studies published between 1985 and 2013 concluded that subtotal cholecystectomy had a morbidity rate comparable to that of total cholecystectomy. This systematic review appraises 17 clinical outcomes in patients undergoing subtotal cholecystectomy. METHODS The study protocol was registered with the International Prospective Register for Systematic Reviews (CRD42020172808). MEDLINE, Embase, Cochrane bibliographic databases, and Google Scholar were used to identify papers published between 1985 and June 2020. Data related to the surgical setting, approach, intervention on the hepatic wall of the gallbladder, type of completion of subtotal cholecystectomy, year of study, and study design were collected. Seventeen clinical outcomes were considered. Meta-analyses were performed using a random-effects model, and the effect size was presented as risk ratios with 95% confidence intervals. RESULTS From 1,017 records, 85 eligible studies were identified and included. These included 3,645 patients who underwent subtotal cholecystectomy. Laparoscopic (80.1%, n = 2,918) and reconstituting (74.6%, n = 2,719) approaches represented the majority of all subtotal cholecystectomy cases. Seven (0.2%) cases of injury to the bile duct were reported. Bile leak was reported in 506 (13.9%) patients. Reconstituting subtotal cholecystectomy was associated with a lower risk for 11 clinical outcomes. Open subtotal cholecystectomy was associated with an increased rate of 30-day mortality and wound infections. CONCLUSION Subtotal cholecystectomy is associated with significant morbidity. Laparoscopic and reconstituting surgery may reduce the risks of some perioperative complications and long-term sequelae after subtotal cholecystectomy.
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Affiliation(s)
| | - Mina Mesri
- North West Schools of Surgery, Health Education England, Liverpool, United Kingdom
| | - Raimundas Lunevicius
- Department of General Surgery, Liverpool University Hospitals NHS Foundation Trust, United Kingdom.
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50
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Koo JGA, Chan YH, Shelat VG. Laparoscopic subtotal cholecystectomy: comparison of reconstituting and fenestrating techniques. Surg Endosc 2021; 35:1014-1024. [PMID: 33128079 DOI: 10.1007/s00464-020-08096-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 10/13/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Laparoscopic subtotal cholecystectomy (LSC) is a safe bailout procedure in situations when dissection of "critical view of safety" is not possible. After the proposed classification of subtotal cholecystectomy into "fenestrating" and "reconstituting" techniques in 2016, a comparative review of the outcomes of both methods is timely. METHODS A literature search of the PubMed, Cochrane Library, and Web of Science database was conducted up to January 31, 2020 for studies that reported LSC. Studies reporting LSC only in patients with Mirizzi syndrome or xanthogranulomatous cholecystitis were excluded. Our analysis includes 39 studies with 1784 cases of LSC. We report a comparison of outcomes between reconstituting and fenestrating LSC on 1505 cases [935 reconstituting (62.1%) and 570 fenestrating (37.9%)]. RESULTS Following LSC, the rate of open conversion is 7.7%, hemorrhage is 0.4%, bile duct injury is 0.3%, bile leak is 15.4%, retained stone is 4.6%, subhepatic or subphrenic collection is 2.9%, superficial surgical site infection is 2.0% and 30-day mortality is 0.2%. 8.8% of patients required postoperative endoscopic retrograde cholangiopancreatography (ERCP), 1.1% required percutaneous intervention, and 2.2% required reoperation. Compared to reconstituting LSC, fenestrating LSC has a higher incidence of open conversion (n = 58, 10.2% vs. n = 43, 4.6%, p < 0.001), retained stones (n = 38, 6.7% vs. n = 38, 4.1%, p = 0.0253), subhepatic or subphrenic collections (n = 33, 5.8% vs. n = 13, 1.4%, p < 0.001), superficial surgical site infections (n = 18, 3.2% vs. n = 14, 1.5%, p = 0.0303), postoperative ERCP (n = 82, 14.4% vs. n = 62, 6.6%, p < 0.001), and need for reoperation (n = 20, 3.5% vs. n = 12, 1.3%, p < 0.001). CONCLUSIONS Although reconstituting LSC has better outcomes, both techniques are complementary. Intraoperative findings and surgical expertise impact the choice.
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Affiliation(s)
- Jonathan G A Koo
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Vishal G Shelat
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
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