Subtotal Cholecystectomy After Failed Critical View of Safety Is an Effective and Safe Bail Out Strategy

Laparoscopic subtotal cholecystectomy for the difficult gallbladder: Evolution of technique at a single teaching hospital

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.

Subtotal vs total cholecystectomy for difficult gallbladders: A systematic review and meta-analysis

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.

D-line Approach for Safe Laparoscopic Cholecystectomy: Initial Experience

Introduction The critical view of safety is an important concept for safe laparoscopic cholecystectomy. However, no standard step-by-step approach for achieving the critical view of safety has been established until now. Therefore, this study aims to evaluate a new approach for achieving the critical view of safety using the diagonal line of liver segment IV as an anatomical landmark. Patients and methods In this prospective non-randomized study, patients (n= 112) who underwent laparoscopic cholecystectomy for symptomatic cholelithiasis were included. The first 47 patients underwent laparoscopic cholecystectomy using the diagonal line approach (DLC group) whereas, the next 65 patients underwent laparoscopic cholecystectomy using the conventional method (CLC group).  Results No significant difference between both groups regarding the preoperative characteristics, operative time, and intraoperative blood loss. Laparoscopic subtotal cholecystectomy was performed more in the DLC group (6% vs 0%, p= 0.07). Whereas, in the CLC group, there was a tendency towards conversion to open cholecystectomy in difficult cases (6% vs 2%, p= 0.40). No intra- or postoperative complications occurred in either group.  Conclusion The diagonal line approach is a feasible and useful step-by-step technique to achieve the critical view of safety in laparoscopic cholecystectomy and enables surgeons to perform safe laparoscopic subtotal cholecystectomy in difficult cases.

Multiple logistic regression model to predict bile leak associated with subtotal cholecystectomy

BACKGROUND

There are no prediction models for bile leakage associated with subtotal cholecystectomy (STC). Therefore, this study aimed to generate a multivariable prediction model for post-STC bile leakage and evaluate its overall performance.

METHODS

We analysed prospectively managed data of patients who underwent STC by a single consultant surgeon between 14 May 2013 and 21 December 2021. STC was schematised into four variants with five subvariants and classified broadly as closed-tract or open-tract STC. A contingency table was used to detect independent risk factors for bile leakage. A multiple logistic regression analysis was used to generate a model. Discrimination and calibration statistics were computed to assess the accuracy of the model.

RESULTS

A total of 81 patients underwent the STC procedure. Twenty-eight patients (35%) developed bile leakage. Of these, 18 patients (64%) required secondary surgical intervention. Multivariable logistic regression revealed two independent predictors of post-STC bile leak: open-tract STC (odds ratio [OR], 7.07; 95% confidence interval [CI], 2.191-25.89; P = 0.0170) and acute cholecystitis (OR, 5.449; 95% CI, 1.584-23.48; P = 0.0121). The area under the receiver-operating characteristic curve was 82.11% (95% CI, 72.87-91.34; P < 0.0001). Tjur's pseudo-R² was 0.3189 and the Hosmer-Lemeshow goodness-of-fit statistic was 4.916 (P = 0.7665).

CONCLUSIONS

Open-tract STC and acute cholecystitis are the most reliable predictors of bile leakage associated with STC. Future prospective, multicentre studies with higher statistical power are needed to generate more specific and externally validated prediction models for post-STC bile leaks.

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'

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.

State of the art in subtotal cholecystectomy: An overview

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.

Thinking Your Way Through a Difficult Laparoscopic Cholecystectomy: Technique for High-Quality Subtotal Cholecystectomy

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).

Efficacy of bailout surgery for preventing intraoperative biliary injury in acute cholecystitis

BACKGROUND

Bailout surgery (BOS; partial cholecystectomy, open conversion, and fundus-first approach) has been recommended for difficult cases to ensure safe performance of cholecystectomy. However, the efficacy of BOS for preventing intraoperative massive bleeding and bile duct injury (BDI) remains unclear, especially in the context of acute cholecystitis (AC). This study aimed to retrospectively validate the feasibility of BOS for AC.

METHODS

We enrolled 479 patients who underwent emergency cholecystectomies for AC between 2011 and 2021. Univariate and multivariate analyses were performed to detect the risk factors for BOS in patients with AC. Perioperative variables were compared between patients who underwent total cholecystectomy (TC) and those who underwent BOS. Propensity score matching analysis was performed to compare the two groups.

RESULTS

Significant differences in American Society of Anesthesiologists physical status and Charlson Comorbidity Index scores, TG18 severity grading, white blood cell count, and albumin and C-reactive protein (CRP) levels were found between the TC and BOS groups. Preoperative CT imaging demonstrated severe inflammation evidenced by gallbladder wall thickness, enhancement of the liver bed, and duodenal edema in the BOS group compared to the TC group. Postoperative complications were significantly higher in the BOS group than in the TC group. Further, BDI was completely prevented by BOS. Multivariate analysis identified TG18 grade ≥ II, CRP ≥ 7.7, and duodenal edema as independent risk factors for BOS. After PSM analysis, postoperative complications were not worse in patients who underwent BOS rather than TC. Among BOS procedures, laparoscopic BOS (lap-BOS) was the most efficacious in preventing intraoperative blood loss and postoperative bile leakage.

CONCLUSION

Severity grading > II, elevated CRP levels, or duodenum edema revealed by CT were determined to be risk factors impeding total cholecystectomy. BOS is a safe, feasible, and efficacious procedure for preventing BDI. Among BOS procedures, lap-BOS showed better postoperative outcomes.

Preoperative risk score to predict subtotal cholecystectomy after gallbladder drainage for acute cholecystitis: Secondary analysis of data from a multi-institutional retrospective study (CSGO-HBP-017B)

INTRODUCTION

Subtotal cholecystectomy (STC) has become recognized as a "bailout procedure" to prevent bile duct injury in patients undergoing laparoscopic cholecystectomy (LC). Predictors of conversion to STC have not been identified because LC difficulty varies based on pericholecystic inflammation. We analyzed data from patients enrolled in a previously performed multi-institutional retrospective study of the optimal timing of LC after gallbladder drainage for acute cholecystitis (AC). These patients presumably had a considerable degree of pericholecystic inflammation.

METHODS

In total, 347 patients who underwent LC after gallbladder drainage for AC were analyzed to examine preoperative and perioperative factors predicting conversion to STC.

RESULTS

Three hundred patients underwent total cholecystectomy (TC) and 47 underwent conversion to STC. Eastern Cooperative Oncology Group Performance Status (ECOG PS) (P < .01), severity of cholecystitis (P = .04), previous history of treatment for common bile duct stones (CBDS) (P < .01), and surgeon experience (P = .03) were significantly associated with conversion to STC. Logistic regression analyses showed that ECOG PS (odds ratio 0.2; P < .0001) and previous history of treatment for CBDS (odds ratio 0.37; P = .0073) were independent predictors of conversion to STC. Our predictive risk score using these two variables suggested that a score ≥2 could discriminate between TC and STC (P < .0001).

CONCLUSION

Poor ECOG PS and previous history of treatment for CBDS were significantly associated with conversion to STC after gallbladder drainage for AC.