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Etherington MS, Handzel R, Ongchin M, Choudry MH, Tohme ST, Paniccia A, Lee KK, Zureikat A, Geller DA. Remnant completion cholecystectomy is on the rise: Don't three-putt it. HPB (Oxford) 2024; 26:1072-1074. [PMID: 38735816 DOI: 10.1016/j.hpb.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/19/2024] [Indexed: 05/14/2024]
Affiliation(s)
- Mark S Etherington
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert Handzel
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Melanie Ongchin
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - M Haroon Choudry
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Samer T Tohme
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alessandro Paniccia
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kenneth K Lee
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Amer Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David A Geller
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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2
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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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Jacoby H, Rayman S, Oliphant U, Nelson D, Ross S, Rosemurgy A, Sucandy I. Current Operative Approaches to the Diseased Gallbladder. Diagnosis and Management Updates for General Surgeons. Am Surg 2024; 90:122-129. [PMID: 37609924 DOI: 10.1177/00031348231198107] [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: 08/24/2023]
Abstract
Cholecystitis is a common diagnosis which requires management by general surgeons. Morbidity from cholecystitis is often life-threatening, especially in patients with underlying liver cirrhosis or other medical comorbidities. Diagnosis and management of this disease can vary among providers and hospitals. The decision to utilize a radiological or endoscopic temporizing maneuver in severe acute cholecystitis and the timing of later definitive cholecystectomy are relevant points of discussion within general surgery societies. In the last 5 years, the use of intraoperative ductal imaging by conventional vs fluorescence cholangiography had gained significant interest due to the widespread availability of indocyanine green. Finally, the operative strategies and how to manage intra-/postoperative complications are very important to optimizing patient outcomes. In this review paper, we discuss all treatment aspects of cholecystitis and provide updates in its management.
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Affiliation(s)
- Harel Jacoby
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
| | - Shlomi Rayman
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
| | - Uretz Oliphant
- Department of Surgery, Carle Foundation Hospital, Urbana, IL, USA
| | - Daniel Nelson
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Sharona Ross
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
| | | | - Iswanto Sucandy
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
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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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5
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Peng B, Jiao Y, Zhang Y, Li S, Chen S, Xu S, Gao P, Fan Y, Yu W. Bulbospinal nociceptive ON and OFF cells related neural circuits and transmitters. Front Pharmacol 2023; 14:1159753. [PMID: 37153792 PMCID: PMC10157642 DOI: 10.3389/fphar.2023.1159753] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/10/2023] [Indexed: 05/10/2023] Open
Abstract
The rostral ventromedial medulla (RVM) is a bulbospinal nuclei in the descending pain modulation system, and directly affects spinal nociceptive transmission through pronociceptive ON cells and antinociceptive OFF cells in this area. The functional status of ON and OFF neurons play a pivotal role in pain chronification. As distinct pain modulative information converges in the RVM and affects ON and OFF cell excitability, neural circuits and transmitters correlated to RVM need to be defined for an in-depth understanding of central-mediated pain sensitivity. In this review, neural circuits including the role of the periaqueductal gray, locus coeruleus, parabrachial complex, hypothalamus, amygdala input to the RVM, and RVM output to the spinal dorsal horn are discussed. Meanwhile, the role of neurotransmitters is concluded, including serotonin, opioids, amino acids, cannabinoids, TRPV1, substance P and cholecystokinin, and their dynamic impact on both ON and OFF cell activities in modulating pain transmission. Via clarifying potential specific receptors of ON and OFF cells, more targeted therapies can be raised to generate pain relief for patients who suffer from chronic pain.
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Affiliation(s)
- Bingxue Peng
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, Shanghai, China
| | - Yingfu Jiao
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, Shanghai, China
| | - Yunchun Zhang
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, Shanghai, China
| | - Shian Li
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, Shanghai, China
| | - Sihan Chen
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, Shanghai, China
| | - Saihong Xu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, Shanghai, China
| | - Po Gao
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, Shanghai, China
| | - Yinghui Fan
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, Shanghai, China
- *Correspondence: Yinghui Fan, ; Weifeng Yu,
| | - Weifeng Yu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, Shanghai, China
- *Correspondence: Yinghui Fan, ; Weifeng Yu,
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Huang H, Du D, Wang Z, Xie Y, Ni Z, Li X, Jin H. Application of Intraoperative Fluorescence Imaging with Indocyanine Green in the Difficult Gallbladder: A Comparative Study between Indocyanine Green-Guided Fluorescence Cholangiography and Conventional Surgery. J Laparoendosc Adv Surg Tech A 2022; 33:404-410. [PMID: 36577039 DOI: 10.1089/lap.2022.0467] [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: 12/29/2022] Open
Abstract
Background: In the difficult gallbladder, the rate of bile duct injury (BDI) remains high. To lessen iatrogenic biliary injury, we attempted to utilize indocyanine green (ICG)-guided fluorescence cholangiography during surgery to illuminate the extrahepatic biliary tract. Materials and Methods: According to admission criteria, 38 patients were diagnosed with difficult gallbladder and underwent percutaneous transhepatic gallbladder drainage (PTGBD). Consecutive patients who underwent ICG-assisted laparoscopic biliary surgery (n = 18, ICG group) or conventional laparoscopic biliary surgery (n = 20, white light [WL group) were enrolled in this study. ICG group received ICG fluorescent cholangiography via PTGBD tube during operation; 16 cases of laparoscopic cholecystectomy (LC) and 2 cases of LC plus laparoscopic common bile duct exploration (LC+LCBDE) were performed by fluorescent laparoscopy. In the WL group, 16 cases of LC, 1 case of laparoscopic subtotal cholecystectomy (LSC), and 3 cases of LC+LCBDE were performed under white light without ICG. Result: The biliary system was successfully established in the ICG group. Compared with the WL group, the anatomy of the Calot's triangle with severe abdominal adhesion or local inflammatory edema was more clearly displayed by fluorescence. Laparoscopic surgery was completed in both groups without conversion to laparotomy. There were no significant differences in surgery-related complications (P = .232) and postoperative hospital stay (P = .074) between the two groups. However, compared with the WL group, the ICG group had less intraoperative blood loss (P = .002) and shorter operation duration (P = .006). Conclusion: ICG fluorescence cholangiography has good clinical application value in the difficult gallbladder, which can avoid iatrogenic BDI, reduce surgery-related complications and intraoperative blood loss, and shorten the duration of surgery.
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Affiliation(s)
- Hai Huang
- Department of General Surgery, Hangzhou Hospital of Traditional Chinese Medicine, affiliated to Zhejiang Chinese Medicine University, Hangzhou, China
| | - Danwei Du
- Department of General Surgery, Hangzhou Hospital of Traditional Chinese Medicine, affiliated to Zhejiang Chinese Medicine University, Hangzhou, China
| | - Ziqiang Wang
- Department of Breast Armor Surgery, the First People's Hospital of Xiaoshan District, Hangzhou, China
| | - Yangyang Xie
- Department of General Surgery, Hangzhou Hospital of Traditional Chinese Medicine, affiliated to Zhejiang Chinese Medicine University, Hangzhou, China
| | - Zhongkai Ni
- Department of General Surgery, Hangzhou Hospital of Traditional Chinese Medicine, affiliated to Zhejiang Chinese Medicine University, Hangzhou, China
| | - Xiaowen Li
- Department of General Surgery, Hangzhou Hospital of Traditional Chinese Medicine, affiliated to Zhejiang Chinese Medicine University, Hangzhou, China
| | - Haimin Jin
- Department of General Surgery, Hangzhou Hospital of Traditional Chinese Medicine, affiliated to Zhejiang Chinese Medicine University, Hangzhou, China
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7
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Patel N, Jensen KK, Shaaban AM, Korngold E, Foster BR. Multimodality Imaging of Cholecystectomy Complications. Radiographics 2022; 42:1303-1319. [PMID: 35904983 DOI: 10.1148/rg.210106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cholecystectomy is one of the most common surgeries performed in the United States. Although complications are uncommon, the high incidence of this surgery means that a radiologist will likely encounter these complications in practice. Complications may arise in the immediate postoperative period or can be delayed for weeks, months, or years after surgery. Vague and nonspecific symptoms make clinical diagnosis challenging. As a result, multimodality imaging is important in postoperative evaluation. US and multidetector CT are the usual first-line imaging modalities. Hepatobiliary scintigraphy, SPECT/CT, and MRI with conventional or gadoxetate hepatobiliary contrast material are important and complementary modalities that are used for workup. The authors begin with a brief discussion of surgical technique and expected postoperative findings and then describe complications organized into four groups: (a) biliary complications, (b) stone-related complications, (c) iatrogenic complications, and (d) gallbladder complications. Biliary complications include bile leaks and bilomas, acute biliary obstruction, and biliary stricture. Stone-related complications include retained and recurrent stones and spillage of stones into the peritoneum. Iatrogenic complications include hemorrhage, vasculobiliary injury, arterial pseudoaneurysms, duodenal injury, and migration of clips. Gallbladder complications include recurrent cholecystitis after subtotal reconstituting cholecystectomy and unexpected gallbladder cancer. An invited commentary by Mullens and Ibrahim is available online. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Neel Patel
- From the Department of Diagnostic Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (N.P., K.K.J., E.K., B.R.F.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Kyle K Jensen
- From the Department of Diagnostic Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (N.P., K.K.J., E.K., B.R.F.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Akram M Shaaban
- From the Department of Diagnostic Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (N.P., K.K.J., E.K., B.R.F.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Elena Korngold
- From the Department of Diagnostic Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (N.P., K.K.J., E.K., B.R.F.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Bryan R Foster
- From the Department of Diagnostic Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (N.P., K.K.J., E.K., B.R.F.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
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8
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Boyd K, Bradley NA, Cannings E, Shearer C, Wadhawan H, Wilson MSJ, Crumley A. Laparoscopic subtotal cholecystectomy; change in practice over a 10-year period. HPB (Oxford) 2022; 24:759-763. [PMID: 34776369 DOI: 10.1016/j.hpb.2021.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/27/2021] [Accepted: 10/06/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic subtotal cholecystectomy is a recognised safe, alternative strategy when a critical view of safety cannot be obtained. This study audits the change in practice at a District General Hospital following the adoption of subtotal cholecystectomy in 2013. METHODS Retrospective case series included consecutive cholecystectomies over a ten-year period in a single institution. Cases were divided into subgroups based on operation date. Primary outcome was the proportion of patients undergoing laparoscopic total cholecystectomy, laparoscopic subtotal and laparoscopic converted to open cholecystectomy. Secondary outcomes included incidence of bile leak, complication rate, return to theatre, and length of stay. RESULTS There were 4217 cases: 1381 in Group A (pre-adoption of subtotal cholecystectomy 2009-2012), and 2836 in Group B (post-adoption of subtotal cholecystectomy 2013-2019). The rate of laparoscopic total cholecystectomy was higher in Group A than Group B (95.4% vs. 92.8%, p < 0.001). In the subtotal group (n = 114, 14 (12.3%) patients had bile leak, 6 (5.3%) underwent re-laparoscopy, and median length of stay was 2 days. CONCLUSION Laparoscopic subtotal cholecystectomy appears to be an acceptable alternative technique at this centre, reducing the rate of open conversion and length of stay, with a low reintervention rate for bile leak.
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Affiliation(s)
- Kirsten Boyd
- Department of General Surgery, Forth Valley Royal Hospital, Larbert, UK.
| | | | | | | | - Himanshu Wadhawan
- Department of General Surgery, Forth Valley Royal Hospital, Larbert, UK
| | | | - Andrew Crumley
- Department of General Surgery, Forth Valley Royal Hospital, Larbert, UK
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9
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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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10
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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: 6.7] [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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11
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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: 9.7] [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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Acar N, Acar T, Sür Y, Bağ H, Kar H, Yılmaz Bozok Y, Dilek ON. Is subtotal cholecystectomy safe and feasible? Short- and long-term results. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:263-271. [PMID: 33058478 DOI: 10.1002/jhbp.847] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/01/2020] [Accepted: 09/20/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cholecystectomy is one of the most commonly performed surgical procedures. However, it may result in some unpleasant conditions such as bile duct injury (BDI), bile leak, and vessel injury. Subtotal cholecystectomy (SC), which has been introduced as an alternative method for reducing the complication rates, has been reported to have lower risk of BDI when compared to total cholecystectomy. This study aimed to evaluate the indications for SC, its early and late complications and their management, and the risk factors affecting the bile leak. METHODS Fifty-seven patients who underwent SC were included in the study, and their medical records were retrospectively reviewed. RESULTS Thirty-three patients were male (57.9%) and the mean age was 64.84 ± 11.35 (range: 29-86). All patients had at least one episode of cholecystitis. Forty-seven (82.5%) patients underwent surgery under emergency conditions. Postoperative bile leak/fistula, surgical site infection, and fluid collection were developed in 12 (21.1%), eight (14%), and six (10.5%) patients, respectively. Leaving the remnant tissue pouch open, presence of comorbidity and emergency operative condition were found to increase the risk of leak development (P < .001). During the average follow-up of 49 months (range: 13-98), symptomatic choledocholithiasis, symptomatic gallstones in the remnant tissue, and incisional hernia were detected within the first year of surgery in three (5.3%), four (7%), and seven (12.3%) patients, respectively. CONCLUSIONS Although SC is not an equivalent to total cholecystectomy, its vital benefit of lowering the risk of BDI should be considered in difficult cases.
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Affiliation(s)
- Nihan Acar
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - Turan Acar
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - Yunus Sür
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - Halis Bağ
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - Haldun Kar
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - Yeliz Yılmaz Bozok
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - Osman Nuri Dilek
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
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