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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 DOI: 10.1016/j.amjsurg.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 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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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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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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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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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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Nationwide trends in the use of subtotal cholecystectomy for acute cholecystitis. Surgery 2020; 167:569-574. [DOI: 10.1016/j.surg.2019.11.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 10/16/2019] [Accepted: 11/02/2019] [Indexed: 12/24/2022]
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Mannino M, Toro A, Teodoro M, Coccolini F, Sartelli M, Ansaloni L, Catena F, Di Carlo I. Open conversion for laparoscopically difficult cholecystectomy is still a valid solution with unsolved aspects. World J Emerg Surg 2019; 14:7. [PMID: 30820240 PMCID: PMC6380008 DOI: 10.1186/s13017-019-0227-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 02/10/2019] [Indexed: 12/24/2022] Open
Abstract
The difficult laparoscopic cholecystectomy remains a surgical challenge for surgeons who must decide between laparoscopic continuation and open conversion. The balance between the lack of open surgery training of young surgeons and the risk of maintaining the laparoscopic approach in difficult laparoscopic cholecystectomy is still an unresolved problem. Furthermore, the time that must be spent in an attempt to complete laparoscopic surgery before conversion is still controversial. The authors in this letter discuss about these and other questions that still require an answer.
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Affiliation(s)
- M Mannino
- 1Department of Surgical Sciences and Advanced Technologies "GF Ingrassia", Cannizzaro Hospital, University of Catania, Via Messina, 829, 95126 Catania, Italy
| | - A Toro
- Department of Surgery, Augusta Hospital, Augusta, SR Italy
| | - M Teodoro
- 1Department of Surgical Sciences and Advanced Technologies "GF Ingrassia", Cannizzaro Hospital, University of Catania, Via Messina, 829, 95126 Catania, Italy
| | - F Coccolini
- 3General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - M Sartelli
- Department of Surgery, Macerata Hospital, Macerata, Italy
| | - L Ansaloni
- 3General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - F Catena
- 5Emergency Surgery, Parma Hospital, Parma, Italy
| | - I Di Carlo
- 1Department of Surgical Sciences and Advanced Technologies "GF Ingrassia", Cannizzaro Hospital, University of Catania, Via Messina, 829, 95126 Catania, Italy
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Navaratne L, Al-Musawi J, Mérida AA, Vilaça J, Isla AM. Trans-infundibular choledochoscopy: a method for accessing the common bile duct in complex cases. Langenbecks Arch Surg 2018; 403:777-783. [PMID: 30058037 DOI: 10.1007/s00423-018-1698-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/23/2018] [Indexed: 12/24/2022]
Abstract
PURPOSE During laparoscopic common bile duct exploration (LCBDE) where Calot's triangle cannot be safely dissected due to a 'frozen' hepatic hilum secondary to severe inflammation or fibrosis, the preferred transcystic approach to the common bile duct (CBD) is precluded. The aim of this paper is to describe a safe method of accessing the CBD via a trans-infundibular approach (TIA) in complex cases where conventional access to the cystic duct or CBD is denied. METHODS A retrospective review of 154 consecutive patients who underwent LCBDE at a single centre between 2014 and 2018 was performed. Outcomes of this study were successful access to the CBD to achieve choledochoscopy, successful stone clearance (when required), conversion to open surgery, total or subtotal cholecystectomy, post-operative complications, and length of hospital stay. RESULTS Nine (5.8%) patients underwent access to the CBD via TIA choledochoscopy. TIA-LCBDE resulted in a stone extraction rate of 86% with one patient requiring choledochotomy. There were zero conversions to open surgery, and total/near total cholecystectomy was achieved in all patients. One patient suffered a post-operative complication for bilateral atelectasis and lower respiratory tract infection. Median length of hospital stay was 3 days. CONCLUSIONS The use of a trans-infundibular approach to the CBD is indicated when the hepatic hilum is 'frozen' with severe inflammation and/or fibrosis precluding safe dissection of the critical structures within Calot's triangle. This strategy enables exploration of the CBD via the transcystic route without the need for critical view dissection or choledochotomy.
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Affiliation(s)
- Lalin Navaratne
- Department of Upper GI Surgery, Northwick Park Hospital and St Marks Hospitals, Watford Road, London, HA1 3UJ, UK.
| | - Jasim Al-Musawi
- Department of Upper GI Surgery, Northwick Park Hospital and St Marks Hospitals, Watford Road, London, HA1 3UJ, UK
| | - Asuncion Acosta Mérida
- Department of General Surgery, The Doctor Negrin University Hospital of Gran Canaria, Las Palmas, Spain
| | - Jaime Vilaça
- Department of Surgery, Hospital da Luz Oporto, Oporto, Portugal
| | - Alberto Martinez Isla
- Department of Upper GI Surgery, Northwick Park Hospital and St Marks Hospitals, Watford Road, London, HA1 3UJ, UK
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