Outcomes of laparoscopic subtotal cholecystectomy: a comparative analysis of fenestrating and reconstituting approaches in 170 cases.

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.

Derivation and validation of a predictive model for subtotal cholecystectomy.

INTRODUCTION: Rates of subtotal cholecystectomy (STC) are increasing in response to challenging cases of laparoscopic cholecystectomy (LC) to avoid bile duct injury, yet are associated with significant morbidity. The present study identifies risk factors for STC and both derives and validates a risk model for STC. METHODS: LC performed for all biliary pathology across three general surgical units were included (2015-2020). Clinicopathological, intraoperative and post-operative details were reported. Backward stepwise multivariable regression was performed to derive the most parsimonious predictive model for STC. Bootstrapping was performed for internal validation and patients were categorised into risk groups. RESULTS: Overall, 2768 patients underwent LC (median age, 53 years; median ASA, 2; median BMI, 29.7 kg/m2), including 99 cases (3.6%) of STC. Post-operatively following STC, there were bile leaks in 29.3%, collections in 19.2% and retained stones in 10.1% of patients. Post-operative intervention was performed in 29.3%, including ERCP (22.2%), laparoscopy (5.0%) and laparotomy (3.0%). The following variables were positive predictors of STC and were included in the final model: age > 60 years, male sex, diabetes mellitus, acute cholecystitis (AC), increased severity of AC (CRP > 90 mg/L), ≥ 3 biliary admissions, pre-operative ERCP with/without stent, pre-operative cholecystostomy and emergency LC (AUC = 0.84). Low, medium and high-risk groups had a STC rate of 0.8%, 3.9% and 24.5%, respectively. DISCUSSION: The present study determines the morbidity of STC and identifies high-risk features associated with STC. A risk model for STC is derived and internally validated to help surgeons identify high-risk patients and both improve pre-operative decision-making and patient counselling.

Fenestrating vs reconstituting laparoscopic subtotal cholecystectomy: a systematic review and meta-analysis.

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.

Intraoperative imaging and management of common duct stones during subtotal cholecystectomy.

BACKGROUND: Subtotal cholecystectomy is advocated in patients with severe inflammation and distorted anatomy preventing safe removal of the entire gallbladder. Not well documented in this surgically complex population is the feasibility of intraoperative imaging and management of common bile duct (CBD) stones. We evaluated these operative maneuvers in our subtotal cholecystectomy patients. METHODS: We retrospectively reviewed all cholecystectomy cases from 2014 to 2023 at a single Veterans Affairs (VA) Medical Center using VASQIP (VA Surgical Quality Improvement Program), selecting subtotal cholecystectomy cases for detailed analysis. We reviewed operative reports, imaging and laboratory studies, and clinical notes to understand biliary imaging, stone management, complications, and late outcomes including retained stones (within 6 months), and recurrent stones (beyond 6 months). RESULTS: 419 laparoscopic (n = 406) and open (n = 13) cholecystectomies were performed, including 40 subtotal cholecystectomies (36 laparoscopic, 4 laparoscopic converted to open). Among these 40 patients IOC was attempted in 35 and completed in 26, with successful stone management in 11 (9 common bile duct exploration [CBDE], 2 intraoperative endoscopic retrograde cholangiopancreatography [ERCP]). In follow-up, 3 additional patients had CBD stones managed by ERCP, including 1 with a negative IOC and 2 without IOC. Thus, 14 (35%) of 40 patients had CBD stones. Of note, IOC permitted identification and oversewing or closure of the cystic duct in 32 patients. There were no major bile duct injuries and one cystic duct stump leak (2.5%) that resolved spontaneously. CONCLUSIONS: Subtotal cholecystectomy patients had a high incidence of bile duct stones, with most detected and managed intraoperatively with CBDE, making a strong argument for routine IOC and single-stage care. When intraoperative imaging is not possible, postoperative imaging should be considered. Routine imaging, biliary clearance, and cystic duct closure during subtotal cholecystectomy is feasible in most patients with low rates of retained stones and bile leaks.

Laparoscopic subtotal cholecystectomy outcomes across a low-and middle-income country metropolitan health service.

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.

The Rationale of sub-hepatic drainage on a specialist biliary unit: a review of 6140 elective and urgent laparoscopic cholecystectomies and bile duct explorations.

BACKGROUND: Drains are used to reduce abdominal collections after procedures where such risk exists. Using abdominal drains after cholecystectomy has been controversial since the open surgery era. Universally accepted indications and agreement exist that routine drainage is unnecessary but the role of selective drainage remains undetermined. This study evaluates the indications and benefits of sub-hepatic drainage in patients undergoing laparoscopic cholecystectomy (LC) and bile duct exploration (BDE) in a specialist unit with a large biliary emergency workload. METHODS: Prospectively collected data from 6,140 LCs with a 46.6% emergency workload over 30 years was reviewed. Demographic factors, pre-operative presentations, imaging and operative details in patients with and without drains were compared. Sub-hepatic drains were inserted after all transductal explorations, subtotal cholecystectomies, almost all open conversions and 94% of LC for empyemas. Adverse or beneficial postoperative drain-related outcomes were analysed. RESULTS: Abdominal drains were utilised in 3225/6140 (52.5%). Patients were significantly older with more males. 59.4% were emergency admissions. Preoperative imaging showed thick-walled gallbladders in 25.2% and bile duct stones or dilatation in 36.2%. At operation they had cystic duct stones in 19.8%, acute cholecystitis, empyema or mucocele in 28.4% and operative difficulty grades III or higher in 59%. 38% underwent BDE, 5.4% had fundus-first dissection and the operating times were longer ( 80 vs.45 min). Drain related complications were rare; 3 abdominal pains after anaesthetic recovery settling when drains were removed, 2 drain site infections and one re-laparoscopy to retrieve a retracted drain. 55.8% of 43 bile leaks and 35% of 20 other collections in patients with drains resolved spontaneously. CONCLUSIONS: The utilisation of drains in this study was relatively high due to the high emergency workload and interest in BDE. While drains allowed early detection of bile leakage, avoiding some complications and monitoring conservative management to allow early reinterventions, the study has identified operative criteria that could potentially limit drain insertion through a selective policy.

Standardization of a goal-oriented approach to acute cholecystitis: easy-to-follow steps for performing subtotal cholecystectomy.

BACKGROUND: A critical view of safety (CVS) is important to ensure safe laparoscopic cholecystectomy. When the CVS is not possible, subtotal cholecystectomy is performed. While considering subtotal cholecystectomy, surgeons are often concerned about preventing bile leakage from the cystic ducts. The two main types of subtotal cholecystectomy for acute cholecystitis are fenestrating and reconstituting. Previously, there were no selection criteria for these two; therefore, open conversion was performed. This study aimed to evaluate our goal-oriented approach to choose fenestrating or reconstituting subtotal cholecystectomy for acute cholecystitis. METHODS: We introduced our goal-oriented approach in April 2019. Before introducing this approach, laparoscopic cholecystectomy for acute cholecystitis was performed without criteria for subtotal cholecystectomy. After our approach was introduced, laparoscopic cholecystectomy for acute cholecystitis was performed according to the subtotal cholecystectomy criteria. We retrospectively reviewed the medical records of patients who underwent laparoscopic cholecystectomy for acute cholecystitis between 2015 and 2021. Laparoscopic cholecystectomy for acute cholecystitis was performed by surgeons regardless of whether they were novices or veterans. RESULTS: The period from April 2015 to March 2019 was before the introduction (BI) of our approach, the period from April 2019 to December 2021 was after the introduction (AI) of our approach. There were 177 and 186 patients with acute cholecystitis during the BI and AI periods, respectively. There were no significant differences between groups in terms of preoperative characteristics, operative time, and blood loss. No difference in the laparoscopic subtotal cholecystectomy rate between groups (10.2% [BI] vs. 13.9% [AI]; p = 0.266) was obserbed. The open conversion rate during the BI period was significantly higher than that during the AI period (7.4% vs. 1.6%; p = 0.015). CONCLUSIONS: Our goal-oriented approach is feasible, safe, and easy for many surgeons to understand.

Mirizzi syndrome: Problems and strategies.

Mirizzi syndrome is a serious complication of gallstone disease. It is caused by the impacted stones in the gallbladder neck or cystic duct. One of the features of Mirizzi syndrome is severe inflammation or dense fibrosis at the Calot's triangle. In our clinical practice, bile duct, branches of right hepatic artery and right portal vein clinging to gallbladder infundibulum are often observed due to gallbladder infundibulum adhered to right hepatic hilum. The intraoperative damage of branches of right hepatic artery occurs more easily than that of bile duct, all of which are hidden pitfalls for surgeons. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are the preferable tools for the diagnosis of Mirizzi syndrome. Anterograde cholecystectomy in Mirizzi syndrome is easy to damage branches of right hepatic artery and bile duct due to gallbladder infundibulum adhered to right hepatic hilum. Subtotal cholecystectomy is an easy, safe and definitive approach to Mirizzi syndrome. When combined with the application of ERCP, a laparoscopic management of Mirizzi syndrome by well-trained surgeons is feasible and safe. The objective of this review was to highlight its existing problems: (1) low preoperative diagnostic rate, (2) easy to damage bile duct and branches of right hepatic artery, and (3) high concomitant gallbladder carcinoma. Meanwhile, the review aimed to discuss the possible therapeutic strategies: (1) to enhance its preoperative recognition by imaging findings, and (2) to avoid potential pitfalls during surgery.

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.

Mirizzi Syndrome-The Past, Present, and Future.

Mirizzi syndrome is a complication of gallstone disease caused by an impacted gallstone in the infundibulum of the gallbladder or within the cystic duct, causing chronic inflammation and extrinsic compression of the common hepatic duct or common bile duct. Eventually, mucosal ulceration occurs and progresses to cholecystobiliary fistulation. Numerous systems exist to classify Mirizzi syndrome, with the Csendes classification widely adopted. It describes five types of Mirizzi syndrome according to the presence of a cholecystobiliary fistula and its corresponding severity, and whether a cholecystoenteric fistula is present. The clinical presentation of Mirizzi syndrome is non-specific, and patients typically have a longstanding history of gallstones. It commonly presents with obstructive jaundice, and can mimic gallbladder, biliary, or pancreatic malignancy. Achieving a preoperative diagnosis guides surgical planning and improves treatment outcomes. However, a significant proportion of cases of Mirizzi syndrome are diagnosed intraoperatively, and the presence of dense adhesions and distorted anatomy at Calot's triangle increases the risk of bile duct injury. Cholecystectomy remains the mainstay of treatment for Mirizzi syndrome, and laparoscopic cholecystectomy is increasingly becoming a viable option, especially for less severe stages of cholecystobiliary fistula. Subtotal cholecystectomy is feasible if total cholecystectomy cannot be performed safely. Additional procedures may be required, such as common bile duct exploration, choledochoplasty, and bilioenteric anastomosis. Conclusions: There is currently no consensus for the management of Mirizzi syndrome, as the management options depend on the extent of surgical pathology and availability of surgical expertise. Multidisciplinary collaboration is important to achieve diagnostic accuracy and guide treatment planning to ensure good clinical outcomes.

Patient and surgeon factors contributing to bailout cholecystectomies: a single-institutional retrospective analysis.

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.

Open conversion in laparoscopic cholecystectomy and bile duct exploration: subspecialisation safely reduces the conversion rates.

BACKGROUND: Open conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time. METHODS: Prospectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28 years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature. RESULTS: 28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%. CONCLUSION: Although open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies.

Cause and outcome of aborting a difficult laparoscopic cholecystectomy due to severe inflammation: a study of operative notes.

BACKGROUND: Upon encountering a difficult cholecystectomy in which, after a reasonable trial of dissection, anatomical identification has not been attained due to severe inflammation, and the risk of additional dissection is deemed to be hazardous, "bail-out" strategies are encouraged safety valves. One strategy is to abort the cholecystectomy and refer the patient to a HPB center for further management. METHODS: A retrospective review was conducted of cholecystectomies performed by HPB surgeons at our center between 2005 and 2019. We identified 63 patients who had an aborted cholecystectomy because of acute or chronic cholecystitis and were referred for additional care. Of these, operative notes and other clinical records were available for 43 patients who were included in this study. RESULTS: 42 cholecystectomies (98%) were started laparoscopically. 25 patients (58%) had chronic cholecystitis, and 18 (42%) had acute cholecystitis. 40 cases (93%) fell into the highest level of difficulty on the Nassar scale (Grade 4). Procedures were aborted at the following stages of dissection: in 10 patients (23%), none of the gallbladder was identified; in another 11 (26%), only the dome of gallbladder was identified; the body of the gallbladder was exposed in 13 (30%); and dissection of the hepatocystic triangle was attempted unsuccessfully in 9 (21%). Following referral to our center, 30 patients (70%) were managed with total cholecystectomy while in 13 cases (30%), subtotal cholecystectomy was performed. CONCLUSION: Aborting cholecystectomy and referring the patient to an HPB center is rarely needed but is an effective bail-out strategy for general surgeons encountering highly difficult operative conditions due to inflammation.

Efficacy of endoscopic gallbladder drainage in patients with acute cholecystitis.

BACKGROUND: Early cholecystectomy is recommended for patients with acute cholecystitis. However, emergency surgery may not be indicated due to complications and disease severity. Patients requiring drainage are usually treated with percutaneous transhepatic gallbladder drainage (PTGBD), whereas patients with biliary duct stones undergo endoscopic stones removal followed by endoscopic gallbladder drainage (EGBD). Herein, we investigated the efficacy of EGBD in patients with acute cholecystitis. METHODS: Overall, 101 patients receiving laparoscopic cholecystectomy between September 2019 and September 2020 in our department were retrospectively analyzed. RESULTS: The patients (n = 101) were divided into three groups: control group that did not undergo drainage (n = 68), a group that underwent EGBD (n = 7), and a group that underwent PTGBD (n = 26). Median surgery time was 107, 166, and 143 min, respectively. Control group had a significantly shorter surgery time, whereas it did not significantly differ between EGBD and PTGBD groups. The median amount of bleeding was 5 g, 7 g, and 7.5 g, respectively, and control group had significantly less bleeding than the drainage group. We further divided patients into the following subgroups: patients requiring a 5 mm clip to ligate the cystic duct, patients requiring a 10 mm clip due to the thickness of the cystic duct, patients requiring an automatic suturing device, and patients undergoing subtotal cholecystectomy due to impossible cystic duct ligation. There was no significant difference between EGBD and PTGBD regarding the clip used or the need for an automatic suturing device and subtotal cholecystectomy. CONCLUSIONS: There was no significant difference between EGBD and PTGBD groups regarding surgery time or bleeding amount when surgery was performed after gallbladder drainage for acute cholecystitis. Therefore, EGBD was considered a useful preoperative drainage method requiring no drainage bag.

The second 'gallbladder operation'.

Background: Subtotal cholecystectomy has been reported in 8% and 3.3% of patients undergoing open and laparoscopic cholecystectomy, respectively. According to a recent nationwide survey, the utilisation of subtotal cholecystectomy in the treatment of acute cholecystitis is on the rise. In 1.8% of subtotal cholecystectomies, a reoperation is required. Reoperations for residual gallbladder (GB), gallstones, and related complications accounted for half of the reoperations described in the literature after subtotal cholecystectomy. The purpose of this study was to evaluate the clinical profile, risk of complications, and feasibility of laparoscopic approaches and surgical procedures in patients with recurrent symptoms from a residual GB that necessitated a completion cholecystectomy. Methods: Patients who underwent surgery for residual GB with stones and/or complications between January 2007 and January 2020 were included in the study group. A prospectively maintained database was used to review patient information retrospectively. The demographic profile, operation details of the index surgery, current presentation, investigations performed, surgery details, morbidity and mortality were all included in the clinical information. Results: There were 13 patients who underwent completion cholecystectomy. The median age was 55 years (22-63 years). Prior operative notes mentioned subtotal cholecystectomy in only seven patients. The average time between the index surgery and the onset of symptoms was 30 months (2-175 months). A final diagnosis of residual GB with or without calculi was made by ultrasound (USG) in 11 patients and by magnetic resonance cholangiopancreatography (MRCP) in two others. Choledocholithiasis (n = 4, 30.7%), acute cholecystitis (n = 2, one with empyema and GB perforation) and Mirizzi syndrome (n = 1) were seen as complications of residual gallstones in seven patients. All 13 patients underwent successful laparoscopic procedures. A fifth port was used in all. A critical view of safety was achieved in 12 patients. Two patients required laparoscopic common bile duct (CBD) exploration for CBD stones. Intraoperative cholangiograms were done in eight patients (61.5%). There were no conversions, injuries to the bile duct or deaths. Morbidity was seen in one. The patient required therapeutic endoscopic retrograde cholangiography for cholangitis and CBD clearance on the fifth post-operative day. The median hospital stay was 4 days (3-7 days). At a median follow-up of 99 months, symptom resolution was seen in all 13 patients. Conclusion: Gallstones in the residual GB are associated with more complications than conventional gallstones. The diagnosis requires a high level of suspicion. MRCP is more accurate in establishing the diagnosis and identifying the associated complications, even if the diagnosis is made on USG in most patients. A pre-operative roadmap is provided by the MRCP. For patients with residual GB, laparoscopic completion cholecystectomy is a feasible and safe option.

Laparoscopic subtotal cholecystectomy: comparison of reconstituting and fenestrating techniques.

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.

Does preoperative MRCP imaging predict risk for conversion to subtotal cholecystectomy in patients with acute cholecystitis?

BACKGROUND: Subtotal cholecystectomy (SC) is a useful procedure for avoiding bile duct injury in patients with difficult gallbladder. However, risk factors for conversion to SC, especially preoperative magnetic resonance cholangiopancreatography (MRCP) findings that predict conversion to SC, have not been investigated in detail. METHODS: A total of 290 patients with acute cholecystitis who underwent laparoscopic cholecystectomy at our hospital between November 2011 and March 2020 were included. Patient characteristics and perioperative outcomes were reviewed, and preoperative clinical factors predicting conversion to SC were investigated. RESULTS: Forty-three patients underwent SC, whereas the remaining 247 patients underwent total cholecystectomy. An American Society of Anesthesiologists (ASA) score of 3 or greater (p = 0.011), surgery on or after 9 days from symptom onset (p < 0.001), obscuration of the gallbladder wall around the neck on MRCP images (p = 0.010) and disruption of the common hepatic duct on MRCP images (p < 0.001) were significantly associated with conversion to SC. Logistic regression analyses revealed that an ASA score of 3 or greater (odds ratio = 2.667, p = 0.020), surgery on or after 9 days from symptom onset (odds ratio = 4.229, p < 0.001) and disruption of the common hepatic duct on MRCP images (odds ratio = 4.478, p = 0.002) were independent predictors for conversion to SC. CONCLUSIONS: Early surgery yielded a lower risk for conversion to SC. Disruption of the common hepatic duct on preoperative MRCP images is associated with a risk for conversion to SC.

Less is more in the difficult gallbladder: recent evolution of subtotal cholecystectomy in a single HPB unit.

INTRODUCTION: Subtotal cholecystectomy (SC) is a technique to manage the difficult gallbladder and avoid hazardous dissection and biliary injury. Until recently it was used infrequently. However, because of reduced exposure to open total cholecystectomy in resident training, we recently adopted subtotal cholecystectomy as the bail-out procedure of choice for resident teaching. This study reports our experience and outcomes with subtotal cholecystectomy in the years immediately preceding adoption and since adoption. METHODS: A retrospective analysis was conducted of patients undergoing SC from July 2010 to June 2019. Outcomes, including bile leak, reoperation and need for additional procedures, were analyzed. Complications were graded by the Modified Accordion Grading Scale (MAGS). RESULTS: 1571 cholecystectomies were performed of which 71 were SC. Subtotal cholecystectomy patients had several indicators of difficulty including prior attempted cholecystectomy and previous cholecystostomy tube insertion. The most common indication for SC was marked inflammation in the hepatocystic triangle (51%). As our experience increased, fewer patients required open conversion to accomplish SC and SC was completed laparoscopically, usually subtotal fenestrating cholecystectomy (SFC). Most patients (85%) had a drain placed and 28% were discharged with a drain. The highest MAGS complication observed was grade 3 (11 patients, 15%). Six patients had a bile leak from the cystic duct resolved by ERCP. At mean follow-up of about 1 year no patient returned with recurrent symptoms. CONCLUSIONS: Subtotal fenestrating cholecystectomy is a useful technique to avoid biliary injury in the difficult gallbladder and can be performed with very satisfactory rates of bile fistula, ERCP, and reoperation.

Achieving the critical view of safety in the difficult laparoscopic cholecystectomy: a prospective study of predictors of failure.

BACKGROUND: Bile duct injury rates for laparoscopic cholecystectomy (LC) remain higher than during open cholecystectomy. The "culture of safety" concept is based on demonstrating the critical view of safety (CVS) and/or correctly interpreting intraoperative cholangiography (IOC). However, the CVS may not always be achievable due to difficult anatomy or pathology. Safety may be enhanced if surgeons assess difficulties objectively, recognise instances where a CVS is unachievable and be familiar with recovery strategies. AIMS AND METHODS: A prospective study was conducted to evaluate the achievability of the CVS during all consecutive LC performed over four years. The primary aim was to study the association between the inability to obtain the CVS and an objective measure of operative difficulty. The secondary aim was to identify preoperative and operative predictors indicating the use of alternate strategies to complete the operation safely. RESULTS: The study included 1060 consecutive LC. The median age was 53 years, male to female ratio was 1:2.1 and 54.9% were emergency admissions. CVS was obtained in 84.2%, the majority being difficulty grade I or II (70.7%). Displaying the CVS failed in 167 LC (15.8%): including 55.6% of all difficulty grade IV LC and 92.3% of difficulty grade V. There were no biliary injuries or conversions. CONCLUSION: All three components of the critical view of safety could not be demonstrated in one out of 6 consecutive laparoscopic cholecystectomies. Preoperative factors and operative difficulty grading can predict cases where the CVS may not be achievable. Adapting instrument selection and alternate dissection strategies would then need to be considered.

Laparoscopic subtotal cholecystectomy after percutaneous transhepatic gallbladder drainage for grade II or III acute cholecystitis.

BACKGROUND: Severe adhesions and fibrosis between the posterior wall of the gallbladder and liver bed often render total cholecystectomy after percutaneous transhepatic gallbladder drainage (PTGBD) difficult, leading to high open conversion rates. Since the publication of Tokyo Guidelines 2018 (TG18), our policy has shifted from open conversion to subtotal cholecystectomy (SC) when total laparoscopic cholecystectomy for difficult cases of cholecystitis is not feasible. Recently, SC has been frequently applied as bailout surgery for complicated cholecystitis. Nonetheless, the efficacy and validity of laparoscopic SC after PTGBD remain unclear. This study aimed to evaluate the safety and feasibility of laparoscopic SC after PTGBD for grade II or III acute cholecystitis (AC) by comparing two periods of altered surgical strategies. METHODS: This retrospective cohort study was conducted between January 2013 and December 2020. A total of 44 eligible patients with grade II or III AC were divided according to the time of cholecystitis onset into the pre-TG18 group (2013-2017, n = 17) and post-TG18 group (2018-2020, n = 27). Patients' background demographics, surgical method, surgical results, and postoperative complications were compared. RESULTS: The interval between PTGBD and surgery was significantly longer in the post-TG18 group than in the pre-TG18 group (15 [interquartile range: 9-42] days vs. 8 [4-11] days; P = 0.010). The frequency of laparoscopic cholecystectomy significantly increased from 52.9% in the pre-TG18 group to 88.9% in the post-TG18 group (P = 0.007), whereas the frequency of SC was 23.5% and 40.7%, respectively, which showed no statistically significant difference (P = 0.241). However, the rate of laparoscopic SC significantly increased from 0 to 90.9% among 15 SC cases, whereas the rate of open SC significantly plummeted from 100 to 9.1% (P = 0.001). Significant differences in the operative time, amount of intraoperative bleeding, and incidence of postoperative complications (wound infection and subhepatic abscess) were not observed. Mortality, bile leakage, and bile duct injury did not occur in either group. CONCLUSIONS: For grade II or III AC after PTGBD, aggressive adoption of SC increased the completion rate of laparoscopic surgery. Laparoscopic SC is a safe and feasible treatment option.