Page 8 - World Journal of Laparoscopic Surgery

Frequency, Complications, and Predictive Factors for Performing Subtotal Laparoscopic Cholecystectomy in an HPB Unit
patients over the age of 18, who had a cholecystectomy, however, dIscussIon
excision of the GB was performed at the level of Hartmann’s pouch
or the posterior wall of the GB was left in situ. Patients under the The main use of a subtotal cholecystectomy is in the context of
age of 18 or in cases where method that had been used was unclear acute cholecystitis or repeated cholecystitis where inflammation
were excluded from the study. Data were collected from electronic and fibrosis may make safe dissection of Calot’s triangle more
patient records, regarding age, gender, indication for surgery, difficult. In such a situation, conversion to open procedure is
procedure done (either LC or LSC), preoperative liver function tests, more common, and thus subtotal cholecystectomy may be of
ultrasound scan results, common bile duct (CBD) dilatation, BMI, GB use in situations where cholecystectomy for acute inflammation
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thickness on ultrasound, other investigations such as endoscopic is slightly delayed. However, there have been reports of longer
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13,14
retrograde cholangiopancreatography (ERCP), magnetic resonance operating times and more blood loss as well as increased
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cholangiopancreatography (MRCP), or hepatobiliary iminodiacetic hospital stay when compared to normal cholecystectomy. Our
acid (HIDA) (scintigraphy) scans, intraoperative details, length of data confirms a slightly higher complication rate and longer
stay, and postoperative complications. hospital stay. However, other studies have shown no differences in
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A matched, randomized sample was drawn from the LC complications and hospital stay, and a meta-analysis has found
cohort, using Research Randomizer®. The two groups, LSC and that the complication rates for subtotal cholecystectomy are similar
LC, were compared to determine that characteristics, if any, that to total cholecystectomy, so that it can be made a simple and
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could predict the need for LSC and whether the groups differed effective procedure for difficult GB.
with respect to complications and length of stay. Odds ratios When compared with procedures converted to open
were calculated to assess the risk of patients having a subtotal cholecystectomy, patients with LSC had more bile duct injury,
cholecystectomy. These were assessed using IBM SPSS V23. less wound infection, shorter hospital stay, more recurrent biliary
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events, more postoperative ERCP, and a higher reintervention rate.
results It is, however, less complicated than open cholecystectomy and has
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A total of 1,613 patients underwent LC in the HPB unit during this decreased costs. Another possible complication of LSC is retention
of stone within the Hartmann’s pouch, which may even require
period, of which, 102 (6.3%) had an LSC (55 females and 47 males) reoperation, though this was not seen in our cohort. 19
and 4 (0.24%) were converted to open surgery. Thirty-six (2.23%) of No defined risk factors were reported for subtotal
these LSCs were done in the acute setting for cholecystitis, while cholecystectomy, though there have been associations with
only 16 (15.7%) of the LC group were done acutely. high C-reactive protein (CRP) and Tokyo grading. Shingu et al.
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Indications for LSC were acute cholecystitis (56 patients, 54.9%), attempted to create a predictive score for LSC which consisted
gallstones causing biliary colic (25 patients 24.5%), gallstone of preoperative CRP elevation, wall thickened GB, atrophic GB,
pancreatitis (10 patients, 9.8%), cholangitis (6 patients, 5.9%), pericholecystic abscess, and structure of the hepatic bile duct. Mean
Mirizzi’s syndrome (2 patients, 1.96%), CBD stones (2 patients 1.96%), of the predictive score in LSC was 8.2, and ideal cutoff point for score
and acalculous cholecystitis (1 patient, 0.98%). Indications for LC was 8; specificity and sensitivity toward LSC was 76.0% and 77.0%,
were gallstones causing biliary colic (66 patients 64.7%), acute respectively. However, the use of such a score has not been widely
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cholecystitis (21 patients, 20.6%), gallstone pancreatitis (13 patients, implemented. We have seen that our study partially corroborates
12.7%), dyskinesia (1 patient, 0.98%), and GB polyp (1 patient, 0.98%). this, as patients who had previous cholecystitis, thickened GB wall
Complications in each group are shown in Table 1. on imaging, and previous ERCP (p < 0.01) were more likely to require
Odds ratios were calculated to assess the correlation between subtotal cholecystectomy. This may be related to increased local
several characteristics and the likelihood of having LSC rather than LC. inflammation in the area causing difficulty in dissecting Calot’s
We can see that previous cholecystitis, thickened GB wall on ultrasound triangle in patients with several episodes of cholecystitis and those
scan, and previous ERCP led to a higher likelihood that subtotal requiring ERCP.
cholecystectomy would be required. These are shown in Table 2.

Table 1: Indication for LSC were acute cholecystitis are shown in each conclusIon
group
Laparoscopic subtotal cholecystectomy is a safe procedure to
LSC LC p value perform in cases of difficult cholecystectomy, despite a slightly
Complications 13 (12.7%) 5 (4.9%) <0.001 higher length of stay and complication rate than LC. It is more
Bile leak 4 (3.9%) 1 (0.98%) <0.001 likely in patients with repeated episodes of cholecystitis, requiring
Collection (with drainage) 1 (0.98%) 0 <0.001 previous ERCP or having a thickened GB wall. In the future, these
CBD injury 0 1 (0.98%) <0.001 characteristics may be used in the formation of a predictive score
Retained stone 1 (0.98%) 0 <0.001
Gastric ulcer 2 (1.96%) 0 <0.001 Table 2: Predictive factors for subtotal cholecystectomy
Hospital-acquired pneumonia 1 (0.98%) 0 <0.001 Preoperative characteristic Odds ratio (95% CI)
Ileus 1 (0.98%) 0 <0.001 Jaundice 1.8 (0.9–3.6)
Bleeding 0 2 (1.96%) <0.001 Pancreatitis 0.8 (0.4–1.9)
Readmission 9 (8.8%) 4 (3.92%) 0.526 Cholecystitis 4.3 (2.3–8.0)
Other complications 3 (2.94%) 1 (0.98%) <0.001 Thickened gallbladder wall 6.1 (3.3–11.1)
Median length of stay/days (IQR) 2 (2–3) 0 (0–1) <0.001
LSC, laparoscopic subtotal cholecystectomy; LC, laparoscopic chole - ERCP 4.7 (2.2–9.9)
cystectomy; CBD, common bile duct; IQR, interquartile range. p < 0.05 was BMI > 30 1.2 (0.7–2.1)
considered statistically significant CI, confidence interval; BMI, body mass index

54 World Journal of Laparoscopic Surgery, Volume 12 Issue 2 (May–August 2019)