2794 Subtotal Cholecystectomy Outcomes

Abstract

INTRODUCTION: Subtotal cholecystectomies have become a viable alternative to converting laparoscopic cholecystectomies to open cholecystectomies in complicated gallbladder etiologies. There are two subtypes of subtotal cholecystectomies: fenestrating and reconstituting. Fenestrating subtotal cholecystectomy requires an internal suture of the cystic duct with removal of most of the gallbladder. Reconstituting subtotal cholecystectomy creates a gallbladder remnant. Bile leak is a common adverse outcome of subtotal cholecystectomies. ERCP is the standard intervention for high output bile leaks. METHODS: This was a retrospective analysis of patients at Coney Island Hospital who underwent any cholecystectomy during January 2010 to December 2018. The inclusion criterion was patients who underwent subtotal cholecystectomy. The exclusion criteria was any patient who underwent prior ERCP or sphincterotomy. We reviewed patient’s age, initial WBC, alkaline phosphatase, total bilirubin, AST, ALT, total output of JP drain, duration of JP drain, and hospitalization length. Data was analyzed using XTabs, ANOVA, and T-test using Prism and SAS software. RESULTS: 1423 cholecystectomies performed at Coney Island Hospital during this period. Of these, 106 were subtotal cholecystectomies: 11 were reconstituting and 96 were fenestrating. 34 subtotal cholecystectomies required ERCP intervention. Fenestrating subtotal cholecystectomies were associated with higher total bile output from JP drain and longer duration of JP drain. Cases requiring ERCP intervention were associated with larger bile output from JP drain, higher total bilirubin, and longer hospitalization duration. 68 of the fenestrated subtypes were left with an open cystic duct without internal closure. CONCLUSION: ERCP has been demonstrated to be an effective intervention in treating post operative bile leaks in cases showing large JP drain output and increased total bilirubin on initial presentation. However, a majority of subtotal cholecystectomies can be managed without intervention. We noted that 68 of the 96 fenestrating subtotal cholecystectomies had the cystic ducts remain open instead of the traditional internal suture. Cystic duct obliteration or severe inflammation may impede suturing. Regardless, close monitoring of JP drain output is recommended. Our research concludes that there are better outcomes with reconstituting subtotal cholecystectomies and fenestrating subtotal cholecystectomies in which there was an internal suture placed at the cystic duct.