Cholecystectomy For Severe Cholecystitis Research Articles

A comparison of outcomes including bile duct injury of subtotal cholecystectomy versus open total cholecystectomy as bailout procedures for severe cholecystitis: A multicenter real-world study

BackgroundDense inflammation obscuring the hepatocystic anatomy can hinder the ability to perform a safe standard laparoscopic cholecystectomy in severe cholecystitis, requiring use of a bailout procedure. We compared clinical outcomes of laparoscopic and open subtotal cholecystectomy against the traditional standard of open total cholecystectomy to identify the optimal bailout strategy for the difficult gallbladder. MethodsA multicenter, multinational retrospective cohort study of patients who underwent bailout procedures for severe cholecystitis. Procedures were compared using one-way analysis of variance/Kruskal-Wallis tests and χ2 tests with multiple pairwise comparisons, maintaining a family-wise error rate at 0.05. Multiple multivariate linear/logistical regression models were created. ResultsIn 11 centers, 727 bailout procedures were conducted: 317 laparoscopic subtotal cholecystectomies, 172 open subtotal cholecystectomies, and 238 open cholecystectomies. Baseline characteristics were similar among subgroups. Bile leak was common in laparoscopic and open fenestrating subtotal cholecystectomies, with increased intraoperative drain placements and postoperative endoscopic retrograde cholangiopancreatography(P < .05). In contrast, intraoperative bleeding (odds ratio = 3.71 [1.9, 7.22]), surgical site infection (odds ratio = 2.41 [1.09, 5.3]), intensive care unit admission (odds ratio = 2.65 [1.51, 4.63]), and length of stay (Δ = 2 days, P < .001) were higher in open procedures. Reoperation rates were higher for open reconstituting subtotal cholecystectomies (odds ratio = 3.43 [1.03, 11.44]) than other subtypes. The overall rate of bile duct injury was 1.1% and was not statistically different between groups. Laparoscopic subtotal cholecystectomy had a bile duct injury rate of 0.63%. ConclusionLaparoscopic subtotal cholecystectomy is a feasible surgical bailout procedure in cases of severe cholecystitis where standard laparoscopic cholecystectomy may carry undue risk of bile duct injury. Open cholecystectomy remains a reasonable option.

Laparoscopic subtotal cholecystectomy in severe cholecystitis with unclear anatomy

Background: Aim of the study was to determine the differences between laparoscopic cholecystectomy and laparoscopic subtotal cholecystectomy as regards bile duct injury and post-operative complications rates in patients with severe cholecystitis and obscure anatomy.Methods: We retrospectively reviewed the charts and postoperative outcomes of 293 patients with severe cholecystitis who underwent either laparoscopic cholecystectomy or laparoscopic subtotal cholecystectomy between September 2011 and January 2020. Patients with intraoperative altered anatomy which leaded to difficult dissection were defined as having severe cholecystitis.Results: There were 304 cholecystectomies done for patients with severe cholecystitis. Of those, 203 underwent laparoscopic cholecystectomy (LC group), 90 underwent laparoscopic subtotal cholecystectomy (LSC group). There was no significant difference in male to female ratio, age, cases performed on an elective or emergency basis, hospital length of stay or initial operative findings. There were 5 patients with detected intraoperative biliary injury in LC group only. Postoperative bile leaks were significantly higher in the LSC (11.1%) than in the LC group (3.9%). Postoperative collections which needed percutaneous aspiration were also significantly higher in the LSC group (18.9%) than in the LC group (7.4%). Reoperation for collection was required in 8 patients in LC group and in 5 patients in LSC group. The rates of retained common bile duct stones, port site hernia, wound infections, and total complications were not significantly different between the two groups (28.1% v. 45.6%).Conclusions: Our study demonstrated that laparoscopic subtotal cholecystectomy is a safe procedure which reduces the risk of bile duct injury and is comparable to laparoscopic cholecystectomy in patients with severe cholecystitis with unclear anatomy.

Colecistectomía subtotal: una alternativa en el manejo de la colecistectomía difícil

Introducción. Alrededor de un 10 % de las laparoscopias se convierten a cirugía abierta por dificultades en obtener una visión crítica durante la colecistectomía en colecistitis severas. La colecistectomía subtotal es una posibilidad terapéutica disponible, que disminuye la tasa de conversión en cirugía laparoscópica y mantiene bajas tasas de morbilidad y mortalidad.&#x0D; Métodos. Estudio descriptivo, retrospectivo, de pacientes sometidos a colecistectomía subtotal en la Clínica CES (Medellín, Colombia) entre enero y diciembre de 2015. Se identificaron variables demográficas, detalles de la cirugía, morbilidad y mortalidad.&#x0D; Resultados. De un total de 710 colecistectomías en dicho periodo, a 17 (2,4 %) se les realizó colecistectomía subtotal. Quince (88 %) de ellas fueron por laparoscopia y dos requirieron conversión. La distribución en cuanto a sexo fue similar (10 mujeres / 7 hombres) y la edad promedio fue de 51 años. El tiempo quirúrgico promedio fue de 119 minutos. En 14 (82 %) pacientes se dejó drenaje subhepático. Dos pacientes presentaron fístula biliar y un paciente reingresó por un hematoma; no se presentaron otras complicaciones. La estancia hospitalaria promedio fue de 5,2 días. &#x0D; Discusión. La colecistectomía subtotal es una alternativa en pacientes con colecistectomía difícil y en nuestra experiencia presenta una alta tasa de éxito.

Argon plasma coagulation for successful treatment of bile leakage after subtotal cholecystectomy

BackgroundSubtotal cholecystectomy is an effective surgical method to decrease the risk of complications for gallbladders that are difficult to remove. However, there is a risk for postoperative refractory bile leakage through the gallbladder stump. Here, we report a new management technique involving the use of argon plasma coagulation (APC) to stop bile leakage after a subtotal cholecystectomy.Case presentationA 74-year-old man was referred to our hospital for abdominal pain and fever. Contrast-enhanced computed tomography of the abdomen showed fluid collection, such as an abscess, surrounding the gallbladder and hepatic flexure colon. The patient was diagnosed with colonic perforative peritonitis, and he underwent emergency surgery. On laparotomy, the abscess was observed outside of the hepatic flexure colon and gallbladder necrosis was detected. The neck of the gallbladder and the area close to the hepatoduodenal ligament was severely inflamed prohibiting dissection. The hepatic flexure colon was part of the abscess wall, and resection was needed. A subtotal cholecystectomy and right hemicolectomy confirmed peritonitis caused by cholecystic perforation. The mucous membrane of the gallbladder neck that remained was necrotic or detached. Therefore, the stump of the gallbladder was closed by primary sutures without cauterization of the mucosa. On postoperative day 6, bile leakage from the gallbladder stump was revealed. Percutaneous and endoscopic retrograde cholangiography drainage were performed. However, the liquid, which seemed to be secreted from the mucosa of the remnant gallbladder, was continuously obtained. We used APC to cauterize the gallbladder mucosa through the fistula of the abdominal drainage tube. Bile leakage and mucus discharge were improved after three rounds of APC cauterization.ConclusionsAPC effectively treated refractory bile leakage from a gallbladder stump after subtotal cholecystectomy for severe cholecystitis.

Experience with partial cholecystectomy in severe cholecystitis.

Backgrounds/AimsPartial cholecystectomy (PC) is often an inevitable operative procedure when Calot triangle is severely inflamed and fibrosed with conglomerated structures. We reviewed our clinical outcomes of PC to compare its feasibility with conventional total cholecystectomy (TC), especially for its possible application to laparoscopic procedure.MethodsFrom Aug. 2000 to July 2008, 20 cases of PC by laparotomy were performed, including converted cases during laparoscopic cholecystectomy. Sixty-eight cases of TC by open method during the same period were compared in a mean follow-up period of 108 months.ResultsBile fistula was observed in 3 cases of PC; one case needed endoscopic biliary stent for management and a second case showed fistula that closed by supportive care in 2 months. The last patient died from peritonitis. No bile fistula was observed in PC. Morbidities were found in 9 cases of PC (45%) and in 11 cases of TC (16.2%). Bile fistula (n=3) and wound infection (n=3) were prominent in the PC group, and wound infection (n=7) in the TC group. Reoperations were necessary for 5 (25.0%) and 4 (5.9%) patients from PC and TC, respectively. Mortality occurred in 2 (2/10 10%) and 4 cases (4/68 5.9%) of PC and TC, respectively. Two mortalities in each group resulted from direct extension of cholecystitis.ConclusionsConsidering the higher risks of complications and mortality, PC should be avoided as long as possible, and patients should always be informed of its clinical outcomes postoperatively. Further elaboration of a safer operative plan should be sought.