Difficult Gallbladder Research Articles

Bailout for the Difficult Gallbladder: Subtotal vs. Open Cholecystectomy-A Retrospective Tertiary Care Center Experience.

Background and Objectives: A difficult gallbladder anatomy augments the risk of bile duct injuries (BDIs) and other complications during a laparoscopic cholecystectomy. This study compares the outcomes of a laparoscopic subtotal cholecystectomy (LSTC) and open total cholecystectomy (OTC) for difficult cholecystectomies. Materials and Methods: This retrospective analysis of gallbladder procedures (LSTC or OTC) from 2016 to 2023 examined patient demographics, surgical details, and postoperative results. The primary outcome was the incidence of a BDI. Secondary outcomes included operative duration, blood loss, and postoperative complications. Results: Seventy-one patients were included in the study. Of them, 59.2% (n = 42) underwent an LSTC and 44.6% (n = 29) underwent an OTC. The LSTC cohort was more likely to have a day-surgery case with a same-day discharge (33.3% vs. 0%, p = 0.009), less blood loss (71.4 ± 82.26 vs. 184.8 ± 234.86, p = 0.009), and a shorter operative duration (187.86 ± 68.74 vs. 258.62 ± 134.52 min, p = 0.008). Furthermore, BDI was significantly lower in the LSTC group (2.4% vs. 17.2%, p = 0.045). However, there were no significant differences between the two groups concerning intraoperative drain placement, peri-cholecystic fluid collection, bile leak, and other complications (p > 0.05). Conclusions: LSTC is a safe and effective alternative to OTC for challenging gallbladder cases. Further studies with larger sample sizes and longer follow-up periods as well as different study designs are warranted.

Clinical and patient-reported outcomes following subtotal cholecystectomy: 10-year single-institution experience

ObjectiveSubtotal cholecystectomy provides a safe, bail-out alternative for difficult gallbladders. However, long-term outcomes comparing fenestrating and reconstituting subtotal cholecystectomy subtypes remain underexplored. MethodsThis retrospective cohort included patients who underwent subtotal cholecystectomy between 2010 and 2020 within a single hospital system. Subtotal cholecystectomy was identified by parsing operative notes for keywords. Demographic and clinical variables were collected by manual review. Patient-reported outcomes were collected via phone using an abbreviated Gastrointestinal Quality-of-Life Index. ResultsWe identified 218 subtotal cholecystectomies, with 113 (51.8%) fenestrating subtotal cholecystectomy and 105 (48.2%) reconstituting subtotal cholecystectomy and a median follow-up of 63 months (interquartile range 27–106). Rates of bile duct injury (0.9% vs 1.0%; P > .99), bile leak (10.6% vs 9.5%; P > .99), and 30-day readmission (7.6% vs 8.0%; P > .99) did not differ between fenestrating and reconstituting subtotal cholecystectomy. For fenestrating subtotal cholecystectomy, the postoperative bile leak rate decreased fourfold when cystic duct closure was achieved (6.0% vs 24.1%; P = .012). Subtotal cholecystectomies completed laparoscopically had fewer postoperative bile leaks (2.9% vs 16.8%; P = .001), fewer wound complications (4.8% vs 13.3%; P = .035), and decreased length of stay (7.00 ± 9.07 vs 10.15 ± 13.50 days; P < .001) compared with open operations. The survey response rate was 38.9% (n = 51/131); 47 patients (92.2%) did not report recurrent biliary pain or postprandial nausea or vomiting, but 19 patients (37.2%) reported dietary restriction. Long-term completion cholecystectomy rate was 0.9%. ConclusionGiven no notable difference in postoperative or quality of life outcomes between subtotal cholecystectomy subtypes, consideration of technique depends on intraoperative conditions. Cystic duct closure during fenestrating subtotal cholecystectomy and laparoscopic completion of subtotal cholecystectomy are associated with improved postoperative outcomes.

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

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. 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. 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. 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.

Surgical Skill Decay as a Result of the COVID-19 Pandemic.

This study aimed to objectively evaluate the impact of the gap in surgical practice caused by COVID-19 on surgical skill decay. This retrospective cohort study enrolled 148 cases of adult patients who were qualified for elective or urgent laparoscopic cholecystectomy. This study compared the period of nine months before the pandemic outbreak and nine months after the end of the pandemic. We analyzed the duration of surgery, the number of intraoperative adverse events (IAEs), postoperative complications (PCs), and differences between the surgeries performed by residents and those performed by specialists. The number of IAEs did not differ significantly between groups (after COVID-19 (AC) and before COVID-19 (BC)). A difficult gallbladder (DGB) was associated with an increased risk of IAEs during surgery in both groups (BC:OR = 2.94, p = 0.049; AC:OR = 2.81, p = 0.35). The multivariate analyses showed no significant differences in IAEs or PCs when the residents performed surgeries compared to specialists. The average duration of surgery was significantly longer in the post-pandemic group (BC-102.4 min vs. AC-119.9 min, p = 0.024). Measurable determinants of surgical skills are the duration of surgery and the number of intraoperative adverse events. By defining this indicators, our study objectively shows that the reduction in the volume of surgeries during COVID-19 resulted in a phenomenon known as surgical skill decay.

Converting From Laparoscopic Cholecystectomy to Open Cholecystectomy: A Systematic Review of Its Advantages and Reasoning.

Cholecystectomy is the standard treatment for symptomatic cholelithiasis and asymptomatic impending biliary obstruction, which is typically carried out laparoscopically. However, difficult gallbladders, due to distorted anatomy or increased risk of bleeding, can necessitate conversion to open surgery. This systematic review evaluates the advantages, disadvantages, complications, and outcomes of laparoscopic versus converted open cholecystectomy. We screened articles published from 2011 to 2024 by utilizing advanced filters of PubMed, Cochrane, and Scholar databases. Exclusion criteria included non-English language articles, duplicates, and animal studies. After analyzing relevant articles, 31 articles were included in this study. The total number of participants who underwent laparoscopic procedures was 28,054, of which 5,847 were converted from laparoscopic to open procedures. Conversions were primarily due to bleeding, adhesions, and obscured anatomy, with bile leakage being the most common short-term complication. Converted cases showed higher rates of long-term complications, increased hospital stays, and higher morbidity and mortality. Laparoscopic cholecystectomy remains safe and effective, but identifying high-risk patients for conversion is important. Preoperative identification of high-risk patients and recognizing predictive factors for conversion can enhance surgical outcomes and cost-effectiveness. While laparoscopic cholecystectomy is generally preferred, timely conversion to open surgery is essential for patient safety.

648 Predictive Factors for Subtotal Cholecystectomy

Abstract Introduction Subtotal-cholecystectomy (STC) is a rescue procedure in dealing with difficult gallbladders undertaken when a critical view of safety is not possible to allow complete cholecystectomy, thereby avoiding complications. Aim Determine what patient factors increase risk of STC in patients undergoing elective laparoscopic cholecystectomy (LC) and therefore aid prediction in patients reduced suitability for day surgery. Method Data was collected between 01/01/2022 and 31/07/2023 from three hospitals throughout the Aneurin-Bevan University Health-Board, Wales, UK. All patients receiving elective LC had data collected on age, BMI, gender, ERCP preceding operation, surgical duration, length of stay and 30-day complications, amongst others. Results Of a total of 1060 patients were included in this study(77.36%female, 22.64%male), 81 where STC (7.64% of total LC; 56.8%female, 43.2%male). There were three 30-day mortalities, one of whom underwent STC(p= 0.09). The overall complication rate was 6.41%, significantly raised in the STC group(13.58%vs5.82%;p=0.007). As expected, there was a significant increase in bile-leak following subtotal(12.35%vs1.12%; p=0.0001) , however, there was no increase significance for bleed (0%vs0.41%;p=0.5644), wound infection(0%vs3.68%;p=0.079), collection(0.09%vs0.51%;p=0.404) or bile duct injury(0%vs1.02%; p=0.0001). Predictors for STC were higher age(70-79years;p=0.0016), male gender(p=0.0001), and ERCP preceding surgery(p=0.0001). Both length of stay(median 1vs 0days;p=0.0001) and length of procedure (median 122vs 76minutes;p=0.0001) were increased following STC. High BMI, diabetes(p=0.1991) and smoking(p=0.7921) had no association. Conclusions Subtotal cholecystectomy is a safe alternative when facing difficult cholecystectomy where critical view of safety is not achievable. Factors predicting STC were male gender, advanced age and prior ERCP.

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 difficult gallbladder: Our experience in a tertiary care center.

Open cholecystectomy is becoming obsolete and laparoscopic cholecystectomy has become the treatment of choice in gallstone diseases. Difficult gallbladders are encountered whenever there is a frozen calot's triangle, obliterated cystic plate, or both. Rather than converting to open procedure, there has been a growing preference for laparoscopic subtotal cholecystectomy (LSC) during difficult gallbladders. This study aimed to assess the advantages, indications, and viability of LSC in difficult gallbladders. The study included patients undergoing laparoscopic cholecystectomy in NIMS Hospital, Jaipur, from January 2021 to January 2023. Data of the patients who underwent LSC for difficult gallbladders included demographics, comorbidities, operative time, conversion to open cholecystectomy, length of hospital stay, and complications. LSC was classified into three types depending on the part of the gallbladder remnant. A total of 728 patients underwent laparoscopic cholecystectomy. Among them, 41 patients (5.6%) were attempted for LSC. However, one patient was converted to an open procedure and the rest 40 underwent LSC. LSC was divided into 3 types, 4 patients underwent LSC type I, 34 patients underwent type II, and 2 patients type III. The average operating time and postoperative length of hospital stay were 86.2 minutes and 2.1 days, respectively. Two patients had surgical site infection. No patient had a bile leak and none required intensive care unit care. LSC is a safe and feasible option for use in difficult gallbladders.

Bailout Surgery for Difficult Gallbladders: Surgical Approach and Outcomes.

Inflammation in acute cholecystitis may cause a cholecystectomy to be more challenging. Due to the difficult dissection, conversion to subtotal cholecystectomy via laparoscopic or open procedure may be required. This is done to reduce the risk of bile duct injury and hemorrhage. We sought to describe the incidence and risk factors, safety, morbidity, and outcomes associated with bailout procedures. A single academic center, retrospective review of laparoscopic cholecystectomies that resulted in bailout procedures performed between January 2015 and December 2020. Data collected from the chart review included demographics, comorbidities, length of presenting symptoms, vital signs, laboratory and imaging, intraoperative findings, length of surgery, and outcome. A total of 1892 cholecystectomies were performed with 147 bailout procedures. For bailout 92 (63.4%) were converted to open, with 66% resulting in complete cholecystectomy. Hypertension and diabetes were the most common comorbidities. The median duration of symptoms was 4days. Difficult anatomy in the hepatocystic triangle (66%) and dense adhesions (31%) were the most common reasons for bailout. The mean duration of surgery was 145.76 (SD 102.94) minutes. There were 2 bile duct injuries, both in open total cholecystectomy subgroup. Bile leak occurred in 23.8% with majority in subtotal cholecystectomy group. There was no difference in hospital length of stay, surgical site infection, or mortality among different bailout procedures. Subtotal cholecystectomy represents a safe alternative to total cholecystectomy during challenging cases to avoid damaging surrounding structures. The choice of laparoscopic or open subtotal approach is dependent on the surgeons' expertise.

Laparoscopic subtotal cholecystectomy for difficult gallbladders: single Center retrospective cohort study.

Laparoscopic subtotal cholecystectomy for difficult gallbladders: single Center retrospective cohort study.

Subtotal vs total cholecystectomy for difficult gallbladders: A systematic review and meta-analysis

IntroductionWith 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. MethodsMedline-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. ResultsTen 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). ConclusionSC 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.

OGBN P10 Fenestrating versus reconstituting subtotal cholecystectomy for difficult gallbladder: A systematic review and meta-analysis

Abstract Background To evaluate comparative outcomes of fenestrating and reconstituting subtotal cholecystectomy (STC) in patients with difficult gallbladder. Methods A systematic search of electronic data sources and bibliographic reference lists were conducted. All comparative studies reporting outcomes of laparoscopic fenestrating and reconstituting STC were included and their risk of bias were assessed using ROBINS-I tool. Results Seven comparative studies were included enrolling 590 patients undergoing laparoscopic STC using either fenestrating (n=353) or reconstituting (n=237) approaches. Although fenestrating STC was associated with a significantly higher rate of bile leak (OR:2.47, p=0.007) compared to reconstituting STC, both approaches were comparable in terms of resolution of bile leak without (RD:-0.02, p=0.86) or with (OR:1.84, p=0.40) postoperative ERCP. Moreover, there was no significant difference in development of bile duct injury (RD:-0.02, p=0.16), need for postoperative ERCP (OR:1.36, p=0.49), wound infection (RD:0.03, p=0.27), re-operation (OR:0.95, p=0.95), gallbladder remnant cholecystitis (OR:0.21, p=0.09) or need for completion cholecystectomy (RD:0.01, p=0.59) between two groups. Conclusions Although fenestrating STC increases risk of bile leak compared with the reconstituting approach, this can be managed successfully with postoperative ERCP if not resolved spontaneously. We encourage low threshold for fenestrating approach in difficult situations, considering its relatively benign postoperative course and long-term outcomes.

Achieving Critical View of Safety via a New Technique: The Triple One (111) Technique.

Misidentification of anatomical structures is one of the most common causes of bile duct injury following laparoscopic cholecystectomy. Achieving Critical View of Safety (CVS) is a standard step in conducting safe cholecystectomy all over the world. In our institute, we achieve CVS via a unique technique called Triple One or 111 and find it very helpful and easy to achieve CVS. Moreover, the rate of conversion has also decreased while achieving CVS via this technique. The unique aspect of the Triple One technique is that by following this method, even new laparoscopic surgeons can achieve CVS very easily in difficult cases and, hence, it decreases the chances of vasculobiliary injury (VBI). This study aimed to determine how effective the Triple One technique is in achieving CVS as well as in lessening the chances of VBI. A total of 545 patients were admitted through the outpatient department, ranging in age from 30 to 70 years, with a mean of 50 years. The study comprised patients with American Society of Anaesthesiologists (ASA) I & II, acute and chronic cholecystitis, and symptomatic cholelithiasis. The study excluded patients with co-morbidities, prior abdominal procedures, and suspected complications. On the second postoperative day, all patients received their discharge papers and on the seventh postoperative day, follow-up was completed. Successful gallbladder extraction using the Triple One technique was achieved in 540 (99%) cases. The other five (1%) cases converted to open cholecystectomy because of the difficult gallbladder anatomy and extensive scarring. No VBI or bile duct injury was noted. No mortality was recorded during the study period. By incorporating CVS using the Triple One technique into our policies and curriculum, we may encourage safe cholecystectomy practices and prevent bile duct injuries.

ThTP1.12 Stitch Closure of Gall Bladder Remnant during Laparoscopic Retrograde Subtotal Cholecystectomy for Difficult Gall Bladders

Abstract Background and Aim Laparoscopic Retrograde Subtotal cholecystectomy (LRSC) recommended for difficult gall bladders (Grade 3&amp;4, Nassar et al) reduces CBD injury (.08%), however, increases subhepatic collections (2.9%), reoperations (1.8%) and bile leaks (18%). Assess whether intracorporeal stitch closure of gall bladder remnant reduces complications and improves outcome. Patients and Method Prospective study of 1722 consecutive patients undergoing LC in a large DGH (2007-2022) with data of age, sex, BMI, ASA, grade of operation with postoperative stay and complications were collected and analysed. Group A: Conventional laparoscopic total cholecystectomy (LTC). Group B: LRSC includes a ‘fundus first approach’, piecemeal anterior &amp; posterior wall transection with &amp;lt;1cm gall bladder remnant that is closed with a figure of 8 absorbable sutures. Results Group A: 1584(92%) with Male: Female 1:4 (363:1221), Age 51* (16-89) years, BMI 27* (17-65), ASA 2* (1-3), Grade 1* (1-4), Operating time 45* (15-200) minutes, PO stay 0* (0-15) day. 11(.7%) conversions, 3(.18%) CBD injury, 4 (.25%) bile leaks, 3(.18%) ERCPs, 13 (.82%) collections requiring 9 surgical wash outs and 4 radiological drainages. Group B: 138(8%) with Male: Female 1:1 (64:74), Age 61* (21-88) years, BMI 29 * (19-60), ASA 2* (1-3), Grade 4* (3-4), Operating time 100 *(40-240) minutes, PO stay 1 *(0-13) day. One (.72%) conversion, 6(4.3%) bile leaks, 3(2.17%) ERCPs and 3(2.17%) collections requiring 1 surgical wash out and 2 radiological drainages. Conclusion We recommend routine stitch closure of the gall bladder remnant during LRSC that significantly reduces post operative morbidity (bile leak and collection) for a better outcome. * Median

Laparoscopic subtotal cholecystectomy by linear stapler: A simple and feasible technique for difficult cases with severe cholecystitis. A case series

IntroductionLaparoscopic subtotal cholecystectomy (LSC) is recognized as a safe, feasible alternative method for avoiding common bile duct injuries in 'difficult' gallbladders. We describe the details of an LSC technique that uses a linear stapler with the reconstituting method for severe cholecystitis. MethodsWe retrospectively analyzed the cases of 19 Japanese patients diagnosed with acute cholecystitis who underwent LSC (Jan. 2017–Dec. 2020). In each patient, we first attempted to perform a standard laparoscopic cholecystectomy. Four trocars were inserted in all patients. When it was extremely difficult to expose and dissect the triangle of Calot or the neck of the gallbladder due to severe inflammation and fibrosis, an LSC was performed. The gallbladder was divided downward from the gallbladder fundus to the neck. We opened the gallbladder wall at the fundus and removed all gallstones with suction and saline flushing. The gallbladder was transected by a laparoscopic linear stapler. ResultsThe median operation time was 166 min; intraoperative blood loss was 35 mL. One patient (5.3%) had minor bile leakage that promptly resolved after the transpapillary approach. The median postoperative hospital stay was 7 days. ConclusionUsing a linear stapler to divide the gallbladder neck is a simple, feasible strategy for LSCs in difficult gallbladders.

A systematic review on laparoscopic subtotal cholecystectomy for difficult gallbladders: a lifesaving bailout or an incomplete operation?

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. 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. 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. LSTC is an acceptable alternative in patients with a "difficult" Calot's triangle.

Outcome of Early Versus Delayed Laparoscopic Cholecystectomy in Acute Calculus Cholecystitis

Background: The timing of cholecystectomy for acute cholecystitis has been debated with most studies favoring early cholecystectomy. However, most surgeons in Bangladesh prefer to delay surgery in the acute phase. The study aimed to compare between early Laparoscopic Cholecystectomy (LC) with that of delayed laparoscopic cholecystectomy in the management of acute calculus cholecystitis. Materials and methods: This quasi-experimental study included a total of 74 patients with a diagnosis of acute calculous cholecystitis as per Tokyo guideline from the Surgery Department, Chittagong Medical College Hospital, during August 2019 to July 2020. Thirty-seven patients underwent early cholecystectomy (Within 7 days of onset of symptoms) and 37 patients underwent elective or delayed cholecystectomy (After a gap of 6-8 weeks from the acute attack). Peroperative events, postoperative complications, length of hospital stay and days needed to return to full activity were compared between two groups. Results: Both early and delayed groups were similar in-terms of their baseline demographic and clinical characteristics. Significantly higher number of patients in the early group had difficult Callot’s triangle dissection (59.4% vs. 27.1%, p&lt;0.01) and lower number of patients had difficult gallbladder bed dissection (5.4% vs. 37.8%, p&lt;0.001) than the delayed group. The proportion of the patients required conversion to open surgery was 10.8% and 6.1%, respectively in early and delayed group (p=0.691). Total hospital stay was shorter in the early surgery group than the delayed surgery group (6.05±0.52 vs. 12.03±1.46 days, p=0.001). Wound infection, duration of hospital stays following surgery, and days need to return to full activity after surgery was similar between two groups. Conclusion: Early cholecystectomy is feasible and safe for acute cholecystitis and is better method of treatment because of its shorter hospital stay, which is a major economic benefit to both the patient and health care system. IAHS Medical Journal Vol 5(2), Dec 2022; 11-14

Carcinoma of the gall bladder

Gallbladder carcinoma is fifth most common gastrointestinal malignancy. Main indication for cholecystectomy is gallstone disease. Majority of gallbladder carcinomas are diagnosed during the course of histopathological evaluation of specimens obtained at cholecystectomy. Accomplishing radical cholecystectomy is advisable in these patients. Technically difficult gallbladder dissection during the course of laparoscopic surgery should raise a high suspicion of malignancy. Specimen retrieval bags should be used in all cases to avoid external spillage of bile giving rise to port side metastasis. A good outcome depends on prompt diagnosis and radical surgical resection. It is essential for a general surgeon to be aware of predisposing factors, pathology, patterns of presentation, and surgical options in gallbladder carcinoma.

Subtotal Cholecystectomy in Preventing Major Complications in Difficult Cholecystectomy Cases: A Comprehensive Single Center Study

ABSTRACT Background: Cholecystectomy is a commonly performed laparoscopic surgery but because of variability in anatomy, surrounding inflammation and fibrosis because of recurrent attacks of cholecystitis, can be a potentially difficult surgery. Laparoscopic total cholecystectomy in difficult gall bladder cases sometimes can cause severe complications. Laparoscopic subtotal cholecystectomy can be a bridge and a safe and feasible option between open subtotal cholecystectomy and laparoscopic cholecystectomy. Aim: To study indications, morbidity and clinical outcomes in patients undergoing subtotal cholecystectomy with laparoscopy or with open surgery. Settings and Design: It was a prospective observational study. Patients presenting with signs and symptoms of cholecystitis in either OPD or IPD and in emergency were included in this study. Materials and Methods: Total 38 patients who presented to our institute with clinical and ultrasonographic evidence of acute cholecystitis were included in the study. All patients underwent detailed and thorough clinical examination, laboratory investigations, ultrasonographic, and contrast enhanced computed tomography scan in selected patients. Based on intraoperative findings, decision of subtotal cholecystectomy either by laparoscopy or via open method was made. Various outcomes like intraoperative complications, postoperative complications and need of postoperative interventions, hospital stay, and returning to daily activity were observed and charted. Statistical Analysis: The data obtained were tabulated in Microsoft Excel and analyzed using SPSS version 17.0. Continuous variables were expressed as mean ± standard deviation value. Probability value (P value) was used to determine the level of significance. P value &lt;.05 was considered as significant; P value &lt;0.001 was considered as highly significant. Results: The common indications for subtotal cholecystectomy were severe cholecystitis with dense fibrous adhesions (97.4%), empyema (34.2%) or gangrenous gallbladder (31.6%), and Mirizzi syndrome (2.6%). Conversion rate was 21.1%. Morbidity rates were relatively low with subtotal cholecystectomy (bile leak 21.1%, sub hepatic collections 10.5%, retained stones 5.3%, paralytic ileus 18.4%, wound infection 7.9%, and common bile duct stricture 2.6%). Postoperative interventions were necessary in 18.4% of the cases (retained stones 5.3%, bile leak 7.9%, common bile duct stricture 2.6%, and subhepatic collection 2.6%). Mean duration of hospital stay was 7.5 days and returning to routine daily activity was 11.05 days. Conclusion: Subtotal cholecystectomy is a safe and feasible method for difficult gallbladder cases with a positive outcome. Laparoscopic subtotal cholecystectomy decreases the conversion rate in difficult gallbladder cases but it is not a substitute to open conversion if deemed necessary.

Comparison of Postoperative Outcomes, Costs, and Readmission Between Total and Subtotal Cholecystectomy.

An increasing body of literature supports subtotal cholecystectomy (STC) in the management of patients with difficult gallbladder anatomy; however, large-scale studies examining outcomes of total cholecystectomy and STC are lacking. All adults undergoing total cholecystectomy or STC were tabulated from the 2016-2019 Nationwide Readmissions Database. Entropy balancing was performed to adjust for patient differences based on extent of resection. Subsequent multivariable regression models were used to assess the association of STC with major adverse events, postoperative length of stay (pLOS), hospitalization costs, and 30-day non-elective readmission rates. Of an estimated 854357 patients, 7089 (.8%) underwent STC. Compared to total, STC patients were significantly older, less commonly female, and had a higher Elixhauser Index (all P < .001). Both cohorts had similar rates of postoperative ERCP (1.7% vs 1.5%, P = .33); however, the STC cohort had significantly higher utilization of subsequent drainage procedures (1.8% vs .5%, P < .001). After entropy balancing and multivariable risk-adjustment, STC was not associated with greater odds of MAE (AOR 1.11, 95% CI .99-1.23, P = .06). Notably, relative to total, STC was associated with longer pLOS (β .14, 95% CI .11-.17, P < .001) and greater hospitalization costs (β + $1,900, 95% CI 1300-2,500, P < .001). However, the extent of resection was not associated with the likelihood of 30-day non-elective readmission (AOR 1.01, 95% CI .91-1.13, P = .86). Our findings suggest that STC is a viable, yet resource intensive, option in the management of complex cholecystitis.