Laparoscopic Subtotal Cholecystectomy Research Articles

Laparoscopic Cholecystectomy in Acute Cholecystitis: An Updated Review

Laparoscopic cholecystectomy is the gold standard for the management of gallstone disease, but it has recently been incorporated into the treatment of acute cholecystitis. It is divided into early and delayed laparoscopic cholecystectomy. Early laparoscopic cholecystectomy is done within 72 hours of the onset of symptoms, and delayed laparoscopic cholecystectomy is done after eight weeks. As there is no consensus on the timing of early laparoscopic cholecystectomy in adults and elderly patients, we have conducted this review article to examine the timing of early laparoscopic cholecystectomy, the risk factors for conversion to open cholecystectomy, and the role of laparoscopic subtotal cholecystectomy in the management of acute cholecystitis.

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

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. 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. 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 30days, one mortality, and no BDIs occurred in the LSC cohort. LSC provides a feasible surgical option that should be utilized in complex cholecystitis.

What Happens After Discharge? A 2+ Year Follow-Up After Laparoscopic Subtotal Fenestrating and Reconstituting Cholecystectomy.

Laparoscopic subtotal cholecystectomy (LSC) is utilized to prevent complications in the difficult cholecystectomy. Medium-term outcomes are poorly studied for fenestrating and reconstituting operative techniques. A single-institution retrospective review was undertaken of all LSCs. A telephone survey was used to identify complications addressed at other institutions. We performed subgroup analyses by operative approach and of patients requiring postoperative endoscopic intervention (ERC). 28 patients met inclusion criteria. The median follow-up was 32.7 months. There were no bile duct injuries or reoperations. 21% of patients required a postoperative ERC and 50% were discharged home with a drain. Bile leaks were found to be more prevalent in the fenestrating LSC group (38% vs 0%, P = .003). The case series suggested more severe recurrent biliary disease in patients undergoing reconstituting LSC. Laparoscopic subtotal cholecystectomy appears to have satisfactory medium-term outcomes. The reconstituting LSC group trends toward more severe recurrent disease which warrants further investigation.

Incidence of Endoscopic Retrograde Cholangiography after Subtotal Fenestrating and Reconstituting Cholecystectomy.

Laparoscopic subtotal cholecystectomy (SC) is used for the difficult cholecystectomy, but published experience with resource utilization for SC is limited. We hypothesized that the need for advanced resources are common after SC. Retrospective review of laparoscopic cholecystectomies between 2017 and 2021 at a large center. SC cases were identified using a medical record tool. Baseline characteristics were assessed with student's t-test and chi-squared. Primary outcome was ERC within 60-days. Secondary outcomes were reconstituted SC on post-op ERC and length of stay (LOS). Uni- and multivariable logistic regression were used for binary outcomes. Multiple linear regression was used for LOS. Covariates included age, sex, BMI, ASA class. A total of 1222 laparoscopic cholecystectomies were performed between 2017 and 2021. Of these, 87 (7%) were SC. Male (p<0.001) and older (p<0.001) patients were more likely to undergo SC. Odds of post-op ERC were higher in the SC group (OR 9.79 95% CI 5.90, 16.23 p<0.001). There was no difference in pre-op ERC (17% vs 21% p=0.38). Reconstituting SC had lower odds of post-op ERC (OR 0.12, 0.023-0.58, p=0.009). LOS was 1.81 times higher in the SC group(p=<0.001). Post-op ERC was not associated with LOS (p=.24). We present one of the largest single-center series of SC. SC patients are more likely to be male, older, have higher ASA class, and have increased LOS. SC should be performed when access to ERC and interventional radiology is available. Absent these adjuncts, reconstituting SC decreases the need for early ERC, but long-term outcomes are unknown.

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.

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

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. 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. 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. 4days p < 0.01). 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.

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.

Evaluating Clinical Outcomes of Laparoscopic Subtotal and Total Cholecystectomy for Complicated Acute Cholecystitis: A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis aimed to compare clinical outcomes in patients with complicated acute cholecystitis undergoing laparoscopic total vs subtotal cholecystectomy. This systematic review and meta-analysis was conducted according to PRISMA guidelines and queried PubMed, Embase, ProQuest, Google Scholar, and Cochrane databases from inception to May 2023. The primary outcome was complication rates including common bile duct injury, wound infection, reoperation, bile leak, retained stones, and subhepatic collection, whereas secondary outcomes were in-hospital mortality and hospital length of stay. A total of 7 studies with 135,233 cases were included for meta-analysis. Patients who underwent laparoscopic total cholecystectomy had a significantly lower risk of postoperative bile leaks (RR: .15; 95% CI: .03, .80) and subhepatic fluid collection (RR: 0.19; 95% CI: .06, .63) and were 2.94 times less likely to die compared to those who underwent subtotal cholecystectomy (RR .34; 95% CI: .15, .77). Patients who underwent subtotal cholecystectomy had significantly longer hospital length of stay (mean difference 1.0days; 95% CI: .5days, 1.4days). In adult patients presenting with complicated cholecystitis, management with laparoscopic subtotal cholecystectomy presents a unique complication profile with increased risk of postoperative bile leak and subhepatic fluid collection, in-hospital mortality, and longer hospital length-of-stay when used as an alternative approach to laparoscopic total cholecystectomy. Further research into the most appropriate clinical scenarios and patient populations for the use of the subtotal cholecystectomy approach may prove useful in improving its associated outcomes.

D-line Approach for Safe Laparoscopic Cholecystectomy: Initial Experience.

Introduction The critical view of safety is an important concept for safe laparoscopic cholecystectomy. However, no standard step-by-step approach for achieving the critical view of safety has been established until now. Therefore, this study aims to evaluate a new approach for achieving the critical view of safety using the diagonal line of liver segment IV as an anatomical landmark. Patients and methods In this prospective non-randomized study, patients (n= 112) who underwent laparoscopic cholecystectomy for symptomatic cholelithiasis were included. The first 47 patients underwent laparoscopic cholecystectomy using the diagonal line approach (DLC group) whereas, the next 65 patients underwent laparoscopic cholecystectomy using the conventional method (CLC group). Results No significant difference between both groups regarding the preoperative characteristics, operative time, and intraoperative blood loss. Laparoscopic subtotal cholecystectomy was performed more in the DLC group (6% vs 0%, p= 0.07). Whereas, in the CLC group, there was a tendency towards conversion to open cholecystectomy in difficult cases (6% vs 2%, p= 0.40). No intra- or postoperative complications occurred in either group. Conclusion The diagonal line approach is a feasible and useful step-by-step technique to achieve the critical view of safety in laparoscopic cholecystectomy and enables surgeons to perform safe laparoscopic subtotal cholecystectomy in difficult cases.

Continuous suture closure using a LapraTy® suture clips is an effective method for reconstruction of cystic duct stump after laparoscopic subtotal cholecystectomy

ObjectiveRecently, number of laparoscopic subtotal cholecystectomy (LSC) has been increasing. Summary background dataLSC is suitable as a treatment as it can avoid intraoperative bile duct injury and bleeding for difficult laparoscopic cholecystectomy. On the other hand, improper handling of remnant of GB can lead to postoperative bile leakage. MethodsHere, we report our positive experience utilizing new technique of continuous suture closure and omental covering using Lapra Ty® suture clips on the remnant of GB. ResultsFrom January 2016 to July 2021, we experienced 30 cases of LSC for LC patients who had difficulty securing critical view of safety (CVS). In six of the 30 cases, we repaired remnant of GB using continuous suture closure and omental covering with Lapra Ty® suture clips. The median operating time was 136 min (range 112–199 ml), and amount of bleeding was 1 ml (range 1–100). There were no cases of postoperative bile leakage (postope. BL), remnant cystic duct stone, and abscess formation in abdomen. Conclusionwe recommend this new suturing technique for closure of remnant of GB as it was very effective in preventing postope. BL after LSC.

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.

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.

Laparoscopic Subtotal Cholecystectomy without cystic Duct Ligation

Laparoscopic Subtotal Cholecystectomy without cystic Duct Ligation

Impact of fundus-first laparoscopic cholecystectomy for severe cholecystitis.

The Tokyo Guidelines 2018 proposed fundus-first laparoscopic cholecystectomy (FFLC) as a bailout surgery. This study investigated the clinical impact of FFLC for severe cholecystitis. This study reviewed 772 patients who underwent laparoscopic cholecystectomy (LC) between 2015 and 2018. Of these patients, 171 patients were diagnosed with severe cholecystitis according to our difficulty scoring system. FFLC was not prevalent in our faculty for the first 2years [early period group (EG)], whereas FFLC was predominantly used for the last 2years [late period group (LG)]. There were 81 patients (47%) belonging to the EG and 90 patients (53%) in the LG. The clinical data and the surgical outcomes of these patients were retrospectively analyzed. The difficulty score did not differ between the two groups (11 vs. 11 points, p = 0.846). Patients underwent FFLC significantly more frequently in the LG (63% vs. 12%, p = 0.020). Laparoscopic subtotal cholecystectomy (LSC) was done in 10 patients (11%) of the LG, which was significantly low compared to that in the EG (n = 20, 25%) (p = 0.020). In all patients, LC was safely achieved without bile duct injury or conversion to laparotomy. The incidence of choledocholithiasis was significantly low in the LG (0 vs. 4, p = 0.048). The median postoperative hospital stay was significantly shorter in the LG (6 vs. 4days, p < 0.001). After the introduction of FFLC, there were significant improvements in the surgical outcomes of LC for severe cholecystitis, including the rate of LSC, incidence of choledocholithiasis, and duration of postoperative hospital stay.

The Safe Cholecystectomy: Evaluating the Use of Laparoscopic Subtotal Cholecystectomy Between Junior and Senior Faculty.

Laparoscopic Subtotal Cholecystectomy (SC) is a technique for performing safe cholecystectomy when excessive inflammation prevents exposure of the Critical View of Safety. Studies have evaluated outcomes and complications of laparoscopic cholecystectomy (LC), with mixed results in terms of surgeon experience. It is unclear if the rate of SC is associated with experience. We hypothesized that the rate of SC would decrease as surgical experience increased. We performed a retrospective review of LC performed at an academic medical center. Demographics were analyzed using descriptive statistics. We performed a multivariable logistic regression to examine the relationship between years in practice and performance of SC. We performed a sensitivity analysis comparing those in their first year on faculty with all others. Between November 1, 2017, and November 1, 2021, there were 1222 LC performed. 771 patients (63%) were female. 89 patients (7.3%) underwent SC. There were no bile duct injuries requiring reconstruction. Controlling for age, sex, and ASA class, there was no difference in the rate of SC by years of experience (OR .98, 95% CI .94-1.01). In a sensitivity analysis comparing first-year faculty to those beyond their first year, there was also no difference (OR .76, 95% CI 0.42-1.39). We find no difference in the rate of performance of SC between junior and senior faculty. This reflects consistency, in keeping with best practice guidelines. This could be confounded by junior faculty requesting assistance during difficult operations. Further investigation into factors affecting decision-making may clarify this.

Residual Gallbladder Stones After Cholecystectomy: A Case Report

Introduction: Cholecystectomy is one of the most common surgeries in the world. The gallbladder is removed due to acute or chronic cholecystitis, obstruction of the bile duct, or residual stones. In some cases, part of the gallbladder may remain in place for various reasons, including lack of access and visibility. Case Presentation: In this study, we introduced a 41-year-old male patient who, after subtotal laparoscopic cholecystectomy, showed residual symptoms of the gallbladder and underwent laparoscopic surgery to remove the remnants. Conclusions: Performing subtotal cholecystectomy surgery involves a lot of complications and costs due to the possibility of recurrence and the need for re-surgery, which should be minimized.

Utility of Tokyo Guidelines 2018 in early laparoscopic cholecystectomy for mild and moderate acute calculus cholecystitis: A retrospective cohort study.

Tokyo Guidelines 2018 (TG18) proposed laparoscopic cholecystectomy (LC) for acute calculus cholecystitis (ACC) irrespective of the duration of symptoms. This retrospective study assessed the impact of utility of TG18 in early LC for ACC. From 2018 to 2020, 66 patients with mild (grade I) and moderate (grade II) ACC who underwent early surgery were studied. Subgroup analyses were based on timing of surgery and operation time. A total of 32 and 34 patients were operated within and beyond 7 days since ACC onset. More patients with grade II ACC were in the beyond 7 days group (P < 0.05). More patients with enlarged gallbladder were in the within 7 days group (P < 0.05). The duration of symptoms to admission, symptoms to LC, and operation time were longer in the beyond 7 days group (P < 0.05). There were no significant differences regarding intraoperative blood loss, conversion to bail-out procedures, complication rate, hospital stay, and cost between the two groups (P > 0.05). Longer operation time was significantly associated with duration of symptoms to admission, symptoms to LC, and conversion to laparoscopic subtotal cholecystectomy (LSC) (P < 0.05). In a subset of carefully selected patients, applying TG18 in early LC for mild and moderate ACC results in acceptable clinical outcomes. Standardized safe steps and conversion to LSC in difficult cases are important.

Does the subtotal cholecystectomy rate for acute cholecystitis change with previous endoscopic retrograde cholangiopancreatography?

Acute cholecystitis is one of the most common emergent surgeries. As a safe alternative in challenging operations, laparoscopic subtotal cholecystectomy (LSC) is widely used. We questioned whether the results in acute cholecystitis cases changed with a history of endoscopic retrograde cholangiopancreatography (ERCP). When we searched the literature, we could not find a study focusing on the subtotal cholestectomy results in acute cholecystitis. In our study, we aimed to investigate whether the history of ERCP affects the rates of subtotal cholecystectomy (SC) in acute cholecystitis. The results of patients (n=470) who underwent surgery for acute cholecystitis at our clinic between 2016 and 2019 were retrospectively evaluated. The patients were divided into two groups according to their history of ERCP. The primary outcome was the SC rate. The secondary outcomes were conversion to open, postoperative complications, serious complications, operative duration, and length of hospital stay. The standard group included 437 patients, whereas the ERCP group included 33 patients. A total of 16 patients underwent SC, with 15 in the standard group and 1 in the ERCP group. There was no significant difference in terms of SC rates between groups (P=0.902). While four cases of operation were completed with conversion to open in the non-ERCP group, no conversion was seen in the ERCP group (P=0.581). No significant differences were detected between the groups in terms of complications, serious compli-cations, operation duration, length of hospital stay, and mortality. The results of this study showed that ERCP is not related to an increased rate of SC and conversion in patients with acute cholecystitis. Laparoscopic cholecystectomy for acute cholecystitis can be safely performed in patients with a history of ERCP. LSC is a safe procedure in challenging patients, and fenestrating SC can be preferred to avoid hazardous consequences in such cases.

Predictive factors for subtotal cholecystectomy in delayed elective cholecystectomy after the acute presentation

Background: Approximately 15% of adults in the United Kingdom (UK) are predicted to have gallstone disease, with about 80% of these having asymptomatic gallstones. Patients with symptomatic gallstone disease are recommended to undergo cholecystectomy. Currently, in the UK approximately 60,000 cholecystectomies are performed. During complex laparoscopic cholecystectomies, surgeons may still need to resort to historic procedures such as an open cholecystectomy (5-10%) or even a cholecystostomy. Alternatively considering a subtotal cholecystectomy has been shown to reduce the need for conversion to an open procedure. The aim of our study is to identify pre-operative factors that would predict the need for a subtotal cholecystectomy.Methods: A retrospective study, over a period of 01 March 2019 to 29 February 2020 was undertaken at one of London’s major tertiary centres. We reviewed all adult patients that had undergone laparoscopic cholecystectomies and subtotal cholecystectomies.Results: 243 patients were included in the study after being vetted through the inclusion and exclusion criteria, 95 males and 148 females. 243 patients were identified initially for elective cholecystectomy. 230 were managed surgically, 208 with a total laparoscopic cholecystectomy, and 22 with subtotal laparoscopic cholecystectomy. 243 patients were identified initially for elective cholecystectomy. 230 were managed surgically, 208 with a total laparoscopic cholecystectomy, and 22 with subtotal laparoscopic cholecystectomy.Conclusions: Age, male sex, body mass index (BMI) greater than 30 kg/m2 patients, previous endoscopic retrograde cholangiopancreatography (ERCP), thickened gallbladder walls, and raised preoperative leucocytosis were associated with a greater risk of patients consented for laparoscopic cholecystectomies to undergo a conversion to a subtotal cholecystectomy.