Indications and Outcomes of Completion Cholecystectomy: A 5-year Experience From a Rural Tertiary Center

Abstract

Background Completion cholecystectomy (CC) is performed for recurrent or persistent biliary symptoms following subtotal cholecystectomy (STC) or incomplete cholecystectomy (IC). Due to its complexity, cases are often referred to hepato-pancreato-biliary (HBP) surgeons. There is little published literature on indications or outcomes of CC. Methods Completion cholecystectomy cases performed between 2016 and 2021 by the sole HPB surgeon covering a rural referral base of >250-mile radius in West Texas were included. Primary variables of interest include indications and outcomes of CC. Results Of the eleven patients included, 5 (45.5%) had laparoscopic STC, 3 patients (27.3%) had laparoscopic converted to open STC, and 2 (18.2%) had laparoscopic IC. Most STC cases (6/9, 66.6%) were reconstituting, while 3 STC cases were fenestrating (all had persistent bile leak). For reconstituting STC, indications were symptomatic cholelithiasis in 5 patients (45.5%), and choledocholithiasis in 3 patients (27.3%). The median (IQR) duration between index procedure and subsequent CC was 15 (1.4-92) months. The median (IQR) remnant gallbladder length was 4 (3-4.5) cm. Completion cholecystectomy was performed robotically in 8 cases (72.7%). Post-CC complications occurred in 3 patients (27.3%); these were 1 superficial surgical site infection, 1 hepatic abscess requiring percutaneous drainage, and lastly atrial fibrillation. Conclusions All patients requiring CC had residual gallbladder remnant >2.5 cm; this is longer than recommended for STC. Completion cholecystectomy is a complex operation that carries significant morbidity, even when performed using minimally invasive techniques. As bailout procedures become more common in severely inflamed cholecystitis, it is important to collate more data on the outcomes of requiring CC.

Choledocholithiasis secondary to a remnant gallbladder post cholecystectomy more than 20 years ago

“…2 Risk factors for post-cholecystectomy choledocholithiasis (PCC) are long cystic duct stump and SC or IC. [3][4][5] A study of 362 patients who had undergone a laparoscopic cholecystectomy (LC) for benign disease had a PCC incidence of 23.5%. The authors found a median cystic duct stump length on MRI of 31mm or greater was a significant risk factor for PCC.…”

“…7,8 IC differs from SC in that it is due to improper identification of the anatomy intraoperatively resulting in ligation and division of the gallbladder body or fundus instead of the cystic duct, therefore leaving a reconstituted gallbladder remnant. 4 Currently, there is no consensus on the optimal method of SC and each subtype has its own pitfalls.…”

“…There is a paucity of data to guide which patients should undergo CC after SC, however single centre studies have quoted rates of between 0% and 9%. 4,8,9 Review of the current literature suggests that, with the exception of symptomatic patients, elective CC may be justifiable with imaging evidence of a large gallbladder remnant, recurrent/residual calculi with consideration to patient and surgeon preference.…”

Comparing Outcomes of Sub-Total Cholecystectomy Versus Open Cholecystectomy as Bailout Procedures for the Difficult Gallbladder

“…These procedures were completed robotically without complication, and the patients had no further issues. 13 There is a possibility that among the 12.3% of patients in the group that were lost to followup, some may have been lost before the need for reintervention was recognized and may have sought care at other referral centers for this complication; this would result in under-estimation of the reoperation rate.…”

“…These procedures were performed by a hepatopancreaticobiliary surgeon at the same institution, and are described in detail elsewhere. 13…”