Subtotal Cholecystectomy Results in High Peri‐operative Morbidity and Its Risk‐Profile Should be Emphasised During Consent

Abstract

Background Subtotal cholecystectomy aims to reduce the likelihood of bile duct injury but risks a multitude of less severe, yet significant complications. The primary aim of the present study was to report peri-operative outcomes of subtotal laparoscopic cholecystectomy (SLC) relative to total laparoscopic cholecystectomy (TLC) to inform the consent process. Method All laparoscopic cholecystectomies between 2015 and 2020 in one health board were included. The peri-operative outcomes of SLC (n = 87) and TLC (n = 2650) were reported. Pre-operative variables were compared between the two groups to identify risk factors for SLC. The outcomes between the SLC and TLC were compared using univariate, multivariate and propensity analysis. Results Risk factors for SLC included higher age, male gender, cholecystitis, increased biliary admissions, ERCP, cholecystostomy and emergency cholecystectomy. Following SLC, rates of post-operative complication (45.9%), imaging (37.9%) intervention (28.7%) and readmission (29.9%) were significant. The risk profile was vastly heightened compared to that of TLC: intra-operative complications (RR 9.0; p < 0.001), post-operative complications [bile leak (RR 58.9; p < 0.001), collection (RR 12.2; p < 0.001), retained stones (RR 7.2; p < 0.001) and pneumonia (RR 5.4; p < 0.001)], post-operative imaging (RR 4.4; p < 0.001), post-operative intervention (RR 12.3; p < 0.001), prolonged PLOS (RR 11.3; p < 0.001) and readmission (RR 4.5; p < 0.001). The findings were consistent using multivariate logistic regression and propensity analysis. Conclusion The relative morbidity associated with SLC is significant and high-risk patients should be counselled for the peri-operative morbidity of subtotal cholecystectomy.

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

“…It should be noted that not only was this study conducted outside of the US, but the authors also do not indicate a timeframe for readmission. 18 It should be noted that both of these studies use propensity matching, which may have introduced bias by further reducing sample sizes.…”

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

“…The quality of evidence was assessed by using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group Criteria. 20 The quality of evidence was high to moderate in five studies 13,15,16,18,19 and low in two studies 14,17 (Supplementary file: eTable 2). The risk of bias was evaluated using the Joanna Briggs Institute (JBI) critical appraisal checklist for observational studies (Supplementary file: eTable 3).…”

“…Three studies evaluated the rate of subhepatic collection. 12,13,15 Two studies 12,13 found a greater rate of subhepatic collection in the subtotal cohort, and one study 15 found no difference. Seven studies evaluated inhospital mortality, of which one study 19 reported significantly higher in-hospital mortality in the subtotal group compared to the total group, and six studies [13][14][15][16][17][18] did not find a significant difference between cohorts.…”

“…Complicated acute cholecystitis was defined by the presence of pericholecystic adhesions, empyema, gangrene, perforation, or severe inflammation. [13][14][15][16][17][18][19] Data Collection…”

“…Seven studies evaluated inhospital mortality, of which one study 19 reported significantly higher in-hospital mortality in the subtotal group compared to the total group, and six studies [13][14][15][16][17][18] did not find a significant difference between cohorts. 13,[16][17][18] Seven studies evaluated hospital length of stay (H-LOS), of which two studies 15,19 reported significantly higher H-LOS days for the subtotal group, and four studies 14,[16][17][18] reported no significant difference. One study found higher H-LOS in the subtotal group but did not provide a P-value (Table 1) (Table 2).…”