Predictive factors for subtotal cholecystectomy in delayed elective cholecystectomy after the acute presentation
Keywords:Cholecystectomy, Laparoscopic cholecystectomy, Subtotal cholecystectomy
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.
National institute for health and care excellence. Guidance: Gallstone diseases. 2014. Available at https://www.nice.org.uk/guidance/qs104/documents/gallstone-disease-qs-briefing-paper2. Accessed on 13 September 2022.
Joar S, Litynski GS. Highlights in the history of laparoscopy. Eur J Surg. 1998;11:165-8.
Walker R. The First Laparoscopic Cholecystectomy. JSLS. 2001;5(1):89-94.
Tang A, Cohan CM, Beattie G, Mooney CM, Chiang A, Keeley JA. Factors that Predict the Need for Subtotal Cholecystectomy. Am Surg. 2021;87(8):1245-51.
Murray AC, Markar S, Mackenzie H, Baser O, Wiggins T, Askari A, et al. An observational study of the timing of surgery, use of laparoscopy and outcomes for acute cholecystitis in the USA and UK. Surg Endosc. 2018;32(7):3055-63.
Fouad MMB, Rezk SSS, Saber AT, Khalifa A, Ibraheim P, Ibraheim SMN. Effect of the COVID-19 Pandemic on the Management of Acute Cholecystitis and Assessment of the Crisis Approach: A Multicenter Experience in Egypt. Asian J Endosc Surg. 2022;15(1):128-36.
Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020;(4):844-7.
Duca S, Bãlã O, Al-Hajjar N, Lancu C, Puia IC, Munteanu D, Graur F. Laparoscopic cholecystectomy: incidents and complications. A retrospective analysis of 9542 consecutive laparoscopic operations. HPB (Oxford). 2003;5(3):152-8.
LeCompte MT, Robbins KJ, Williams GA, Sanford DE, Hammill CW, Fields RC, Hawkins WG, Strasberg SM. Less is more in the difficult gallbladder: recent evolution of subtotal cholecystectomy in a single HPB unit. Surg Endosc. 2021;35(7):3249-57.
Sabour AF, Matsushima K, Love BE, Alicuben ET, Schellenberg MA, Inaba K, Demetriades D. Nationwide trends in the use of subtotal cholecystectomy for acute cholecystitis. Surgery. 2020;167(3):569-74.
Nassar AHM, Hodson J, Ng HJ, Vohra RS, Katbeh T, Zino S, Griffiths EA; CholeS Study Group, West Midlands Research Collaborative. Predicting the difficult laparoscopic cholecystectomy: development and validation of a pre-operative risk score using an objective operative difficulty grading system. Surg Endosc. 2020;34(10):4549-61.
Elshaer M, Gravante G, Thomas K, Sorge R, Al-Hamali S, Ebdewi H. Subtotal cholecystectomy for "difficult gallbladders": systematic review and meta-analysis. JAMA Surg. 2015;150(2):159-68.
Macdonald N, Clements C, Sobti A, Rossiter D, Unnithan A, Bosanquet N. The building backlog of NHS elective cases post Covid-19. Br J Surg. 2020;107(10):e377-8.
Dobbs TD, Gibson JAG, Fowler AJ, Abbott TE, Shahid T, Torabi F, et al. Surgical activity in England and Wales during the COVID-19 pandemic: a nationwide observational cohort study. Br J Anaesth. 2021;127(2):196-204.
Boyle LI, Boyle A, Jay S, Marnewick J. COVID-19 lockdown impact on common general surgical acute presentations to a regional centre in New Zealand. N Z Med J. 2020;133(1525):96-105.