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Laparoscopic subtotal cholecystectomy after percutaneous transhepatic gallbladder drainage for grade II or III acute
Masafumi Ie1, Morihiro Katsura2, Yukihiro Kanda2
1Department of General Surgery, Okinawa Chubu Hospital, 281 Miyazato, Uruma, Okinawa, Japan. iemasafumi1201@yahoo.co.jp.
Insights
Subtotal cholecystectomy (SC) is a safe and feasible option for managing difficult acute cholecystitis (AC) after percutaneous transhepatic gallbladder drainage (PTGBD). This approach increases laparoscopic surgery completion rates, reducing open conversions.
Area of Science:
- Hepatobiliary surgery
- Minimally invasive surgery
- Gastroenterology
Background:
- Severe adhesions post-PTGBD complicate total cholecystectomy, increasing open conversion rates.
- Tokyo Guidelines 2018 (TG18) shifted strategy towards subtotal cholecystectomy (SC) for difficult cholecystitis cases.
- Laparoscopic SC efficacy after PTGBD requires further evaluation.
Purpose of the Study:
- To evaluate the safety and feasibility of laparoscopic SC after PTGBD for grade II or III acute cholecystitis (AC).
- To compare surgical outcomes between pre-TG18 and post-TG18 eras with altered surgical strategies.
Main Methods:
- Retrospective cohort study (2013-2020) of 44 patients with grade II or III AC.
- Patients divided into pre-TG18 (n=17) and post-TG18 (n=27) groups.
- Comparison of demographics, surgical methods, outcomes, and complications.
Main Results:
- Laparoscopic cholecystectomy rates increased significantly post-TG18 (52.9% to 88.9%).
- Laparoscopic SC rates increased significantly (0% to 90.9% of SC cases), while open SC decreased (100% to 9.1%).
- No significant differences in operative time, blood loss, or major complications; no mortality, bile leakage, or bile duct injury.
Conclusions:
- Aggressive adoption of SC after PTGBD improves laparoscopic surgery completion rates for AC.
- Laparoscopic SC is a safe and feasible treatment option for complex cholecystitis cases.
Background:
Severe adhesions and fibrosis between the posterior wall of the gallbladder and liver bed often render total cholecystectomy after percutaneous transhepatic gallbladder drainage (PTGBD) difficult, leading to high open conversion rates. Since the publication of Tokyo Guidelines 2018 (TG18), our policy has shifted from open conversion to subtotal cholecystectomy (SC) when total laparoscopic cholecystectomy for difficult cases of cholecystitis is not feasible. Recently, SC has been frequently applied as bailout surgery for complicated cholecystitis. Nonetheless, the efficacy and validity of laparoscopic SC after PTGBD remain unclear. This study aimed to evaluate the safety and feasibility of laparoscopic SC after PTGBD for grade II or III acute cholecystitis (AC) by comparing two periods of altered surgical strategies.
Methods:
This retrospective cohort study was conducted between January 2013 and December 2020. A total of 44 eligible patients with grade II or III AC were divided according to the time of cholecystitis onset into the pre-TG18 group (2013-2017, n = 17) and post-TG18 group (2018-2020, n = 27). Patients' background demographics, surgical method, surgical results, and postoperative complications were compared.
Results:
The interval between PTGBD and surgery was significantly longer in the post-TG18 group than in the pre-TG18 group (15 [interquartile range: 9-42] days vs. 8 [4-11] days; P = 0.010). The frequency of laparoscopic cholecystectomy significantly increased from 52.9% in the pre-TG18 group to 88.9% in the post-TG18 group (P = 0.007), whereas the frequency of SC was 23.5% and 40.7%, respectively, which showed no statistically significant difference (P = 0.241). However, the rate of laparoscopic SC significantly increased from 0 to 90.9% among 15 SC cases, whereas the rate of open SC significantly plummeted from 100 to 9.1% (P = 0.001). Significant differences in the operative time, amount of intraoperative bleeding, and incidence of postoperative complications (wound infection and subhepatic abscess) were not observed. Mortality, bile leakage, and bile duct injury did not occur in either group.
Conclusions:
For grade II or III AC after PTGBD, aggressive adoption of SC increased the completion rate of laparoscopic surgery. Laparoscopic SC is a safe and feasible treatment option.
