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Efficacy of bailout surgery for preventing intraoperative biliary injury in acute cholecystitis
Tomoyuki Abe1, Akihiko Oshita2,3, Nobuaki Fujikuni2
1Department of Surgery, Onomichi General Hospital, 1-10-23 Hirahara, Onomichi, Hiroshima, Japan. t.abe.hiroshima@gmail.com.
Insights
Bailout surgery (BOS) is a safe and effective approach for difficult acute cholecystitis cases, preventing bile duct injury. Laparoscopic BOS offers the best outcomes, reducing bleeding and bile leakage.
Area of Science:
- Gastroenterology
- Surgical Innovation
- Patient Safety
Background:
- Bailout surgery (BOS) is recommended for complex cholecystectomies.
- Its effectiveness in preventing bleeding and bile duct injury (BDI) in acute cholecystitis (AC) is not well-established.
Purpose of the Study:
- To retrospectively validate the feasibility and safety of BOS for AC.
- To identify risk factors associated with the need for BOS in AC patients.
Main Methods:
- Retrospective analysis of 479 patients undergoing emergency cholecystectomy for AC.
- Univariate, multivariate, and propensity score matching (PSM) analyses were used.
- Comparison of perioperative variables between total cholecystectomy (TC) and BOS groups.
Main Results:
- BOS patients had higher ASA and Charlson scores, TG18 grade, WBC, and lower albumin/CRP.
- CT showed severe inflammation in BOS group; however, PSM analysis revealed no significant difference in postoperative complications.
- BOS completely prevented BDI, and laparoscopic BOS (lap-BOS) was most effective in reducing blood loss and bile leakage.
Conclusions:
- TG18 grade ≥II, CRP ≥7.7, and duodenal edema are independent risk factors for BOS.
- BOS is a safe, feasible, and effective procedure for preventing BDI in AC.
- Laparoscopic BOS demonstrates superior postoperative outcomes compared to other BOS methods.
Background:
Bailout surgery (BOS; partial cholecystectomy, open conversion, and fundus-first approach) has been recommended for difficult cases to ensure safe performance of cholecystectomy. However, the efficacy of BOS for preventing intraoperative massive bleeding and bile duct injury (BDI) remains unclear, especially in the context of acute cholecystitis (AC). This study aimed to retrospectively validate the feasibility of BOS for AC.
Methods:
We enrolled 479 patients who underwent emergency cholecystectomies for AC between 2011 and 2021. Univariate and multivariate analyses were performed to detect the risk factors for BOS in patients with AC. Perioperative variables were compared between patients who underwent total cholecystectomy (TC) and those who underwent BOS. Propensity score matching analysis was performed to compare the two groups.
Results:
Significant differences in American Society of Anesthesiologists physical status and Charlson Comorbidity Index scores, TG18 severity grading, white blood cell count, and albumin and C-reactive protein (CRP) levels were found between the TC and BOS groups. Preoperative CT imaging demonstrated severe inflammation evidenced by gallbladder wall thickness, enhancement of the liver bed, and duodenal edema in the BOS group compared to the TC group. Postoperative complications were significantly higher in the BOS group than in the TC group. Further, BDI was completely prevented by BOS. Multivariate analysis identified TG18 grade ≥ II, CRP ≥ 7.7, and duodenal edema as independent risk factors for BOS. After PSM analysis, postoperative complications were not worse in patients who underwent BOS rather than TC. Among BOS procedures, laparoscopic BOS (lap-BOS) was the most efficacious in preventing intraoperative blood loss and postoperative bile leakage.
Conclusion:
Severity grading > II, elevated CRP levels, or duodenum edema revealed by CT were determined to be risk factors impeding total cholecystectomy. BOS is a safe, feasible, and efficacious procedure for preventing BDI. Among BOS procedures, lap-BOS showed better postoperative outcomes.
