Fenestrating or Reconstituting? The Impact of Subtotal Cholecystectomy Technique on Postoperative Outcomes and...

Although subtotal cholecystectomy (STC) is a safe bailout procedure for difficult cholecystectomies, usage of fenestrating or reconstituting operative techniques by surgeons and the subsequent outcomes achieved are unclear. As existing data are primarily limited to small, single-institution studies, we leveraged data from a statewide, multi-institutional collaborative to evaluate the impact of the STC technique on postoperative outcomes and procedures.

We prospectively identified patients who underwent STC across 11 hospitals in an Emergency General Surgery Collaborative Quality Initiative over 5 years. Patients were classified into those using fenestrating or reconstituting technique by standardized definitions. We also captured interventional radiology and ERCP procedures during index admission and subsequent encounters. Risk-adjusted outcomes were evaluated using multivariable regression models accounting for sociodemographic, comorbidity, and disease severity data.

A total of 369 patients underwent STC. Fenestrating technique usage varied widely across hospitals (45% to 95%). Fenestrating technique was associated with an increased rate of bile leak (22.0% vs 6.9%, adjusted odds ratio 4.34, 95% CI 1.95 to 9.65, p < 0.001), and reconstituting technique was associated with an increase in retained common bile duct stones (14.3 vs 4.2%, adjusted odds ratio 4.72, 95% CI 2.27 to 9.83, p < 0.001). Other clinical outcomes were similar. Fenestrating technique was associated with more postoperative interventional radiology or ERCP procedures (36.3% vs 19.4%, p = 0.01), and 71% of ERCPs occurred by postoperative day 2. Forty percent of all postoperative ERCPs were not associated with a finding of bile leak or retained common bile duct stones.

The distinct clinical outcomes and postoperative procedure profiles imply that the STC technique should be tailored to clinical circumstances. Patient characteristics, advanced endoscopy availability, and surgeon familiarity should guide the choice of STC technique. Creation of guidance measures to optimize postoperative ERCP usage should be undertaken.