Fenestrating vs Reconstituting - Outcomes following 170 subtotal cholecystectomies.
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Authors
Brown, Jamie
Horgan, Liam
Thomas, C.
Wintrip, D.
Issue Date
2022
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Abstract
Background: Laparoscopic subtotal cholecystectomy (LSC) is a recognised option when the “critical view” cannot be safely delineated. It carries a high morbidity rate with increased frequencies of a bile leak occurring however reducing the risk of bile duct injury. LSC can be classified into fenestrating or reconstituting cholecystectomy and surgical practice varies as reconstituting is considered to be more complex. Our aim of the study was to look at LSC with respect to the techniques used, complications and the overall outcomes.
Methods: All adult patients undergoing LSC between January 2015 – December 2021 were retrospectively identified on our electronic database. Data gathered included: Patient demographics, previous acute biliary presentations, operative details/technique, length of stay (LOS), 30-complications, 30-day mortality, readmissions and follow up investigations/procedures. Descriptive statistics, Chi squared, and relative risk were used to analyse results.
Results: 170 patients underwent LSC in the study period with the rate increasing most years. Median age was 67 with 86:84 Female to Male ratio. Rates varied drastically between different surgeons from 0.1% to 19% compared to total number of laparoscopic cholecystectomies. 130 (76%) were performed in the acute setting and 63/170 (37%) had previous acute biliary presentations. Median LOS was 5 days. Most patients had Fenistrating LSC (155 [67.6%] vs. 55 [32.3%]).
80 (47%) patients had complications. These were graded by Clavin-dindo grade: I – 3 (3.7%); II – 34 (42.5%); IIIa – 26 (32.5%); IIIb – 16 (20%) and IV – 1 (1.25%). The most frequent complication was bile leak; 60 (35.2%) followed by collection 8 (4.7%). Other notable complications were pancreatitis; 3 (1.7%), AKI; 2 (1%), bile duct injury; 1 (0.5%) and duodenal injury; 1 (0.5%). 16 (9.4%) patients had returns to theatre, 14 (8.2%) patients had readmissions and 35 (20.5%) had multiple attendances to the day unit following discharge. Further analysis demonstrated that that fenestrated technique was associated with a greater risk of bile leak (p<0.01 RR 2.1 [95% C.I. 1.3–6.3]) and post operative ERCP (p<0.01 RR 3.8 [95% C.I. 1.6–14]). 2 (1.1%) patients required completion cholecystectomy, one form each technique.
Conclusions: We present one of the largest single unit datasets on LSC, and the 2nd largest from UK population. Our rate of LSC is increasing, likely as a safe alternative to open conversion, with large surgeon variability. The majority are performed in the acute setting with the fenestrated technique. We have demonstrated however that LSC has a high morbidity, both in reoperation/reintervention rate, readmission and complications accompanied by high follow-up requirement. Despite fenestrated being the favoured technique in our unit we have shown that it has poorer outcomes. Our data would suggest that if LSC is to be performed then the reconstituted technique should be used if possible.
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Thomas, C., Wintrip, D., Horgan, L. and Brown, J. (2022) OGBN P07 Fenestrating vs Reconstituting - Outcomes following 170 subtotal cholecystectomies. British Journal of Surgery; 109 (supp_9) : znac404.052.
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British Journal of Surgery
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1365-2168