Subtotal Versus Total Cholecystectomy in Complicated

Cholecystitis

Daniel Kaplan, BA, Kenji Inaba, MD, Konstantinos Chouliaras, MD, Garren M. I. Low, MS, Elizabeth Benjamin, MD, Lydia Lam, MD,

Daniel Grabo, MD, Demetrios Demetriades, MD, PhD 

LAC+USC Medical Center, Division of Trauma Surgery and Surgical Critical Care, University of Southern California, Los Angeles, CA

• No disclosures

Financial Disclosures

2

• 10-15% of adults developed world

• ~$6.2 billion annually

• Lap chole most common elective surgery US

Burden of Gallstone Disease

3Stinton L, Shaffer, E. Epidemiology of Gallbladder Disease: Cholelithiasis and Cancer. Gut and Liver. 2012. Apr;6(2): 172-187.

4

Difficult Cholecystectomy• Severe inflammation • Fibrosis• Aberrant anatomy

Calot’s Triangle

Complications• CBD injury• Vascular injury• Hollow viscous injury

5

Conversion to Open total chole• Conversion rates vary btw 1.5-10%

Tang B, Cuschieri A. Conversions during laparoscopic cholecystectomy: risk factors and effects on patient outcome. J Gastrointest Surg. 2006. (10):1081-1091.

6

Subtotal Cholecystectomy• Introduced by

Bornman et al. 1985 to reduce CBD injury

• Involves excision of anterior wall and closure of cystic duct from within GB

Michalowski K, Bornman PC, Krige JE, Gallagher PJ, Terblanche J. Laparoscopic subtotal cholecystectomy in patients with complicated acute cholecystitis or fibrosis. Br J Surg. 1998 Jul;85(7):904-6.

7

Objective• To compare the outcomes between

subtotal cholecystectomy vs. open total cholecystectomy in patients with complicated cholecystitis

• Retrospective analysis• 1/2008 - 12/2012 (5 years)

• ICD-9 codes for Open Cholecystectomy and Subtotal Cholecystectomy

Methods

8

• Study groups• Subtotal Cholecystectomy (63)• Lap converted to OTC (151)

Methods

9

• Chart review• Preoperative labs • Imaging• Operative and discharge notes

Methods

10

• Outcomes• HLOS• ICU LOS• Intraoperative complications

• CBD injury• Vascular injury• Hollow viscous injury• Bile Leak• Retained Gallstones• Wound Infections• Subhepatic Abscesses

Methods

11

Severe Complications

SC (N=63) OTC (N=151)

p-value

Age 47.9±14.3 45.3±14.3 0.219

Gender (female)

54.0% 51.7% 0.758

Diabetes 12.7% 13.2% 0.914

HTN 17.5% 17.3% 0.966

Results: Demographics

12

Eleva

ted

Tot.

Bili (>

1.2)

Eleva

ted

Alk. P

hos (>

140)

Eleva

ted

ALT (>

56)

Eleva

ted

AST (>

40)

Eleva

ted

Lipa

se (>

100)

Eleva

ted

Amyl

ase

(>14

0)

Eleva

ted

Lact

ate

(>2.

2)0.00%

10.00%20.00%30.00%40.00%50.00%60.00%

SCOTC

Pre-op Labs

*WBC counts for SC and OTC groups were 13.7±4.7 and 14.3±5.4 respectively

Imaging and Operative Findings

0%

20%

40%

60%

SCOTC

SC (N=63) OTC (N=151)

p-value

HLOS 11.5±11 6.7±7 0.002

ICU LOS 3.9±7.3 4.9±10.8 0.685

Length of Stay

15

Complications

Wou

nd In

fect

ions

Vascu

lar I

njur

y

CBD inju

ry

Hol

low v

isco

us in

jury

Subh

epat

ic a

bsce

sses

Retai

ned

Ston

es

Fluid

col

lect

ions

Bile L

eaks

0.00%1.00%2.00%3.00%4.00%5.00%6.00%

Subtotal Open Total

*Only complications occurring after conversion were included in this analysis

SC (N=63) OTC (N=151)

p-value

Vascular Injury

0.0% 4.0% 0.325

CBD injury 0.0% 3.3% 0.108

Hollow Viscous

0.0% 0.6% 1.000

Total 0.0% 7.9% 0.036

Severe Complications

17

18

Conclusions• SC is a viable alternative• Significant decrease severe

complications• CBD injury + vascular injury + hollow

viscous• Further study is needed

• Prospective design using predictive scale to control for difficulty of cholecystectomy

Thank You