Early Outcomes of Subtotal vs Total Cholecystectomy for Acute Cholecystitis

Subtotal cholecystectomy (STC) is increasingly used as an alternative to total cholecystectomy (TC) for difficult gallbladder surgeries.¹ Prior studies suggested a decreased rate of bile duct injuries.² However, the remnant gallbladder after STC may lead to significant postoperative complications, including bile leak.³ With increasing rates of STC in the US,⁴ understanding risks of this procedure is important. This multicenter study compared short-term outcomes after STC vs TC.

In this cohort study, a multi-institutional retrospective review was performed at 3 public US hospitals. Patients who underwent nonelective cholecystectomy from January 2016 to December 2020 were included. Primary outcomes included 30-day morbidity, reinterventions (ie, endoscopic retrograde cholangiopancreatography [ERCP], percutaneous drainage, and reoperation), and postoperative length of stay (LOS). The study was approved by the institutional review board at each institution, which determined the research met the criteria for an exempt determination (45 CFR 46.104). We followed the STROBE reporting guideline. Data were analyzed using SAS, version 9.4. Two-sided P < .05 was significant.

A total of 741 patients underwent cholecystectomy, of which 87 (11.7%) were STC. Compared with patients undergoing TC, patients undergoing STC were more likely to be male (43 [49.4%] vs 248 [37.9%]; P = .04) and older (median [IQR] age, 48 [38-61] vs 45 [33-55] years; P = .01) and to have a drain placed during surgery (63 [72.4%] vs 83 [12.7%]; P < .001). Cholecystitis severity was similar between groups, as defined by Tokyo grades (Table 1).

The STC cohort had higher rates of 30-day complications (29 [33.3%] vs 46 [7.0%]; P < .001), including bile leak (19 [21.8%] vs 6 [0.9%]; P < .001) and intra-abdominal abscess (5 [5.7%] vs 7 [1.1%]; P = .008) (Table 2). STC was associated with higher rates of reintervention (30 [34.5%] vs 28 [4.3%]; P < .001) and longer postoperative LOS (median [IQR], 3 [2-5] vs 1 [1-2] days; P < .001). The TC group had 2 bile duct injuries (0.3%), and the STC group had none (P > .99). The STC group had higher 30-day readmission rates (17 [19.5%] vs 29 [4.4%]; P < .001), but 30-day mortality was similar. In multivariate regression analysis adjusting for comorbidity, grade of cholecystitis, demographics, and hospital, STC was independently associated with more 30-day complications (OR, 4.3; 95% CI, 3.6-5.4; P < .001) and reinterventions (OR, 3.5; 95% CI, 3.0-4.1; P < .001) and longer postoperative LOS (median difference, 2.5 days; 95% CI, 2.1-2.9 days; P < .001).

Subanalysis of laparoscopic STC (n = 60) vs open TC (n = 47) revealed similar complications, LOS, and 30-day readmissions. The laparoscopic STC group was more than twice as likely to require reintervention (OR, 2.6; 95% CI, 1.0-6.9; P = .045).

In this study, STC was associated with more short-term complications, longer LOS, and higher rates of readmission vs TC, regardless of cholecystitis grade. The rate of bile duct injury was higher with TC. However, these data are limited by sample size and may not accurately reflect differences in these rare complications.

Surgeons encountering significant inflammation at the hepatocystic triangle have the dilemma of proceeding with a difficult dissection or opting for partial resection. The optional approach of conversion to an open procedure has become less common,⁴ with fewer surgeons trained in open cholecystectomy. Our study suggests that laparoscopic STC has similar complications, LOS, and readmissions vs open TC; however, laparoscopic STC required more reinterventions. Therefore, conversion to open cholecystectomy may be preferred.

STC has gained popularity as an option for challenging gallbladder surgeries; however, in this study, STC was associated with significantly higher postoperative morbidity vs TC. Prospective studies are needed to guide patient selection for each procedure and better understand long-term complications. Although STC may have a role in challenging gallbladder surgeries, its use should be weighed against associations with increased morbidity, longer LOS, and higher readmission rates.

Accepted for Publication: May 18, 2022.

Published Online: September 14, 2022. doi:10.1001/jamasurg.2022.3146

Corresponding Author: Caitlyn Braschi, MD, Department of Surgery, Harbor-UCLA Medical Center, 1000 W Carson St, Box 461, Torrance, CA 90505 (cbraschi@dhs.lacounty.gov).

Author Contributions: Dr Keeley had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Braschi, Tang, Keeley.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Braschi, Keeley.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Braschi.

Administrative, technical, or material support: Tung, Tang, Delgado, Uribe, Senekjian.

Supervision: Senekjian, Keeley.

Conflict of Interest Disclosures: None reported.

Additional Contributions: Amy Kaji, MD, PhD (Harbor-UCLA Medical Center), performed statistical analysis. Darin Saltzman, MD, PhD (UCSF-East Bay), assisted with study design and oversight. Caitlin Cohan, MD (UCSF-East Bay), Genna Beattie, MD (UCSF-East Bay), and Anibal La Riva, MD (Harbor-UCLA Medical Center), contributed to data collection. They were not compensated for their work.