P-BN62 Predictive factors for subtotal cholecystectomy in delayed elective cholecystectomy after acute biliary presentation
Authors: Ebied Husam , Refalo Andrew , Widlund Hedda , white Annabelle 
Published: December 2021

Background

Laparoscopic cholecystectomy is introduced as a treatment option for symptomatic gall bladder disease in 1987 and it is now the gold standard treatment for symptomatic gall bladder disease.

The rate of conversion from laparoscopic to open ranges between 5 and 10% .The step of paramount importance in cholecystectomy is the clear identification of the cystic duct and artery, which in some situations can be difficult especially in presence of dense adhesions or severely inflamed gall bladder, increasing the risk for common bile duct (CBD) injury.  The traditional response to encountering a difficult laparoscopic cholecystectomy procedure is to perform conversion to an open procedure but the open conversion has its drawbacks; The subtotal cholecystectomy has been shown to reduce the need for conversion to an open procedure, thus reducing complications associated with the open cholecystectomy. Studies have also shown that this procedure decreases the bile duct injury rate . Subtotal cholecystectomy rates increased nationally over the past decade.

The aim of our study is to identify factors which could predict the need for a subtotal cholecystectomy in the acute biliary admission group  having delayed elective Laparoscopic cholecystectomy  ,hence proper planning in terms on theatre timing, expertise and patients consenting

Methods

We conducted a retrospective analysis of patients who had delayed elective laparoscopic subtotal cholecystectomy after admission with Acute Biliary disease and managed conservatively  in a tertiary London hospital, between 01/03/2019-29/02/2020 

We collected data for  all patients whose primary diagnosis was either Acute Cholecystitis, Cholelithiasis, Ascending Cholangitis, Choledocholithiasis and Gallstone Pancreatitis, and analysed these in terms of patient demographics, , duration of index admission, laboratory and radiological results during the acute admission and need to intervention during the acute phase either as a drain (cholecystostomy) or ERCP during initial management.

Data were collected from electronic patient records, regarding age, gender, indication for surgery, operative notes, preoperative  gall bladder wall thickness on US scan, laboratory results during acute admission. BMI, other  interventions such as endoscopic retrograde cholangiopancreatography (ERCP) and cholecystostomy Odds ratios were calculated to assess the risk of patients having a subtotal cholecystectomy.

Results

243 patients presented between 01/03/19-29/02/2020 which acute biliary pathology – 95 Male and 148  Female,

230 patients had delayed elective laparoscopic cholecystectomy at least 6 weeks post-acute admission

Of 230 laparoscopic cholecystectomies, 22 (9.56%) cases had a subtotal cholecystectomy

13(59.9%) patients were male patients, median age 72

(54.5%) had BMI more than 30 

No open conversion.

The indication for cholecystectomy in the subtotal group was as follows:

Acute cholecystitis 12 (54.54%), Ascending cholangitis 4 (18.18%), Choledocholithiasis 3(13.63%), gall stone pancreatitis 1(4.5%), Cholelithiasis 2 (9.09%)The  subtotal cholecystectomy group had Gall bladder wall thickness  during index admission  documented 4 (18.18%)patients had Gall bladder wall thickness  less than 4 or equal 4 mm, 18(81.81%) patients had Gall bladder wall thickness more 4 mm.

Odds ratios were calculated to assess the correlation between several characteristics and the likelihood of having a subtotal cholecystectomy  in the delayed elective cholecystectomy, we concluded that Older age, male sex, BMI more than 30, previous ERCP, thickened GB wall on ultrasound scan more than 4 mm  WCC &gt; 15000  during acute admission, all increased the likelihood of having a subtotal cholecystectomy

Conclusions

Older age, male sex, BMI more than 30, previous ERCP, thickened GB wall on ultrasound scan more than 4 mm  WCC &gt; 15000  during acute admission all increased the likelihood of having a subtotal cholecystectomy. 

We recommend all these information should be documented during planning for laparoscopic cholecystectomy to allow proper theatre time planning and patient consenting for the possibility of having a subtotal cholecystectomy.