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

Document Type

Article

Publication Date

2025

Publication Title

Journal of the American College of Surgeons

Abstract

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

STUDY DESIGN: 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 fenestrating or reconstituting technique by standardized definitions. We also captured interventional radiology (IR) and endoscopic retrograde cholangiopancreatography (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.

RESULTS: 369 patients underwent STC. Fenestrating technique utilization varied widely across hospitals (45-95%). Fenestrating technique was associated with an increased rate of bile leak (22.0 vs 6.9%, aOR 4.34, 95% CI 1.95-9.65, p< 0.001), and reconstituting technique was associated with an increase in retained common bile duct stones (14.3 vs 4.2%, aOR 4.72, 95% CI 2.27-9.83, p< 0.001). Other clinical outcomes were similar. Fenestrating technique was associated with more postoperative IR or ERCP procedures (36.3 vs 19.4%, p=0.01), and 71% of ERCPs occurred by postoperative day 2. 40% of all postoperative ERCPs were not associated with a finding of bile leak or retained common bile duct stones.

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

DOI

10.1097/xcs.0000000000001651

ISSN

1879-1190

PubMed ID

41051080

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