Difficulties in performing cholecystectomy include a lack of clarity of the anatomical orientation of the Calot’s triangle, resulting from severe, acute inflammation or chronic atrophic sclerotic change. In this situation, subtotal cholecystectomy is recommended for a safe surgery. Subtotal cholecystectomy can be performed using 2 methods: dissecting the neck of the gallbladder rather than approaching the Calot’s triangle to prevent bile duct injury or not removing the posterior wall of the gallbladder to prevent bleeding from the liver bed. In the latter method, ablation of the remaining mucosa is common and is referred to as CM.
In principle, the gallbladder should be completely resected, as gallbladder carcinoma has been reported in 0.3–1.5% of patients who have undergone cholecystectomy [26
]; therefore, it is necessary to check for any signs of malignancy during preoperative diagnostic imaging. Because CM or subtotal cholecystectomy may result in an intraoperative bile leak into the abdominal cavity, these procedures are associated with potential dissemination. Although there are no reports of residual gallbladder cancer following CM or subtotal cholecystectomy, Shimizu et al. reported a case of biliary tract cancer in the liver bed after subtotal cholecystectomy. They considered the possibility of a peripheral type of intrahepatic cholangiocarcinoma as well as carcinomas from the residual gallbladder mucosa or the Luschka duct [28
]. Therefore, regular follow-ups with diagnostic imaging are needed, even when the patient does not show pathological evidence of malignancy.
The frequency of postoperative complications in subtotal cholecystectomies has been reported to be 6.7–20.7% [17
], with the patients having an average age of 53–62.9
years. In the current study, a relatively high incidence of postoperative complications (33% [6/18]) was observed, and the average age of patients in the CM group was 71.1
years. In particular, 2 patients were found to have postoperative bile leakage, both of whom were treated with drainage only, without processing of the bile duct stump. One patient required endoscopic biliary drainage (EBD) and the other recovered spontaneously without any additional treatment. The reason for the spontaneous closure was presumed to be the result of postoperative firm adhesion and scar formation, which is expected in patients with advanced inflammation. The SC group had 4 patients with postoperative bile leakage. Two patients required a reoperation for bile leakage closure, and the other 2 were treated by diversion of bile from the leakage site by EBD or percutaneous transhepatic cholangial drainage. There were no significant differences between the two groups in additional treatment (P
0.06), but the treatment for bile leakage in SC group was more difficult.
Few detailed studies have reported on intraoperative findings in these types of cholecystectomies. In the CM group, there was no evidence of intraoperative damage to the biliary tract, a finding that was similar in the SC group. Additionally, there was no significant difference in the amount of bleeding between the 2 groups, and the CM group did not include patients exhibiting massive bleeding (>1000
mL). During cholecystectomy, bleeding primarily originates from the cystic arteries and the liver bed; CM and subtotal cholecystectomy help prevent bleeding from these important locations.
The conversion rate to OC was 35.3% in the CM group, which was higher than that in previous reports (1.7–7.7%) [18.19.21]. Thus, we emphasize on safety in our surgical procedures and convert to OC without hesitation in difficult cases. The lack of intraoperative complications in the CM group is probably the result of these efforts. Furthermore, patients who needed reoperation were observed only in the SC group, highlighting the need for a flexible approach according to patient characteristics rather than adherence to a particular policy of laparoscopic surgery in order to avoid unnecessary intraoperative complications and conversion to laparotomy.
OCs are typically more closely associated with advanced age, poor general condition, or a high inflammatory response than are laparoscopic surgeries [29
]. These same characteristics are also associated with an increased severity of acute cholecystitis, which may result in a more difficult surgery. The aforementioned patient characteristics are collective, but not independent, risk factors for postoperative complications of acute gangrenous cholecystitis [30
]. In addition, Schäfer et al. have reported that advanced age and a high serum CRP level may be predictive factors for the surgical procedures that are used in patients undergoing laparotomy and patients who were converted to laparotomy [32
]. The current study was a retrospective study, with a selection bias based on intraoperative findings; the CM group showed an advanced age and a high serum CRP level. With the transition to CM and open surgery in mind, the conversion to a safe surgical procedure should be considered in elderly patients with high inflammation of the gallbladder neck.