MSSP770: POSTOPERATIVE MANAGEMENT FOLLOWING FENESTRATING SUBTOTAL CHOLECYSTECTOMIES; A SCOPING REVIEW
Tiffany Kippenberger, DO; Ester Gilbert, MD; Joel Brockmeyer, MD; Marcos Aranda, MD; Dwight D. Eisenhower Army Medical Center
OBJECTIVES: Doctors in the United States perform upwards of 700,000 cholecystectomies annually to address multiple acute and chronic conditions of the hepatobiliary system. The majority are laparoscopic with total removal. However, if the gallbladder cannot be safely dissected, a laparoscopic subtotal cholecystectomy (STC)—a surgical procedure that preserves an intracorporeal portion of the gallbladder—may be an option. Based upon the approach to the remnant gallbladder, the procedure can be classified as either fenestrating or reconstituting.
STCs have increased significantly in the past two decades with well-documented post-operative complications including bile leakage. Nonetheless, little guidance exists on STC post-operative management. This review evaluates the existing literature regarding management of bile leaks and drains after fenestrating STC. It also identifies areas for further investigation.
METHODS: This study completed two comprehensive searches on PubMed and the Cochrane Database using the following keywords: “‘subtotal cholecystectomy’ OR ‘fenestrating Cholecystectomy’ AND ‘drain’” and “‘subtotal cholecystectomy’ OR ‘fenestrating cholecystectomy’ AND ‘bile leak.’” The search yielded 67 abstracts as of August 2024. The Study excluded duplicate articles and those in which the surgical indication was not gallbladder in origin, those only discussing reconstituting STCs, those lacking full text, and non-English articles. Arksey and O’Malley’s Six-Step Approach was the basis for the scoping review protocol.
RESULTS: Full articles were available for 63 of the 67 abstracts identified in the aforementioned search, all of which were thoroughly reviewed. Thirty-five articles met inclusion criteria.
In patients recovering from fenestrating STC, bile leaks were identified in 3.9-47%, of which, treatment was managed with drain alone in 5.6-69.7% across 1-37 days. The presence of a bile leak was evaluated via ultrasound, CT, HIDA, MRCP, ERCP, and drain bilirubin levels. Beyond drain placement, treatment options varied to include antibiotics, continued drainage, endoscopic decompression, and reoperation. There was no consensus on intraoperative drain placement, timing of post-operative drain placement, criteria for drain removal in the presence or absence of leak, simultaneous treatment modalities, or post-pull follow up.
CONCLUSION: Fenestrating STCs are a frequent option for gallbladders that are not amenable to complete removal but present an increased risk of bile leakage compared to the standard laparoscopic approach. Nonetheless, little data is present to direct post-operative management, particularly drain care. Within existing available literature, there is no evidence-based criteria to direct post-operative management, highlighting a significant deficiency in general surgery knowledge and recommending further focused investigation.