Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
Veterans Affairs Medical Center, White River Junction, VT, USA.
Surg Endosc. 2024 Oct;38(10):6083-6089. doi: 10.1007/s00464-024-11143-9. Epub 2024 Aug 26.
Subtotal cholecystectomy is advocated in patients with severe inflammation and distorted anatomy preventing safe removal of the entire gallbladder. Not well documented in this surgically complex population is the feasibility of intraoperative imaging and management of common bile duct (CBD) stones. We evaluated these operative maneuvers in our subtotal cholecystectomy patients.
We retrospectively reviewed all cholecystectomy cases from 2014 to 2023 at a single Veterans Affairs (VA) Medical Center using VASQIP (VA Surgical Quality Improvement Program), selecting subtotal cholecystectomy cases for detailed analysis. We reviewed operative reports, imaging and laboratory studies, and clinical notes to understand biliary imaging, stone management, complications, and late outcomes including retained stones (within 6 months), and recurrent stones (beyond 6 months).
419 laparoscopic (n = 406) and open (n = 13) cholecystectomies were performed, including 40 subtotal cholecystectomies (36 laparoscopic, 4 laparoscopic converted to open). Among these 40 patients IOC was attempted in 35 and completed in 26, with successful stone management in 11 (9 common bile duct exploration [CBDE], 2 intraoperative endoscopic retrograde cholangiopancreatography [ERCP]). In follow-up, 3 additional patients had CBD stones managed by ERCP, including 1 with a negative IOC and 2 without IOC. Thus, 14 (35%) of 40 patients had CBD stones. Of note, IOC permitted identification and oversewing or closure of the cystic duct in 32 patients. There were no major bile duct injuries and one cystic duct stump leak (2.5%) that resolved spontaneously.
Subtotal cholecystectomy patients had a high incidence of bile duct stones, with most detected and managed intraoperatively with CBDE, making a strong argument for routine IOC and single-stage care. When intraoperative imaging is not possible, postoperative imaging should be considered. Routine imaging, biliary clearance, and cystic duct closure during subtotal cholecystectomy is feasible in most patients with low rates of retained stones and bile leaks.
对于严重炎症和解剖结构扭曲导致无法安全切除整个胆囊的患者，提倡行次全胆囊切除术。在这种手术复杂的人群中，术中影像学检查和处理胆总管（CBD）结石的可行性尚未得到充分记录。我们评估了这些手术操作在我们的次全胆囊切除术患者中的应用。
我们使用 VA 手术质量改进计划（VASQIP）回顾性分析了 2014 年至 2023 年在一个退伍军人事务部（VA）医疗中心进行的所有胆囊切除术病例，选择次全胆囊切除术病例进行详细分析。我们查阅了手术报告、影像学和实验室研究以及临床记录，以了解胆道影像学、结石处理、并发症以及包括 6 个月内残留结石和 6 个月后复发结石在内的晚期结果。
共进行了 419 例腹腔镜（n=406）和开放（n=13）胆囊切除术，其中包括 40 例次全胆囊切除术（36 例腹腔镜，4 例腹腔镜转为开放）。在这 40 例患者中，尝试进行术中胆管造影（IOC）的有 35 例，完成 IOC 的有 26 例，其中 11 例成功进行了结石处理（9 例行胆总管探查术[CBDE]，2 例行术中内镜逆行胰胆管造影术[ERCP]）。在随访中，另外 3 例 CBD 结石患者通过 ERCP 进行了处理，其中 1 例 IOC 阴性，2 例无 IOC。因此，40 例患者中有 14 例（35%）患有 CBD 结石。值得注意的是，IOC 允许在 32 例患者中识别并缝合或关闭胆囊管。无主要胆管损伤，1 例胆囊管残端漏（2.5%）自行缓解。
次全胆囊切除术患者胆管结石发生率较高，大多数患者通过 CBDE 进行了术中检测和处理，这有力地支持了常规 IOC 和单阶段治疗的观点。如果无法进行术中影像学检查，应考虑术后影像学检查。在大多数患者中，次全胆囊切除术中常规进行影像学检查、胆道通畅和胆囊管关闭是可行的，残留结石和胆管漏的发生率较低。
