Motter Sarah Bueno, de Figueiredo Sérgio Mazzola Poli, Marcolin Patrícia, Trindade Bruna Oliveira, Brandao Gabriela R, Moffett Jennifer M
Medical School, Universidade Federal de Ciências da Saúde de Porto Alegre, Rua Sarmento Leite, 245, Centro Histórico, Porto Alegre, 90050-170, Brazil.
Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA.
Surg Endosc. 2024 Dec;38(12):7475-7485. doi: 10.1007/s00464-024-11225-8. Epub 2024 Sep 12.
Laparoscopic cholecystectomy is one of the most frequently performed procedures by general surgeons. Strategies for minimizing bile duct injuries including use of the critical view of safety method, as outlined by the SAGES Safe Cholecystectomy Program, are not always possible. Subtotal cholecystectomy has emerged as a safe "bail-out" maneuver to avoid iatrogenic bile duct injury in these difficult cases. Strasberg and colleagues defined two main types of subtotal cholecystectomies: reconstituting and fenestrating. As there is a paucity of studies comparing the two subtypes of laparoscopic subtotal cholecystectomy (LSC), we performed a systematic review and meta-analysis comparing the reconstituting and fenestrating techniques for managing the difficult gallbladder.
A search of PubMed, Embase, and Cochrane databases was conducted to identify prospective and retrospective studies comparing fenestrating and reconstituting LSC. The outcomes of interest were bile leak, reoperation, readmissions, completion cholecystectomy, postoperative ERCP, and retained CBD stones.
We screened 2855 studies and included 13 studies with a total population of 985 patients. Among them, 330 patients (33.5%) underwent reconstituting LSC and 655 patients (55.5%) underwent fenestrating LSC. Twelve studies were retrospective, and one was prospective. Notably, reconstituting STC was associated with decreased incidence of bile leak (OR 0.29; CI 95% 0.16-0.55; p = 0.0002; I = 36%). We also noted increased rates of postoperative ERCP with fenestrating STC in sensitivity analysis (OR 0.32; CI 95% 0.16-0.64; p = 0.001; I = 31%). In addition, there was no difference between the two techniques regarding the rates of completion of cholecystectomy, reoperation, readmission, and retained CBD stones.
Fenestrating LSC leads to a higher incidence of postoperative bile leakage. In addition, our sensitivity analysis revealed that the fenestrating technique is associated with a higher incidence of postoperative ERCP. Further randomized trials and studies with longer-term follow-up are still necessary to better understand these techniques in the difficult gallbladder cases.
腹腔镜胆囊切除术是普通外科医生最常开展的手术之一。按照美国胃肠内镜外科医师学会（SAGES）安全胆囊切除术计划概述的将安全视野法作为最小化胆管损伤的策略并非总是可行。在这些困难病例中，次全胆囊切除术已成为一种安全的“补救”操作，以避免医源性胆管损伤。斯特拉斯伯格及其同事定义了两种主要的次全胆囊切除术类型：重建型和开窗型。由于比较腹腔镜次全胆囊切除术（LSC）两种亚型的研究较少，我们进行了一项系统评价和荟萃分析，比较用于处理困难胆囊的重建型和开窗型技术。
检索了PubMed、Embase和Cochrane数据库，以识别比较开窗型和重建型LSC的前瞻性和回顾性研究。感兴趣的结局包括胆漏、再次手术、再次入院、完成胆囊切除术、术后内镜逆行胰胆管造影（ERCP）和胆总管残留结石。
我们筛选了2855项研究，纳入了13项研究，总共有985例患者。其中，330例患者（33.5%）接受了重建型LSC，655例患者（55.5%）接受了开窗型LSC。12项研究为回顾性研究，1项为前瞻性研究。值得注意的是，重建型次全胆囊切除术与胆漏发生率降低相关（比值比[OR]0.29；95%置信区间[CI]0.16 - 0.55；p = 0.0002；I² = 36%）。在敏感性分析中，我们还注意到开窗型次全胆囊切除术术后ERCP发生率增加（OR 0.32；95%CI 0.16 - 0.64；p = 0.001；I² = 31%）。此外，在胆囊切除术完成率、再次手术、再次入院和胆总管残留结石发生率方面，两种技术之间没有差异。
开窗型LSC导致术后胆漏发生率更高。此外，我们的敏感性分析显示，开窗型技术与术后ERCP发生率更高相关。仍需要进一步的随机试验和长期随访研究，以更好地了解这些技术在困难胆囊病例中的应用。
