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A 10-Year Real World Assessment of Longitudinal Outcomes Following Bailout Procedures for Severe Cholecystitis
*Zhi Ven Fong1, *Pei-Wen Lim1, *Po Hong Tan1, *Yu-Hui Chang1, *Mehrdad Motamed1, *Irving Jorge1, *Megan H. Nelson1, *Peter F. Johnston1, *Chee-Chee H. Stucky1, *Nabil Wasif1, *James A. Madura1, Keith D. Lillemoe2
1Surgery, Mayo Clinic Arizona, Phoenix, AZ; 2Surgery, Massachusetts General Hospital, Boston, MA

Objective(s): Severe cholecystitis often causes dense inflammation that distorts the hepatocystic anatomy and can make safe dissection during cholecystectomy (CCY) challenging. However, controversy exists regarding the optimal bailout procedure in such situations. Herein, we comparatively analyzed the longitudinal outcomes of conversion to open procedure, laparoscopic subtotal CCY, and laparoscopic cholecystostomy tube placement.

Methods: The New York and Florida State all-claims databases were queried for patients who underwent laparoscopic CCY for acute cholecystitis from 2012 to 2021. Hierarchical logistic regression models were used to obtain adjusted estimates, with fixed effects assigned to patient-level variables and random effects assigned to hospital identifiers to adjust for intraclass correlation.

Results: Of 357,512 laparoscopic CCYs performed, 5,235 (1.5%) were not completed laparoscopically; 1,223 underwent conversion to open procedure, 2,601 underwent laparoscopic subtotal CCY, and 1,411 underwent laparoscopic cholecystostomy tube placement. The conversion to open rate went down from 0.7% in 2012 to 0.3% in 2021, while the laparoscopic subtotal CCY rate increased from 0.3% in 2012 to 1.4% in 2021. The 1-year bile duct injury (BDI) rate was highest for the conversion to open group (2.5%), followed by the laparoscopic subtotal CCY (0.7%) and laparoscopic cholecystostomy tube groups (0.3%, p<0.001). On adjusted analysis with the conversion to open group as the control, laparoscopic subtotal CCY (OR 0.27, p<0.001) and laparoscopic cholecystostomy tube were associated with lower BDI rates (OR 0.11, p<0.001, Figure). The 1-year postoperative endoscopic biliary intervention rate was lowest for the conversion to open group (2.7%) followed by the laparoscopic subtotal CCY (8.0%) and the laparoscopic cholecystostomy tube groups (8.0%, p<0.001). The secondary CCY rates for the laparoscopic subtotal CCY and laparoscopic cholecystostomy tube groups were 2.1% and 21.3% respectively. Among secondary CCYs, the open rates were 57.4% in the laparoscopic subtotal CCY group versus 20.9% in the laparoscopic cholecystostomy tube group (p<0.001).

Conclusions: In patients with severe cholecystitis requiring a bailout procedure, the BDI rate was highest after conversion to open procedure. Laparoscopic subtotal CCY and laparoscopic cholecystostomy tube were associated with lower BDI rates at the cost of higher postoperative endoscopic biliary intervention rates. Secondary CCYs were required in 2.1% and 21.3% of patients who underwent laparoscopic subtotal CCY and laparoscopic cholecystostomy tube placement respectively, of which the former group’s CCY was more likely to require an open operation.
Figure. Hierarchical logistic regression model for the one-year incidence of common bile duct injury after bailout procedures for severe cholecystitis.
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