CLINICAL OUTCOME OF STUMP CLOSURE TECHNIQUES AFTER SUBTOTAL CHOLECYSTECTOMY-OUR EXPERIENCE.
Acute cholecystitis and difficult gall bladder have severe inflammation and anatomical deformities like Mirizzi syndrome, empyema and gangrene.  Subtotal cholecystectomy is a procedure, in which body and infundibulum of the gall bladder are removed and cystic duct is not closed. It is performed when there is frozen Calot's triangle and structures cannot be identified and situation contraindicating total cholecystectomy.  This method aims to decrease the risk of complications such as bile duct injury, hepatic artery injury and bleeding.
Now-a-days, there has been an increasing trend towards subtotal cholecystectomy and general acceptance is higher due to higher incidence of complications in difficult gall bladder.  Although, the results are satisfactory, postoperative bile leak is a problem in subtotal cholecystectomy. So, many techniques have been advocated, but bile leakage compared to closing of cystic duct directly is very high in subtotal cholecystectomy.  We developed an innovative technique of plugging in omentum into the stump of the subtotal cholecystectomy and fixed it with interrupted stitches through omentum and both walls of the stump and other technique, in which only interrupted stitches were taken without omentum. The aim of the present study was to assess the safety and efficacy of both the operative techniques and determine as to which procedure is better in preventing post-operative bile leakage.
MATERIALS AND METHODS
This is an observational study. In 2015, we developed the (OPT) Technique and Primary Closure Technique (PCT) to prevent bile leak in cases were total cholecystectomy could not be performed. From 2015 to 2018, we studied all the patients with the scan diagnosis of cholelithiasis and selected the patients who had undergone subtotal cholecystectomy for gallstone diseases with both OPT and PCT Technique. The 800 patients of laparoscopic cholecystectomy were taken for convenience. The patients were operated in our institution, among them 48 patients (6%) underwent subtotal cholecystectomy, 21 patients in OPT and 24 patients in PCT control group were selected randomly by computer generated numbers. 3 patients were excluded in the total 48, because the stump could not be closed in 3 patients. The outcomes of patients who had undergone OPT with PCT control group were compared. The outcomes of interest were Per-operative data, post-operative complications including bile leakage and necessity for intervention duration of drainage and hospital stay. For all the patients interoperative drainage tube was placed. Macroscopic identification of bile coming out through the tube was considered as bile leakage.
All patients were operated under general anaesthesia. All the patients who underwent subtotal cholecystectomy were first decompressed at the fundus with the suction and harmonic scalpel or l-hook was used for transection of gall bladder and wash was given and both the anterior and posterior walls were excised leaving an anterior and posterior wall intact and omentum 2 to 3 cm was plugged inside the stump and sutured with interrupted Ethibond 2.0. It was tight enough that the omentum formed a watertight can and edges are closed with close proximity. In PCT the same way the gall bladder was transected, but only non-absorbable Ethibond stitches were used in closed proximity and the mucosa of the gall bladder was coagulated with diathermy and closed without Omentum. A sub-hepatic drain was placed in both the groups. During the study period, all the cases were done by experienced surgeons.
Chi-square is calculated for categorical values and T value is calculated for continuous variables. Unpaired student T-test were used to find out statistical significance. A p-value <0.005 was taken as significant. SPSS version 20 was used for statistical analysis.
A flow chart of the current study is shown from 2015 to 2018. 800 patients of laparoscopic cholecystectomy were operated in our institution, among them 48 patients (6%) underwent subtotal cholecystectomy, 21 patients in OPT and 24 patients in PCT control group were selected. 3 patients were excluded in the total 48, because the stump could not be closed in 3 patients.
Chi-square is calculated for categorical values and T-value is calculated for continuous variables.
Flowchart of the Study- Omentum plugging technique vs primary closure technique.
The results and various outcomes are displayed in the study group. A minor complication of wound infection happened in 1 patient in OPT Group and another 1 patient developed bile leakage that resolved in 48 hours. In the PCT group, 1 patient had subhepatic abscess.
In major complication, 1 patient in PCT had atelectasis and underwent mechanical ventilation and 1 patient in OPT group developed post-operative pneumonitis and required ventilation.
Dr. Madding first reported subtotal cholecystectomy in 1955 as an alternative procedure for total cholecystectomy, which minimised bile duct and vascular injuries.  Subtotal cholecystectomy is performed in patients with difficult gall bladder where injury to cystic duct, CBD junction occurs. The rate of complication in total cholecystectomy is very high compared to subtotal cholecystectomy in difficult gall bladder. Definitely, the aims of safety margin are achieved more in subtotal cholecystectomy compared to total cholecystectomy in difficult gall bladders.
A systematic review shows that bile leak is more in subtotal cholecystectomy compared to total cholecystectomy. In other review shows there is no clinically relevant difference in bile leakage when stump is closed or left open likewise in the control group. PCT technique 12 out of 24 patients developed bile leak and 3 which were left open without closing also had bile leaks.  The leakage rates are similar to those previous reviews. It is difficult in gall bladder with tissue of the gall bladder stump having oedema. Once the oedema reduces the primary closure technique loses strength and there is bile leak and it is the same if you leave it open alternatively. Improper closure can also lead to bile leakage, so in the OPT technique we used non-vascularised omentum to be plugged into the dorsal part of the gall bladder stump and water tight closure with omental tissue can be achieved and we did not use vascular pedicle because of inadequacy of length due to inflammation and after suturing vascularity would not be maintained. 
The absence of bile leakage in the OPT group means OPT Technique is preferable to PCT and leaving the stump open. Moreover, the lake of difference in the operating time and the bleeding is same making the OPT Technique a safe and easier technique. [8, 9] Our results show that OPT Technique can reliably prevent post-operative bile leakage and other postoperative complication and reducing the necessity for ERCP and hospital stay and cost. Direct closure of cystic duct is the best technique, but when a difficult cholecystectomy is encountered with the frozen calot's OPT technique is helpful for completing a safe sub-total cholecystectomy with minimum post-operative complication.
We strongly recommend OPT in Subtotal Cholecystectomy on Laparoscopy. Our study has some limitations and considering the results due to the small number of subtotal cholecystectomies; but the difference in bile leakage in OPT technique is very low compared to PCT. In about 800 patients of laparoscopic cholecystectomy, 48 patients underwent subtotal cholecystectomy. Thus, our findings could only be validly generalised if a multicentric study of many of these cases achieved similar outcomes. Some recent reports have demonstrated the advantage of laparoscopic Subtotal Cholecystectomy for patients with difficult gall bladder. Therefore, the OPT and the PCT should be evaluated through laparoscopic Subtotal Cholecystectomy in large number of patients with difficult gall bladders in high volume centre.
When a difficult gall bladder is encountered, subtotal cholecystectomy is the procedure of choice with OPT Technique. It appears to be a safe and more feasible alternative for prevention of bile leak compared to other techniques.
This work was supported by Karpagam Faculty of Medical Sciences and Research, Coimbatore and Central Research Laboratory by providing the necessary facilities.
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M. C. R. S. Shanker (1), Kavitha Shanker (2)
(1) Assistant Professor, Department of General Surgery, Karpagam Faculty of Medical Sciences and Research, Coimbatore, Tamilnadu, India.
(2) Assistant Professor, Department of Obstetrics and Gynaecology, Karpagam Faculty of Medical Sciences and Research, Coimbatore, Tamilnadu, India.
'Financial or Other Competing Interest': None.
Submission 09-11-2018, Peer Review 23-11-2018, Acceptance 26-11-2018, Published 03-12-2018.
Kavitha Shanker, Assistant Professor, Department of Obstetrics and Gynaecology, Karpagam Faculty of Medical Sciences and Research, Coimbatore, Tamilnadu, India.
Caption: Figure 1. Omentum Plugging Tech
Caption: Figure 2. Omentum Plugging Tech
Caption: Figure 3. Primary Closure Tech
Table 1. Clinical Study Characteristic according to the Study Group OPT Group PCT Group n=21 Control n=24 Age (years) 56.38 [+ or -] 13.75 46.04 [+ or -] 16.91 Sex (male/ female) 15/6 4/20 Operative Procedure Laparoscopy Laparoscopy History of CBD Stone 6 (28.5%) 4 (16.6%) History of Abdominal 1% NIL Surgery ASA Classification 2/ 8/ 10/ 1 5/ 9/ 9/ 1 (1/2/3/4) Intra-operative 105 100 Haemorrhage Duration of Operation 116 [+ or -] 16.16 79.33 [+ or -] 6.98 Time Table 2. Comparison of outcome of OPT and PCT Group OPT PCT Group Group Control n=21 n=24 Total post- operative 2 patients 12 patients complication Post-operative 2 patients 12 patients bile leakage Other major 1 4 complication Minor 2 1 complication Post-operative 1 9 intervention Duration of drain 4.9 [+ or -] 1.09 9.92 [+ or -] 1.41 Post-operative 7.67 [+ or -] 12.25 [+ or -] hospital stay 1.80 1.48 Chi- square/ P value T value Total post- operative 8.562 0.003 ** complication Post-operative 8.562 0.003 ** bile leakage Other major 1.607 0.205 complication Minor 0.517 0.472 complication Post-operative 6.945 0.008 * intervention Duration of drain -13.180 0.000 ** Post-operative -9.373 0.000 ** hospital stay
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|Title Annotation:||Original Research Article|
|Author:||Shanker, M.C.R.S.; Shanker, Kavitha|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Dec 3, 2018|
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