title: Subtotal cholecystectomy for "difficult gallbladders": systematic review and meta-analysis.
abstract: OBJECTIVE
  Subtotal cholecystectomy (SC) is a procedure that removes portions of the gallbladder when structures of the Calot triangle cannot be safely identified in "difficult gallbladders."
  
  
  OBJECTIVE
  To conduct a systematic review and meta-analysis to evaluate current studies and present an evidence-based assessment of the outcomes for the techniques available for SC.
  
  
  METHODS
  A literature search of the PubMed/MEDLINE (1954 to November 2013) and EMBASE (1974 to November 2013) databases was conducted. Search criteria included the words subtotal, partial, insufficient or incomplete, and cholecystectomy.
  
  
  METHODS
  Inclusion criteria were all randomized, nonrandomized, and retrospective studies with data on SC techniques and outcomes. Exclusion criteria were studies that reported data on SC along with other interventions (eg, cholecystostomy) without the possibility to discriminate results specific to SC.
  
  
  METHODS
  This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.
  
  
  METHODS
  The primary outcome of the study was the occurrence of common bild duct injury. Secondary outcomes included the occurrence of other SC-related morbidities, such as hemorrhage, subhepatic collection, bile leak, retained stones, postoperative endoscopic retrograde cholangiopancreatography, wound infection, reoperation, and mortality.
  
  
  RESULTS
  Thirty articles were included. Subtotal cholecystectomy was typically performed using the laparoscopic technique (72.9%), followed by the open (19.0%) and laparoscopic converted to open (8.0%) techniques. The most common indications were severe cholecystitis (72.1%), followed by cholelithiasis in liver cirrhosis and portal hypertension (18.2%) and empyema or perforated gallbladder (6.1%). Morbidity rates were relatively low (postoperative hemorrhage, 0.3%; subhepatic collections, 2.9%; bile duct injury, 0.08%; and retained stones, 3.1%); the rate for bile leaks was higher (18.0%). Reoperations were necessary in 1.8% of the cases; the 30-day mortality rate was 0.4%. The laparoscopic approach produced less risk of subhepatic collection (odds ratio [OR], 0.4; 95% CI, 0.2-0.9), retained stones (OR, 0.5; 95% CI, 0.3-0.9), wound infection (OR, 0.07; 95% CI, 0.04-0.2), reoperation (OR, 0.5; 95% CI, 0.3-0.9), and mortality (OR, 0.2; 95% CI, 0.05-0.9) but more bile leaks (OR, 5.3; 95% CI, 3.9-7.2) compared with the open approach.
  
  
  CONCLUSIONS
  Subtotal cholecystectomy is an important tool for use in difficult gallbladders and achieves morbidity rates comparable to those reported for total cholecystectomy in simple cases. The various technical differences appear to influence outcomes only for the laparoscopic approach.
authors.affiliation: Department of Surgery, Kettering General Hospital, Kettering, England.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Elshaer
authors.affiliation: Department of Surgery, Kettering General Hospital, Kettering, England.
authors.forename: Gianpiero
authors.initials: G
authors.lastname: Gravante
authors.affiliation: Department of Surgery, Kettering General Hospital, Kettering, England.
authors.forename: Katie
authors.initials: K
authors.lastname: Thomas
authors.affiliation: Department of Human Physiology, Laboratory of Biometry, University of Tor Vergata, Rome, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Sorge
authors.affiliation: Department of Surgery, Kettering General Hospital, Kettering, England.
authors.forename: Salem
authors.initials: S
authors.lastname: Al-Hamali
authors.affiliation: Department of Surgery, Kettering General Hospital, Kettering, England.
authors.forename: Hamdi
authors.initials: H
authors.lastname: Ebdewi
mesh_terms: D002763:Cholecystectomy / Q000009:adverse effects / Q000379:methods*; D005705:Gallbladder Diseases / Q000150:complications / Q000473:pathology / Q000601:surgery*; D006801:Humans