Laparoscopic subtotal cholecystectomy compared to total cholecystectomy: a matched national analysis

Background Laparoscopic subtotal cholecystectomy (LSC) is considered a safe alternative to laparoscopic cholecystectomy (LC) if biliary anatomy is obscured by inflammation. While case series studies have observed low morbidity rates with LSC, the impact of operative conversion on patient outcomes is poorly understood. Methods A national analysis of all patients who underwent LC or LSC from 2009 to 2013 was performed using the University HealthSystem Consortium database. A 1:1 propensity score match was used to compare procedural outcomes accounting for clinical and demographic factors. Matched samples had <10% standardized differences of each baseline covariate. Results A total of 131,082 LC and 487 LSC were performed during the study period. Compared with LC, patients undergoing LSC were more likely to be older (56 versus 48 years), male (54.2% versus 32.3%), and have higher severity of illness scores on admission (9.2% versus 3.5% extreme severity of illness; P < 0.001 each). LSC patients had a prolonged hospital length of stay (LOS, 4 versus 3 days), greater total direct cost ($9053 versus $6398), higher readmission rates (11.9% versus 7.0%), and higher mortality rates (0.82% versus 0.28%, P < 0.05 each). After matching, the difference in total direct cost persisted ($9053 versus $7,581, P < 0.001), but there were no differences in hospital LOS, readmission rates, or overall mortality. Conclusions LSC is an important alternative to LC for the difficult gallbladder. Conversion to LSC is associated with increased patient morbidity and resource utilization leading to perceived poor outcomes, but this is due to patient factors at initial presentation. Health care providers should consider LSC if the patient may be at risk for iatrogenic injury to the biliary tract.