Subtotal cholecystectomy (SC) is used too often out of habit rather than clear necessity as a bailout procedure to prevent bile duct injuries (BDIs) when a surgeon can’t get a clear picture of safety during cholecystectomy (CC), authors of a new study wrote.

Ramsey Michael Dallal, MD, of Jefferson Health-Einstein Bariatric Surgery in Elkins Park, Pennsylvania, led a retrospective study that analyzed 17,299 CCs performed by 111 surgeons across 12 hospitals within a large healthcare system. The study used logistic regression to model the risk for SC and reinterventions and accounted for patient-, surgeon-, and hospital-level factors.

Choice May Be Surgeon-Driven

Their data suggest that surgeon-related factors, such as experience, training, and institutional practices, may influence the choice to perform SC, the authors wrote.

Among 157 SC cases, 94 (60%) were performed by just eight surgeons, who collectively accounted for only 13% of all CCs. Additionally, 136 cases (87%) of SC were clustered in three hospitals, accounting for 31% of all CCs. Researchers found that surgeons with more experience performing SC were significantly more likely to perform the procedure (odds ratio [OR], 1.13; P = .004). Conversely, the more CCs a surgeon performed, the lower the odds of performing an SC (OR, 0.998; P < .001).

No Reduction in Major BDI With SC

They also found that the choice to use the procedure was linked with substantially increased postoperative reintervention without a reduction in major BDI. BDI is devastating but rare, the authors noted, occurring in 0.3%-0.5% of cases. The 30-day reintervention rate was significantly higher after SC than after total CC (22.3% vs 5.1%; P < .0005). There was no rise in reinterventions among surgeons or hospitals that had never or rarely performed SC. Additionally, six major BDIs requiring reconstruction were seen after CC (BDI rate, 0.03%).

SC was performed more often on older patients and male patients. They were more likely to be performed during unscheduled inpatient admissions and were linked with a higher rate of conversion to open surgery.

The authors concluded that well-intentioned use of SC may increase patient harm, and they call for curbing its overuse.

Anatomy Should Dictate Choice

“By prioritizing avoidance of rare catastrophic injury over prevention of common morbidity, discretionary SC use risks perpetuating preventable complications,” they write. “The solution lies not in abandoning SC but in reserving it for unequivocal circumstances — those in which anatomy rather than habit or fear dictates necessity.”

“I completely agree with their conclusion,” Christopher DuCoin, MD, MPH, chief of the Division of Gastrointestinal Surgery at the University of South Florida in Tampa, Florida, told Medscape Medical News. He said he was surprised by the number of SCs the paper documents.

He said SC should be used only if there’s “significant inflammation or with a necrotic or ischemic gallbladder — if you can’t do the proper dissection and a safe resection.”

DuCoin noted the potential for harm with SC. “As long as there’s a reservoir for the bile to accumulate, you’re still going to have the potential to form gallstones, and if you can form gallstones, you can still get inflammation and infection in your gallbladder,” he said. “When you remove someone’s gallbladder in a proper cholecystectomy, you’re really removing the potential of any sort of acute or chronic cholecystitis. If you do a subtotal cholecystectomy, they can still get ill from their gallbladder.”

SC Concentrated Among a Few Surgeons

The number of surgeons performing SC documented in this paper “is the money shot,” Caitlin Hicks, MD, MS, vascular surgeon at Johns Hopkins Medicine in Baltimore, told Medscape Medical News. “There is clearly a select group of people who are doing more than everybody else. It’s hard to know in retrospective data why.”

SC could be overused, but it also could be that those surgeons are referred the really difficult cases, she said. However, she said, “The fact that higher-volume cases are not associated with subtotal cholecystectomy — it would be strange if the hardest cases were referred to the lower-volume surgeons. This suggests there is room for improvement in performance.”

Hicks, who researches quality and efficiency improvement in surgical procedures, said her research has found that benchmarking surgeons’ performance, ideally anonymously, has been quite successful in changing behavior.

“Sometimes the simplest thing to do is to let people know they’re an outlier,” she said. With a report card system, she said, “We’ve seen a marked improvement in about 50% of physicians, simply by having awareness that what they’re doing is not the norm.”

She said a larger study involving more surgeons will help clarify whether this behavior is really outside the national norm or outside the norm for this particular health system.

Authors and Hicks declared having no relevant financial relationships. DuCoin reported working with Intuitive Surgical, Johnson & Johnson, and Medtronic.

Marcia Frellick is an independent, Chicago-based healthcare journalist and a regular contributor to Medscape.