Operative strategies for the acute difficult gallbladder: a Society for Surgery of the Alimentary Tract state-of-the-art systematic review and meta-analysis of subtotal cholecystectomy outcomes.

BACKGROUND

The "difficult gallbladder" in acute cholecystitis can preclude safe achievement of the critical view of safety, prompting subtotal cholecystectomy (STC) as a guideline-supported bailout. We performed a contemporary synthesis to clarify STC's safety effectiveness trade-offs vs total cholecystectomy (TC) and delineate technique-specific outcomes and patient factors that may influence risk.

METHODS

We conducted a systematic review and meta-analysis of studies from 2010 to June 2025. Three comparisons were evaluated: (i) single-arm outcomes after STC, (ii) STC vs TC, and (iii) fenestrating STC (f-STC) vs reconstituting STC (r-STC). Random-effects models were applied, with prespecified subgroup analyses, leave-one-out sensitivity analyses, and exploratory meta-regression.

RESULTS

In single-arm analysis, bile duct injury (BDI) occurred in 0.3%, bile leak in 13.5%, retained stones in 6.1%, and overall complications in 24.7% of patients. Readmission and reoperation occurred in 17.8% and 6.3%, whereas mortality was 0.8%. Postprocedural endoscopic retrograde cholangiopancreatography (ERCP) occurred in 16.2%, and percutaneous drainage in 5.7%. Compared with TC, STC had significantly higher bile leak, retained stones, overall complications, readmission, reoperation, and ERCP, with no significant difference in mortality, intensive care unit admission, or length of stay (LOS). Meta-regression linked diabetes with higher leak, complications, and ERCP, and male sex with higher surgical site infection. f-STC had significantly higher bile leak and longer LOS than r-STC, with ERCP trending higher.

CONCLUSION

STC carries a very low BDI rate, but higher postoperative morbidity and secondary interventions than TC. r-STC demonstrated superior outcomes to f-STC. Diabetes and male sex were important risk modifiers. STC remains a rational bailout when the critical view cannot be achieved.