Patient-reported outcomes following subtotal cholecystectomy: results from a cross-sectional survey of 71 patients operated on between 2012 and 2021

Introduction

An ageing and growing population has contributed to the rising prevalence and global burden of benign biliary disease, with gallstone disease and its associated complications representing the predominant cause (1). Laparoscopic cholecystectomy (LC), as the established standard for managing gallstone disease since the 1990s (2), faces increasing challenges owing to pericholecystic severe inflammatory changes and associated heightened operative complexity. Consequently, there has been a progressive shift towards damage-control strategies and limitation surgical procedures in selected cases to reduce intraoperative risk and prevent life-altering iatrogenic complications (3,4).

Preventing the progression of severe cholecystitis remains a cornerstone of contemporary biliary surgery. Early LC during the index admission for acute cholecystitis or mild gallstone pancreatitis is a widely accepted surgical strategy to reduce operative complexity and adverse outcomes. Multiple expert society recommendations and clinical guidelines—including those from NICE, AUGIS, EASL, WSES, and the Tokyo Guidelines—and a recent JAMA review consistently support LC within 3–7 days of presentation (5-11).

Subtotal cholecystectomy (STC) is an established bailout procedure when critical inflammation or fibrosis precludes safe dissection of the cystic pedicle or hepatocystic interface (12). While perioperative and long-term clinical outcomes following STC have been reported in detail (13-16), evidence regarding patient-reported outcome measures (PROMs) after STC remains limited (17,18). In contrast, PROMs after total cholecystectomy (TC) have been extensively evaluated (19-21).

Understanding patient-reported gastrointestinal and general health outcomes after STC is crucial to support its ongoing role in the management of complex gallstone disease and to inform patient counselling, shared decision-making, and postoperative care. Therefore, our primary aim in this study was to assess long-term patient-reported symptoms and health-related quality of life (QoL) following STC for complicated gallstone disease. The secondary aim was to examine associations between perioperative factors and PROMs. We present this article in accordance with the CROSS reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-2026-1-0004/rc) (22).

Methods

Study design, setting, registration, and adherence

In this observational, cross-sectional study, we evaluated patient-reported symptoms and health-related QoL following STC at Aintree University Hospital in Liverpool. Anonymised data were managed in accordance with FAIR principles (23).

Study period, participants, and variables

Two institutional databases from previous STC studies (14,16) were used to identify a cohort of adults who underwent STC between 1 January 2011 and 31 December 2021. Of the identified patients, we excluded those who had died, with missing contact details or other key information, and who did not respond upon being contacted via telephone. Patients who responded to the survey were considered ‘responders’, whereas the remaining patients were considered ‘non-responders’.

Demographic, preoperative (24), intraoperative (25-27), and postoperative (28) data were collected (Table 1). The collected data included the Charlson Age-adjusted Comorbidity Index (CACI) (24), American Society of Anesthesiologists (ASA) physical status classes (29), STC setting and mode, STC technical resection variants and subvariants (25), types of STC completion (26,27), ranking of postoperative complications according to Clavien-Dindo (28), specific intraoperative and postoperative complications, and postoperative length of hospital stay. Completion of cholecystectomy status and survival data were re-verified as of May 2023 via electronic hospital systems.

Semi-structured telephone interviews were conducted over 3 weeks in May 2023 by a single researcher (I.C.N.) who was not involved in patients’ clinical care. After discussion of how to speak to the patients and informal office-based training (I.C.N. and R.L.), confidential interviews began via a hospital phone line with a standardised introduction outlining the study aims, followed by verbal informed consent and administration of a structured 5-section questionnaire (30).

Questionnaire

The questionnaire (Figure S1), which feasibility was confirmed in a pilot testing (31), comprises five sections. Section 1 recorded patient demographics, comorbidities, and operative characteristics. Section 2 captured patient-reported post-STC events, including readmission, endoscopic retrograde cholangiopancreatography (ERCP), re-operation for gallbladder remnant, incisional hernia, and hernia repair. Section 3 assessed long-term gastrointestinal symptoms using the Gastrointestinal Quality of Life Index-10 (GIQLI-10) (32-34). This instrument comprises 10 questions; 9 of them include the phrase ‘how often during the past 2 weeks’, whereas the tenth question concerns restricted foods. Each question has five response options, scored from 0 to 4, with 4 representing the best outcome (i.e., the absence of symptoms). The total GIQLI-10 score (range of 0–40) was calculated by summing the individual item scores. Higher scores indicate better gastrointestinal health-related QoL, and a score of 40 represents perfect gastrointestinal health-related QoL.

Section 4 evaluated general health using the General Health and Change-in-Health domains of the Short Form-36 (SF-36) (35-37). Responses were scored on a 5-point scale ranging from 100 (optimal reported health) to 0 (least desirable), enabling calculation of central tendency metrics for SF-36 General Health scores: 0, 25, 50, 75, and 100 (Table S1) (38). Section 5 applied the World Health Organization definition of health, describing health as a state of complete physical, mental, and social well-being rather than merely the absence of disease or infirmity (39,40). Participants subsequently rated their overall health on a 0–100 visual scale (0= death; 100= perfect health). This measure was termed the health self-assessment (HSA).

Statistical analysis

After data collection, responses were entered into a predefined Microsoft Excel worksheet for Mac (version 16.77.1; Microsoft Corporation, Redmond, WA, USA) and anonymised for use by the study authors only. Statistical analyses were conducted using GraphPad Prism (version 10.6.0; GraphPad Software LLC, Boston, MA, USA) and IBM SPSS (version 29.0.2.0; IBM Corp., Armonk, NY, USA). Categorical data were summarised as counts and percentages. Continuous one-dimensional data were presented using measures of central tendency: the mean with standard deviation (SD) and median with interquartile range (IQR) along with 95% confidence intervals (CIs). For categorical variables, differences between responders and non-responders were tested using the Pearson² test. To assess the strength of the association between two categorical variables—classified as negligible (from 0 to 0.10), weak (from 0.10 to 0.20), moderate (from 0.20 to 0.40), relatively strong (from 0.40 to 0.60), strong (from 0.60 to 0.80), and very strong (from 0.80 to 1)—in a contingency table, Cramér’s V was used (41). The Student’s t-test was used to calculate P values from the observed means of both samples (responders and non-responders). The bootstrap test was used to assess any significant difference between the two samples’ medians (P<0.05).

Spearman’s rank-order correlation coefficient was used to assess associations between QoL measures. A P value <0.05 was considered statistically significant. Correlations greater than or equal to 0.7 were deemed to be strong (42). Associations between PROMs and perioperative variables were assessed using the Mann-Whitney U test for two groups and the Kruskal-Wallis test for more than two groups. Given that multiple statistical tests were conducted, the Bonferroni correction was applied (=0.05); only results with P<0.0042 were considered significant. All statistical tests were conducted as two-tailed tests.

Ethical considerations

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Clinical Audit and Effectiveness Department Board of the NHS University Hospitals of Liverpool Group (No. 10816). Verbal informed consent was obtained from all patients prior to the interviews.

Results

Study participants

Of the 226 eligible patients, 37 (16.4%) had died, 29 (12.8%) were excluded owing to missing contact details or other key information, and 74 (32.7%) did not respond. Among the 88 patients who answered telephone calls, 15 declined participation, and 73 provided verbal consent for the survey, yielding an overall positive response rate of 38.3% when excluding deceased patients.

Among the 162 contactable patients, the response rate was 45.1% (73 patients). As 2 patients subsequently underwent complete cholecystectomy, the final cohort comprised 71 responders (43.8%). They underwent STC between 2012 and 2021 (Figure 1). The remaining 155 patients were classified as ‘non-responders’.

Figure 1 Patient selection flowchart.

Characteristics of the study participants

Table 1 summarises characteristics of the 71 responders (age 28–82 years). Over half of the patients were female (57.7%). Mean ages at surgery and interview were 59.0±12.0 and 65.8±12.3 years, respectively. Mean preoperative body mass index (BMI) was 30.0±6.1 kg/m², similar to BMI at follow-up (29.6±6.7 kg/m²). Digestive tract diseases (excluding biliary disease) and musculoskeletal disorders were most common, present in 26 (36.6%) and 24 (33.8%) patients, respectively. The CACI was 0–4 in 65 (91.5%) patients and ≥5 in 6 (8.5%) patients. Most patients (85.9%) had ASA physical status classes I–II; 7 (9.9%) and 3 (4.2%) had ASA physical status class III and IV, respectively.

A history of chronic and acute cholecystitis was noted in 39 (54.9%) and 32 (45.1%) patients, respectively. Emergency surgery was undertaken in 46 patients (64.8%). Laparoscopic STC was performed in 45 (63.4%) patients, whereas 26 (36.6%) underwent open surgery (primary open, 14 (19.7%); conversion, 12 (16.9%)). The STC-1 resection technique (partial excision of both peritoneal and hepatic gallbladder walls) was used in most cases (74.7%), whereas STC-2 was performed in 16 (22.5%) patients (25,27). The gallbladder remnant was closed in 47 (66.2%) cases.

Postoperative complications occurred in 62 (87.3%) patients [Clavien-Dindo grades I–II in 41 (57.7%), grade III in 13 (18.3%), and grade IV in 8 (11.3%)]; 9 (12.7%) experienced no complications (28). Bile leakage was most common (29.6%), followed by surgical site infection (9.9%) and bile duct injury (1.4%). Postoperative ERCP was required in 19 (26.8%) patients. Mean postoperative hospital stay was 5.5±5.1 days (range, 0–28 days), and the unplanned 30-day readmission rate was 15.5%. Incisional hernias were reported by 16 patients (22.5%), 3 (4.2%) of whom underwent hernia repair. The median interval between STC and survey was 80 months (IQR, 60–97 months).

Difference testing between responders and non-responders

Results of the bivariate analysis are summarised in Table 1. No statistically significant differences were observed between responders and non-responders for most variables. Significant differences were observed only for the following four variables: ASA physical status class II, STC setting (elective, emergency), and STC resection techniques STC-1 and STC-2. Notably, three of these differences were weak, and one was moderate (see Table 1 footnote).

STC-related events reported by patients

Among 11 patients who reported readmission, 3 described multiple hospitalisations. Six (8.5%) recalled undergoing postoperative ERCP. Sixteen (22.5%) patients reported an incisional hernia, of whom three (4.2%) underwent hernia repair.

Gastrointestinal health

All 71 responders reported at least one gastrointestinal symptom (Figure 2). The most frequently reported persistent symptoms (occurring most or all of the time) were fatigue (21, 29.6%), bloating (15, 21.1%), and flatulence (14, 19.7%). The proportion of patients reporting no symptoms ranged from 53.5% (38 patients) for flatulence to 94.4% (67 patients) for blood in stool. Nine patients (12.7%) reported dietary restriction most or all of the time.

Figure 2 Responses of survey participants to the ten symptom items of the GIQLI-10 questionnaire. Interpretation: never, equivalent to excellent health; seldom, equivalent to very good health; some of the time, equivalent to good health; most of the time, equivalent to less-than-satisfactory health; all of the time, equivalent to poor health. On average, 73.24% of patients rated their health as excellent or very good; 86.20% rated it as excellent, very good, or good. GIQLI-10, Gastrointestinal Quality of Life Index-10.

Persistent abdominal pain (9, 12.7%), diarrhoea (12.7%), nausea (6, 8.5%), and belching (5, 7.0%) were less common. Figure 3 illustrates distribution of 10 symptoms by the mean item score with SD and percentage proportion. The overall mean GIQLI-10 score was 31.68 (95% CI: 30.02–33.33; SD 6.98), with a median of 33 (95% CI: 31–36; IQR, 28–37), equivalent to 82.5% of the maximum score.

Figure 3 Distribution of GIQLI-10 symptoms among 71 patients who underwent subtotal cholecystectomy. Higher scores indicate better quality of life and fewer gastrointestinal symptoms. (A) Frequency distribution of individual symptom scores by percentage of patients. (B) Mean scores with standard deviations for each symptom. The absolute numbers of patients for each symptom are as follows (arranged by five categories ‘never’, ‘seldom’, ‘some of the time’, ‘most of the time’, ‘all the time’): blood in stool: 67, 2, 1, 1, 0; nausea: 55, 4, 6, 6, 0; belching: 51, 7, 8, 4, 1; diarrhoea: 51, 4, 7, 6, 3; constipation: 44, 8, 10, 4, 5; pain: 42, 7, 13, 5, 4; restricted food: 42, 8, 12, 4, 5; bloating: 40, 7, 9, 6, 9; flatulence: 38, 6, 13, 7, 7; fatigue: 29, 8, 13, 3, 18. The standard deviations for the means were as follows: blood in stool, 0.45; nausea, 0.97; belching, 1.00; diarrhoea, 1.20; constipation, 1.27; pain, 1.26; restricted foods, 1.28; bloating, 1.48; flatulence, 1.42; and fatigue, 1.64. GIQLI-10, Gastrointestinal Quality of Life Index-10.

SF-36 General Health

As shown in Figure 4, 45 patients (63.4%) rated their general health as excellent (8, 11.3%), very good (11, 15.5%), or good (26, 36.6%). Seventeen (23.9%) reported fair health, and nine (12.7%) rated it as poor. Compared with 1 year prior, patient-reported health remained unchanged in 35 patients (49.3%), improved in 10 (14.1%), and worsened in 26 (36.6%). Mean and median SF-36 General Health scores were 55.77 (95% CI: 48.74–62.81; SD 29.72) and 60 (95% CI: 45–70; IQR, 35–85), respectively.

Figure 4 Responses of survey participants to six general health-related statements from the SF-36 questionnaire. SF, short form.

Figure 5 illustrates responses to the four SF-36 items. For items where higher scores indicated denial of poor health (‘I expect my health to get worse’ and ‘I seem to get sick a little easier than other people’), 26 and 32 patients, respectively, selected ‘definitely false’; meanwhile, 7 and 5, respectively, selected ‘definitely true’. For items indicating better health (‘My health is excellent’ and ‘I am as healthy as anybody I know’), 8 and 14 patients, respectively, selected ‘definitely true’, whereas 25 and 24, respectively, selected ‘definitely false’. The number of patients who responded ‘don’t know’ ranged from 5 to 14 across items.

Figure 5 Heat map showing the distribution of patient-reported outcomes for four SF-36 general health statements following subtotal cholecystectomy. Lighter colours indicate better perceived health, while darker colours reflect poorer self-reported health. Statements: A, ‘My health is excellent’; B, ‘I am as healthy as anybody I know’; C, ‘I expect my health to get worse’; D, ‘I seem to get sick a little easier than other people’. Colour coding: yellow = score 100 (best outcome), orange =75, dark red =50, purple =25, and solid blue =0 (worst outcome). SF-36, Short Form-36.

HSA

The mean self-rated health score was 67.94 (95% CI: 63.19–72.70; SD 20.09), with a median of 70 (95% CI: 60–75; IQR, 50–80). Seven patients (9.9%) rated their health at 100, while two (2.8%) gave a score of 20. Over half (40, 56.3%) reported scores between 70 and 100, as shown in Figure 6.

Figure 6 Distribution of health self-assessment scores by decile, ranging from 20 to 100. The highest score, 100 (seven patients), fell within the last decile. The highest-intensity green highlights the best outcome, whereas the lowest-intensity green indicates the worst outcome. The number of cases in each decile is as follows: 20–29: 3 (1 female, 2 males); 30–39: 2 (females); 40–49: 3 (females); 50–59: 12 (9 females, 3 males); 60–69: 11 (6 females, 5 males); 70–79: 17 (12 females, 5 males); 80–89: 9 (3 females, 6 males); and 90–100: 14 (5 females, 9 males).

Impact of operative characteristics on QoL

Bivariate analyses of 11 perioperative variables showed no statistically significant associations with GIQLI-10, SF-36 General Health, or HSA scores (Table 2). Surgical urgency, operative approach, STC technique, completion type, and postoperative complications (including bile leakage, bile duct injury, and infection) were not associated with long-term patient-reported outcomes.

Correlation between QoL metrics

Significant correlations were observed among all three QoL measures. The strongest correlation occurred between HAS and SF-36 General Health (r=0.81; P<0.001) (Table S2).

Discussion

Systematic translation of subjective patient experiences into measurable quantitative data should be integral to every surgical strategy, including damage-control gallbladder procedures such as STC. Questionnaires comprising structured statements with predefined response options remain the most reliable approach for assessing chronic postoperative symptoms and health-related QoL, collectively referred to as PROMs. Such questionnaires are crucial for evaluating the long-term effects of surgical decision-making and of bailout surgery and for predicting postoperative symptoms, optimising follow-up protocols, and strengthening patient counselling and treatment (43).

To our knowledge, no targeted, developed, and validated PROM questionnaires specific to biliary disease or surgery is currently available. As a result, various PROM tools have been used to evaluate outcomes following TC (19-21,44,45). Only two previous studies have reported long-term PROMs in patient cohorts after STC, with median follow-up of 6 and 7.25 years (17,18). In these cohorts, 16% of patients experienced persistent abdominal pain (17), 10% reported occasional abdominal pain (18), 9% reported diarrhoea, and 7% reported reflux symptoms, with no significant differences between fenestrating and reconstituting STC (Figure 7). A recent study published in 2025, utilising a short biliary-surgery-specific questionnaire, reported that recurrent biliary symptoms were uncommon (<10%), although dietary restrictions persisted in over one-third of patients (18). Comprehensive and quantitative STC-related PROM data, thus, remain scarce.

Figure 7 Key characteristics and results of studies on health-related quality of life and patient-reported symptoms following subtotal cholecystectomy (17,18). ^‡, pattern, represented by bar plots with error bars; ^§, all or most of the time. –, no data. STC, subtotal cholecystectomy; TC, total cholecystectomy following conversion from a laparoscopic to an open procedure; GIQLI, Gastrointestinal Quality of Life Index; EQ5D, EuroQoL 5 Dimensions; VAS, Visual Analogue Score; SF-36, Short-Form 36 Questionnaire; PCS, physical health component summary; MCS, mental health component summary; HSA, health self-assessment.

In the absence of biliary-specific instruments to collect data on and investigate patient-reported outcomes (44-47), we developed a concise five-section questionnaire incorporating two validated tools (GIQLI-10 and SF-36 components). We used this questionnaire to survey 71 adults who underwent STC between 2012 and 2021, with a mean follow-up of nearly seven years. Comorbidity was common, particularly related to digestive tract (37%), musculoskeletal (34%), and cardiac (17%) disorders. Nearly half of patients had moderate-to-severe comorbidity categorised as CACI ≥3.

Regarding STC-specific early postoperative morbidity, the frequency of post-STC bile leak (29.6%) was higher than the estimated bile leak rate reported in four systematic reviews: 18% (48), 15.4% (49), 13.9% (13), and 6.4% (50). However, a recent large-scale multicentre study reported a similar bile leak rate of 28.8% (15). The reasons for these varying rates are multifactorial, including the technical features of the final stage of STC—fenestrating versus reconstituting (26) and open-tract STC versus closed-tract STC (16,27), residual choledocholithiasis, and the inclusion of a significant number of single-centre studies that reported very low rates of post-STC morbidity and surgical procedures in the systematic reviews (51). Thus, the definition and confirmation of a bile leak in unclear cases might have been included in these studies. To date, no formal criteria for STC-related bile leaks exist (for example, bilirubin concentration in the sero-bilous fluid, and duration of this type of leak); thus, bile leak interpretation bias was also possible in our study.

The postoperative ERCP rate (26.8%) was high among our patients. We observed a similar pattern upon comparing this finding with those of previous studies (13,15,17,48-50): systematic reviews report lower postoperative ERCP rates, such as 4.1% (48), 8.8% (49), 6.9% (13), and 8.6% (50), whereas multicentre studies report higher rates, such as 18.3% (17) and 36.4% (15). Further analysis of data of specific granularity and understanding of institutional policies and locally established cultures is necessary to explain this pattern. Our data suggest a possible correlation with reported post-STC bile leak rates.

In this study, responders and non-responders were similar across nearly all demographic and perioperative variables, with significant differences observed only in ASA physical status class II, STC setting (elective, emergency), and STC resection techniques STC-1 and STC-2. Given the clinical context of this cross-sectional study and no significant differences among essential variables, such as age, comorbidities, STC mode, STC completion type, postoperative bile leak, ERCP, and length of hospital stay after surgery, we believe that the significant differences in the four variables were non-substantial. Hence, the 71-responder cohort can be regarded as representative for this study.

Overall, patients reported acceptable long-term health outcomes, although some gastrointestinal symptoms persisted. The mean GIQLI-10 score was 82.5% of the maximum. Persistent or frequent abdominal pain was reported by 13% of respondents, consistent with previous reports (8–16%) (17,18). Fatigue was observed in one-third of patients; bloating, flatulence, constipation, and diarrhoea each occurred in 10–20%. These findings are consistent with existing literature showing good patient-reported long-term gastrointestinal health outcomes following STC despite 41% of the patients reporting dietary restrictions (18). However, because these non-specific symptoms overlap with other chronic medical conditions and considering the cross-sectional study design, causal inferences cannot be drawn from this study. Larger-scale research with a TC comparator in a matched difficult-cholecystitis cohort is needed to further assess the impact of STC on health-related QoL.

The concept of a ‘post-STC syndrome’ may offer a useful clinical framework for categorising long-term sequelae. In our cohort, bile duct injury occurred in one patient (1.4%); incisional hernias were reported by 22.5% of patients, with only three of them (4.2%) undergoing hernia repair. Persistent or recurrent biliary symptoms may be attributable to residual gallstones, gallbladder remnant size or closure technique. These factors parallel the multifactorial pathophysiology of post-cholecystectomy syndrome (52), although the distinct anatomical features of STC suggest that post-STC symptoms may constitute a separate clinical entity.

General health outcomes were also acceptable. Nearly two-thirds of patients rated their general health as ‘excellent’, ‘very good’, or ‘good’, and a similar proportion reported their health status as ‘better or unchanged’ compared with the previous year. The HSA score slightly exceeded the SF-36 General Health domain (mean 67.9 vs. 55.8; median 70 vs. 60), likely reflecting the inclusion of broader emotional and psychosocial variables. A strong correlation (r=0.81) between HSA and SF-36 supports HSA as a practical, concise indicator when extended PROMs are not feasible.

Direct comparison of our data with TC-related PROMs was challenging because of differences in patient characteristics, disease severity, follow-up duration, and study design. Published mean SF-36 General Health scores after TC range from approximately 60 to 74 in the first 3–9 postoperative months among typically younger, lower-risk populations (53-56). The comparable health perception in our STC cohort suggests that, despite greater biliary disease complexity and operative risk, health-related QoL after STC aligns with patient-reported outcomes after TC. Additionally, no associations were observed between perioperative variables and PROMs in our study, implying that long-term QoL may be more strongly influenced by individual patient factors, comorbidities, and medication use than by intraoperative variables. This assumption is consistent with the findings from previous studies (17,18).

The strengths of this study include its acute biliary population at a tertiary academic centre, the use of both disease-specific and general PROMs, and complete questionnaire responses. Combining GIQLI-10 (to capture symptoms over the preceding 2 weeks) and the brief SF-36 subset enabled an efficient and comprehensive assessment of patients’ gastrointestinal and overall health via semi-structured telephone interviews. The information provided in this study can aid preoperative discussions, patient counselling, and shared decision-making before gallbladder surgery. This study shows that the demographic, clinical, and operative characteristics of the included 71 patients, including age, sex, comorbidity burden, STC type, bile leakage, and postoperative ERCP rates, were consistent with those reported in prior studies (14,16). Despite this, the results of these studies complement each other with respect to PROMs (for example, post-STC pain and dietary restrictions). A bivariate analysis showed no substantial differences between responders and non-responders in basic demographic and perioperative clinical variables, indicating minimal selection bias.

However, some limitations of the study should be considered. First, there is a lack of patient involvement in PROM selection. Second, it is a single-centre design, and reliance on telephone follow-up (neither mail nor email alternatives were available) up to 10 years postoperatively, which may introduce recall bias, particularly regarding specific post-STC events such as bile leakage and ERCP. Third, the absence of a cholecystectomy-specific PROM necessitated adaptation of some existing tools. The OTAGO questionnaire was not used as it was designed to evaluate the role of cholecystectomy in resource-constrained settings (57). While full versions of SF-36 and GIQLI are recommended (58,59), abbreviated and validated tools (such as GIQLI-10) are practical for postoperative PROM assessment (21,60). Fourth, clinician-reported long-term outcomes following STC at the time of interview were not considered during study planning. Fifth, including a control group of patients who underwent TC during the study period would have enabled a comparison of patient-reported outcomes and health-related QoL after STC with those after TC, thereby strengthened this study. In this regard, quantifying the minimal clinically important differences (44) in postoperative QoL between the control and study groups would be a valuable addition to the STC concept. To date, there are no data comparing QoL after STC versus TC (61).

Future research should employ prospective methods, include preoperative baseline PROMs to assess improvements in overall and gastrointestinal QoL, and monitor patient-reported symptoms after STC at scheduled intervals, as conducted in 51 patients who underwent index admission LC for acute cholecystitis in a previous study (34). Such an observational longitudinal follow-up study would allow researchers to identify temporal trends and demonstrate how and when STC restores patients’ QoL and influences individual symptoms.

Conclusions

This study provides important evidence on long-term patient-reported gastroenterological symptoms and general health-related QoL following STC. We also reported new quantitative details of sufficient granularity on overall health-related QoL and individual postoperative symptoms. This information can be used for preoperative discussions and shared decision-making before cholecystectomy and postoperative counselling. The findings support STC as a safe damage-control and limiting procedure for gallbladder surgery when indicated. Operative setting, surgical approach, STC type, and biliary-surgery-related morbidity do not appear to influence long-term PROMs. A strong correlation between the SF-36 General Health domain and a single HSA score highlights the utility of simplified PROM measures. Further multicentre prospective research is warranted.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CROSS reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-2026-1-0004/rc

Data Sharing Statement: Available at https://asj.amegroups.com/article/view/10.21037/asj-2026-1-0004/dss

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-2026-1-0004/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-2026-1-0004/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Clinical Audit and Effectiveness Department Board of the NHS University Hospitals of Liverpool Group (No. 10816). Verbal informed consent was obtained from all patients prior to the interviews.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the noncommercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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