SHORT-TERM OUTCOME OF EARLY LAPAROSCOPIC CHOLECYSTECTOMY

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1 SHORT-TERM OUTCOME OF EARLY LAPAROSCOPIC CHOLECYSTECTOMY Muhammad Iftikhar, Rashid Aslam, Irfan ul Islam Nasir ABSTRACT Background: Laparoscopic cholecyectomy is being used in increasing frequency for cholecyectomy. Objective: To evaluate the short-term outcome of early laparoscopic cholecyectomy in terms of length of hospital ay, complications and patient satisfaction. Methodology: After approval of the initute's research evaluation committee, this cross sectional udy was conducted at the department of General and laparoscopic surgery, Hayatabad Medical Complex, Peshawar from January to 3 December 05. Clinical features, operative findings and pooperative outcome was recorded in terms of length of ay (LOS), complications and overall patient satisfaction. The data was entered and analyzed by using SPSS version 0. Results: Mean age was 48.3 years ± 0.86 with 3 (4.%) males and 4 (75.9%) females. The overall no to low satisfaction rate was 3(4.07%), while 7(.96%) patients remained neutral. The re of the 34(63%) patients rated their satisfaction as high or adequate. Significantly associated complications to open cholecyectomy included development of pooperative pyrexia (p = 0.006), wound infection (p < 0.00), and seroma formation (p < 0.00). The diributions of median satisfaction scores were atiically significantly different for the two groups of procedures (p < 0.00). Conclusion: laparoscopic cholecyectomy is a safe and effective choice for patients of gallone disease with significantly shorter length of ay and higher overall satisfaction rates. Keywords: Acute cholecyitis, Early laparoscopic cholecyectomy, Complications, Satisfaction JSZMC 06;7(4): INTRODUCTION Gallones disease is common in both Weern and our societies. A majority of gallones are asymptomatic and are discovered either incidentally or after they cause symptoms of acute cholecyitis. Surgical intervention isnecessaryfor,3 preventing complications of gallones. L a p a r o s c o p i c c h o l e c y s t e c t o m y ( C L ) revolutionised the treatment of gallone disease by a significant decrease in pooperative 4-6 morbidity and hospital ay. The diagnosis and early management principles of acute cholecyitis were developed in a series of large multicentre Japanese udies and summarised the recommendations in the Tokyo guidelines, initially in 007 (TG07)7, 8 and later in 03 (TG3) 9. These guidelines and numerous meta-analyses,0 have recommended that early laparoscopic intervention is beneficial for acute gallone cholecyitis and should be encouraged -4 if the expertise is available. We present our experience with early LC and show our short term outcome in terms of length of ay, complications and overall patient satisfaction. This will improve our underanding of the benefits of early LC and consequently the outcomes of our patients. METHODOLOGY This was a cross sectional cohort udy conducted from January to 3 December 05. The udy was commenced after approval by the Initutes Ethical Review Committee at the Department of General and Laparoscopic Surgery Unit of Hayatabad Medical Complex Peshawar. All patients included were informed and verbal consent was taken. Inclusion Criteria: Patients with acute gallone cholecyitis irrespective of their gender and with age range of 6 to 65 years. Exclusion Criteria: Complicated gallone cholecyitis (pancreatitis, cholangitis, choleatic jaundice) were excluded. Patients with acalculous cholecyitis, diagnosed cases of GB tumours and gangrene or abscess formation were excluded. Patients who were patients were not fit for LC due to bleeding problems, previous upper abdominal surgery or liver disease were also excluded. Operative Procedure: Under GA and after aseptic measures, a nasogaric tube was passed to decompress the omach. Pneumoperitoneum was. General Surgery, Peshawar Initute of Medical Sciences Hayatabad Peshawar, Khyber Pakhtunkhwa, Pakian.. Shaukat Khanum Hospital Lahore, Pakian. Correspondence: Dr. Muhammad Iftikhar, Department: General Surgery, Peshawar Initute of Medical Sciences Hayatabad Peshawar, KPK, Pakian. iffi_khattak@hotmail.com Mobile: Received: Accepted: JSZMC Vol.7 No.4 088

2 created after insertion of Veress needle. Intraabdominal pressure was kept between 8 to mm Hg. Four ports were used, while the umbilical 0 mm port was used for optical telescope insertion. Epigaric port was used for suction and irrigation.the 5 mm trocars in right flank and right upper quadrant were used for dissection and grasping. Once the adhesions were removed, the gallbladder was decompressed. Calot's triangle was identified and gallbladder was dissected away from its fossa. Liga-clips were used for cyic duct and artery ligation. Gallbladder was retrieved using retrieval bag method. Haemoasis was ensured and pneumoperitoneum was released. In case of severe bleeding or major injury to the CBD, or dense adhesions in the vicinity of gallbladder, the procedure was converted to open. A right upper quadrant Kocher's incision was made and the gallbladder dissection was done using monopolar diathermy. Drains were used if significant bleed or leak were encountered during the surgery. Data collection was done for clinical features, laboratory findings, intraoperative complications, procedure time and length of ay. During the pooperative follow-up, data was collected about development of complications. At 3-month follow-up, patients were presented with 5-items Likert scale regarding their satisfaction with the surgical intervention IBM SPSS Statiics version.0 was used for data analysis. Chi-square te was used for association between dichotomous categorical variables, Mann-Whitney U te was used for determining atiical significance of patient satisfaction. Spearman rank correlations were determined for correlation of various factors with each other. RESULTS A total of 54 patients were operated during the udy period. Out of these 3 (4.%) were males and 4 (75.9%) were females. Mean age was 48.3 ± 0.86 years. The mean duration of onset of symptoms was.78 ± 0. days. The descriptive atiics including total leukocyte counts and liver function tes are summarised in Table I. Right upper quadrant (RUQ) pain was present in 47(87%) which was followed in frequency by nausea and vomiting 36 (66.7%) and dyspepsia 9( 35.%). Intra-operative complications were bleeding 0(8.5%), difficult anatomy 7(3%) or intraoperative bile leak due to CBD injury 4 (7.4%). (Table II) The overall no to low satisfaction rate was 3(4.07%), while 7(.96%) patients remained neutral. The re of the 34(63%) patients rated their satisfaction as high or satisfied. It was noted that 9(6%) of patients who were converted to open rated their experience as not satisfying while only (3.7%) scored as satisfied or highly satisfied. (Table III) No mortality was recorded in our udy. Seroma formation 6(9.6%) and che infection 4 (5.9%) were the commone complications observed in this udy. (Table II) Significantly associated complications with conversion to open cholecyectomy included development of pooperative pyrexia (p = 0.006), wound infection (p < 0.00), and seroma formation (p < 0.00). The differences in satisfaction scores for the laparoscopic group and those who were converted to open procedure, were atiically significantly different for the two groups of procedures (p < 0.00) (Table III). The diribution of median scores for length of ay was also atiically significantly different for the two groups of procedures (p < 0.00). (Figure I) Table I: Descriptive Statiics of patients Age of patient Duration of symptoms TLC Total Bilirubin ALT Alkaline Phos Procedure time Length of ay Mean Median Mode Std. Deviation Minimum Maximum JSZMC Vol.7 No.4 089

3 Table II: Clinical variables and their frequency diributions Clinical variable Frequency (n) % age Gender Male 3 4.% Female % Clinical features RUQ Pain % Nausea % Vomiting 0.4% Fever 8 4.8% Dyspepsia 9 35.% Ultrasonographic findings Diended GB % Thickened GB 40.7% Pericholecyic 9 35.% fluid Murphy s Sign % Intraoperative complications Difficult anatomy 7 3.% Bleed 0 8.5% Leak 4 7.4% Conversion to Open 5 7.8% Pooperative Complications Pyrexia 0.4% Wound 5 9.5% infection Che Infection 4 5.9% Bile leak 0 3.7% Bleeding from 0 7.4% wound Seroma 6 9.6% Figure I: Mean length of udy in hospital in laprascopic versus conversion to open cholecyectomy Mean length of ay Error Bars: 95% CI Yes Conversion to open cholecyectomy DISCUSSION Gallone disease is a serious disorder considering its sequelae in the form of pancreatitis, CBD obruction 5 and gallone ileus. Although dependent upon the expertise of the surgeon and the occurrence of adverse events, overall morbidity due to this disorder have improved by the introduction and widespread use of laparoscopic cholecyectomy, such that, LC has become the andard of treatment for gallone 5, 6 disease as was predicted more than 0 years ago. Although the debate ill continues about quantifying the benefits of early cholecyectomy from earlier 7,8 intervention in acute cholecyitis. The demographic features of our subset of patients in this udy are generally in agreement with other 9,0 udies, with abundance of female patients (75.9%), of young to middle age groups (mean: 48.3 years). In a recent udy by Oskardes AB et al, mean age was years with 66.7% females, mean duration of 5.57 days and 0% cases with concomitant comorbidity. They encountered 3.3% conversion to open cholecyectomy with a mean procedure time of 67 minutes. Chandio A et al have described the factors which could lead to conversion to open cholecyectomy and they found No Groups Satisfaction Levels Laparoscopic procedure (n) Open Procedure (n) Total no. of patients Table III: Satisfaction levels in both groups 0 (0.0%) 9 (6.6%) 9 (6.7%) 3 (7.69%) (.9%) 4 (7.4%) 6 (.%) (.9%) 7 (3%) 5 (7.7%) (3.7%) 7 (3.5%) 5 (7.7%) (3.7%) 7 (3.5%) Total No (%) 39 (7.%) 5 (7.7%) 54 (00%) JSZMC Vol.7 No.4 090

4 increasing age, obesity, acute cholecyitis, previous abdominal surgery, gallones, and CBD ones as the factors which significantly affect conversion of a laparoscopic cholecyectomy to open procedure. We could not find a significant association (p = 0.93) between age and conversion to open procedure, probably due to lower age of the patients in our patients as compared to the above cited udies. Chandio A et al, has also found a 67% conversion rate for LC performed in acute cholecyitis which is quite high as compared to our conversion rates (7%). 3 Cheng Y et al, in their retrospective data analysis of early LC have concluded that early LC is a safe and effective choice for patients during acute cholecyitis even in the elderly population and have not found an impact of age on the occurrence 3 of adverse events. These observations are 4 compounded by Lo C et al, findings of no significant incidence of conversion rates or major complications, although, they have noted that a successful completion of the procedure requires more time (mean; 37. minutes). In our udy, the mean operation time was minutes, and though it was significantly shorter than the open procedure, we could not compare it to those patients who undergo elective LC. In our udy the LC group had a mean length of ay 3.03 ± 0.67 days while those who were converted to OC had a mean LOS of 4.73 ±.03 days. Similarly, high pooperative complication rates and low overall satisfaction scores were associated with OC patients as compared to LC 5 group. Similar findings are noted by Ciftci F et al, who has described a significantly longer LOS and higher complication rates. They have concluded that increased GB wall thickness, male gender, pericholecyic collection on ultrasonography and gangrenous cholecyitis were significantly 5 associated with conversion to OC. 6 Saber A et al, have evaluated the early LC to delayed LC in terms of readmission rates and overall patient satisfaction. Their results showed that readmissions were significantly higher in the delayed LC group while for early LC the overall satisfaction scores were 9.66 as compared to 6 delayed LC (75.34). These findings are in agreement with our udy where we found high satisfaction scores for more than 85% of our early LC patients. However, in patients who unfortunately were converted to OC, majority of them were not satisfied and had prolonged hospital ay. This udy is limited by shorter followup period as in our set up the loss to follow is increasingly high due to multiple reasons. Smaller sample size is another weakness of this udy which could be alleviated by designing large prospective randomised udies. Since we did not have a comparative group from either the delayed LC or elective OC, this weakness could be removed by designing randomised comparative udies in future. CONCLUSION Early cholecyectomy is a safe choice for patients with acute cholecyitis where shorter morbidity and lower complication rates makes it very favourable in the current healthcare syem which is already overburdened. Conversion rates for early LC are comparable to elective LC and associated with low rates of complications and higher patient satisfaction. REFERENCES. Brandon JC, Velez MA, Teplick SK, Mueller PR, Rattner DW, Broadwater JR, Jr., et al Laparoscopic cholecyectomy: Evolution, early results, and impact on nonsurgical gallone therapies. AJR Am J Roentgenol. 99;57(): Sondenaa K. Evidence-based treatment of gallone disease. J Garointe Surg. 03;7(): Chuang SC, Hsi E, Lee KT. Genetics of gallone disease. Adv Clin Chem. 03;60: Rock JA, Warshaw JR. The hiory and future of operative laparoscopy. Am J Obet Gynecol. 994;70( Pt ): Cooperman AM. Laparoscopic cholecyectomy: results of an early experience. Am J Garoenterol. 99;86(6): Saia M, Mantoan D, Buja A, Bertoncello C, Baldovin T, Callegaro G, et al. Time trend and variability of open versus laparoscopic cholecyectomy in patients with symptomatic gallone disease. Surg Endosc. 03;7(9): Hirota M, Takada T, Kawarada Y, Nimura Y, Miura F, Hirata K, et al. Diagnoic criteria and severity assessment of acute cholecyitis:tokyo Guidelines. J Hepatobiliary Pancreat Surg 007;4(): Kimura Y, Takada T, Kawarada Y, Nimura Y, Hirata K, Sekimoto M, et al. Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecyitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg. 007;4(): Takada T, Strasberg SM, Solomkin JS, Pitt HA, Gomi H, Yoshida M, et al. TG3: Updated Tokyo Guidelines for the management of acute cholangitis and cholecyitis. J Hepatobiliary Pancreat Sci. 03;0(): Nair R. Early laparoscopic cholecyectomy for acute cholecyitis: is it safe for patients? South Med J. 05;08(): Nishino T, Hamano T, Mitsunaga Y, Shirato I, Shirato M, JSZMC Vol.7 No.4 09

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