Laparoscopic Cholecystectomy and Cirrhosis: A Case-Control Study of Outcomes

Transcription

1 Laparoscopic Cholecystectomy and Cirrhosis: A Case-Control Study of Outcomes Neville F. Fernandes, * Wayne H. Schwesinger, Susan G. Hilsenbeck, * Glenn W.W. Gross, * Michael K. Bay, * Kenneth R. Sirinek, and Steven Schenker * The incidence of gallstone disease in patients with cirrhosis is greater than that in healthy patients. Previous surgical literature reported greater morbidity and mortality in patients with cirrhosis with both open and laparoscopic cholecystectomy (LC). We compared our recent experience with LC in patients with cirrhosis and controls. A retrospective review was performed using the search terms, cirrhosis and laparoscopic cholecystectomy. Forty-eight patients with cirrhosis were identified and randomly matched with healthy controls by age and sex. Four controls were assigned per patient with cirrhosis. Outcomes assessed included mortality, duration of surgery, length of hospital stay, blood transfusion requirement, postoperative complications, and need for conversion to open cholecystectomy. Forty-eight patients with cirrhosis and 187 healthy controls underwent LC. Child- Pugh classification of severity of liver disease was as follows: Child s class A, 38 of 48 patients; Child s class B, 10 of 48 patients; and Child s class C, 0 of 48 patients. Patients with cirrhosis had statistically significantly lower albumin levels (P.0001) and prolonged prothrombin times (P.05). Average duration of surgery for patients with cirrhosis was 1.71 versus 1.57 hours (P.57) for controls. Average length of hospital stay for patients with cirrhosis was 6.47 versus 4.77 days (P.152) for controls. Average number of units of blood transfused in patients with cirrhosis was versus 0.0 units (P.025) in controls. Complications occurred in 6 of 48 patients with cirrhosis (12.5%) and 8 of 187 controls (4.2%; P F.05). No child s class C patient underwent LC. Four patients with cirrhosis (8.3%) and no controls were converted to open cholecystectomy. No postoperative infections were noted. There was no mortality in either group. LC in patients with Child s class A and B cirrhosis is reasonably safe and shows no increase in morbidity or mortality or worsening of outcome. Further studies are required to evaluate the management of acute gallbladder disease in Child s class C patients. (Liver Transpl 2000;6: ) From the Departments of *Medicine and Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX. Presented in part at the American College of Gastroenterology 64th Annual Scientific Meeting, Phoenix, AZ, October 18-20, Address reprint requests to Steven Schenker, MD, Division of Gastroenterology and Nutrition, Department of Medicine, UTHSCSA, 7703 Floyd Curl Dr, San Antonio, TX Telephone: ; FAX: Copyright 2000 by the American Association for the Study of Liver Diseases /00/ $3.00/0 doi: /lv C linical and autopsy studies have suggested that the prevalence of gallstones is increased in patients with cirrhosis, a finding generally attributed to accelerated pigment stone formation. 1-4 When patients with cirrhosis with gallstones become symptomatic or develop complications, consideration of surgical intervention is warranted. However, the risks may be greater than in the healthy population. Early cohort studies of open cholecystectomy in patients with cirrhosis showed that surgery was associated with excessive morbidity and mortality secondary to intraoperative hemorrhage, liver failure, and/or sepsis. 5-8 As a result, the presence of moderate to severe cirrhosis has been generally considered a relative contraindication to open cholecystectomy. 9 Only limited information has been added to this subject since the introduction of less invasive laparoscopic techniques. The aim of this report is to document our recent experience with laparoscopic cholecystectomy (LC) in patients with cirrhosis and determine whether there is a significant difference in perioperative morbidity and mortality in this group compared with a control population without cirrhosis. Materials and Methods A computerized surgical database was used to identify 48 consecutive patients with gallstones with well-documented cirrhosis undergoing LC at either the University Hospital or the South Texas Veterans Health Center between January 1993 and July Institutional review board approval was obtained from both hospitals. Patients were included on the study if they were aged 18 years or older and were diagnosed with cirrhosis either at the time of or before surgery. The assessment was inclusive of all such patients. A diagnosis of cirrhosis was based on specific histological findings after liver biopsy (20 patients) or surgical finding of a nodular liver combined with appropriate clinical and biochemical features. All patients underwent a standard LC under general endotracheal anesthesia. The Hasson technique was used for placement of the periumbilical trocar, and insufflation pressure was maintained at 13 to 15 mm Hg. Control patients were selected by matching patients without cirrhosis of the same age and sex to patients with cirrhosis who had undergone LC at approximately the same time by using random number tables, and 4 controls without cirrhosis were selected for each patient with cirrhosis. 340 Liver Transplantation, Vol 6, No 3 (May), 2000: pp

2 Laparoscopic Cholecystectomy in Cirrhotics 341 Data collected included patient age, date of surgery, duration of surgery, blood transfusion requirements, complications, length of hospital stay, and confounding comorbidities. Outcomes assessed and compared included mortality, all major and minor complications, conversions to open cholecystectomy, duration of surgery, length of hospital stay, and blood transfusion requirements. The accuracy of the surgical database was confirmed by randomly cross-checking approximately 50% of all patients with information from hospital records. During this process, a single control was identified as having cirrhosis, although not included in the cirrhotic group on the database. The patient was added to the cirrhotic group, resulting in a total of 48 patients with cirrhosis and 187 controls. The single error (1 of 188 controls; 0.5%) was not deemed significant. Identification of the cause of cirrhosis was attempted in each case by examination of the medical and pathological records. In addition, severity of liver disease was graded according to the Child-Pugh classification. Statistical analysis included descriptive statistics using Chi-squared and Student s 2-tailed paired t-tests. Statistical significance is defined as P less than.05. Results Forty-eight patients with cirrhosis and 187 controls without cirrhosis underwent LC for symptomatic gallstones. Forty-four patients with cirrhosis (94%) and 169 controls (79%) presented with acute cholecystitis or choledocholithiasis, whereas 6 patients with cirrhosis (13%) and 29 controls (15%) presented with biliary pancreatitis. Table 1 lists pertinent demographic and selected laboratory data. The cirrhotic and noncirrhotic groups are closely similar in age and sex. Of the 48 patients with cirrhosis, 38 were classified as Child s class A and 10 as Child s class B. No patient was Child s Table 1. Demographic and Clinical Characteristics of Study Patients Patient Characteristics Cirrhotics Noncirrhotics No. of patients Age (yr) Sex (M/F) 29/19 111/76 Child s class (A/B/C) 38/10/0 NA Acute cholecystitis (%) 10 (20.8) 34 (18.1) Albumin (g/dl) Alkaline phosphatase (IU/L) Total bilirubin (mg/dl) Prothrombin time (s) Abbreviation: NA, not applicable. Table 2. Surgical Outcomes After LC Outcome Measures Cirrhotics Noncirrhotics P Surgical time (min) Hospital length of stay (d) Transfusions (units/ patient) Conversions (%) 4 (8.3) Complications (%) 5 (10.4) 4 (2.1).05 class C, and no patient presented with encephalopathy. However, 4 of 48 patients (8.3%) showed ascites in the preoperative period. Cirrhosis was visually documented in all patients at the time of surgery by the presence of typical hepatic nodularity. Additionally, 20 patients had confirmatory liver biopsies performed. In 26 patients, cirrhosis was alcohol related. Eight patients had hepatitis C, and 2 patients had both hepatitis C and a long-standing history of alcohol use. There was 1 case each of cryptogenic cirrhosis and autoimmune hepatitis. In 10 patients, no specific cause was determined. All cholecystectomies were attempted laparoscopically, but 4 patients with cirrhosis required conversion to an open procedure (8.3%; P.0001) because of adhesions (2 patients), discovery of an unexpected liver mass (1 patient), and avulsion of the cystic artery (1 patient). No control patient required conversion. In 5 of the patients with cirrhosis, laparoscopy was performed as an emergency procedure (P.0008). All control cholecystectomies were performed electively. Table 2 lists overall surgical outcomes. The mean duration of the surgical procedure was minutes for patients with cirrhosis and minutes for controls (P.57). The hospital lengths of stay were versus days (P.15) for patients with cirrhosis and controls, respectively. Comparison of patients with Child s class A and B cirrhosis showed that those with Child s class B cirrhosis had overall longer surgical times, duration of hospital stays, and blood transfusion requirements, although none of these differences was statistically significant. Intraoperative cholangiography was performed in 17 of the patients with cirrhosis (35.4%) and 84 of the controls (44.9%). Endoscopic retrograde cholangiopancreatography (ERCP) was performed preoperatively in 11 of 48 patients with cirrhosis (23%) and 56 controls (29.9%). The mean blood transfusion requirement for patients with cirrhosis was 0.16

3 342 Fernandes et al 0.42 units; no control patient required perioperative blood or blood products (P.025). Complications occurred in 5 of 48 patients with cirrhosis (10.4%) and 4 of 187 controls (2.1%) (P.05), but none produced residual disability. Complications in patients with cirrhosis included intraoperative bleeding requiring transfusion in 2 patients (4.2%), peritonitis in 1 patient (2.1%), and perforation of the cystic duct in 2 patients (4.2%). Complications in the 187 control patients included bleeding (1 patient), perforation of the cystic duct (1 patient), avulsion of the cystic duct (1 patient), and small-bowel perforation requiring enterotomy (1 patient). Bleeding was not related to thrombocytopenia in patients with cirrhosis or to liver biopsies intraoperatively. No patient required readmission or outpatient treatment for delayed complications after hospital discharge. Discussion Available cohort studies have generally shown that LC is an acceptably safe and effective procedure in selected patients with cirrhosis. However, most of these studies were small, and none used meaningful (nonhistorical) control groups for comparison (Table 3). The present study, one of the largest published, uses a rigorous concurrent case-control method to compare cirrhotic and noncirrhotic groups. Generally, this study confirms earlier evidence that patients with Child s class A or B cirrhosis and symptomatic gallstone disease tolerate LC nearly as well as those without cirrhosis. No patient in the current study died, and no major differences in surgical times or lengths of hospital stay between the patients with cirrhosis and the controls without cirrhosis were observed. However, the transfusion requirements in the cirrhotic group (Table 2) were modestly increased. Presumably, bleeding is related to the intraperitoneal hypervascularity that commonly accompanies portal hypertension and may be further aggravated by coagulation abnormalities associated with liver disease. Previous experience with open cholecystectomy has documented that hemorrhage in patients with cirrhosis is closely correlated with reduced hepatic reserve, evidenced by an increased Child s class and prolonged prothrombin time. 17,18 In advanced cases, intensive preoperative preparation and attentive postoperative care can help optimize and preserve hepatic function and thereby improve clinical outcomes. 19 When emergency surgery is required and preparation is limited, greater surgical blood loss and increased morbidity may be expected. In both elective and emergent cases, vasopressin (Intravenous Pitressin; Fujisawa USA Inc, Deerfield, IL) is an effective adjunct to handle problematic intraoperative bleeding. 20 This approach proved useful in temporarily controlling hemorrhage in 22 of our patients with cirrhosis. Another complication, peritonitis, occurred in a single patient with cirrhosis with ascites. In general, septic problems are most common with advanced cirrhosis and contribute heavily to the increased mortality. 20 In part, the increased infection rate may be explained by the impairment of Kupffer cell function that results in decreased intravascular clearance of enteric organisms. In addition, ascitic fluid may provide an ideal growth medium for bacterial contaminants released during cholecystectomy. Even though Table 3. Comparison of Literature and Studies Comparing LC in Patients With Cirrhosis Lacy et al 10 Gugenhei et al 11 Reference D Albuquerque Angrisani et al 12 Yerdel et al 13 Sleeman et al 14 Friel et al 16 et al 15 No. of patients Year Child s class 7A/3B/1C 9A 8A/4B 6A/1C 16A/9B NR 20A/11B Surgical duration (min) NR 90 Hospital stay (d) Blood transfusion (units) 0 NR NR 1 Complication None 1 Ascites 4 None % 8 Conversion to O/C 1 NR Abbreviations: NR, not reported; O/C, open cholecystectomy.

4 Laparoscopic Cholecystectomy in Cirrhotics 343 splanchnic and renal deterioration have been noted after LC in previous reports, 21 we did not encounter such overt events. Wound infection and delayed wound healing are another major source of septic morbidity in patients with cirrhosis, especially those undergoing open cholecystectomy, although we did not observe wound problems in either the laparoscopic or converted (open) patients. Overall, the relative risk for septic complications depends on the severity of cirrhosis. Numerous investigators have correlated the prevalence of sepsis with the patient s Child-Pugh classification. 6,8,22 Patients with cirrhosis in the present study also showed an increased conversion rate (8.3% v 0%), which was not found in all reports. In at least 3 of our converted cases, cirrhosis was undoubtedly a contributing factor, particularly for 1 patient with a hepatic mass and those patients with hypervascular adhesions. Notably, conversion was performed to explore the common bile duct or extract intraductal stones. The increased morbidity and mortality with common bile duct exploration in cirrhosis is well described. 5,19 As a result, we prefer preoperative ERCP when common bile duct stones are clinically suspected. During this study, we did not attempt LC in a patient with Child s class C cirrhosis. These patients are clearly at a substantially greater risk for an adverse outcome. As a result, a more conservative approach seems preferable despite the lack of definitive clinical trials. 23 A partial cholecystectomy, performed either laparoscopically or by open technique, has occasionally been recommended, but the available reports have not used controls. 24 A larger experience supports the use of ERCP in those high-risk patients who present with biliary obstruction. Endoscopic drainage of the gallbladder has been added in some cases but remains an uncommon procedure. 25,26 Alternatively, percutaneous cholecystostomy may reverse the progression of inflammation in patients with cholecystitis and often provides prompt symptomatic relief. 27 However, in the presence of portal hypertension and/or ascites, its use is also associated with hemorrhage or sepsis. Based on our experience, we conclude that LC, once considered contraindicated in patients with cirrhosis, is a reasonable option for most Child s class A and B patients but should be avoided, if possible, in class C patients. This approach may be particularly useful in liver transplant candidates who develop significant biliary symptoms because LC is associated with fewer postoperative adhesions and more rapid recuperation. Moreover, appropriate preoperative preparations and careful intraoperative techniques can curb the risks for complications during laparoscopy. 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