Pre-operative Prediction of Difficult Laparoscopic Cholecystectomy

Transcription

1 128 Original Article Indian Medical Gazette APRIL 2013 Pre-operative Prediction of Difficult Laparoscopic Cholecystectomy Partha Bhar, Assistant Professor, Shyamal Kumar Halder, Associate Professor, Rajendra Prasad Ray, Senior Resident, Prosanta Kumar Bhattacharjee, Professor Department of Surgery, IPGME&R/SSKM Hospital, Kolkata. Abstract Laparoscopic cholecystectomy is the gold standard for the symptomatic gall stone disease. Sometime conversion to an open procedure may be necessary due to some difficulties encounter during laparoscopic cholecystectomy. The aim of this study is to determine whether variability of some of pre-defined pre-operative factors may have some bearing of the degree of difficulties that may be encounter during laparoscopic cholecystectomy. Seven parameters Age, Sex, BMI, ASA class, Hypertension, Diabetes and Previous Abdominal Surgery were studied in 112 patients in our department of Surgery, I.P.G.M.E&R and S.S.K.M. Hospital, Kolkata. Univariate analysis was performed using the chi-squared test to determine the factors that were associated with difficult LC, and odds ratios and their 95% confidence intervals were calculated. In 25(22.32%) patients pre-operative difficulties were encountered and out of these 6(5.35%) required conversion to open procedure. ASA class (OR 6.81, 95%CI , p <0.001), Hypertension (OR 7.76, 95%CI , p <0.001) and Diabetes mellitus (OR 4.26, 95%CI , p 0.025) were found to be statistically significant predictor of difficult laparoscopic cholecystectomy.however, age (p 0.247), male sex (p 1.00), BMI (p 0.161) and past abdominal surgery (p 0.115) were not found to be statistically significant variables. Difficult laparoscopic cholecystectomy can be predicted pre-operatively and that may help in proper pre-operative planning and counseling to reduce overall complications and morbidity. Keywords cholecystectomy, laparoscopy, difficult laparoscopic Introduction Cholecystectomy is the commonest operation of the biliary tract. Laparoscopic cholecystectomy (LC) is the standard of care for the treatment of symptomatic gallbladder disease 1, 2. It has advantages over traditional open cholecystectomy in terms of minimal postoperative pain, shorter hospital stay, better cosmesis and earlier recovery 1, 3 5. However, approximately 2% to 15% of patients require conversion to open surgery for various reasons 6,7. Sometime, the laparoscopic cholecystectomy may pose undue difficulties during access or dissection and it is considered as a difficult when safe completion of the laparoscopic procedure cannot be ensured 8. Difficulties encountered in cholecystectomy are due to anatomical ductal and vascular anomaly or distorted anatomy following acute or chronic inflammation. Pre-operative prediction of difficult laparoscopic cholecystectomy may not only improve patient safety but also be useful in reducing the overall cost of therapy. A Address for correspondence: Dr Partha Bhar, 8/502, Old Kapasdanga, Hooghly , West Bengal. bharpartha@gmail.com

2 Indian Medical Gazette APRIL statistically proven positive correlation with one or more of these variables may be helpful in assigning them as possible predictive risk factor for difficult laparoscopic cholecystectomy. Preoperative prediction of possible difficulties may help a surgeon in deciding the approach ( open /laparoscopic) most suitable for a particular patient, counseling the patient about it, thereby reducing the morbidity, complication, rate of conversion and overall cost of therapy. Method This prospective observational study was conducted in surgery dept of IPGME&R and SSKM Hospital from January 2008 to September patients between age group of 22 to 68 years who underwent laparoscopic cholecystectomy were included in this study. Patients with acute cholecystitis, choledocholithiasis and with co-morbid conditions such as coagulopathy, COPD, recent AMI, cirrhosis and suspicion of malignancy were excluded from this study. All LCs, where the operative time from insertion of the first port to removal of gall bladder was more than 1 hr due to difficulties in access, dissection or extraction of the gallbladder or where the laparoscopic approach had to be abandoned and conversion resorted to because of nonprogression were categorized as difficult laparoscopic cholecystectomy. Age (<45 or >=45), sex (male or female), ASA class (I or II) were used as a dichomatous variable. BMI was used as a continuous variable. While abdominal surgery was categorized as none versus any previous abdominal surgery. Co-morbidities such as hemolytic anemia, diabetes and hypertension were categorized as present or absent. All patients received one dose of intravenous (i.v) levofloxacin (500 mg) at the time of induction of anesthesia. All the cases were done under general anesthesia. The fourport technique was used. IPGME&R & SSKM Hospital during January 2008 to September 2009 were included in this study. 29 patients were male and 83 were female. The mean age was 42.4 (±2.83) years with a range from 22 to 68 years % (n=42) of the patients were >45 years of age. The mean BMI was (range of to 31.53). An ASA score II was found in 20 (17.86%) patients. 19 (16.96%) patients were hypertensive and 12 (10.71%) patients were diabetic (Table 1). Difficulties during laparoscopic cholecystectomy as defined at the beginning of our study were encountered in 25(22.32%) patients. Out of these 6(5.35%) were required conversion to open. Adhesion was the most common reason for difficulties encountered during laparoscopic attempt (n=7, 28%). 6(24%) of the patients had to be converted because of frozen Calot s triangle making visualization of duct and vessels impossible (Table 2). Mean duration of surgery of the 19 difficult LC that were successfully completed was 91.6 min vis-à-vis 47.6min for rest 87 patients considered in this study. Statistical Analysis Univariate analysis was performed using the chi-squared test to determine the factors that were associated with difficult LC, and odds ratios and their 95% confidence intervals were calculated. Results 112 Laparoscopic cholecystectomies performed at

3 130 Indian Medical Gazette APRIL 2013 Various available literatures suggest that male gender is as a risk factor of difficult cholecystectomy. A.Zisman, R. Gold-Deutch, et al 9 in 1995 identified a statistically significant difference in probability of conversions rates in males over females i.e. 21% and 4.5%, respectively (p =0.0001). This five fold greater probability was explained by significantly more adhesions (p = ) and anatomical difficulties (p = 0.003) in males. Similar conclusions were drawn by Heng-Hui Lein, Ching-Shui Huang 10 of Taiwan in They found that male patients had significantly longer (p = 0.04) operating time than females and they suggested that surgeons are more likely to offer men an open procedure rather than a laparoscopic procedure with a high likelihood of conversion. In 1994, Fried, et al 11 published a study suggesting that the most significant predictors of conversion were increasing age, obesity, thickened gallbladder wall by preoperative ultrasound and acute cholecystitis. Male sex was also one of them. In our study ASA class (OR 6.81, 95%CI , p <0.001), Hypertension (OR 7.76, 95%CI , p <0.001) and Diabetes mellitus (OR 4.26, 95%CI , p 0.025) are found to be statistically significant as predictor of difficult laparoscopic cholecystectomy on univariate analysis. However, age (p 0.247), male sex (p 1.00), BMI (p o.161) and past abdominal surgery (p 0.115) are not statistical significant. Discussion Conversion from laparoscopic to open cholecystectomy is required when safe completion of the laparoscopic procedure cannot be ensured. It is considered as a sound judgement rather than failure of laparoscopic surgery to avoid complications and reduce morbidity. The identification of parameters predicting conversion helps in preoperative patient counseling, provides for better perioperative planning and avoids laparoscopy associated complications by converting to open procedure as and when appropriate. However, in some series male sex was not an independent predictor of conversion to open cholecystectomy 12. In our study, male sex was not found to be a statistically significant predictor of difficult LC (p 1.00). This finding was in conformity with that of P. Schrenk, R. Woisetschlager, et al. 22. They did not find male sex to be a predictive factor of difficult cholecystectomy. Michael Rosen, Fred Brody, Jeffrey Ponsky, et al 12 examined predictive factors for conversion of laparoscopic cholecystectomy and found in their series that male sex was not an independent predictor of conversion to open cholecystectomy. Fried, et al 11 published a study suggesting some significant predictors of conversion in Increasing age was one of them. Brodsky, et al 13 identified male gender and age >60years as being pre-operative factors associated with conversion in acute cholecystitis. Similarly, Liu, et al 15 found that age >65 years, obesity, elective laparoscopic cholecystectomy for acute cholecystitis, and a thickened gallbladder wall predicted higher incidence of conversion. Several other series had reported that advanced age was associated with the need to convert 11, Elderly patients probably have a longer history of gallbladder disease with more episodes of acute attacks causing fibrotic adhesions. In our study, we did not find any positive correlation

4 Indian Medical Gazette APRIL between age of the patient and the need for conversion (p 0.247). Similar was the findings of Edward H. Livingston, Robert V. Rege, et al. 20. They found very little correlation between age and the need to convert to an open operation. One Indian study by S. S. Sikora, Ashok Kumar, R. Saxena, et al. 21 in their series failed to identify statistically significant correlation between age and conversion to open cholecystectomy. In our study, we found ASA class to be a statistically significant predictor (p <0.001) of difficult laparoscopic cholecystectomy. When ASA II was compared with ASA I the former was found to have a greater probability of difficult cholecystectomy. Some of the studies have mentioned previous abdominal surgery as a risk factor predicting difficult LC Particularly surgery of the stomach and duodenum may make laparoscopic biliary surgery more difficult 25. In 2002, Samer A. Kanaan, Kenric M. Murayama, Louis T. Merriam, Lillian G. Dawes, Jay B. Prystowsky, Robert V. Rege, and Raymond J. Joehl 26 found that prior abdominal surgery was not a factor predicting the necessity for conversion from laparoscopic to open cholecystectomy. Jeremy M. Lipman, Jeffrey A. Claridge, Manjunath Haridas, Matthew D. Martin, David C. Yao, Kevin L. Grimes, and Mark A. Malangoni 8 in 2007 also suggested that previous abdominal surgery and obesity as preoperative factors, did not predict difficult cholecystectomy. Our result is somewhat similar. We did not find any significant correlation (p 0.115) between past abdominal surgeries and difficulties encountered during laparoscopic cholecystectomy. This observation is consistent with previous published Works 6.23,27. Although obesity has been considered a risk factor for increased conversion 15,23, several investigators have reported conversion rates similar to those in non obese patients 6,14,21,28. Liu, et al 23 in 1996 and in 1994 Fried, et al 11 have linked obesity to a higher incidence of conversions. Michael Rosen, Fred Brody, Jeffrey Ponsky 44 found in their series that obesity independently predicted conversion to open cholecystectomy in patients with acute cholecystitis. In our series, BMI was not found to be a predictor (p 0.127) of difficult cholecystectomy. This result was in conformity with that of S. S. Sikora, Ashok Kumar, R. Saxena, V. K. Kapoor, S. P. Kaushik, et al 21. In their series they failed to identify statistical significance of BMI in predicting conversion. Wen-Tsan Chang, King-Teh Lee et al 29 also studied the impact of body mass index on laparoscopic cholecystectomy in Taiwan. Based on their results, they opined BMI was not associated with clinical outcomes and that LC is a safe procedure in obese patients with uncomplicated gallstone disease and laparoscopic surgery has been suggested by some as the preferred approach for obese patients 30. Some literatures had studied cardiovascular disease as predictor of difficult LC. Samer A. Kanaan, Kenric M. Murayama, Louis T. Merriam, Lillian G. Dawes, Jay B. Prystowsky, Robert V. Rege, and Raymond J. Joehl 26 in 2002 found that patients with a history of cardiovascular disease had an increased risk for conversion to open cholecystectomy in both the acute and chronic cholecystitis groups particularly in male sex. In our study hypertension has been found to be a statistically significant (p<0.001) predictor of difficult laparoscopic cholecystectomy. No literature review was found to link this variable as a predictor of difficult laparoscopic cholecystectomy. As with hypertension, diabetes also had positive correlation with difficulties encountered in laparoscopic cholecystectomy (p 0.025). In diabetic patients there may be several attacks of sub acute inflammation causing more scarring and making cholecystectomy more difficult. 31,32 Few studies had found diabetes as a predictor of difficult laparoscopic cholecystectomy 33,34. Samer A. Kanaan, Kenric M. Murayama, Louis T. Merriam, Lillian G. Dawes, Jay B. Prystowsky, Robert V. Rege, and Raymond J. Joehl 26 in 2002 did not find any increased risk of conversion in diabetic patients. Conclusion In conclusion, higher ASA class, hypertension and diabetes were found to be independent statistically significant predictor of difficult laparoscopic cholecystectomy. Preoperative identification of these factors may help in categorizing these cases as probably Difficult and necessary counseling may be done. Complications and morbidity may be decreased if inexperienced surgeons don t attempt laparoscopic cholecystectomy in such cases. References 1. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med. 324: , 1991.

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