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The Contribution of Acute Cholecystitis, Obesity, and Previous Abdominal Surgery on the Outcome of Laparoscopic Cholecystectomy

July 1, 2007

By Simopoulos, Constantinos Botaitis, Sotirios; Karayiannakis, Anastasios J; Tripsianis, Grigorios; Et al

The aim of this study was to evaluate the impact of acute cholecystitis (AC), obesity, and previous abdominal surgery on laparoscopic cholecystectomy (LC) outcomes. Records of 1940 patients undergoing LC in 1992 and 2004 were reviewed in order to assess the independent and joint effects of the above risk factors on conversion, morbidity, operation time, and hospital stay. In multivariate regression analysis, adjusting for sex and age, AC alone and in combination with obesity or previous abdominal surgery increased the risk of conversion and complications and was associated with prolonged operation time and hospital stay compared with the patients without any of the risk factors (reference group). The independent and joint effects of obesity and previous abdominal surgery were significant only on operation time. On the contrary, previous upper abdominal surgery alone and in combination with AC was associated with 3- and 17-fold relative odds of conversion, respectively. The combined presence of AC, obesity, and previous abdominal surgery yielded an odds ratio for conversion of 7.5 and for complications of 10.7, as well as a longer operation time and hospital stay. The presence of previous upper abdominal surgery with AC and obesity had a substantial effect on conversion, with an odds ratio of 87.1 compared with the reference group. LC is safe in patients with AC, previous abdominal surgery, or obesity. However, the presence of inflammation alone or in combination with obesity and/or previous (especially upper) abdominal surgery is the main factor that influences the adverse outcomes of LC. THE INCREASING EXPERIENCE With lapaiOSCOpic ctlOlecystectomy (LC) has led to an expansion of the indications for LC, a reduction in contraindications of the procedure, and more complex cases being operated laparoscopically.1″4 Although most patients will also benefit from the laparoscopic approach, difficult cases are at a higher risk for conversion and the resulting complications5 that may overshadow all advantages of the laparoscopic procedure, making this approach unsafe, uneconomic, inefficient, and hence possibly inferior to traditional open cholecystectomy. The ability to identify the subset of patients with unfavorable conditions may help in planning the laparoscopic approach or in proceeding directly to open cholecystectomy.

This study evaluated the outcome of LC in patients with gallstones and complex cases that are commonly encountered, namely acute cholecystitis (AC), previous abdominal surgery, and obesity.

Materials and Methods

We reviewed the medical records of 1940 consecutive patients who underwent LC from May 1992 to December 2004. Data used in the analysis included patient demographic characteristics (gender, age, height, and weight), data from the preoperative evaluation (history of previous abdominal surgery and inflammation of gallbladder), intraoperative findings, conversion to open cholecystectomy, postoperative complications, operative time, and hospital stay.

The primary outcomes were the conversion of the LC to an open procedure and the development of complications. As secondary outcomes, the operative time and the duration of hospital stay were considered. The choice of LC or open cholecystectomy was determined by the patient’s risk and, in particular, by the surgeon’s experience in laparoscopic surgery, with no strict preoperative criteria or guidelines determining the surgeon’s decision. The operative procedures were performed by three surgeons with differing degrees of surgical training, all of whom had experience with at least 50 cases of elective LC. The decision about when to convert to laparotomy was made by the surgeon without strict criteria during the course of the procedure. Operative time was calculated from the initiation of skin incision to the completion of skin closure. The hospital stay was calculated as the period from the admission day until discharge.

The presence of AC, previous abdominal surgery, and obesity, three initial relative or absolute contraindications or, today, risk factors for LC, were the main determinants. The diagnosis of AC was based on at least two of the following conditions being present: first, local pain and/or tenderness in the right upper quadrant, a temperature higher than 37.5[degrees] C, and/or leukocytosis (white blood cell count >/=9 x 10^sup 9^TL) and ultrasonic evidence of AC (thickening of the gallbladder wall, distended gallbladder, or fluid adjacent to the gallbladder, as well as the presence of gallstones) at the admission; and second, operative and pathological confirmation of AC. The diagnosis of empyema or hydrops of the gallbladder was based on the presence of pus or mucus in the gallbladder when it was aspirated laparoscopically. The severity of AC was then classified as acute edematous cholecystitis, hydrops, or suppurative cholecystitis. Previous abdominal surgery though a midline or paramedian incision was classified as upper or lower abdominal surgery based on whether the scar extended above or below the umbilicus, respectively. Transverse or oblique abdominal incisions also were classified on the basis of their relation to the umbilicus as upper or lower abdominal surgery. Body mass index (BMI), expressed as weight/ height2 (kg/m^sup 2^), was used as a standard for the assessment of obesity. Patients with a BMI >/= 30 kg/m^sup 2^ were considered obese. The covariates gender and age ( =65 and >65 years old) were considered for potential confounding. The intraoperative cholangiography (IOC) initially was performed in 18 elective LC for gallstone disease with no risk factors, in association with difficult recognition of the elements, but the results were not considered as satisfactory. So IOC was not performed on all patients. We strongly believe that IOC did not influence the outcome of LC, perhaps only the operative time. Therefore, these 18 patients were excluded from the analyses.

The LC was performed using a standard fourpuncture technique in all patients. Pneumoperitoneum was created using a Veress needle except in a few patients who had previously undergone a midline incision and in those with suspected adhesions, in which it was performed using the Hasson technique.

Statistical analysis of the data was performed using SPSS, version 11.0 (SPSS, Inc., Chicago, IL). The normality of continuous variables was tested with the Kolmogorov-Smirnov test. Continuous variables were expressed as mean +- SD (normally distributed) and as median and range (non-normally). Categorical variables were expressed as frequencies and percentages.

Student’s t test and a chi^sup 2^ test were used in the univariate analyses. The crude and adjusted (aOR) odd ratios were estimated by means of simple and multivariate logistic regression analyses to evaluate any potential association of conversion and complications with AC, obesity, and previous abdominal surgery. Multivariate linear regression analyses were used to assess the effects of the above three main determinants on the operation time and hospital stay. A patient’s gender and age were the major confounders in all multivariate models. Operation time was logarithmically transformed to approach the normal distribution.

Patients were then classified into eight groups according to the presence of AC, obesity, and previous abdominal surgery (Table 1). The group of patients without any of these risk factors was considered the reference group. To assess the independent effects of AC, obesity, and previous abdominal surgery, as well as their joint effect on the conversion, complications, operation time, and hospital stay, all groups with at least one risk factor were contrasted to the reference group using the same multivariate logistic and linear regression models, adjusted for gender and ag[section], All tests were two tailed and statistical significance was considered at P = 0.05.

Results

The 1940 patients who underwent LC comprised 1474 women and 466 men, with a median age of 54 years (range, 15-87 years). Of these, 280 (14.4%) patients had an inflamed gallbladder (125 with acute edematous cholecystitis, 59 with hydrops, and 96 with empyema of the gallbladder), 534 (27.5%) patients had undergone previous abdominal surgery (485 lower and 69 upper abdominal surgery), and 491 (25.3%) patients were obese. AC and previous abdominal surgery were more prevalent among obese patients compared with the patients with a BMI

TABLE 1. Groups of Patients According to the Presence of AC, Obesity, and Previous Abdominal Surgery

The primary and secondary outcomes of LC in relation to AC, obesity, and previous abdominal surgery are presented in Table 2. In univariate analyses, significantly higher conversion and complication rates and longer operative times and hospital stays were found in patients with AC compared with patients with elective LC (all P

The combined presence of AC, obesity, and previous abdominal surgery yielded an odds ratio for conversion of 7.5 (95% CI = 2.8- 20.3) and for complications of 10.7 (95% CI = 3.2-35.1) compared with the reference group. In addition, the presence of AC with obesity and the combined presence of AC, obesity, and previous abdominal surgery were associated with further increased risk for complications compared with AC alone (aOR = 4.2, 95% CI = 1.2-14.7; aOR = 4.8, 95% CI = 1.2-19.2, respectively). The presence of AC with previous upper abdominal surgery and the combined presence of AC, obesity, and previous upper abdominal surgery had substantial effects on conversion, with respective odds ratios of 16.7 (95% CI = 1.7-68.3) and 87.1 (95% CI = 15.4-370.8) compared with the reference group.

TABLE 2. The Outcome of LC in Relation to the Presence of AC, Obesity, and Previous Abdominal Surgery

TABLE 3. Independent and Join Effects of AC, Obesity, and Previous Abdominal Surgery the Risk of Conversion and Complications in LC

Table 4 shows the operation times and hospital stays in the eight groups, excluding the converted cases. Multivariate linear regression analyses, including gender and age, revealed significantly longer operation time compared with the reference group (all P

Discussion

Although LC is widely accepted as the conventional therapy for chronic biliary disease, its application in the setting of known combined effects of AC, previous abdominal surgery, and obesity is less well defined. Initially, these cases considered relative or absolute contraindications because of the technical difficulties involved in the procedure.

The initial inclusion of obesity as a contraindication6,7 was attributed to abundant abdominal wall and intra-abdominal fat interfering with the exposure and dissection of Calot’s triangle.8 Previous abdominal surgery, especially upper abdominal, was included as a contraindication because it was associated with difficulty in placing the initial trocar and obtaining adequate exposure to the gallbladder.9 The potential risk for injury of organs adherent to the abdominal wall during insertion of the Veress needle or trocar as well as the necessity for adhesiolysis and its attendant complications are the two major specific problems experienced by surgeons performing LC on patients with previous abdominal surgery. AC has been considered to be a contraindication for LC because of the technical difficulties involved in the procedure.10 An edematous gallbladder is difficult to grasp for retraction, and inflammatory processes can lead to adhesions around the gallbladder obscuring the anatomy in Calot’s triangle.11

Although numerous studies have demonstrated the safety and effectiveness of LC for AC,12-15 previous abdominal surgery,16-18 and a BMI >/= 30 kg/m^sup 2^,19-21 reports for patients with a combination of these risk factors are difficult to find in the literature. The laparoscopic procedure in these conditions is more complicated and more challenging than in cases of simple cholelithiasis.

TABLE 4. Independent and Joint Effects of AC, Obesity, and Previous Abdominal Surgery on the Operation Time and Hospital Stay of Successful LC

The statistical analysis of the data leads us to the following important conclusions. AC is the risk factor that influences more of the indicators of surgery outcome, as the incidence of AC was associated with higher conversion and complication rates as well as with longer operative time and hospital stay. The conversion was more prevalent in empyema of gallbladder, complication-related conversion was more prevalent in acute oedematous cholecystitis, and the operation time and hospital stay were longer in patients with hydrops and empyema of the gallbladder.

In contrast, BMI and previous abdominal surgery were significantly associated with longer operating time for gallbladder dissection, with it being even longer in patients with a previous surgery in the upper abdomen. The conversion and complication rates as well as the postoperative hospital stay in patients with previous abdominal surgery and a BMI >/= 30 kg/m^sup 2^ were not significantly different from those in patients with no risk factors, although the conversion rate was higher in patients with previous upper abdominal surgery than in those with previous lower abdominal surgery.

The combined effect of AC, previous abdominal surgery, and obesity on the outcome of LC shows that the conversion rate, complication rate, operation time, and hospital stay increased significantly with the number of risk factors. Compared with patients without any risk factors, the risk of conversion was higher in patients with AC and a BMI >/= 30 kg/m^sup 2^, with AC and previous upper abdominal surgery, or with a BMI >/= 30 kg/m^sup 2^ and previous upper abdominal surgery. The conversion rate in patients with all three risk factors present was 20 per cent, with it being remarkably higher (by 71.4%) in patients with AC, a BMI >/ = 30 kg/m^sup 2^, and previous upper abdominal surgery. Patients with AC and previous abdominal surgery, with AC and a BMI >/= 30 kg/ m^sup 2^, or with all three risk factors present exhibited higher complication rates.

The operation time tended to be longer in patients with all combinations of two risk factors or with all three of them, but this trend did not reach statistical significance. The operation time in all of these groups of patients was significantly longer than in patients without any risk factors. Patients with two risk factors, one of which was AC, had longer operation times. Compared with those with no risk factors, the hospital stay was longer among patients with AC and a BMI >/= 30 kg/m^sup 2^ or with AC and previous abdominal surgery, and in patients with a combination of all three risk factors, although none of the above was significantly different from that in patients with AC only.

In conclusion, this study has shown that LC can be performed safely in commonly encountered complex cases that are commonly encountered, including AC, previous abdominal surgery, or obesity. However, the presence of inflammation alone or in combination with obesity and/or previous abdominal surgery, especially in the upper abdomen, is the main factor that influences the adverse outcome of LC.

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CONSTANTINOS SIMOPOULOS, SOTIRIOS BOTAITIS, ANASTASIOS J. KARAYIANNAKIS, GRIGORIOS TRIPSIANIS, MICHAIL PITIAKOUDIS ALEXANDROS POLYCHRONIDIS, M.D.

From the Second Department of Surgery, Democritus University of Thrace, Alexandroupolis, Greece

Address correspondence and reprint requests to Alexandros Polychronidis, Associate Professor of Surgery, 15 Kolokotroni Street, Alexandroupolis 68100, Greece.

Copyright Southeastern Surgical Congress Apr 2007

(c) 2007 American Surgeon, The. Provided by ProQuest Information and Learning. All rights Reserved.




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