On gallstone disease : complications and surgical treatment

Abstract

Background: Gallstone disease is an important cause of morbidity in the Western world. Symptomatic gallbladder stones have been managed by cholecystectomy since 1882. After the introduction of laparoscopic cholecystectomy (LC) several questions were raised concerning both the indications for and safety of the minimal invasive procedure, especially in complicated gallstone disease.

Objective: To investigate the impact of LC on the outcome of cholecystectomies in a National Database with special regard to morbidity and mortality from postoperative bile leakage. To assess the long-term results after laparoscopic treatment of common bile duct stones (CBDS) regarding complications related to the bile duct system. To study variables that may predict surgical difficulties in LC in acute cholecystitis (AC), and finally to identify risk factors for and incidence time trends of iatrogenic bile duct injuries (BDI) in cholecystectomy in relation to the introduction of the laparoscopic technique.

Methods: In a nationwide population-based study of open and laparoscopic cholecystectomies, 3860 patients in the Norwegian National Cholecystectomy Registry (NNCR) were prospectively registered from 1993 through 1995 and the outcome of the two different surgical approaches was assessed. To measure the long-term results of laparoscopic common bile duct exploration (LC13DE), 175 consecutive patients were prospectively registered for a 7-year period beginning in 1992. A retrospective chart review was performed and identified patients were sent a questionnaire that focused on presumed long-term symptoms. To assess the difficulty of LC in AC, a video evaluation method was developed, and the videos reviewed by three independent observers. Preoperative variables in 29 patients were analyzed in relation to the difficulty score set by the reviewers. To analyze BDI, cholecystectomies from 1987 through 2001 were identified in the Swedish Inpatient Register. ICD codes pertaining to any reconstructive bile duct surgery among the cholecystectomized patients were then searched in order to perform risk factor and incidence analysis.

Results: A significant difference in mortality and morbidity in favor of minimal invasive technique was found among 3860 patients registered in NNCR. Fifty-seven bile duct leakages were identified among whom the mortality rate was 8.8%. In the majority of the bile leakage patients, no specific site of leakage was found. The etiology was bile duct injuries in 22.8% and leakage from the cystic duct, with or without CBDS in 24.4%. In the long-term study of LCBDE, 90% of the questionnaires were returned at a mean follow-up of 36 months. Six re-interventions had been performed, but no suspicion of bile duct stricture or mortality related to the prior surgery was registered. Of 31 included patients in the AC study, two was excluded due to technical problems during video recording. No operations were converted. The reviewers' inter-observer agreement was good. Abdominal tenderness and duration of present biliary episode predicted difficulty in the overall operation. Predicting difficulties in dissection of Calot's triangle was most difficult and not dependent upon CRP value. Among 152 776 cholecystectomies registered in the Swedish Inpatient Registry, 613 (0.40%) reconstructed iatrogenic BDI were identified. Advanced age and male gender were positively associated with BDI, whereas intraoperative cholangiogram (IOC) was protective. The incidence proportion of BDI decreased from 0.40% in the pre-laparoscopic era to 0.32% in 1991-1995 during the introduction of LC only to increase to 0.47% in 1996-2001. The mean yearly hospital volume of cholecystectomies did not affect the risk of injury.

Conclusion: LC was found to be a safe procedure in selected cases during its introduction in Norway. Postoperative bile leak is a serious complication with high mortality and morbidity rates. LC13DE is a safe procedure, also regarding long-term complications. Predicting a difficult LC in AC may only partly be based on preoperative variable. No overall increased incidence in iatrogenic BDI was observed during the introduction of LC. Male gender and age increased the risk of BDI whereas IOC was protective.