- Email: [email protected]
Cholecystectomy: Clinical experience with a large series
Cholecystectomy: Clinical Experience With a Large Series
Joseph d. Ganey, MD, FACS, B&ton, Paid A. ,hhson,
Jr., MD, FACS, Brtiton,
Florida
Florida
Paul E. Pdllaman, MD, FACS, Brxkmtun, Florida George R. hkSwah, MD, FACS, Bradenton, Florida
With modern improvements in preoperative and postoperative care, a more aggressive surgical approach to calculus and inflammatory disease of the gallbladder has evolved. Well-trained surgeons and aacillary specialists are becoming available in many community hospitals not connected with major medical centers. This study was undertaken to compare the published results of large medical centers with the results of a large number of gallbladder operations performed by four surgeons in private practice over a short period of time. Furthermdre, although these operations are among the most firequent in abdominal surgery, ti number of controversies still exist regarding diagnostic and therapeutic approaches and techniques. Some authorities encourage routine early operation for acute cholecystitis [1,2], and others have shown reduced morbidity and mortality by delaying operation for an arbitrary period, usually several weeks, after medical resolution of an acute attack [3]. Some recommend a planned cholecyatostomy in elderly or high risk patients with acute cholecystitis [4,51. It is well recognized that the elderly have both a higher incidence of cdmplications of biliary tract disease and a higher rate of mortality from biliary tract surgery [8]. Elective cholecystectomy has been advocated in elderly patients with symptomatic biliary tract disease [ 71.The place of surgery for biliary calculi which may frequently be complicated by From the Departments of Surgery, Manatee Memorial Hospital and L. W. Blake Memorial Hospital, Bradenton, Florida. Requests for reprints should be addressed to Gesorge R. McSwaln. MD. 501 Second Street West. Bradenton. Florida 33505.
352
jaundice in the high risk group of patienta with cirrhosis lias yet to be clarified [8,9]. Emljhasis has been placed on routine use of intraoperative choiangiography to decrease the incidence of unnecessaiy common duct eqplorations, as well as unsuspected ‘and retained common duct stones [IO]. More recent reports have shown a far less than universal acceptance of intraoperative cholangiography and have &&ionedits routine use [II ,121. Although most surgeons continue td use drains routinely, there are reports confirming that drains can be selectively omitted for uncomplicated cholecyst&tomy [23], and others suggest that the important factor is the type of draixi [24], the techique of drainage [15], and how promptly the drain is renioved [16]. Material
and Methds
Between 1978 and 1983, a group of fo& surgeons performed 1,035 bperations with a primary diagnosis of inflammatory or calculus disease of the gallbladder.. Excluded from the series were many patie& whose primary diagnosis suggested an obstructing mass of the pancreas preoperatively. Data were accumulated from the records of patients operated on at Manatee Memorial Hospital, a 512 bed community hospital, and at L.W. Blake Memorial Hospital, a 360 bed private communitjr hospital. Neither hospital has any connection with a major medical center. The data were then analyzed for various factors related to cause; treatment technique, length of hospitalization, and complications. The usual practice was to treat patients with acute cholecystitis for a period of 6 to 12 hours with antibiotics and intravenous fluids for correction of intravascular volume and electrolyte abnormalities. Cholecystectdmy was then carried out immediately when the condition was stabilized unless there was dramatic improvement. In
lho Am&an
Journal ol Surgery
Cholecystectomy:
such a case, operation may have been delayed, especially in the presence of pancreatitis, but rarely for more than an additional 48 hours. All operations were performed under general anesthesia regardless of patient age or condition. Almost all operations were carried out by way of a right subcostal incision. Cholecystectomy was completed at the primary operation whenever possible, despite an acute gangrenous or ruptured gallbladder. The cystic duct and artery were doubly ligated with fine silk ties or, occasionally. metal clips in a very obese patient. Antibiotics, usually a second generation cephalosporin, were administered preoperatively when an acute gangrenous or ruptured gallbladder was suspected, or prophylactically when a common duct exploration was planned or performed, or in patients who were obese, diabetic, or over 60 years of age. Operative or cystic duct cholangiograms were obtained only rarely. Common duct, exploration was carried out for the usual indications such as a history of jaundice, an elevated serum amylase level, or a common duct diameter greater than 10 mm. The common duct was then drained with a T tube. ATtube cholangiogram was then obtained in the office 3 weeks lat.er and the tube generally removed the next day. The subhepatic space was drained in every case with a soft Penrose drain which was removed on the second postoperative day unless there appeared to be unusual drainage, in which case it was advanced out stepwise over the next several days.
Results
The greatest incidence of disease was in patients between 60 and 80 years old. The youngest patient was 15 years old and the oldest patient was 94. Table I shows the age and sex of the patients. Females accounted for the majority of patients in all age categories, but the difference was most marked in the younger age groups. Cholecystect.omy was rarely performed in the male patients under 30 years of age. Overall, 70 percent of the patients were female and 30 percent were male. The presenting symptoms are shown in Table II. Almost all patients reported abdominal pain at some time during the course of their illness, although the location was not always in the right upper quadrant of the abdomen or the epigastrium. Asymptomatic patients were rare, accounting for only 2.3 percent of the total. The department of radiology was of great help in diagnosing gallbladder disease. The diagnosis was based on oral cholecystogram in 510 patients, on ultrasound examination in 231 patients, and on radionuclide biliary scan in 157 patients. More than one of these tests was necessary to confirm the diagnosis in 119 patients. Oral cholecystogram was the test most frequently used to evaluate patients with chronic gallbladder disease, whereas a radionuclide biliary scan was used for acute cases. Ultrasound examination was frequently used when the clinical impression of gallbladder disease was high but not confirmed by one of the other two tests. Referring
Volume 151,March 1986
TABLE I
Clinical
With a Large Series
Experience
Age and Sex of Patients
Age Group
Male
Female
10-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90
15 71 55 76 114 180 150 51 6
16 73 74 95 160 267 257
90+
1 2 19 19 46 a7 107 33 3
Total
317
718
1,035
TABLE II
Total
a4
9
Symptoms
Presenting Symptom
Number
Abdominal pain Nausea and vomiting Fatty food intolerance Jaundice Fever Asymptomatic
987 576 222 101 92 24
Patients Percentage 95 56 21 10 9 2.3
physicians frequently duplicated positive reports on two or more tests. The procedures performed are shown in Table III. Cholecystectomy was almost always able to be performed successfully, and in only one case was it necessary to perform a cholecystectomy because of the circumstances found during operation. In a number of cases, a bypassing or short-circuiting operation was performed because of an obstructing mass in the pancreas or because of a large number of recurrent common duct stones or stones that were difficult to remove. Various other operations were carried out concurrently when the need arose, but no major vascular reconstructive procedures were performed at the same time as a cholecystectomy. Only 20 intraoperative or cystic duct cholangiograms were performed, representing only 1.9 percent of the entire series. These were only carried out if a slightly elevated bilirubin level made evaluation of the common bile duct necessary, but acute inflammation and a small caliber common duct made exploration appear more difficult or risky. A few were performed in association with exploration of the duct when the anatomic characteristics were not clear or residual stones were suspected. Table IV shows the histopathologic diagnoses. The majority of patients had chronic cholecystitis, most of whom had calculous disease. Histologically normal gallbladders without evidence of stones were removed from only 10 patients (1 percent). In half of these, the clinical findings definitely indicat-
353
Ganey et
al
TABLE III
Procedures
TABLE V
Procedures Cholecystectomy Cholecystojejunostomy Cholecystostomy Common duct exploration Choledochoduodenostomy Gastrojejunostomy Biopsy of liver or pancreas Appendectomy Hernia repair Hysterectomy, salpingectomy Vagotomy and pyloroplasty Colectomy Gastrectomy lntraooerative cholanaioaram
TABLE IV
Patients (n)
and oophorectomy
1,024 10 1 270 16 14 67 35 24 13 9 6 2 20
Histopathologlc Dlagnosls
Diagnosis
Number
Chronic cholecystitis Cholelithiasis Acute cholecystitis Gangrenous gallbladder Ruptured gallbladder Cholesterolosis Carcinoma of pancreas Pancreatitis Choledocholithiasis
801 814 163 88 12 61 17 47 98
Patients Percentage 77 79 16 9 1.2 6 1.8 5 9
ed that they had spontaneously passed one or more stones. A number of patients were found to have an obstructing malignant or inflammatory mass in the pancreas which had not been anticipated from the preoperative workup. In some of these cases, an acute gangrenous or ruptured gallbladder complicated the ductal obstruction. Common duct exploration was carried out on 270 patients (26 percent). Of these, stones were recovered from the common duct in 98 (36 percent), and no stones were found in the remaining 172 (64 percent). There was no significant correlation between the age of patients and the frequency of common duct exploration or the percentage of positive explorations. Only seven patients (0.7 percent) required a repeat operation for residual or retained common duct stones. Four of these had undergone common duct exploration at the initial operation, and three had cholecystectomy alone. All three of the latter patients had acute gangrenous cholecystitis without jaundice, and none had an operative cholangiogram at the initial procedure. In one of these, only some residual sludge material and no actual stone was found at operation. An additional three patients were operated on for postcholecystectomy syn-
354
Compllcatlons
Complication
Number
Retained stone Wound infection Pneumonia Urinary tract infection Acute myocardial infarction Death
7 4 8 14 4 5
Patients Percentage 0.7 0.4 0.8 1.4 0.4 0.5
drome with a suspicion of a retained common duct stone, but no stones were found. One patient was believed clinically to have passed the stone spontaneously, another underwent a choledochoduodenostomy for an ampullary stricture, and the third had excision of a cystic duct granuloma which caused her symptoms. Other complications were rare and are shown in Table V. There were no episodes of postoperative hemorrhage or abscess in the subphrenic or subhepatic space requiring reoperation. There were no major bile duct injuries. No postoperative pancreatitis of any clinical significance was observed, although a brief increase in the serum amylase level was observed in several patients who underwent common duct exploration after a recent bout of pancreatitis. One wound dehiscence occurred in an obese patient with a mild wound infection and significant preexisting pulmonary disease. This was repaired without sequelae. The postoperative deaths are shown in Table VI. All five patients were over age 73. All five operations were urgent because of acute gallbladder disease or jaundice. In only one would a cholecystostomy as a less stressful operation possibly have sufficed. All deaths appeared more related to preexisting disease in high risk patients rather than to immediate complications of the operation itself, and no deaths occurred within the first postoperative week. There were no deaths in patients operated on electively for chronic cholecystitis or asymptomatic stones. One patient who died had an associated advanced malignancy, and three had associated advanced hepatic cirrhosis. Interestingly, there were no deaths in the patients over age 90, even though only three of the nine operations could be considered to have been performed under elective circumstances. The calculated mortality rate was 0.5 percent overall, 0.8 percent for patients over age 60,1.4 percent for patients over age 70, and 3.2 percent for patients over age 80. Patients in their twenties were able to be discharged from the hospital more quickly on the average than teenagers or older patients. The briefest hospital recuperation period was 4 days, and the longest postoperative stay was 67 days. There was a definite increase in average hospital days in relation to increasing age, with very elderly patients needing
The American Journal of Surgery
Cholecystectomy: Clinical Experience With a Large Series
a significantly longer time for recovery. Since T tubes were generally clamped on the sixth postoperative day to be removed in the office, a common duct exploration in itself did not usually prolong the hospital stay, except in younger patients. The average stay increased from 8 days to 11 days when a common duct exploration was performed.
TABLE VI
Deaths
Patient
Age (yr)
1
85
2
89
3
73
4
75
5
83
Comments The large number of patients in this series over a relatively short period of time compares favorably with the few large series reported from both community hospitals and large medical centers in the past 10 years [3,17-191. The results further confirm the premise that operations commonly performed in private practice and community hospitals can be performed as safely, expediently, and effectively as those in large university centers where presumably more skilled personnel and advanced equipment and techniques are available. The west coast of Florida is a retirement area, and consequently, both the prevalence of patients over age 70 and the peak incidence of the gallbladder disease between age 60 and 80, which is several decades higher than most other reports, is not surprising, but might be expected to contribute to higher levels of morbidity and mortality. This was not found to be true. There appeared to be a relatively low incidence of what might be interpreted by some as unnecessary surgery, with only 2.3 percent of operations performed for asymptomatic stones as compared with 4.5 percent reported by Briele et al [18] or 6 percent reported by Meyer et al [19]. Furthermore, histologically normal gallbladders without evidence of stones were removed from only 1 percent of patients compared with 2.3 percent reported by Haff and Ballinger [3]. Modern radiologic techniques appear to have contributed to the high accuracy of preoperative diagnosis. Proper use of tests can avoid unnecessary duplication and expense. Our policy of early cholecystectomy for acute cholecystitis was supported by the low rates of morbidity and mortality observed. The overall mortality of 0.5 percent was lower than that reported by Haff and Ballinger [3] for either immediate or delayed surgical intervention. They failed to distinguish between those patients operated on early and electively and those operated on out of necessity. Analysis of the five patients in our series who died showed that all were thought to require urgent operations because of acute symptoms. Indeed, two already had perforation or jaundice. We found no evidence to recommend a more delayed approach to acute cholecystitis and agree with the recommendations of Gardner et al [I] and Linden and Sunzel[2]. Proponents of planned cholecystostomy for acute cholecystitis in elderly and high risk patients sug-
Volume 151, March 1996
Diagnosis and Time of Death Cholelithiasis with subacute and chronic cholecystitis Diabetic and severe cardiac cripple Died 1 week postop from myocardlal failure Gangrenous and perforated gallbladder Died 12 days postop from myocardial infarction Gangrenous and perforated gallbladder Severe cirrhosis and advanced carcinoma of pancreas Died 3 weeks postop Negative common duct exploration for jaundice Died 3 weeks postop from chronic hepatltls Stones found in gallbladder and common duct Pancreatitis and advanced hepatic cirrhosis Died 10 days postop from hepatorenal syndrome
gest that this procedure will lower the mortality rate and the risk of common duct injury due to operating in an acutely inflamed operative field [4,5]. There were no common duct injuries in our series despite the fact that cholecystectomy was performed at the initial operation in all but one case of acute cholecystitis. Furthermore, our mortality rates of 0.8 percent for patients over 60 years of age, 1.4 percent for patients over 70, and 3.2 percent for patients over 80 are sufficiently lower than the 5.1 percent rate for patients over 65 years of age reported by Glenn [5] or the 24.6 percent rate for patients treated with cholecystectomy reported by Gingrich [4]. Careful analysis of our five patients who died showed only one who might have benefited from a planned cholecystostomy as a lesser procedure, since the other four either had gangrenous and perforated gallbladders or required common duct exploration for jaundice. These mortality rates in elderly patients are in agreement with the findings of DeMarco [6], that the mortality rate is markedly increased for patients over 60 years of age. These rates also agree with the findings of Huber et al [ 7] and Sullivan et al [20] that elective cholecystectomy can be carried out safely, even in elderly patients. These investigators also point out the high morbidity and mortality of an emergency operation and the high morbidity and mortality of untreated calculus disease and thus advocate more frequent elective operations for symptomatic gallstones in elderly patients. The consensus is not clear in another high risk group-patients with cirrhosis. Careful correction of blood coagulation abnormalities preoperatively prevented any major hemorrhagic complications as were noted by Van Landingham [9]. Cirrhosis clear-
355
Ganey et al
ly was a major factor in several of the deaths in our series. Some investigators have previously highlighted both the increased incidence of gallstones in patients with cirrhosis and the increased operative risk [8,9]. The patient with known cirrhosis and gallstones who becomes jaundiced presents a unique problem as to cause and effect. A more aggressive preoperative approach with techniques such as endoscopic retrograde cholangiography or percutaneous transhepatic cholangiography has been suggested. Operation can be avoided if no ductal obstruction is found. Advocates of operative cholangiography suggest that its routine use will decrease the number of negative or unnecessary common duct explorations and decrease the numbers of residual and retained common duct stones [IO]. Opponents argue that the increased expense, prolonged operating time, frequent technical problems, possibility of contamination of the operative field, and difficulties of interpretation are not justified by the reported results. The percentage of unsuspected common duct stones discovered by routine operative cholangiography of approximately 5 percent is offset by an equal percentage of unnecessary common duct explorations performed because of false-positive cholangiograms [II]. Meyer et al [19] reported an incidence of recurrent or residual common duct stones of 0.72 percent, which was identical to the rate in our series and similar to the rate reported elsewhere [72]. It is clear that the majority of unsuspected retained and residual common duct stones either never become symptomatic or pass spontaneously. The usual frequency of common duct exploration is reported to be from 15 percent to 30 percent, with stones being found about half of the time [17-191. This corresponds to the 26 percent frequency in this series with stones recovered in only 36 percent of these cases. A negative operative cholangiogram is almost 100 percent accurate and eliminates the need for common duct exploration [12]. Furthermore, a positive operative cholangiogram is reported to improve the yield of common duct exploration to better than 90 percent [11,12]. Preexploration cholangiograms might have decreased the number of negative common duct explorations performed. Whether this justifies the time, expense, and aggravation of the unnecessary cholangiograms cannot be argued. Although common duct exploration did prolong the average hospital stay, it appears that this is due to more severe disease in patients requiring duct exploration rather than the delay caused by the procedure itself. The wisdom of draining the subhepatic space by way of a separate peritoneal stab incision and routinely removing the drain after 48 hours if there is no unusual drainage is supported by the low (0.4 per-
356
cent) incidence of significant wound complications and the absence of any episodes of bile peritonitis or subhepatic abscess. This policy combines the best suggestions of Kambouris et al [13], Todd and Reemtsma [15], and Williams et al [16] without the risk of deciding subjectively which gallbladder beds to leave undrained and it improves on the 1.4 to 7.8 percent infection rate these investigators reported. Summary This large series of 1,035 consecutive operations with a primary diagnosis of inflammatory or calculus disease of the gallbladder included a large number of elderly patients with the greatest incidence in the seventh and eighth decades of life. Operation was performed after initial stabilization when acute illness presented and without prolonged delay of medical treatment. Cholecystectomy was almost always able to be performed successfully at the initial operation. This approach produced low rates of morbidity and mortality when compared with reports from large university centers and with reports advocating delayed operation for acute cholecystitis or planned cholecystostomy in elderly and high risk patients. Operative cholangiograms were rarely performed and rates of residual or retained common duct stones were low. Length of hospital stay was related to age and performance of a common duct exploration. Draining the subhepatic space routinely by way of a separate peritoneal stab incision and removing the drain within 48 hours produced a low rate of wound complications. References 1. Gardner B, Masur R, Fujimoto J. Factors influencing the timing of cholecystectomy in acute cholecystitis. Am J Surg 1973;125:730-3. 2. Linden W, Sunzel H. Early versus delayed operation for acute cholecystitis. Am J Surg 1970;120:7-13. 3. Haff R, Ballinger W. Biliary tract operations, a review of 1,000 patients. Arch Surg 1969;98:428-34. 4. Gingrich R, Awe W, Boyden A, Peterson C. Cholecystostomy in acute cholecystitis. Am J Surg 1968;116:310-5. 5. Glenn F. Cholecystostomy in the high risk patient with biliary tract disease. Ann Surgery 1977;185:185-91. 6. DeMarco A, Nance F, Cohn I. Chronic cholecystitis: experience in a large charity institution. Surgery 1968;63:750-6. 7. Huber D, Martin E, Cooperman M. Cholecystectomy in elderly patients. Am J Surg 1983;146:719-22, 8. Castaing D. Houssin D, Lemoine J, Bismuth H. Surgical management of gallstones in cirrhotic patients. Am J Surg 1983;146:310-3. 9. Van Landingham S. Cholecystectomy in cirrhotic patients. South Med J 1984;77:38-40. 10. Jolly P, Baker J, Schmidt H, Walker J, Holm J. Operative cholangiography: a case for its routine use. Ann Surg 1968;168:551-64. 11. Trooskin S, Littlejohn C, Greco R. The utilization of cystic duct cholangiography. Am Surg 1983;49:591-3. 12. Levine S, Lerner H, Leifer E, Lindheim S. lntraoperative chol-
The American Journal of Surgery
Cholecystectomy:
angiography. Ann Surg 1983;198:892-7. 13. Kambouris A, Carpenter W, Allaben R. Cholecystectomy without drainage. Surg Gynecol Obstet 1973;137:613-7. 14. Gupta S, Rauscher G, Stillman R, Fitzgerald J, Powers J. The ratjonal use.of drains after cholecystectomy. Surg Gynecol Obstet 1978;146:191-2. 15. Todd G. Reemtsma K. Cholecystectomy with drainage. Am J Surg 1978;135:822-3. 16. Williams C. Halpin D, Knox A. Drainage following cholecystectomy. Br J Surg 1972;59:293-6.
Volume 151, March 1996
Clinical
Experience
With a Large Series
17. Magee R, MacDuffee R. One thousand consecutive cholecystectomies._Arch Surg 1968;96:858-62. 18. Briele H, Long W, Parks L. Gallbladder disease and cholecystectomy: experience with 1509 patients managed in a community hospital. Am Surg 1969;35:218-22. 19. Meyer K, Capos N. Mittelpunkt A. Personal experiences with 1,261 cases of acute and chronic cholecystitis and cholelithiasis. Surgery 1967;61:661-8. 20. Sullivan D. Hood T, Griffen W. Biliary tract surgery in the elderly. Am J Surg 1982;143:218-20.
357
Joseph d. Ganey, MD, FACS, B&ton, Paid A. ,hhson,
Jr., MD, FACS, Brtiton,
Florida
Florida
Paul E. Pdllaman, MD, FACS, Brxkmtun, Florida George R. hkSwah, MD, FACS, Bradenton, Florida
With modern improvements in preoperative and postoperative care, a more aggressive surgical approach to calculus and inflammatory disease of the gallbladder has evolved. Well-trained surgeons and aacillary specialists are becoming available in many community hospitals not connected with major medical centers. This study was undertaken to compare the published results of large medical centers with the results of a large number of gallbladder operations performed by four surgeons in private practice over a short period of time. Furthermdre, although these operations are among the most firequent in abdominal surgery, ti number of controversies still exist regarding diagnostic and therapeutic approaches and techniques. Some authorities encourage routine early operation for acute cholecystitis [1,2], and others have shown reduced morbidity and mortality by delaying operation for an arbitrary period, usually several weeks, after medical resolution of an acute attack [3]. Some recommend a planned cholecyatostomy in elderly or high risk patients with acute cholecystitis [4,51. It is well recognized that the elderly have both a higher incidence of cdmplications of biliary tract disease and a higher rate of mortality from biliary tract surgery [8]. Elective cholecystectomy has been advocated in elderly patients with symptomatic biliary tract disease [ 71.The place of surgery for biliary calculi which may frequently be complicated by From the Departments of Surgery, Manatee Memorial Hospital and L. W. Blake Memorial Hospital, Bradenton, Florida. Requests for reprints should be addressed to Gesorge R. McSwaln. MD. 501 Second Street West. Bradenton. Florida 33505.
352
jaundice in the high risk group of patienta with cirrhosis lias yet to be clarified [8,9]. Emljhasis has been placed on routine use of intraoperative choiangiography to decrease the incidence of unnecessaiy common duct eqplorations, as well as unsuspected ‘and retained common duct stones [IO]. More recent reports have shown a far less than universal acceptance of intraoperative cholangiography and have &&ionedits routine use [II ,121. Although most surgeons continue td use drains routinely, there are reports confirming that drains can be selectively omitted for uncomplicated cholecyst&tomy [23], and others suggest that the important factor is the type of draixi [24], the techique of drainage [15], and how promptly the drain is renioved [16]. Material
and Methds
Between 1978 and 1983, a group of fo& surgeons performed 1,035 bperations with a primary diagnosis of inflammatory or calculus disease of the gallbladder.. Excluded from the series were many patie& whose primary diagnosis suggested an obstructing mass of the pancreas preoperatively. Data were accumulated from the records of patients operated on at Manatee Memorial Hospital, a 512 bed community hospital, and at L.W. Blake Memorial Hospital, a 360 bed private communitjr hospital. Neither hospital has any connection with a major medical center. The data were then analyzed for various factors related to cause; treatment technique, length of hospitalization, and complications. The usual practice was to treat patients with acute cholecystitis for a period of 6 to 12 hours with antibiotics and intravenous fluids for correction of intravascular volume and electrolyte abnormalities. Cholecystectdmy was then carried out immediately when the condition was stabilized unless there was dramatic improvement. In
lho Am&an
Journal ol Surgery
Cholecystectomy:
such a case, operation may have been delayed, especially in the presence of pancreatitis, but rarely for more than an additional 48 hours. All operations were performed under general anesthesia regardless of patient age or condition. Almost all operations were carried out by way of a right subcostal incision. Cholecystectomy was completed at the primary operation whenever possible, despite an acute gangrenous or ruptured gallbladder. The cystic duct and artery were doubly ligated with fine silk ties or, occasionally. metal clips in a very obese patient. Antibiotics, usually a second generation cephalosporin, were administered preoperatively when an acute gangrenous or ruptured gallbladder was suspected, or prophylactically when a common duct exploration was planned or performed, or in patients who were obese, diabetic, or over 60 years of age. Operative or cystic duct cholangiograms were obtained only rarely. Common duct, exploration was carried out for the usual indications such as a history of jaundice, an elevated serum amylase level, or a common duct diameter greater than 10 mm. The common duct was then drained with a T tube. ATtube cholangiogram was then obtained in the office 3 weeks lat.er and the tube generally removed the next day. The subhepatic space was drained in every case with a soft Penrose drain which was removed on the second postoperative day unless there appeared to be unusual drainage, in which case it was advanced out stepwise over the next several days.
Results
The greatest incidence of disease was in patients between 60 and 80 years old. The youngest patient was 15 years old and the oldest patient was 94. Table I shows the age and sex of the patients. Females accounted for the majority of patients in all age categories, but the difference was most marked in the younger age groups. Cholecystect.omy was rarely performed in the male patients under 30 years of age. Overall, 70 percent of the patients were female and 30 percent were male. The presenting symptoms are shown in Table II. Almost all patients reported abdominal pain at some time during the course of their illness, although the location was not always in the right upper quadrant of the abdomen or the epigastrium. Asymptomatic patients were rare, accounting for only 2.3 percent of the total. The department of radiology was of great help in diagnosing gallbladder disease. The diagnosis was based on oral cholecystogram in 510 patients, on ultrasound examination in 231 patients, and on radionuclide biliary scan in 157 patients. More than one of these tests was necessary to confirm the diagnosis in 119 patients. Oral cholecystogram was the test most frequently used to evaluate patients with chronic gallbladder disease, whereas a radionuclide biliary scan was used for acute cases. Ultrasound examination was frequently used when the clinical impression of gallbladder disease was high but not confirmed by one of the other two tests. Referring
Volume 151,March 1986
TABLE I
Clinical
With a Large Series
Experience
Age and Sex of Patients
Age Group
Male
Female
10-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90
15 71 55 76 114 180 150 51 6
16 73 74 95 160 267 257
90+
1 2 19 19 46 a7 107 33 3
Total
317
718
1,035
TABLE II
Total
a4
9
Symptoms
Presenting Symptom
Number
Abdominal pain Nausea and vomiting Fatty food intolerance Jaundice Fever Asymptomatic
987 576 222 101 92 24
Patients Percentage 95 56 21 10 9 2.3
physicians frequently duplicated positive reports on two or more tests. The procedures performed are shown in Table III. Cholecystectomy was almost always able to be performed successfully, and in only one case was it necessary to perform a cholecystectomy because of the circumstances found during operation. In a number of cases, a bypassing or short-circuiting operation was performed because of an obstructing mass in the pancreas or because of a large number of recurrent common duct stones or stones that were difficult to remove. Various other operations were carried out concurrently when the need arose, but no major vascular reconstructive procedures were performed at the same time as a cholecystectomy. Only 20 intraoperative or cystic duct cholangiograms were performed, representing only 1.9 percent of the entire series. These were only carried out if a slightly elevated bilirubin level made evaluation of the common bile duct necessary, but acute inflammation and a small caliber common duct made exploration appear more difficult or risky. A few were performed in association with exploration of the duct when the anatomic characteristics were not clear or residual stones were suspected. Table IV shows the histopathologic diagnoses. The majority of patients had chronic cholecystitis, most of whom had calculous disease. Histologically normal gallbladders without evidence of stones were removed from only 10 patients (1 percent). In half of these, the clinical findings definitely indicat-
353
Ganey et
al
TABLE III
Procedures
TABLE V
Procedures Cholecystectomy Cholecystojejunostomy Cholecystostomy Common duct exploration Choledochoduodenostomy Gastrojejunostomy Biopsy of liver or pancreas Appendectomy Hernia repair Hysterectomy, salpingectomy Vagotomy and pyloroplasty Colectomy Gastrectomy lntraooerative cholanaioaram
TABLE IV
Patients (n)
and oophorectomy
1,024 10 1 270 16 14 67 35 24 13 9 6 2 20
Histopathologlc Dlagnosls
Diagnosis
Number
Chronic cholecystitis Cholelithiasis Acute cholecystitis Gangrenous gallbladder Ruptured gallbladder Cholesterolosis Carcinoma of pancreas Pancreatitis Choledocholithiasis
801 814 163 88 12 61 17 47 98
Patients Percentage 77 79 16 9 1.2 6 1.8 5 9
ed that they had spontaneously passed one or more stones. A number of patients were found to have an obstructing malignant or inflammatory mass in the pancreas which had not been anticipated from the preoperative workup. In some of these cases, an acute gangrenous or ruptured gallbladder complicated the ductal obstruction. Common duct exploration was carried out on 270 patients (26 percent). Of these, stones were recovered from the common duct in 98 (36 percent), and no stones were found in the remaining 172 (64 percent). There was no significant correlation between the age of patients and the frequency of common duct exploration or the percentage of positive explorations. Only seven patients (0.7 percent) required a repeat operation for residual or retained common duct stones. Four of these had undergone common duct exploration at the initial operation, and three had cholecystectomy alone. All three of the latter patients had acute gangrenous cholecystitis without jaundice, and none had an operative cholangiogram at the initial procedure. In one of these, only some residual sludge material and no actual stone was found at operation. An additional three patients were operated on for postcholecystectomy syn-
354
Compllcatlons
Complication
Number
Retained stone Wound infection Pneumonia Urinary tract infection Acute myocardial infarction Death
7 4 8 14 4 5
Patients Percentage 0.7 0.4 0.8 1.4 0.4 0.5
drome with a suspicion of a retained common duct stone, but no stones were found. One patient was believed clinically to have passed the stone spontaneously, another underwent a choledochoduodenostomy for an ampullary stricture, and the third had excision of a cystic duct granuloma which caused her symptoms. Other complications were rare and are shown in Table V. There were no episodes of postoperative hemorrhage or abscess in the subphrenic or subhepatic space requiring reoperation. There were no major bile duct injuries. No postoperative pancreatitis of any clinical significance was observed, although a brief increase in the serum amylase level was observed in several patients who underwent common duct exploration after a recent bout of pancreatitis. One wound dehiscence occurred in an obese patient with a mild wound infection and significant preexisting pulmonary disease. This was repaired without sequelae. The postoperative deaths are shown in Table VI. All five patients were over age 73. All five operations were urgent because of acute gallbladder disease or jaundice. In only one would a cholecystostomy as a less stressful operation possibly have sufficed. All deaths appeared more related to preexisting disease in high risk patients rather than to immediate complications of the operation itself, and no deaths occurred within the first postoperative week. There were no deaths in patients operated on electively for chronic cholecystitis or asymptomatic stones. One patient who died had an associated advanced malignancy, and three had associated advanced hepatic cirrhosis. Interestingly, there were no deaths in the patients over age 90, even though only three of the nine operations could be considered to have been performed under elective circumstances. The calculated mortality rate was 0.5 percent overall, 0.8 percent for patients over age 60,1.4 percent for patients over age 70, and 3.2 percent for patients over age 80. Patients in their twenties were able to be discharged from the hospital more quickly on the average than teenagers or older patients. The briefest hospital recuperation period was 4 days, and the longest postoperative stay was 67 days. There was a definite increase in average hospital days in relation to increasing age, with very elderly patients needing
The American Journal of Surgery
Cholecystectomy: Clinical Experience With a Large Series
a significantly longer time for recovery. Since T tubes were generally clamped on the sixth postoperative day to be removed in the office, a common duct exploration in itself did not usually prolong the hospital stay, except in younger patients. The average stay increased from 8 days to 11 days when a common duct exploration was performed.
TABLE VI
Deaths
Patient
Age (yr)
1
85
2
89
3
73
4
75
5
83
Comments The large number of patients in this series over a relatively short period of time compares favorably with the few large series reported from both community hospitals and large medical centers in the past 10 years [3,17-191. The results further confirm the premise that operations commonly performed in private practice and community hospitals can be performed as safely, expediently, and effectively as those in large university centers where presumably more skilled personnel and advanced equipment and techniques are available. The west coast of Florida is a retirement area, and consequently, both the prevalence of patients over age 70 and the peak incidence of the gallbladder disease between age 60 and 80, which is several decades higher than most other reports, is not surprising, but might be expected to contribute to higher levels of morbidity and mortality. This was not found to be true. There appeared to be a relatively low incidence of what might be interpreted by some as unnecessary surgery, with only 2.3 percent of operations performed for asymptomatic stones as compared with 4.5 percent reported by Briele et al [18] or 6 percent reported by Meyer et al [19]. Furthermore, histologically normal gallbladders without evidence of stones were removed from only 1 percent of patients compared with 2.3 percent reported by Haff and Ballinger [3]. Modern radiologic techniques appear to have contributed to the high accuracy of preoperative diagnosis. Proper use of tests can avoid unnecessary duplication and expense. Our policy of early cholecystectomy for acute cholecystitis was supported by the low rates of morbidity and mortality observed. The overall mortality of 0.5 percent was lower than that reported by Haff and Ballinger [3] for either immediate or delayed surgical intervention. They failed to distinguish between those patients operated on early and electively and those operated on out of necessity. Analysis of the five patients in our series who died showed that all were thought to require urgent operations because of acute symptoms. Indeed, two already had perforation or jaundice. We found no evidence to recommend a more delayed approach to acute cholecystitis and agree with the recommendations of Gardner et al [I] and Linden and Sunzel[2]. Proponents of planned cholecystostomy for acute cholecystitis in elderly and high risk patients sug-
Volume 151, March 1996
Diagnosis and Time of Death Cholelithiasis with subacute and chronic cholecystitis Diabetic and severe cardiac cripple Died 1 week postop from myocardlal failure Gangrenous and perforated gallbladder Died 12 days postop from myocardial infarction Gangrenous and perforated gallbladder Severe cirrhosis and advanced carcinoma of pancreas Died 3 weeks postop Negative common duct exploration for jaundice Died 3 weeks postop from chronic hepatltls Stones found in gallbladder and common duct Pancreatitis and advanced hepatic cirrhosis Died 10 days postop from hepatorenal syndrome
gest that this procedure will lower the mortality rate and the risk of common duct injury due to operating in an acutely inflamed operative field [4,5]. There were no common duct injuries in our series despite the fact that cholecystectomy was performed at the initial operation in all but one case of acute cholecystitis. Furthermore, our mortality rates of 0.8 percent for patients over 60 years of age, 1.4 percent for patients over 70, and 3.2 percent for patients over 80 are sufficiently lower than the 5.1 percent rate for patients over 65 years of age reported by Glenn [5] or the 24.6 percent rate for patients treated with cholecystectomy reported by Gingrich [4]. Careful analysis of our five patients who died showed only one who might have benefited from a planned cholecystostomy as a lesser procedure, since the other four either had gangrenous and perforated gallbladders or required common duct exploration for jaundice. These mortality rates in elderly patients are in agreement with the findings of DeMarco [6], that the mortality rate is markedly increased for patients over 60 years of age. These rates also agree with the findings of Huber et al [ 7] and Sullivan et al [20] that elective cholecystectomy can be carried out safely, even in elderly patients. These investigators also point out the high morbidity and mortality of an emergency operation and the high morbidity and mortality of untreated calculus disease and thus advocate more frequent elective operations for symptomatic gallstones in elderly patients. The consensus is not clear in another high risk group-patients with cirrhosis. Careful correction of blood coagulation abnormalities preoperatively prevented any major hemorrhagic complications as were noted by Van Landingham [9]. Cirrhosis clear-
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Ganey et al
ly was a major factor in several of the deaths in our series. Some investigators have previously highlighted both the increased incidence of gallstones in patients with cirrhosis and the increased operative risk [8,9]. The patient with known cirrhosis and gallstones who becomes jaundiced presents a unique problem as to cause and effect. A more aggressive preoperative approach with techniques such as endoscopic retrograde cholangiography or percutaneous transhepatic cholangiography has been suggested. Operation can be avoided if no ductal obstruction is found. Advocates of operative cholangiography suggest that its routine use will decrease the number of negative or unnecessary common duct explorations and decrease the numbers of residual and retained common duct stones [IO]. Opponents argue that the increased expense, prolonged operating time, frequent technical problems, possibility of contamination of the operative field, and difficulties of interpretation are not justified by the reported results. The percentage of unsuspected common duct stones discovered by routine operative cholangiography of approximately 5 percent is offset by an equal percentage of unnecessary common duct explorations performed because of false-positive cholangiograms [II]. Meyer et al [19] reported an incidence of recurrent or residual common duct stones of 0.72 percent, which was identical to the rate in our series and similar to the rate reported elsewhere [72]. It is clear that the majority of unsuspected retained and residual common duct stones either never become symptomatic or pass spontaneously. The usual frequency of common duct exploration is reported to be from 15 percent to 30 percent, with stones being found about half of the time [17-191. This corresponds to the 26 percent frequency in this series with stones recovered in only 36 percent of these cases. A negative operative cholangiogram is almost 100 percent accurate and eliminates the need for common duct exploration [12]. Furthermore, a positive operative cholangiogram is reported to improve the yield of common duct exploration to better than 90 percent [11,12]. Preexploration cholangiograms might have decreased the number of negative common duct explorations performed. Whether this justifies the time, expense, and aggravation of the unnecessary cholangiograms cannot be argued. Although common duct exploration did prolong the average hospital stay, it appears that this is due to more severe disease in patients requiring duct exploration rather than the delay caused by the procedure itself. The wisdom of draining the subhepatic space by way of a separate peritoneal stab incision and routinely removing the drain after 48 hours if there is no unusual drainage is supported by the low (0.4 per-
356
cent) incidence of significant wound complications and the absence of any episodes of bile peritonitis or subhepatic abscess. This policy combines the best suggestions of Kambouris et al [13], Todd and Reemtsma [15], and Williams et al [16] without the risk of deciding subjectively which gallbladder beds to leave undrained and it improves on the 1.4 to 7.8 percent infection rate these investigators reported. Summary This large series of 1,035 consecutive operations with a primary diagnosis of inflammatory or calculus disease of the gallbladder included a large number of elderly patients with the greatest incidence in the seventh and eighth decades of life. Operation was performed after initial stabilization when acute illness presented and without prolonged delay of medical treatment. Cholecystectomy was almost always able to be performed successfully at the initial operation. This approach produced low rates of morbidity and mortality when compared with reports from large university centers and with reports advocating delayed operation for acute cholecystitis or planned cholecystostomy in elderly and high risk patients. Operative cholangiograms were rarely performed and rates of residual or retained common duct stones were low. Length of hospital stay was related to age and performance of a common duct exploration. Draining the subhepatic space routinely by way of a separate peritoneal stab incision and removing the drain within 48 hours produced a low rate of wound complications. References 1. Gardner B, Masur R, Fujimoto J. Factors influencing the timing of cholecystectomy in acute cholecystitis. Am J Surg 1973;125:730-3. 2. Linden W, Sunzel H. Early versus delayed operation for acute cholecystitis. Am J Surg 1970;120:7-13. 3. Haff R, Ballinger W. Biliary tract operations, a review of 1,000 patients. Arch Surg 1969;98:428-34. 4. Gingrich R, Awe W, Boyden A, Peterson C. Cholecystostomy in acute cholecystitis. Am J Surg 1968;116:310-5. 5. Glenn F. Cholecystostomy in the high risk patient with biliary tract disease. Ann Surgery 1977;185:185-91. 6. DeMarco A, Nance F, Cohn I. Chronic cholecystitis: experience in a large charity institution. Surgery 1968;63:750-6. 7. Huber D, Martin E, Cooperman M. Cholecystectomy in elderly patients. Am J Surg 1983;146:719-22, 8. Castaing D. Houssin D, Lemoine J, Bismuth H. Surgical management of gallstones in cirrhotic patients. Am J Surg 1983;146:310-3. 9. Van Landingham S. Cholecystectomy in cirrhotic patients. South Med J 1984;77:38-40. 10. Jolly P, Baker J, Schmidt H, Walker J, Holm J. Operative cholangiography: a case for its routine use. Ann Surg 1968;168:551-64. 11. Trooskin S, Littlejohn C, Greco R. The utilization of cystic duct cholangiography. Am Surg 1983;49:591-3. 12. Levine S, Lerner H, Leifer E, Lindheim S. lntraoperative chol-
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angiography. Ann Surg 1983;198:892-7. 13. Kambouris A, Carpenter W, Allaben R. Cholecystectomy without drainage. Surg Gynecol Obstet 1973;137:613-7. 14. Gupta S, Rauscher G, Stillman R, Fitzgerald J, Powers J. The ratjonal use.of drains after cholecystectomy. Surg Gynecol Obstet 1978;146:191-2. 15. Todd G. Reemtsma K. Cholecystectomy with drainage. Am J Surg 1978;135:822-3. 16. Williams C. Halpin D, Knox A. Drainage following cholecystectomy. Br J Surg 1972;59:293-6.
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Experience
With a Large Series
17. Magee R, MacDuffee R. One thousand consecutive cholecystectomies._Arch Surg 1968;96:858-62. 18. Briele H, Long W, Parks L. Gallbladder disease and cholecystectomy: experience with 1509 patients managed in a community hospital. Am Surg 1969;35:218-22. 19. Meyer K, Capos N. Mittelpunkt A. Personal experiences with 1,261 cases of acute and chronic cholecystitis and cholelithiasis. Surgery 1967;61:661-8. 20. Sullivan D. Hood T, Griffen W. Biliary tract surgery in the elderly. Am J Surg 1982;143:218-20.
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