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Laparoscopic Cholecystectomy in Patients With Mild Cirrhosis and Symptomatic Cholelithiasis
CANDIDATES
Laparoscopic Cholecystectomy in Patients With Mild Cirrhosis and Symptomatic Cholelithiasis G. Curro, U. Baccarani, G. Adani, and E. Cucinotta ABSTRACT Background. Our goal was to support the emerging opinion that laparoscopic cholecystectomy is safe and well tolerated in selected cirrhotic patients with indications for surgery. We present our experience with 50 laparoscopic cholecystectomies performed on patients with mild cirrhosis. Methods. We retrospectively reviewed and analyzed the outcomes of 50 laparoscopic cholecystectomies performed between January 1995 and May 2006 in patients with Child-Pugh A and B cirrhosis. Results. Laparoscopic cholecystectomy was uneventful for 35 cirrhotic patients. Conversion to an open procedure was necessary in two Child-Pugh B patients with chronic cholelcystitis. One Child-Pugh B cirrhotic patient required blood transfusion. Postoperative complications occurred in 12 patients, including hemorrhage, wound infection, intra-abdominal collection, and cardiopulmonary complications. The mean postoperative stay was 5 days (range, 3 to 13). No deaths occurred. Conclusions. Laparoscopic cholecystectomy is a safe procedure in well-selected ChildPugh A and B cirrhotic patients and should be the gold standard for patients with mild cirrhosis and symptomatic cholelithiasis.
T
HE PREVALENCE of cholelithiasis in cirrhotic patients seems to be twice that in noncirrhotic persons.1 Historically, the presence of cirrhosis was believed to be an absolute or relative contraindication to laparoscopic cholecystectomy (LC) because of the potential risks of bleeding or liver failure.2 However, with increased experience with laparoscopic surgery, LC has been demonstrated to be safe and well-tolerated in selected cirrhotic patients with indications for surgery. Several studies have reported encouraging results on the efficacy and safety of LC among cirrhotic patients. Our goal was to present our experience on 50 LC performed on patients with mild cirrhosis.
PATIENTS AND METHODS We retrospectively reviewed the records of 50 laparoscopic cholecystectomies performed on patients with Child-Pugh A and B cirrhosis from January 1995 to May 2006. The 50 patients included 19 men and 31 women of mean age 5 years (range, 28 to 83). The diagnosis of cirrhosis was determined according to clinical history
From the Department of Human Pathology (G.C., E.C.), University of Messina, Messina, Italy; and the Transplantation (U.B., G.A.), University of Udine, Messina, Italy. Address reprint requests to Dr G. Curro, Strada Panoramica 30/A, Mesina 98168, Italy. E-mail: [email protected]
© 2007 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/07/$–see front matter doi:10.1016/j.transproceed.2007.01.086
Transplantation Proceedings, 39, 1471–1473 (2007)
1471
1472
CURRO, BACCARANI, ADANI ET AL Table 1. LC in Patients With Child-Pugh A and B Cirrhosis: Review of the Literature Child-Pugh Author 13
Yerdel et al Angrisani et al16 Jan and Chen17 Sleeman et al18 Poggio et al12 Morino et al8 Fernandes et al19 Urban et al20 Clark et al9 Tuech et al7 Yeh et al10 Cucinotta et al4 Wu Ji et al14 Present study
Year
No. of Patients
A
B
Morbidity, n (%)
Morbidity, n
Hospital Stay (days)
Operative Time (min)
1997 1997 1997 1998 2000 2000 2000 2001 2001 2002 2002 2003 2004 2006
6 31 21 25 26 31 48 19 23 26 226 22 34 50
6 20 18 25 22 27 38 19 14 22 193 12 19 32
0 11 3 0 4 4 10 0 9 4 33 10 15 18
0 8 (25) 1 (4.8) 8 (32) 5 (19) 0 6 (12.5) 0 13 (52) 7 (27) 15 (6.6) 8 (36) 7 (13.2) 12 (24)
0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 3 4.1 1.7 2.3 2.8 6.5 3.5 4 5 4.7 5 — 5
155 — — 116 116 114 — 64 107 126 — 115 — 105
and laboratory data. The etiology of cirrhosis was hepatitis B in 9 patients, hepatitis C in 30, alcoholic abuse in 11, and unknown in 1. All patients were classified according to the Child-Pugh score: 32 Child-Pugh A (64%) and 18 Child- Pugh B (36%). Ascites was present in 10 cases, splenomegaly in 14, and esophageal varices in 11. The diagnosis of cholelithiasis was confirmed by ultrasonography. The indication for surgery was symptomatic cholelithiasis (n ⫽ 36) or cholecystitis (n ⫽ 14). In all cases, a standard laparoscopic procedure was performed with some modifications.
RESULTS
Laparoscopic cholecystectomy was uneventful in 35 cirrhotic patients. Conversion to an open procedure was necessary because of adhesions in two Child-Pugh B patients with chronic cholelcystitis (conversion rate, 4%). One Child-Pugh B patient required a blood transfusion. The mean operative time was 105 minutes (range, 55 to 165). Postoperative morbidity occurred in 5 of 32 Child-Pugh A cirrhotic patients (16%) and in 7 of 18 Child-Pugh B cirrhotic patients (38%). Postoperative complications included wound infections, hemorrhage, and intra-abdominal collections. There were no significant differences in outcomes between Child-Pugh A and B cirrhotic patients who underwent LC (P ⬎ .05). The mean length of postoperative stay was 5 days (range, 3 to 13). No deaths occurred. DISCUSSION
Cholelithiasis is a common disease among patients with cirrhosis.3 Intravascular hemolysis and functional alterations of the gallbladder are some pathogenic factors leading to an increase in unconjugated bilirubin secretion and, thereafter, to the formation of stones.4 Open cholecystectomy in cirrhotic patients is associated with high morbidity and mortality rates, namely up to 17% to 27%.4,5 In early clinical experiences with LC, cirrhosis was thought to be an absolute or relative contraindication because of potential risks of bleeding and liver failure.5,6 Several studies have examined the efficacy and safety of LC in
cirrhotic patients and the results have been encouraging (Table 1).7–14 These data seem to correlated with several causes. Magnification of the surgical field in laparoscopy permits meticulous care during hemostasis and pneumoperitoneum seems to play a role in promoting hemostasis (barohemostasis).11 Laparoscopy avoids the subcostal incision that would increase hemorrhage, particularly in patients with coagulopathy. Hemorrhage is the most common, dreadful complication in these patients. Bleeding may result from abdominal varices or coagulopathy secondary to depressed clotting factor synthesis and thrombocytopenia from hypersplenism. It is advisable to correct the coagulopathy in the perioperative period by platelet replacement and transfusion of fresh frozen plasma. Furthermore, technically, particular care is necessary when performing LC in cirrhotic patients; some modifications should be made to avoid the risk of heavy bleeding. First, care must be taken to avoid bleeding from periumblical wall varices. Second, transillumination of the abdominal wall by the laparoscope helps to identify major collaterals in the abdominal wall. Third, placement of the subxyphoid port should be more to the right of the midline to avoid injury to the falciform ligament and the umbilical vein. Fourth, excessive traction must be avoided to prevent avulsion of the gallbladder from the liver bed and bleeding. We used a harmonic scalpel for tissue and gallbladder dissection and radiofrequency energy to control bleeding from the gallbladder bed.15 Based on our results as well as those of others, LC is a safe procedure that should be the treatment of choice for symptomatic cholelithiasis or cholecystitis in well-selected Child-Pugh A and B cirrhotic patients.
REFERENCES 1. Schwesinger WH, Kurtin WE, Levine BA, et al: Cirrhosis and alcholism as pathogenetic factors in pigment gallstone formation. Ann Surg 201:319, 1985 2. NIH consensus conference statement on gallstones and laparoscopic cholecystectomy. Am J Surg 165:390, 1993
LAPAROSCOPIC CHOLECYSTECTOMY 3. Bouchier IAD: Postmortem study of the frequency of gallstones in patients with cirrhosis of the liver. Gut 10:705, 1969 4. Cucinotta E, Lazzara S, Melita G: Laparoscopic cholecystectomy in cirrhotic patients. Surg Endosc 17:1958, 2003 5. Gadacz TR, Talamini MA: Traditional versus laparoscopic cholecystectomy. Am J Surg 161:336, 1991 6. Cuschieri A, Dubois F, Mouiel J, et al: The European experience with laparoscopic cholecystectomy. Am J Surg 161:385, 1991 7. Tuech JJ, Pessaux P, Regenet N, et al: Laparoscopic cholecystectomy in cirrhotic patients. Surg Laparosc Endosc Percutan Tech 12:227, 2002 8. Morino M, Cavuoti G, Miglietta C, et al: Laparoscopic cholecystectomy in cirrhosis: contraindication or privileged indication? Surg Laparosc Endosc Percutan Tech 10:360, 2000 9. Clark JR, Wills VL, Hunt DR: Cirrhosis and laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 11:165, 2001 10. Yeh CN, Chen MF, Jan YY: Laparoscopic cholecystectomy in 226 cirrhotic patients. Surg Endosc 16:1583, 2002 11. Curro G, Iapichino G, Melita G, et al: Laparoscopic cholecystectomy in Child-Pugh class C cirrhotic patients. JSLS 9:311, 2005
1473 12. Poggio JL, Rowland CM, Gores GJ, et al: A comparison of laparoscopic and open cholecystectomy in patients with compensated cirrhosis and symptomatic gallstone disease. Surgery 127:405, 2000 13. Yerdel MA, Koksoy C, Aras N, et al: Laparoscopic versus open cholecystectomy in cirrhotic patients: a prospective study. Surg Laparosc Endosc 7:483, 1997 14. Ji W, Li LT, Chen XR, et al: Application of laparoscopic cholecystectomy in patients with cirrhotic portal hypertension. Hepatobili Pancreat Dis Int 3:270, 2004 15. Navarra G, Lorenzini C, Currò G, et al: Early results after radio-frequency assisted liver resection. Tumori 90:32, 2004 16. Angrisani L, Lorenzo M, Corcione F, et al: Gallstones in cirrhotics revisited by a laparoscopic view. J Laparoendsoc Adv Surg Tech A 7:213, 1997 17. Jan YY, Chen MF: Laparoscopic cholecystectomy in cirrhotic patients. Hepatogastroenterology 44:1584, 1997 18. Sleeman D, Namias N, Levi D, et al: Laparoscopic cholecystectomy in cirrhotic patients. J Am Coll Surg 187:400, 1998 19. Fernandes NF, Schwesinger WH, Hilsenbeck SG, et al: Laparoscopic cholecystectomy and cirrhosis: a case-control study of outcomes. Liver Transpl 6:340, 2000 20. Urban L, Eason GA, ReMine S, et al: Laparoscopic cholecystectomy in patient with early cirrhosis. Curr Surg 58:312, 2001
Laparoscopic Cholecystectomy in Patients With Mild Cirrhosis and Symptomatic Cholelithiasis G. Curro, U. Baccarani, G. Adani, and E. Cucinotta ABSTRACT Background. Our goal was to support the emerging opinion that laparoscopic cholecystectomy is safe and well tolerated in selected cirrhotic patients with indications for surgery. We present our experience with 50 laparoscopic cholecystectomies performed on patients with mild cirrhosis. Methods. We retrospectively reviewed and analyzed the outcomes of 50 laparoscopic cholecystectomies performed between January 1995 and May 2006 in patients with Child-Pugh A and B cirrhosis. Results. Laparoscopic cholecystectomy was uneventful for 35 cirrhotic patients. Conversion to an open procedure was necessary in two Child-Pugh B patients with chronic cholelcystitis. One Child-Pugh B cirrhotic patient required blood transfusion. Postoperative complications occurred in 12 patients, including hemorrhage, wound infection, intra-abdominal collection, and cardiopulmonary complications. The mean postoperative stay was 5 days (range, 3 to 13). No deaths occurred. Conclusions. Laparoscopic cholecystectomy is a safe procedure in well-selected ChildPugh A and B cirrhotic patients and should be the gold standard for patients with mild cirrhosis and symptomatic cholelithiasis.
T
HE PREVALENCE of cholelithiasis in cirrhotic patients seems to be twice that in noncirrhotic persons.1 Historically, the presence of cirrhosis was believed to be an absolute or relative contraindication to laparoscopic cholecystectomy (LC) because of the potential risks of bleeding or liver failure.2 However, with increased experience with laparoscopic surgery, LC has been demonstrated to be safe and well-tolerated in selected cirrhotic patients with indications for surgery. Several studies have reported encouraging results on the efficacy and safety of LC among cirrhotic patients. Our goal was to present our experience on 50 LC performed on patients with mild cirrhosis.
PATIENTS AND METHODS We retrospectively reviewed the records of 50 laparoscopic cholecystectomies performed on patients with Child-Pugh A and B cirrhosis from January 1995 to May 2006. The 50 patients included 19 men and 31 women of mean age 5 years (range, 28 to 83). The diagnosis of cirrhosis was determined according to clinical history
From the Department of Human Pathology (G.C., E.C.), University of Messina, Messina, Italy; and the Transplantation (U.B., G.A.), University of Udine, Messina, Italy. Address reprint requests to Dr G. Curro, Strada Panoramica 30/A, Mesina 98168, Italy. E-mail: [email protected]
© 2007 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/07/$–see front matter doi:10.1016/j.transproceed.2007.01.086
Transplantation Proceedings, 39, 1471–1473 (2007)
1471
1472
CURRO, BACCARANI, ADANI ET AL Table 1. LC in Patients With Child-Pugh A and B Cirrhosis: Review of the Literature Child-Pugh Author 13
Yerdel et al Angrisani et al16 Jan and Chen17 Sleeman et al18 Poggio et al12 Morino et al8 Fernandes et al19 Urban et al20 Clark et al9 Tuech et al7 Yeh et al10 Cucinotta et al4 Wu Ji et al14 Present study
Year
No. of Patients
A
B
Morbidity, n (%)
Morbidity, n
Hospital Stay (days)
Operative Time (min)
1997 1997 1997 1998 2000 2000 2000 2001 2001 2002 2002 2003 2004 2006
6 31 21 25 26 31 48 19 23 26 226 22 34 50
6 20 18 25 22 27 38 19 14 22 193 12 19 32
0 11 3 0 4 4 10 0 9 4 33 10 15 18
0 8 (25) 1 (4.8) 8 (32) 5 (19) 0 6 (12.5) 0 13 (52) 7 (27) 15 (6.6) 8 (36) 7 (13.2) 12 (24)
0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 3 4.1 1.7 2.3 2.8 6.5 3.5 4 5 4.7 5 — 5
155 — — 116 116 114 — 64 107 126 — 115 — 105
and laboratory data. The etiology of cirrhosis was hepatitis B in 9 patients, hepatitis C in 30, alcoholic abuse in 11, and unknown in 1. All patients were classified according to the Child-Pugh score: 32 Child-Pugh A (64%) and 18 Child- Pugh B (36%). Ascites was present in 10 cases, splenomegaly in 14, and esophageal varices in 11. The diagnosis of cholelithiasis was confirmed by ultrasonography. The indication for surgery was symptomatic cholelithiasis (n ⫽ 36) or cholecystitis (n ⫽ 14). In all cases, a standard laparoscopic procedure was performed with some modifications.
RESULTS
Laparoscopic cholecystectomy was uneventful in 35 cirrhotic patients. Conversion to an open procedure was necessary because of adhesions in two Child-Pugh B patients with chronic cholelcystitis (conversion rate, 4%). One Child-Pugh B patient required a blood transfusion. The mean operative time was 105 minutes (range, 55 to 165). Postoperative morbidity occurred in 5 of 32 Child-Pugh A cirrhotic patients (16%) and in 7 of 18 Child-Pugh B cirrhotic patients (38%). Postoperative complications included wound infections, hemorrhage, and intra-abdominal collections. There were no significant differences in outcomes between Child-Pugh A and B cirrhotic patients who underwent LC (P ⬎ .05). The mean length of postoperative stay was 5 days (range, 3 to 13). No deaths occurred. DISCUSSION
Cholelithiasis is a common disease among patients with cirrhosis.3 Intravascular hemolysis and functional alterations of the gallbladder are some pathogenic factors leading to an increase in unconjugated bilirubin secretion and, thereafter, to the formation of stones.4 Open cholecystectomy in cirrhotic patients is associated with high morbidity and mortality rates, namely up to 17% to 27%.4,5 In early clinical experiences with LC, cirrhosis was thought to be an absolute or relative contraindication because of potential risks of bleeding and liver failure.5,6 Several studies have examined the efficacy and safety of LC in
cirrhotic patients and the results have been encouraging (Table 1).7–14 These data seem to correlated with several causes. Magnification of the surgical field in laparoscopy permits meticulous care during hemostasis and pneumoperitoneum seems to play a role in promoting hemostasis (barohemostasis).11 Laparoscopy avoids the subcostal incision that would increase hemorrhage, particularly in patients with coagulopathy. Hemorrhage is the most common, dreadful complication in these patients. Bleeding may result from abdominal varices or coagulopathy secondary to depressed clotting factor synthesis and thrombocytopenia from hypersplenism. It is advisable to correct the coagulopathy in the perioperative period by platelet replacement and transfusion of fresh frozen plasma. Furthermore, technically, particular care is necessary when performing LC in cirrhotic patients; some modifications should be made to avoid the risk of heavy bleeding. First, care must be taken to avoid bleeding from periumblical wall varices. Second, transillumination of the abdominal wall by the laparoscope helps to identify major collaterals in the abdominal wall. Third, placement of the subxyphoid port should be more to the right of the midline to avoid injury to the falciform ligament and the umbilical vein. Fourth, excessive traction must be avoided to prevent avulsion of the gallbladder from the liver bed and bleeding. We used a harmonic scalpel for tissue and gallbladder dissection and radiofrequency energy to control bleeding from the gallbladder bed.15 Based on our results as well as those of others, LC is a safe procedure that should be the treatment of choice for symptomatic cholelithiasis or cholecystitis in well-selected Child-Pugh A and B cirrhotic patients.
REFERENCES 1. Schwesinger WH, Kurtin WE, Levine BA, et al: Cirrhosis and alcholism as pathogenetic factors in pigment gallstone formation. Ann Surg 201:319, 1985 2. NIH consensus conference statement on gallstones and laparoscopic cholecystectomy. Am J Surg 165:390, 1993
LAPAROSCOPIC CHOLECYSTECTOMY 3. Bouchier IAD: Postmortem study of the frequency of gallstones in patients with cirrhosis of the liver. Gut 10:705, 1969 4. Cucinotta E, Lazzara S, Melita G: Laparoscopic cholecystectomy in cirrhotic patients. Surg Endosc 17:1958, 2003 5. Gadacz TR, Talamini MA: Traditional versus laparoscopic cholecystectomy. Am J Surg 161:336, 1991 6. Cuschieri A, Dubois F, Mouiel J, et al: The European experience with laparoscopic cholecystectomy. Am J Surg 161:385, 1991 7. Tuech JJ, Pessaux P, Regenet N, et al: Laparoscopic cholecystectomy in cirrhotic patients. Surg Laparosc Endosc Percutan Tech 12:227, 2002 8. Morino M, Cavuoti G, Miglietta C, et al: Laparoscopic cholecystectomy in cirrhosis: contraindication or privileged indication? Surg Laparosc Endosc Percutan Tech 10:360, 2000 9. Clark JR, Wills VL, Hunt DR: Cirrhosis and laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 11:165, 2001 10. Yeh CN, Chen MF, Jan YY: Laparoscopic cholecystectomy in 226 cirrhotic patients. Surg Endosc 16:1583, 2002 11. Curro G, Iapichino G, Melita G, et al: Laparoscopic cholecystectomy in Child-Pugh class C cirrhotic patients. JSLS 9:311, 2005
1473 12. Poggio JL, Rowland CM, Gores GJ, et al: A comparison of laparoscopic and open cholecystectomy in patients with compensated cirrhosis and symptomatic gallstone disease. Surgery 127:405, 2000 13. Yerdel MA, Koksoy C, Aras N, et al: Laparoscopic versus open cholecystectomy in cirrhotic patients: a prospective study. Surg Laparosc Endosc 7:483, 1997 14. Ji W, Li LT, Chen XR, et al: Application of laparoscopic cholecystectomy in patients with cirrhotic portal hypertension. Hepatobili Pancreat Dis Int 3:270, 2004 15. Navarra G, Lorenzini C, Currò G, et al: Early results after radio-frequency assisted liver resection. Tumori 90:32, 2004 16. Angrisani L, Lorenzo M, Corcione F, et al: Gallstones in cirrhotics revisited by a laparoscopic view. J Laparoendsoc Adv Surg Tech A 7:213, 1997 17. Jan YY, Chen MF: Laparoscopic cholecystectomy in cirrhotic patients. Hepatogastroenterology 44:1584, 1997 18. Sleeman D, Namias N, Levi D, et al: Laparoscopic cholecystectomy in cirrhotic patients. J Am Coll Surg 187:400, 1998 19. Fernandes NF, Schwesinger WH, Hilsenbeck SG, et al: Laparoscopic cholecystectomy and cirrhosis: a case-control study of outcomes. Liver Transpl 6:340, 2000 20. Urban L, Eason GA, ReMine S, et al: Laparoscopic cholecystectomy in patient with early cirrhosis. Curr Surg 58:312, 2001