- Email: [email protected]
The role of laparoscopy in chronic and recurrent abdominal pain
The Role of Laparoscopy in Chronic Recurrent Abdominal Pain
and
Karl Miller, MD, Edith Mayer, MD, Erich Moritz, MD, Salzburg, Austria
BACKGROUND: This study was designed to determine the efficacy of laparoscopy on patients with a history of recurrent and chronic abdominal pain longer than 3 months, of unknown origin. METHODS: From September 1990 to May 1994, we performed 66 laparoscopic treatments on 59 patients. The assessment of life quality ensured the disability score, the McGill pain questionnaire, and the visual analogue pain scale, which were completed preoperatively, then on the day of discharge, and finally at a mean period follow-up of 75.3 weeks. Laparoscopy provided diagnosis on 53 of 59 patients (89.8%). RESULTS: All 66 attempted laparoscopic procedures were completed successfully, no conversion to laparotomy was necessary, and no postoperative complication occurred. Five out of 59 patients (8.5%) revealed no improvement of pain postoperatively, and 6 out of 56 (10.7%) still suffer from pain at the time of the follow-up. CONCLUSIONS: The pain assessment and disability score was statistically significant postoperatively and at the time of the follow-up in relation to the preoperative score. Am J Surg. 1996;172:353-357.
T
hough diagnostic laparoscopy was a precursor to endoscopic surgery, ‘,z in general surgery it has not been widely accepted in contrast to that concerning cholecystectomy. Gynecologists recognized the potential of laparoscopy 30 years ago, and it became one of their most important diagnostic and therapeutic tools. In case of diagnostic uncertainty, laparoscopy may help avoid unnecessary laparotomy, provide accurate diagnosis, and help plan surgical treatment-s Chronic abdominal pain of unknown origin represents a significant problem in surgical patients. In some cases, even a battery of investigations do not reveal the cause of pain. Due to improvements in instrumentation and greater experience with therapeutic laparoscopy, the procedure is no longer limited to visualization. Operative treatment can be provided in many instances and will be performed more frequently. The purpose of the current study is to determine the efficacy of laparoscopy on patients with recurrent and chronic undi-
From the Second Surgical Department, Landeskrankenanstalten Salzburg, Salzburg, Austria. Requests for reprints should be addressed to K. Miller, MD, Second Surgical Department, Landeskrankenanstalten Salzburg, MulIner Hauptstr. 48, A-5020 Salzburg, Austria. Manuscript submitted September 11, 1995 and accepted in revised form March 25, 1996.
0 1996 by Excerpta All rights reserved.
Medica,
Inc.
agnosed abdominal pain and investigate its relationship concerning long-term follow-up after laparoscopy.
PATIENTS
AND
METHODS
Patients with a history of abdominal pain for longer than 3 months were included in the study after clinical examination, laboratory tests, and noninvasive imaging techniques had been carried out, and where gynecological examination did not yield accurate diagnoses. All patients were informed about the risks and possible complications and consent was obtained. Oncological patients, pregnant women, women who had recently given birth, patients with severe coagulation defects, and with substantially distended intestinal loops were excluded from the study. Study Design Initial clinical parameters, history of persistent of abdominal pain, and failed diagnostic and therapeutic procedures were documented. The assessment of life quality involved the establishment of the disability score (1 being very well to 5 being extremely bad), the short-form McGill pain questionnaire.” and the visual analogue pain scale (O-50 mm). ” Anamnestic q uestionnaire and clinical examination were documented preoperatively (Time A), then on the day of discharge (Time B), and finally at a follow-up of 1 year (Time C) obtained from visits to clinics. Additionally, all patients had to answer the question of whether they would recommend having laparoscopic procedure carried out on them at the time of the follow-up. Technique The procedures were performed under general endotracheal anesthesia, muscle relaxation, and controlled ventilation. Pneumoperitoneum was undertaken by insufflating approximately 3-4 liters CO* into the abdominal cavity; the intraabdominal pressure was adjusted to 12 mm Hg. A lo-mm periumbilical incision was chosen for the 0” videooptic. The technique of insertion of the laparoscope into the scarred abdomen is described in detail elsewhere.” Depending upon intra-abdominal findings the secondary trocars were placed under direct vision. Statistical Analysis All data were further analyzed by use of an IBM-486 personal computer using the software programs of the IDVVersuchsplanung und Datenanalyse (Gauting, Munich, Germany ) . On each observation, median, standard deviation, standard error, range, upper and lower quartile, and total mean values were calculated. Univariate analyses were performed using the Wilcoxon-Mann-Whitney U-test for continuous variables and by using a Chi-square test on a 2 x 2 table for binary variables (Fisher exact). The P values 0002-961 O/96/$1 5.00 PII SOOO2-961 0(96)00187-O
353
LAPAROSCOPY TABLE
IN CHRONIC
ABDOMINAL
PAIN/MILLER
ET
AL
I Patient
Characteristics
of the
Main
Laparoscopic Appendectomy
Data represent
mean value (standard
are those computed significant variables (two tailed).
TABLE II Laparoscopic
for each comparison and statistically taken as predictors at the 0.05 level
Findings
Appendectomies In 28 patients with chronic abdominal pain laparoscopic appendectomy was performed. Ten patients had various pathological combinations. In 7 of them combined adhesiolysis was performed, in 2 resection of hydatides, and in 1 the resection of Meckel’s diverticulum. The characteristics of these patients are listed in Table I. Histologically confirmed chronic appendicitis was found in 17 patients. Chronic inflammation was diagnosed when lymphocytes and eosinophils were present within the appendiceal wall with associated fibrosis. A pathologic diag nosis of acute inflammation of the appendix was described in 6 cases, and 1 case showed appendiceal neuroma. Four specimens were histologically without pathological findings. In 4 of 6 patients with macroscopically bland appenJOURNAL
All Patients
2/l 24.7 14 2.7
17142 29.3 (12.5) 68.3 (172.1) 3.5 (1.5)
0 (1.5) (4.8) (0.5)
OF
SURGERY@
VOLUME
172
Findings and Treatments on 5g Patients Recurrent and Chronic Abdominal Pain
at Laparoscopy
Adhesions Chronic and acute appendicitis lnguinal hernia Meckel’s divetticulum Endometriosis Ovarian cyst Adnexitis Hydatides No pathology found
n 26 24 2 2 3 1 1 4 2 4
with
Laparoscopic Treatment Adhesiolysis Appendectomy Hernial repair Transresection Endocoagulation Cyst resection Exploration Resection Exploration only Appendectomy
dix, the appendix was removed, as discussed with the patient prior to the operation. The pain assessment and disability score numbers were statistically high at Times B and C in relation to Time A (Table III).
Adhesiolyses Adhesions were found in 26 patients and were able to be related to the location of pain. In 7 cases the appendix was in direct relation to the adhesions and the appendix was removed. Adhesiolysis on its own was performed on 19 patients and the characteristics of these patients are listed in Table I. The pain assessment and disability score were significantly different statistically in respect to postoperative treatment (Time B) and at the time of the follow-up (Time C) in relation to the preoperative score number (Time A) (Table III).
AMERICAN
Miscellaneous
deviation).
RESULTS
THE
Solely
?/I2 36.9 (12.6) 103.5 (119.8) 3.8 (1.7)
Patient Characteristics From September 1990 to May 1994, 59 patients were involved the study. There were 42 women and 17 men with a mean age of 29.3 -C 12.5 years (range, 15-71 years). The mean history of persistent abdominal pain was 68.3 2 172.1 weeks (range, 11 weeks to 20 years). The patient characteristics of main laparoscopic treatments are summarized in Table I. Fifty-six patients (94.9%) were monitored by way of direct contact at a mean follow-up period of 75.3 -+ 15.3 weeks (range, 55-95 weeks). Laparoscopy provided diagnosis for 53 of the 59 patients (89.8%) (Table II). The main laparoscopic procedures were appendectomies, adhesiolyses, and gynecological treatments. Of the 66 attempted laparoscopic procedures, all were completed successfully, no patient had to undergo laparotomy, and no postoperative complication occurred.
354
Procedures
Treatment
Adhesiolysis
a/20 28.1 (12.7) 70.8 (150.2) 3.5 (1.4)
Sex (male/female) Age (yrs) History of pain (wks) Hospital stay (days)
Laparoscopic
-
Miscellaneous Conditions In 2 female patients, an unknown inguinal hernia was found to be responsible for recurrent pain. In 1 female and 1 male patient a Meckel’s diverticulum was detected. The diverticula were successfully treated using laparoscopic techniques.‘* In one of them the appendix showing signs of inflammation was also removed. Endocoagulation of foci of endometriosis was performed on 3 patients. In 1 patient an ovarian cyst was seen and resected. In 2 patients masses of hydatides as pathological findings only were detected and were resected. Six out of 59 patients revealed no pathologic findings. In 4 of them, the appendix was removed, and in 2 of them the procedure was completed as exploratory laparoscopy, as discussed with the patient prior to surgery. In the group with miscellaneous conditions the pain assessment and disability score number was statistically high at Times B and C compared with Time A (Table III). The visual analogue pain scale of all patients is visualized in a boxplot-presentation (Figure). The visual analogue pain scale factor was statistically high at Times B and C compared with Time A. Five out of 59 patients (8.5%) revealed no improvement of pain postoperatively, and 6 out of 56 (10.7%) patients still suffer from pain and would not recommend the procedure at a follow-up (1 appendectomy with no histopathological finding, 3 cases with only adhesiolysis, and 2 with negative finding at laparoscopy). OCTOBER
1996
1 LAPAROSCOPY-iN TABLE
CHRONIC
ABDOMINAL
PAIN/MILLER
ET AL
III Anamnestic
Questionnaire McGill
Laparoscopic Treatment Appendectomy Adhesiolysis Miscellaneous All patients
Patients (n) .. 28 19 12 59
solely conditions
Time 17.7 17.1 11.5 16.7
and
Clinical
Examination
Pain Questionaire: Mean Value (SD)
A
Time
(8.5) (7.7) (11 .O) (8.2)
8.6 7.9 2.7 7.4
B
(7.9) (7.6) (1.5)* (7.3)
Disabilitv Score: Mean Value (SD) Time 4.3 6.0 1 .o 4.0
C
(8.6)f (6.1) (0.5)* (7.3)+
Data are preoperative rime A/, then on the day of discharge rime Bj and at the follow-up rime C) obtained performed using the Wkoxon-Mann-Whitney U-test for continues variabies Time A vs Time B vs Time C. *P
p~0.0001 5
mm
45
t p=o.o015
I
I
x
T
4
m
95 3 i-
I,5T-
z5 2
x
1 i
45 0 It
45 -
Time A
m
Time B
Figure. Box plot presentation of the visual analogue pain scale of all patients. Examination preoperatively (Time A), then on the day of discharge (Time B), and at the follow-up (Time C) obtained from visits to the clinic. Statistical analyses were performed using the Wilcoxon-Mann-Whitney U-test for continuous variables Time A vs Time B vs Time C. m = median.
DISCUSSION Recurrent abdominal pain is a common problem, dealt with by a variety of medical specialists. Even after an extensive workup in some patients, no pathologic condition is found by noninvasive investigations, and the pain is often attributed to one of a number of vague and even unsubstantiated diagnoses. The role of diagnostic laparoscopy in chronic and recurrent abdominal pain remains to some controversial. Wood and Cuschieri13 reported a prospective series of patients with undiagnosed abdominal pain. A significant pathologic etiology was found in 30% of this group by laparoscopy. Nagy and James3 demonstrated their assessment of chronic abdominal pain in 11 patients. They yielded a diagnostic accuracy in 9 (82%) and laparotomy was avoided in 7 (64%). They concluded that in the evaluation of chronic abdominal pain, laparoscopy was insufficient. A survey of published reports showed laparoscopically diagnosable abnormalities in 61% of patients complaining of chronic abdominal pain, compared with abnormalities in 28% of women without chronic pelvic pain.14 Overall, the data showed that less than 50% of women with chronic pelvic pain were helped by diagnostic and operative laparoscopy. THE
AMERICAN
Time 3.7 3.5 4.7 3.8
A
Time
(0.8) (0.8) (0.5) (0.8)
from v&s
2.1 2.4 2.0 2.2
B
(0.7)* (0.5) (0.6)’ (0.6)*
to the clmic. Sfaksticai
Time
C
1.3 1.9 1.2 1.4
(0.8)+ (0.9) (0.5)* (0.8)+
anaiyses
were
Schrenk et al” reported on 31 patients suffering undiagnosed chronic abdominal pain. Five out of 31 ( 16%) revealed no pathologic findings during laparoscopy. However, following surgery they found 29 patients (93.5%) free of pain during follow-up examination. These results compare favorably with our series of results, giving a diagnostic accuracy of 89.8% and an improvement in pain suffered of 90% during the time of the follow-up examination. Laparoscopy is the method to choose for diagnosis of acute and chronic right pelvic pain in young women.‘j-li In these patients, laparoscopy may distinguish between gynecologic disorders and appendicitis. Doubt remains whether the appendix should be removed in the case of inconclusive findings. There is no difference in laparoscopic and conventional appendectomy as regards safety and complications. 15~‘s~1yFrangenheim observed in laparoscopy that the macroscopic findings do not correlate well with the histopathology.*@ Of these patients, 64.4% had already been living with their symptoms for more than 6 months. The appendectomies are justified in the final analysis by the postoperative freedom from symptoms and by the pathological findings of chronic recurrent or fibrosing inflammation. Recurrent and chronic appendicitis do exist as disease of the appendix.” However, after an appropriate work-up study, one may consider chronic inflammation of the appendix as one cause of symptoms, and surgical exploration should be considered too. Investigation of the appendix should be included in the workup of recurrent or chronic abdominal pain when no other diagnosis is readily apparent.‘2 In our study the appendix was removed when the patient had a history of recurrent pain in the right iliac fossa, even when there was no pathology found laparoscopically. In 2 patients with macroscopically bland appendix, the appendix was not removed, in line with that discussed with the patient prior to operation. The two patients undergoing just diagnostic laparoscopy, in whom we left the appendix in place, still suffered from pain at the time of the follow-up. It seems unlikely to be able to interpret the advantages of diagnostic laparoscopy as “placebo effect.” In a number of cases, adhesions of the appendix or the cecum also indicated chronic inflammation. The number of multiple operations shows the most diverse combinations of pathology that can be found during laparoscopy. It is not possible to distinguish with certainty, which of these findings are of crucial significance for the symptoms of the paJOURNAL
OF SURGERYa
VOLUME
172
OCTOBER
1996
355
/ LAPAROSCOPY
IN CHRONIC
ABDOMINAL
PAIN/MILLER
ET AL :
tients.” In our series, 10 out of 28 (35.7%) patients having an appendectomy had various pathological combinations. Schreiber reported on 57.1% multiple operations involvmg various combinations in laparoscopic appendectomy.‘” Adhesions are considered to be responsible for chronic abdominal pain and may becaused by scars of the abdominal wall. When adhesions are suspected, sonography of the abdominal wall is a useful investigation.24 For insertion of the laparoscope in the scarred abdomen we adapt the conventional laparoscopic approach, the peritoneum perforation under vision, and the open laparoscopic approach, all of which are reported in detail elsewhere.12 The role of adhesiolysis in chronic and recurrent abdominal pain remains for some controversial. Peters et all5 reported upon a prospective randomized trial comparing open adhesiolysis involving no surgery in a definitive analysis of results after 9-12 months. After 9-12 months there were no overall significant differences between the two groups overall with regard to pelvic pain. They concluded that adhesiolysis for the treatment of pelvic pain is not indicated in women having light or moderate degrees of pelvic adhesions. Ikard26 advocated in an editorial that there is no current indication to favor laparoscopic adhesiolysis in treating abdominal pain. Bastug et alL7 reported a successfully treated small bowel obstruction a secondary aspect to an adhesive band by means of laparoscopic adhesiolysis. Leidig and Krakamp” could find 70% improvement in their patients with laparoscopic adhesiolysis. Schrenk et al” successfully treated 10 out of 12 patients with dense adhesions. In our series 3 out of 19 (15.7%) patients involving just adhesiolysis still suffered from pain at the time of the follow-up. After a mean period of 18 months there was a significant overall improvement with regard to pelvic pain (Table III). We showed that in appropriate patient selection, laparoscopy is a useful method in treating abdominal adhesions, in the presence of chronic abdominal pain. In our opinion this is mainly achieved by optimal visualization of the whole abdomen and pelvis by the method of minimal invasive surgery. This method is generally accepted as being less traumatic than open surgery, so that less adhesion formation is very likely. Laparoscopy will not supplant accurate preoperative physical examination and noninvasive diagnostic tests. On the contrary, the more information the surgeon gets through noninvasive diagnostic techniques, the more can be expected from laparoscopy. We believe that laparoscopy is a very useful therapeutic tool in the armamentarium of modern general surgery and should not be confined to diagnostic evaluation only. Nevertheless, patient selection and appropriate operative techniques are essential for a rewarding outcome.
REFERENCES 1. Kelling G. Verhandlung Deutscher Naturforscher und Aeate. Leipzig: Vogel, 1902. 2. Jacobeus HC. Kurze tibersicht iiber meine erfahrungen mit der laparoskopie. Munch Med Wochenschr. 1911;58:2017. 3. Nagy AG, James D. Diagnostic laparoscopy. Am .J Surg. 1989;157:490-493. 4. Easter DW, Cushieri A, Nathanson LK, Lavelle-Jones M. The utility of diagnostic laparoscopy for abdominal disorders. Arch Surg. 1992;127:379-383. 5. Sackier J. Diagnostic laparoscopy in nonmalignant disease. Surg CIin North Am. 1992;72:1033-1043. 356
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AMERICAN
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OF SURGERY@
VOLUME
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6. Berci G. Elective and emrgant laparoscopy. World 1 Surg. 1993;17:8-15. 7. Cushieri A. The spectrum of laparoscopic surgery. Worki ] Surg. 1992;16:1089-1097. 8. Schrenk I’, Woisetschkiger R, Wayand U, et al. Diagnostic laparoscopy: a survey of 92 patients. Am J Surg. 1994; 168:348-35 1. 9. Melzack R. The short-form McGill pain questionaire. Pain. 1987;30:191-197. 10. Jensen MP, Karoly I’, Braver S. The measurement of clinical pain intensity: comparison of six methods. Pain. 1986;27:117126. 11. Miller K, Halbling N, Hutter J, et al. Laparoscopic cholecystectomy for patients who have had previous abdominal surgery. Surg Endosc. 1993;7:400-403. 12. Miller K, Hutter J. Videolapan>scopic treatment of Meckel’s diverticulum. Endoscopy. 1993;5:373. 13. Wood RAB, Cuschieri A. Lapxoscopy for chronic abdominal pain. Br J Surg. 1997;60:900-902. 14. Howard FM. The role of laparoscopy In chronic pelvic pain: promise and pitfalls. Obstet Gynecol Sure. 1993;6:357387. 15. Clarke PJ, Hands LJ, Gough MH, Kettlewell MGW. The use of laparoscopy in the management of right iliac fossa pain. Ann R Cod Surg Engl. 1986;68:68-69. 16. Schreiber JH. Early experience with laparoscopic appendectomy in women. Surg E&SC. 1987;1:211-216. 17. Spirtos NM, Eisenkop SM, Spirtos TW, et al. Laparoscopy: a diagnostic aid in case of suspected appendicitis. Am J Obstrt Gynecol. 1987;156:90-94. 18. Hebebrand D, Troidl H, Spangenherger W, et al. Laparoscopische oder klassische appendektnmie! Eine prospektlv randomisierte studie. Chirurg. 1994;65:112-120. 19. Vallina VL, Velasco JM, McCulloch CS. Laparoscopic versus conventional appendectomy. Ann Surg. 1993;5:685-692. 20. Frangenheim H. Diagnostische und Operative Laparoskopie in der Gynikologie. Marseile: Miinchen, 96-194. 21. Crabbe MM, Norwood SH, Robertson HD, Silva JS. Recurrent and chronic appendicitis. Surg Gynecol Obstet. 1986;163:11-13. 22. Seidman JD, Andersen DK, Ulrlch S, et al. Recurrent abdominal pain due to chronic appendiceal disease. South Med J. 1991;84:913-916. 23. Uebermuth H. Abdominalchirurgle in der schwangerschaft. In: Klinik der Frauenheilkunde und Geburtshilfe, Vol 2. Munich, Vienna: Urban & Schwarzenberg, 1994:289-293. 24. Martin G, Bergama S, Miola E, et al. Prelaparoscopic echography used to detect abdominal adhesions. Endoscopy. 1987;19:147149. 25. Peters AA, Trimbos-Kemper GC, Admiraal C, et al. A randomized clinical trial on the benefit of adhesiolysis in patients with intraperitoneal adhesions and chronic pelvic pain. Br J Obstet Gynaecol. 1992;99:59-62. 26. Ikard RW. There is no current indicanon for laparoscopic adhesiolysis to treat abdominal pain. South Med J. 1992;85:939940. 27. Bastug DF, Trammel SW, Boland JP, et al. Laparoscopic adhesiolysis for small bowel obstructton. Surg Laparosc E&SC. 1991;4:259-262. 28. Leidig I’, Krakamp B. Laparoskoplsche adhssiolyse: einfache methode zur diagnose und therapie verwachsungsbedingter abdominalschmerzen. Leber Magen Dartn. 1992;22:27-28.
EDITORIAL
COMMENT
The benefits of laparoscopy in patients with chronic abdominal pain have never been clear. Many studies, like this one, attempt to draw conclusions about the benefits (or lack of benefit) of intervening with a very heterogeneous group of patients with a wide range of final diagnoses. This study OCTOBER
1996
--. ..~ 1 LAPAROSCOPY L
makes the very optimistic statement that 90% of these patients benefitted from laparoscopy. Interestingly, it appears that the quality of pain relief was identical, no matter what the final diagnosis was. Those with chronic appendicitis or adhesions did equally well at short and long term (median, 75 months) follow-up. Most previous studies heralding the benefits of laparoscopy have not shown such clear benefits when patients are followed for more than a year. In fact, the one prospective randomized trial cited in the excellent discussion section could demonstrate no difference between those that had laparotomy and enterolysis and those that had no treatment. An ideal study of this difficult topic would require a large number of patients with a single di-
THE
AMERICAN
IN CHRONIC
.- ABDOMINAL
PAIN/MILLER
ET AL T
agnosis, say chronic adhesions. This population would be randomized to laparoscopy and adhesiolysis, management in a pain clinic, and management by interrusts or gastroenterologists. The median follow-up should be at least 3 years. As surgeons, we have been strong believers that “if you operate for pain, pain is what you get.” Nonetheless, we cannot refuse to consider the tindings of studies like this demonstrating a ray of hope for these long suffering patients. John G. Hunter, MD Department of Surgery Emory University Atlanta, GA
JOURNAL
OF SURGERYa
VOLUME
172
OCTOBER
1996
357
and
Karl Miller, MD, Edith Mayer, MD, Erich Moritz, MD, Salzburg, Austria
BACKGROUND: This study was designed to determine the efficacy of laparoscopy on patients with a history of recurrent and chronic abdominal pain longer than 3 months, of unknown origin. METHODS: From September 1990 to May 1994, we performed 66 laparoscopic treatments on 59 patients. The assessment of life quality ensured the disability score, the McGill pain questionnaire, and the visual analogue pain scale, which were completed preoperatively, then on the day of discharge, and finally at a mean period follow-up of 75.3 weeks. Laparoscopy provided diagnosis on 53 of 59 patients (89.8%). RESULTS: All 66 attempted laparoscopic procedures were completed successfully, no conversion to laparotomy was necessary, and no postoperative complication occurred. Five out of 59 patients (8.5%) revealed no improvement of pain postoperatively, and 6 out of 56 (10.7%) still suffer from pain at the time of the follow-up. CONCLUSIONS: The pain assessment and disability score was statistically significant postoperatively and at the time of the follow-up in relation to the preoperative score. Am J Surg. 1996;172:353-357.
T
hough diagnostic laparoscopy was a precursor to endoscopic surgery, ‘,z in general surgery it has not been widely accepted in contrast to that concerning cholecystectomy. Gynecologists recognized the potential of laparoscopy 30 years ago, and it became one of their most important diagnostic and therapeutic tools. In case of diagnostic uncertainty, laparoscopy may help avoid unnecessary laparotomy, provide accurate diagnosis, and help plan surgical treatment-s Chronic abdominal pain of unknown origin represents a significant problem in surgical patients. In some cases, even a battery of investigations do not reveal the cause of pain. Due to improvements in instrumentation and greater experience with therapeutic laparoscopy, the procedure is no longer limited to visualization. Operative treatment can be provided in many instances and will be performed more frequently. The purpose of the current study is to determine the efficacy of laparoscopy on patients with recurrent and chronic undi-
From the Second Surgical Department, Landeskrankenanstalten Salzburg, Salzburg, Austria. Requests for reprints should be addressed to K. Miller, MD, Second Surgical Department, Landeskrankenanstalten Salzburg, MulIner Hauptstr. 48, A-5020 Salzburg, Austria. Manuscript submitted September 11, 1995 and accepted in revised form March 25, 1996.
0 1996 by Excerpta All rights reserved.
Medica,
Inc.
agnosed abdominal pain and investigate its relationship concerning long-term follow-up after laparoscopy.
PATIENTS
AND
METHODS
Patients with a history of abdominal pain for longer than 3 months were included in the study after clinical examination, laboratory tests, and noninvasive imaging techniques had been carried out, and where gynecological examination did not yield accurate diagnoses. All patients were informed about the risks and possible complications and consent was obtained. Oncological patients, pregnant women, women who had recently given birth, patients with severe coagulation defects, and with substantially distended intestinal loops were excluded from the study. Study Design Initial clinical parameters, history of persistent of abdominal pain, and failed diagnostic and therapeutic procedures were documented. The assessment of life quality involved the establishment of the disability score (1 being very well to 5 being extremely bad), the short-form McGill pain questionnaire.” and the visual analogue pain scale (O-50 mm). ” Anamnestic q uestionnaire and clinical examination were documented preoperatively (Time A), then on the day of discharge (Time B), and finally at a follow-up of 1 year (Time C) obtained from visits to clinics. Additionally, all patients had to answer the question of whether they would recommend having laparoscopic procedure carried out on them at the time of the follow-up. Technique The procedures were performed under general endotracheal anesthesia, muscle relaxation, and controlled ventilation. Pneumoperitoneum was undertaken by insufflating approximately 3-4 liters CO* into the abdominal cavity; the intraabdominal pressure was adjusted to 12 mm Hg. A lo-mm periumbilical incision was chosen for the 0” videooptic. The technique of insertion of the laparoscope into the scarred abdomen is described in detail elsewhere.” Depending upon intra-abdominal findings the secondary trocars were placed under direct vision. Statistical Analysis All data were further analyzed by use of an IBM-486 personal computer using the software programs of the IDVVersuchsplanung und Datenanalyse (Gauting, Munich, Germany ) . On each observation, median, standard deviation, standard error, range, upper and lower quartile, and total mean values were calculated. Univariate analyses were performed using the Wilcoxon-Mann-Whitney U-test for continuous variables and by using a Chi-square test on a 2 x 2 table for binary variables (Fisher exact). The P values 0002-961 O/96/$1 5.00 PII SOOO2-961 0(96)00187-O
353
LAPAROSCOPY TABLE
IN CHRONIC
ABDOMINAL
PAIN/MILLER
ET
AL
I Patient
Characteristics
of the
Main
Laparoscopic Appendectomy
Data represent
mean value (standard
are those computed significant variables (two tailed).
TABLE II Laparoscopic
for each comparison and statistically taken as predictors at the 0.05 level
Findings
Appendectomies In 28 patients with chronic abdominal pain laparoscopic appendectomy was performed. Ten patients had various pathological combinations. In 7 of them combined adhesiolysis was performed, in 2 resection of hydatides, and in 1 the resection of Meckel’s diverticulum. The characteristics of these patients are listed in Table I. Histologically confirmed chronic appendicitis was found in 17 patients. Chronic inflammation was diagnosed when lymphocytes and eosinophils were present within the appendiceal wall with associated fibrosis. A pathologic diag nosis of acute inflammation of the appendix was described in 6 cases, and 1 case showed appendiceal neuroma. Four specimens were histologically without pathological findings. In 4 of 6 patients with macroscopically bland appenJOURNAL
All Patients
2/l 24.7 14 2.7
17142 29.3 (12.5) 68.3 (172.1) 3.5 (1.5)
0 (1.5) (4.8) (0.5)
OF
SURGERY@
VOLUME
172
Findings and Treatments on 5g Patients Recurrent and Chronic Abdominal Pain
at Laparoscopy
Adhesions Chronic and acute appendicitis lnguinal hernia Meckel’s divetticulum Endometriosis Ovarian cyst Adnexitis Hydatides No pathology found
n 26 24 2 2 3 1 1 4 2 4
with
Laparoscopic Treatment Adhesiolysis Appendectomy Hernial repair Transresection Endocoagulation Cyst resection Exploration Resection Exploration only Appendectomy
dix, the appendix was removed, as discussed with the patient prior to the operation. The pain assessment and disability score numbers were statistically high at Times B and C in relation to Time A (Table III).
Adhesiolyses Adhesions were found in 26 patients and were able to be related to the location of pain. In 7 cases the appendix was in direct relation to the adhesions and the appendix was removed. Adhesiolysis on its own was performed on 19 patients and the characteristics of these patients are listed in Table I. The pain assessment and disability score were significantly different statistically in respect to postoperative treatment (Time B) and at the time of the follow-up (Time C) in relation to the preoperative score number (Time A) (Table III).
AMERICAN
Miscellaneous
deviation).
RESULTS
THE
Solely
?/I2 36.9 (12.6) 103.5 (119.8) 3.8 (1.7)
Patient Characteristics From September 1990 to May 1994, 59 patients were involved the study. There were 42 women and 17 men with a mean age of 29.3 -C 12.5 years (range, 15-71 years). The mean history of persistent abdominal pain was 68.3 2 172.1 weeks (range, 11 weeks to 20 years). The patient characteristics of main laparoscopic treatments are summarized in Table I. Fifty-six patients (94.9%) were monitored by way of direct contact at a mean follow-up period of 75.3 -+ 15.3 weeks (range, 55-95 weeks). Laparoscopy provided diagnosis for 53 of the 59 patients (89.8%) (Table II). The main laparoscopic procedures were appendectomies, adhesiolyses, and gynecological treatments. Of the 66 attempted laparoscopic procedures, all were completed successfully, no patient had to undergo laparotomy, and no postoperative complication occurred.
354
Procedures
Treatment
Adhesiolysis
a/20 28.1 (12.7) 70.8 (150.2) 3.5 (1.4)
Sex (male/female) Age (yrs) History of pain (wks) Hospital stay (days)
Laparoscopic
-
Miscellaneous Conditions In 2 female patients, an unknown inguinal hernia was found to be responsible for recurrent pain. In 1 female and 1 male patient a Meckel’s diverticulum was detected. The diverticula were successfully treated using laparoscopic techniques.‘* In one of them the appendix showing signs of inflammation was also removed. Endocoagulation of foci of endometriosis was performed on 3 patients. In 1 patient an ovarian cyst was seen and resected. In 2 patients masses of hydatides as pathological findings only were detected and were resected. Six out of 59 patients revealed no pathologic findings. In 4 of them, the appendix was removed, and in 2 of them the procedure was completed as exploratory laparoscopy, as discussed with the patient prior to surgery. In the group with miscellaneous conditions the pain assessment and disability score number was statistically high at Times B and C compared with Time A (Table III). The visual analogue pain scale of all patients is visualized in a boxplot-presentation (Figure). The visual analogue pain scale factor was statistically high at Times B and C compared with Time A. Five out of 59 patients (8.5%) revealed no improvement of pain postoperatively, and 6 out of 56 (10.7%) patients still suffer from pain and would not recommend the procedure at a follow-up (1 appendectomy with no histopathological finding, 3 cases with only adhesiolysis, and 2 with negative finding at laparoscopy). OCTOBER
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III Anamnestic
Questionnaire McGill
Laparoscopic Treatment Appendectomy Adhesiolysis Miscellaneous All patients
Patients (n) .. 28 19 12 59
solely conditions
Time 17.7 17.1 11.5 16.7
and
Clinical
Examination
Pain Questionaire: Mean Value (SD)
A
Time
(8.5) (7.7) (11 .O) (8.2)
8.6 7.9 2.7 7.4
B
(7.9) (7.6) (1.5)* (7.3)
Disabilitv Score: Mean Value (SD) Time 4.3 6.0 1 .o 4.0
C
(8.6)f (6.1) (0.5)* (7.3)+
Data are preoperative rime A/, then on the day of discharge rime Bj and at the follow-up rime C) obtained performed using the Wkoxon-Mann-Whitney U-test for continues variabies Time A vs Time B vs Time C. *P
p~0.0001 5
mm
45
t p=o.o015
I
I
x
T
4
m
95 3 i-
I,5T-
z5 2
x
1 i
45 0 It
45 -
Time A
m
Time B
Figure. Box plot presentation of the visual analogue pain scale of all patients. Examination preoperatively (Time A), then on the day of discharge (Time B), and at the follow-up (Time C) obtained from visits to the clinic. Statistical analyses were performed using the Wilcoxon-Mann-Whitney U-test for continuous variables Time A vs Time B vs Time C. m = median.
DISCUSSION Recurrent abdominal pain is a common problem, dealt with by a variety of medical specialists. Even after an extensive workup in some patients, no pathologic condition is found by noninvasive investigations, and the pain is often attributed to one of a number of vague and even unsubstantiated diagnoses. The role of diagnostic laparoscopy in chronic and recurrent abdominal pain remains to some controversial. Wood and Cuschieri13 reported a prospective series of patients with undiagnosed abdominal pain. A significant pathologic etiology was found in 30% of this group by laparoscopy. Nagy and James3 demonstrated their assessment of chronic abdominal pain in 11 patients. They yielded a diagnostic accuracy in 9 (82%) and laparotomy was avoided in 7 (64%). They concluded that in the evaluation of chronic abdominal pain, laparoscopy was insufficient. A survey of published reports showed laparoscopically diagnosable abnormalities in 61% of patients complaining of chronic abdominal pain, compared with abnormalities in 28% of women without chronic pelvic pain.14 Overall, the data showed that less than 50% of women with chronic pelvic pain were helped by diagnostic and operative laparoscopy. THE
AMERICAN
Time 3.7 3.5 4.7 3.8
A
Time
(0.8) (0.8) (0.5) (0.8)
from v&s
2.1 2.4 2.0 2.2
B
(0.7)* (0.5) (0.6)’ (0.6)*
to the clmic. Sfaksticai
Time
C
1.3 1.9 1.2 1.4
(0.8)+ (0.9) (0.5)* (0.8)+
anaiyses
were
Schrenk et al” reported on 31 patients suffering undiagnosed chronic abdominal pain. Five out of 31 ( 16%) revealed no pathologic findings during laparoscopy. However, following surgery they found 29 patients (93.5%) free of pain during follow-up examination. These results compare favorably with our series of results, giving a diagnostic accuracy of 89.8% and an improvement in pain suffered of 90% during the time of the follow-up examination. Laparoscopy is the method to choose for diagnosis of acute and chronic right pelvic pain in young women.‘j-li In these patients, laparoscopy may distinguish between gynecologic disorders and appendicitis. Doubt remains whether the appendix should be removed in the case of inconclusive findings. There is no difference in laparoscopic and conventional appendectomy as regards safety and complications. 15~‘s~1yFrangenheim observed in laparoscopy that the macroscopic findings do not correlate well with the histopathology.*@ Of these patients, 64.4% had already been living with their symptoms for more than 6 months. The appendectomies are justified in the final analysis by the postoperative freedom from symptoms and by the pathological findings of chronic recurrent or fibrosing inflammation. Recurrent and chronic appendicitis do exist as disease of the appendix.” However, after an appropriate work-up study, one may consider chronic inflammation of the appendix as one cause of symptoms, and surgical exploration should be considered too. Investigation of the appendix should be included in the workup of recurrent or chronic abdominal pain when no other diagnosis is readily apparent.‘2 In our study the appendix was removed when the patient had a history of recurrent pain in the right iliac fossa, even when there was no pathology found laparoscopically. In 2 patients with macroscopically bland appendix, the appendix was not removed, in line with that discussed with the patient prior to operation. The two patients undergoing just diagnostic laparoscopy, in whom we left the appendix in place, still suffered from pain at the time of the follow-up. It seems unlikely to be able to interpret the advantages of diagnostic laparoscopy as “placebo effect.” In a number of cases, adhesions of the appendix or the cecum also indicated chronic inflammation. The number of multiple operations shows the most diverse combinations of pathology that can be found during laparoscopy. It is not possible to distinguish with certainty, which of these findings are of crucial significance for the symptoms of the paJOURNAL
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tients.” In our series, 10 out of 28 (35.7%) patients having an appendectomy had various pathological combinations. Schreiber reported on 57.1% multiple operations involvmg various combinations in laparoscopic appendectomy.‘” Adhesions are considered to be responsible for chronic abdominal pain and may becaused by scars of the abdominal wall. When adhesions are suspected, sonography of the abdominal wall is a useful investigation.24 For insertion of the laparoscope in the scarred abdomen we adapt the conventional laparoscopic approach, the peritoneum perforation under vision, and the open laparoscopic approach, all of which are reported in detail elsewhere.12 The role of adhesiolysis in chronic and recurrent abdominal pain remains for some controversial. Peters et all5 reported upon a prospective randomized trial comparing open adhesiolysis involving no surgery in a definitive analysis of results after 9-12 months. After 9-12 months there were no overall significant differences between the two groups overall with regard to pelvic pain. They concluded that adhesiolysis for the treatment of pelvic pain is not indicated in women having light or moderate degrees of pelvic adhesions. Ikard26 advocated in an editorial that there is no current indication to favor laparoscopic adhesiolysis in treating abdominal pain. Bastug et alL7 reported a successfully treated small bowel obstruction a secondary aspect to an adhesive band by means of laparoscopic adhesiolysis. Leidig and Krakamp” could find 70% improvement in their patients with laparoscopic adhesiolysis. Schrenk et al” successfully treated 10 out of 12 patients with dense adhesions. In our series 3 out of 19 (15.7%) patients involving just adhesiolysis still suffered from pain at the time of the follow-up. After a mean period of 18 months there was a significant overall improvement with regard to pelvic pain (Table III). We showed that in appropriate patient selection, laparoscopy is a useful method in treating abdominal adhesions, in the presence of chronic abdominal pain. In our opinion this is mainly achieved by optimal visualization of the whole abdomen and pelvis by the method of minimal invasive surgery. This method is generally accepted as being less traumatic than open surgery, so that less adhesion formation is very likely. Laparoscopy will not supplant accurate preoperative physical examination and noninvasive diagnostic tests. On the contrary, the more information the surgeon gets through noninvasive diagnostic techniques, the more can be expected from laparoscopy. We believe that laparoscopy is a very useful therapeutic tool in the armamentarium of modern general surgery and should not be confined to diagnostic evaluation only. Nevertheless, patient selection and appropriate operative techniques are essential for a rewarding outcome.
REFERENCES 1. Kelling G. Verhandlung Deutscher Naturforscher und Aeate. Leipzig: Vogel, 1902. 2. Jacobeus HC. Kurze tibersicht iiber meine erfahrungen mit der laparoskopie. Munch Med Wochenschr. 1911;58:2017. 3. Nagy AG, James D. Diagnostic laparoscopy. Am .J Surg. 1989;157:490-493. 4. Easter DW, Cushieri A, Nathanson LK, Lavelle-Jones M. The utility of diagnostic laparoscopy for abdominal disorders. Arch Surg. 1992;127:379-383. 5. Sackier J. Diagnostic laparoscopy in nonmalignant disease. Surg CIin North Am. 1992;72:1033-1043. 356
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6. Berci G. Elective and emrgant laparoscopy. World 1 Surg. 1993;17:8-15. 7. Cushieri A. The spectrum of laparoscopic surgery. Worki ] Surg. 1992;16:1089-1097. 8. Schrenk I’, Woisetschkiger R, Wayand U, et al. Diagnostic laparoscopy: a survey of 92 patients. Am J Surg. 1994; 168:348-35 1. 9. Melzack R. The short-form McGill pain questionaire. Pain. 1987;30:191-197. 10. Jensen MP, Karoly I’, Braver S. The measurement of clinical pain intensity: comparison of six methods. Pain. 1986;27:117126. 11. Miller K, Halbling N, Hutter J, et al. Laparoscopic cholecystectomy for patients who have had previous abdominal surgery. Surg Endosc. 1993;7:400-403. 12. Miller K, Hutter J. Videolapan>scopic treatment of Meckel’s diverticulum. Endoscopy. 1993;5:373. 13. Wood RAB, Cuschieri A. Lapxoscopy for chronic abdominal pain. Br J Surg. 1997;60:900-902. 14. Howard FM. The role of laparoscopy In chronic pelvic pain: promise and pitfalls. Obstet Gynecol Sure. 1993;6:357387. 15. Clarke PJ, Hands LJ, Gough MH, Kettlewell MGW. The use of laparoscopy in the management of right iliac fossa pain. Ann R Cod Surg Engl. 1986;68:68-69. 16. Schreiber JH. Early experience with laparoscopic appendectomy in women. Surg E&SC. 1987;1:211-216. 17. Spirtos NM, Eisenkop SM, Spirtos TW, et al. Laparoscopy: a diagnostic aid in case of suspected appendicitis. Am J Obstrt Gynecol. 1987;156:90-94. 18. Hebebrand D, Troidl H, Spangenherger W, et al. Laparoscopische oder klassische appendektnmie! Eine prospektlv randomisierte studie. Chirurg. 1994;65:112-120. 19. Vallina VL, Velasco JM, McCulloch CS. Laparoscopic versus conventional appendectomy. Ann Surg. 1993;5:685-692. 20. Frangenheim H. Diagnostische und Operative Laparoskopie in der Gynikologie. Marseile: Miinchen, 96-194. 21. Crabbe MM, Norwood SH, Robertson HD, Silva JS. Recurrent and chronic appendicitis. Surg Gynecol Obstet. 1986;163:11-13. 22. Seidman JD, Andersen DK, Ulrlch S, et al. Recurrent abdominal pain due to chronic appendiceal disease. South Med J. 1991;84:913-916. 23. Uebermuth H. Abdominalchirurgle in der schwangerschaft. In: Klinik der Frauenheilkunde und Geburtshilfe, Vol 2. Munich, Vienna: Urban & Schwarzenberg, 1994:289-293. 24. Martin G, Bergama S, Miola E, et al. Prelaparoscopic echography used to detect abdominal adhesions. Endoscopy. 1987;19:147149. 25. Peters AA, Trimbos-Kemper GC, Admiraal C, et al. A randomized clinical trial on the benefit of adhesiolysis in patients with intraperitoneal adhesions and chronic pelvic pain. Br J Obstet Gynaecol. 1992;99:59-62. 26. Ikard RW. There is no current indicanon for laparoscopic adhesiolysis to treat abdominal pain. South Med J. 1992;85:939940. 27. Bastug DF, Trammel SW, Boland JP, et al. Laparoscopic adhesiolysis for small bowel obstructton. Surg Laparosc E&SC. 1991;4:259-262. 28. Leidig I’, Krakamp B. Laparoskoplsche adhssiolyse: einfache methode zur diagnose und therapie verwachsungsbedingter abdominalschmerzen. Leber Magen Dartn. 1992;22:27-28.
EDITORIAL
COMMENT
The benefits of laparoscopy in patients with chronic abdominal pain have never been clear. Many studies, like this one, attempt to draw conclusions about the benefits (or lack of benefit) of intervening with a very heterogeneous group of patients with a wide range of final diagnoses. This study OCTOBER
1996
--. ..~ 1 LAPAROSCOPY L
makes the very optimistic statement that 90% of these patients benefitted from laparoscopy. Interestingly, it appears that the quality of pain relief was identical, no matter what the final diagnosis was. Those with chronic appendicitis or adhesions did equally well at short and long term (median, 75 months) follow-up. Most previous studies heralding the benefits of laparoscopy have not shown such clear benefits when patients are followed for more than a year. In fact, the one prospective randomized trial cited in the excellent discussion section could demonstrate no difference between those that had laparotomy and enterolysis and those that had no treatment. An ideal study of this difficult topic would require a large number of patients with a single di-
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agnosis, say chronic adhesions. This population would be randomized to laparoscopy and adhesiolysis, management in a pain clinic, and management by interrusts or gastroenterologists. The median follow-up should be at least 3 years. As surgeons, we have been strong believers that “if you operate for pain, pain is what you get.” Nonetheless, we cannot refuse to consider the tindings of studies like this demonstrating a ray of hope for these long suffering patients. John G. Hunter, MD Department of Surgery Emory University Atlanta, GA
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