|
Wu Ji,
Ling-Tang Li, Zhi-Ming Wang, Zhu-Fu Quan, Jie-Shou Li, Research
Institute of General Surgery, Nanjing General Hospital of Nanjing
PLA Command Area, Nanjing 210002, Jiangsu Province, China
Xun-Ru Chen, Department of Hepatobiliary Surgery, Kunming
General Hospital of Chengdu PLA Command Area, Kunming 650032, Yunnan
Province, China
Correspondence to: Professor Jie-Shou Li, Research Institute
of General Surgery, Nanjing General Hospital of Nanjing PLA Command
Area, 305 Eastern Zhongshan Road,
Nanjing 210002, Jiangsu Province, China.
lijiesou@public1.ptt.js.cn
Telephone: +86-25-80860065
Fax: +86-25-4803956
Received: 2003-03-05
Accepted: 2004-05-13
Abstract
Aim: To evaluate
the characters, risks and benefits of laparoscopic cholecystectomy
(LC) in cirrhotic portal hypertension (CPH) patients.
Methods: Altogether 80 patients with symptomatic
gallbladder disease and CPH, including 41 Child class A, 32 Child
class B and 7 Child class C, were randomly divided into open
cholecystectomy (OC) group (38 patients) and LC group (42 patients).
The cohorts were well-matched for number, age, sex, Child
classification and types of disease. Data of the two groups were
collected and analyzed.
Results: In LC
group, LC was successfully performed in 36 cases, and 2 patients
were converted to OC for difficulty in managing bleeding under
laparoscope and dense adhesion of Calot’s triangle. The rate of
conversion was 5.3%. The surgical duration was 62.6±15.2 min. The
operative blood loss was 75.5±15.5 mL. The time to resume diet was
18.3±6.5 h. Seven postoperative complications occurred in five
patients (13.2%). All patients were dismissed after an
average of 4.6±2.4 d. In OC group, the operation time was 60.5±17.5
min. The operative blood loss was 112.5±23.5 mL. The time to resume
diet was 44.2±10.5 h. Fifteen postoperative complications occurred
in 12 patients (30.0%). All patients were dismissed after an average
of 7.5±3.5 d. There was no significant difference in operation time
between OC and LC group. But LC offered several advantages over OC,
including fewer blood loss and lower postoperative complication
rate, shorter time to resume diet and shorter length of
hospitalization in patients with CPH.
Conclusion: Though
LC for patients with CPH is difficult, it is feasible, relatively
safe, and superior to OC. It is important to know the technical
characters of the operation, and pay more attention to the
meticulous perioperative managements.
© 2005 The WJG Press and Elsevier Inc. All rights reserved.
Key words: LC; CPH; OC
Ji W, Li LT, Wang ZM, Quan ZF, Chen XR, Li JS. A randomized
controlled trial of laparoscopic versus open cholecystectomy in
patients with cirrhotic portal hypertension. World J
Gastroenterol 2005;
11(16): 2513-2517
http://www.wjgnet.com/1007-9327/11/2513.asp
INTRODUCTION
The advantages of laparoscopic cholecystectomy (LC) have been
extensively published, and LC has become the “golden standard”
in treating benign gallbladder diseases[1-4].
When LC began in the early 1990s, cirrhosis and pregnancy, previous
abdominal surgery, obesity, acute cholecystitis were considered
absolute contraindications for performance of the laparoscopic
technique. Growing experience has allowed the use of LC in more
complex procedures, such as in cirrhotic patients[5,6].
In recent years, several studies have reported good results and
suggested liberal use of LC in patients with symptomatic gallbladder
disease and cirrhosis[7-10].
However, its feasibility, benefits and successful use in patients
with cirrhotic portal hypertension (CPH) are meagerly
well-documented. Based on our previous studies on the influence of
LC on the hepatic function and our experience with LC for cirrhotic
patients, we have successively performed LC in patients with CPH.
The present study is a retrospective analysis comparing the results
of OC and LC in patients with symptomatic gallbladder disease and
CPH.
MATERIALS AND METHODS
Eligibility of patients
Altogether 80 patients, including 65 male and 15 female,
aged 52.3±12.2 years, were all diagnosed as symptomatic gallbladder
disease and CPH. The diagnosis was mainly according to the disease
history and ultrasound, spiral CT and esophageal barium swallow
examination results, combined with laparoscopic examination results
of the typical modular lesions in liver lobes. Clinical signs
included megaspleen (62 cases), widened portal vein (diameter over
14 mm) (52 cases), ascites (27 cases), varices of esophagus and
gastric fundus veins (31 cases). Seventy-one patients were hepatic
cirrhosis (hepatitis B in 58 and hepatitis C in 13). Nine other
patients had alcoholic cirrhosis. The Child-Pugh classification
system was used to assess the severity of CPH. On preoperative
assessment, 41 patients were classified as Child class A, 32 were
Child class B and 7 were Child class C. Significant comorbidity was
present in 25 (31.3%) patients, including cardiac disease (12
cases), respiratory compromise (10 cases), diabetes mellitus (6
cases), and renal impairment (3 cases). Nine (11.3%) patients had
disease in more than two organ systems. No previous upper abdominal
operation had been conducted in these patients. Randomization was
done before operation by use of sealed envelopes. Patients were
randomly divided into OC group (42 cases) and LC group (38 cases).
The patients’ characteristics of the two groups are listed in
Table 1. These two groups were well-matched for number, age, sex,
Child classification and types of disease. The study was approved by
the local hospital ethics committee. Written informed consent to
participate in the study was obtained from all patients.
Table 1 Comparison
of patients’ characteristics between two groups
| |
LC
group (n = 38) |
OC
group (n = 42) |
P |
| Age
(yr) |
50.2±11.6 |
53.8±14.2 |
0.606 |
| Sex |
|
|
0.943 |
| Male |
31 |
34 |
|
| Female |
7 |
8 |
|
| Child
classification |
|
|
0.432 |
| A |
19 |
22 |
|
| B |
15 |
17 |
|
| C |
4 |
3 |
|
| Type
of disease |
|
|
0.761 |
| Gallbladder
polypus |
3 |
2 |
|
| Gallbladder
stones |
35 |
40 |
|
Methods
Patients underwent standard preoperative workup, including
conventional blood tests, chest radiograph, electrocardiogram,
ultrasonography, spiral CT scan, and/or esophageal barium swallow
examination. No special preparation before operation was needed for
Child class A cases. Hepatic function protection and supporting,
ascites controlling and portal vein pressure reduction were
considered individually for most Child class B and C cases. If the
patient had class C cirrhosis, attempts were made to improve the
patient’s hepatic function to near class B level. Only after that,
surgical operations arranged were allowed for a safer
elective operation.
The patients were put in the supine position
under general anesthesia with intratracheal intubation. A standard
four ports laparoscopic procedure was performed for all LC cases by
using two 5-mm and 10-mm ports after pneumoperitoneum was
established using a Veress needle. The intraabdominal CO2
pressure was controlled at about 1.33 kPa. The OC was completed with
a 10-14 cm subxiphoid incision. A silicon drain was placed in the
operation field for all patients, which was usually pulled out in
24-72 h after operation.
The patients inhaled oxygen after returning to
the ICU ward. Changes of vital signs were monitored for 24-48 h.
Fluid infusion, anti-inflammation, hemorrhage prevention, liver
function protection and analgesics treatments were prescribed. Data
on these two groups were collected and analyzed.
Statistical method
SPSS10.0 statistics software was used to establish the
database. Statistical comparisons between OC and LC groups were made
with Student’s t test for categorical variables.
Statistical significance was defined as P<0.05.
RESULTS
In LC group, LC was successfully performed in 36 of 38 cases,
including three laparoscopic subtotal cholecystectomies. Two
conversions to OC were necessary. One was due to difficulty in
managing bleeding in the gallbladder bed under laparoscope and
another for dense adhesion of Calot’s triangle. The rate of
conversion was 5.3%. The mean operative time was 62.6±15.2 min. The
operative blood loss was 75.5±15.5 mL. The mean time to resume diet
was 18.3±6.5 h. Seven postoperative complications occurred in five
patients (13.2%). They were tracker infection (one case),
respiratory system infection (one case), urinary system infection
(one case), upper gastrointestinal bleeding (one case), mild hepatic
encephalopathy (one case) and ascites aggravation (two cases). All
patients were cured and dismissed after 4.6±2.4 d.
While in OC group, the mean operative time was 60.5±17.5 min. The
operative blood loss was 112.5±23.5 mL. The mean time to resume
diet was 44.2±10.5 h. Fifteen postoperative complications occurred
in 12 patients (30.0%). They were wound infection (two cases),
respiratory system infection (four cases), urinary system infection
(two cases), mild hepatic encephalopathy (two cases) and ascites
worsening (five cases). All patients were cured and dismissed after
7.5±3.5 d.
Comparison of perioperative parameters of two groups is listed in
Table 2. There was no significant difference in operative time
between the two groups. But LC offered several advantages over OC,
including fewer blood loss and lower postoperative complication
rate, shorter time to resume diet and shorter hospital stay in
patients with CPH.
Table 2 Comparison
of perioperative parameters of two groups
| Group |
Operative
time (min) |
Blood
loss (mL) |
Time
to resume diet
(h) |
Postoperative
complication rate
(%) |
Length
of hospitalization after
operation (d) |
| LC
group (n = 38) |
62.6±15.2 |
75.5±17.5 |
18.3±6.5 |
13.2 |
4.6±2.4 |
| OC
group (n = 40) |
60.5±17.5 |
112.5±23.5b |
44.2±10.5b |
30.0b |
7.5±3.5a |
aP<0.05,
bP<0.01
vs LC.
DISCUSSION
In a review of 4 895 postmortem records, Bouchier[11]
found that the frequency of gallbladder stone in patients with
cirrhosis was 29.4%, more than twice the noncirrhotic frequency.
Factors implicated in the higher incidence of gallbladder disease in
these patients include: hypersplenism, increased levels of estrogen,
and increased intravascular hemolysis with a reduction in
gallbladder emptying and motility. Though there is no definite data
on the frequency of gallbladder diseases in patients with CPH, it is
estimated that the frequency might be 2-5 times higher than the
noncirrhotic’s. Most of these patients remain asymptomatic.
Nevertheless, the management of symptomatic gallbladder diseases in
patients with CPH has remained problematic. In the early 1980s, OC
in cirrhotic patients was associated with a postoperative mortality
ranging from 7% to 26%. The increased risks led to reluctance to
undertake elective cholecystectomy in patients with cirrhosis and
symptomatic gallbladder disease. By the late 1980s, better surgical
results had been published for cirrhotic patients who underwent
elective cholecystectomy[12].
OC was subsequently considered as an acceptable therapeutic option
in cirrhotic patients with relatively normal hepatic function. Since
the introduction of LC in 1990s, the question of whether cirrhotic
patients might benefit from this less invasive approach has arisen[13,14].
It is well known that LC allows for shorter hospital stay and
operative time, faster operative rehabilitation, and reduced wound
complications for noncirrhotic patients when compared with OC.
Several recent studies have also demonstrated that LC in Child A and
B cirrhosis was safer and better tolerated than OC[15-18].
Cholecystectomy for patients with CPH is more complicated than that
for cirrhotic cases. Excessive blood loss, postoperative liver
failure, and sepsis were the most prominent problems for these
special patients[19].
There have been few reports with limited cases of OC for patients
with CPH. The results were relatively acceptable. But there has been
no such report of LC for patients with CPH.
In our previous series studies, we have observed
that laparoscopic surgery had obvious influence on the hepatic
function. We have also demonstrated in our animal experiments that
ischemia-reperfusion injury caused by pneumoperitonium played an
important role in liver impairment. Methods to diminish this injury,
for example, lowering pneumoperitonium pressure, shortening
operation time, perioperative liver function protection and
supporting were also proposed thereafter. We have carefully
performed more than 200 LCs in cirrhotic patients since 1999. Based
on the clinical and experimental experience, we tried LC in patients
with CPH since 2001. This study was designed to prospectively
compare the characters, risks and benefits of LC and OC in patients
with CPH. We found that there was no significant difference in
surgical duration between LC and OC groups. But LC offered several
advantages over OC, including less amount of intraoperative
hemorrhage and lower postoperative complication rate, reduced time
to resume diet and hospital stay after operation. The results of our
present study confirm that LC is a relatively feasible and safe
operative approach, and it is superior to OC for patients with CPH.
We speculate that LC can offer the following advantages for patients
with CPH: (1) LC is a minimally invasive operation, which has little
influence on patients, and ensures a quicker recovery. So it can
improve the patient’s tolerability for cholecystectomy, and thus
extend the indication for cholecystectomy for patients with CPH[20,21].
(2) Ascitic infection which occurs frequently after OC, can result
in intra-abdominal sepsis and death. Access to the sterile
peritoneal cavity by millimetric (5 and 10 mm) channels may have an
important role in the prevention of inadvertent bacterial seeding
and contamination of the ascites. (3) Laparoscopy has the ability of
magnification, which is helpful to make observation of minute organ
structures more clearly. It is also beneficial to the observation of
dilated and twisted portal vein branches in the operation field and
congested gallbladder bed, thus can effectively avoid meaningless
injury of blood vessel and the following bleeding. (4) LC is
reported to have fewer postoperative complications, such as wound
infection, incisional hernia and respiratory, urinary system
infection. Reduction of these common complications is especially
important for patients with CPH[22].
(5) Many patients with CPH also had various hepatitis virus
infection. During laparoscopic surgical operation, the surgeon did
not directly touch the patient’s blood and viscera, so that the
possibility of iatrogenic infections could be reduced. (6) Some
patients with CPH may accept liver transplantation in the future.
LC, without opening abdominal cavity, offers the potential for fewer
right upper quadrant adhesions postoperatively. This will benefit
liver transplantation.
LC still has shortages and our management
measures to overcome them for patients with CPH included: (1) During
LC, CO2
pneumoperitonium can cause ischemia-reperfusion injury to the
internal organs, such as liver and kidney. This may aggravate the
damage of the hepatic function. Since this injury was positively
correlated with the pressure of pneumoperitonium[23-25],
we routinely establish the pneumoperitonium with a lower flow of CO2,
maintain the intra-abdominal pressure at about 1.33 kPa, and
gradually relieve the pneumoperitonium after LC. We think these can
reduce further damage to hepatic function. It has been reported that
gasless pneumoperitonium can avoid ischemia-reperfusion injury to
the internal organs. But we have no such experience. It may be worth
trying. (2) It may not be as direct and convenient for LC in
managing bleeding under laparoscope, especially when extensive
bleeding and permeating bleeding occurred. We think it is critical
for operators to proficiently master laparoscopic techniques as
compression, electronic coagulation, and transfix. On the other
hand, complete preparation of various laparoscopic apparatus is
suggested. (3) Sometimes CPH can lead to atrophy-hypertrophy and
displacement of liver lobes. This may cause inconvenient exposure of
operative field under laparoscope. Adjustment of the tracker
location is usually needed in this situation.
The results of this series indicated that LC for
patients with CPH in the management of symptomatic gallbladder
diseases is feasible and relatively safe. Nevertheless, the
procedure is still complicated and highly difficult which associates
with significant morbidity compared with that of patients without
cirrhosis[26].
LC for patients with CPH should be performed by experienced
laparoscopic surgeons. We think that more attention should be paid
to the following aspects: (1) Functions of important organs, such as
liver, kidney, heart, lung, should be carefully checked before the
operation to make clear patients’ general status. Individual
preoperative preparation should be conducted mainly based on
patients’ Child classification. Generally, no special preparation
was needed for Child class A cases. Special individual measures
should be taken to improve the patient’s liver function for class
B and C cases. For the patients with class C cirrhosis, attempts
should be made to improve the patients’ hepatic function to near
class B, then surgical operation was arranged. Attempts which we
have made included hepatic function protection, control of ascites,
nutritional support, coagulation function amelioration and portal
vein pressure reduction to allow for a safer elective operation.
Correction of coagulopathy with platelets or fresh frozen plasma
before surgery is advised, and availability of these products
intraoperatively is essential. (2) Bleeding complications are
significantly more common in patients with CPH. Several technical
modifications should be made[27].
At the commencement of the laparoscopic procedure, special care
should be taken during trocar insertion to avoid injury to dilated
abdominal wall veins. The subxiphoid 5-mm port was placed more to
the right of the midline to completely avoid the falciform ligament
and its accompanying umbilical vein. Portal hypertension with large
venous collaterals in the liver hilum provides a major challenge in
the surgical management of the biliary tract[28].
This pathology is a major source of intraoperative and postoperative
complications. We believe that meticulous care be taken to maintain
hemostasis. Extreme caution with constant control of hemostasis was
the hallmark of the procedure. Blunt dissection was avoided to
minimize bleeding once the cystic duct was identified and divided
and all tissues were clipped/ligated and cut. A variety of
techniques other than unipolar electrocautery, including argon beam
coagulation, ultrasonic dissection, and thrombin spray are available
for use[29,30].
In a few cases, involving large collateral veins around the
gallbladder, when severe bleeding is likely from large varices,
subtotal cholecystectomy could be performed to prevent massive blood
loss from the gallbladder bed[31,32].
This technique avoids dissection in the hepatic hilum. In our
patient population, this maneuver was necessary in three patients.
Surgeons should be aware of this procedure to lessen the risk of
excessive blood loss during LC. All access ports were checked
internally for bleeding just before completion of the procedure.
Drainage of the operative field was performed routinely for all
patients in this study, which was pulled out in 24-48 h after
operation. This is helpful for postoperative observation and
management. (3) In recent reports, conversion rates during LC ranged
from 0% to 9%[33].
In this study, the rate of conversion to OC was 5.3%, which was
similar to published data for LC conversion in a noncirrhotic
patient population. A low threshold for conversion from LC to OC
should be maintained. Conversion is not a complication, but a means
to prevent more serious problems. Absolute indications for
conversion include bleeding not readily controlled laparoscopically
and an inability to recognize the anatomy properly[34,35].
The surgeon should not be reluctant to convert immediately to OC
when there is uncertainty about the safety and efficiency of the
operative procedure.
Our study has demonstrated the feasibility and
advantages of LC in well-compensated patients with CPH. In the hands
of an experienced surgical team, LC should be the procedure of
choice in the treatment of gallbladder disease in these patients. We
believe that along with further understanding of LC technique
characteristics in patients with CPH, continuous improvements in the
perioperative management, the expansive application of new surgical
operation apparatus (such as ultrasound knife), as well as
improvement of operator’s technical skills, more and more patients
with CPH will benefit from LC in the near future.
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