Symptomatic outcome 1 year after laparoscopic and minilaparotomy cholecystectomy: a randomized trial

The Symptomatic Outcomes of Cholecystectomy for Gallstones

Cholecystectomy is the definite treatment for symptomatic gallstones, and rates are rapidly rising. Symptomatic complicated gallstones are generally treated with cholecystectomy, but there is no consensus on the clinical selection of patients with symptomatic uncomplicated gallstones for cholecystectomy. The aim of this review is to describe symptomatic outcomes before versus after cholecystectomy in patients with symptomatic gallstones as reported in prospective clinical studies and to discuss patient selection for cholecystectomy. Following cholecystectomy, resolution of biliary pain is high and reported for 66-100%. Dyspepsia has an intermediate resolution of 41-91% and may co-exist with biliary pain but may also develop following cholecystectomy with an increase of 150%. Diarrhea has a high increase and debuts in 14-17%. Persisting symptoms are mainly determined by preoperative dyspepsia, functional disorders, atypical pain locations, longer duration of symptoms, and poor psychological or physical health. Patient satisfaction following cholecystectomy is high and may reflect symptom alleviation or a change in symptoms. Comparison of symptomatic outcomes in available prospective clinical studies is limited by variations in preoperative symptoms, clinical presentations, and clinical management of post-cholecystectomy symptoms. When selecting patients with biliary pain only in a randomized controlled trial, 30-40% still have persisting pain. Strategies for the selection of patients with symptomatic uncomplicated gallstones based on symptoms alone are exhausted. For the development of a selection strategy, future studies should explore the impact of objective determinants for symptomatic gallstones on pain relief following cholecystectomy.

Postcholecystectomy diarrhoea rate and predictive factors: a systematic review of the literature

OBJECTIVES

Cholecystectomy is one of the most common surgical procedures performed worldwide to treat gallstone-related disease. Postcholecystectomy diarrhoea (PCD) is a well-reported phenomenon, however, the actual rate, predictive factors and mechanism of action have not been well determined. A systematic review was undertaken to determine the rate and predictive factors associated with diarrhoea in the postcholecystectomy setting.

METHODS

The review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol. Databases searched included Medline, Embase, Pubmed, Cochrane and Google Scholar up to 29 September 2020. The inclusion criteria consisted of cohort studies or randomised trials which investigated the rate of PCD and predictive factors. Case reports, case series, conference abstracts and expert opinion pieces were excluded as were other systematic reviews as all the original articles from those reviews were included in this review. Papers that did not include PCD as a separate entity were excluded. Bias assessment was performed using the Newcastle-Ottawa Scale for cohort studies and the Cochrane risk of bias tool for randomised controlled trials as appropriate. Data were extracted by two authors (AF and JAA) and an overall rate of PCD was calculated. Predictive factors were also extracted and compared between studies.

RESULTS

1204 papers were obtained and 21 were found to contain relevant information about PCD, including the number of patients developing diarrhoea, method of symptom assessment and time of onset postcholecystectomy. A pooled total of 3476 patients were included across the identified studies with 462 (13.3%) patients developing PCD. Possible predictive factors varied across all studies, with characteristics such as gender, age and weight of patients postulated as being predictive of PCD, with no agreement across studies.

DISCUSSION

PCD is therefore relatively common (13.3%). This has important implications for patient consent. Patients ought to be investigated early for bile acid diarrhoea in suspected PCD. More studies are required to determine the possible predictive factors for PCD. Limitations of the study included that most studies were not powered for calculation of PCD, and assessment methods between studies varied.

PROSPERO REGISTRATION NUMBER

CRD42019140444.

Inflammatory response to surgical trauma in patients with minilaparotomy cholecystectomy versus laparoscopic cholecystectomy: a randomised multicentre study

OBJECTIVE

The aim of the study was to evaluate the inflammatory response to surgical trauma in minilaparotomy cholecystectomy (MC) compared to laparoscopic cholecystectomy (LC). Assessment of inflammatory response to surgical trauma in MC has not been addressed properly. Therefore, we investigated five interleukins (IL) and C-reactive protein (CRP) in MC versus LC group in a prospective randomised trial.

METHODS

Initially, 106 patients with non-complicated symptomatic gallstone disease were randomised into MC (n = 56) or LC (n = 50) groups. Plasma levels of five interleukins (IL-1β, IL-1ra, IL-6, IL-8, IL-10) and hs-CRP were measured at three time points; before operation (PRE), immediately after operation (POP1) and six hours after operation (POP2). The primary end-point of the study was to compare the plasma levels of five interleukins and CRP in LC versus MC group.

RESULTS

The demographic variables and the surgical data were similar in the study groups. The patients in the MC group had higher elevation of the CRP mean values post-operatively (p = 0.01). However, the patients in the MC group had higher elevation of the IL-1ra mean values post-operatively, the mean pre-/post-operative IL-1ra values being 299/614 pg/ml in the MC group versus 379/439 pg/ml in the LC group (p = 0.003). There was no statistical significance in IL-6 mean values between the MC and LC groups pre- and post-operatively (POP1). However, the patients in the MC group had higher IL-6 mean values six hours post-operatively (POP2), the mean IL-6 values being 27.6 pg/ml in the MC group versus 14.8 pg/ml in the LC group (p = 0.037). In addition, the patients in the MC group had higher elevation of the IL-6 mean values post-operatively, the mean pre-/post-operative IL-6 values being 4.1/27.6 pg/ml in the MC group versus 3.8/14.8 pg/ml in the LC group (p = 0.04). There was no statistical significance in IL-8, IL-10, and IL-1β mean values between the MC and LC groups pre- and post-operatively.

CONCLUSION

Our results suggest that the inflammatory response in MC versus LC groups was similar based on the IL-8, IL-10, and IL-1β values. A new finding with possible clinical relevance in the present work is higher relative elevation of the IL-1ra and IL-6 mean values post-operatively in the MC group.

Consistency of patient-reported outcomes after cholecystectomy and their implications on current surgical practice: a prospective multicenter cohort study

Background

Persistent postoperative pain (up to 41 %) and significant practice variation necessitate better patient selection for cholecystectomy. Patient-reported outcome measures (PROMs) are nowadays known to serve as a tool for better patient selection, although variability within these subjective outcomes may be a point for debate. This study determines associations of both the preoperative pain and patient characteristics with PROMs at 24 weeks after cholecystectomy. In order to evaluate variability of PROMs, we also determined consistency of these outcomes in time.

Methods

This prospective multicenter cohort study included adult patients diagnosed with uncomplicated symptomatic cholecystolithiasis. Twenty-four weeks after surgery, a questionnaire study was carried out, containing Gastrointestinal Quality of Life Index (GIQLI) and Patients’ Experience of Surgery Questionnaire. Results were compared to preoperative data and results 12 weeks post-cholecystectomy. Logistic regression analyses were performed to determine associations. Additional post hoc analysis on associations between preoperative selection criteria and PROMs was done.

Results

A total of 360 patients (85 %) responded. Postoperative absence of pain was reported by 59.2 %. Associated characteristics were symptoms ≤1 year prior to surgery [OR 1.85 (95 % CI 1.11–3.09)] and high baseline GIQLI score [OR 1.04 (95 % CI 1.02–1.05)]. General improvement in abdominal symptoms and positive result of surgery were found in 90 %; no preoperative variables were significantly associated. PROMs showed consistency at 12 and 24 weeks postoperatively. Post hoc analysis showed no significant associations.

Conclusion

PROM-based preoperative selection criteria need to be considered to select those patients who achieve freedom of pain after surgical treatment of uncomplicated symptomatic cholecystolithiasis. Other patients might consider cholecystectomy as successful, but are less likely to be free of pain. Usefulness of PROMs is underscored as they proved to be consistent in time in evaluating surgical outcome.

Prospective multicentre cohort study of patient-reported outcomes after cholecystectomy for uncomplicated symptomatic cholecystolithiasis

BACKGROUND

Up to 33 per cent of patients with uncomplicated symptomatic cholecystolithiasis report persistent pain after cholecystectomy. The aim of this study was to determine characteristics associated with patient-reported absence of abdominal pain after cholecystectomy, improved abdominal symptoms, and patient-reported positive cholecystectomy results in a prospective cohort multicentre study.

METHODS

Patients aged 18 years or more with symptomatic cholecystolithiasis who had a cholecystectomy between June 2012 and June 2014 in one of three hospitals were included. Before surgery all patients were sent the Gastrointestinal Quality of Life Index (GIQLI) questionnaire and the McGill Pain Questionnaire (MPQ). At 12 weeks after surgery, patients were invited to complete the GIQLI and Patients' Experience of Surgery Questionnaire (PESQ). Logistic regression analyses were performed to determine associations.

RESULTS

Questionnaires were sent to 552 patients and returned by 342 before and after surgery. Postoperative absence of abdominal pain was reported by 60·5 per cent of patients. A high preoperative GIQLI score, episodic pain, and duration of pain of 1 year or less were associated with postoperative absence of pain. These factors showed no association with improved abdominal symptoms (reported by 91·5 per cent of patients) or a positive surgery result (reported by 92·4 per cent).

CONCLUSION

Preoperative characteristics determine the odds for relief of abdominal pain after cholecystectomy. However, these factors were not associated with patient-reported improvement of abdominal symptoms or patient-reported positive cholecystectomy results, highlighting the variation of internal standards and expectations of patients before cholecystectomy.

Clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones or cholecystitis: a systematic review and economic evaluation

BACKGROUND

Approximately 10-15% of the adult population suffer from gallstone disease, cholelithiasis, with more women than men being affected. Cholecystectomy is the treatment of choice for people who present with biliary pain or acute cholecystitis and evidence of gallstones. However, some people do not experience a recurrence after an initial episode of biliary pain or cholecystitis. As most of the current research focuses on the surgical management of the disease, less attention has been dedicated to the consequences of conservative management.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management in people presenting with uncomplicated symptomatic gallstones (biliary pain) or cholecystitis.

DATA SOURCES

We searched all major electronic databases (e.g. MEDLINE, EMBASE, Science Citation Index, Bioscience Information Service, Cochrane Central Register of Controlled Trials) from 1980 to September 2012 and we contacted experts in the field.

REVIEW METHODS

Evidence was considered from randomised controlled trials (RCTs) and non-randomised comparative studies that enrolled people with symptomatic gallstone disease (pain attacks only and/or acute cholecystitis). Two reviewers independently extracted data and assessed the risk of bias of included studies. Standard meta-analysis techniques were used to combine results from included studies. A de novo Markov model was developed to assess the cost-effectiveness of the interventions.

RESULTS

Two Norwegian RCTs involving 201 participants were included. Eighty-eight per cent of people randomised to surgery and 45% of people randomised to observation underwent cholecystectomy during the 14-year follow-up period. Participants randomised to observation were significantly more likely to experience gallstone-related complications [risk ratio = 6.69; 95% confidence interval (CI) 1.57 to 28.51; p = 0.01], in particular acute cholecystitis (risk ratio = 9.55; 95% CI 1.25 to 73.27; p = 0.03), and less likely to undergo surgery (risk ratio = 0.50; 95% CI 0.34 to 0.73; p = 0.0004), experience surgery-related complications (risk ratio = 0.36; 95% CI 0.16 to 0.81; p = 0.01) or, more specifically, minor surgery-related complications (risk ratio = 0.11; 95% CI 0.02 to 0.56; p = 0.008) than those randomised to surgery. Fifty-five per cent of people randomised to observation did not require an operation during the 14-year follow-up period and 12% of people randomised to cholecystectomy did not undergo the scheduled operation. The results of the economic evaluation suggest that, on average, the surgery strategy costs £1236 more per patient than the conservative management strategy but was, on average, more effective. An increase in the number of people requiring surgery while treated conservatively corresponded to a reduction in the cost-effectiveness of the conservative strategy. There was uncertainty around some of the parameters used in the economic model.

CONCLUSIONS

The results of this assessment indicate that cholecystectomy is still the treatment of choice for many symptomatic people. However, approximately half of the people in the observation group did not require surgery or suffer complications in the long term indicating that a conservative therapeutic approach may represent a valid alternative to surgery in this group of people. Owing to the dearth of current evidence in the UK setting a large, well-designed, multicentre trial is needed.

STUDY REGISTRATION

The study was registered as PROSPERO CRD42012002817.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Increased Risk of Depressive Disorder following Cholecystectomy for Gallstones

Background

Prior studies indicate a possible association between depression and cholecystectomy, but no study has compared the risk of post-operative depressive disorders (DD) after cholecystectomy. This retrospective follow-up study aimed to examine the relationship between cholecystectomy and the risk of DD in patients with gallstones in a population-based database.

Methods

Using ambulatory care data from the Longitudinal Health Insurance Database 2000, 6755 patients who received a first-time principal diagnosis of gallstones at the emergency room (ER) were identified. Among them, 1197 underwent cholecystectomy. Each patient was then individually followed-up for two years to identify those who were later diagnosed with DD. Cox proportional hazards regressions were performed to estimate the risk of developing DD between patients with gallstone who did and those who did not undergo cholecystectomy.

Results

Of 6755 patients with gallstones, 173 (2.56%) were diagnosed with DD during the two-year follow-up. Among patients who did and those who did not undergo cholecystectomy, 3.51% and 2.36% later developed depressive disorder, respectively. After adjusting for the patient’s sex, age and geographic location, the hazard ratio (HR) of DD within two years of gallstone diagnosis was 1.43 (95% CI, 1.02–2.04) for patients who underwent cholecystectomy compared to those who did not. Females, but not males, had a higher the adjusted HR of DD (1.61; 95% CI, 1.08–2.41) for patients who underwent cholecystectomy compared to those who did not.

Conclusions

There is an association between cholecystectomy and subsequent risk of DD among females, but not in males.

Fate of dyspeptic or colonic symptoms after laparoscopic cholecystectomy

BACKGROUND/AIMS

Gallbladder diseases can give rise to dyspeptic or colonic symptoms in addition to biliary pain. Although most biliary pain shows improvement after cholecystectomy, the fates of dyspeptic or colonic symptoms still remain controversial. This study as-sessed whether nonspecific gastrointestinal symptoms improved after laparoscopic cholecystectomy (LC) and identified the char-acteristics of patients who experienced continuing or exacerbated symptoms following surgery.

METHODS

Sixty-five patients who underwent LC for uncomplicated gallbladder stones or gallbladder polyps were enrolled. The patients were surveyed on their dyspeptic or colonic symptoms before surgery and again at 3 and 6 months after surgery. Patients' mental sanity was also assessed using a psychological symptom score with the Symptom Checklist-90-Revised questionnaire.

RESULTS

Forty-four (67.7%) patients showed one or more dyspeptic or colonic symptoms before surgery. Among these, 31 (47.7%) and 36 (55.4%) patients showed improvement at 3 and 6 months after surgery, respectively. However, 18.5% of patients showed continuing or exacerbated symptoms at 6 months after surgery. These patients did not differ with respect to gallstone or gall-bladder polyps, but differed in frequency of gastritis. These patients reported lower postoperative satisfaction. Patients with ab-dominal symptoms showed higher psychological symptom scores than others. However, poor mental sanity was not related to the symptom exacerbation.

CONCLUSIONS

Elective LC improves dyspeptic or colonic symptoms. Approximately 19% of patients reported continuing or exacerbated symp-toms following LC. Detailed history-taking regarding gastritis before surgery can be helpful in predicting patients' outcome after LC.

Diagnosis and management of gallbladder calculus disease

BACKGROUND

The number and rate of cholecystectomy are increasing worldwide, although indications for operative treatment remain empirical, and several issues in the understanding of the condition are not concisely outlined. Our intention is to summarize and interpret current opinion regarding the indications and timing of cholecystectomy in calculous gallbladder disease.

METHODS

Publications concerned with gallstone disease and related topics were searched for in MEDLINE using PubMed and summarized according to clinical scenarios with an emphasis on recent research.

RESULTS

Only one randomized controlled trial has investigated the management (conservative vs. surgery) of patients with acute cholecystitis and several have compared early with deferred surgery. Two RCTs have examined treatment of uncomplicated, symptomatic gallstone disease. Apart from these, the overwhelming majority of publications are retrospective case series.

CONCLUSIONS

Recent literature confirms that cholecystectomy for an asymptomatic or incidental gallstone is not justified. Symptomatic, uncomplicated gallstone disease may be classified into four severity groups based on severity and frequency of pain attacks, which may guide indication for cholecystectomy. Most patients below the age of 70 seem to prefer operative treatment. Acute cholecystitis may be treated with early operation if reduction of hospital days is an issue. Patients older than 70 years with significant comorbidities may forego surgical treatment without undue hazard. Symptoms following cholecystectomy remain in 25% or more and recent evidence suggest these are caused by a functional gastrointestinal disorder.

Post-cholecystectomy symptoms were caused by persistence of a functional gastrointestinal disorder

AIM: To classify gallstone disease as a basis for assessment of post-cholecystectomy symptoms.

METHODS: One hundred and fifty three patients with a clinical and ultrasonographic diagnosis of gallstones filled out a structured questionnaire on abdominal pain symptoms and functional gastrointestinal disorder (FGID) before and at six months after cholecystectomy. Symptom frequency groups (SFG) were categorized according to frequency of pain attacks. According to certain pain characteristics in gallstone patients, a gallstone symptom score was accorded on a scale from one to ten. A visual analogue scale was used to quantify pain. Operative specimens were examined for size and magnitude of stone contents as well as presence of bacteria. Follow-up took place after six months with either a consultation or via a mailed questionnaire. Results were compared with those obtained pre-operatively to describe and analyze symptomatic outcome.

RESULTS: SFG groups were categorized as severe (24.2%), moderate (38.6%), and mild (22.2%) attack frequency, and a chronic pain condition (15%). Pain was cured or improved in about 90% of patients and two-thirds of patients obtained complete symptom relief. Patients with the most frequent pain episodes were less likely to obtain symptom relief. FGID was present in 88% of patients pre-operatively and in 57% post-operatively (P = 0.244). Those that became asymptomatic or improved with regard to pain also had most relief from FGID (P = 0.001). No pre-operative FGID meant almost complete cure.

CONCLUSION: Only one third of patients with FGID experienced postoperative relief, indicating that FGID was a dominant cause of post-cholecystectomy symptoms.

Trait anxiety predicts outcome 6 weeks after cholecystectomy. A prospective follow-up study

Background

A substantial group of patients with gallstone disease experience negative outcome after surgical removal of the gallbladder (cholecystectomy). Early identification of these patients is important.

Purpose

The aim of the study is to identify predictors (clinical symptoms and trait anxiety) of negative symptomatic outcomes at 6 weeks after cholecystectomy.

Methods

Consecutive patients (n = 133), 18–65 years, with symptomatic gallstone disease, completed symptom checklists and the state-trait anxiety inventory preoperatively and at 6 weeks after cholecystectomy.

Results

High trait anxiety was the only predictor of persistence of biliary symptoms at 6 weeks after cholecystectomy (OR = 6.88).

Conclusion

In addition to clinical symptoms, high trait anxiety is a predictor of negative symptomatic outcome at 6 weeks after cholecystectomy. Trait anxiety should be evaluated to aim at a patient-tailored approach in gallstone disease.

The association between cholecystectomy and gastroesophageal reflux symptoms: a prospective controlled study

OBJECTIVE

A large controlled prospective observational study to compare pre- and postsurgery changes in reflux symptoms between cholecystectomy and hernia repair surgery patients.

SUMMARY BACKGROUND DATA

Six studies have suggested that gastroesophageal reflux worsens after cholecystectomy. However, all these studies had design limitations.

METHODS

We recruited 302 patients scheduled to undergo elective cholecystectomy (study group) or hernia repair (controls) at 2 hospitals. Both groups filled out the validated Reflux Symptom Score (RSS) and Gastrointestinal Symptom Rating Scale (GSRS) questionnaires 1 to 15 days prior to and 4 to 12 weeks after the operation. Changes in symptom scores between the pre and postsurgery assessments were measured, and compared between the 2 groups.

RESULTS

Baseline RSS and GSRS reflux subscores were higher in the study group than controls (1.44 vs. 1.02 and 1.91 vs. 1.43, respectively; P < 0.05). There were no significant differences in any of the symptom score changes between the 2 groups except for the GSRS pain subscore, which decreased more in the study group than the control group (-0.59 vs. -0.10; P < 0.001). With regard to reflux, the RSS decreased by -0.34 in the study group and -0.14 in controls (P = 0.27), while the GSRS reflux subscore decreased by -0.32 in the study group and -0.05 in controls (P = 0.12). GSRS diarrhea and constipation subscores decreased slightly after surgery, to the same extent in both groups.

CONCLUSIONS

This large prospective controlled study, the only one using validated reflux symptom questionnaires, shows that cholecystectomy does not lead to an increase in reflux symptoms. As expected, GSRS pain subscores were decreased in the cholecystectomy group but not the controls.

Systematic review: open, small-incision or laparoscopic cholecystectomy for symptomatic cholecystolithiasis

BACKGROUND

Laparoscopic cholecystectomy has become the method of choice for gallbladder removal, although evidence of superiority over open and small-incision cholecystectomy is lacking.

AIM

To compare the effects of open, small-incision and laparoscopic cholecystectomy techniques for patients with symptomatic cholecystolithiasis.

METHODS

We conducted updated searches until January 2007 in multiple databases. We assessed bias risk.

RESULTS

Fifty-nine trials randomized 5556 patients. No significant differences in primary outcomes (mortality and complications) were found among all three techniques. Both minimal invasive techniques show advantages over open cholecystectomy in terms of convalescence. Small-incision cholecystectomy showed shorter operative time compared with laparoscopic cholecystectomy (random effects, weighted mean difference, 16.4 min; 95% confidence interval, 8.9-23.8), but the two techniques did not differ regarding hospital stay and conversions.

CONCLUSIONS

No significant differences in mortality and complications were found among all three techniques. Laparoscopic cholecystectomy and small-incision cholecystectomy are preferred over open cholecystectomy for quicker convalescence. Laparoscopic cholecystectomy and small-incision cholecystectomy show no clear differences on patient outcomes.

Prospective 6 weeks follow-up post-cholecystectomy: the predictive value of pre-operative symptoms

OBJECTIVE

Many patients with symptomatic cholelithiasis report persisting symptoms after elective cholecystectomy. The current prospective follow-up study aims at the identification and valuation of risk factors for negative symptomatic outcome at 6 weeks.

METHODS

Consecutive patients (n = 183), age 18-65 years, indicated for elective cholecystectomy due to symptomatic cholelithiasis, completed a self-report questionnaire. At 6 weeks post-operatively, the same self-report questionnaires were completed (n = 129). Predictors of the persistence and emergence of biliary and dyspeptic symptoms at 6 weeks post-cholecystectomy were investigated using univariate and multivariate logistic regression.

RESULTS

At 6 weeks post-operatively, the report of post-operative biliary symptoms was independently predicted by pre-operative dyspeptic symptoms (OR = 6.60) and bad taste (OR = 3.55). Pre-operative flatulence was an independent predictor of the report of biliary and dyspeptic symptoms ((OR = 3.33) and (OR = 3.27), respectively) and persisting biliary symptoms (OR = 4.21). Predictors of symptomatic outcome were only identified in women, not in men.

CONCLUSION

Patients with pre-operative dyspeptic symptoms, notably bad taste and flatulence, have an increased risk of negative post-cholecystectomy outcomes at 6 weeks. A symptom-specific approach should lead to optimalization of the indication of cholecystectomy and information of patients. Known risk factors for long-term outcomes might be valuable in female patients only.

Defined indications for elective cholecystectomy for gallstone disease

BACKGROUND

This study examined symptomatology and quality of life following elective cholecystectomy for symptomatic gallstone disease with defined indications for surgery.

METHODS

In this prospective study of 200 consecutive patients (161 women; median age 46.5 (range 24-79) years), strict indications for elective cholecystectomy were stipulated. Digestive symptoms and quality of life were recorded with a self-administered questionnaire before and at 3 and 12 months after surgery.

RESULTS

Of 149 patients who experienced abdominal pain with typical location before surgery, 136 (91.3 per cent) reported total remission or reduced frequency of that type of pain 12 months later. Of 35 patients who reported atypical or multiple pain location before operation, 27 (77 per cent) experienced reduced frequency or disappearance of that type of pain. Frequency of pain episodes, atypical or multiple pain location, specific food intolerance and frequency of disturbing abdominal gas at baseline correlated positively with the frequency of abdominal pain episodes at 12 months after surgery. There was a tendency towards an inverse relation to age.

CONCLUSION

The frequency of persistent abdominal pain after elective cholecystectomy was low among patients with typical pain location before surgery. Atypical pain location, and frequent pain episodes before operation significantly reduced the chance of becoming pain-free.

The influence of alexithymia on persistent symptoms of dyspepsia after laparoscopic cholecystectomy

OBJECTIVE

The aim of this study was to evaluate whether preoperative alexithymia might play a role in the persistence of gastrointestinal symptoms after laparoscopic cholecystectomy.

METHODS

A sample of 52 consecutive patients with gallstone disease and symptoms of dyspepsia were assessed with validated scales for alexithymia (20-item Toronto Alexithymia Scale), and psychological (90-item Symptom Checklist) and gastrointestinal (GI) (Gastrointestinal Symptom Rating Scale) symptoms before surgery. GI symptoms were evaluated also one year after surgery. Change from preoperative to postoperative GI symptoms and level of GI symptoms after surgery were used to form groups of improved (n = 31) and unimproved (n = 21) patients.

RESULTS

Unimproved patients had significantly higher preoperative alexithymia, psychological distress, and gastrointestinal symptom scores than patients who had improved. Regression analyses showed that alexithymia predicted the persistence of gastrointestinal symptoms more strongly than did psychological distress, even after controlling for preoperative gastrointestinal symptoms.

CONCLUSION

Alexithymia played a substantial and predictive role in the persistence of GI symptoms in gallstone patients after surgery. Treatment planning and outcome of gallstone disease might be improved by preoperative assessment of alexithymia.

Laparoscopic cholecystectomy versus mini-laparotomy cholecystectomy: a meta-analysis of randomised control trials

AIMS

To use meta-analytic techniques to compare peri-operative and short term post-operative outcomes for patients undergoing cholecystectomy via the laparoscopic or mini-open approach.

METHODS

Randomised control trials published between 1992 and 2005, cited in the literature of elective laparoscopic (LC) versus mini-open cholecystectomy (MoC) for symptomatic gallstone disease were included. End points evaluated were adverse events, operative and functional outcomes. A random effects meta-analytical model was used and between-study heterogeneity assessed. Subgroup analysis was performed to evaluate the difference in results for study size and quality and data reported from 2000.

RESULTS

Nine randomised studies of 2032 patients were included in the analysis. There was considerable variation in the size and type of incision used for MoC in the studies. There was a significantly longer operating time for the LC group, by 14.14 minutes (95% CI 2.08, 26.19; p < 0.0001). Length of stay was reduced in the LC group by 0.37 days (95% CI -0.53, -0.21; p < 0.0001), with no significant heterogeneity for either outcome. For all other operative and post-operative outcomes, there was no significant difference between the two groups.

CONCLUSION

MoC appeared to have similar outcomes compared to LC, however LC did reduce the length of hospital stay. MoC is a viable and safe option for healthcare providers without the financial resources for laparoscopic equipment and appropriately trained surgical teams.

Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis

BACKGROUND

Cholecystectomy is one of the most frequently performed operations. Open cholecystectomy has been the gold standard for over 100 years. Laparoscopic cholecystectomy was introduced in the 1980s.

OBJECTIVES

To compare the beneficial and harmful effects of laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis.

SEARCH STRATEGY

We searched TheCochrane Hepato-Biliary Group Controlled Trials Register (April 2004), The Cochrane Library (Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), Web of Science (1988 to January 2004), and CINAHL (1982 to January 2004) for randomised trials.

SELECTION CRITERIA

All published and unpublished randomised trials in patients with symptomatic cholecystolithiasis comparing any kind of laparoscopic cholecystectomy versus any kind of open cholecystectomy. No language limitations were applied.

DATA COLLECTION AND ANALYSIS

Two authors independently performed selection of trials and data extraction. The methodological quality of the generation of the allocation sequence, allocation concealment, blinding, and follow-up was evaluated to assess bias risk. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed when appropriate.

MAIN RESULTS

Thirty-eight trials randomised 2338 patients. Most of the trials had high bias risk. There was no significant difference regarding mortality (risk difference 0,00, 95% confidence interval (CI) -0.01 to 0.01). Meta-analysis of all trials suggests less overall complications in the laparoscopic group, but the high-quality trials show no significant difference ('allocation concealment' high-quality trials risk difference, random effects -0.01, 95% CI -0.05 to 0.02). Laparoscopic cholecystectomy patients have a shorter hospital stay (weighted mean difference (WMD), random effects -3 days, 95% CI -3.9 to -2.3) and convalescence (WMD, random effects -22.5 days, 95% CI -36.9 to -8.1) compared to open cholecystectomy.

AUTHORS' CONCLUSIONS

No significant differences were observed in mortality, complications and operative time between laparoscopic and open cholecystectomy. Laparoscopic cholecystectomy is associated with a significantly shorter hospital stay and a quicker convalescence compared with the classical open cholecystectomy. These results confirm the existing preference for the laparoscopic cholecystectomy over open cholecystectomy.

Small-incision versus open cholecystectomy for patients with symptomatic cholecystolithiasis

BACKGROUND

Cholecystectomy is one of the most frequently performed operations. Open cholecystectomy has been the gold standard for over 100 years. Small-incision cholecystectomy is a less frequently used alternative.

OBJECTIVES

To compare the beneficial and harmful effects of small-incision versus open cholecystectomy for patients with symptomatic cholecystolithiasis.

SEARCH STRATEGY

We searched TheCochrane Hepato-Biliary Group Controlled Trials Register (6 April 2004), The Cochrane Library (Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), Web of Science (1988 to January 2004), and CINAHL (1982 to January 2004) for randomised trials.

SELECTION CRITERIA

All published and unpublished randomised trials in patients with symptomatic cholecystolithiasis comparing any kind of small-incision or other kind of minimal incision cholecystectomy versus any kind of open cholecystectomy. No language limitations were applied.

DATA COLLECTION AND ANALYSIS

Two authors independently performed selection of trials and data extraction. The methodological quality of the generation of the allocation sequence, allocation concealment, blinding, and follow-up was evaluated to assess bias risk. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed if appropriate.

MAIN RESULTS

Seven trials randomised 571 patients. Bias risk was high in the included trials. No mortality was reported. The total complication proportions are respectively 9.9% and 9.3% in the small-incision and open group, which is not significantly different (risk difference all trials, random-effects 0.00, 95% confidence interval (CI) -0.06 to 0.07). There are also no significant differences considering severe complications and bile duct injuries. However, small-incision cholecystectomy has a shorter hospital stay (weighted mean difference, random-effects -2.8 days (95% CI -4.9 to -0.6)) compared to open cholecystectomy.

AUTHORS' CONCLUSIONS

Small-incision and open cholecystectomy seem to be equivalent regarding risks of complications, but the latter method is associated with a significantly longer hospital stay. The quicker recovery of small-incision cholecystectomy compared with open cholecystectomy confirms the existing preference of this technique over open cholecystectomy.

Laparoscopic versus small-incision cholecystectomy for patients with symptomatic cholecystolithiasis

BACKGROUND

Cholecystectomy is one of the most frequently performed operations. Open cholecystectomy has been the gold standard for over 100 years. Small-incision cholecystectomy is a less frequently used alternative. Laparoscopic cholecystectomy was introduced in the 1980s.

OBJECTIVES

To compare the beneficial and harmful effects of laparoscopic versus small-incision cholecystectomy for patients with symptomatic cholecystolithiasis.

SEARCH STRATEGY

We searched TheCochrane Hepato-Biliary Group Controlled Trials Register (6 April 2004), The Cochrane Library (Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), Web of Science (1988 to January 2004), and CINAHL (1982 to January 2004) for randomised trials.

SELECTION CRITERIA

All published and unpublished randomised trials in patients with symptomatic cholecystolithiasis comparing any kind of laparoscopic cholecystectomy versus small-incision or other kind of minimal incision open cholecystectomy. No language limitations were applied.

DATA COLLECTION AND ANALYSIS

Two authors independently performed selection of trials and data extraction. The methodological quality of the generation of the allocation sequence, allocation concealment, blinding, and follow-up was evaluated to assess bias risk. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed if appropriate.

MAIN RESULTS

Thirteen trials randomised 2337 patients. Methodological quality was relatively high considering the four quality criteria. Total complications of laparoscopic and small-incision cholecystectomy are high: 26.6% versus 22.9%. Total complications (risk difference, random-effects -0.01, 95% confidence interval (CI) -0.07 to 0.05), hospital stay (weighted mean difference (WMD), random-effects -0.72 days, 95% CI -1.48 to 0.04), and convalescence were not significantly different. High-quality trials show a quicker operative time for small-incision cholecystectomy (WMD, high-quality trials 'blinding', random-effects 16.4 minutes, 95% CI 8.9 to 23.8) while low-quality trials show no significant difference.

AUTHORS' CONCLUSIONS

Laparoscopic and small-incision cholecystectomy seem to be equivalent. No differences could be observed in mortality, complications, and postoperative recovery. Small-incision cholecystectomy has a significantly shorter operative time. Complications in elective cholecystectomy are prevalent.

Gallstone disease: Surgical aspects of symptomatic cholecystolithiasis and acute cholecystitis

Indications for cholecystectomy are limited to clearly symptomatic gallstones. Relatively high failure rates of pain relief are probably caused by incorrect selection of patients for the operation. Contraindications for (laparoscopic) cholecystectomy are related to anaesthesiological considerations. Laparoscopic cholecystectomy was accepted by consensus as the gold standard within 5 years of its introduction. Nevertheless, both the classical open and small-incision cholecystectomies are safe alternatives, and superiority of any one of the three techniques over the others has not been proven. Primary outcome measures (mortality, complications, and symptom relief) seem to be equal for the three techniques. Acute cholecystitis is a complication of gallstones. Generally it is recommended that early cholecystectomy be performed, as delayed cholecystectomy is associated with longer total hospital stay and convalescence due to recurrent cholecystitis episodes. Cholecystostomy is an alternative technique for patients unfit for general anaesthesia. Reported complication and conversion rates in cholecystectomy for acute cholecystitis vary, but are higher than for symptomatic cholecystolithiasis. New developments--such as robot-assisted surgery--are expected to have a significant impact in the near future.

Minimally invasive surgery

In 1987 Mouret performed the first laparoscopic cholecystectomy, starting a revolution in surgery. For paediatricians it is difficult to appreciate the magnitude of what has occurred in this short period. The development of minimal access techniques represents the most significant change in surgical practice since the introduction of aseptic technique or safe anaesthesia. As with many innovations, rapid change, technical language, and the evangelism of pioneers has left confusion in its wake.

Abdominal pain and patient overall and cosmetic satisfaction one year after cholecystectomy: outcome of a randomized trial comparing laparoscopic and minilaparotomy cholecystectomy

BACKGROUND

Previous studies with long-term follow-up after cholecystectomy have shown that residual abdominal symptoms are common. Laparoscopic cholecystectomy (LC) and minilaparotomy cholecystectomy (MC) can both give a smoother, early postoperative course than conventional open cholecystectomy (OC). The present study concerns abdominal pain and patient overall and cosmetic satisfaction one year after LC and MC.

METHODS

In a prospective, single-blind study, 724 patients were randomly allocated to LC or MC. Patients completed questionnaires including items concerning abdominal pain before and one year after surgery and overall and cosmetic satisfaction one year after surgery.

RESULTS

There was no difference in reduction of abdominal pain between LC and MC patients. For four different aspects of abdominal pain, 31%, 24%, 30% and 16% of patients operated with LC reported residual abdominal pain one year after surgery. The corresponding figures for MC were 28%, 20%, 27% and 18% (P values 0.55, 0.32, 0.55 and 0.63, respectively). According to questionnaire answers, there was no significant difference in the cosmetic result and overall patient satisfaction between LC and MC patients.

CONCLUSIONS

There are no differences between laparoscopic and minilaparotomy cholecystectomy in long-term outcome regarding abdominal pain and patient overall and cosmetic satisfaction. A large proportion of patients have abdominal pain one year after cholecystectomy. Future studies should include preoperative assessment and indications for cholecystectomy.

Impact of laparoscopic cholecystectomy: a population-based study

BACKGROUND

We assessed the effect of the introduction of laparoscopic cholecystectomy on surgical outcomes in routine practice.

METHODS

Hospital discharge and death-certificate data were linked for all patients undergoing cholecystectomy (n=85120) in Scottish public-sector hospitals (n=51) between January, 1981, and June, 1999. The primary endpoints were cholecystectomy rate, hospital stay, and postoperative mortality. Regression methods were used to examine the effect of laparoscopic experience and surgeon caseload on postoperative mortality and hospital stay.

FINDINGS

From 1989 to 1999, the proportion of cholecystectomies done laparoscopically rose from none to 80%, and the age-standardised cholecystectomy rate increased by 20% (95% CI 15-26). Postoperative mortality did not change in the 1990s (odds ratio 0.99 [0.7-1.4], p=0.99). The mean postoperative hospital stay fell from 8.0 (SD 3.7) to 2.9 (3.2) days. There was wide variation between hospitals in the proportion of cholecystectomies done laparoscopically and in average hospital stay. For individual surgeons, increasing laparoscopic experience and annual caseload were associated with higher proportions of laparoscopic procedures and shorter hospital stays. Postoperative mortality was higher during the first ten laparoscopic cholecystectomies done by a surgeon (compared with >200 procedures, odds ratio 2.3 [1.2-4.6], p=0.015).

INTERPRETATION

The laparoscopic method reduced hospital stay but had no overall effect on postoperative mortality. Studies to assess the appropriateness of the increased cholecystectomy rate are merited. The wide variation in the proportion done laparoscopically, together with evidence of better results for surgeons doing more procedures, suggests scope for further reductions in hospital stay and morbidity.

Cholecystectomy in Sweden 1989 and 1994: long admissions assessed by the inpatient registry

The purpose of this study was to compare cholecystectomy in Sweden (pop. 8.9 million) 1989 to 1994 when the diffusion of laparoscopic cholecystectomy (LC) was completed, focusing on long hospital admissions as a proxy indicator of adverse events. This was an observational study of all patients operated on with cholecystectomy in 1989 and 1994 (n = 19,432) from the National Inpatient Registry. The risk of a long admission was analyzed by multivariate analyses. Odds ratios of long admissions were computed considering gender, age groups, acute or chronic gallstone disease, 1989 and 1994, county level of operations per 1000 inhabitants, and hospital categories. Stratified analyses were performed by acuteness of disease, and year. Long admissions were defined as lasting longer than 20 days in 1989 and 14 days in 1994. Odds ratios of a long admission increased steeply with age and acute gallstone disease. The county level of operations per 1000 inhabitants had no influence on risk nor did hospital category. The absolute number of those operated on with an acute gallstone disease changed little between 1989 and 1994, whereas operations for chronic disease increased significantly. Stratification revealed that their risk of a long admission was increased both in 1989 and 1994, particularly for women. Those with chronic gallstone disease had no increased risk. After the introduction of the laparoscope and a rise in the number of cholecystectomies, patients with chronic gallstone disease seem to have a constant risk of long hospital stay. However, because patients with acute disease had an increased risk in both 1989 and 1994, further longitudinal analyses are needed to analyze the level of complications in this group.

Preoperative prediction model of outcome after cholecystectomy for symptomatic gallstones

BACKGROUND

After cholecystectomy for symptomatic gallstone disease 20%-30% of the patients continue to have abdominal pain. The aim of this study was to investigate whether preoperative variables could predict the symptomatic outcome after cholecystectomy.

METHODS

One hundred and two patients were referred to elective cholecystectomy in a prospective study. Median age was 45 years; range, 20-81 years. A preoperative questionnaire on pain, symptoms, and history was completed, and the questions on pain and symptoms were repeated 1 year postoperatively. Preoperative cholescintigraphy and sonography evaluated gallbladder motility, gallstones, and gallbladder volume. Preoperative variables in patients with or without postcholecystectomy pain were compared statistically, and significant variables were combined in a logistic regression model to predict the postoperative outcome.

RESULTS

Eighty patients completed all questionnaires. Twenty-one patients continued to have abdominal pain after the operation. Patients with pain 1 year after cholecystectomy were characterized by the preoperative presence of a high dyspepsia score, 'irritating' abdominal pain, and an introverted personality and by the absence of 'agonizing' pain and of symptoms coinciding with pain (P < 0.000001). In a constructed logistic regression model 15 of 18 predicted patients had postoperative pain (PVpos = 0.83). Of 62 patients predicted as having no pain postoperatively, 56 were pain-free (PVneg = 0.90). Overall accuracy was 89%.

CONCLUSION

From this prospective study a model based on preoperative symptoms was developed to predict postcholecystectomy pain. Since intrastudy reclassification may give too optimistic results, the model should be validated in future studies.

Mini-lap cholecystectomy: a viable alternative to laparoscopic cholecystectomy for the Third World?

BACKGROUND

Laparoscopic cholecystectomy (LC) requires expensive equipment and special training. Mini-lap cholecystectomy (MLC) has no start-up costs but no large series from a single centre has been reported as the procedure is considered hazardous because of inadequate exposure of the surgical field.

METHODS

We retrospectively reviewed the outcome of 737 cholecystectomies performed through a 3-5-cm transverse subcostal incision and compared the results to published series of laparoscopic cholecystectomy.

RESULTS

The operating time (61.6 min; range 35-130), conversion rate (4%), rate of postoperative complications (3.6%), bile duct injuries (0.3%), number of analgesic doses required (3.4; range 3-8), duration of postoperative hospital stay (1.4; range 1-15 days), and the time off work (13.3 days; range 8-61) compare well with the reported results of laparoscopic and MLC. Ninety-three per cent of the patients were followed up for a median period of 28.4 months and none developed biliary stricture.

CONCLUSIONS

Mini-lap cholecystectomy is considered a safe, viable alternative to LC in the Third World.

Pain patterns after distension of the gallbladder in patients with acute cholecystitis

BACKGROUND

Visceral pain is characterized by poor pain localization and a referred or radiating pain pattern. Its clinical importance in the abdomen is stressed by the finding that about one-third of patients still complain of abdominal pain after cholecystectomy. A better understanding of symptoms arising from the gallbladder and the underlying pathophysiology is therefore desirable. The aim of the present study was consequently primarily to characterize the symptom patterns after distension of the gallbladder. Secondary aims were to describe the pressure-volume relation in the gallbladder and the cystic duct opening pressure.

METHODS

Twelve patients (nine women, three men) treated with cholecystostomy for acute cholecystitis were investigated. Simultaneous cholescintigraphy and measurement of changes in intraluminal gallbladder pressure after injections of saline through a gallbladder catheter were performed. After each injection of saline the localization of pain and the presence of nausea and vomiting were registered. The injections continued until the patient felt abdominal pain necessitating cessation of the investigation or until the cystic duct opened (visualized on cholescintigraphy).

RESULTS

Distension of the gallbladder caused pain in 10 of the 12 patients. In 70% the pain was localized under the right costal margin or in the epigastrium. No mathematical formula could describe the pressure-volume relation in the gallbladder. The cystic duct opening pressure varied between 3 and 44 mmHg.

CONCLUSIONS

Pain caused by increased gallbladder pressure is localized mostly, but not always, under the right curvature and in the epigastrium. A substantial variation in cystic duct opening pressure was found.

Minilaparotomy approach to tumors of the right colon

OBJECTIVE

The study contained herein was undertaken to describe the minilaparotomy approach to tumors of the right colon.

METHOD

Clinical data were prospectively registered from 47 patients who were undergoing resection of the right colon via minilaparotomy.

RESULTS

Bowel function returned after two days and passage of stools after four days. Pain medication was necessary only during the first three postoperative days. Major complications were few, and no postoperative deaths occurred. Tumors 10 cm or smaller could be handled by minilaparotomy, and the technique allowed a relevant number of lymph nodes to be removed. No local recurrences were detected during the early postoperative period.

CONCLUSION

The minilaparotomy approach to tumors of the right colon seems to be an attractive alternative to conventional colon surgery.

Neuroticism in relation to recovery and persisting pain after laparoscopic cholecystectomy

BACKGROUND

Persisting pain is seen in 20%-30% of patients after cholecystectomy for symptomatic gallbladder stones. The only preoperative factor that seems predictive is psychic vulnerability or neuroticism. Findings with regard to the influence of psychologic factors on recovery are contradictory, too. The aim of the present study was to examine a possible relationship between neuroticism and recovery and the outcome of operation.

METHODS

Ninety-four patients who had had a laparoscopic cholecystectomy performed were tested psychologically with a Danish psychic vulnerability scale and with the Eysenck Neuroticism Scale before and 1 year after operation. The course of recovery was registered 1 month after operation, and outcome with regard to persisting pain 1 year postoperatively.

RESULTS

No correlations were found between neuroticism scores and postoperative hospital stay or time to regain work/normal activities (P > 0.05). Persisting pain was found in 18% of the patients 1 year after operation. Although the patients with persisting pain had higher neuroticism scores preoperatively, the difference from the patients with successful outcome of the operation first became statistically significant 1 year postoperatively (P < 0.01-0.05).

CONCLUSIONS

The results do not indicate that neuroticism influences the short recovery process after laparoscopic cholecystectomy. With regard to persisting pain, the higher neuroticism scores in these patients 1 year after the operation could be the consequence of the pain rather than aetiologic factors.

Symptoms of oesophageal reflux are more common following laparoscopic cholecystectomy than in a control population

Previous studies have shown that up to 40 per cent of patients have symptoms after cholecystectomy or laparoscopic cholecystectomy (LC). There are concerns, however, that these symptoms reflect those of the general population and are not a specific post-operative phenomenon. Abdominal symptoms of 212 patients following LC were compared to a healthy acalculous control population (n = 62). Patients and controls were assessed by questionnaire. Age and sex profiles were similar in both groups. There was no significant difference in the incidence of abdominal pain, bloating or nausea between the 2 groups. Frequent heartburn was a symptom in 19.3 per cent of patients following LC as compared to 3.2 per cent of control patients (p = 0.004, chi-squared 9.39, 1 d.f.). Furthermore 11.3 per cent of post-operative patients complained of dysphagia versus 6.4 per cent of the control group (p = 0.08, chi-squared 1.245, 1 d.f.). One hundred and twenty (57.1 per cent) patients judged their operation to be a complete success, while 9 (4.3 per cent) were dissatisfied. Five of the latter group cited frequent heartburn as the cause of their dissatisfaction. We conclude that abdominal pain, bloating and nausea occur as frequently in the general population as in patients following LC. Patients are more likely to suffer from heartburn and dysphagia following LC than a normal population supporting a link between cholecystectomy and lower oesophageal dysfunction.

Pain and dyspepsia after elective and acute cholecystectomy

BACKGROUND

Postcholecystectomy pain occurs in 20-30%. The main cause of this pain remains unclear. Whether the underlying gallbladder disease influences the outcome after cholecystectomy is not fully established.

METHODS

A multicenter questionnaire study comparing the occurrence of abdominal pain and dyspepsia 5-10 years after cholecystectomy in 345 (222 women, 123 men) patients cholecystectomized for acute cholecystitis and in a control group of 296 (213 women, 83 men) patients cholecystectomized for uncomplicated symptomatic gallbladder stones.

RESULTS

Of 641 questionnaires, 534 (83%) were completed. Complaints of abdominal pain and dyspepsia were found with similar frequencies in the acute cholecystitis and gallstone groups. Women had abdominal pain more often than men (42% versus 29%) (P = 0.01). Although more than one-third complained of abdominal pain after cholecystectomy, 93% had improved or were cured.

CONCLUSION

The outcome after cholecystectomy seems to be independent of the underlying gallbladder disease (acute cholecystitis or elective operations for gallstones).

Incidence of persistent symptoms after laparoscopic cholecystectomy: a prospective study

BACKGROUND AND AIMS

Laparoscopic cholecystectomy is the standard treatment for symptomatic gall stone disease. This study aimed to assess the effect of the operation on patients' symptoms.

METHODS

One hundred consecutive patients undergoing laparoscopic cholecystectomy between June 1994 and June 1995 were evaluated using standard questionnaires examining demographic details, indication for laparoscopic cholecystectomy, characteristics of pain, and other associated dyspeptic and colonic symptoms. A history of psychiatric disturbances and of hysterectomy were also recorded. The same questionnaires were administered again six months after the operation. Operation notes and histological reports were reviewed.

RESULTS

Three patients were converted to open surgery and were excluded from analysis. The median age of the remaining 97 patients was 50.9 (19-85) years; 19 were men. There was one complication each of bleeding and biliary leak. Indications for laparoscopic cholecystectomy were biliary type pain (66 patients) and complicated gall stone disease (acute cholecystitis 21, cholestatic jaundice six, and pancreatitis four). Thirteen patients (13%) had persistent pain and two (3%) developed diarrhoea at follow up. Only one patient with persistent pain after laparoscopic cholecystectomy originated from the complicated gall stone disease group. Logistic discriminant analysis showed that bloating (p < 0.001), constipation (p < 0.05), and previous and current use of psychotrophic drugs (p < 0.001) were significantly more common among those with a poor outcome after laparoscopic cholecystectomy. Heartburn was unaffected. Of patients with persistent symptoms after cholecystectomy 77% had no or mild histological changes of cholecystitis as compared with 30% in the pain free group.

CONCLUSIONS

The incidence of persistent pain after laparoscopic cholecystectomy was 13%. Abdominal bloating and psychiatric medications were predictive for persistence of pain after laparoscopic cholecystectomy.

Laparoscopic-assisted rectopexy using a novel hand-access port

Many surgeons who were ready converts to laparoscopic cholecystectomy did not translate the technique to more advanced procedures. There are several reasons: increased operating times, a steeper learning curve, concern for oncological efficacy, and the loss of manual tactile ability. As shown with this report on laparoscopic assisted rectopexy, many of these difficulties can be overcome using the IntromitTM while still maintaining the benefits of minimally invasive surgery.