Health-related quality of life and appropriateness of cholecystectomy

ASYMPTOMATIC CHOLELITHIASIS: EXPECTANT OR CHOLECYSTECTOMY. A SYSTEMATIC REVIEW

BACKGROUND

Asymptomatic cholelithiasis is a highly prevalent disease, and became more evident after the currently greater access to imaging tests. Therefore, it is increasingly necessary to analyse the risks and benefits of performing a prophylactic cholecystectomy.

AIMS

To seek the best evidence in order to indicate prophylactic cholecystectomy or conservative treatment (clinical follow-up) in patients with asymptomatic cholelithiasis.

METHODS

A systematic review was performed using the PubMed/Medline database, according to PRISMA protocol guidelines. The review was based on studies published between April 26, 2001 and January 07, 2022, related to individuals older than 18 years., The following terms/operators were used for search standardization: (asymptomatic OR silent) AND (gallstones OR cholelithiasis).

RESULTS

We selected 18 studies eligible for inference production after applying the inclusion and exclusion criteria. Also, the Tokyo Guideline (2018) was included for better clarification of some topics less or not addressed in these studies.

CONCLUSIONS

Most evidence point to the safety and feasibility of conservative treatment (clinical follow-up) of asymptomatic cholelithiasis. However, in post-cardiac transplant patients and those with biliary microlithiasis with low preoperative surgical risk, a prophylactic cholecystectomy is recommended. To establish these recommendations, more studies with better levels of evidence must be conducted.

Health-Related Quality of Life After Laparoscopic Cholecystectomy

Background

This study aimed to determine the mean improvement in the quality of life (QoL) after laparoscopic cholecystectomy (LC) in patients with symptomatic cholelithiasis.

Methodology

After obtaining approval from the hospital’s ethical committee, the Gastrointestinal Quality of Life Index (GIQLI) proforma was filled on admission (T0) and at week six (T1) postoperatively. All data were collected, and GIQLI scores were calculated for individual patients.

Results

In our study, among the 70 patients undergoing LC, 20% (n = 14) were aged 18-30 years and 80% (n = 56) were aged 31-60 years, with the mean ± standard deviation calculated as 41.56 ± 10.13 years. Overall, 44.29% (n = 31) of patients were men and 55.71% (n = 39) were women. GIQLI scores were 94.64 ± 2.24 for pre-treatment and 106.09 ± 2.40 for post-treatment, with a mean change of 11.44 ± 3.29, and a p-value of 0.001, showing a significant difference.

Conclusions

The mean improvement in QoL after LC in patients with symptomatic cholelithiasis is significantly higher when compared with pretreatment.

Index admission laparoscopic cholecystectomy for acute cholecystitis restores Gastrointestinal Quality of Life Index (GIQLI) score

BACKGROUNDS/AIMS

Previous studies have evaluated quality of life (QoL) in patients who underwent laparoscopic cholecystectomy (LC) for cholelithiasis. The purpose of this study was to evaluate QoL after index admission LC in patients diagnosed with acute cholecystitis (AC) using the Gastrointestinal Quality of Life Index (GIQLI) questionnaire.

METHODS

Patients ≥21 years admitted to Tan Tock Seng Hospital, Singapore for AC and who underwent index admission LC between February 2015 and January 2016 were evaluated using the GIQLI questionnaire preoperatively and 30 days postoperatively.

RESULTS

A total of 51 patients (26 males, 25 females) with a mean age of 60 years (24-86 years) were included. Median duration of abdominal pain at presentation was 2 days (1-21 days). 45% of patients had existing comorbidities, with diabetes mellitus being most common (33%). 31% were classified as mild AC, 59% as moderate and 10% as severe AC according to Tokyo Guideline 2013 (TG13) criteria. Post-operative complications were observed in 8 patients, including retained common bile duct stone (n=1), wound infection (n=2), bile leakage (n=2), intra-abdominal collection (n=1) and atrial fibrillation (n=2). 86% patients were well at 30 days follow-up and were discharged. A significant improvement in GIQLI score was observed postoperatively, with mean total GIQLI score increasing from 106.0±16.9 (101.7-112.1) to 120.4±18.0 (114.8-125.9) (p<0.001). Significant improvements were also observed in GIQLI subgroups of gastrointestinal symptoms, physical status, emotional status and social function status.

CONCLUSIONS

Index admission LC restores QoL in patients with AC as measured by GIQLI questionnaire.

Patient-Reported Outcomes after Laparoscopic Ventral Hernia Repair

Approximately 350,000 ventral hernia repairs are performed in the United States each year. Patients expect fast recovery after laparoscopic ventral hernia repair (LVHR) and undisturbed postoperative quality of life (QOL). We examined the utility of a brief, validated 10-point Linear Analog Self-Assessment coupled with the Visual Analog Scale pain scale to discern risk factors for decreased postoperative QOL. Between January 2011 and May 2013, we prospectively assessed patient-reported outcomes for patients who underwent LVHR. Visual Analog Scale pain scale and Linear Analog Self-Assessment items were recorded preoperatively and postoperatively at four hours, one day, and seven days. Eighteen patients were included, 11 were female (61%) and 8 > 60 years old (44%). Patient-reported fatigue increased clinically and statistically from baseline over time ( P = 0.007) as did pain ( P < 0.001). There was a statistically significant difference in QOL scores over time by gender with women reporting worse scores than men ( P = 0.001). In conclusion, our study detected significant changes from baseline in both fatigue and pain over the seven days after LVHR. Age is associated with postoperative differences in physical well-being. Gender is associated with differences in postoperative course in QOL and physical well-being.

Episodic Abdominal Pain Characteristics Are Not Associated with Clinically Relevant Improvement of Health Status After Cholecystectomy

BACKGROUND

Cholecystectomy is the therapy of first choice in patients with uncomplicated symptomatic cholecystolithiasis, but it remains unclear which patients truly benefit in terms of health status improvement. Patients generally present with episodic abdominal pain of varying frequency, duration, and intensity. We assessed whether characteristics of abdominal pain episodes are determinants of clinically relevant improvement of health status after cholecystectomy.

METHODS

In a post hoc analysis of a prospective multicenter cohort study, patients of ≥18 years of age with uncomplicated symptomatic cholecystolithiasis subjected to cholecystectomy were included. Preoperatively, patients received a structured interview and a questionnaire consisting of the visual analogue scale (VAS; range 0-100) and gastrointestinal quality of life index (GIQLI). At 12 weeks after cholecystectomy, the GIQLI was again administered. Logistic regression analyses were performed to determine significant associations.

RESULTS

Questionnaires were sent to 261 and returned by 166 (63.6 %) patients (128 females, mean age at surgery 49.5 ± 13.8). A total of 131 (78.9 %) patients reported a clinically relevant improvement of health status. The median (interquartile range) frequency, duration, and intensity of abdominal pain episodes were 0.38 (0.18-0.75) a week, 4.00 (2.00-8.00) hours, and 92 (77-99), respectively. None of the characteristics was associated with a clinically relevant improvement of health status at 12 weeks after cholecystectomy.

CONCLUSIONS

Characteristics of abdominal pain episodes cannot be used to inform patients with symptomatic cholecystolithiasis who are skeptic about the timing of cholecystectomy for optimal benefit. Timing of cholecystectomy should therefore be based on other characteristics and preferences.

Effects of Intra-abdominally Instilled Isotonic Saline on Pain, Recovery, and Health-Related Quality-of-Life Following Laparoscopic Cholecystectomy: A Randomized Prospective Double-Blind Controlled Study

INTRODUCTION

The postoperative installation of isotonic saline in the abdomen has been suggested as a method to reduce the effect of local toxins, thereby reducing postoperative pain in patients undergoing laparoscopic surgery. The aim of this randomized prospective double-blind trial was to assess whether installation of isotonic saline can reduce postoperative pain and nausea following laparoscopic cholecystectomy (LC).

METHODS

Altogether 71 LC patients were randomized to either intra-abdominal instillation of isotonic saline group (S) (n = 36) or no saline (NS) group (n = 35) at the end of surgery. Data were collected by means of questionnaires. The postoperative recovery profile questionnaire was answered prior to surgery and 1 week postoperatively, SF-36 prior to surgery and at 1 month postoperatively, and a pain diary recording a Visual Analogue Scale score each day during the first week.

RESULTS

The overall response rate was 94%. No significant differences were seen between the groups regarding abdominal and shoulder pain. However, the NS group reported more pain (NS = 53 %, S = 29 %) and fatigue (NS = 50%, S = 35%) than the S group postoperative day 7. Moreover, the most frequently reported problem in both groups 7 days after surgery was getting back to normal life (60%). Females reported a slower recovery profile than males and also more postoperative symptoms day 7. HRQoL results were similar between the groups.

CONCLUSION

Instillation of isotonic saline does not improve recovery after laparoscopic cholecystectomy. Postoperative pain was more often reported in the NS group than in the S group, though the difference was not significant.

Patient-reported outcomes of symptomatic cholelithiasis patients following cholecystectomy after at least 5 years of follow-up: a long-term prospective cohort study

BACKGROUND

Up to 41% of patients report pain after cholecystectomy and in most studies follow-up for these symptoms did not exceed 5 years. The episodic nature of abdominal pain associated with symptomatic cholelithiasis warrants long-term follow-up studies. We assessed which patient and surgical factors were associated with absence of pain and patient-reported success of surgery after ≥ 5 years of follow-up.

METHODS

Patients of ≥ 18 years of age with symptomatic cholelithiasis, classified as ASA I or II, who had previously returned a preoperative questionnaire were sent a questionnaire consisting of the gastrointestinal quality of life index (GIQLI) and patient ratings of current versus presurgical abdominal symptoms and of surgery result. Logistic regression analysis was performed to determine associations.

RESULTS

Questionnaires were sent to 197 patients and returned by 126 (64.0%) patients (73.8 % female, mean age at surgery 47.5 ± 12.2 years) at a mean of 10.0 ± 1.0 years after cholecystectomy. Absence of abdominal pain was reported by 60.3% of the patients. Patients classified as ASA II as opposed to ASA I were less likely to report absence of pain (OR 0.41, 95% CI 0.17-0.99). A positive rating of long-term postsurgical versus presurgical abdominal symptoms was given by 89.7% of the patients and 90.5% considered the cholecystectomy result to be good. No variables were significantly associated with these latter two outcome measures.

CONCLUSIONS

We found a high patient-reported surgery success rate after >5 years of follow-up after cholecystectomy despite residual abdominal pain in some of these patients. None of the patient and surgery-related characteristics were consistently associated with all three outcome measures. This discrepancy between patient' outcomes highlights the need for realistic expectations prior to cholecystectomy.

[Evaluation of the gastrointestinal quality of life index as a system to prioritize patients on the waiting list for laparoscopic cholecystectomy]

INTRODUCTION

We prospectively evaluated health-related quality of life (HRQoL) through the gastrointestinal quality of life index (GIQLI) as a system to prioritize patients on the waiting list for laparoscopic cholecystectomy (LC) and its correlation with a linear prioritization system developed in the General and Gastrointestinal Surgery Institute of Clínica Quirón in Valencia.

MATERIAL AND METHODS

There were 100 consecutive patients who underwent elective outpatient LC. The main outcome measures consisted of: 1) assessment of the impact of the disease, measured through the GIQLI; 2) evaluation of an objective system based on technical scientific criteria; 3) evaluation of the utility of LC in improving HRQoL through the GIQLI by analyzing expected and obtained utility through the change ratio, and 4) analysis of the correlation between the objective linear system, HRQoL and utility.

RESULTS

The GIQLI was useful in evaluating the impact of the disease. LC significantly improved HRQoL in both oligosymptomatic and symptomatic patients. The objective or clinical factors did not allow perceptions of the process to be evaluated or the impact on HRQoL to be measured or inferred. A prioritization system based on GIQLI scores allows patients to be selected according to the expected utility (worsening of HRQoL) and obtained utility (improvement in HRQoL) of CL.

CONCLUSIONS

Prioritization systems should include utility to guarantee equity. The GIQLI shows the impact of the disease on the patient while the clinical/objective factors are unrelated to the expectation of prioritization. Prioritization systems should include both elements to maintain the balance between impact and appropriate indication.

Persistent and de novo symptoms after cholecystectomy: a systematic review of cholecystectomy effectiveness

BACKGROUND

Cholecystectomy is the preferred treatment option for symptomatic gallstones, but the exact relationship between cholecystectomies and symptoms still is unclear. This study aimed to assess the effectiveness of elective cholecystectomy for patients with cholecystolithiasis in terms of both persistent and de novo symptoms.

METHODS

A systematic literature search was conducted in Pubmed and Embase. The search included studies comprising patients 18 years of age or older undergoing elective cholecystectomy for symptomatic cholecystolithiasis. The proportions of symptoms after cholecystectomy were calculated and then subdivided into persistent and de novo symptoms.

RESULTS

A total of 38 studies reported the presence of postcholecystectomy symptoms. The results showed that upper abdominal pain, the main indication for cholecystectomy in the majority of the patients, mostly disappeared after surgery. However, it persisted in up to 33 % of the patients and arose de novo in up to 14 %. Diarrhea (85 %) and constipation (76 %) were the persistent symptoms most often reported, whereas upper abdominal pain and vomiting were the least often reported. Flatulence (62 %) was the most often reported new symptom. However, large variations in symptoms were found between studies.

CONCLUSIONS

The review indicates that cholecystectomy often is ineffective with regard to persistent and de novo symptoms. The finding that the types and proportions of persistent symptoms differ from those that arise de novo suggests that this distinction may be useful in predicting which patients would and which would not benefit from a cholecystectomy.

Health-related quality of life outcomes after cholecystectomy

Gallbladder diseases are very common in developed countries. Complicated gallstone disease represents the most frequent of biliary disorders for which surgery is regularly advocated. As regards, cholecystectomy represents a common abdominal surgical intervention; it can be performed as either an elective intervention or emergency surgery, in the case of gangrene, perforation, peritonitis or sepsis. Nowadays, the laparoscopic approach is preferred over open laparotomy. Globally, numerous cholecystectomies are performed daily; however, little evidence exists regarding assessment of post-surgical quality of life (QOL) following these interventions. To assess post-cholecystectomy QOL, in fact, documentation of high quality care has been subject to extended discussions, and the use of patient-reported outcome satisfaction for quality improvement has been advocated for several years. However, there has been little research published regarding QOL outcomes following cholecystectomy; in addition, much of the current literature lacks systematic data on patient-centered outcomes. Then, although several tools have been used to measure QOL after cholecystectomy, difficulty remains in selecting meaningful parameters in order to obtain reproducible data to reflect postoperative QOL. The aim of this study was to review the impact of surgery for gallbladder diseases on QOL. This review includes Medline searches of current literature on QOL following cholecystectomy. Most studies demonstrated that symptomatic patients profited more from surgery than patients receiving an elective intervention. Thus, the gain in QOL depends on the general conditions before surgery, and patients without symptoms profit less or may even have a reduction in QOL.

Sense of coherence and other predictors of pain and health following laparoscopic cholecystectomy

INTRODUCTION

Pain is the most common symptom following laparoscopic cholecystectomy (LC) and might delay discharge from hospital after day surgery. A patient's ability to manage stressful situations can be assessed by the sense of coherence (SOC) and has been proposed to predict health. The aim of this study was to investigate predictors of average pain the first postoperative week after LC, and predictors of changes in perceived health, with special reference to individual coping resources measured by the Sense of Coherence Scale. Furthermore, a test-re-test was performed on SOC to evaluate the stability in the context of LC surgery.

METHOD

Seventy-three patients completed questionnaires about SOC, health status, pain, anxiety, symptom occurrence and symptom distress preoperatively, postoperative day 1-7 and after 1 and 6 months following LC.

RESULTS

By multiple regression, 23% of the variability in pain intensity could be explained by the variables age, SOC and education. Age was the strongest predictor. Further, 19% of the change in health between day 7 and 1 month could be explained by the two variables symptom distress the first postoperative day and SOC. The test-re-test of SOC had a correlation coefficient (r) of 0.55. Forty-six patients (63%) remained within ±10% of their preoperative SOC score at 6 months, 11 patients (15%) decreased and 16 patients (22%) increased their SOC values.

CONCLUSION

SOC was found to be a significant but weak predictor of pain intensity the first week after LC. Furthermore, patients scoring low SOC values experienced a delay in their health improvement. SOC was more unstable over time than previously suggested. Further, interventional studies are needed to clarify if SOC might be a clinically useful measure to identify vulnerable patients undergoing LC surgery.

Appropriateness criteria for surgery improve clinical outcomes in patients with low back pain and/or sciatica

STUDY DESIGN

Prospective, controlled, observational outcome study using clinical, radiographic, and patient/physician-based questionnaire data, with patient outcomes at 12 months follow-up.

OBJECTIVE

To validate appropriateness criteria for low back surgery.

SUMMARY OF BACKGROUND DATA

Most surgical treatment failures are attributed to poor patient selection, but no widely accepted consensus exists on detailed indications for appropriate surgery.

METHODS

Appropriateness criteria for low back surgery have been developed by a multispecialty panel using the RAND appropriateness method. Based on panel criteria, a prospective study compared outcomes of patients appropriately and inappropriately treated at a single institution with 12 months follow-up assessment. Included were patients with low back pain and/or sciatica referred to the neurosurgical department. Information about symptoms, neurologic signs, the health-related quality of life (SF-36), disability status (Roland-Morris), and pain intensity (VAS) was assessed at baseline, at 6 months, and at 12 months follow-up. The appropriateness criteria were administered prospectively to each clinical situation and outside of the clinical setting, with the surgeon and patients blinded to the results of the panel decision. The patients were further stratified into 2 groups: appropriate treatment group (ATG) and inappropriate treatment group (ITG).

RESULTS

Overall, 398 patients completed all forms at 12 months. Treatment was considered appropriate for 365 participants and inappropriate for 33 participants. The mean improvement in the SF-36 physical component score at 12 months was significantly higher in the ATG (mean: 12.3 points) than in the ITG (mean: 6.8 points) (P = 0.01), as well as the mean improvement in the SF-36 mental component score (ATG mean: 5.0 points; ITG mean: -0.5 points) (P = 0.02). Improvement was also significantly higher in the ATG for the mean VAS back pain (ATG mean: 2.3 points; ITG mean: 0.8 points; P = 0.02) and Roland-Morris disability score (ATG mean: 7.7 points; ITG mean: 4.2 points; P = 0.004). The ATG also had a higher improvement in mean VAS for sciatica (4.0 points) than the ITG (2.8 points), but the difference was not significant (P = 0.08). The SF-36 General Health score declined in both groups after 12 months, however, the decline was worse in the ITG (mean decline: 8.2 points) than in the ATG (mean decline: 1.2 points) (P = 0.04). Overall, in comparison to ITG patients, ATG patients had significantly higher improvement at 12 months, both statistically and clinically.

CONCLUSION

In comparison to previously reported literature, our study is the first to assess the utility of appropriateness criteria for low back surgery at 1-year follow-up with multiple outcome dimensions. Our results confirm the hypothesis that application of appropriateness criteria can significantly improve patient outcomes.

Validation of a physical activity questionnaire (CHAMPS) as an indicator of postoperative recovery after laparoscopic cholecystectomy

BACKGROUND

Although many surgical innovations are said to "shorten recovery," recovery has not been consistently defined or measured. The goal of this study was to assess the validity of a physical activity questionnaire (The Community Health Activities Model Program for Seniors [CHAMPS]) as an indicator of postoperative recovery.

METHODS

CHAMPS includes 41 questions asking the subject to estimate the time spent on a range of activities in the previous week; responses are converted into kcal/kg/wk. Patients scheduled for laparoscopic cholecystectomy were assessed preoperatively, 1 week and 1 month postoperatively (sensitivity to change). To assess construct validity, results were compared with other measures used to estimate recovery, including pain (VAS), health-related quality of life (SF-36), and complications. CHAMPS was also compared with a measure of exercise capacity, the 6-minute walk test (6MWT). Data expressed as median (IQR).

RESULTS

A total of 50 patients, 72% female, mean (SD) age 51 (17) years, participated. CHAMPS-estimated energy expenditure decreased from 42 [25-64] preop to 18 [9-30] kcal/kg/wk (P < .001) 1 week postoperatively. It remained below baseline at 30 [16-61] kcal/kg/wk 1 month postoperatively (P = .042). At all time points, SF-36 Physical Function, pain with movement, and 6MWT distance significantly correlated with CHAMPS. At 1 month, physical activity was lower in patients reporting complications (16 [10-32] vs 42 [18-77], P < .01).

CONCLUSION

Evidence is provided for construct validity for a physical activity questionnaire as a measure of surgical recovery.

Comparing quality-of-life outcomes in symptomatic patients undergoing laparoscopic or open ventral hernia repair

BACKGROUND

The aim of this study was to compare quality-of-life outcomes in patients with symptomatic hernias who were undergoing laparoscopic and open repairs.

MATERIALS AND METHODS

Clinical data for patients undergoing ventral hernia repair were reviewed with quality-of-life surveys administered before and at least 6 months following surgery.

RESULTS

The study included 56 symptomatic patients. Forty-one patients (73%) underwent laparoscopic repair, and 15 patients (27%) underwent open repair. There was no difference in preoperative quality-of-life scores on the SF-36 Health Survey between patients having laparoscopic or open repairs. Postoperative quality-of-life scores on the SF-36 survey were significantly improved in the laparoscopic group, compared with the open group, in general health (46% vs. 37%; P=0.0217), vitality (53% vs. 45%; P=0.0491), role-emotional (45% vs. 35%; P=0.0480), and mental health (49% vs. 39%; P=0.0381). Postoperative quality-of-life scores on the Carolinas Comfort Scale (CCS) were significantly improved in the laparoscopic group, compared with the open group, in bending over (3.15 vs. 5.87, P=0.0158), sitting up (2.51 vs. 5.13; P=0.0211), activities of daily living (2.48 vs. 5.75; P=0.0139), coughing or deep breathing (2.95 vs. 5.75; P=0.0314), walking (2.36 vs. 4.62; P=0.0427), exercising (3.19 vs. 6.14; P=0.0222), and total comfort scale (17.62 vs. 40.23; P=0.0084).

CONCLUSIONS

Laparoscopic ventral hernia repair provides improved quality-of-life, compared with open repair, 6 months postoperatively. Nearly all physical variables measured by the CCS were significantly better when ventral hernias were repaired laparoscopically.

Responsiveness and minimal clinically important differences after cholecystectomy: GIQLI versus SF-36

INTRODUCTION

To compare responsiveness and minimal clinically important differences (MCID) between the Gastrointestinal Quality of Life (GIQLI) and the Short Form 36 (SF-36), we prospectively analyze 159 patients undergoing cholecystectomy at two tertiary academic hospitals.

PATIENTS AND METHODS

All patients completed the disease-specific GIQLI and the generic SF-36 before and 3 months after surgery. Scores using these instruments were interpreted by generalized estimating equation before and after cholecystectomy. The bootstrap estimation was used to derive 95% confidence intervals for differences in the responsiveness estimates.

RESULTS AND DISCUSSION

Mean changes in all GIQLI and the SF-36 subscales were statistically significant (p < 0.05). Comparisons of effect size (ES), standardized response means (SRM), and relative efficiency (>1) indicated that the responsiveness of the GIQLI was superior to that of the SF-36. In the equivalence test, all lower or upper confidence limits presented no equivalence (>5), indicating good MCID. The ES and SRM for emotions and physical function in the GIQLI significantly differed from those of the SF-36 (p < 0.05).

CONCLUSION

The data in this study indicate that clinicians and health researchers should weight disease-specific measures more heavily than generic measures when evaluating treatment outcomes.

The impact of thyroidectomy on psychiatric symptoms and quality of life

INTRODUCTION

Existing trials investigated the impact of medical treatment of thyroid disorders on health-related quality of life (QOL) and psychiatric symptoms. The aim of this prospective study is to analyze the impact of thyroid surgery on QOL and severity of psychiatric symptoms.

MATERIALS AND METHODS

Forty-seven patients undergoing thyroid surgery (TS) were assessed before thyroidectomy (T0) and 37 also after surgery, >or=6 months after euthyroidism was achieved (T1). QOL and psychiatric symptoms were evaluated at T0 and T1 using the Medical Outcomes Study Short Form Survey (SF-36) and the Symptom Checklist-90 (SCL-90-R). Scores at T0 were compared with those of patients undergoing surgery for non-thyroidal disease and the SF-36 scores were also compared with the normative Italian sample. Changes in QOL and psychiatric symptoms between T0 and T1 were also examined.

RESULTS

Health-related QOL in TS patients before surgery was poorer than in the comparison group on the SF-36 mental component summary measure and social functioning. Mental health improved significantly after surgery but social functioning remained markedly impaired. A significant reduction in the severity of psychiatric symptoms was observed.

DISCUSSION

Our results indicate that even long after euthyroidism is achieved after surgery, patients show a significant improvement of mental health and a reduction of psychiatric symptoms. Nevertheless, patients continue to have a poorer QOL compared to the Italian normative sample.

Improvement in gastrointestinal symptoms and quality of life after cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) is the accepted treatment for symptomatic cholelithiasis but has been criticized as an overused procedure. This study assesses the effectiveness of LC on reduction in gastrointestinal (GI) symptoms and the impact on quality of life (QOL).

METHODS

A prospective cohort of subjects evaluated for gallstone disease between August 2001 and July 2004 completed preoperative and postoperative GI gallbladder symptom surveys (GISS) and SF36 QOL surveys. The GISS was developed to quantify the magnitude, severity, and distressfulness of 16 GI symptoms. Surveys were scored and evaluated using paired t tests.

RESULTS

Fifty-five subjects were included in the final analysis. The GISS revealed significant improvement in biliary type symptoms but not reflux or irritable bowel symptoms after LC (P > .05). Significant improvement was seen in QOL (P < .01).

CONCLUSION

This study supports the utility of LC by showing not only a significant reduction of GI symptoms but also marked improvement in patients' general QOL.

Explicit criteria for prioritization of cataract surgery

BACKGROUND

Consensus techniques have been used previously to create explicit criteria to prioritize cataract extraction; however, the appropriateness of the intervention was not included explicitly in previous studies. We developed a prioritization tool for cataract extraction according to the RAND method.

METHODS

Criteria were developed using a modified Delphi panel judgment process. A panel of 11 ophthalmologists was assembled. Ratings were analyzed regarding the level of agreement among panelists. We studied the effect of all variables on the final panel score using general linear and logistic regression models. Priority scoring systems were developed by means of optimal scaling and general linear models. The explicit criteria developed were summarized by means of regression tree analysis.

RESULTS

Eight variables were considered to create the indications. Of the 310 indications that the panel evaluated, 22.6% were considered high priority, 52.3% intermediate priority, and 25.2% low priority. Agreement was reached for 31.9% of the indications and disagreement for 0.3%. Logistic regression and general linear models showed that the preoperative visual acuity of the cataractous eye, visual function, and anticipated visual acuity postoperatively were the most influential variables. Alternative and simple scoring systems were obtained by optimal scaling and general linear models where the previous variables were also the most important. The decision tree also shows the importance of the previous variables and the appropriateness of the intervention.

CONCLUSION

Our results showed acceptable validity as an evaluation and management tool for prioritizing cataract extraction. It also provides easy algorithms for use in clinical practice.