VIMS Journal: December 2017

Original Article

Does History, Clinical Feature and USG Abdomen Findings Help to Predict Conversion in Laparoscopic Cholecystectomy

Dr. S. N. Basak, Dr. K. A. Mukherjee

Abstract :
Introduction :
Laparoscopic cholecystectomy is the gold standard treatment for Gall stone disease in present days. It is also seen that even today some percentage of patients need conversion to open surgery. Our study is to find out what positive history can be elicited in patients who need conversion from laparoscopy to open surgery.

Material and Method : It is a retrospective observational study. We took patients who were converted from laparoscopic cholecystectomy to open surgery over last one year in our unit. We try to find certain gall stone specific history in those patients. Also we see the clinical finding and Ultrasonography findings for those patients.

Result :
There were 327 patients who were posted laparoscopic cholecystectomy and 12 patients were converted to laparoscopic to open cholecystectomy in last one year i.e. August 2016 to July 2017 in our unit. It is found that 9 patients had recurrent attacks, 10 patients had last attack more than 1 months time. 6 had history of gall stone pancreatitis, 3 had ERCP for CBD stone, 7 patients had history of taking homeopathic medication. Clinically, only 3 patients had tenderness at right hypochondrium but no one had palpable gall bladder. USG had detected 2 contracted GB and one was suspected to have Mirizzi Syndrome.

Conclusion :
Gall stone related history is important to predict conversion. We suggest a larger study to find out exact statistical correlation with these history and conversion.

Introduction:
Gallstone disease is a common health problem. Over last couple of decades laparoscopic cholecystectomy (LC) has become the gold standard for the surgical treatment of gall stone disease. Several difficulties have been encountered during LC, and these along with several other factors can necessitate the conversion from LC to open cholecystectomy (OC). It must be mentioned that conversion is not a technical failure but should rather be accepted as a better surgical practice by a surgeon when indicated. Every institution has different rate and causes of conversion to open surgery. We decided to retrospectively review our series and to find out that whether gall stone disease related history, clinical feature and Ultrasonography (USG) findings helps to predict this conversion or not.

Study Design : This is a Retrospective Observational study. We took those patients who were converted to laparoscopic to open cholecystectomy in last one year i.e. August 2016 to July 2017 in our unit. All these conversions were done by consultants who have done more than 1000 laparoscopic cholecystectomy.

In History - We ask the patient about the
(i) Recurrent attacks,
(ii) Time since last Attack
(iii) History of gall stone related complication like pancreatitis or obstructive jaundice and
(iv) Any biliary intervention like ERCP
(v) Received alternative medicinal treatment

Clinically - Right Hypochondrial tenderness or palpable gall bladder

USG findings - Within 2 days before surgery. Presence of any of followings are documented
(i) Increase wall thickness/Contracted Gall Bladder
(ii) Hugely distended Gall bladder (GB)
(iii) Mirizzi or other complicated conditions where anatomy are distorted

Result :
There were 327 patients who were posted laparoscopic cholecystectomy and 12 patients were converted to laparoscopic to open cholecystectomy in last one year i.e. August 2016 to July 2017 in our unit. All the conversions were done purely on surgical reasons. It is found that nine patients had recurrent attacks, ten patients had last attack 1 months or more time. Three patients had history of gall stone pancreatitis 3 had ERCP for CBD stone or gall stone pancreatitis. Seven patients had history of taking homeopathic medication for gall stone disease before surgery.

Patient Serial No Recurrent attacks Time since last attack stone related complication pancreatitis or obstructive jaundice (Obs Jaundice) ERCP Alternative medical treatment
1 Yes 5wks No No Yes
2 Yes 4wks No No No
3 Yes 4 days No No Yes
4 No 4wks Obstructive jaundice ERCP Yes
5 Yes 2months no no yes
6 No 7 days no no no
7 No 6wks pancreatitis no no
8 Yes 2 months pancreatitis ERCP yes
9 Yes 10 weeks no no yes
10 Yes 3 months no no yes
11 Yes pancreatitis 5wks no no
12 Yes 4wks Obs Jaundice ERCP NO

Table 1: Gall Stone disease related history in patients who converted to open surgery

It was found that all but one patient has some positive history related to Gall Stone disease which helps us to recognize the surgery could be difficult one. More than half of the patients (7 out of 12) have multiple positive history. Clinically, only 3 patients had tenderness at right hypochondrium but no one had palpable gall bladder. USG had detected 2 contracted GB and one was suspected to have Mirizzi Syndrome.

Discussion : The conversion from LC to OC results in a some change in outcome for the patient because of the higher postoperative complications and the longer hospital stay.[1] The conversion rate and complications associated with LC depend on the experience of the surgeon and the degree of difficulty faced during surgery, which can be affected various intraoperative complications but it is important to able to recognize the possible difficulties so we can plan accordingly. We know many factors in history should be considered before surgery. But it is interesting to find that almost 90% of those patients who underwent conversion had some positive history. Another finding also deserves to get attention that 58% patients received homeopathic medicine. Clinically and USG only predict difficulty in 25% of cases. A large series reported from Turkey found that previous history and/or new inflammation are two of the most frequent situations carrying an increased operative risk and are the main reasons for conversion to the open procedure.[2] Studies also suggest acute cholecystitis and recent obstructive jaundice are independent predictive risk factors for conversion.[3] A meta analysis suggest acute cholecystis is a predictor for conversion but no significant conversion documented in preoperative endoscopic retrograde cholangiopancreatography (ERCP) and the gallstone pancreatitis.[4] Although our series found good percentage of patients have history of gall stone pancreatitis or ERCP (more than 40% calculating together). We find 7 out of 12 patients have history of homeopathic medicine intake, there is minimal study to support this but this finding need further study to see actual influence with statistical significance.

Conclusion: Our study found some known factors in history associated to conversion. Clinical examination or USG abdomen is not very helpful to predict conversion. We also suggest a control study to calculate significance of those factors to predict conversion.

References
  1. Simopoulos C, Botaitis S, Polychronidis A, Tripsianis G, Karayiannakis AJ. Risk factors for conversion of laparoscopic cholecystectomy to open cholecystectomy. Surg Endosc. 2005; 19:905-9.

  2. Volkan Genc et al. What necessitates the conversion to open cholecystectomy? A retrospective analysis of 5164 consecutive laparoscopic operations Clinics (Sao Paulo). 2011 Mar; 66(3): 417-420.

  3. Van der Steeg HJ1, Alexander S, Houterman S, Slooter GD, Roumen RM. Risk factors for conversion during laparoscopic cholecystectomy - experiences from a general teaching hospital 2011;100(3):169-73.

  4. Yang TF, Guo L, Wang Q. Evaluation of Preoperative Risk Factor for Converting Laparoscopic to Open Cholecystectomy:AMeta-Analysis. Hepatogastroenterology 2014 Jun;61(132):958-65.

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