Purpose: In this study, we aimed to discuss the laparoscopic cholecystectomy in patients with end stage renal disease compared to the general population. Materials and Methods: We retrospectively evaluated a group of patients with (n = 45) and without (n = 90) end-stage renal disease undergoing laparoscopic cholecystectomy. The groups were compared in terms of length of surgery; duration of hospitalization after surgery; use of blood derivatives; mortality rates; and perioperative, postoperative, and postdischarge complications. Results: Patients with end-stage renal disease exhibited a higher frequency of associated diseases; lower hemoglobin levels; and elevated alkaline phosphatase, blood urea nitrogen, and creatinine values. Statistically significant differences were found between the two groups regarding length of surgery (83.6 ± 14.88 vs. 71.7 ± 11.42 minutes; p < 0.001); duration of hospitalization (1.7 ± 0.47 vs. 1.4 ± 0.31 days; p < 0.001). In the group of patients with end-stage renal disease had significantly higher perioperative ( p = 0.011), postoperative ( p < 0.001), and postdischarge complication ( p = 0.011) rates. Among all patients with end-stage renal disease, 12 (26.7%) were converted to an open procedure ( p < 0.001). Conclusion: Despite higher complication rates of laparoscopic cholecystectomy in end-stage renal disease patients, laparoscopic cholecystectomy could be performed safely in patients with end-stage renal disease with low levels of complications and no associated mortality.
The prevalence of gallstones in patients with end-stage renal disease (ESRD) undergoing dialysis is similar to the prevalence in the general population [
In this study, we aimed to discuss the laparoscopic cholecystectomy in patients with end stage renal disease compared to the general population.
From July 2006 to October 2011, 135 consecutive patients who underwent laparoscopic cholecystectomy for symptomatic gallstones were divided into two groups depending on whether they had ESRD (case group) or not. Data was evaluated retrospectively. Of these 135 patients, 45 had ESRD and were on dialysis. All of the patients were provided medical history followed by physical examination. Demographic features, co-morbidities (in ad- dition to ESRD), causes of renal failure, the American Society of Anesthesiologists (ASA) score and previous abdominal surgery were evaluated. Patients who had history of continuous ambulatory peritoneal dialysis (CAPD) were accepted as having previous abdominal surgery. Preoperative abdominal ultrasonography was performed in all patients, revealed gallstones with no additional pathologic findings except renal changes. Patients with acute cholecystitis, cholangitis, pancreatitis or suspected malignancy were excluded from the study. The study was ap- proved by the Institutional Ethics Committee.
All patients underwent laparoscopic cholecystectomy with standard 4 port technique under general anesthesia. Pneumoperitoneum was created using a Veress needle and then first port was inserted supraumbilically. If a pa- tient had previous abdominal surgery or CAPD operation, pneumoperitoneum was created through the first port supraumbilically by means of the open technique. Cholecystectomy was elective in all patients.
Preoperative laboratory findings, perioperative findings, duration of operation, length of hospital stay after surgery, complications and conversion to open rate were recorded prospectively.
The data were presented as means ± standard deviation. Compliance to normal distribution of data was check- ed by using Kolmogorov-Smirnov test. Homogeneity of variances was evaluated with Levene’s homogeneity test. A non-parametric test (Mann Whitney U test) was used for the data not normally distributed to compare mean values; categorical variables were analyzed with Pearson chi-square test or Fisher exact test. A value of 0.05 was taken as the level of significance.
The study included 135 patients; 45 in the case group and 90 in the control group. Demographic and clinical characteristics can be seen in
Preoperative laboratory data of two groups are shown in
Clinical parameters are summarized in
Parameter | With ESRD (n = 45) | Without ESRD (n = 90) |
---|---|---|
Age (mean ± st deviation) | 48.4 ± 12.09 | 49.6 ± 17.08 |
Sex (M/F) | 19/26 | 38/52 |
Chronic cholecystitis | 45 | 90 |
ESRD treatment HD | 45 | - |
ASA score 3 and greater | 45 (100%) | 20 (22%) |
BMI (kg/m2) | 25 ± 1.31 | 27 ± 1.24 |
HCV and HBV | 8 (17%) | 0 |
Associated diseases | 34 (75.5%) | 31 (34.4%) |
Previous surgery | 21 (46%) | 10 (11.1%) |
ASA, American Society of Anesthesiologists; BMI, body mass index; ESRD, end-stage renal disease; HCV, hepatitis C virus; HBV, hepatitis B virus; F, female; M, male; N, without ESRD.
Variable | With ESRD (n = 45) | Without ESRD (n = 90) | p |
---|---|---|---|
Hemoglobin (g/dL) | 10.4 ± 1.02 | 12.1 ± 1.6 | <0.001 |
WBC (/μL) | 6624 ± 1048 | 7680 ± 1554 | 0.246 |
Platelet (×103/μL) | 205.2 ± 86.1 | 250 ± 78.3 | 0.886 |
BUN (mg/dL) | 64.3 ± 16.2 | 14.1 ± 5 | <0.001 |
Creatinine (mg/dL) | 6.3 ± 0.53 | 0.86 ± 0.2 | <0.001 |
Bilirubin (total) (mg/dL) | 0.73 ± 0.26 | 0.88 ± 0.31 | 0.160 |
Bilirubin (direct) (mg/dL) | 0.27 ± 0.1 | 0.38 ± 0.12 | 0.157 |
AST (IU/L) | 26.6 ± 12.06 | 29.2 ± 15.18 | 0.503 |
ALT (IU/L) | 29.1 ± 5.98 | 33.2 ± 13.98 | 0.112 |
ALP (IU/L) | 181.1 ± 32.36 | 78.2 ± 27.72 | <0.001 |
PTT (second) | 13.3 ± 0.8 | 13 ± 1.3 | 0.226 |
aPTT (second) | 29.9 ± 1.7 | 30.3 ± 4.3 | 0.636 |
INR | 1.07 ± 0.1 | 1.01 ± 0.1 | 0.150 |
perforation of the gallbladder (two patients with ESRD, 6%; four patients without ESRD, 3.3%) and bleeding from the liver bed (two patients with ESRD, 6%; one patient without ESRD, 1.1%). Twelve patients were con- verted to open in the case group; only 2 patients were converted to open in control group. Conversion rate was significantly higher in the case group (p < 0.001). The reason for conversion in both groups was difficult dissec- tion because of adhesions. Comparing the duration of ESRD among patients who underwent laparoscopic cho- lecystectomy (n = 33, 65.6 ± 55.4 months) and those converted to open cholecystectomy (n = 12, 71.2 ± 35.9 months), no statistically significant difference was found (p = 0.697). The duration of previous CAPD catheter was 16.5 ± 8.7 months. Postoperative complications were seen only in patients with ESRD and included three cases (6.6%) of abdominal wall hematoma, two cases (4.4%) of superficial trocar site infection, two cases (4.4%) of wound dehiscence, and one case (2.2%) of bile leakage from the cystic duct. One patient had bile drainage from abdominal drain on the second postoperative day underwent emergency endoscopic retrograde cholangio- pancreaticography. Sphincterotomy and temporary biliary stent placement were performed. This patient was
Variable | With ESRD (n = 45) | Without ESRD (n = 90) | p |
---|---|---|---|
Surgery time, min (mean) | 83.6 ± 14.88 | 71.7 ± 11.42 | <0.001 |
Length of hospitalization, days (mean) | 1.7 ± 0.47 | 1.4 ± 0.31 | <0.001 |
Perioperative complications | 4 (8.9%) | 5 (4.4%) | 0.011 |
Postoperative complications | 8 (17.8%) | 0 | <0.001 |
Postdischarge complications | 4 (8.9%) | 0 | 0.011 |
Conversion rate | 12 (26.7%) | 2 (2.2%) | <0.001 |
Use of blood derivatives | 1 (2.2%) | 0 | 0.333 |
ESRD, end-stage renal disease; N, those without ESRD.
treated without any complications and no additional intervention was needed. There was no mortality in either group. Hospital stay was 1.7 ± 0.47 days in the case group and 1.4 ± 0.31 in the control group (p < 0.001).
The incidence of biliary stones does not increase in ESRD patients. Patients with ESRD have been regarded as being for surgery because of platelet dysfunction, activated fibrinolysis and impaired healing. In our study, there was significant more complications, higher conversion rates and longer hospital stay in ESRD group. Fortunately, these complications were easily handled without any serious morbidity or mortality. However, certain co-mor- bidities like hepatitis C virus (HCV) infection may change this opinion. In this group of patients, there are no additional risk factors when compared to the general population. It is an important cause of chronic liver disease and predispose to gallbladder stone among ESRD patients. Estimates of the prevalence of HCV antibodies in patients on hemodialysis (HD) in developed countries range from 7% to 40% and are higher in the developing countries of the world [
The incidence of active HCV disease is similar in both ESRD patients and general population (nearly 85%) [
Lowell et al. demonstrated a high prevalence of cholelithiasis in diabetic patients with ESRD (27.3%) [
Single dose prophylactic intravenous antibiotic is recommended in ESRD patients to decrease the peritonitis risk due to gallbladder perforation and spillage of bile and gallstones [
Data of this study group basically reflects the common laboratory and clinical characteristics of ESRD pa- tients. These consist of lower hemoglobin levels, mild thrombocytopenia, elevated phosphatase, blood urea ni- trogen, and creatinine values and normal coagulation profile and high American Society of Anesthesiologists scores. In this study, there is no difference between the groups in terms of usage of blood derivates due to he- morrhage. We conclude that in general, uremic bleeding which is widely known, is well-controlled with HD treatment thus bleeding tendency should not be a major problem. Similarly, bleeding is not a problem in CAPD patients in LC [
There is no consensus about the management of asymptomatic gallstone disease among the ESRD patients and no evidence was found for increased morbidity or mortality related to gallbladder disease. Cholecystectomy is indicated only in symptomatic cholelithiasis patients with ESRD, as in the general population [
In our study, statistically significant differences were found regarding perioperative complications between the two groups (p = 0.011). Gentle handling and grasping the gallbladder is important to avoid perforation. Fria- ble gallbladders can be aspirated before starting the surgery. We aspirated three patients’ gallbladders intraope- ratively before we dissected Calot’s triangle. Although four patients’ gallbladders (two in each group) were per- forated during the grasping, spillage of bile or stones did not occur.
Patients with ESRD have higher additional disease rate and greater ASA scores. The co morbidities are leng- thened hospital stay after laparoscopic cholecystectomy in patients with ESRD; mean length of hospitalization is significantly higher for patients with ESRD than it is for patients without ESRD (p < 0.001).
Approximately 5% to 15% of the patients (without ESRD) undergoing laparoscopic cholecystectomy require conversion to open cholecystectomy for various reasons [
In the first cases with ESRD, operation time was higher compared to the general population due to limited la- paroscopic experience. All patients in this study were operated on electively, and only one of them (2.2%) need- ed blood derivatives.
Postoperative complications were seen only in the case group. Most of the postoperative complications seen in patients with ESRD were less severe and could be conservatively treated. Postoperatively, three patients (9%) with abdominal wall hematomas were treated conservatively. Care must be taken when placing the trocars and when dissecting the gallbladder from the liver bed. Post discharge complications were treated clinically and re- solved.
The limitations of this study were retrospective data collection and small number of patients. Therefore, we aimed compare two different populations; it is impossible to randomize between groups. Even though there was a non-randomized control group, this type of study protocol exactly serves to test our hypothesis.
In conclusion, laparoscopic cholecystectomy is feasible and safe for ESRD patients, and perioperative, post- operative, and postdischarge complications can be conservatively treated and are probably less severe than with an open procedure. The laparoscopic technique requires a certain level of experience. The limited number of pa- tients used in this study will serve as a guide for other surgeons. Further studies with larger number of patients might have sufficient power to show statistically significant complication rates.