Abstract
BackgroundWith improved laparoscopic techniques, experience, and availability of newer tools and instruments like ultrasonic shears; laparoscopic cholecystectomy (LC) became a feasible option in cirrhotic patients, the aim of this study was to analyze the outcome of LC in cirrhotic patients. Methods: We retrospectively analyzed 213 cirrhotic patients underwent LC, in the period from 2011 to 2019; the overall male/female ratio was 114/99. Results: The most frequent Child-Turcotte-Pugh (CTP) score was A, The most frequent cause of cirrhosis was hepatitis C virus (HCV), while biliary colic was the most frequent presentation. The harmonic device was used in 39.9% of patients, with a significant correlation between it and lower operative bleeding, lower blood and plasma transfusion rates, higher operative adhesions rates, lower conversion to open surgery and 30-day complication rates, shorter operative time and post-operative hospital stays where operative adhesions and times were independently correlated. The 30-day morbidity and mortality were 22.1% and 2.3% respectively while overall survival was 91.5%, higher CTP, and model for end-stage liver disease (MELD) scores, higher mean international normalization ratio (INR) value, lower mean platelet count, higher operative bleeding, higher blood, and plasma transfusion rates, longer mean operative time and postoperative hospital stays were significantly correlated with all conversion to open surgery, 30-day morbidities and mortalities. Conclusion: LC can be safely performed in cirrhotic patients. However, higher CTP and MELD scores, operative bleeding, more blood and plasma transfusion units, longer operative time, lower platelet count, and higher INR values are predictors of poor outcome that can be improved by proper patient selection and meticulous peri-operative care and by using Harmonic scalpel shears.
Highlights
Despite cirrhosis was previously considered as absolute or relative contraindication for laparoscopic cholecystectomy (LC) due to deaths from postoperative liver failure, sepsis, and hemorrhage [5]; LC became a safe and effective procedure in patients with symptomatic cholelithiasis and liver cirrhosis especially Child-Turcotte-Pugh (CTP) A and B after improved laparoscopic surgery, availability of newer instruments and better peri-operative care [8,9], it remains a challenging procedure that should be performed by surgeons with experience in both the procedure and the peri-operative management of those patients [3]
Acute cholecystitis (AC), biliary colic, and gall stone pancreatitis were the presentations in 26.3%, 68.1%, and 5.6% of them respectively
Pre-operative upper endoscopy (UE) was performed in 65.3% of patients that showed varices and portal hypertensive gastropathy (PHG) in 23% and 6.6% of them respectively
Summary
Cholelithiasis in cirrhotic patients has a higher prevalence (2–3 folds) in comparison to the general population due to several reasons (I.e. intravascular hemolysis from hypersplenism, reduced gallbladder motility and emptying due to high estrogen levels, and metabolic liver failure) [1,2,3,4,5,6,7].Despite cirrhosis was previously considered as absolute or relative contraindication for laparoscopic cholecystectomy (LC) due to deaths from postoperative liver failure, sepsis, and hemorrhage [5]; LC became a safe and effective procedure in patients with symptomatic cholelithiasis and liver cirrhosis especially Child-Turcotte-Pugh (CTP) A and B after improved laparoscopic surgery, availability of newer instruments (i.e. ultrasonic shears) and better peri-operative care [8,9], it remains a challenging procedure that should be performed by surgeons with experience in both the procedure and the peri-operative management of those patients [3]. There are increased rates of conversion to open surgery, morbidities, and mortalities after LC in cirrhotic patients in comparison to the general population [5,6,10,11] Those outcomes are affected by several risk factors (i.e. Intra-operative bleeding, transfusion requirements, CTP and Model for end-stage liver disease (MELD) scores) [3]. The 30-day morbidity and mortality were 22.1% and 2.3% respectively while overall survival was 91.5%, higher CTP, and model for end-stage liver disease (MELD) scores, higher mean international normalization ratio (INR) value, lower mean platelet count, higher operative bleeding, higher blood, and plasma transfusion rates, longer mean operative time and postoperative hospital stays were significantly correlated with all conversion to open surgery, 30-day morbidities and mortalities. Higher CTP and MELD scores, operative bleeding, more blood and plasma transfusion units, longer operative time, lower platelet count, and higher INR values are predictors of poor outcome that can be improved by proper patient selection and meticulous perioperative care and by using Harmonic scalpel shears
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