Laparoscopic cholecystectomy is a good choice for many patients with liver cirrhosis who need the procedure.
In addition to quickly and effectively addressing the acute illness, laparoscopic cholecystectomy may offer a future advantage, Dr. Vincenzo Neri said at the minimally invasive surgery week annual meeting and endo expo.
"Some cirrhotic patients may be candidates for liver transplantation in the future," said Dr. Neri of the University of Foggia, Italy. "Laparoscopic cholecystectomy offers the chance of fewer right upper quadrant postoperative adhesions" that might complicate later transplant surgery.
He presented a retrospective analysis designed to evaluate the safety and usefulness of a laparoscopic approach in cirrhotic patients undergoing a cholecystectomy. The series comprised 65 patients with hepatic cirrhosis and symptomatic gallstone disease. Of these, six had planned open procedures and the rest laparoscopic procedures. There were 12 conversions to open surgery.
The patients were a mean of 58 years old. More than half had at least two comorbid conditions, including hypertension (14%), cardiac disease (9%), diabetes (12%), respiratory conditions (8%), cerebrovascular disease (4%), and other problems (11%).
Total bilirubin was more than 1 mg/dL in 51% of the group. Albumin was elevated in 61%, and platelets were below 160,000/mcL in 31%. More than a quarter (27%) had a prolonged prothrombin time. About 45% were a Child-Pugh class A, 20% were class B, and the rest were class C.
Cirrhosis was known preoperatively in only 24 patients. The diagnosis was made during the hospital stay in the rest of the patients.
The most common indication for admission and surgery was biliary colic (37%). Other indications included acute cholecystitis (17%), acute biliary pancreatitis (5%), gallbladder and common bile duct stones (5%), and acute cholecystitis with cholangitis (1%). Other indications were not specified.
Of the 12 conversions, 4 were due to acute cholecystitis. Other reasons for conversion were previous laparoscopy (3), acute pancreatitis (2), hypertrophic left hepatic lobe (2), and intraoperative cholangiography (1).
The investigators compared surgical outcomes to those in an unselected control group of 81 patients without cirrhosis who had undergone laparoscopic cholecystectomy.
The mean operative time in the laparoscopic cirrhotic group was 89 minutes – similar to that in the control group (85 minutes). Among the cirrhotic patients, both planned open and converted procedures lasted about the same time (141 and 149 minutes, respectively).
Length of stay was 5 days in the cirrhotic laparoscopy group and 3 in the noncirrhotic control group. Patients with open or converted surgery stayed a mean of 9 and 8 days, respectively.
The blood transfusion rate was 4% in the laparoscopic group, and 17% in both the open and converted groups. Fourteen percent of the laparoscopic group needed transfusion of blood products, compared with 17% of the open group and 33% of the converted group. Transfusions were significantly more common among patients with a Child-Pugh B score, with 26% needing plasma, 21% blood, and 21% platelets. Among Child-Pugh class A patients, 4% needed plasma, 3% blood, and 3% platelets. There were no transfusions in the Child-Pugh class C patients.
Postoperative complications were significantly more common among patients with planned open and converted procedures than total laparoscopies (27% vs. 5%). These included transient ascites (16% vs. 8%) and wound hematoma (8% vs. 4%).
The meeting was presented by the Society of Laparoendoscopic Surgeons and affiliated societies. Dr. Neri had no financial disclosures.