Results
From 1999 to 2008, 987 patients underwent a cholecystectomy. Among these, 105 patients (10.64%) underwent a primary open operation and 51 patients (5.17%) experienced a conversion to laparotomy after a laparoscopic attempt, so these 156 patients were excluded from the study. Among the remaining 831 patients, 495 (59.57%) were female. The main characteristics of these patients are shown in Table 1 Twenty-nine (3.49%) patients were diabetic and 20 (2.41%) were cirrhotic. The median age (25–75th percentile) was 57 years (43–68).
The operative trend during the nine-year period with regard to the approaches performed is shown in Figure 1 and Table 2 which compare the number of laparoscopic cholecystectomies performed with open cholecystectomies and conversions to laparotomy. The study started when the laparoscopic cholecystectomy had already become the standard of care in our practice, replacing the open approach in most uncomplicated patients. At the beginning of 1999, the percentage of open cholecystectomy was higher, as a residual of the previous trend.
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Figure 1.
The operative trend during the nine-year period of study, with regard to the approaches performed. The study started when the laparoscopic cholecystectomy had already become the standard of care at our Department, replacing the open approach in most uncomplicated patients. A residual of the previous trend is evident at the beginning of the 1999, when the percentage of open cholecystectomy was higher. VLS: laparoscopic cholecistectomies; OPEN: open cholecystectomies; CONV: conversions.
Median time (25–75th percentile) from admission to operation was 2 (1–5) days, and median (25–75th percentile) postoperative stay was 2 (1–3) days with a median (25–75th percentile) overall hospital stay of 4 (2–8) days.
The main causes of admission followed by surgery were: abdominal pain, jaundice, acute pancreatitis and abdominal trauma.
At discharge, all patients were diagnosed as follows (Figure 2): 358 patients (43.08%) were operated on because of at least one previous episode of biliary colic before the one at admission and among these, 314 (37.79%) had simple gallstones at pathological exam, 36 (4.33%) had chronic lithiasic cholecystitis and 8 (0.96%) had gallbladder carcinoma. One hundred seventeen patients (14.08%) presented with acute lithiasic cholecystitis (defined by the presence of right upper quadrant pain with fever, raised WBC count, ultrasonographic evidence of gallstones with associated signs of inflammation). One hundred twenty-two patients (14.68%) were operated on because of an increase in bilirubin level (51 of these with radiological detection of choledocholithiasis and 26 with associated increase of WBC count). Thirteen patients (1.56%) were operated on because of a previous episode of jaundice with normal bilirubin at admission. Six patients (0.72%) had gallbladder adenomas. Six patients (0.72%) had cholangitis. Three patients (0.36%) had biliodigestive fistula and one patient (0.12%) had acalculous cholecystitis. No Mirizzi or Bouveret syndrome was detected.
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Figure 2.
Criteria of inclusion and indications to surgery with related diagnosis at discharge.
The main characteristics of this subpopulation of 176 patients are reported in Table 3 Most of these patients (64.77%) were female, with a median age (25–75 percentile) of 54 (44–65) years.
At follow-up, 150 of 176 patients (85,23%) were contacted by telephone (19 were unavailable and 7 died for causes unrelated to gallbladder disease) and an oral questionnaire was administered with the following results: 6 patients (4%) experienced early recurrence of pain within 30 days after the cholecystectomy; 34 patients (22,66%) experienced late recurrence of pain (30 days after operation); 107 patients (71,33%) referred no improvement in symptoms after operation, with persistence of the same preoperative vague pain whose source required further exams (e.g. gastroscopy, computed tomography, magnetic resonance imaging) to be identified. Only 3 patients (2%) referred complete disappearance of pain after operation. In conclusion, for 147 patients (98%) included in follow-up, cholecystectomy determined no early or late improvement in symptoms, confirming that these symptoms were not related to gallstones and the operation should have been avoided.