Laparoscopic Cholecystectomy in Acalculous Biliary Disease

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Laparoscopic Cholecystectomy in Acalculous
Biliary Disease

• Anthony Freeman
• April 2000

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Acalculous Biliary Disease

• First described gt100 years ago
• Duncan J., 1884, North J. Med 2151-2
• Femoral hernia gangrene of gall bladder
• extravasation of bile peritonitis death.
• Acute acalculous cholecystits associated with
  major trauma, burns, sepsis
• Chronic acalculous cholecytitis increasing
  recognised in otherwise healthy outpatients
• Savoca P.E. et al., 1990, Ann Surg 211433-7

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Acalculous Biliary Disease

• 5-10 patients with classic biliary colic
• Absence of calculi (USS/pathology)
• Absence of other pathology (PUD)
• Two proposed entities
• Cholecystitis/cholesterosis/adenomyosis (path)
• Biliary dyskinesia (functional)

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Laparoscopic Cholecystectomy

• Acalculous cholecystitis
• benefit with open cholecystectomy
• Yap L. et al., 1991, Gastroenterology 101786-93
• Laparoscopic cholecystectomy
• Less morbidity
• Shortened hospital stay
• Earlier return to work

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Hepatobiliary Scanning

• Noninvasive
• Assesses excretion of bile into GIT
• 99mTechnecium injection
• Cholecystokinin administration
• Objective GB ejection fraction (Ngt35)
• Subjective reproduction of symptoms (IBS)

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Question

• Which patients with a clinical diagnosis of
  biliary colic and a normal ultrasound will loose
  their symptoms after laparoscopic
  cholecystectomy?
• Can these patients be distinguished prior to
  surgery?

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Literature Review

• Medline search 54
• Laparoscopic cholecysectomy
• Acalculous cholecystitis
• Biliary dyskinesia
• Cholecystokinin
• English/Human/1990-Feb2000 48

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Literature Review

• 48 Citations
• 18 Abstracts
• 8 Papers and 2 Cited Papers
• 1 Study presented
• Journal impact factor and availability
• Sample size, methodology and results
• Does it answer our question?

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• Laparoscopic cholecystectomy alleviates pain in
  patients with acalculous biliary disease
• Paul Frassinelli et al.
• Pennsylvania, USA
• Surgical Laparoscopy and Endoscopy 830-34
• 1998

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Methods

• Retrospective review of patients with acalculous
  biliary disease who had a laparoscopic
  cholecystectomy (1990-1994)
• Follow-up telephone interview of symptoms
• ? Duration of follow-up
• ? Chi-squared method

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Patients

• 2557 laparoscopic cholecystectomies
• 243 (9.5) with acalculous biliary disease
• 195 (80.2) chronic acalculous cholecystitis
• 30 (12.3) acute acalculous cholecystitis
• 18 (7.4) biliary dyskinesia
• 184 (75.5) female 59 (24.3) male
• Age 14-80 (43.715.5)
• 181 (75) successfully followed-up

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Results

• Hospital Stay 3.93.0 days
• Post-operative stay 1.71.6 days (0-12)

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Symptom Outcome

• Pre-op symptoms 1-660 days (35.884.6)

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Hepatobiliary Scanning

• 177 (72.8) HIDA Scans
• Ejection fraction 1814.2 (0-92)
• 99 (55.9) symptomatic with CCK
• 238 (97.5) symptomatic CCK or EFlt40
• No association between ejection fraction and
  symptom relief/pathological findings

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Duration of symptoms

• Patients who suffered longer were more likely to
  obtain relief from cholecystectomy
• (p0.05)
• 25 of patients will improve spontaneously
• with a duration of symptoms lt 6 months
• Goncalves R.M. et al., 1998, The Am Surgeon
  64493-497

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Conclusion

• A test has not been identified which accurately
  and reliably selects patients with acalculous
  biliary colic for cholecystectomy
• Hepatobiliary Scan
• sensitivity 0.56 specificity 0.57
• Smythe A.W. et al., 1998, Gut 43571-574
• positive p.v. 0.78 negative p.v. 0.20
• Adams D.B. et al., 1998, The Am Surgeon 641-5

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• History
• Symptoms
• Duration
• Sex/Age

Acalculous Biliary Disease
Hepatobiliary Scan
Abdominal Ultrasound
Exclude alt. diagnosis
Stones
Cholecystectomy
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Caution

• Increase in the proportion of patients having
  cholecystectomy for acalculous disease
• Johanning J.M., 1998, The Am Surgeon 64643-647
• 1985-1990 90/3247 (2.3)
• 1990-1995 211/3247 (4.2)
• Jones-Monahan K., 1999, JSLS 3221-224
• 3 of patients will need another operation

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Studies