ORIGINAL ARTICLE
Early Hospital Readmission After Laparoscopic Cholecystectomy Gurcan Simsek, MD,* Adil Kartal, MD,w Baris Sevinc, MD,* Halil I. Tasci, MD,w and Serhat Dogan, MDw
Introduction: Laparoscopic cholecystectomy (LC) now has become the golden standard in the treatment of symptomatic gallstone cholecystitis. Aim: This retrospective analysis was conducted to clarify the reasons of early return to the hospital after discharge following a procedure like LC that has been frequently performed in daily surgical practice. Materials and Methods: This study covers 586 patients, who were called to follow-ups and thus evaluated, of 676 patients who had had LCs at Meram Medical School’s General Surgery Clinic between January 2010 and May 2011. Findings: The rate of representation to the hospital during the early phase following LC was found to be 2.4% in our study. It was observed that 71% of returning patients had presented to the hospital with complaints of abdominal pain. Discussion: We believe that the rate of 2.4% early return to the hospital in our series is a bit high when all the complications are taken into consideration. This retrospective analysis, however, has shown that this rate can further be decreased by taking simple measures. Key Words: readmission, complication, laparoscopic, cholecystectomy
(Surg Laparosc Endosc Percutan Tech 2015;25:254–257)
O
ne hundred five years after the first cholecystectomy to remove gallstones performed by Carl Langenbuch in 1882, the first laparoscopic cholecystectomy (LC) was successfully performed by Philippe Mourret in 1987 in France. After this date LC has rapidly become widespread all around the world. So much so that, while in 1990 LC made up for 10% of all cholecystectomies performed in the United States, this percentage reached as high as 90% in 1992. No other novelty spread so rapidly in the history of surgery. LC now has become the golden standard in the treatment of symptomatic gallstone cholecystitis.1 The possible complications seen after LC are generally identical to that of the classic cholecystectomy procedure. In LC, however, complications related to the pneumoperitoneum and the trocars might also be seen.2 This retrospective analysis was conducted to clarify the reasons of early return to the hospital after discharge
Received for publication September 23, 2014; accepted March 2, 2015. From the *Department of General Surgery, Konya Research and Training Hospital; and wDepartment of General Surgery, Meram Medical Faculty, Necmettın Erbakan University, Konya, Turkey. The authors declare no conflicts of interest. Reprints: Gurcan Simsek, MD, Selcuk mah. Cevreyolu cad. No:28/30, 42100 Selc¸uklu/Konya, Turkey (e-mail: [email protected]) Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
254 | www.surgical-laparoscopy.com
following a procedure like LC that has been frequently performed in daily surgical practice.
MATERIALS AND METHODS This study covers 586 patients, who were called to follow-ups and thus evaluated, of 676 patients who had had LCs at Meram Medical School’s General Surgery Clinic between January 2010 and May 2011. All the patients were operated by the classic 4-port (two 10 mm and two 5 mm) technique. The cases where the surgeons passed on to the open procedure, procedures performed from a single incision, and cases for which incomplete or excess ports were used were excluded from the study. If there had been no risk factors for the surgical site in elective LCs, no prophylactic antibiotics were used. Drains were not routinely used following LCs. Trocar sites, especially subnavel trocar site fascia, were routinely sutured in obese and diabetic cases. LC patients, who were older than 50 were discharged on postoperative day 2, whereas those younger than 50 were discharged on postoperative day 1 without any problems. Within the scope of this retrospective analysis, the LC patients who had complaints about this procedure within 30 days after discharge were evaluated in detail. Those patients among the mentioned ones who were hospitalized for 24 hours or more were included in the study. The demographic data, whether the procedure was urgent or not, presentation complaints, time of the start of complaints, diagnosis methods, and the diagnoses of the patients included in the study were recorded. Further, the duration of hospitalization and treatment results were also evaluated.
FINDINGS Fourteen of 586 patients covered by this study presented to the hospital again during the early phase and were treated by hospitalization. The rate of representation to the hospital during the early phase following LC was found to be 2.4% in our study. Among the 14 returning patients, 10 were (71%) female, whereas 4 (29%) were male. The mean age of the patients was 46 years (range, 26 to 82 y). Seventy-four (13%) of 586 patients covered by the study had emergency LC procedures. The diagnosis of all the emergency LCs was acute cholecystitis. It was seen that 8 (57%) of 14 returning patients had elective LCs, whereas 6 (43%) had emergency LCs. It was observed that 71% of returning patients had presented to the hospital with complaints of abdominal pain. Other presentation symptoms and their incidence rates are shown in Table 1. Among the returning cases following LC, the most frequent diagnosis was bilioma. All
Surg Laparosc Endosc Percutan Tech
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TABLE 1. Presentation Symptoms and Incidence Rates
Symptoms
Incidence (%)
Abdominal pain Abdominal swelling Nausea Vomiting Inability to pass gas-stool Fever Pain in the scar area Leakage from the scar area Jaundice
71 36 14 28 28 42 21 7 7
these cases had abdominal pain and fever. Two cases also had vomiting complaints. In 4 (30%) of 14 patients, who had returned to the hospital during the early phase after their discharge following LC in our series, bilioma (bile leakage) was present. All these cases had been detected during the postoperative period and it was seen that no drains were used for any of them. The common presentation symptoms of these patients were abdominal pain and fever. In addition to these symptoms, 2 patients had vomiting problems. The patients had been diagnosed through ultrasonography (USG). The most frequent finding as achieved by the USG was the high-density fluid in the gallbladder loge. The localization of bilioma in all cases was found to be the subhepatic area. The size of the collection was reported to be 6 to 9 cm. Bilioma cases in this series were treated by USG-guided drainage. None of the cases surpassed daily drain output of 300 mL/d and the patients were followed up without any additional intervention. Drains of 2 patients were removed on the fourth day, whereas the drains of the other 2 were removed on the third day. The bilioma cases were discharged without any problems. No collections were detected by the control USG performed on day 10 after the discharge.
Early Hospital Readmission
Among the patients in this series, 2 incarcerated trocar hernia cases treated through laparotomy presented with complaints of abdominal pain, abdominal swelling, nausea, vomiting, and inability to pass gas-stool. One of these patients was taken into hemodialysis twice because of acute renal failure before the laparotomy. It was learnt that in 2 cases with incarcerated trocar hernia, the hernias were located in the subnavel trocar entry point and that the trocar entry points could not be sutured during the surgeries. One of the cases underwent segmental small bowel resection as it was seen that the incarcerated hernia was the Richter type. It was also seen that the 2 cases treated by laparotomy were not diabetic. The body mass index of one patient was >30, whereas the other’s was 27. The 14 cases evaluated within this retrospective analysis were hospitalized for an average of 2 days (range, 1 to 4 d). When the early returning patients’ time of presentation to the hospital is studied, it was seen that 8 (57%) patients returned to the hospital within the first 7 days, whereas the other 6 returned on various days after the first 7. It is significant that the bilioma and nonspecific abdominal pain cases, which comprise most of the patients in our series, presented to the hospital again within the first 3 days of discharge. The latest return within this series was a case that returned to the hospital 19 days after the discharge and this patient had abscess in the subxiphoid trocar entry point and remaining stone. The most frequent pathology seen in the early returning patients was bilioma with an incidence rate of 30%. Detailed information on the patients is given in Table 2.
DISCUSSION LC has less postoperative pain, shorter hospitalization, less labor loss, and better cosmetic results when compared with open cholecystectomy.3 Further, in LC surgical-site infections are seen less in comparison with open cholecystectomy.4 Despite these advantages, bile duct
TABLE 2. Diagnoses and Therapeutic Approaches to 14 Cases
Diagnosis 1 2 3 4 5
11
Bilioma (subhepatic) Bilioma (subhepatic) Bilioma (subhepatic) Bilioma (subhepatic) Surgical-site infection (subnavel incision) Surgical-site infection (subxiphoid incision) Surgical-site infection (subxiphoid incision) Nonspecific abdominal pain Nonspecific abdominal pain Nonspecific abdominal pain Incarcerated trocar hernia
12 13 14
6 7 8 9 10
Diagnostic Method
Type of Surgery
USG USG USG USG PE
Elective LC Emergency LC Emergency LC Elective LC Emergency LC
PE
Emergency LC
PE
Emergency LC
CT + USG
Emergency LC
CT + USG
Elective LC
CT + USG
Emergency LC
CT
Elective LC
Incarcerated trocar hernia
CT
Elective LC
Subhepatic hematoma Cholangitis
USG USG + MRCP
Emergency LC Elective LC
Treatment Percutaneous drainage Percutaneous drainage Percutaneous drainage Percutaneous drainage Scar exploration and medical treatment Scar exploration and medical treatment Abscess drainage, stone extraction, and medical treatment Medical treatment (NSAI analgesic) Medical treatment (NSAI analgesic) Medical treatment (opioid analgesic) Laparotomy (small bowel resection) Laparotomy (reduction, primary repair) Percutaneous drainage Medical treatment
Duration of Hospitalization (d) 3 4 3 4 2 3 2 2 1 2 16 5 3 7
CT indicates computed tomography; LC, laparoscopic cholecystectomy; MRCP, magnetic resonance cholangiopancreatography; NSAI, nonsteroid antiinflammatory; USG, ultrasonography.
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Simsek et al
injuries, which are the most feared complications of cholecystectomies, are more frequently seen in LCs than open cholecystectomies.5 The incidence of bile duct injuries in LCs are 0.4%, whereas the same rate is reported to be 0.2% for open cholecystectomies.6 LC is a more comfortable procedure than open cholecystectomy. Today this information is also known by patients themselves. The surgeon passes this piece of information when he/she informs the patient about the procedure. But the return of the patient to the hospital after being discharged following such an advantageous procedure is hard both for the patient and the surgeon. The goal of the surgeon in this case should be to diagnose the patient rapidly and to discharge the patient again as soon as possible following appropriate treatment. There are no analyses in literature which state the reasons of early readmission to the hospital after LC procedures. Fourteen of 586 patients covered by this study returned to the hospital during the early phase and were hospitalized and treated thus. The percentage of early return to the hospital following discharge after LC in the series was found to be 2.4%. When the large series regarding LC in literature are studied, it was seen that the rate of complication was reported be between 1.8% and 6.9%.2 Deziel et al7 found 2% rate of complication in their multicentered study covering 77,604 patients which was published in 1993. When these figures are taken into consideration 2.4% early return rate may sound high. Another interesting point in our study was the high rate of return following emergency LCs. Eight of 14 early returning patients had emergency LCs. We believe that the reason for this is that LC is harder in acute cholecystitis and difficulties like prolonged intraoperational time and the possibility that the bladder might be empyemic. The term bilioma not only refers to bile ducts but also to bile accumulation. This term was first defined by Gould and Patel in 1979.8 Biliomas most of the time develop as a complication of biliary surgical intervention. But they may also develop based on trauma, percutaneous procedures in the liver and the bile ducts, endoscopic retrograde cholangiopancreatography, and spontaneous bile duct ruptures.9 The procedure that most frequently causes bilioma is cholecystectomy.10 Biliomas are not only asymptomatic but they can also give way to nonspecific complaints like abdominal pain, abdominal fullness, and nausea-vomiting. Biliomas can also cause bile peritonitis and abscess formation.11 In a bilioma series covering 18 cases Vasquez et al12 stated that the diameter of the bilioma reached a maximum of 19 cm and the bilioma localization was most frequently subhepatic and subdiaphragmatic. The most frequent reason of return flowing LCs in our series was bilioma (30%). All these cases had abdominal pain and fever. Therefore, the immediate complication that needs to be thought of with patients returning with complaints of abdominal pain and fever following LCs should be bile leakage and bilioma. All the bilioma cases in our series were diagnosed through USG and their treatments were performed by USG-guided percutaneous drainage procedure. Thus, the patients suspected to have bilioma should certainly be evaluated by USG. Computed tomography (CT) scan is more sensitive than USG in the diagnosis of biliomas because CTs enable physicians to have more information on whether the collection is bilioma, hematoma, or nonbiliary abscess.13 In the diagnosis of bilioma, following the determination of the size, amount, and localization of the collection through CT its drainage guided by USG or
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CT and the patient’s follow-up with USG seems to be accepted in literature.12–15 The fact that drainage was removed during the early phase and none of the cases surpassed daily drain output of 300 mL/d in the bilioma cases in our series point out to the fact that bile leakage is not related to serious bile duct injuries. If the output is >300 mL/d and the drainage continues >5 to 7 days in a case with drainage because of bilioma, large bile duct injury should be considered.1 Trocar entry point hernias are seen between 0.14% and 3% of the cases following all laparoscopic procedures.16 These hernias cause Richter (pincement laterale) type hernias and might give way to bowel obstruction.17,18 Trocar hernia development following LC is a rare but well-known complication. The incidence of trocar hernias following LCs has been reported to be 0.02% to 5% in literature.19,20 Most of the trocar hernias seen after LCs take place in the subnavel trocar entry point and in entry points where 10 mm or larger trocars are used.21 The percentage of incarcerated trocar hernias among the early returning patients following LC in our series is 14%. Within this series 2 patients treated by laparotomy were also operated because of incarcerated trocar hernia. CT was very useful in the detection of incarcerated trocar hernias in our cases. The most significant risk factors in the development of trocar hernias are diabetes and obesity.22 Studies in literature state that suturing especially 10 mm subnavel trocar entry points decrease the incidence rate of trocar hernias.23,24 The incidence rate of shoulder pain following laparoscopic procedures has been stated as 20% to 25% in literature.24,25 It is known that this symptom is related to the compression of gas under the diaphragm or the irritant effect of gas in the peritoneum. However, no information on severe abdominal pain with unknown etiology following LC can be found in the literature. Three cases in our series presented to the emergency department with complaints of severe abdominal pain within 24 hours of discharge. These cases had severe abdominal pain without acute abdomen findings. Abdominal CT scans were performed for cases with normal abdominal USG results and no pathologies were seen. The patients received analgesic and fluid replacement. Two patients responded to simple nonsteroid anti-inflammatory drugs, but in 1 case the pain was controlled by a weak-effect opioid. All 3 cases stopped feeling pain within 24 hours of hospitalization and they no longer needed analgesics. We were unable to find a reason explaining abdominal pain in these 3 cases. Surgical-site infections are seen less in LCs than open cholecystectomies.4 LC performed because of chronic stone cholecystitis is an example of clean-contaminated scar and it has prophylactic antibiotic indication. In a study conducted by Uludag˘ et al,26 however, the authors concluded that prophylactic antibiotic administration in cholecystectomies did not reduce surgical-site infections. Therefore, prophylactic antibiotic administration for cases without risk factors may not be needed. We have not been using prophylaxis for elective LC cases in the low-risk group at our clinic. The reason of return for 3 cases in our series is surgical-site infection. Two of these 3 cases had emergency operations because of acute cholecystitis. Both of them were diabetic. Both cases had prophylaxis. Infection developed in the subxiphoid incision in both cases. It was observed that the gallbladder was perforated during the surgery and that it was removed from the abdomen after being placed in a bag in the abdomen.
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The subhepatic hematoma case in the series had presented to the emergency department with complaints of abdominal pain and fever on the third day after discharge. The subhepatic collection detected through the abdominal USG of the patient was interpreted as bilioma and when percutaneous drainage was performed to the patient hematoma was seen. About 250 mL of hematoma was drained and the patient’s symptoms regressed. We think that this hematoma was caused by the bleeding in the form of a leak from the gallbladder bed. Therefore, we believe that paying utmost attention to the hemostasis during the surgery may eliminate one of the reasons of early return to the hospital following LC. This study was conducted to clarify the reasons of early return to the hospital following a comfortable operation like LC. We believe that the rate of 2.4% early return to the hospital in our series is a bit high when all the complications are taken into consideration. This retrospective analysis, however, has shown that this rate can further be decreased by taking simple measures. The leading measure that can be taken is to be more attentive to the bile and blood leaks from the gallbladder bed during the surgery. Moreover, performing prophylaxis for cases in the risk group for surgical-site infection and suturing the subnavel trocar for cases in the risk group are among the other significant measures. We also believe that detecting complications before the patient’s discharge will bring about better results than the return of the patient in the early phase. Therefore, patients who are disinterested in their surroundings, who are restless and inappetent should not be discharged. But return to the hospital in the early phase following LC will continue to exist, as it does in every surgical intervention, despite all the measures taken. We believe that studies conducted with larger series may determine the rate of early return following LCs.
8. 9.
10. 11. 12. 13. 14.
15.
16. 17.
18. 19. 20.
REFERENCES 1. Hunter JG, Thompson SK. Laparascopic cholecystectomy, intraoperative cholangiography and bile duct exploration. In: Fischer JE, ed. Mastery of Surgery, 5th ed. Philadelphia: Lippincott Williams &Wilkins; 2006:1342–1354. 2. Alexander PN, Nathaniel JS. Cholecystectomy (open and laparascopic). In: Zinner MJ, Ashley SW, eds. Maingot’s Abdominal Operations, 11th ed. Boston: McGraw-Hill Companies; 2007:892–899. 3. McMahon AJ, Russell IT, Baxter JN, et al. Laparoscopic versus mini laparotomy cholecystectomy: a randomized trial. Lancet. 1994;1:135–138. 4. Barbaros U. Minimal invazif cerrahide enfeksiyon riski [Infection risk in minimally invasive surgery]. ANKEM Derg. 2010;24(Ek 2):72–76. 5. Calvete J, Sabater L, Camps B, et al. Bile duct injury during laparoscopic cholecystectomy: myth or reality of the learning curve? Surg Endosc. 2000;14:608–611. 6. Strasberg S, Hertl N, Soper N. An analysis of the problem of biliary injury during laparascopic cholecystectomy. J Am Coll Surg. 1995;180:101–125. 7. Deziel DJ, Millian KW, Economou SG, et al. Complications of laparoscopic cholecystectomy: a national survey of 4,292
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26.
Early Hospital Readmission
hospitals and an analysis of 77,604 cases. AM J Surg. 1993; 165:9–14. Gould L, Patel A. Ultrasound detection of extrahepatic encapsulet bile: “bilioma”. AJR. 1979;132:1014–1015. Binmoeller KF, Katon RM, Shneidman R. Endoscopic management of postoperative biliary leaks: review of 77 cases and report of two cases with bilioma formation. Am J Gastroenterol. 1991;86:227–231. Gleen F. Complication following operations upon the biliary tract. Management of Surgical Complications. Philadelphia: Saunders; 1975:501–533. O¨zkan H, Kaya M. Spontaneous rupture of an intrahepatic bile duct with bilioma secondary to choledocolithiasis. Turk J Gastroenterol. 1999;10:295–297. Vazquez JL, Thoesen MK, Dodds WJ, et al. Evaluation and treatment of intraabdominal biliomas. AJR. 1985;144:933–938. Lee CM, Stewart L, Way LW. Postcholecystectomy abdominal bile collections. Arch Surg. 2000;135:538–542. Fujivara H, Yamamoto M, Tabahashi M, et al. Spontaneous rupture of an intrahepatic bile duct with bi-lioma treated by percutaneous drainage and endoscopic sphincterotomy. Am J Gastroenterol. 1998;93:2282–2284. Stampfl U, Hackert TH, Radeleff B, et al. Percutaneous management of postoperatis¸ve bile leaks after upper gastrointestinal surgery. Cardiovasc Intervent Radiol. 2011;34: 808–815. Lundberg O. Port site metastases after laparascopic cholecystectomy. Eur J Surg. 2000;166(suppl 585):27–30. Merlin TL, Hiller JE, Maddern GJ, et al. Systematic review of the safety and effectiveness of methods used estabilish pneumoperitoneum in laparascopic surgery. Br J Surg. 2003; 90:668–679. Li TC, Richmond M, Cooke ID. Complication of laparascopic pelvic surgery: recognition, management and prevention. Hum Reprod Update. 1997;3:505–515. Bowrey DJ, Blom D, Crookes PF, et al. Risk factors and the prevalence of trocar site herniation after laparoscopic fundoplication. Surg Endosc. 2001;15:663–666. Lajer H, Wıdecrantz S, Heısterberg L. Hernias in trocar ports following abdominal laparoscopy. Acta Obstet Gynecol Scand. 1997;76:389–393. Boughey JC, Nottingham JM, Walls AC. Richter’s hernia in the laparoscopic era: four case reports and review of the literature. Surg Laparosc Endosc Percutan Tech. 2003;13: 55–58. Leron E, Piura B, Ohana E, et al. Delayed recognition of major vascular injury during laparoscopy. Obstet Gynecol. 1998; 79:91–93. Azurin DJ, Go LS, Arroyo LR, et al. Trocar site herniation following laparoscopic cholecystectomy and the significance of an incidental preexisting umbilical hernia. Am Surg. 1995;61: 718–720. Szem JW, Hydo L, Barie PS. A double-blinded evaluation of intraperitoneal bupivacaine vs saline for the reduction of postoperative pain and nausea after laparoscopic cholecystectomy. Surg Endosc. 1996;10:44–48. Cunnife MG, McAnena OJ, Dar MA, et al. A prospective randomized trial of intraoperative bupivacaine irrigation for management of shoulder-tip pain following laparoscopy. Am J Surg. 1998;176:258–261. Uludag MY, Etkin G, Citgez B. The role of prophylactic antibiotics in elective laparoscopic cholecystectomy. JSLS. 2009;13:337–341.
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257
Early Hospital Readmission After Laparoscopic Cholecystectomy Gurcan Simsek, MD,* Adil Kartal, MD,w Baris Sevinc, MD,* Halil I. Tasci, MD,w and Serhat Dogan, MDw
Introduction: Laparoscopic cholecystectomy (LC) now has become the golden standard in the treatment of symptomatic gallstone cholecystitis. Aim: This retrospective analysis was conducted to clarify the reasons of early return to the hospital after discharge following a procedure like LC that has been frequently performed in daily surgical practice. Materials and Methods: This study covers 586 patients, who were called to follow-ups and thus evaluated, of 676 patients who had had LCs at Meram Medical School’s General Surgery Clinic between January 2010 and May 2011. Findings: The rate of representation to the hospital during the early phase following LC was found to be 2.4% in our study. It was observed that 71% of returning patients had presented to the hospital with complaints of abdominal pain. Discussion: We believe that the rate of 2.4% early return to the hospital in our series is a bit high when all the complications are taken into consideration. This retrospective analysis, however, has shown that this rate can further be decreased by taking simple measures. Key Words: readmission, complication, laparoscopic, cholecystectomy
(Surg Laparosc Endosc Percutan Tech 2015;25:254–257)
O
ne hundred five years after the first cholecystectomy to remove gallstones performed by Carl Langenbuch in 1882, the first laparoscopic cholecystectomy (LC) was successfully performed by Philippe Mourret in 1987 in France. After this date LC has rapidly become widespread all around the world. So much so that, while in 1990 LC made up for 10% of all cholecystectomies performed in the United States, this percentage reached as high as 90% in 1992. No other novelty spread so rapidly in the history of surgery. LC now has become the golden standard in the treatment of symptomatic gallstone cholecystitis.1 The possible complications seen after LC are generally identical to that of the classic cholecystectomy procedure. In LC, however, complications related to the pneumoperitoneum and the trocars might also be seen.2 This retrospective analysis was conducted to clarify the reasons of early return to the hospital after discharge
Received for publication September 23, 2014; accepted March 2, 2015. From the *Department of General Surgery, Konya Research and Training Hospital; and wDepartment of General Surgery, Meram Medical Faculty, Necmettın Erbakan University, Konya, Turkey. The authors declare no conflicts of interest. Reprints: Gurcan Simsek, MD, Selcuk mah. Cevreyolu cad. No:28/30, 42100 Selc¸uklu/Konya, Turkey (e-mail: [email protected]) Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
254 | www.surgical-laparoscopy.com
following a procedure like LC that has been frequently performed in daily surgical practice.
MATERIALS AND METHODS This study covers 586 patients, who were called to follow-ups and thus evaluated, of 676 patients who had had LCs at Meram Medical School’s General Surgery Clinic between January 2010 and May 2011. All the patients were operated by the classic 4-port (two 10 mm and two 5 mm) technique. The cases where the surgeons passed on to the open procedure, procedures performed from a single incision, and cases for which incomplete or excess ports were used were excluded from the study. If there had been no risk factors for the surgical site in elective LCs, no prophylactic antibiotics were used. Drains were not routinely used following LCs. Trocar sites, especially subnavel trocar site fascia, were routinely sutured in obese and diabetic cases. LC patients, who were older than 50 were discharged on postoperative day 2, whereas those younger than 50 were discharged on postoperative day 1 without any problems. Within the scope of this retrospective analysis, the LC patients who had complaints about this procedure within 30 days after discharge were evaluated in detail. Those patients among the mentioned ones who were hospitalized for 24 hours or more were included in the study. The demographic data, whether the procedure was urgent or not, presentation complaints, time of the start of complaints, diagnosis methods, and the diagnoses of the patients included in the study were recorded. Further, the duration of hospitalization and treatment results were also evaluated.
FINDINGS Fourteen of 586 patients covered by this study presented to the hospital again during the early phase and were treated by hospitalization. The rate of representation to the hospital during the early phase following LC was found to be 2.4% in our study. Among the 14 returning patients, 10 were (71%) female, whereas 4 (29%) were male. The mean age of the patients was 46 years (range, 26 to 82 y). Seventy-four (13%) of 586 patients covered by the study had emergency LC procedures. The diagnosis of all the emergency LCs was acute cholecystitis. It was seen that 8 (57%) of 14 returning patients had elective LCs, whereas 6 (43%) had emergency LCs. It was observed that 71% of returning patients had presented to the hospital with complaints of abdominal pain. Other presentation symptoms and their incidence rates are shown in Table 1. Among the returning cases following LC, the most frequent diagnosis was bilioma. All
Surg Laparosc Endosc Percutan Tech
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Volume 25, Number 3, June 2015
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 3, June 2015
TABLE 1. Presentation Symptoms and Incidence Rates
Symptoms
Incidence (%)
Abdominal pain Abdominal swelling Nausea Vomiting Inability to pass gas-stool Fever Pain in the scar area Leakage from the scar area Jaundice
71 36 14 28 28 42 21 7 7
these cases had abdominal pain and fever. Two cases also had vomiting complaints. In 4 (30%) of 14 patients, who had returned to the hospital during the early phase after their discharge following LC in our series, bilioma (bile leakage) was present. All these cases had been detected during the postoperative period and it was seen that no drains were used for any of them. The common presentation symptoms of these patients were abdominal pain and fever. In addition to these symptoms, 2 patients had vomiting problems. The patients had been diagnosed through ultrasonography (USG). The most frequent finding as achieved by the USG was the high-density fluid in the gallbladder loge. The localization of bilioma in all cases was found to be the subhepatic area. The size of the collection was reported to be 6 to 9 cm. Bilioma cases in this series were treated by USG-guided drainage. None of the cases surpassed daily drain output of 300 mL/d and the patients were followed up without any additional intervention. Drains of 2 patients were removed on the fourth day, whereas the drains of the other 2 were removed on the third day. The bilioma cases were discharged without any problems. No collections were detected by the control USG performed on day 10 after the discharge.
Early Hospital Readmission
Among the patients in this series, 2 incarcerated trocar hernia cases treated through laparotomy presented with complaints of abdominal pain, abdominal swelling, nausea, vomiting, and inability to pass gas-stool. One of these patients was taken into hemodialysis twice because of acute renal failure before the laparotomy. It was learnt that in 2 cases with incarcerated trocar hernia, the hernias were located in the subnavel trocar entry point and that the trocar entry points could not be sutured during the surgeries. One of the cases underwent segmental small bowel resection as it was seen that the incarcerated hernia was the Richter type. It was also seen that the 2 cases treated by laparotomy were not diabetic. The body mass index of one patient was >30, whereas the other’s was 27. The 14 cases evaluated within this retrospective analysis were hospitalized for an average of 2 days (range, 1 to 4 d). When the early returning patients’ time of presentation to the hospital is studied, it was seen that 8 (57%) patients returned to the hospital within the first 7 days, whereas the other 6 returned on various days after the first 7. It is significant that the bilioma and nonspecific abdominal pain cases, which comprise most of the patients in our series, presented to the hospital again within the first 3 days of discharge. The latest return within this series was a case that returned to the hospital 19 days after the discharge and this patient had abscess in the subxiphoid trocar entry point and remaining stone. The most frequent pathology seen in the early returning patients was bilioma with an incidence rate of 30%. Detailed information on the patients is given in Table 2.
DISCUSSION LC has less postoperative pain, shorter hospitalization, less labor loss, and better cosmetic results when compared with open cholecystectomy.3 Further, in LC surgical-site infections are seen less in comparison with open cholecystectomy.4 Despite these advantages, bile duct
TABLE 2. Diagnoses and Therapeutic Approaches to 14 Cases
Diagnosis 1 2 3 4 5
11
Bilioma (subhepatic) Bilioma (subhepatic) Bilioma (subhepatic) Bilioma (subhepatic) Surgical-site infection (subnavel incision) Surgical-site infection (subxiphoid incision) Surgical-site infection (subxiphoid incision) Nonspecific abdominal pain Nonspecific abdominal pain Nonspecific abdominal pain Incarcerated trocar hernia
12 13 14
6 7 8 9 10
Diagnostic Method
Type of Surgery
USG USG USG USG PE
Elective LC Emergency LC Emergency LC Elective LC Emergency LC
PE
Emergency LC
PE
Emergency LC
CT + USG
Emergency LC
CT + USG
Elective LC
CT + USG
Emergency LC
CT
Elective LC
Incarcerated trocar hernia
CT
Elective LC
Subhepatic hematoma Cholangitis
USG USG + MRCP
Emergency LC Elective LC
Treatment Percutaneous drainage Percutaneous drainage Percutaneous drainage Percutaneous drainage Scar exploration and medical treatment Scar exploration and medical treatment Abscess drainage, stone extraction, and medical treatment Medical treatment (NSAI analgesic) Medical treatment (NSAI analgesic) Medical treatment (opioid analgesic) Laparotomy (small bowel resection) Laparotomy (reduction, primary repair) Percutaneous drainage Medical treatment
Duration of Hospitalization (d) 3 4 3 4 2 3 2 2 1 2 16 5 3 7
CT indicates computed tomography; LC, laparoscopic cholecystectomy; MRCP, magnetic resonance cholangiopancreatography; NSAI, nonsteroid antiinflammatory; USG, ultrasonography.
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Simsek et al
injuries, which are the most feared complications of cholecystectomies, are more frequently seen in LCs than open cholecystectomies.5 The incidence of bile duct injuries in LCs are 0.4%, whereas the same rate is reported to be 0.2% for open cholecystectomies.6 LC is a more comfortable procedure than open cholecystectomy. Today this information is also known by patients themselves. The surgeon passes this piece of information when he/she informs the patient about the procedure. But the return of the patient to the hospital after being discharged following such an advantageous procedure is hard both for the patient and the surgeon. The goal of the surgeon in this case should be to diagnose the patient rapidly and to discharge the patient again as soon as possible following appropriate treatment. There are no analyses in literature which state the reasons of early readmission to the hospital after LC procedures. Fourteen of 586 patients covered by this study returned to the hospital during the early phase and were hospitalized and treated thus. The percentage of early return to the hospital following discharge after LC in the series was found to be 2.4%. When the large series regarding LC in literature are studied, it was seen that the rate of complication was reported be between 1.8% and 6.9%.2 Deziel et al7 found 2% rate of complication in their multicentered study covering 77,604 patients which was published in 1993. When these figures are taken into consideration 2.4% early return rate may sound high. Another interesting point in our study was the high rate of return following emergency LCs. Eight of 14 early returning patients had emergency LCs. We believe that the reason for this is that LC is harder in acute cholecystitis and difficulties like prolonged intraoperational time and the possibility that the bladder might be empyemic. The term bilioma not only refers to bile ducts but also to bile accumulation. This term was first defined by Gould and Patel in 1979.8 Biliomas most of the time develop as a complication of biliary surgical intervention. But they may also develop based on trauma, percutaneous procedures in the liver and the bile ducts, endoscopic retrograde cholangiopancreatography, and spontaneous bile duct ruptures.9 The procedure that most frequently causes bilioma is cholecystectomy.10 Biliomas are not only asymptomatic but they can also give way to nonspecific complaints like abdominal pain, abdominal fullness, and nausea-vomiting. Biliomas can also cause bile peritonitis and abscess formation.11 In a bilioma series covering 18 cases Vasquez et al12 stated that the diameter of the bilioma reached a maximum of 19 cm and the bilioma localization was most frequently subhepatic and subdiaphragmatic. The most frequent reason of return flowing LCs in our series was bilioma (30%). All these cases had abdominal pain and fever. Therefore, the immediate complication that needs to be thought of with patients returning with complaints of abdominal pain and fever following LCs should be bile leakage and bilioma. All the bilioma cases in our series were diagnosed through USG and their treatments were performed by USG-guided percutaneous drainage procedure. Thus, the patients suspected to have bilioma should certainly be evaluated by USG. Computed tomography (CT) scan is more sensitive than USG in the diagnosis of biliomas because CTs enable physicians to have more information on whether the collection is bilioma, hematoma, or nonbiliary abscess.13 In the diagnosis of bilioma, following the determination of the size, amount, and localization of the collection through CT its drainage guided by USG or
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CT and the patient’s follow-up with USG seems to be accepted in literature.12–15 The fact that drainage was removed during the early phase and none of the cases surpassed daily drain output of 300 mL/d in the bilioma cases in our series point out to the fact that bile leakage is not related to serious bile duct injuries. If the output is >300 mL/d and the drainage continues >5 to 7 days in a case with drainage because of bilioma, large bile duct injury should be considered.1 Trocar entry point hernias are seen between 0.14% and 3% of the cases following all laparoscopic procedures.16 These hernias cause Richter (pincement laterale) type hernias and might give way to bowel obstruction.17,18 Trocar hernia development following LC is a rare but well-known complication. The incidence of trocar hernias following LCs has been reported to be 0.02% to 5% in literature.19,20 Most of the trocar hernias seen after LCs take place in the subnavel trocar entry point and in entry points where 10 mm or larger trocars are used.21 The percentage of incarcerated trocar hernias among the early returning patients following LC in our series is 14%. Within this series 2 patients treated by laparotomy were also operated because of incarcerated trocar hernia. CT was very useful in the detection of incarcerated trocar hernias in our cases. The most significant risk factors in the development of trocar hernias are diabetes and obesity.22 Studies in literature state that suturing especially 10 mm subnavel trocar entry points decrease the incidence rate of trocar hernias.23,24 The incidence rate of shoulder pain following laparoscopic procedures has been stated as 20% to 25% in literature.24,25 It is known that this symptom is related to the compression of gas under the diaphragm or the irritant effect of gas in the peritoneum. However, no information on severe abdominal pain with unknown etiology following LC can be found in the literature. Three cases in our series presented to the emergency department with complaints of severe abdominal pain within 24 hours of discharge. These cases had severe abdominal pain without acute abdomen findings. Abdominal CT scans were performed for cases with normal abdominal USG results and no pathologies were seen. The patients received analgesic and fluid replacement. Two patients responded to simple nonsteroid anti-inflammatory drugs, but in 1 case the pain was controlled by a weak-effect opioid. All 3 cases stopped feeling pain within 24 hours of hospitalization and they no longer needed analgesics. We were unable to find a reason explaining abdominal pain in these 3 cases. Surgical-site infections are seen less in LCs than open cholecystectomies.4 LC performed because of chronic stone cholecystitis is an example of clean-contaminated scar and it has prophylactic antibiotic indication. In a study conducted by Uludag˘ et al,26 however, the authors concluded that prophylactic antibiotic administration in cholecystectomies did not reduce surgical-site infections. Therefore, prophylactic antibiotic administration for cases without risk factors may not be needed. We have not been using prophylaxis for elective LC cases in the low-risk group at our clinic. The reason of return for 3 cases in our series is surgical-site infection. Two of these 3 cases had emergency operations because of acute cholecystitis. Both of them were diabetic. Both cases had prophylaxis. Infection developed in the subxiphoid incision in both cases. It was observed that the gallbladder was perforated during the surgery and that it was removed from the abdomen after being placed in a bag in the abdomen.
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Volume 25, Number 3, June 2015
The subhepatic hematoma case in the series had presented to the emergency department with complaints of abdominal pain and fever on the third day after discharge. The subhepatic collection detected through the abdominal USG of the patient was interpreted as bilioma and when percutaneous drainage was performed to the patient hematoma was seen. About 250 mL of hematoma was drained and the patient’s symptoms regressed. We think that this hematoma was caused by the bleeding in the form of a leak from the gallbladder bed. Therefore, we believe that paying utmost attention to the hemostasis during the surgery may eliminate one of the reasons of early return to the hospital following LC. This study was conducted to clarify the reasons of early return to the hospital following a comfortable operation like LC. We believe that the rate of 2.4% early return to the hospital in our series is a bit high when all the complications are taken into consideration. This retrospective analysis, however, has shown that this rate can further be decreased by taking simple measures. The leading measure that can be taken is to be more attentive to the bile and blood leaks from the gallbladder bed during the surgery. Moreover, performing prophylaxis for cases in the risk group for surgical-site infection and suturing the subnavel trocar for cases in the risk group are among the other significant measures. We also believe that detecting complications before the patient’s discharge will bring about better results than the return of the patient in the early phase. Therefore, patients who are disinterested in their surroundings, who are restless and inappetent should not be discharged. But return to the hospital in the early phase following LC will continue to exist, as it does in every surgical intervention, despite all the measures taken. We believe that studies conducted with larger series may determine the rate of early return following LCs.
8. 9.
10. 11. 12. 13. 14.
15.
16. 17.
18. 19. 20.
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