Br. J. Surg. 1992, Vol. 79, November, 1174-1 177
B. M. Ure, H. Troidl, W. Spangenberger, R. Lefering, A. Dietrich and H. Sommer Surgical Clinic, Department of Surgery I/, University of Cologne, Ostmerheimerstrah'e 200, 0 - 5 0 0 0 Koln 91, Germany Correspondence to. Dr B. M . Ure
Evaluation of routine upper digestive tract endoscopy before la pa roscopic cholecystectomy Endoscopy of the upper digestive tract was performed in 376 patients with symptomatic gallstone disease before elective laparoscopic cholecystectomy. Abnormalities were found in 60 patients (16.0 per cent); these included peptic ulcer (n = 14), gastric erosions (n = 15) and oesophagitis (n = 11). Thirty patients were treated medically and two by endoscopic polypectomy. In four patients endoscopy led to cancellation of cholecystectomy; in two the complaints have persisted. Statistical analysis of 28 variables showed f e w signijicant diflerences in symptoms between patients with normal and those with abnormal appearances at endoscopy. It is concluded that routine endoscopy before laparoscopic cholecystectomy is neither clinically useful nor cost eflective in patients with symptomatic gallstone disease. This conclusion is related exclusively to patients with typical gallstone symptoms according to the dejinition used in this department.
The identification of symptoms specific for gallstones has been the aim of numerous studies'-5. Nevertheless, 'to date, it has never been established which symptoms are specifically caused by stones in the ga1lbladdef6. Endoscopic abnormalities of the upper digestive tract have been reported in u p t o 44 per cent of patients with so-called symptomatic gallstone disease7.'. I t is not known t o what extent these abnormalities may cause symptoms themselves, or may be the cause of the complaints before or after operation in some patients with gallstones. For these reasons routine endoscopy of the upper digestive tract before elective cholecystectomy has been advised'. O n e of the main benefits of laparoscopic cholecystectomy is improved comfort of the patient in the postoperative period9-''. Because endoscopy of the upper digestive tract is uncomfortable, patients ask about its benefit. The purpose of this study was t o evaluate this benefit, a n d in particular t o determine the prevalence of abnormal findings a t endoscopy in patients before elective laparoscopic cholecystectomy, a n d the role of the investigation in determining treatment. In addition, attempts were made t o assess to what extent symptoms predicted the presence of abnormalities in the upper gastrointestinal tract.
All patients underwent real-time ultrasonography using a 5-MHz probe (Sonoline AC; Siemens, Erlangen, Germany). Gallstones, polyps, an empty gallbladder or non-visualization of the gallbladder were defined by the criteria of Jorgensen12. All patients had some abnormality on ultrasonography. Endoscopy of the oesophagus, stomach and duodenum was carried out using forward-viewing instruments and simultaneous videorecording (Olympus GIFl00 and OTV-F2; Olympus, Hamburg, Germany). Before endoscopy, atropine sulphate 0.5 mg, N-butylscopolamine bromide 60 mg and midazolam 2.5-5 mg were given intravenously. All endoscopic findings were recorded prospectively on a computer database. Endoscopic findings were classified as: normal (including type I hiatus hernia without oesophagitis); oe~ophagitis'~ grades 1-3; gastric erosion^'^; ulcer diseaselS; polyps or polypoid structures, scars or deformities of the duodenal bulb16; and diverticula of the duodenum. A self-administered questionnaire covering 68 variables was given to every patient before endoscopy. Twenty-eight of these, selected after study of publications on symptoms in gallstone d i s e a ~ e were ~~~~~, analysed in detail. Attacks of pain were not differentiated from colic. Instead, pain was evaluated for localization, radiation, duration, and intensity. Alcohol consumption and smoking were noted. Obesity was defined as body-weight z 10 per cent above normal (normal weight in kilograms was defined for men as height in centimetres minus 100 and for women as 90 per cent of height in centimetres minus 100).
Patients and methods
Statistical analysis Data were analysed by the biomedical data package PC-90 (BMDP Statistical Software, Cork, Ireland). Univariate analysis was carried out using the Wilcoxon rank sum test and x2 test with Yates' correction as appropriate. P i 0.05 was accepted as significant. Regression tree analysis was performed to discriminate between the group of patients with inflammatory diseases of the upper intestinal tract (ulcers, erosions or oesophagitis) and those with normal findings (Knowledge Seeker software, version 2.07; First Mark Technologies, Ottawa, Canada). This analysis takes missing values into consideration.
A total of 533 patients were admitted for elective laparoscopic cholecystectomy between October 1990 and March 1991.All underwent endoscopy of the upper digestive tract before cholecystectomy. In 153 patients the investigation had been performed by the family doctor within 3 months before admission and was reported to be normal. Consequently endoscopy was not repeated and these patients were excluded from the study. Of the 380 patients in whom endoscopy was performed, four did not tolerate the procedure, leaving 376 for analysis. Symptomatic gallstone disease was diagnosed clinically in the presence of the following symptoms for more than 4 weeks": severe attacks of pain or colic, usually in the epigastrium and right upper abdomen; pain radiating to the back and right shoulder; and pain or other gastrointestinal symptoms provoked by food or stress. In addition, some patients who had symptoms not entirely typical of gallstone disease also underwent cholecystectomy and were included in the study. The severity of symptoms was graded on a scale2 from 0 to 3. Patients with specific symptoms of essential dyspepsia were identified using the score of Talky et a1.4 and those with a score of 60 points or more excluded. Tenderness of the right upper abdomen and abnormal laboratory findings were not present in every case.
1174
Results Th e median age of the 376 patients was 51 (range 18-87) years, the female:male ratio 282:94 (3: 1) ,the median weight 70 (range 41-148) k g an d the median height 168 (range 148-193) cm. Severity of symptoms' was graded for 50 patients as grade 0, for 205 as grade 1, for 117 as grade 2 an d for four as grade 3. Th e 50 patients with grade 0 were, however, n o t symptom-free; they had symptoms different from typical gallstone symptoms according to o u r definition". This number includes patients with polyps of the gallbladder, those awaiting transplantation
0007-1323/92/111174-04
0 1992 Butterworth-Heinernann Ltd
Endoscopy before cholecystectomy: B.M. Ure et al.
Table 1 Endoscopicfindings in the upper digestive tract in 376 patients before laparoscopic cholecystectomy Diagnosis
No.
Additional treatment
Gastric erosions Peptic ulcer Oesophagitis Scars Polyps Duodenal diverticula Oesophageal stenosis Type I1 hiatal hernia
15 (4.0) 14 (3.7) 11 (2.9) 9 (2.4) 8 (2.1) 1 1 1
15 14 1 0 2 0 0 0
Abnormal findings
60 (16.0)
32 (8.5)
Values in parentheses are percentages
and those who travelled frequently and were afraid of unexpected complications. Previous treatments included analgesic drugs (n=188), drugs to dissolve the stones (n=30), papillotomy ( n = 5 ) , lithotripsy (n=6) and others (n=19). A total of 128 patients (34.0 per cent) did not report any previous treatment. There were no complications of gastroscopy. No abnormalities were found in 316 patients (84.0 per cent) including 80 (21.3 per cent) with type I hiatal hernia without oesophagitis. Altogether, 60 patients (16-0 per cent) had abnormal findings (Table I ) . The most common finding was gastric erosions, present in 15 patients (4.0 per cent). All patients with erosions were treated with omeprazole and colloidal bismuth subcitrate orally. In one patient the erosions were so extensive that cholecystectomy was not performed. This patient is still being treated by diet for abdominal symptoms but is free of pain. All other patients with erosions underwent cholecystectomy. Fourteen patients (3.7 per cent) had peptic ulcers, gastric in eight and duodenal in six; none of these ulcers had been suspected previously. All were treated with omeprazole and colloidal bismuth subcitrate orally. Nine of these patients had typical gallbladder symptoms and underwent cholecystectomy after histological confirmation that their ulcers were benign. Three patients with gastric and two with duodenal ulcers were not operated on because of atypical symptoms of gallbladder disease. Persisting abdominal symptoms after the gastric ulcer had healed led to cholecystectomy in two patients 8 and 12 months later. Both are now symptom-free. Eleven patients (2.9 per cent) had oesophagitis, grade 1 in ten and grade 2 in one. The latter patient was treated with cisapride orally. Scars or deformities without inflammation were present in nine patients (2.4 per cent), four in the antrum or pylorus and five in the duodenal bulb. Eight patients (2.1 per cent) had polyps, seven in the stomach and one in the duodenum. Two large polyps were removed endoscopically, one from the cardia (histological examination showed a villous adenoma) and one from the duodenum (tubular adenoma). Other abnormalities comprised duodenal diverticula (n = l), a small benign stenosis of the oesophagus (n= 1) and a type I1 hiatal hernia (n= 1). Endoscopy resulted in additional treatment for 32 patients (8.5 per cent). These included 15 with gastric erosions, 14 with gastroduodenal ulcers and one with grade 2 oesophagitis; all received medical treatment. Endoscopic polypectomy was carried out in two patients. Of the six who were not operated on immediately, two underwent surgery later for persisting symptoms. Only four patients (1.1 per cent) did not undergo cholecystectomy because of endoscopic findings : three who had ulcers and one with gastric erosions. One patient with a duodenal ulcer and one with extensive gastric erosions still have symptoms but have declined cholecystectomy. The distribution of the 28 predefined variables in patients with normal endoscopic findings is shown on Table 2. The most
Br. J . Surg.. Vol. 79, No. 11, November 1992
Table 2 Analysis
of history, symptoms and covariables in 316 patients with normal endoscopic jindings before laparoscopic cholecystectomy
Age (years)* Sex ratio (M:F) Time since diagnosis of gallstones (months)* Obesity (percentage over normal weight)* Weight loss in past 3 months (kg)*
49.9 24.1:75.9 46.9 10.2 1.1
Pain Time since first occurrence (months)* Time since last attack (months)* Duration of attacks < 30 min 30 min-6 h >6h Not identified Location Right upper abdomen Epigastrium All over upper abdomen Before meals After meals Improvement after meals or milk Intensity on visual analogue scale (&loo)*
82.9 38.9 2.4
Other symptoms Feeling of abdominal pressure Bloating Nausea Vomiting Loss of appetite Early satiation Avoidance of food in general Intolerance of fatty meals Restricted diet because of abdominal symptoms Lifestyle Alcohol consumption Smoking Time off work because of abdominal symptoms (months)*
13.6 51.6 25.9 9-9
59-2 13.9 23.4 22.1 72.2 14.6 41.0 86.9 71.2 59.5 35.8 38.0 71.5 84.8 69.9 41.5 5.4 22.2 1.1
*Values are medians; all other values are percentages
common were a feeling of abdominal pressure (86-9 per cent), abdominal pain (82.9 per cent) and unwillingness to eat (84.8 per cent). On univariate analysis there were no significant differences in the intensity of pain as assessed by a visual analogue scale between patients with ulcers, erosions, oesophagitis, scars or polyps and those with normal endoscopic findings. Pain was present after meals significantly less often in patients with gastric erosions ( P =0.014). Obesity was more common among patients with gastric erosions (P=0.035) and the time since the last attack of pain was longer in those with oesophagitis ( P = 0.002). No significant differences were found for variables of patients with peptic ulcers, scars or polyps. The group of patients with inflammatory diseases (including ulcers, erosions and oesophagitis) had pain over the whole upper abdomen less often (P=0.033) and less pain after meals ( P = 0.033) than those with normal endoscopic findings. As the positive predictive values of all variables were weak (1-9 per cent) it was not possible to identify patients with specific lesions by a single variable. Regression tree analysis was performed to compare patients with peptic ulcer, erosion or oesophagitis and those with normal appearances. The combination of weight loss during the past 3 months and age showed a significant difference. Among patients whose loss of weight was < 1.5 kg and who were aged under 45 years (n= 72), the prevalence of inflammatory disease was only 2.8 per cent, whereas in those over 72 years old with weight loss < 1.5kg ( n = 21) it was 28.6 per cent. The prevalence among all 376 patients was 10.6 per cent. If endoscopy had been performed only in the group of patients over 72 years old with weight loss
B. M. Ure, H. Troidl, W. Spangenberger, R. Lefering, A. Dietrich and H. Sommer Surgical Clinic, Department of Surgery I/, University of Cologne, Ostmerheimerstrah'e 200, 0 - 5 0 0 0 Koln 91, Germany Correspondence to. Dr B. M . Ure
Evaluation of routine upper digestive tract endoscopy before la pa roscopic cholecystectomy Endoscopy of the upper digestive tract was performed in 376 patients with symptomatic gallstone disease before elective laparoscopic cholecystectomy. Abnormalities were found in 60 patients (16.0 per cent); these included peptic ulcer (n = 14), gastric erosions (n = 15) and oesophagitis (n = 11). Thirty patients were treated medically and two by endoscopic polypectomy. In four patients endoscopy led to cancellation of cholecystectomy; in two the complaints have persisted. Statistical analysis of 28 variables showed f e w signijicant diflerences in symptoms between patients with normal and those with abnormal appearances at endoscopy. It is concluded that routine endoscopy before laparoscopic cholecystectomy is neither clinically useful nor cost eflective in patients with symptomatic gallstone disease. This conclusion is related exclusively to patients with typical gallstone symptoms according to the dejinition used in this department.
The identification of symptoms specific for gallstones has been the aim of numerous studies'-5. Nevertheless, 'to date, it has never been established which symptoms are specifically caused by stones in the ga1lbladdef6. Endoscopic abnormalities of the upper digestive tract have been reported in u p t o 44 per cent of patients with so-called symptomatic gallstone disease7.'. I t is not known t o what extent these abnormalities may cause symptoms themselves, or may be the cause of the complaints before or after operation in some patients with gallstones. For these reasons routine endoscopy of the upper digestive tract before elective cholecystectomy has been advised'. O n e of the main benefits of laparoscopic cholecystectomy is improved comfort of the patient in the postoperative period9-''. Because endoscopy of the upper digestive tract is uncomfortable, patients ask about its benefit. The purpose of this study was t o evaluate this benefit, a n d in particular t o determine the prevalence of abnormal findings a t endoscopy in patients before elective laparoscopic cholecystectomy, a n d the role of the investigation in determining treatment. In addition, attempts were made t o assess to what extent symptoms predicted the presence of abnormalities in the upper gastrointestinal tract.
All patients underwent real-time ultrasonography using a 5-MHz probe (Sonoline AC; Siemens, Erlangen, Germany). Gallstones, polyps, an empty gallbladder or non-visualization of the gallbladder were defined by the criteria of Jorgensen12. All patients had some abnormality on ultrasonography. Endoscopy of the oesophagus, stomach and duodenum was carried out using forward-viewing instruments and simultaneous videorecording (Olympus GIFl00 and OTV-F2; Olympus, Hamburg, Germany). Before endoscopy, atropine sulphate 0.5 mg, N-butylscopolamine bromide 60 mg and midazolam 2.5-5 mg were given intravenously. All endoscopic findings were recorded prospectively on a computer database. Endoscopic findings were classified as: normal (including type I hiatus hernia without oesophagitis); oe~ophagitis'~ grades 1-3; gastric erosion^'^; ulcer diseaselS; polyps or polypoid structures, scars or deformities of the duodenal bulb16; and diverticula of the duodenum. A self-administered questionnaire covering 68 variables was given to every patient before endoscopy. Twenty-eight of these, selected after study of publications on symptoms in gallstone d i s e a ~ e were ~~~~~, analysed in detail. Attacks of pain were not differentiated from colic. Instead, pain was evaluated for localization, radiation, duration, and intensity. Alcohol consumption and smoking were noted. Obesity was defined as body-weight z 10 per cent above normal (normal weight in kilograms was defined for men as height in centimetres minus 100 and for women as 90 per cent of height in centimetres minus 100).
Patients and methods
Statistical analysis Data were analysed by the biomedical data package PC-90 (BMDP Statistical Software, Cork, Ireland). Univariate analysis was carried out using the Wilcoxon rank sum test and x2 test with Yates' correction as appropriate. P i 0.05 was accepted as significant. Regression tree analysis was performed to discriminate between the group of patients with inflammatory diseases of the upper intestinal tract (ulcers, erosions or oesophagitis) and those with normal findings (Knowledge Seeker software, version 2.07; First Mark Technologies, Ottawa, Canada). This analysis takes missing values into consideration.
A total of 533 patients were admitted for elective laparoscopic cholecystectomy between October 1990 and March 1991.All underwent endoscopy of the upper digestive tract before cholecystectomy. In 153 patients the investigation had been performed by the family doctor within 3 months before admission and was reported to be normal. Consequently endoscopy was not repeated and these patients were excluded from the study. Of the 380 patients in whom endoscopy was performed, four did not tolerate the procedure, leaving 376 for analysis. Symptomatic gallstone disease was diagnosed clinically in the presence of the following symptoms for more than 4 weeks": severe attacks of pain or colic, usually in the epigastrium and right upper abdomen; pain radiating to the back and right shoulder; and pain or other gastrointestinal symptoms provoked by food or stress. In addition, some patients who had symptoms not entirely typical of gallstone disease also underwent cholecystectomy and were included in the study. The severity of symptoms was graded on a scale2 from 0 to 3. Patients with specific symptoms of essential dyspepsia were identified using the score of Talky et a1.4 and those with a score of 60 points or more excluded. Tenderness of the right upper abdomen and abnormal laboratory findings were not present in every case.
1174
Results Th e median age of the 376 patients was 51 (range 18-87) years, the female:male ratio 282:94 (3: 1) ,the median weight 70 (range 41-148) k g an d the median height 168 (range 148-193) cm. Severity of symptoms' was graded for 50 patients as grade 0, for 205 as grade 1, for 117 as grade 2 an d for four as grade 3. Th e 50 patients with grade 0 were, however, n o t symptom-free; they had symptoms different from typical gallstone symptoms according to o u r definition". This number includes patients with polyps of the gallbladder, those awaiting transplantation
0007-1323/92/111174-04
0 1992 Butterworth-Heinernann Ltd
Endoscopy before cholecystectomy: B.M. Ure et al.
Table 1 Endoscopicfindings in the upper digestive tract in 376 patients before laparoscopic cholecystectomy Diagnosis
No.
Additional treatment
Gastric erosions Peptic ulcer Oesophagitis Scars Polyps Duodenal diverticula Oesophageal stenosis Type I1 hiatal hernia
15 (4.0) 14 (3.7) 11 (2.9) 9 (2.4) 8 (2.1) 1 1 1
15 14 1 0 2 0 0 0
Abnormal findings
60 (16.0)
32 (8.5)
Values in parentheses are percentages
and those who travelled frequently and were afraid of unexpected complications. Previous treatments included analgesic drugs (n=188), drugs to dissolve the stones (n=30), papillotomy ( n = 5 ) , lithotripsy (n=6) and others (n=19). A total of 128 patients (34.0 per cent) did not report any previous treatment. There were no complications of gastroscopy. No abnormalities were found in 316 patients (84.0 per cent) including 80 (21.3 per cent) with type I hiatal hernia without oesophagitis. Altogether, 60 patients (16-0 per cent) had abnormal findings (Table I ) . The most common finding was gastric erosions, present in 15 patients (4.0 per cent). All patients with erosions were treated with omeprazole and colloidal bismuth subcitrate orally. In one patient the erosions were so extensive that cholecystectomy was not performed. This patient is still being treated by diet for abdominal symptoms but is free of pain. All other patients with erosions underwent cholecystectomy. Fourteen patients (3.7 per cent) had peptic ulcers, gastric in eight and duodenal in six; none of these ulcers had been suspected previously. All were treated with omeprazole and colloidal bismuth subcitrate orally. Nine of these patients had typical gallbladder symptoms and underwent cholecystectomy after histological confirmation that their ulcers were benign. Three patients with gastric and two with duodenal ulcers were not operated on because of atypical symptoms of gallbladder disease. Persisting abdominal symptoms after the gastric ulcer had healed led to cholecystectomy in two patients 8 and 12 months later. Both are now symptom-free. Eleven patients (2.9 per cent) had oesophagitis, grade 1 in ten and grade 2 in one. The latter patient was treated with cisapride orally. Scars or deformities without inflammation were present in nine patients (2.4 per cent), four in the antrum or pylorus and five in the duodenal bulb. Eight patients (2.1 per cent) had polyps, seven in the stomach and one in the duodenum. Two large polyps were removed endoscopically, one from the cardia (histological examination showed a villous adenoma) and one from the duodenum (tubular adenoma). Other abnormalities comprised duodenal diverticula (n = l), a small benign stenosis of the oesophagus (n= 1) and a type I1 hiatal hernia (n= 1). Endoscopy resulted in additional treatment for 32 patients (8.5 per cent). These included 15 with gastric erosions, 14 with gastroduodenal ulcers and one with grade 2 oesophagitis; all received medical treatment. Endoscopic polypectomy was carried out in two patients. Of the six who were not operated on immediately, two underwent surgery later for persisting symptoms. Only four patients (1.1 per cent) did not undergo cholecystectomy because of endoscopic findings : three who had ulcers and one with gastric erosions. One patient with a duodenal ulcer and one with extensive gastric erosions still have symptoms but have declined cholecystectomy. The distribution of the 28 predefined variables in patients with normal endoscopic findings is shown on Table 2. The most
Br. J . Surg.. Vol. 79, No. 11, November 1992
Table 2 Analysis
of history, symptoms and covariables in 316 patients with normal endoscopic jindings before laparoscopic cholecystectomy
Age (years)* Sex ratio (M:F) Time since diagnosis of gallstones (months)* Obesity (percentage over normal weight)* Weight loss in past 3 months (kg)*
49.9 24.1:75.9 46.9 10.2 1.1
Pain Time since first occurrence (months)* Time since last attack (months)* Duration of attacks < 30 min 30 min-6 h >6h Not identified Location Right upper abdomen Epigastrium All over upper abdomen Before meals After meals Improvement after meals or milk Intensity on visual analogue scale (&loo)*
82.9 38.9 2.4
Other symptoms Feeling of abdominal pressure Bloating Nausea Vomiting Loss of appetite Early satiation Avoidance of food in general Intolerance of fatty meals Restricted diet because of abdominal symptoms Lifestyle Alcohol consumption Smoking Time off work because of abdominal symptoms (months)*
13.6 51.6 25.9 9-9
59-2 13.9 23.4 22.1 72.2 14.6 41.0 86.9 71.2 59.5 35.8 38.0 71.5 84.8 69.9 41.5 5.4 22.2 1.1
*Values are medians; all other values are percentages
common were a feeling of abdominal pressure (86-9 per cent), abdominal pain (82.9 per cent) and unwillingness to eat (84.8 per cent). On univariate analysis there were no significant differences in the intensity of pain as assessed by a visual analogue scale between patients with ulcers, erosions, oesophagitis, scars or polyps and those with normal endoscopic findings. Pain was present after meals significantly less often in patients with gastric erosions ( P =0.014). Obesity was more common among patients with gastric erosions (P=0.035) and the time since the last attack of pain was longer in those with oesophagitis ( P = 0.002). No significant differences were found for variables of patients with peptic ulcers, scars or polyps. The group of patients with inflammatory diseases (including ulcers, erosions and oesophagitis) had pain over the whole upper abdomen less often (P=0.033) and less pain after meals ( P = 0.033) than those with normal endoscopic findings. As the positive predictive values of all variables were weak (1-9 per cent) it was not possible to identify patients with specific lesions by a single variable. Regression tree analysis was performed to compare patients with peptic ulcer, erosion or oesophagitis and those with normal appearances. The combination of weight loss during the past 3 months and age showed a significant difference. Among patients whose loss of weight was < 1.5 kg and who were aged under 45 years (n= 72), the prevalence of inflammatory disease was only 2.8 per cent, whereas in those over 72 years old with weight loss < 1.5kg ( n = 21) it was 28.6 per cent. The prevalence among all 376 patients was 10.6 per cent. If endoscopy had been performed only in the group of patients over 72 years old with weight loss
