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Cholecystectomy: studies on surgical methods, incidence and economy
Linköping University, Department of Biomedicine and Surgery. Linköping University, Faculty of Health Sciences.
2005 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

After almost a century without change in the surgical care of gallstone disease since the first cholecystectomy in 1882, a profound change in surgical treatment of gallstones has taken place over the last three decades with the introduction of endoscopic sphincterotomy for treatment of bile duct stones (EST), minilaparotomy cholecystectomy (MC), and laparoscopic cholecystectomy (LC). The epidemiology of gallstone surgery has changed since these minimally invasive procedures were introduced. This thesis is based on studies on surgical methods, incidence and outcome in cholecystectomy.

Paper I. Changes in the surgical treatment of gallstones from the 1970's to the 1990's in the town of Jönköping, with a population of about 110.000, was studied. During these years EST, MC and LC was introduced as alternatives to conventional cholecystectomy (OC) in gallstone treatment. The development of different strategies for gallstone treatment has given the surgeon the possibility to plan each patient's treatment individually. Hospital stay after treatment decreased, but post-operative morbidity and mortality did not decrease. The cholecystectomy rate decreased from the 1970's to the 1980's, but was then stable up to the 1990's. However there was an increase in cholecystectomy rate in the 1990's amongst women. The proportion of urgent surgery increased over the whole period.

Paper II. All cholecystectomies in Sweden in the years 1987-1995 was studied in a retrospective study based on information from the Swedish Hospital Discharge Register with special reference to outcomes measured as re-admissions with re-interventions and mortality. Simple cholecystectomy was defined as a cholecystectomy without bile duct exploration. LC was rapidly introduced in 1991-1992. Over the period studied there was an increase in total cholecystectomy rate and in the proportion of simple cholecystectomies. There was an increase in re-admission with endoscopic or percutaneous re-intervention after cholecystectomy in Sweden between 1987 and 1995. During the same period re-admissions with re-operations on the bile ducts first decreased and then increased after 1991. There was a higher risk for re-admission with endoscopic or percutaneous re-intervention after simple LC than simple OC. Mortality was higher after simple cholecystectomies completed as OC than after simple LC.

Papers III-VI. A prospective, randomised, single-blind, multicenter study on LC versus MC was performed. In order to examine the external validity of the randomised trial, also all non-randomised patients undergoing cholecystectomy at participating departments were prospectively registered. During the study period 1719 cholecystectomies were scheduled, of those 724 patients entered and fulfilled the randomised study. Based on the results from the trial the following was concluded. Operating time is shorter for MC than LC. Postoperative recovery (pain, hospital stay, sick-leave, time back to normal activities) is shorter after LC than MC. Differences are small but significant. There is no difference in postoperative complication rate after LC and MC. Differences in health-related quality of life between LC and MC are small and of short duration. Health-care costs are higher for LC than MC. Taking the cost of sick-leave into account there are no differences in costs between LC and MC. Health economy does not include costs for surgical training. At long-term follow-up, no differences are seen regarding abdominal pain, patient satisfaction with surgery scar(s) and overall patient satisfaction after LC and MC. A large proportion of patients have abdominal pain after cholecystectomy. Patients not included in the randomised trial were older and more ill, had a higher chance of undergoing conventional open surgery and urgent surgery, and were found to have a higher mortality than included patients. The assignment of healthier patients to studies comparing MC and LC limits the external validity of conclusions reached in such trials.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet , 2005. , 74 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 921
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-31177Local ID: 16917ISBN: 91-85299-30-8 (print)OAI: oai:DiVA.org:liu-31177DiVA: diva2:252000
Public defence
2005-11-25, Föreläsningssalen Originalet, Qulturum, Länssjukhuset Ryhov, Jönköping, 13:00 (Swedish)
Opponent
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2012-10-01Bibliographically approved
List of papers
1. Surgical treatment of gallstones: changes in a defined population during a 20-year period
Open this publication in new window or tab >>Surgical treatment of gallstones: changes in a defined population during a 20-year period
2002 (English)In: European Journal of Surgery, ISSN 1102-4151, E-ISSN 1741-9271, Vol. 168, no 1, 13-17 p.Article in journal (Refereed) Published
Abstract [en]

Objective:

To study developments in routine gallstone surgery in a defined population over a 20-year period with regard to incidence of operations, implementation of new methods, postoperative complications, and postoperative duration of hospital stay.

Design:

Retrospective study of medical records.

Setting:

County hospital, Sweden.

Subjects:

All patients who were residents of Jönköping during one of the three-year periods 1976–1978, 1986–1988, or 1996–1998 and had their first surgical treatment, either cholecystectomy/choledochotomy or therapeutic endoscopy for gallstone disease.

Results:

The overall annual incidence of operations for gallstones decreased from 2.01 to 1.13/1000 inhabitants between the first and second period (p < 0.001). This is explained by a significant reduction in the number of elective operations while the number of urgent operations increased between the first and second periods from 0.39 to 0.53/1000 (p < 0.05) and continued to increase and reached 0.75/1000 during the third period (p < 0.001). New methods were introduced for the treatment of gallstones that gradually made this type of operation more varied and complex in routine practice. The postoperative hospital stay decreased from 7.0 days during the 1970s to 3.9 days during the 1990s. Postoperative morbidity was unchanged.

Conclusions:

The decreasing rate of gallstone surgery noted between the 1970s and 1980s did not continue through the 1990s. Urgent surgery for gallstone disease has gradually become more common and now predominates over elective surgery in routine practice. The introduction of less traumatic surgical techniques contributed to the significant decrease in hospital stay after gallstone surgery. However, morbidity has not decreased and the diversification of surgical techniques used for treatment of gallstones requires continuous evaluation in routine practice.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-82120 (URN)10.1080/110241502317307517 (DOI)
Available from: 2012-10-01 Created: 2012-10-01 Last updated: 2017-12-07Bibliographically approved
2. Reintervention after laparoscopic and open cholecystectomy in Sweden 1987-1995: analysis of data from a hospital discharge register
Open this publication in new window or tab >>Reintervention after laparoscopic and open cholecystectomy in Sweden 1987-1995: analysis of data from a hospital discharge register
2002 (English)In: European Journal of Surgery, ISSN 1102-4151, E-ISSN 1741-9271, Vol. 168, no 12, 695-700 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE:

To find out the incidence of cholecystectomy and of reintervention after cholecystectomy in Sweden 1987 to 1995, and to compare mortality and reintervention after simple laparoscopic and conventional open cholecystectomy (without exploration of the common bile duct or simultaneous operation).

DESIGN:

Analysis of data from Swedish national registers.

SETTING:

Two hospitals and government department, Sweden.

MAIN OUTCOME MEASURES:

Mortality and reintervention during readmission within one year after cholecystectomy classified as: reoperation on bile duct, endoscopic or percutaneous reintervention, or reoperation for wound complication, bleeding, or unspecified cause.

RESULTS:

Incidence of cholecystectomy rose between 1987-89 and 1993-95 from 0.97 to 1.04 for men and from 1.70 to 2.05 operations/1000 inhabitants for women. Reoperation on the bile ducts declined from 1987 to 1991 but returned to previous levels thereafter. Endoscopic reinterventions increased tenfold from 1987 to 1995, whereas those for general complications and mortality did not change significantly. Among simple cholecystectomies laparoscopic surgery was associated with an increased risk of endoscopic reintervention, odds ratio 1.8 (95% CI 1.2 to 2.6), and with a lower risk for postoperative mortality, odds ratio 0.5 (95% CI 0.3 to 0.8).

CONCLUSIONS:

Incidence, mortality, and readmission with reintervention are important endpoints in gallbladder surgery. Significant changes in these variables were identified after the introduction of laparoscopic cholecystectomy.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-82121 (URN)15362578 (PubMedID)
Available from: 2012-10-01 Created: 2012-10-01 Last updated: 2017-12-07Bibliographically approved
3. Laparoscopic cholecystectomy versus mini-laparotomy cholecystectomy: a prospective, randomized, single-blind study
Open this publication in new window or tab >>Laparoscopic cholecystectomy versus mini-laparotomy cholecystectomy: a prospective, randomized, single-blind study
Show others...
2001 (English)In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 234, no 6, 741-749 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To analyze outcomes after open small-incision surgery (minilaparotomy) and laparoscopic surgery for gallstone disease in general surgical practice.

Methods: This study was a randomized, single-blind, multicenter trial comparing laparoscopic cholecystectomy (LC) to minilaparotomy cholecystectomy (MC). Both elective and acute patients were eligible for inclusion. All surgeons normally performing cholecystectomy, both trainees under supervision and consultants, operated on randomized patients. LC was a routine procedure at participating hospitals, whereas MC was introduced after a short training period. All nonrandomized cholecystectomies at participating units during the study period were also recorded to analyze the external validity of trial results. The randomization period was from March 1, 1997, to April 30, 1999.

Results: Of 1,705 cholecystectomies performed at participating units during the randomization period, 724 entered the trial and 362 patients were randomized to each of the procedures. The groups were well matched for age and sex, but there were fewer acute operations in the LC group than the MC group. In the LC group 264 and in the MC group 150 operations were performed by surgeons who had done more than 25 operations of that type. Median operating times were 100 and 85 minutes for LC and MC, respectively. Median hospital stay was 2 days in each group, but in a nonparametric test it was significantly shorter after LC. Median sick leave and time for return to normal recreational activities were shorter after LC than MC. Intraoperative complications were less frequent in the MC group, but there was no difference in the postoperative complication rate between the groups. There was one serious bile duct injury in each group, but no deaths.

Conclusions: Operating time was longer and convalescence was smoother for LC compared with MC. Further analyses of LC versus MC are necessary regarding surgical training, surgical outcome, and health economy.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-82122 (URN)10.1097/00000658-200112000-00005 (DOI)11729380 (PubMedID)
Available from: 2012-10-01 Created: 2012-10-01 Last updated: 2017-12-07Bibliographically approved
4. Cholecystectomy: costs and health-related quality of life: a comparison of two techniques
Open this publication in new window or tab >>Cholecystectomy: costs and health-related quality of life: a comparison of two techniques
Show others...
2004 (English)In: International Journal for Quality in Health Care, ISSN 1353-4505, E-ISSN 1464-3677, Vol. 16, no 6, 473-482 p.Article in journal (Refereed) Published
Abstract [en]

Background. Outcomes of previous health economic evaluations comparing minilaparotomy cholecystectomy and laparoscopic cholecystectomy have been inconsistent.

Objective. To compare costs for minilaparotomy cholecystectomy and laparoscopic cholecystectomy and to study changes in quality of life induced by these operations.

Design. Single-blind, randomized controlled trial, run from 1 March 1997 to 30 April 1999.

Setting. One university hospital and four non-university hospitals in Sweden.

Main measures. Cost and perceived health estimation according to the global quality of life instrument EuroQol-5D.

Results. Of 1719 cholecystectomy patients at five centres, 724 entered the trial and were treated with minilaparotomy cholecystectomy or laparoscopic cholecystectomy, 362 in each group. Total health care costs were less for minilaparotomy cholecystectomy than for laparoscopic cholecystectomy (median values US$2428 for minilaparotomy cholecystectomy versus US$2613 or US$3006 for laparoscopic cholecystectomy with 100 operations per year and reusable trocars or 50 operations per year and disposable trocars, respectively). There was no significant difference in total costs (including costs due to loss of production) between minilaparotomy cholecystectomy and laparoscopic cholecystectomy with 100 operations per year and reusable trocars in laparoscopic cholecystectomy (US$3731 versus US$3649, respectively). However, in calculations assuming 50 operations per year and disposable trocars in laparoscopic cholecystectomy, this technique was more expensive than minilaparotomy cholecystectomy (US$4042 versus US$3731). Health-related quality of life was slightly but significantly lower for the minilaparotomy cholecystectomy group 1 week after surgery. One month and 1 year postoperatively no difference between the randomized groups was found.

Conclusion. Total costs did not differ between minilaparotomy cholecystectomy and laparoscopic cholecystectomy with high-volume surgery and disposable trocars, whereas laparoscopic cholecystectomy was more expensive with fewer operations and disposable trocars. The gain in health-related quality of life with laparoscopic cholecystectomy compared with minilaparotomy cholecystectomy was small and of limited duration.

Keyword
cholecystectomy, health care costs, quality of life
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-23935 (URN)10.1093/intqhc/mzh077 (DOI)3483 (Local ID)3483 (Archive number)3483 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2013-09-24Bibliographically approved
5. Abdominal pain and patient overall and cosmetic satisfaction one year after cholecystectomy: outcome of a randomized trial comparing laparoscopic and minilaparotomy cholecystectomy
Open this publication in new window or tab >>Abdominal pain and patient overall and cosmetic satisfaction one year after cholecystectomy: outcome of a randomized trial comparing laparoscopic and minilaparotomy cholecystectomy
2004 (English)In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, Vol. 39, no 8, 773-777 p.Article in journal (Refereed) Published
Abstract [en]

Background: Previous studies with long‐term follow‐up after cholecystectomy have shown that residual abdominal symptoms are common. Laparoscopic cholecystectomy (LC) and minilaparotomy cholecystectomy (MC) can both give a smoother, early postoperative course than conventional open cholecystectomy (OC). The present study concerns abdominal pain and patient overall and cosmetic satisfaction one year after LC and MC.

Methods: In a prospective, single‐blind study, 724 patients were randomly allocated to LC or MC. Patients completed questionnaires including items concerning abdominal pain before and one year after surgery and overall and cosmetic satisfaction one year after surgery.

Results: There was no difference in reduction of abdominal pain between LC and MC patients. For four different aspects of abdominal pain, 31%, 24%, 30% and 16% of patients operated with LC reported residual abdominal pain one year after surgery. The corresponding figures for MC were 28%, 20%, 27% and 18% (P values 0.55, 0.32, 0.55 and 0.63, respectively). According to questionnaire answers, there was no significant difference in the cosmetic result and overall patient satisfaction between LC and MC patients.

Conclusions: There are no differences between laparoscopic and minilaparotomy cholecystectomy in long‐term outcome regarding abdominal pain and patient overall and cosmetic satisfaction. A large proportion of patients have abdominal pain one year after cholecystectomy. Future studies should include preoperative assessment and indications for cholecystectomy.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-28282 (URN)10.1080/00365520410005540 (DOI)13389 (Local ID)13389 (Archive number)13389 (OAI)
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2012-10-01Bibliographically approved
6. Non-randomised patients in a cholecystectomy trial: characteristics, procedures, and outcomes
Open this publication in new window or tab >>Non-randomised patients in a cholecystectomy trial: characteristics, procedures, and outcomes
Show others...
2006 (English)In: BMC Surgery, ISSN 1471-2482, Vol. 6, no 17Article in journal (Refereed) Published
Abstract [en]

  Background

Laparoscopic cholecystectomy is now considered the first option for gallbladder surgery. However, 20% to 30% of cholecystectomies are completed as open operations often on elderly and fragile patients. The external validity of randomised trials comparing mini-laparotomy cholecystectomy and laparoscopic cholecystectomy has not been studied. The aim of this study is to analyse characteristics, procedures, and outcomes for all patients who underwent cholecystectomy without being included in such a trial.

Methods

Characteristics (age, sex, co-morbidity, and ASA-score), operation time, hospital stay, and mortality were compared for patients who underwent cholecystectomy outside and within a randomised controlled trial comparing mini-laparotomy and laparoscopic cholecystectomy.

Results

During the inclusion period 1719 patients underwent cholecystectomy. 726 patients were randomised and 724 of them completed the trial; 993 patients underwent cholecystectomy outside the trial. The non-randomised patients were older – and had more complications from gallstone disease, higher co-morbidity, and higher ASA – score when compared with trial patients. They were also more likely to undergo acute surgery and they had a longer postoperative hospital stay, with a median 3 versus 2 days (p < 0.001 for all comparisons). Standardised mortality ratio within 90 days of operation was 3.42 (mean) (95% CI 2.17 to 5.13) for non-randomised patients and 1.61 (mean) (95%CI 0.02 to 3.46) for trial patients. For non-randomised patients, operation time did not differ significantly between mini-laparotomy and open cholecystectomy in multivariate analysis. However, the operation for laparoscopic cholecystectomy lasted 20 minutes longer than open cholecystectomy. Hospital stay was significantly shorter for both mini-laparotomy and laparoscopic cholecystectomy compared to open cholecystectomy.

Conclusion

Non-randomised patients were older and more sick than trial patients. The assignment of healthier patients to trials comparing mini-laparotomy cholecystectomy and laparoscopic cholecystectomy limits the external validity of conclusions reached in such trials.

Keyword
External validity, Randomised controlled trial, Cholecystectomy
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-37112 (URN)10.1186/1471-2482-6-17 (DOI)33729 (Local ID)33729 (Archive number)33729 (OAI)
Available from: 2009-10-10 Created: 2009-10-10 Last updated: 2013-09-24Bibliographically approved

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