Journal of Surgery

Features of Upper Abdominal Pain that Predict Symptoms Relief after Cholecystectomy in Patients with Uncomplicated Gallstones Disease

Abstract

Wafaa Mohammed Soliman, Mohammed Abdallah Hablus, Khaled Mohamed Zaghloul, Loai Mohamed Elahawal and Ashraf Ahmed Alattar

Introduction: Gallbladder disease is common and results in high health care costs. Indeed, estimates of the lifetime risk of gallstone formation are as high as 10% to 20% of the general population. The natural history of symptomatic gallstone disease is such that approximately 70% of patients will continue to have episodic symptoms or experience a complication of gallstones within 2 years of initial diagnosis. Adding to this potential confusion is the occurrence of abdominal pain thought to resemble gallbladder pain but without gallstones present. Laparoscopic cholecystectomy remains the gold standard for treatment of symptomatic cholelithiasis. However, persistent symptoms after cholecystectomy occur in 10 to 33% of patients. Although a variety of clinical characteristics have been evaluated as preoperative factors associated with outcome after cholecystectomy, preoperative symptoms are generally used as a reference point for diagnosis and determination of need of cholecystectomy. Characterizing and identifying symptoms that predict relief from upper abdominal pain after cholecystectomy could better guide physicians to recommend cholecystectomy so as to reduce morbidity, mortality and cost and minimize unnecessary surgery.
Aim: The objective of this study is to identify symptoms predicting complete relief of upper abdominal pain (UAP) after cholecystectomy to help better selection of patients who might benefit from surgery.
Subjects and methods: This study is a prospective analysis involving 950 adult patients undergoing cholecystectomy for symptomatic cholelithiasis. The study included 721 females (75.89%) and 229 males (24.11%). The patients were asked to complete a previously-validated biliary symptoms questionnaire (BSQ) before operation and 3 months postoperatively as well. At the end of the last questionnaire, each patient was required to define whether (as overall) his symptoms were relieved or not. Our patients were divided into two groups according to pain relief after surgery; Group (I) included patients who had pain relief after surgery (713 patients-75.05%) and group (2) included patients who did not have pain relief after surgery (237 patients-24.95%).
Results: Our study shows that the likelihood of having pain relief is greater in patients who have UAP onset one year or less preoperatively, UAP of short duration, UAP occurring most frequently in the evening or at night time and whose pain awakens them by night, patients who do not have lower abdominal pain, patients who have normal bowel habit pattern, patients who have infrequent nausea attacks, patients who do not often have excessive gas bloat or burps and patients who do not suffer concomitant GERD or IBS.
Conclusion: Laparoscopic cholecystectomy is an effective management option for symptomatic cholelithiasis, with a cure rate of 75.05% in our study. Better rates of pain relief can be achieved by better selection of patients, as sub analysis of symptoms showed better cure rates in the subgroups. The followings were found as good predictors of outcome: older age, female patients, short onset of the disease (≤ 1 year), infrequent attacks of pain once or less per week, short duration of attacks less than 30 minutes, attacks occurring by night or awakening the patient by night, attacks of moderate to severe intensity, patient with normal bowel habits, absence of lower abdominal symptoms, absence of gas bloating, and absence of GERD or IBS. Our study shows that pain relief progressively increases with increasing the number of positive predictive symptoms, being the best at the level of 4 positive predictive symptoms. Further larger studies are still needed to further define reliable prognostic symptoms to assure better selection of patients.