Abstract

INTRODUCTION

It is commonly accepted that removal of the gallbladder is the best treatment for symptomatic gallstone disease. However, less focus has been on patient selection and typical or common symptoms of this disease in order to understand prevailing symptoms after surgery[1-4]. Although disease severity has been used[5-7], these efforts have not been united into useful and widely accepted working terms for preoperative clinical use and outcome assessment. As a consequence, the indication for cholecystectomy is sometimes vague and assessment of outcome suffers accordingly[8].

Pain is a key element in gallstone symptoms but pain is a general symptom. Therefore pain characteristics and additional symptoms reported in classical descriptions of the disease has expanded the interpretation[9-11]. Functional gastrointestinal disorder (FGID) is quite common in the population and the two diseases often appear together[12]. FGID may go away or appear more distinct to the patient after cholecystectomy and thus distort the sense of postoperative relief. Up to 30% of patients have some symptoms following cholecystectomy[13,14]. No consistent physiological substrate for such pain has been documented[2]. It is somewhat unclear to what degree post-cholecystectomy symptoms resemble the exact symptoms before removal of the gallbladder[13]. Most studies are retrospective with follow-up periods commonly ranging from a few weeks to a couple of years[6,14,15]. A recent, prospective study lacked clinically useful working terms with a mixture of both pain associated symptoms and FGID[3].

Our aim was to categorize gallstone disease according to the severity of clinical symptoms, pain characteristics, and quantify FGID to define postoperative outcome in terms of new or persistent symptoms.

MATERIALS AND METHODS

One hundred and fifty-three patients with an ultrasonographic diagnosis of gallstones admitted for elective laparoscopic treatment of symptomatic, uncomplicated gallstone disease in a Norwegian (n = 100) and a US (n = 53) institution.

RESULTS

The patient demographics are shown in Table ​Table44.

DISCUSSION

Gallstone symptoms are still classified simply as biliary colic long after a variety of pain characteristics have been described for these pain attacks[9,10]. Thus, studies of outcome of gallstone disease are usually hampered by lack of scientifically acceptable definitions and designs[3,5,6,16]. This includes an inadequate definition of gallstone symptoms, lack of proper recognition of FGID as a concomitant complaint, prospective design and defined follow-up methods. Freedom of pain attacks is a major outcome measure after cholecystectomy. Complete cure of a biliary type pain in contrast to a persisting dull aching pain, has been reported as a reasonable goal for surgery[18]. Previous studies have reported that so-called biliary colic remained in only 8%-9% of patients in contrast to non-colicky pain in 18%-32%[13,19]. Others have found an incidence of around 20% of persistent pain of the same character as before the operation[20,21]. Lublin and coworkers[6] reported presence of pain in 25% and non-pain symptoms in 43% . It seems that distinct or marked pain is present in up to 4%-9%[12,13] whereas pain or “discomfort” connected with dyspeptic symptoms are not clearly categorized[22]. Around 25% of our patients improved without being completely cured after removal of the gallbladder. This corresponds to previous figures of 18%[13] and the frequency of more diffuse intestinal symptoms found by others during post-operative examination[12]. One author mentioned similar findings without giving figures but did not find interference with quality of life measurements[23]. Up to 93% satisfaction has been reported after removal of the gallbladder[13,15,22,24,25].

FGID consists of two main subgroups, functional dyspepsia and irritable bowel syndrome (IBS), with overlapping features making them both symptomatic of an irritable or dysfunctional gut[26,27]. The criteria in the Rome II and the more recent Rome III questionnaire give a formal definition of FGID[17,28]. In the West, there tends to be a female predominance. FGID appears as a real condition of gallstone disease[3,12,22,29]. The pathological connection is still obscure but a common dysfunctional trait has been shown[30]. A diagnostic problem arises only when gallstone disease becomes vague with regard to pain expression[3,5,22]. Lublin and coworkers[6] reported that 80% of patients had so-called non-pain symptoms pre-operatively in accordance with an 88% incidence of FGID in our patients. In our practices, nearly all gallstone patients coming to surgery have upper abdominal pain either in the right upper quadrant or epigastrium although a small percentage has intolerable nausea or food intolerance that dominates over pain. FGID was therefore judged a concomitant condition in most cases. Our outcomes are quite similar to those of others who have attempted to classify pre-operative symptoms[5,6]. It could be perceived that freedom of pain with an attack pattern was the decisive factor when cure or relief was achieved, whereas FGID of various intensities caused the bulk of the persistent symptoms, because FGID persisted in 57% of the patients. The post-operative GSS and VAS were markedly decreased and it is therefore likely that the patients were cured of the pain attacks that led to cholecystectomy. Besides, even so-called bilary colic, even if it resembles pre-operative symptoms, needs a substrate when the gallbladder has been removed. It has not been proved that this stems from the common bile duct (CBD) or the sphincter of Oddi, even though symptoms caused by CBD disease, such as a stone, may be quite similar. Therefore, we will argue that there is reasonable evidence pointing to FGID as a cause of persisting symptoms after surgery.

Some investigators have reported that patients with the most severe, frequent or bothersome pre-operative symptoms are less likely to be cured[5,6,13,22]. The present study corroborated this as results showed that only frequency of pain attacks expressed as SFG separated the patients with regard to severity in the pre-operative evaluation. GSS only separated the pain attack groups against the chronic group. This is broadly correlated with a Swedish study but differed insofar that we amalgamated what were their two most severe groups into one[5]. Lublin and coworkers[6] used frequency without a more specific definition. The disease may wax and wane and this may influence the response to the questionnaire[3,5]. A minority of 15% had chronic symptoms with daily occurrence as the rule. We suspect that some of the patients with daily symptoms reported by Halldestam and coworkers[5] might have been classified as a chronic symptom group by our definition. This would distort comparison of outcome because these two groups responded differently to operative treatment in our study. It is also difficult to ascertain the meaning of “atypical” or multiple locations of pain[5]. Pain in the right upper quadrant or epigastrium is a core issue in the diagnosis of gallstone disease but admittedly in a small minority of patients other symptoms dominate. However, as long as these symptoms can be assigned to gallstone disease, they are not a contraindication to surgery in such cases.

Although patients with the highest pre-operative mean GSS had the largest relative score reduction, this group retained a higher post-operative score and had the highest VAS score. The reason for that was largely assumed as being caused by persistent symptoms of FGID even though this could not be established with certainty because of overlapping symptoms in gallstone patients. It was, however, consistent with the observation that the severe SFG had more patients with no relief and also had a slightly larger GSS burden and consequently higher post-operative GSS and VAS score, indicating that a larger disease burden or more symptoms was in concert with a higher VAS. This may be interpreted as more persistent pain. One study found that patients with the most bothersome symptoms before surgery had less chance of cure[22]. The highest odds ratio for persistence was obtained by “gas/flatulence”, a common symptom of IBS or FGID. This could easily be interpreted as caused by FGID but it has been unusual to explicitly label post-cholecystectomy symptoms as FGID even though many symptoms fit this diagnosis[22]. One explanation may be that these symptoms has for too long been discerned as part of a wider range of gallstone symptoms while we will argue that they are two concomitant disease expressions with many overlapping features making it difficult to separate them.

Compared with measurements before surgery VAS has reached levels of around 68 (of 100) pre-operatively to levels of 35 to 45 post-operatively[13,15,19,21]. In the present study, VAS was similar across all four GSS groups and it fell after surgery to a mean of 18 (range 9 to 33). Therefore, it could not by itself be used to distinguish between the patients before or after surgery. Our post-operative median score value indicates no more than mild to moderate pain[31].

Theoretically, a bile duct focus might cause pain quite similar to that originating in the gallbladder but only about 2% has common bile duct stones after removal of the gallbladder[6,13]. Psychometric testing has shown that a psychosomatic disturbance may influence outcome after cholecystectomy[8,32]. It has been observed that women tend to have more postoperative pain[33] while some have reported that gender is irrelevant[15,20,34]. Women under the age of 60-years have been found to have significantly more pain of the diffuse, more continuous type that is also described in functional dyspepsia, and satisfaction has been greater for men[13]. We found that women were less likely to become asymptomatic. Age of the patient has not influenced outcome[20,34], whereas the opposite was found when 50 or 55-years-of-age was used as cut off value[4,22]. In contrast to previous studies, patients more than 60-years-of-age fared slightly worse in the present study[5,13]. Stone size and number, bacteriology, or histology[2] did not impact the symptom presentation in this study.

We recommend a follow-up period of 6 mo before assessing outcome after cholecystectomy[8,22]. Whether qualified personnel should interview a study object or a questionnaire be used, remains open for discussion[8,16,22,29]. It may be a point of concern whether a self-assessment questionnaire will make the patient report more complaints than will be revealed by a professional interview[35].

Approximately 10% of patients did not improve or even got worse whereas the condition of 25% improved and the rest was cured. Patients with the most SFG were less likely to be completely cured and this group also had a higher pre-operative symptom score (GSS). Post-operative FGID persisted in 57% of patients and indirect evidence suggests that persistent symptoms were caused mainly by FGID. The main indication for elective cholecystectomy in uncomplicated gallstone disease should be pain attacks. Patients should be informed about the chance of persistent symptoms.

COMMENTS

Footnotes

References