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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 3  |  Page : 78-83

Effect of diabetes mellitus on operative outcome following laparoscopic cholecystectomy: A one year cross sectional study at tertiary care hospital


Department of General Surgery, KAHER J. N. Medical College, Belgaum, Karnataka, India

Date of Submission24-Jan-2020
Date of Acceptance05-Jun-2020
Date of Web Publication23-Sep-2020

Correspondence Address:
Dr. Kiran S Mahapure
Mahapure Hospital, Shivaji Nagar, Peth Vadgaon, Dist, Kolhapur - 416 112, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_3_20

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  Abstract 


Background: Diabetes is reported to be a risk factor for gallstone formation. Diabetic patients are more prone to operative and post-operative morbidities. This study was aimed to find intra-operative difficulties and complications during laparoscopic cholecystectomy in diabetic and non-diabetic patients
Patients and Method: This is a one year cross-sectional study carried out in a tertiary health center. Operative difficulties and complications studied in a total of 60 patients (30 diabetics + 30 non-diabetics) undergoing elective laparoscopic cholecystectomy from January 2014 to December 2014. Statistical analysis consisted of Chi-square test or Fisher's exact test, “p” value of less than or equal to 0.05 at 95% confidence interval considered as statistically significant.
Results: Pre-operative characteristics including clinical presentation, duration of symptoms and vitals were comparable in diabetic and non-diabetics patients (p > 0.050). Significantly higher number of patients in diabetic group underwent open pneumoperitoneum (40% versus 16.67%; P = 0.045). Statistically significant difference noted in appearance of gall bladder, adhesions, dissection of Calot's triangle, releasing adhesions, intra operative bleeding, grasping of gallbladder, removal of gallbladder from liver bed, extraction of specimen, drain placement, and conversion (p < 0.050). The operative time was significantly higher in patients with diabetes mellitus (p < 0.050).
Conclusion: Diabetes mellitus is significantly associated with operative difficulties and prolonged surgical time during laparoscopic cholecystectomy.

Keywords: Diabetes mellitus, laparoscopic cholecystectomy, operative difficulties


How to cite this article:
Mahapure KS, Metgud SC. Effect of diabetes mellitus on operative outcome following laparoscopic cholecystectomy: A one year cross sectional study at tertiary care hospital. Arch Int Surg 2019;9:78-83

How to cite this URL:
Mahapure KS, Metgud SC. Effect of diabetes mellitus on operative outcome following laparoscopic cholecystectomy: A one year cross sectional study at tertiary care hospital. Arch Int Surg [serial online] 2019 [cited 2020 Nov 26];9:78-83. Available from: https://www.archintsurg.org/text.asp?2019/9/3/78/295921




  Introduction Top


Cholelithiasis and Diabetes mellitus have an impact on the clinical course of each other, and this has stimulated research in both of them over the past several decades.[1] Cholecystitis, defined as inflammation of the gallbladder, occurs because of stones in the gallbladder (calculus cholecystitis) in 90% cases, with other 10% of cases representing acalculous cholecystitis.[2] About 10%–15% adult western population suffer from gallstones. Between 1% and 4% become symptomatic in a year.[2] More than half a million cholecystectomies are performed per year in the United States alone. In India, the prevalence of gallbladder diseases is increasing and hence cholecystectomies have also been progressively increasing.[3],[4],[5]

Laparoscopic cholecystectomy provides a safe and effective treatment for most patients with symptomatic gallstones and is the treatment of choice for cholelithiasis. Since the introduction of laparoscopic cholecystectomy, the number of cholecystectomy performed in the United States has increased from 500000 to 700000/year. The advantages of laparoscopic cholecystectomy are earlier return to bowel function, less postoperative pain, aesthetically pleasant scars, shorter length of hospital stay, earlier return to full activity, and decreased overall cost.[4]

From a surgical point of view, diabetes is risk factor for gallstone formation, and complications.[1] Furthermore, diabetic patients are generally more prone to operative and post-operative complications than their normal counterparts. Diabetes Mellitus has evolved into a global epidemic and India has the second largest population with diabetes. The prevalence in India is over 65 million and the figures are expected to increase to over 100 million by 2030.[6],[7],[8] Increased incidence of intra operative complications during laparoscopic cholecystectomy are seen in diabetic patients due to severe inflammation and distortion of anatomy. As a result, operation time, costs, and morbidity are increased in diabetics. Hence diabetes may be considered as an independent risk factor for intraoperative complications for laparoscopic cholecystectomy.[5]

However, morbidity and mortality from gallstones in the diabetic patients in comparison with non-diabetics have always been controversial. Previous studies have detected increased complications while others have proposed no such difference.[7],[8],[9],[10],[11],[12] To assess whether diabetes is associated with increased intra-operative complications of laparoscopic cholecystectomy we studied the intra-operative complications in diabetics and non-diabetics undergoing laparoscopic cholecystectomy. This will help in the perioperative preparation of the diabetic patient and emphasize the intra-operative complications to avoid, in order to achieve best possible outcome.


  Patients and Method Top


Study design

This study was a cross sectional study conducted at a tertiary care center over one year, from January 2014 to December 2014. Inclusion Criteria in the study group was (1) Patients above 18 years of age and below 70 years (2) patients with a confirmed diagnosis of diabetes mellitus. group (3) For control group- otherwise healthy individuals. Exclusion criteria was (1) Emergency Cholecystectomy (2) Unconfirmed history of diabetes (3) Patients less than 18 and above 70 years of age.

A total of 60 patients undergoing elective laparoscopic cholecystectomy were divided into two cohorts of 30 each as diabetics and non-diabetics and were enrolled. The study was approved from the Institutional Ethical Committee. A written informed consent was obtained prior to the enrolment from the patients. The patients were evaluated for operative outcome according to the data obtained from the predesigned pro forma which was filled by the operating surgeon.

Laparoscopic cholecystectomy at our hospital is performed by experienced consultant surgeons. Pre-operative evaluation is done for all patients on the day of admission which include serum glucose levels, liver function tests, coagulation profile, and pre-operative abdominal ultrasound to confirm diagnosis, to look at the site of stones, to measure wall thickness, and look for evidence of inflammation. All the patients were also assessed by anesthetists to get fitness for surgery.

Data Collection

Following the surgical procedure an operative note is recorded, that includes the duration of operation, and any complications that were encountered during the procedure. The gallbladder specimen is sent for histo-pathological evaluation. Patients are then transferred to the surgical ward or the surgical ICU at our hospital depending on their condition. Demographic data including age and gender were noted and also any past history regarding co-morbidities, treatment history and surgical history along with presenting complaints. The patients were classified in two groups, diabetic and non-diabetic. The blood sugar level measurements were done to confirm the presence of diabetes (those having fasting serum glucose level >126 mg/dl or more and random serum glucose level 200 mg/dl or more).[13],[14]

The operative notes of all patients – diabetics and non-diabetics were reviewed. The patients were evaluated for operative outcome for the following parameters: Method of creating pneumoperitoneum, appearance of gallbladder, adhesions, anatomy of Calot's triangle, releasing the adhesions (adhesiolysis), Gall bladder stone, intra-operative bleeding, site of bleeding, grasping gall bladder, removal of gallbladder from liver-bed, extraction of Gall bladder (need for extending the incision), complications encountered during the surgery, need for drain placement and duration of surgery. These variables were documented by the operating surgeon. After collecting the data, difference in the operative outcome of two cohorts that is, diabetic and non-diabetic was measured.

The statistical analysis was done using Chi-square test or Fisher's exact test. A “p” value of less than or equal to 0.05 at 95% confidence interval was considered as statistically significant.


  Results Top


Demographic data

Total 60 patients undergoing elective laparoscopic cholecystectomy during the study period were studied. The male to female ratio was 1.30:1 and 56.67% of the patients were males in diabetic as well as and non-diabetic group. Among the diabetics, 60% were aged between 46 and 60 years compared to 23.33% in non-diabetics (p< 0.001)[Table 1]a. 53.33% of the patients had diabetic duration between 6 and 10 years (mean duration 9.08 ± 5.15 years) and most of the patients (60%) were on oral hypoglycaemic agents and had moderate glycemic control (43.33%).


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Pre-operative evaluation

Pre-operative characteristics like clinical presentation, duration of symptoms, history of other diseases, and vitals were comparable in diabetic and non-diabetics patients (p > 0.050).

Intra-operative outcome

Significantly higher number of patients in diabetic group underwent open pneumoperitoneum (40% versus 16.67%; P = 0.045). Statistically significant difference was noted in appearance of gall bladder [Figure 1] (P = 0.043), adhesions [Figure 2] (P = 0.001), dissection of frozen Calot's triangle [Figure 3] (P < 0.001), adhesionolysis (P < 0.001), intra operative bleeding [Figure 4] (P < 0.001), grasping of gallbladder (P = 0.001), removal of gallbladder from liver (P < 0.001), extraction of specimen (P = 0.025), drain placement (P < 0.001), and conversion (P = 0.026). Total five patients required conversion to open procedure, all of them were diabetic. Furthermore the operative time was significantly high in patients with diabetes mellitus compared to in non-diabetics (103.00 ± 26.54 versus 78.83 ± 19.06 minutes; P < 0.050) [Table 1]a and b].
Figure 1: Uninflammed gall bladder

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Figure 2: Severe adhesions

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Figure 3: Sever Cholecystitis with Frozen Calot's triangle

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Figure 4: Severe Intraoperative bleeding

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  Discussion Top


With improved techniques, Laparoscopic Cholecystectomy has quickly established itself as the surgical procedure of choice for cholelithiasis as it is minimally invasive and allows early postoperative recovery and 1–3% morbidity compared to the open cholecystectomy which has 4.5%. Hence it is the “gold standard” treatment for gallstones in elective setting.

Diabetic patients have high risk for gallstones formation than normal population.[1] However, mortality and morbidity related to gallstones in the diabetic patients as compared to non-diabetics have been controversial. Diabetic patients are more prone to surgical complications due to their background diseases and therefore the morbidity and mortality is higher in these patients.[6] Previous studies have shown increased rate of complications and mortality suggesting a prophylactic cholecystectomy for gallstones in diabetics while a few studies have refuted such a difference.[6],[7],[8],[9],[10],[11] Till date, only few studies focused on intraoperative complications of laparoscopic cholecystectomy in diabetics.[7] In this study, we assessed the operative findings of laparoscopic cholecystectomy in the diabetic patients in comparison with the non-diabetics, which will help to propose the strategies for the prevention of intraoperative complications.

Pneumoperitoneum creation is the first step of laparoscopic cholecystectomy. In this study more than one third of the diabetic patients (40%) underwent open method for pneumoperitoneum creation compared to non-diabetic patients (16.67%) and statistically the difference was significant (p = 0.045) may be due to obesity and surgeon's preference. The appearance of the gallbladder was simple and uncomplicated (non-thickened and uninflammed with clear anatomy) in 26.67% of the diabetics compared to 60% of the non-diabetics while gall bladder was enlarged and inflamed in 40% of the diabetics compared to 36.67% of the non-diabetics. The other findings of gall bladder noted in diabetics were impacted (20%), shrunken and fibrotic (6.67%) thickened gall bladder (3.3%) and sessile gall bladder (3.3%). Whereas, in non-diabetics impacted gall bladder was noted in 3.3% of the patients. This suggest that, the appearance of gall bladder varies significantly in diabetic patients compared to non-diabetics (p = 0.043). The findings of the present study were similar to the study by Ziaee SA et al.[7] who showed that, 14.3% of the diabetics had gangrenous gall bladder as compared to 1.6% of the no diabetics (RR: 8.7; 95% CI: 3.8-20.8).

Significantly higher number of patients with diabetes mellitus had severe (30% versus 6.67%) and moderate adhesions (53.33% versus 33.33%) compared to non-diabetic patients (p = 0.001). Also adhesionolysis was difficult in significantly higher number of patients (73.33%) compared to non-diabetics (p < 0.001). Ziaee SA et al.[7] showed that, diabetes also causes a significant increase in the risk of adhesions formation (28.6% versus 6.2%). Aldaqal SM. et al.[8] in their study reported that increased number of adhesions were present in 46.7% of the diabetic patients compared to 34.7% of the non-diabetics (p= 0.775). In 2006, a study conducted by Ibrahim et al.[10] in Singapore, found an association between poorly controlled diabetes (elevated HbA1c >6) with an increased risk for conversion. They proposed an association between poorly controlled blood sugar levels and severe inflammation distorting the anatomy.[9]

In this study significantly higher number of patients with Diabetes (83.33%) required moderate dissection compared to non-diabetic patients (43.33%) (p < 0.001). The meticulous slow dissection required can be due to an inflamed, thickened gall bladder, and the presence of adhesions. Increased gall bladder wall thickness is related to the inflammation and fibrosis following the repeated attacks of cholecystitis and hence reflects the difficulty in understanding the anatomy intra-operatively.

In this study significantly higher number of patients with diabetes mellitus had complications of moderate (83.33% versus 26.67%) and severe (10% versus none) intra operative bleeding compared to non-diabetics (p < 0.001). In a study by Seyed Hosseini SV et al.[10] also, complications such as bleeding were high in diabetes patients compared to non-diabetics (4 versus 1 patient; P = 0.353). In another study by Aldaqal SM et al.[8] there were total 3 (2.7%) patients who had severe intraoperative bleeding. Two of them were diabetics and one was non-diabetic (11.1% and 1.1%, with a P = 0.068).

The grasping of gallbladder was difficult in significantly higher number of patients with diabetics compared to non-diabetics (50% versus 10%; P = 0.001). The removal of gall bladder from the liver bed was difficult in significantly higher number of patients that is, 60% with diabetes mellitus compared to 13.33% of the non-diabetic patients (p < 0.001).

We observed that. 26.67% of the patients with diabetes mellitus had difficult extraction of gall bladder specimen requiring the extension of incision compared to 3.33% of the non-diabetic patients. This difference was statistically significant (p = 0.025). Also majority of the patients (76.67%) with diabetes mellitus required drain placement compared to non-diabetic patients (26.67%) (p < 0.001). In contrast these findings, Aldaqal SM et al.[8] reported comparable outcome with regard to extraction of gallbladder and drain placement in patients with diabetes mellitus and non-diabetics.

The rate of conversion was 16.60% in patients with diabetes mellitus compared to nil in non-diabetic patients. This difference was statistically significant (p = 0.026). These findings were consistent with several other studies. A study done by Aldaqal SM et al.[8] who reported that, there was conversion of laparoscopic cholecystectomy to open procedure in 5 patients (4.5%). Out of them, 3 patients were diabetics (16.7%) and 2 were non-diabetics (2.1%) (p = 0.029). In 2001, a study conducted in university of Erciyes, Turkey[11] found that operative and postoperative complications of laparoscopic cholecystectomy in diabetics were significantly higher than non-diabetics. Their conversion to open rate was 7.1% in diabetics compared to 2.8% in no diabetics. Paajanen et al.[12] from Kipio University hospital in Finland studied the operative outcome of laparoscopic cholecystectomy in diabetic patients in 2010. The results of their study showed that 16% of the diabetic patients undergoing laparoscopic cholecystectomy required conversion to open procedure in comparison to 7% of the non-diabetic controls.

The mean surgical time was significantly higher in patients with diabetes mellitus that is, 103.00 ± 26.54 minutes compared to 78.83 ± 19.06 minutes in non-diabetics (p < 0.050). In contrast a study by Aldaqal SM et al.[8] reported comparable mean duration in diabetics (114.06 ± 60.01) and non-diabetics (102.30 ± 40.688) (p = 0.305). Another study by Seyed Hosseini SV et al.[10] reported the mean duration of operation on diabetic and non-diabetic patients as 57.22 ± 7.40 and 53.27 ± 11.19 minutes, respectively (P = 0.113).

Overall the present study showed significantly higher complications in patients undergoing laparoscopic cholecystectomy with diabetes compared to non-diabetics. Similar findings have been described in several other studies. A study reported a complication rate of 21% and 9% for diabetic and non-diabetic patients, respectively. According to these studies, complications in diabetics are significantly higher than non-diabetics (P < 0.05).[15]

Rasohoff et al.[16] (1987) concluded that acute cholecystitis is more dangerous in diabetic patients than non-diabetics. Reiss (1993) also concluded that diabetic patients are more prone to surgical complications compared to other patients.

Till date only few studies[7],[16],[17] have assessed the effect of diabetes on the course of gallbladder diseases and diabetes as an independent risk factor for intra-operative complications of laparoscopic cholecystectomy. Moreover, these studies.[17],[18],[19],[20],[21],[22],[23] have shown variable conclusions. As both diabetes and gallstones are on the rising trend our country being important health issues, the aim of the study was to further evaluate their relationship, in order to provide the patients a better healthcare and surgical outcome.

The strength of the study is it included 30 cases of diabetes mellitus which is first to our knowledge and assessed various complications occurred during the laparoscopic cholecystectomy in details. However, the age and certain characteristic of the study population differed significantly which would have created the bias in the study results. Another limitation of the study is different operating surgeons might have different interpretation about operative difficulty but most of the surgeons who operated are well experienced and significant variation of interpretation of inoperative difficulties should be insignificant. Further studies overcoming these pitfalls will explore the feasibility of laparoscopic cholecystectomy in patients with diabetes mellitus.


  Conclusion Top


Based on the results of this study we conclude that, diabetes mellitus is significantly associated with several operative difficulties during laparoscopic cholecystectomy including adhesions distorting the anatomy, difficult dissection of Calot's triangle, difficult adhesionolysis, intra operative bleeding, difficult grasping of gall bladder, difficult removal of gall bladder from liver bed, need to extend the incision for extraction of specimen, drain placement and conversion to open cholecystectomy. The operating surgeon is likely to require higher operative time because of the above. Predicting the complications that may be encountered intra-operatively will help to take precautions and better preparedness of the surgeon to achieve best possible outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Olokoba AB, Bojuwoye BJ, Olokoba LB, Braimoh KT, Inikori AK. Gallstone disease and type-2 diabetes mellitus-the link. J Coll Physicians Surg Pak 2007;17:594-7.  Back to cited text no. 1
    
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Dhanke PS, Ugane SP. Factors predicting difficult laparoscopic cholecystectomy: A single-institution experience. Int J Stud Res 2014;4:3-7.  Back to cited text no. 4
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Hosseini SVS. Evaluation postoperative complication of laparoscopic cholecystectomy in diabetic patients. Int J Curr Res Aca Rev 2014;2:107-16.  Back to cited text no. 5
    
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Ziaee SA, Fanaie SA, Khatib R, Khatibzadeh N. Outcome of cholecystectomy in diabetic patients. Indian J Surg 2005;67:87-9.  Back to cited text no. 7
    
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Aldaqal SM, Albaghdadi AT, Tashkandi HM, El-deek BS, Al-Malki GA, Turki AM, et al. Effect of diabetes mellitus on patients undergoing laparoscopic cholecystectomy: A comparative cross-sectional study. Life Sci J 2012;9:431-9.  Back to cited text no. 8
    
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Paajanen H, Suuronen S, Nordstrom P, Miettinen P, Niskanen L. Laparoscopic versus open cholecystectomy in diabetic patients and postoperative outcome. Surg Endosc 2011;25:764-70.  Back to cited text no. 12
    
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World Health Organization. Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycaemia: Report of a WHO/IDF Consultation. Geneva: World Health Organization; 2006. Available from: https://www.who.int/diabetes/publications/Definition%20and%20diagnosis%20of%20diabetes_new.pdf. [Last accessed on 2020 Apr 17].  Back to cited text no. 14
    
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Lyass S, Perry Y, Venturero M, Muggia-Sullam M, Eid A, Durst A, et al. Laparoscopic cholecystectomy: What does affect the outcome? A retrospective multifactorial regression analysis. Surg Endosc 2000;14:661-5.  Back to cited text no. 18
    
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Simopoulos C, Botaitis S, Polychronidis A, Tripsianis G, Karayiannakis AJ. Risk factors for conversion of laparoscopic cholecystectomy to open cholecystectomy. Surg Endosc 2005;19:905-9.  Back to cited text no. 19
    
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