6 Ocak 2008 Pazar

LAPAROSCOPIC CHOLECYSTECTOMY: REASONS AND RISK FACTORS FOR CONVERSION TO OPEN SURGERY

LAPAROSCOPIC CHOLECYSTECTOMY: REASONS AND RISK FACTORS FOR CONVERSION TO OPEN SURGERY

Mehmet KAPLAN, MD

Department of Surgery, Özel Hatem Hastanesi, Gaziantep, Turkey



Yazışma için : Dr. Mehmet KAPLAN
Özel Hatem Hastanesi
Genel Cerrahi Servisi 27090
Gaziantep - TÜRKİYE
Phone : +90 342 220 15 15
Fax : +90 342 220 32 22
e-mail : meplan69@hotmail.com



SUMMARY
Purpose: The aim of this study was to investigate the reasons for conversion to open surgery (OS) and to evaluate the possible risk factors for conversion in patients who were assigned to laparoscopic cholecystectomy (LC). Methods: Between September 1998 and December 2001, LC was attempted in 300 well-documented patients. Patients who had to be converted were compared with laparoscopically completed cases with regard to demographics, current severity of cholecystitis (acute, chronic, subacute), previous acute attacks, previous abdominal surgery, concurrent intraabdominal diseases, surgical findings, and complications. Results: Twenty-three patients (7.7%) were converted to OS. The reasons for conversion were; inability to proceed with laparoscopic dissection in 11 cases (47.8%), concurrent findings requiring OS in 4 (17.4%), bleeding in 3 (13%), bile duct injury in 2 (8.7%), spillage of multiple stones in 1 (4.35%), colonic perforation in 1, and gallbladder malignancy in 1 case. Conversion to OS was found to be significantly correlated with existence of upper abdominal incisions (OR=28.9), existence of previous acute attacks treated conservatively (OR=14.9), misdiagnosed subacute cholecystitis with inflammatory adhesions (OR=9.8), male gender (OR=5.2). Conclusion: Patient characteristics, such as male gender, existence of upper abdominal incisions, or history of acute attacks, indicate a higher possibility of conversion from laparoscopic to open cholecystectomy.

INTRODUCTION
Since 1985, laparoscopic cholecystectomy (LC) has developed rapidly and become the gold standard treatment of various gallbadder diseases (Asbun HJ 1994). Contrary to the early reports of increased complication rates, recent studies suggest that LC can be performed with lower morbidity and mortality, compared with the traditional open surgery (OS) (Hannan EL 1999, Barkun JS 1992). Its benefits over open cholecystectomy include less patient discomfort, better cosmetic results, shorter hospitalization, and more rapid return to full activities postoperatively (Barkun JS 1992, Schirmer BD 1991, Vitale GC 1991). Nevertheless, conversion to OS may occasionally be obligatory for patients in whom LC cannot be performed safely, and/or because of technical difficulties or intraoperative complications (Frazee 1992, Fried 1994, Liu 1996). The most common reported reasons for conversion have been inability to perform a safe dissection due to obscure anatomy, inflammation, or adhesions, bleeding, and bile duct injuries (Sanabria 1994, McGim 1995, Liu 1996, Wallace 1997, Lo 1997). Other infrequent factors to result in conversion include unexpected malignancies, inability to create pneumoperitoneum, instrument failure (McGinn 1995), multiple tears in the gallbladder (Rotter 1993), and common bile duct stones (Liu 1996, Senabria 1994).
Conversion from LC to OS should not be considered as a failure or a complication of laparoscopic operation, rather, it should be accepted as a step towards a safer surgery when completion of LC is not be possible (Strazberg S 1992). Nevertheless, surgeons are generally relactant to convert the procedure to OS because of the more time consumed, increased surgical costs and expectations of patient. Therefore, preoperative estimation of the risk probability for requirement of conversion to open surgery is important, and it may allow some advantages both for the surgeon and candidates of LC. In this way, the surgeon can discuss with the patients the likelihood of conversion to open surgery more accurately, and the patient will have adequate psychological preparation. Furthermore, more efficient arrangement and realistic planning of the operating schedule can be done, and the necessity of a consultant laparoscopic surgeon can be considered. The last significance of the awereness of the risk factors preoperatively is that, if preventable, the reasons of the conversion would be eliminated or, if not, then the decision of exclusion of more challenging cases would be possible, especially in the training situations.
The aim of this study was to investigate the reasons for conversion to open surgery (OS) and to evaluate the possible risk factors for conversion in patients who were assigned to laparoscopic cholecystectomy (LC).
PATIENTS AND METHODS
From September 1998 to December 2001, 332 patients underwent cholecystectomy, and LC was attempted in 300 (90.4%). There were 32 patients selected directly for open surgery due to various causes, such as severe heart and/or pulmonary diseases, suspicion of malignancy, concomittant disease requiring OS, or multiple previous upper abdominal incisions, and excluded from the analysis. Patients with a single upper abdominal incision were assigned for LC. The demografics and reasons of the selection for open surgery of these patients is shown in Table 1. Of the 300 patients in which LC was attempted, there were 68 male (22.7%) and 232 female patients (77.3%), with a mean age of 52.6 years (range 19 to 81 years). All of the operations were carried out or assisted by the same four consultants with a high level of laparoscopic experience.
We developed a detailed data collection form prior to the initiation of the study. Data included demographics such as age, sex and obesity, current severity of cholecystitis (acute, chronic, subacute), history of previous acute attacks, jaundice and pancreatitis, abnormal preoperative liver function tests, preoperative radiologic findings, previous abdominal surgery, concurrent intraabdominal diseases, surgical findings, and complications. Obesity was defined as body mass index above the cut off value of 28 (kg/m2). Cholecystitis was diagnosed by clinical and laboratory assessments and pathological evaluation.
All patients had routine basic preoperative tests, including liver function tests (serum alanin transaminase, aspartate transaminase, alkaline phosphatase, gamma glutamyl transpeptidase, and bilirubin) and abdominal ultrasonography, and follow-up evaluation six weeks postoperatively. In 12 patients who had clinical, radiologic and/or biochemical evidence of common bile duct stones, selective preoperative ERCP was performed. Endoscopic sphincterotomy and complete stone removal was achieved in 10 patients, who were confirmed to have common bile duct stones. Open trocar insertion was attempted in all patients with previous abdominal surgery because of the probability of intraabdominal adhesions. All patients who presented with acute cholecystitis in the first 72 hours underwent emergency LC. The patients whose the pathological results did not support the clinical and laboratory data were not considered to have acute cholecystitis. If the patients with acute infection were admitted more than 72 hours after the onset of symptoms, elective LC was carried out 8-10 weeks later following a course of conservative treatment (delayed cholecystectomy). The operations were performed with the standard four-port technique.
The statistical analysis was carried out by means of Fisher’s chi-squared test to determine the p values for univariate analysis in order to determine each significant risk factor for conversion. The odds ratios were calculated with their 95% confidence intervals. The variables with numerical values were analysed with Mann-Whitney U test to compare the groups.

RESULTS
Of the 300 patients in whom LC was attempted, 23 (7.7%) required conversion to open surgery (Table 1). In spite of the female predominance in this series, the rate of conversion was found to be significantly higher in males (p<0.001).>0.05). When the type of previous abdominal surgery was considered, it was observed that, in contrast to previous lower abdominal surgery, completion of laparoscopic surgery was significantly affected by previous upper abdominal surgery (p<0.001).>0.05). On the other hand, the patients with the history of documented acute cholecystitis and who had previously been treated with a conservative regimen in this order, had a higher rate of conversion, compared with the patients without such a history (p<0.001). Similarly, the patients with the unexpected operative findings of a severely inflamed gallbladder and dense adhesions to neighboring organs had a higher rate of conversion (p<0.001). In the presence of liver function test abnormalities conversion to OS were found to be significantly higher, in spite of succesful preoperative elimination of CBD stones by way of endoscopic sphincterotomy (p<0.05).
As expected, operation time, duration of hospitalization, and postoperative time to oral intake were significantly longer in conversion group (p<0.001) (Table 2).
All severe complications led to conversion to laparotomy (Table 3 and Table 4). In 2 of 300 patients bile duct injuries occurred and were overcome by primary suture and T-tube drainage. In one patient with previous upper abdominal surgery, transverse colon was perforated accidentally during dissection of adhesions. The perforation was repaired by primary suture and the patient was discharged uneventfully on postoperative day 7. Severe bleeding occurred in 7 patients. In one, inferior vena cava was injured during Veress needle insertion. Following immediate laparotomy the laceration was repaired primarily and the patient was discharged on the 5th postoperative day. Of the remaining 6 patients who had bleeding from cystic artery during dissection of the Calot's triangle, 4 were managed succesfully via laparoscopic intention, but the other 2 patients required conversion to laparotomy and ligation of the artery. Perforation of the gallbladder in 7 patients led to the spillage of multiple milimetric stones into the peritoneal cavity. To avoid late infectious problems, the abdomen was opened and cleaned of the stones in 1 patient because of the inadequacy of laparoscopic intention. In two patients common bile duct stones incidentally identified by intraoperative cholangiogram, were managed by open surgery with common bile duct exploration and T-tube drainage. In 1 of the 3 patients with trocar site herniation, small bowel incarceration developed and was treated immediately.
The reasons for conversion to OS other than the above mentioned were inability to define anatomy in 11 patients (47.8%) and gallbladder malignancy in one (Table 4). This was the most frequent cause of conversion due to edema, dense adhesions between thickened gallbladder with foreshortening of the cystic duct and neighboring tissues, and chronic inflammation.
The rate of conversion to OS was found to be significantly correlated with existence of upper abdominal incisions (OR=28.9), previous acute attacks treated conservatively (OR=14.9), misdiagnosed subacute cholecystitis with inflammatory adhesions (OR=9.8), and male gender (OR=5.2). Furthermore when a cut-off value of 60 years was considered, the risk of conversion of the patients aged ³60 were found to be significantly higher (p<0.05, OR=3.6) (Table 5). To find out the contribution of age to the risk of conversion to open cholecystectomy we compared the patients aged <60 years and ³60 years according to the multiple variables (Tablo 6). Among them, significantly more frequent previous abdominal surgery, intraabdominal adhesions, pericholecystitis, concomittant diseases, drain usage (p<0.001), and longer duration of hospitalization (p<0.05) were found in the patients ³60 years than the younger. Indicating more problematic patients for LC.

DISCUSSION
Not surprisingly in the setting of acute cholecystitis (AC), the presence of pericholecystic adhesions, tissue edema, and inflammation that obscure the anatomy can cause difficulty in dissection and also perforation of distended and fragile gallbladder during traction may occur. In these circumstances the increased conversion and complication rates are expected. In this study, interestingly AC was not found to be a risk factor for conversion to open surgery in contrast to numerous studies (Frazee RC 1992, Schrenk P 1995, Peters JH, Kum CK 1996, Fried GM 1994). Kum CK and associates (1996) have recently investigated and discussed in detail the reasons of conversion in the setting of AC with the findings of the other studies. They concluded that because AC accounted approximately 20% of pathologies requiring cholecystectomy, in the series with AC fewer than 10% of the total cases of LCs, the lower reported rates of conversion to OS might have been due to the selection of some cases of AC directly to open surgery and exclusion from the analysis. In this study, the conversion rate of 33 cases with AC did not statistically differ from the cases without AC (%9.1 vs. %7.5, p>0.05). This may be partly related to the exclusion from the study of 5 out of 38 patients with acute cholecystitis, selected directly to open surgery initially. Furthermore all LCs were performed by experienced senior surgeons with more than 100 LCs.
Even before laparoscopic surgery, managing AC was controversial, some advocating medical treatment and delayed surgery and others preferred early surgery (McArthur P 1975). Our policy is to perform emergency LC for patients with AC admitted in the first 72 hours from the beginning of the symptoms or in the case of failed initial conservative treatment. The patients with the symptoms of AC longer than 72 hours are treated with conservative regimen and scheduled for delayed surgery after 6-8 weeks. The risk of complications and conversion to OS or accomplishing safe laparoscopic surgery in these patients is also somewhat controversial. In fact, until recently AC was regarded as a contraindication for LC (Gadacz TR 1990). However as the experience is gained increasingly difficult operations are being attempted with acceptable success (Wilson RG 1992, Kum CK 1996, Wallace DH 1997). We found that, of the patients admitted with AC when treated with emergency LC showed no risk of conversion whereas in the patients with previous history of documented acute attacks the conversion risk were increased to 14.9 fold than the patients with no such history (40.7% vs. 4.4%, p<0.001). This finding suggested the patients with AC should be treated preferentially by LC when possible.
Older age was considered as a risk factor of conversion to OS (Liu C 1996, Wiebke EA 1996, Lo CM 1997, Sanabria JR 1994, Liu CL 1996, Fried GM 1994). We found that, the mean age of OS group was higher than that of LC group, likewise when a cut-off value of 60 years was considered, the likelihood of conversion to OS was also higher for patients ³60 years. This suggested that additional factor(s) bearing the risk for conversion might exist in the elderly. To examine this factors we analised age with the other variables. We found that increasing age was correlated significantly with the existence of previous abdominal surgery, concomittant systemic disease (severe pulmonary, cardiac and other systemic diseases), more frequent history of acute attacks and jaundice, suspicion and/or existence of malignancy, intraoperative finding of concomittant disease requiring open surgery.

REFERENCES
1. Asbun HJ, Rossi RL. Techniques of laparoscopic cholecystectomy. The difficult operation. Surg Clin North Am 74; 755-775, 1994.
2. Barkun JS, Barkun AN, Sampalis JS et al. Randomised controlled trial of laparoscopic versus mini-cholesistectomy. Lancet 340: 1116-1119, 1992.
3. Schirmer BD, Edge SB, Dix J, Hyser MJ, Hanks JB, Jones RS. Laparoscopic cholecystectomy: treatment of choice for symptomatic cholelithiasis. Ann Surg 213:665-677, 1991.
4. Vitale GC, Collet D, Larson GM, Cheadle WG, Miller FB, Perissat J. Interruption of professional and home activity after laparoscopic cholecystectomy among French and American patients. Am J Surg 161:365-370, 1991.
5. Frazee RC, Roberts JW, Symmonds R, Snyder SK, Hendricks J, Smith R, Custer MD. What are the contraindications for laparoscopic cholecystectomy? Am J Surg 164: 491-495, 1992.
6. Fried GM, Barkun JS, Sigman HH, Joseph L, Clas D, Garzon J, Hinchey EJ, Meakins JL. Factors determinig conversion to laparotomy in patients undergoing laparoscopic cholecystectomy. Am J Surg 167: 35-41, 1994.
7. Liu C, Fan S, Lai ECS, Lo C, Chu K. Factors affecting conversion of laparoscopic cholecystectomy to open surgery. Arch Surg 131: 98-101, 1996.
8. Strazberg S, Sanabria J, and Clavien P. Complications of laparoscopic cholecystectomy. Can J Surg 35: 275-280, 1992.
9. Hannan EL, Imperato PJ, Nenner RP, Starr H. Laparoscopic and open cholecystectomy in New York State: mortality, complications, and choice of procedure. Surgery 125: 223-31, 1999.
10. Schrenk P, Woisetschlager R, Wayand WU. Laparoscopic cholecystectomy. Cause of conversions in 1,300 patients and analysis of risk factors. Surg Endosc 9:25-8, 1995.
11. Peters JH, Krailadsiri W, Incarbone R, Bremner CG, Froes E, Ireland AP, Crookes P, Ortega AE, Anthone GA, Stain SA. Reasons for conversion from laparoscopic to open cholecystectomy in an urban teaching hospital. Am J Surg 168:555-8, 1994.
12. Kum CK, Eypash E, Lefering R, Paul A, Neugebauer E, Troidl H. Laparoscopic cholecystectomy for acute cholecystitis: Is a really safe? World J Surg 20:43-8, 1996.
13. Wiebke EA, Pruitt AL, Howard TJ, Jacobson LE, Broadie TA, Goulet RJ Jr, Canal DF. Conversion of laparoscopic to open cholecystectomy. An analysis of risk factors. Surg Endosc 10:742-5, 1996.
14. Lo CM, Fan ST, Liu CL, Lai EC, Wong J. Early decision for conversion of laparoscopic to open cholecystectomy for treatment of acute cholecystitis. Am J Surg 173:513-7, 1997.
15. Sanabria JR, Gallinger S, Croxford R, Strazberg SM. Risk factors in elective laparoscopic cholecystectomy for conversion to open cholecystectomy. J Am Coll Surg 696-704, 1994.
16. Gadacz TR, Talamani MA, Lillemore KD, Yeo CJ. Laparoscopic cholecystectomy. Surg Clin North Am 70:1249-??, 1990.
17. McArthur P, Cushieri A, Sells RA, Sheilds R. Controlled clinical trial comparing early with interval cholecystectomy for acute cholecystectomy for acute cholecystitis. Br J Surg 62:850-2, 1975.
18. Wallace DH, O'dwyer PJ. Effect of no-conversion policy on patient outcome following laparoscopic cholecystectomy. Br J Surg 84:1680-82, 1997.
19. Wilson RG, Macintyre IMC, Nixon SJ, Saunders JH, Varma JS, King PM. Laparoscopic cholecystectomy as a safe and effective treatment for severe acute cholecystitis. BMJ 305:394-6, 1992.
20.
The likelhood of previous abdominal surgery is increasing with the age.
Associated pulmonary, cardiac and other systemic diseases increase with age.





Table 1. Characteristics of the patients directly selected for OS
Characteristics
No. (%)
Patient number
32 (9.6)
Gender
Men
Women

14 (43.8)
18 (56.2)
Age
Men
Women
70.2 (30-83)*
63,4 (35-83)*
77 (30-83)*
Reasons for selection directly to OS


Severe heart and/or pulmonary diseas
7 (21.8)

Previous multipl upper abdominal surgeries
6 (18.8)

Choledocholitiasis and/or cholangitis
6 (18.8)

Severe acute cholecystitis
5 (15.6)

Suspicion of malignancy
3 (9.4)

Concomittant disease
3 (9.4)

Coagulation disorders
1 (3.1)

Pregnancy
1
*predicted as mean (range)











Table 2. Rate of conversion of laparoscopic to open surgery according to patient characteristics
Patient Group
No.
of Patients
No. (%)
of completed
No. (%)
of conversions
p*
Overall
300
277 (92.3%)
23 (7.7%)

Sex
M
F

68
232

55 (80.9%)
222 (95.7%)

13 (19.1%)
10 (4.3%)

<0.001
Agea

49.1±12.29
59±9.34
<0.05
Age (cut-off value)
>60
<60

44
256

56 (83.6%)
221 (94.8%)

11 (16.4%)
12 (5.2%)

<0.05
Obesity status
Nonobese
Obese (BWI>28)

165
135

150 (90.9%)
127 (94.1%)

15(9.1%)
8 (5.9%)

>0.05
Previous upper abdominal surgery
Yes
No

6
294

2 (33%)
275 (93.5%)

4 (66.7%)
19 (6.5%)

<0.001
Previous lower abdominal surgery
Yes
No

35
265

32 (91.4%)
245 (92.5%)

3 (8.6%)
20 (7.5%)

>0.05
History of acute cholecystitis
Yes
No

27
273

16 (59.3%)
261 (95.6%)

11 (40.7%)
12 (4.4%)

<0.001
Current severity of cholecystitis
Acute
Chronic

33
267

30 (90.9%)
247 (92.5%)

3 (9.1%)
20 (7.5%)

>0.05

Pericholecystitis
Yes
No

26
274

17 (65.5%)
260 (94.9%)

9 (34.6%)
14 (5.1%)

<0.001
Liver function tests
Abnormal
Normal

12
288

8 (66.7%)
269 (93.4%)

4 (33.3%)
19 (6.6%)

<0.05
Operation time (minute)a

55.36±22.58
100±43.96
<0.001
Time to oral administration (hour)a

8.8±4.83
24±9.79
<0.001
Hospitalization (day)a

1.29±0.61
3.5±0.57
<0.001
*Fisher's exact or Mann-Whitney U test, where appropriate
aThe values were given as mean±standart deviation











Table 3. Complications in the LC attempted patients
Complication
No. (%)
Bile duct injury
2
Gastrointestinal injury
1
Bleeding
7
Infection
5
Trocar site herniation
3
Spillage of multiple stones
7
Retained stones
2
Total
27 (9%)


Table 4. Reasons for conversion to open cholecystectomy

No. (%)
Inability to define anatomy
11(47.8%)
Concurrent findings
4 (17.4%)
Bleeding
3 (13%)
Bile duct injury
2 (8.7%)
Spillage of multiple stones
1 (4.35%)
Colonic perforation
1 (4.35%)
Gallbladder malignancy
1 (4.35%)


Table 5. Univariate analysis of risk factors for conversion from
laparoscopic to open surgery
Variables
Converted
No. (%)
Comleted
No. (%)
Total
Odds
Ratio
P Value*
Upper abdominal incision
Yes
No

4 (66.7%)
19 (6.5%)

2 (33.3%)
275 (93.5%)

68
232
28.9

p<0.001
History of cholecystitis
Yes
No

11 (40.7%)
12 (4.4%)

16 (59.3%)
261 (95.6%)

27
273
14.9

p<0.001
Pericholecystitis
Yes
No

9 (34.6%)
14 (5.1%)

17 (65.4%)
260 (94.9%)

26
274
9.8

p<0.001
Gender
Male
Female

13 (19.1%)
10 (4.3%)

55 (80.9%)
222 (95.7%)

68
232
5.2

p<0.001
Age
³60
<60

11 (16.4%)
12 (5.2%)

56 (83.6%)
221 (94.8%)

67
233

3.6

<0.05
*p values were obtained by Fisher's exact test





Table 6. Comparison of the patient characteristics according to age

Age <60 years
Age ³60 years
p value*
Concomittant disease
Yes
No

74 (67.3%)
159 (83.7%)

36 (32.7%)
31 (16.3%)

=0.001
Previous abdominal surgery
Yes
No

19 (46.3%)
214 (82.6%)

22 (53.7%)
45 (17.4%)

<0.001
Intra-abdominal adhesions
Yes
No

26 (54.2%)
204 (82.3%)

22 (45.8%)
44 (17.7%)

<0.001
Pericholecystitis
Yes
No

12 (46.2%)
221 (80.7%)

14 (53.8%)
53 (19.3%)

<0.001
Drain usage
Yes
No

23 (57.5%)
200 (82.6%)

17 (42.5%)
42 (17.4%)

=0.001
Time to oral administration (hour)a
9.12±5.60
8.93±3.43
>0.05
Hospitalizationa
1.27±0.61
1.5±0.80
<0.05
Operation timea
55.41±23.39
58.25±23.89
>0.05
*Fisher's exact or Mann-Whitney U test, where appropriate
aThe values were given as mean±standart deviation














Table 1. Characteristics of the patients directly selected for OS
Characteristics
No. (%)
Patient number
32 (9.6)
Gender
Man
Women

14 (43.8)
18 (56.2)
Age
Man
Women
70.2 (30-83)
63,4 (35-83)
77 (30-83)
Reasons for selection directly to OS


Severe heart and/or pulmonary diseas
8 (25)

Previous multipl upper abdominal surgeries
6 (18.8)

Choledocholitiasis and/or cholangitis
6 (18.8)

Severe acute cholecystitis
4 (12.5)

Suspicion of malignancy
3 (9.4)

Concomittant disease
3 (9.4)

Coagulation disorders
1 (3.1)

Pregnancy
1

Table 2. Reasons for conversion to open cholecystectomy

No. of patients (%)
Inability to define anatomy
11(47.8%)
Concurrent findings
4 (17.4%)
Bleeding
3 (13%)
Bile duct injury
2 (8.7%)
Spillage of multiple stones
1 (4.35%)
Colonic perforation
1 (4.35%)
Gallbladder malignancy
1 (4.35%)

Table 1. Rate of conversion of laparoscopic to open surgery according to patient characteristics
Patient Group
No.
of Patients
No. (%)
of conversions
p*
Overall conversion
300
23 (7.7%)

Sex
M
F

68
232

13 (19.1%)
10 (4.3%)
<0.001
Age
>65
<65

44
256

7(15.9%)
16(6.3%)
>0.05
Obesity status
Nonobese
Obese (BWI>28)

165
135

15(9.1%)
8 (5.9%)
>0.05
Previous upper abdominal surgery
Yes
No

6
294

4 (66.7%)
19 (6.5%)
<0.001
Previous lower abdominal surgery
Yes
No

35
265

3 (8.6%)
20 (7.5%)
>0.05
History of acute cholecystitis
Yes
No

27
273

11 (40.7%)
12 (4.4%)
<0.001
History of pancreatitis
Yes
No

3
297

0
23 (7.7%)
>0.05
History of jaundice
Yes
No

14
286

3 (21.4%)
20 (7.0%)
>0.05
Current severity of cholecystitis
Acute
Chronic

33
267

3 (9.1%)
20 (7.5%)
>0.05

Pericholecystitis
Yes
No

26
274

9 (34.6%)
14 (5.1%)
<0.001





Table 3. Univariate analysis of risk factors for conversion from
laparoscopic to open surgery
Variables
Converted
No. (%)
Comleted
No. (%)
Total
Odds
Ratio
P Value
Upper abdominal incision
Yes
No

4 (66.7%)
19 (6.5%)

2 (33.3%)
275 (93.5%)

68
232
28.9

p<0.001
History of cholecystitis
Yes
No

11 (40.7%)
12 (4.4%)

16 (59.3%)
261 (95.6%)

27
273
14.9

p<0.001
Pericholecystitis
Yes
No

9 (34.6%)
14 (5.1%)

17 (65.4%)
260 (94.9%)

26
274
9.8

p<0.001
Gender
Male
Female

13 (19.1%)
10 (4.3%)

55 (80.9%)
222 (95.7%)

68
232
5.2

p<0.001

3 Ocak 2008 Perşembe

Safra Kesesi Nedir? Op.Dr. Mehmet KAPLAN anlatıyor

SAFRA KESESİ TAŞI NEDİR, NASIL OLUŞUR, TEDAVİSİ NASILDIR?

Op. Dr. Mehmet KAPLAN
Genel Cerrahi Uzmanı
Özel Hatem Hastanesi
Gaziantep

Gaziantep Özel Hatem Hastanesi Cerrahlarından Opr. Dr. Mehmet KAPLAN Safra Kesesi ve taşları ile ilgili şu bilgileri veriyor;
Safra kesesi karaciğer alt yüzüne yapışık armut şeklinde bir organdır. Tam dolduğu zaman 50 ml safra alır. Karaciğerden salgılanan safra kanallardan geçerek safra kesesine gelir ve burada konsantre edilir ve bekler. Yemek yendiği zaman safra kesesi kasılır ve konsantre safra ince barsağa akar ve yemeklerin sindirilmesine yardım eder.



TAŞ NASIL OLUŞUR?
Safra kesesi taşları Kolestrol ve Pigment taşları olarak ikiye ayrılır. Kolestrol taşları mekanizması tam belli olmayan bir nedenle kolestrolun safra kesesi içine çökmesi nedeni ile oluşurlar. Pigment taşları koyu renkli taşlardır ve genelde siroz, safra yolları tıkanıklığı, kan yıkımı olan hastalıklarda görülür.


BESLENME, CİNSİYET, YAŞ, KALITIM GİBİ ETKENLERİN ROLÜ VAR MI?
Safra kesesi taşları bayanlarda erkeklerden 4 kat daha fazla görülür. 40 yaş üzerindeki her 8 bayandan birinde safra kesesi taşı görülür. Beyaz tenli ve kilolu bayanlarda görülme sıklığı daha fazladır.

TAŞIN VUCUDA ZARARI NEDİR? NELERE YOL AÇABİLİR?
Hayati tehdit terimini özellikle kullanıldığını belirten Opr. Dr. Mehmet KAPLAN, Çünkü çalışmalar göstermektedir ki; taş hastalığı olanların %60-80’inde komplikasyon dediğimiz ve sonuçları gerçekten üzücü olan yan etkiler görülür diyor ve ekliyor:
Taşlı safra kesesinin iltihabı sonucu kesenin delinmesi ile safra ve cerahatin karın boşluğuna dökülmesi ameliyat edilmediği taktirde ölümle sonuçlanan bir durumdur. Yine küçük taşların ana safra kanalına kaçmaları ve bu kanalın kalem ucu kadar olan alt ucunu tıkamaları sonucu oluşan tıkanma sarılığı veya cerrahi sarılık acil tedavi edilmediği takdirde ölümle sonuçlanabilen bir diğer durumdur.
Yine safra kesesindeki küçük taşların ana safra kanalının alt ucunda pankreas bezine ait kanalı tıkamaları sonucu oluşan pankreatit de tedavi edilmediğinde %50 ölümle sonuçlanır.
Bir başka önemli husus da safra kesesi kanserleridir. Bu kanserlerde %95 oranında kesede taş mevcuttur. Buda safra kesesi kanserleri ile safra kesesi taşları arasında çok sıkı bir ilişkinin var olduğunu göstermektedir.

SAFRA KESESİ TAŞLARININ BELİRTİLERİ:
Bu hastalarda her hangi bir hastalığa özel olmayan; karın ağrıları, hazımsızlık, şişkinlik, ekşime, yanma gibi sindirim sistemine ait yakınmalar olur.
Bazen hastalarda omuz ve sırt ağrıları uzun yıllar romatizma zannedilerek tedavi edilir. Eskiler buna safra kesesi romatizması derlerdi. Doğrusu hiçde haksız değillerdi. Geçmişte olduğu gibi günümüzde de çok sık rastlanan bir yanılgı safra kesesi hastalarının kalp hastalığı varmışçasına değerlendirilip tedavi edilmeleridir. Burada gerçekten mevcut olan safra kesesi ile kalp koronerleri arasındaki refleks cevap kese hastalığının kalp hastalığı bulguları ile ortaya çıkmasına yol açar. Bunlardaki göğüs ağrıları, sıkıntı, hatta elektrokardiografideki bozukluklar enfarktüs zannedilir. Bunlara uzun yıllar kalp ile ilgili tetkik ve tedaviler uygulanır, oysa safra kesesi kalbi denilen bu sıkıntılar safra kesesinin çıkartılması ile son bulur.

İLAÇLA TEDAVİSİ MÜMKÜN MÜ?
Hayır, safra kesesi taşlarının ilaç tedavisi yok. Tek tedavi ameliyattır.

AMELİYATIN ALTERNATİFİ VAR MI?
Alternatif yok. Ameliyat olmak şarttır.

AMELİYAT EDİLMEDİĞİ TAKDİRDE SONUÇLARI NELERDİR? ÖLÜM NEDENİ OLUR MU?
Taşlı safra keseleri ameliyat edilmediği takdirde tıkanıp , şişebilir ve delinebilir. Tıkanma sarılığı ve buna bağlı karaciğerin bozulmasına neden olabilir. Uzun süre safra kesesinde taş olan hastalarda safra kesesinde kanser gelişme riski vardır, bu saydığımız komplikasyonların hepsi olüm nedeni olabilir. En çok korkulan komplikasyon, taşın safra kesesinden safra yoluna düşerek pankreasın ağzını tıkaması ve pankreatite neden olmasıdır ve ölüm riski çok fazladır.

Günümüzde safra kesesi ameliyatı kapalı (laparoskopik) olarak yapılmaktadır. Ortalama 30 dakikada ameliyat bitiyor ve hasta 1 gece hastanede kalıyor ya da aynı günün akşamı taburcu oluyor. Hastanın karnında kesi olmadığı için ameliyat sonrası ağrı ve sızı olmuyor ve hemen normal hayatına başlayabiliyor.

Safra kesesinde taşı olan herkese komplikasyon gelişmeden biran önce ameliyat öneriyoruz.

Safra kesesi ameliyat videosu
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