Cholecystectomy and Diabetics
Cholecystectomy as one of the most frequent surgeries and diabetics as one of the most prevalent disease have some interrelationships. Hence, the bilateral effects of diabetics on Gallbladder disorders and vice versa have been investigated in many recent studies. In this summary, we will evaluate three of these publications.
2005 Research (Dr. Ziaei, Dr. Fanaei and Colleagues)
In 2005, Dr. Ziaei, Dr. Fanaei and their colleagues investigated the effects of cholecystectomy on patients suffering from diabetics and compared them with healthy subjects. In the abstract of this paper it is stated that: Mortality and morbidity from gallstones in the diabetic patients in comparison with the nondiabetics are always controversial. The aim of this study was to evaluate the risk factors associated with morbidity from gallstones. Materials and Methods: We have analyzed data from 669 cholecystectomies performed between March 2002 and December 2003. They found that among 669 patients, 116 had complications. Complications included 68 adhesions, 26 gangrenes of the gallbladder, 14 pancreatitis, 20 hydropses, and 5 perforations. In univariate analysis, age, diabetes, hypertension, and ischemic heart disease were significantly associated with high risk of complications. In multivariate analysis, only diabetes caused a significant increase in complications with odds ratio of 6.1. Diabetes was also significantly associated with high risk of adhesion, gangrene and pancreatitis. In the conclusion of this study, the authors state that they have detected a higher incidence of advanced inflammatory changes in the gall bladder of the diabetics. The higher rate of gangrene and nonsignificant increased risk of perforation is also compatible with some of the previous studies. Perforations of the gall bladder have been reported higher in some previous studies, but because of very low risk of perforation in this study they did not detect a higher rate of this complication in the diabetics. Although diabetics in this study are older and more likely to have hypertension or Ischemic heart disease, the independent role of diabetes on operative findings in multivariate analysis is in contrast with the idea that increased morbidity in these patients is as a result of older age and concurrent medical disease, claimed in some previous studies.
Today with increasing popularity of laparoscopic cholecystectomy and also due to its safety and less expenses and on the other hand, higher morbidity and mortality of emergency cholecystectomy compared to early elective surgery, prophylactic surgery for gallstones in the diabetics is still in dispute. Although the results of our study do not justify performing prophylactic cholecystectomy in the diabetics with gallstones, but markedly high incidence of advanced inflammatory changes is in favor of expeditious management of gallstones in these patients. However, further studies are required for a better understanding of the pathophysiology of inflammation in the gall bladder of the diabetics. In conclusion it is stated that although this study does not directly support prophylactic cholecystectomy, the increased morbidity in the diabetics implies that diabetic patients with asymptomatic gallstone need more care and attention.
A research of 2012
Diabetes was found to be a risk factor for gallstone formation, and complications. Diabetic patients are generally more prone to operative and post-operative morbidities than their normal counterparts. This study aimed to find whether diabetes is an independent risk factor for morbidities associated with laparoscopic cholecystectomy in our population. This is a comparative cross-sectional study that was conducted at the Department of Surgery in King Abdulaziz University Hospital, Jeddah, Saudi Arabia, from June to December 2011. A total of 112 patients who have undergone laparoscopic cholecystectomy at our hospital were randomly selected and retrieved from the medical records department. A total of 112 patients underwent laparoscopic cholecystectomy for cholelithiasis. 18 patients were male and 94 were female with a ratio of. The mean (±SD) age was 41.23 ± 13.82 years (range 15-75 years). Out of 112 patients, 18 were diabetics and 94 patients were not diabetics. The operation was performed as an elective procedure in 104 patients and as an emergency in 8 patients. Diabetics had a significantly higher rate of emergency admissions (22.2%) compared to nondiabetics. Laparoscopic cholecystectomy was converted to open procedure in 4.5% of patients of which 16.7% were diabetics and 2.1% non-diabetics. This shows a statistically significant higher rate of conversion to open of diabetics compared to non-diabetics. Diabetics had a significantly higher mean length of post-operative hospital stay compared to non-diabetics. The level of HbA1c and fasting glucose level showed no significant effect on conversion to open procedure. The factors that were associated with higher risk of conversion to open were older age, male gender, diabetes, and acute calcular cholecystitis. The authors conclude that diabetes mellitus is associated with more emergency admission due to complicated cholelithiasis, more conversion rate from laparoscopic to open cholecystectomy and prolonged post-operative hospital stay. They found that neither fasting blood glucose level nor HbA1c level have any correlation with intraoperative or post-operative complication or conversion rate. They recommended a pre-operative control of blood glucose until we have a prospective randomized control trial comparing diabetic and non-diabetics patient going for laparoscopic cholecystectomy to know at which level of HbA1c or level of blood glucose should be achieved before surgery.
A research of 2013
In this study, one of the most prevalent diseases meets one of the most frequently performed operations. This topic is becoming more and more important because of the increasing age of the surgical population, paralleling the increasing incidence of diabetes. The purpose of this study was to determine the prevalence of diabetes and its effect on surgical outcomes in patients undergoing emergent, in-patient cholecystectomy for acute cholecystitis. Some 8.3% of the U.S. population has diabetes and this number is projected to rise to 21-33% by 2050. Diabetes is considered to be associated with a higher incidence of acute cholecystitis; however, its impact on outcomes is unknown. The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify all patients with acute cholecystitis who underwent emergent in-patient cholecystectomy from 2004 to 2010. The study population was divided into two groups: diabetics and non-diabetics. Diabetics were further subdivided into those taking oral medication and those on insulin. Demographics, co-morbidities, and wound classification were compared with univariate analysis, and 30-day outcomes were compared with univariate and multivariate analyses. A total of 5,460 patients met the inclusion criteria. Of these 770 (14.10%) had a diagnosis of diabetes. Mortality was higher for diabetics than for non-diabetics. Preoperative perforation rates were 25.1 and 13.0%, respectively. The adjusted risk of cardiovascular events and renal failure was significantly higher for diabetics. Insulin treatment, but not oral medication, was associated with a significant increase in mortality, preoperative perforation, superficial surgical site infection, septic shock, cardiovascular incidents, and renal insufficiency. The authors concluded that in patients undergoing cholecystectomy for acute cholecystitis, diabetes increases the risk of mortality, cardiovascular events, and renal failure. Insulin-treated diabetics have more co-morbidities and poorer outcomes.
In light of the large database and robust multivariate analysis, the authors provide relevant support for their hypothesis. Of interest is the strong impact of diabetes mellitus on the presentation of cholecystitis, with a significantly increased incidence of preoperative gallbladder perforation. Potential causal interactions between the incidence of acute cholecystitis and diabetes will hopefully be addressed in future studies.
Another interesting finding is the impact of insulin use on local and systemic infections compared to its effect on diabetic patients given oral medication and patients without diabetes mellitus. The elevated incidence of infections is unlikely to be explained by the higher incidence of perforations and longer hospital stays. Potentially complex interactions between diabetes and other aspects of the metabolic syndrome-obesity, fatty liver disease, consequences of arteriosclerosis-may influence the incidence of these outcome parameters.
The impact of diabetes on some clinical outcome parameters may be explained in part by differences between the populations because despite being extensive multivariate analysis might not entirely correct for all factors that may have a causal effect on the observed events.
The data of this study pave the way for new studies that address therapeutic aspects in patients with diabetes undergoing laparoscopic cholecystectomy. Optimal blood glucose levels and the intensity of the insulin treatment are of particular clinical interest in this population. With our current knowledge, it is unclear if local and systemic complications are altered by different approaches of intraoperative and postoperative glucose control, including tight glycemic control or standard care.
This article addresses a frequent and highly relevant clinical scenario. In future, surgeons need to investigate further the relevance of the metabolic syndrome and associated diseases to the pathogenesis, outcomes, and clinical management of their patient population
References
[1]. Ziaee SA, Fanaie SA, Khatib R, Khatibzadeh N, “Outcome of cholecystectomy in diabetic patients”, Indian J Surg, vol. 67, pp. 87-89, 2005.
[2]. Schettle M, Beldi G, “Effect of diabetes on outcomes in patients undergoing emergency cholecystectomy for acute cholecystitis”, World J Surg, vol. 37, no. 10, pp. 2265, 2013.
[3]. Saleh M, et al., “Effect of Diabetes Mellitus on Patients Undergoing Laparoscopic Cholecystectomy: A Comparative Cross-Sectional Study”, Life Science Journal, vol. 9, no. 1, 2012.
