Cholecystectomy in a predominantly African population before and after the advent of the laparoscopic technique

S.R. Thomson H.Y. Docrat A.A. Haffejee B. Singh J. Moodley
Department of Surgery, University of Natal, Medical School, Durban

Correspondence to: S.R. Thomson, Department of Surgery, The Nelson R Mandela School of Medicine, UND, Private Bag 7, 4013 Congella, Durban

Introduction Patients and methods

Results Discussion References

Keywords: Cholecystectomy, laparoscopic cholecystectomy, African population
Surg J R Coll Surg Edinb Irel., 1 April 2003, 92-95

Objective: There is a paucity of information on gallbladder disease in an African population. We, therefore, conducted a study to compare the immediate pre-laparoscopic era with the laparoscopic period in the predominantly African population at the King Edward VIII Hospital. Material and Methods: Data from a retrospective analysis of 144 patients undergoing open cholecystectomy (OC) between January 1990 and December 1992 were compared with a prospective analysis of 156 patients who underwent laparoscopic cholecystectomy (LC) between February 1992 and December 1994. Demographic data, presentation, operative management and outcome were the main factors analysed. Results: Eighty-two per cent were Black African and the rest of Indian origin. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed ductal stones in 11 patients in the OC and nine patients in the LC group. Endoscopic duct clearance was achieved in three and nine patients, respectively. Non biliary complications were rare. There were two major duct injuries in the OC group and one cystic duct leak in the LC group. The high conversion rate of 17.9% attests to the severity of their chronic disease making safe dissection in Calot’s triangle problematic. The mortality in patients undergoing OC was 1 (0.07%) and 0% for LC. In South Africa, the hospital prevalence of calculous disease in African patients is increasing. However, cholecystectomy may be safely performed. Conclusion: The absence of any mortality and any major duct injury in the LC group allude to the safety of this procedure when appropriately applied to this population group

INTRODUCTION
Information on gallbladder disease in Black African populations is limited to a few autopsy and hospital prevalence studies.^1-5 Only one study has reported on the outcome of open cholecystectomy in a public hospital which exclusively served a South African Black community.⁶ It was with this background that we analysed the experience with calculous gallbladder disease at a single institution (King Edward VIII Hospital, Durban), which deals with predominantly Black African patients. This coincided with the transition period from open to laparoscopic cholecystectomy at the same institution.

PATIENTS AND METHODS
Medical records of patients who underwent open cholecystectomy (OC) for calculous gallbladder disease from January 1990 and December 1992 were reviewed retrospectively and compared with prospective data of laparoscopic cholecystectomy (LC), from February 1992 to December 1994 - a 34-month period. During this time 144 patients underwent OC while 156 patients underwent LC.

Cholecystectomies performed as part of the operative management for chronic pancreatitis and malignant disease were excluded from the study.

Information on age, sex, preoperative symptoms, associated diseases and radiological data, duration and type of operation performed was correlated with intraoperative findings, post-operative morbidity and mortality.

RESULTS
The racial demographics are shown in Table 1. Eighty-two per cent were African and the rest of the patients were of Indian origin. These proportions mirror those for total admissions to this institution. Fewer than 1 in 10 patients were male. The age distribution is shown in Figure 1.

Figure 1: Age distribution of patients undergoing OC and LC

The hospital prevalence per 100,000 surgical admissions rose yearly from 49.5 in 1990 to 72.6 in 1994. Ultrasound was the most often used diagnostic modality in both groups and was used exclusively in the laparoscopic era. HIDA scans were performed in nine patients in the OC group of which nine were positive. Oral cholecystograms were performed on three patients with poor quality ultrasounds and were all positive. Endoscopic retrograde cholangiopancreatography (ERCP) was performed for suspected choledocholithiasis in 13 patients in the OC group and 13 patients in the LC group. Stones were confirmed in 11 patients in the OC and nine patients in the LC . Duct clearance at ERCP was achieved in three and nine patients, respectively. The remaining eight patients in the OC group had an open duct exploration. Open duct exploration was also performed in another 10 patients in the OC group. Five had a T-Tube placed and one retained distal stone was dealt with by post-operative ERCP. Choledochododenostomy was performed in 12 and hepaticojejunostomy in a single patient.

Empyema of the gallbladder was noted in 12 patients who underwent open cholecystectomy, three of whom had diabetes. Four patients undergoing LC had an empyema of the gallbladder that necessitated conversion to an open operation.

The rate for conversion in the LC group was 18%. The reasons are detailed in Figure 2.

Figure 2: Reasons for conversion from laparoscopic to open cholecystectomy in 27 cases

There were two major bile duct injuries in the OC group dealt with by Roux-en-y hepaticojejunostomy at the initial operation and none in the LC group. A cystic duct leak in the LC group was managed laparoscopically by drainage. Spontaneous resolution of the biliary fistula occurred after seven days. Non-biliary complications for OC and LC were pneumonia in five and three, non-fatal pulmonary embolus in two and zero and wound sepsis in three and two, respectively.

The hospital stay for the groups is detailed in Table 2 with LC including those converted having a significantly shorter hospital stay and operating time than OC. The mortality was 0.69% for the OC group and 0 for the LC group.

DISCUSSION
Autopsy and hospital prevalence studies in the first half of the 20th Century attest to the rarity of cholelithiasis in Black Africans.^1-5 The majority were under 40 years of age and the disease was virtually unheard of in Black African males.⁵ In the early 1970s, Bremner (1971) analysed admissions to a hospital serving an exclusively Black African population.6 He found a six-fold increase in the hospital prevalence of cholecystectomy from 1-2 /100,000 in 1956 to 12/100,000 in 1969. A sevenfold increase in appendicitis occurred over the same period. These changes were attributed to a rapidly urbanising population.

The most recent reported hospital prevalence of gallbladder disease in South Africa is from Parekh et al (1987).⁷ It again highlighted the relatively low but increasing prevalence of gallbladder disease.

Only two small studies have looked at the incidence in the population at large and found a ten-fold reduced incidence in black compared with white women.^8,9 Hence, the true incidence of the disease in the African population is not known. The data are scanty, not population-based and the conclusions about its relative frequency are based on autopsy or hospital prevalence studies which have inherent biases. Calculous gallbladder disease in this population group is now commonplace.⁷ The numbers for the individual years in this cohort tend to confirm this increase with an 18% rise when comparing the first to the second three-year period. Recent data from our institution have also shown a marked increase in the endoscopic management of choledocholithiasis.¹⁰ This, however, may represent the evolving expertise with both ERCP and LC rather than a true increase in the prevalence of calculous gallbladder disease. This apparent increase may reflect better access to health care, a change in referral patterns to this centre, or an increasing awareness by the rapidly urbanising catchment population of the ability of Western medicine to deal with their health problems.

The conversion rate in this series of 18% is in keeping with earlier series reporting on patients with acute cholecystitis undergoing cholecystectomy but is over double the rate in a more recent publication.^1-13 Distorted anatomy in Calots triangle was the commonest reason for conversion in this series and relates to the severity and acuteness of the inflammatory process in the LC group. Proceeding with a laparoscopic approach in this group runs a real risk of ductal injury and conversion remains a prudent approach as shown by the absence of a major bile duct injury in this series.

Larger series have documented a higher bile duct injury rate with a frequency varying from 0.25% to 1%.^13-15 Indeed, the two bile duct injuries in the OC group represents a higher incidence than one would have anticipated for this long-established open procedure where major bile duct injury is generally reported at less than 0.02%.¹⁶ These were both recognised at operation and appropriately dealt with by hepaticojejunostomy. Shrunken gallbladders imply difficult dissection from the liver bed. With evolving experience with laparoscopic subtotal cholecystectomy fewer of these patients may need to be subjected to a conversion, whilst maintaining a low incidence of bile duct injuries.^18-20

Two large North American studies found 21% and 38% of cases presenting to be male, while a UK combined clinical autopsy series showed the prevalence of gallstones to be 12.4% for males and 23.7% for females, with overall mortality of 3.7%.^21-23 In our series, only 10% were male. A possible explanation might be found in the suggestion that only pigment stones occur in Black African males, but stone type was not documented in this series.

Mortality in the Baragwanath series was 10%. Mortality in both the LC and OC in this series was very low and much more in keeping with current reported rates of mortality of 1.3% or less.^17-24

Calculous disease of the gallbladder should now be considered a commonplace disease in the urbanised Black African population with an increasing hospital prevalence. Patients present with severe disease. It can be dealt with by either OC or LC, both of which are associated with a low morbidity and mortality. Although LC has a fairly high conversion rate it is a safe and effective procedure in our hands and is associated with a reduced hospital stay when successfully performed.

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Copyright: 12 December 2002