Quality of Life and Pain in Patients with Acute Cholecystitis

Perception of Pain Expression Among Surgical Patients and Families from Three Ethnic Groups of a Nation: A Multicenter Qualitative Study

Background

Despite its universal nature; perception, coping, responses, treatment options, and overall experiences of pain are influenced by biopsychosocial factors to various extents. Pain perception, expression, and control are progressively learned behaviors among members of a society and are culture-specific. Effects of ethnicity-related culture (ethnoculture) on pain experience in a broader context have increasingly been reported. However, evidence from ethnoculturally diverse groups of a nation, particularly based on surgical patients, is limited. Therefore, as a qualitative research effort of a broader project aimed at assessing ethnocultural determinants of surgical pain management, this study explored the perception of ethnoculturally diverse patients and families about expressing surgical disease-related pain.

Methods

This study follows subjectivist-interpretivist philosophical assumptions as an underpinning research paradigm. We purposively selected 11 patients for in-depth interviews and 12 patients' family members for focus group discussions in three hospitals of ethnic-based regions of Ethiopia. In the phenomenological frame, thematic analysis was employed.

Finding

Ethnocultural background influences how individuals express and respond to pain according to emergent themes of finding- Pain and overlooked cultural influence, Pain expressiveness in cultural context, Stereotypes of pain expressiveness, and Bravehood through stoic response. Pain feelings are commonly hidden where the domestic culture values stoic response to pain compared to ethnoculture where pain expressiveness is encouraged.

Conclusion

Individuals can express and respond to pain differently due to ethnocultural diversity within a nation. Researchers and clinicians should consider cultural context while applying the prevailing one-size-fits-all pain assessment tools among surgical patients of a nation with ethnocultural diversity.

Patient decision-making in symptomatic gallbladder disease

Background

Methods

Results

Conclusion

Protocol for a randomised controlled trial comparing laparoscopic cholecystectomy with observation/conservative management for preventing recurrent symptoms and complications in adults with uncomplicated symptomatic gallstones (C-Gall trial)

BACKGROUND

Gallstone disease (cholelithiasis) is common. In most people it is asymptomatic and does not require treatment, but in about 20% it can become symptomatic, causing pain and other complications requiring medical attention and/or surgery. A proportion of symptomatic people with uncomplicated gallstone disease do not experience further episodes of pain and, therefore, could be treated conservatively. Moreover, surgery carries risks of perioperative and postoperative complications.

METHODS AND ANALYSIS

C-Gall is a pragmatic, multicentre, randomised controlled trial and economic evaluation to assess whether cholecystectomy is cost-effective compared with observation/ conservative management (here after referred to as medical management) at 18 months post-randomisation (with internal pilot).

PRIMARY OUTCOME MEASURE

Patient-reported quality of life (QoL) (36-Item Short Form Survey (SF-36) bodily pain domain) up to 18 months after randomisation.The primary economic outcome is incremental cost per quality-adjusted life year gained at 18 months.

SECONDARY OUTCOME MEASURES

Secondary outcome measures include condition-specific QoL, SF-36 domains, complications, further treatment, persistent symptoms, healthcare resource use, and costs assessed at 18 and 24 months after randomisation. The bodily pain domain of the SF-36 will also be assessed at 24 months after randomisation.A sample size of 430 participants was calculated. Computer-generated 1:1 randomisation was used.The C-Gall Study is currently in follow-up in 20 UK research centres. The first patient was randomised on 1 August 2016, with follow-up to be completed by 30 November 2021.

STATISTICAL ANALYSIS

Statistical analysis of the primary outcome will be intention-to-treat and a per-protocol analysis. The primary outcome, area under the curve (AUC) for the SF-36 bodily pain up to 18 months, will be generated using the Trapezium rule and analysed using linear regression with adjustment for the minimisation variables (recruitment site, sex and age). For the secondary outcome, SF-36 bodily pain, AUC up to 24 months will be analysed in a similar way. Other secondary outcomes will be analysed using generalised linear models with adjustment for minimisation and baseline variables, as appropriate. Statistical significance will be at the two-sided 5% level with corresponding CIs.

ETHICS AND DISSEMINATION

The North of Scotland Research Ethics Committee approved this study (16/NS/0053). The dissemination plans include Health Technology Assessment monograph, international scientific meetings and publications in high-impact, open-access journals.

TRIAL REGISTRATION NUMBER

ISRCTN55215960; pre-results.

Gallstones

Gallstones grow inside the gallbladder or biliary tract. These stones can be asymptomatic or symptomatic; only gallstones with symptoms or complications are defined as gallstone disease. Based on their composition, gallstones are classified into cholesterol gallstones, which represent the predominant entity, and bilirubin ('pigment') stones. Black pigment stones can be caused by chronic haemolysis; brown pigment stones typically develop in obstructed and infected bile ducts. For treatment, localization of the gallstones in the biliary tract is more relevant than composition. Overall, up to 20% of adults develop gallstones and >20% of those develop symptoms or complications. Risk factors for gallstones are female sex, age, pregnancy, physical inactivity, obesity and overnutrition. Factors involved in metabolic syndrome increase the risk of developing gallstones and form the basis of primary prevention by lifestyle changes. Common mutations in the hepatic cholesterol transporter ABCG8 confer most of the genetic risk of developing gallstones, which accounts for ∼25% of the total risk. Diagnosis is mainly based on clinical symptoms, abdominal ultrasonography and liver biochemistry tests. Symptoms often precede the onset of the three common and potentially life-threatening complications of gallstones (acute cholecystitis, acute cholangitis and biliary pancreatitis). Although our knowledge on the genetics and pathophysiology of gallstones has expanded recently, current treatment algorithms remain predominantly invasive and are based on surgery. Hence, our future efforts should focus on novel preventive strategies to overcome the onset of gallstones in at-risk patients in particular, but also in the population in general.

Clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones or cholecystitis: a systematic review and economic evaluation

BACKGROUND

Approximately 10-15% of the adult population suffer from gallstone disease, cholelithiasis, with more women than men being affected. Cholecystectomy is the treatment of choice for people who present with biliary pain or acute cholecystitis and evidence of gallstones. However, some people do not experience a recurrence after an initial episode of biliary pain or cholecystitis. As most of the current research focuses on the surgical management of the disease, less attention has been dedicated to the consequences of conservative management.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management in people presenting with uncomplicated symptomatic gallstones (biliary pain) or cholecystitis.

DATA SOURCES

We searched all major electronic databases (e.g. MEDLINE, EMBASE, Science Citation Index, Bioscience Information Service, Cochrane Central Register of Controlled Trials) from 1980 to September 2012 and we contacted experts in the field.

REVIEW METHODS

Evidence was considered from randomised controlled trials (RCTs) and non-randomised comparative studies that enrolled people with symptomatic gallstone disease (pain attacks only and/or acute cholecystitis). Two reviewers independently extracted data and assessed the risk of bias of included studies. Standard meta-analysis techniques were used to combine results from included studies. A de novo Markov model was developed to assess the cost-effectiveness of the interventions.

RESULTS

Two Norwegian RCTs involving 201 participants were included. Eighty-eight per cent of people randomised to surgery and 45% of people randomised to observation underwent cholecystectomy during the 14-year follow-up period. Participants randomised to observation were significantly more likely to experience gallstone-related complications [risk ratio = 6.69; 95% confidence interval (CI) 1.57 to 28.51; p = 0.01], in particular acute cholecystitis (risk ratio = 9.55; 95% CI 1.25 to 73.27; p = 0.03), and less likely to undergo surgery (risk ratio = 0.50; 95% CI 0.34 to 0.73; p = 0.0004), experience surgery-related complications (risk ratio = 0.36; 95% CI 0.16 to 0.81; p = 0.01) or, more specifically, minor surgery-related complications (risk ratio = 0.11; 95% CI 0.02 to 0.56; p = 0.008) than those randomised to surgery. Fifty-five per cent of people randomised to observation did not require an operation during the 14-year follow-up period and 12% of people randomised to cholecystectomy did not undergo the scheduled operation. The results of the economic evaluation suggest that, on average, the surgery strategy costs £1236 more per patient than the conservative management strategy but was, on average, more effective. An increase in the number of people requiring surgery while treated conservatively corresponded to a reduction in the cost-effectiveness of the conservative strategy. There was uncertainty around some of the parameters used in the economic model.

CONCLUSIONS

The results of this assessment indicate that cholecystectomy is still the treatment of choice for many symptomatic people. However, approximately half of the people in the observation group did not require surgery or suffer complications in the long term indicating that a conservative therapeutic approach may represent a valid alternative to surgery in this group of people. Owing to the dearth of current evidence in the UK setting a large, well-designed, multicentre trial is needed.

STUDY REGISTRATION

The study was registered as PROSPERO CRD42012002817.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Systematic review of the clinical and cost effectiveness of cholecystectomy versus observation/conservative management for uncomplicated symptomatic gallstones or cholecystitis

BACKGROUND

Gallstone disease is a common gastrointestinal disorder in industrialised countries. Although symptoms can be severe, some people can be symptom free for many years after the original attack. Surgery is the current treatment of choice, but evidence suggests that observation is also feasible and safe. We reviewed the evidence on cholecystectomy versus observation for uncomplicated symptomatic gallstones and conducted a cost-effectiveness analysis.

METHODS

We searched six electronic databases (last search April 2014). We included randomised controlled trials (RCTs) or non-randomised comparative studies where adults received either cholecystectomy or observation/conservative management for the first episode of symptomatic gallstone disease (biliary pain or cholecystitis) being considered for surgery in secondary care. Meta-analysis was used to combine results. A de novo Markov model was developed to assess the cost effectiveness of the interventions.

RESULTS

Two RCTs (201 participants) were included. Eighty-eight percent of people randomised to surgery and 45 % of people randomised to observation underwent cholecystectomy during the 14-year follow-up period. Participants randomised to observation were significantly more likely to experience gallstone-related complications (RR = 6.69, 95 % CI = 1.57-28.51, p = 0.01), in particular acute cholecystitis (RR = 9.55, 95 % CI = 1.25-73.27, p = 0.03), and less likely to undergo surgery (RR = 0.50, 95 % CI = 0.34-0.73, p = 0.0004) or experience surgery-related complications (RR = 0.36, 95 % CI = 0.16-0.81, p = 0.01) than those randomised to surgery. Fifty-five percent of people randomised to observation did not require surgery, and 12 % of people randomised to cholecystectomy did not undergo surgery. On average, surgery costs £1,236 more per patient than conservative management, but was more effective.

CONCLUSIONS

Cholecystectomy is the preferred treatment for symptomatic gallstones. However, approximately half the observation group did not require surgery or suffer complications indicating that it may be a valid alternative to surgery. A multicentre trial is needed to establish the effects, safety and cost effectiveness of observation/conservative management relative to cholecystectomy.

The clinical investigation of disparity of utility values associated with gallstone disease: a pilot study

Purpose. The utility evaluation was an effective method to incorporate all of the contributing variables for multiple diseases into one outcome measure. A cross-sectional study was conducted to assess the utility values associated with varying states of gallstone disease among outpatient clinics participants at a teaching hospital in Taipei, Taiwan. Methods. The utility values were measured by using time trade-off method. A total of 120 outpatient clinics participants (30 subjects with no gallstone disease, 30 subjects with single stone, 30 subjects with multiple stones, and 30 subjects with cholecystectomy) evaluated utility values from January 1, 2006 to December 31, 2006. The diagnosis of gallstone disease was performed by a panel of specialists using ultrasound sonography. Results. The overall mean utility value was 0.89 ± 0.13 (95% CI: 0.87-0.91) indicating that study participants were willing to trade about 11% (95% CI: 9-13%) of their remaining life in return for being free of gallstone disease perpetually. The significant associated factors of utility values based on the multiple linear regression analysis were older age and different degrees of gallstone disease. Conclusion. Our results found that in addition to older age, multiple stones and cholecystectomy could influence utility values from the patient's preference-based viewpoint.

Patient-centered outcomes after laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) is the second most common general surgical operation performed in the United States, yet little has been reported on patient-centered outcomes.

METHODS

We prospectively followed 100 patients for 2 years as part of an institutional review board-approved study. The Surgical Outcomes Measurement System (SOMS) was used to quantify quality-of-life (QoL) values at various time points postoperatively.

RESULTS

Maximum pain was reported at 24 h (5.5 ± 2.2), and decreased to preoperative levels at 7 days (1.2 ± 2.3 vs. 2.0 ± 1.6, P = 0.096). Bowel function improved from before the operation to 3 weeks after surgery (10.7 ± 3.8 vs. 12.0 ± 3.2, P < 0.05), but then regressed to preoperative levels. Physical function worsened from before surgery (31.7 ± 6.2) to 1 week (27.5 ± 5.9, P < 0.0001), but surpassed preoperative levels at 3 weeks (33.5 ± 3.4, P < 0.01). Return to the activities of daily living occurred at 6.3 ± 4.7 days and work at 11.1 ± 9.0 days. Fatigue increased from before surgery (15.8 ± 6.2) to week 1 (20.7 ± 6.6, P < 0.0001) before improving at week 3 (14.0 ± 5.8, P < 0.01). Forty-four patients contacted the health care team 61 times before their 3 weeks appointment, most commonly for wound issues (26.2%), pain (24.6%), and gastrointestinal issues (24.6%). Seventy-two percent reported that the procedure had no negative effect on cosmesis at 6 months. Satisfaction with the procedure was high, averaging 9.52 out of 11.

CONCLUSIONS

QoL is significantly affected in the 24 h after LC but returns to baseline at week 3. Cosmesis and overall satisfaction are high, and QoL improvements are maintained in the long term except for bowel function, which regresses to preoperative levels of impairment. Analysis of patient-initiated contacts after LC may provide feedback on discharge counseling to increase patient satisfaction.

TG13 current terminology, etiology, and epidemiology of acute cholangitis and cholecystitis

While referring to the evidence adopted in the Tokyo Guidelines 2007 (TG07) as well as subsequently obtained evidence, further discussion took place on terminology, etiology, and epidemiological data. In particular, new findings have accumulated on the occurrence of symptoms in patients with gallstones, frequency of severe cholecystitis and cholangitis, onset of cholecystitis and cholangitis after endoscopic retrograde cholangiopancreatography and medications, mortality rate, and recurrence rate. The primary etiology of acute cholangitis/cholecystitis is the presence of stones. Next to stones, the most significant etiology of acute cholangitis is benign/malignant stenosis of the biliary tract. On the other hand, there is another type of acute cholecystitis, acute acalculous cholecystitis, in which stones are not involved as causative factors. Risk factors for acute acalculous cholecystitis include surgery, trauma, burn, and parenteral nutrition. After 2000, the mortality rate of acute cholangitis has been about 10 %, while that of acute cholecystitis has generally been less than 1 %. After the publication of TG07, diagnostic criteria and severity assessment criteria were standardized, and the distribution of cases according to severity and comparison of clinical data among target populations have become more subjective. The concept of healthcare-associated infections is important in the current treatment of infection. The treatment of acute cholangitis and cholecystitis substantially differs from that of community-acquired infections. Cholangitis and cholecystitis as healthcare-associated infections are clearly described in the updated Tokyo Guidelines (TG13). Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

Surgery for acute gallbladder disease in Sweden 1989-2006--a register study

OBJECTIVE

Since early 1970s, prospective randomized controlled trials have emphasized the advantages of early cholecystectomy in patients with acute cholecystitis, compared to elective delayed cholecystectomy. The aim of this investigation was to study surgery for acute gallbladder disease in Sweden during a 15-year period when open cholecystectomy was replaced by a laparoscopic procedure.

MATERIAL AND METHODS

Data from the Swedish National Patient Register and the Cause of Death Register 1988-2006 comprising hospital stays with a primary diagnosis of gallbladder/gallstone disease in Sweden were retrieved. Patients were analyzed with reference to timing of cholecystectomy, length of hospital stay, and mortality.

RESULTS

Emergency cholecystectomy at index (first) admission or at readmission within 2 years of index admission was performed in 32.2% and 6.1% of patients, respectively. Elective cholecystectomy within 2 years of index admission was performed in 20.3% patients, whereas 41.3% of all patients did not undergo cholecystectomy within 2 years. Standardized mortality ratio did not significantly change during the audit period. Total hospital stay (days at index stay and subsequent stay(s) for biliary diagnoses within 2 years) was shorter for patients who had emergency cholecystectomy at first admission compared to patients with later or no cholecystectomy within 2 years.

CONCLUSIONS

Around 30% of patients with acute gallbladder disease were operated with cholecystectomy during the first admission with no time trend from 1990 through 2004. A total of 40% of patients with acute gallbladder disease were not cholecystectomized within 2 years. Analysis of outcome of long-term conservative treatment is warranted.

Diagnosis and management of gallbladder calculus disease

BACKGROUND

The number and rate of cholecystectomy are increasing worldwide, although indications for operative treatment remain empirical, and several issues in the understanding of the condition are not concisely outlined. Our intention is to summarize and interpret current opinion regarding the indications and timing of cholecystectomy in calculous gallbladder disease.

METHODS

Publications concerned with gallstone disease and related topics were searched for in MEDLINE using PubMed and summarized according to clinical scenarios with an emphasis on recent research.

RESULTS

Only one randomized controlled trial has investigated the management (conservative vs. surgery) of patients with acute cholecystitis and several have compared early with deferred surgery. Two RCTs have examined treatment of uncomplicated, symptomatic gallstone disease. Apart from these, the overwhelming majority of publications are retrospective case series.

CONCLUSIONS

Recent literature confirms that cholecystectomy for an asymptomatic or incidental gallstone is not justified. Symptomatic, uncomplicated gallstone disease may be classified into four severity groups based on severity and frequency of pain attacks, which may guide indication for cholecystectomy. Most patients below the age of 70 seem to prefer operative treatment. Acute cholecystitis may be treated with early operation if reduction of hospital days is an issue. Patients older than 70 years with significant comorbidities may forego surgical treatment without undue hazard. Symptoms following cholecystectomy remain in 25% or more and recent evidence suggest these are caused by a functional gastrointestinal disorder.

Hepatobiliary scintigraphy in acute cholecystitis

Hepatobiliary scintigraphy is a mature imaging technique for evaluation of patients with acute cholecystitis (AC). It is effective in calculous and acalculous forms of AC. The test is used in contemporary medical practice as the arbiter when the findings from screening abdominal ultrasound do not fit a clinical picture. It is also performed in severely ill patients who have AC suspected on other testing, but whose frail condition and high operative risk demand the highest level of certainty. This review, therefore, examines all technique variations of hepatobiliary scintigraphy, offering an approach that may best fit a variety of clinical situations and philosophies on AC.

Health-related quality of life outcomes after cholecystectomy

Gallbladder diseases are very common in developed countries. Complicated gallstone disease represents the most frequent of biliary disorders for which surgery is regularly advocated. As regards, cholecystectomy represents a common abdominal surgical intervention; it can be performed as either an elective intervention or emergency surgery, in the case of gangrene, perforation, peritonitis or sepsis. Nowadays, the laparoscopic approach is preferred over open laparotomy. Globally, numerous cholecystectomies are performed daily; however, little evidence exists regarding assessment of post-surgical quality of life (QOL) following these interventions. To assess post-cholecystectomy QOL, in fact, documentation of high quality care has been subject to extended discussions, and the use of patient-reported outcome satisfaction for quality improvement has been advocated for several years. However, there has been little research published regarding QOL outcomes following cholecystectomy; in addition, much of the current literature lacks systematic data on patient-centered outcomes. Then, although several tools have been used to measure QOL after cholecystectomy, difficulty remains in selecting meaningful parameters in order to obtain reproducible data to reflect postoperative QOL. The aim of this study was to review the impact of surgery for gallbladder diseases on QOL. This review includes Medline searches of current literature on QOL following cholecystectomy. Most studies demonstrated that symptomatic patients profited more from surgery than patients receiving an elective intervention. Thus, the gain in QOL depends on the general conditions before surgery, and patients without symptoms profit less or may even have a reduction in QOL.

Long-term follow-up of a randomized controlled trial of observation versus surgery for acute cholecystitis: non-operative management is an option in some patients

BACKGROUND

Cholecystectomy is routinely recommended to prevent recurrent disease after an initial episode of acute cholecystitis. Therefore, randomized controlled trials have mainly focused on the timing of surgery, but many patients scheduled for cholecystectomy have deferred surgery with long periods of symptom-free intervals. Our present aim is to examine the long-term feasibility and safety of observation compared with surgery.

METHODS

Trial of 64 patients with acute cholecystitis previously randomized to observation or cholecystectomy, which examined outcome in terms of completed randomized treatment and appearance of further symptoms and the need for surgical treatment. Thirty-three patients were randomized to observation and 31 patients to cholecystectomy. Median follow-up was 14 years.

RESULTS

Of the 33 patients randomized to observation, 11 (33%) experienced a new event of gallstone-related disease (eight (24.2%) had acute cholecystitis) and 11 (33%) were operated. No significant difference (p = 0.565) was found between the two randomized groups with regard to recurrent disease or complications. Virtually no surgery took place after 5 years of follow-up. The difference in completed randomized treatment between the groups was not significant (p = 0.077). Long-term mortality was equal in those operated and in those observed.

CONCLUSIONS

Twenty-four percent of the patients experienced recurrent cholecystitis, but escalation of disease severity or increased mortality was not observed. Long-term observation after acute cholecystitis was feasible in two-thirds of the patients as the risk for recurrent disease was negligible after 5 years.

Quality-of-life measures in Taiwanese adults with symptomatic gallstone disease

PURPOSE

The objective of this study was to investigate the association of quality-of-life status with baseline laboratory findings among Taiwanese adults having symptomatic gallstone disease.

METHODS

A prospective quality-of-life survey was administered at a tertiary referral medical center among 102 consecutive adults with symptomatic gallstone disease. Patients underwent regular laboratory testing at admission and were evaluated using the 36-Item Short-Form Health Survey (SF-36) and the Gastrointestinal Quality of Life Index (GIQLI). Correlation and regression models were used to investigate quality-of-life predictors.

RESULTS

Compared with the general Taiwanese adult population, patients having symptomatic gallstone disease had significantly poorer performance on all eight SF-36 subscales (P < 0.001). Total GIQLI showed moderate to strong correlation with all eight SF-36 subscale scores (gamma = 0.29 ~ 0.62, P < 0.05). In multivariate analysis, serum levels of direct bilirubin (beta = -32.6, P = 0.001) and alkaline phosphatase (beta = -13.6, P = 0.032) were predictive of worse total GIQLI (adjusted R (2) = 0.183).

CONCLUSIONS

Symptomatic gallstone disease may considerably affect patient quality of life in terms of general health status and gastrointestinal-specific measures. Before gallstone surgery, serum levels of direct bilirubin and alkaline phosphatase significantly correlated with quality-of-life measures and can be used to evaluate patient well-being at admission.

Changes in quality-of-life following laparoscopic cholecystectomy in adult patients with cholelithiasis

BACKGROUND

The aim of this study was to evaluate changes in quality-of-life following laparoscopic cholecystectomy (LC) in adults with cholelithiasis.

METHODS

Patients were evaluated with the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and the Gastrointestinal Quality of Life Index (GIQLI) preoperatively and 12 months after LC. Outcome predictors were analyzed using correlation and regression statistics.

RESULTS

Ninety-nine patients were enrolled (male/female, 32:67, age 49.8 +/- 13.7 years old). At baseline, patients performed inferiorly to general population in all SF-36 general health dimensions (p < 0.0001). Postoperatively, the "role-physical", "role-emotional", and "bodily pain" dimensions of health significantly improved. There were significant improvements in GIQLI "total", "physical well-being", "mental well-being", "gastrointestinal digestion", and "defecation" subscales scores. Serum direct bilirubin level and drainage tube indwelling were significant predictors for quality-of-life improvement following LC.

CONCLUSIONS

LC can greatly reduce gastrointestinal symptoms to improve quality-of-life for patients with cholelithiasis. Patients with severe baseline conditions may benefit from greater quality-of-life improvement following LC.