GALLSTONES IN CIRRHOTICS REVISITED BY A LAPAROSCOPIC VIEW

Surgical literature around 1980 has emphasized the technical challenge and the risks of cholecystectomy in cirrhotic patients reporting disc ouraging results. The aim of this study is the retrospective analysis of laparoscopic cholecystectomy in cirrhotics. The collected laparosco pic experience of 3 surgical groups for the last 5 years is reported. Cirrhotics were classified according to Child-Pugh criteria. Postopera tive complications were classified using Clavien's rules. Forty patien ts were recruited; 31 received successful laparoscopic cholecystectomy . Liver cirrhosis was preoperatively diagnosed in all Child-Pugh B (n = 11) and in 11/20 Child-Pugh A patients. Compared with 989 noncirrhot ics undergoing laparoscopic cholecystectomy, cirrhotics were similar i n terms of age (59.9 +/- 10.3 vs. 58.1 +/- 10.9) and sex (male: 51.6% vs. 50.1%). Acute cholecystitis has a similar frequence in cirrhotics and noncirrhotics (3.2% vs. 4.1%, respectively). Bile duct stones and acute pancreatitis were significantly more frequent in cirrhotic patie nts (6.4% vs. 3.7%, p < 0.001; and 6.4% vs. 0.3%, p < 0.001, respectiv ely). Endoscopic papillotomy and stone extraction combined with laparo scopic cholecystectomy was performed in 2 patients. Intraoperatively, technical problems occurred in 5 (16.1%) patients: liver bed bleeding (n = 4) was significatively more frequent in cirrhotics vs. noncirrhot ics (p < 0.001). Mean operative time was 90 min, range 50-180, and it was not significantly longer than in noncirrhotics (85 min, range 30-2 00). Conversion rate was also similar (3%). Seven patients presented 8 postoperative complications (Class II): right side lung effusion (n = 2), ascites (n = 2), temporary worsening of Child-Pugh status (n = 2) , hyperosmotic coma (n = 1), and umbilical hernia (n = 1). Mean hospit al stay in noncomplicated cases was the same for noncirrhotics (3 +/- 1). The authors suggest a more liberal use of laparoscopic cholecystec tomy for symptomatic gallstones in selected Child-Pugh A and B patient s.