Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 67, Num. 2, 2005, pp. 87-89

Indian Journal of Surgery, Vol. 67, No. 2, March-April, 2005, pp. 87-89

Original Article

Outcome of cholecystectomy in diabetic patients

Ziaee SA, Fanaie SA, Khatib R, Khatibzadeh N

Department of Surgery, Milad Hospital, Tehran
Correspondence Address:Number 24, Zarifnia Alley, Pesyan Street, Zaferanie,1987964551, Tehran Email: sali_ziaee@yahoo.com

Code Number: is05021

Abstract

Keywords: Diabetes; gallstone; prophylactic cholecystectomy

It is generally believed that patients with diabetes are at high risk of developing gallstones.[1] However, mortality and especially morbidity from gallstones in the diabetic patients in comparison with the nondiabetics have always been controversial. Previous studies have detected increased complications and mortality rates,[2],[3],[4] and hence suggested prophylactic cholecystectomy for gallstones in the diabetics,[5],[6] while others have justified increased morbidity in the diabetics as a result of older age and co-morbid medical conditions,[7] and a few have denied such a difference. [8],[9]

To date, few studies have assessed intraoperative findings of cholecystectomy in diabetics. In this study, we compared operative findings of cholecystectomy in the diabetic patients with the nondiabetics, after adjusting for other potential confounders.

Materials and methods

Our study included 669 open cholecystectomies performed on patients with gallstones between March 2003 and December 2004. It was a retrospective study and data were stored in documented files, and the same person retrieved all the data. The study was approved by the human research review committee. Patients' records were reviewed carefully to gather the study data including sex, age, presence of diabetes, hypertension, ischemic heart disease, and the operative findings. Diabetes was diagnosed when there had been treatments for diabetes before the admission or when the patient had had fasting serum glucose level higher than 126 mg/dl on more than one occasion during hospitalization. Operative reports were reviewed carefully in each case to determine intraoperative findings including normal gall bladder, hydrops, gangrene, adhesion, perforation of gall bladder, and pancreatitis. The relative risks were calculated for each factor with 95% confidence intervals of limit. Multivariate analysis was performed using the logistic regression model, after adjusting for all potential risk factors.

Results

A total of 669 patients were included in our study consisting of 167 men and 502 women with their mean age of 52 years [Table - 1]. Among 669 patients, 119 were diabetics. Compared to the nondiabetics, diabetics were older in age but equally likely to be women [Table - 1]. Ischemic heart disease and hypertension were more common in the diabetics than in the nondiabetics.

Incidence of any abnormal operative findings was 44.5% in the diabetics, significantly higher than the nondiabetics with prevalence of 11.5% [Relative Risk (RR) 3.9; 95% CI: 2.9-5.3]. Gangrenous gall bladder was seen in 14.3% in the diabetics compared to 1.6% in the nondiabetics (RR: 8.7; 95% CI: 3.8-20.8). Diabetes also caused a significant increase in the risk of adhesion (28.6% vs 6.2%) and pancreatitis (5.9% vs 1.3%) with the RR of 4.6 (95% CI: 2.9-7.3) and 4.6 (95% CI: 1.5-14.4), respectively. However, incidence of hydrops and perforation in the diabetics was not significantly higher than in the nondiabetics.

In the multivariate analysis, using the logistic regression model [Table - 2], diabetes was associated with high risk of gangrene (OR: 7.6; 95% CI: 3.1-18.5), adhesion (OR: 5.9; 95% CI: 3.3-10.5), and pancreatitis (OR: 4.5; 95% CI: 1.3-5.8) but did not cause a significant increase in the risk of hydrops or perforation. Age, sex, ischemic heart disease, and hypertension were not associated with higher rates of any of the outcome variables, which we have studied.

Discussion

In this study, we 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 compatible with the study performed by Landau et al., who detected 33% incidence of gangrene in the diabetics vs 22% in the nondiabetics.[3] In one of the previous studies, the rate of gangrene in the diabetics was similar to the nondiabetics (26.4% vs 25%), but that study included only the acute cholecystitis patients.[4] Perforations of the gall bladder have been reported higher in some previous studies,[7] but because of very low risk of perforation in our study we did not detect a higher rate of this complication in the diabetics. Although diabetics in our 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,[10] 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.

References

Copyright 2005 - Indian Journal of Surgery

The following images related to this document are available:

Photo images