The Outcome of Laparoscopic Cholecystectomy in Diabetic Patients: A Prospective Study

Introduction

Data on the association between cholelithiasis and diabetes mellitus (DM) are controversial. Several studies, from across the world, have reported an increased prevalence of gallbladder disease in patients with DM, and it is thought that an altered glucose metabolism may increase the risk of developing cholelithiasis.^1–6 On the other hand, morbidity and mortality from gallstones in diabetic patients, in comparison with nondiabetics, remains debatable. ⁷ The management of gallstones in diabetic patients has traditionally been considered problematic.^8,9 However, the real risk caused by DM in laparoscopic cholecystectomy (LC) for symptomatic gallbladder stones remains unidentified. ¹⁰ In this study, we compared the outcome of LC in Saudi diabetic patients with nondiabetics, as the prevalence of diabetes in Saudi Arabia is now one of the highest in the world. ¹¹

Patients and Methods

This prospective study was conducted at the Surgery Department in King Fahad Hospital–Al-Ahsa (Hofuf, Saudi Arabia), from January 2005 to June 2008, for all patients with symptomatic gallstones who underwent LC. The patients were divided into nondiabetic (N = 793) and diabetic (N =175) groups. Patient demographics data, laboratory results, presence of diabetes, operative findings, operative time, complications, and length of hospital stay were collected prospectively, using a standardized proforma, and reviewed. A diagnosed of diabetes was made when there had been treatments for diabetes before admission or when the patient had had a fasting serum glucose level higher than 126 mg/dL on two occasions during hospitalization. A standard regimen of thromboprophylaxis was employed. Pre-/ and postoperative subcutaneous administration of low-molecular-weight heparin (LMWH) (Fragmin heparin sodium 5000 U; Fisons Pharmaceuticals, Pty., Ltd., Sydney, NSW, Australia) was administered, according to guidelines. All patients underwent LC with the standard four-port laparoscopic method. The Human Research Review Committee approved the study.

Results

Nine hundred and sixty eight patients were included in our study, consisting of 175 diabetics and 793 nondiabetic patients. Seven hundred and sixteen patients (74%) were female, with a mean age of 31.2 years. Mean body mass index (BMI) was 32.6. No major complications were encountered during the creation of the pneumoperitoneum or cholecystectomy in both groups. Two patients (0.002%) required a conversion to open cholecystectomy (1 case in each group). The causes for conversion were obscure anatomy.

Diabetics were older in age; ischemic heart disease and hypertension were more common in the diabetics, compared to the non-diabetics. There was no significant difference between patients in either group for the factors of age, male-female ratio, BMI, preoperative white blood cell count, platelet count, prothrombin time, activated partial thromboplastin time, or proportion of patients with any thromboembolic risk factors in each group, There was no significant difference between the two groups regarding laboratory results (Table 1).

The difference was not significant in operative time, postoperative complications, and conversion rate between the two groups. In the control group, the mean length of hospital stay was shorter than the study group, and this was the only difference (Table 2). Only 3 patients developed surgical-site infection, which was cured with daily dressings; however, we did not encounter any case of port-site hernia. There was no mortality in this series.

Discussion

Gallstone disease is one of the most common digestive diseases, and recent studies have questioned whether diabetes is an independent risk factor for gallstone formation. ¹² The combination of gallstones and DM are considering a meticulous dilemma. The pathophysiologic features of gallstone formation in diabetic patients are unclear; two probable factors are hypetriglyceridemia and gallbladder hypomotility.^13–15 As a result, many reports have recommended early cholecystectomy for diabetic patients to prevent serious infectious squeal. On the other hand, surgery in diabetic patients is considered risky, with high postoperative complications. ¹⁶ Today, there are few reports on LC in diabetic patients with different results.^17,18

The overall rate of operative (1.14%) and postoperative complications (2.8%) in this series is similar to that found in the current literature,^17,18 and all were managed by conservative measures. In addition, diabetic patients have a higher incidence of advanced inflammatory changes in the gallbladder, compared to nondiabetics. LC for acute cholecystitis is technically demanding and takes a longer time to perform in both groups. Although diabetics in our study were older and more likely to have hypertension or ischemic heart disease, we did not detect a higher rate of this complication in the diabetics.

Although the mean time of anesthesia was longer in diabetics than nondiabetics (91 versus 76 minutes), it was not statistically significant (P = 0.063). Our overall mean operation time (75 minutes) is similar to that of other series.^19–22 In our study, only the mean length of hospital stay was longer (5.6 days) in diabetic patients, compared to 2.4 days in nondiabetic patients. It is attributed to the increased rate of comorbid disease in diabetics requiring medical management before and after surgery. In the present study, male gender was not a significant predictor of the outcome of LC in both groups.

Although the BMI was significantly different in diabetics and nondiabetics (P = 0.001), it had no influence on the outcome of LC. LC was not performed as day-case surgery at the time of this study. Provided that standard perioperative care is ensured and the procedure is performed by experienced surgeons following the basic guiding principles in surgical technique, LC in adults with DM results in low rates of complications and similar outcomes as well as in nondiabetics.

Conclusions

LC in diabetic patients is safe, provided there is a careful preoperative assessment and close postoperative observation, and DM alone does not appear to affect the outcome of Saudi patients who require gallbladder surgery.