Scandinavian Journal of Gastroenterology
ISSN: 0036-5521 (Print) 1502-7708 (Online) Journal homepage: http://www.tandfonline.com/loi/igas20
Persisting Pain after Cholecystectomy: A Prospective Investigation T. Jørgensen, J. Stubbe Teglbjerg, P. Wille-Jørgensen, T. Bille & P. Thorvaldsen To cite this article: T. Jørgensen, J. Stubbe Teglbjerg, P. Wille-Jørgensen, T. Bille & P. Thorvaldsen (1991) Persisting Pain after Cholecystectomy: A Prospective Investigation, Scandinavian Journal of Gastroenterology, 26:1, 124-128, DOI: 10.3109/00365529108996493 To link to this article: http://dx.doi.org/10.3109/00365529108996493
Published online: 08 Jul 2009.
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Citing articles: 14 View citing articles
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Date: 03 December 2016, At: 23:37
Persisting Pain after Cholecystectomy A Prospective Investigation T. JDRGENSEN, J. STUBBE TEGLBJERG, P. WILLE-JDRGENSEN, T. BILLE & P. THORVALDSEN Dept. of Surgery A , Roskilde Hospital, and Dept. of Neurology, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
J0rgensen T, Teglbjerg JS, Wille-J@rgensen P, Bille T, Thorvaldsen P. Persisting pain after cholecystectomy. A prospective investigation. Scand J Gastroenterol 1991, 26, 124-128 A prospective survey of the short-term outcome after cholecystectomy was carried out under circumstances in which the study itself did not influence preoperative decision making or surgical procedures. Of 122 consecutive patients, 115 were evaluable. In all cases gallstones were verified preoperatively either by oral cholecystography or by ultrasonography. Follow-up study was 6 1 2 months postoperatively. Ninety-one patients (79.1%) reported satisfactory outcome in terms of complete relief of preoperative symptoms. Age, sex, preoperative pain characteristics, history of disease, type of surgery, histology, and complications did not predict the surgical outcome. A test for psychic vulnerability was included among preoperative data items. Psychic vulnerability was significantly associated with persisting pain irrespective of the above-mentioned factors. This suggests that psychologic factors influence the outcome after cholecystectomy with regard to pain relief. Key words: Abdominal pain; cholecystectomy; gallstone; psychic constitution Torben Jgrgensen, M . D . , The Glostrup Population Study, Elevboligen 7.sal, KAS Glostrup, DK-2600 Glostrup, Denmark
Most patients are cholecystectomized because of upper abdominal symptoms almost invariably including pain. It is, however, recognized that not all patients are relieved of pain after this operation, a condition commonly referred to as the postcholecystectomy syndrome (1). Prospective investigations have shown a satisfactory outcome in terms of pain relief in 71-77% after cholecystectomy ( 2 4 ) . None of these studies were able to demonstrate preoperative factors predictive of the outcome. Bile flow and motor activity of the sphincter of Oddi have been studied, and decompressive operations have been undertaken in patients with the postcholecystectomy syndrome. The results, however, are not convincing (5). Other factors must be responsible for the residual group with poor outcome with regard to pain relief. No reports hitherto have included standardized measures of psy-
chologic factors as possible determinants of outcome after cholecystectomy, whereas in neurosurgery it is well established that poor outcome after lumbar surgery is associated with psychologic factors (6,7). The present study was undertaken to estimate the outcome after cholecystectomy and to evaluate whether prognostic groups could be identified from self-reported and clinical data readily available under routine circumstances in which the study itself did not influence clinical decision making and surgical procedures. A short psychometric test battery was included preoperatively. MATERIALS AND METHODS From August 1984 to January 1986 a consecutive series of 124 patients underwent cholecystectomy . The patients entered the study once the decision
Short-Term Ouicome after Cholecysiectorny Table I. Psychic vulnerability and surgical outcome
Satisfactory outcome Psychic vulnerability
Yes No
Chi square test risk = 2.69.
=
%
n
65.9 87.3
44 71
6.30, d.f. = 1, p < 0.05, relative
to operate was made by the surgeons of the department. Two patients were excluded from the study, as the indication for surgery did not include pain. Gallstones were preoperatively demonstrated either by oral cholecystography or ultrasonography and confirmed during surgery. A structured interview was administered preoperatively to all patients. They provided information about abdominal pain including location, possible radiation, and description of the pain with regard to character, duration, severity, concomitant symptoms, and provoking and relieving factors. Localized pain in the upper right quadrant (Table 11) means pain under the right curvature, pain in the epigastrium, or upper right transverse abdominal pain, whereas diffuse pain indicates two or more locations in upper right quadrant. Radiation refers to radiation to the back and/ or right shoulder/shoulderblade. Furthermore, record was made of surgical procedures, intraoperative findings, histology, and postoperative hospital stay. Twenty-eight (23%) were operated on subacutely owing t o nonemergency acute cholecystitis, normally the day after the diagnosis was established; the others had elective cholecystectomy. In all cases intraoperative cholangiography was performed. T h e choledochus was explored in 27 patients. In case of choledochotomy, T-tube drainage and postoperative cholangiography were performed after 5-7 days. Four patients had wound sepsis, and a further two were reoperated o n because of complications. Twothirds of the patients were female. T h e median age was 58 years (range, 18-86 years). A test of psychic vulnerability was administered to all patients preoperatively. Psychic vulnerability is a reaction readiness defined by a low
125
threshold of being influenced and a risk of inexpedient reactions in social interaction and healthrelated behaviour. The test is a statistically evaluated rating scale with questions concerning psychosomatic and neurotic symptoms. It provides a semi-quantitative measure of each individual’s psychologic state (8). The score distribution (PV score) may either be interpreted as a ranked order measuring the degree of psychic vulnerability or be dichotomized with a cutting point between 2 and 3 (8). Population studies have shown that increasing scores correlate well with measures of psychic and somatic illness and increased use of the National Health Services and Social Services System (9). The test resembles closely several other such instruments (10, 11). Follow-up interviews were performed in the outpatient clinic 6-12 months postoperatively. One hundred and fifteen (94%) patients were interviewed. Patients not attending the follow-up were dead ( n = 3), had immigrated ( n = l), or refused to participate ( n = 3). The outcome was evaluated from the patients’ statements o n abdominal pain. T h e outcome was considered satisfactory in patients stating that they were relieved of the pain they had before the operation. In case of persisting pain, a full record of pain characteristics and abdominal symptoms was obtained, and intravenous biligraphy was performed. Additional paraclinical examinations were performed as appropriate, normally including gastroscopy. The study was approved by the ethical committee of Roskilde County. Statistical tests were the chi-square test, the Mann-Whitney rank sum test, and Spearman’s rank correlation coefficient. To check for confounding from internal cohesions between covariables, a Mantel-Haenszel summary chisquare test (12) was used. The risk ratios in Table I1 are estimates of the relative risk attributable t o psychic vulnerability. Level of significance was 5%. RESULTS One hundred and fifteen patients were available for analyses. Twenty-five patients complained of
126
T. J@rgensen et al.
Table 11. Proportion of patients with unsatisfactory outcome according to PV score and various variables
PV score
ISSN: 0036-5521 (Print) 1502-7708 (Online) Journal homepage: http://www.tandfonline.com/loi/igas20
Persisting Pain after Cholecystectomy: A Prospective Investigation T. Jørgensen, J. Stubbe Teglbjerg, P. Wille-Jørgensen, T. Bille & P. Thorvaldsen To cite this article: T. Jørgensen, J. Stubbe Teglbjerg, P. Wille-Jørgensen, T. Bille & P. Thorvaldsen (1991) Persisting Pain after Cholecystectomy: A Prospective Investigation, Scandinavian Journal of Gastroenterology, 26:1, 124-128, DOI: 10.3109/00365529108996493 To link to this article: http://dx.doi.org/10.3109/00365529108996493
Published online: 08 Jul 2009.
Submit your article to this journal
Article views: 33
View related articles
Citing articles: 14 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=igas20 Download by: [University of Leeds]
Date: 03 December 2016, At: 23:37
Persisting Pain after Cholecystectomy A Prospective Investigation T. JDRGENSEN, J. STUBBE TEGLBJERG, P. WILLE-JDRGENSEN, T. BILLE & P. THORVALDSEN Dept. of Surgery A , Roskilde Hospital, and Dept. of Neurology, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
J0rgensen T, Teglbjerg JS, Wille-J@rgensen P, Bille T, Thorvaldsen P. Persisting pain after cholecystectomy. A prospective investigation. Scand J Gastroenterol 1991, 26, 124-128 A prospective survey of the short-term outcome after cholecystectomy was carried out under circumstances in which the study itself did not influence preoperative decision making or surgical procedures. Of 122 consecutive patients, 115 were evaluable. In all cases gallstones were verified preoperatively either by oral cholecystography or by ultrasonography. Follow-up study was 6 1 2 months postoperatively. Ninety-one patients (79.1%) reported satisfactory outcome in terms of complete relief of preoperative symptoms. Age, sex, preoperative pain characteristics, history of disease, type of surgery, histology, and complications did not predict the surgical outcome. A test for psychic vulnerability was included among preoperative data items. Psychic vulnerability was significantly associated with persisting pain irrespective of the above-mentioned factors. This suggests that psychologic factors influence the outcome after cholecystectomy with regard to pain relief. Key words: Abdominal pain; cholecystectomy; gallstone; psychic constitution Torben Jgrgensen, M . D . , The Glostrup Population Study, Elevboligen 7.sal, KAS Glostrup, DK-2600 Glostrup, Denmark
Most patients are cholecystectomized because of upper abdominal symptoms almost invariably including pain. It is, however, recognized that not all patients are relieved of pain after this operation, a condition commonly referred to as the postcholecystectomy syndrome (1). Prospective investigations have shown a satisfactory outcome in terms of pain relief in 71-77% after cholecystectomy ( 2 4 ) . None of these studies were able to demonstrate preoperative factors predictive of the outcome. Bile flow and motor activity of the sphincter of Oddi have been studied, and decompressive operations have been undertaken in patients with the postcholecystectomy syndrome. The results, however, are not convincing (5). Other factors must be responsible for the residual group with poor outcome with regard to pain relief. No reports hitherto have included standardized measures of psy-
chologic factors as possible determinants of outcome after cholecystectomy, whereas in neurosurgery it is well established that poor outcome after lumbar surgery is associated with psychologic factors (6,7). The present study was undertaken to estimate the outcome after cholecystectomy and to evaluate whether prognostic groups could be identified from self-reported and clinical data readily available under routine circumstances in which the study itself did not influence clinical decision making and surgical procedures. A short psychometric test battery was included preoperatively. MATERIALS AND METHODS From August 1984 to January 1986 a consecutive series of 124 patients underwent cholecystectomy . The patients entered the study once the decision
Short-Term Ouicome after Cholecysiectorny Table I. Psychic vulnerability and surgical outcome
Satisfactory outcome Psychic vulnerability
Yes No
Chi square test risk = 2.69.
=
%
n
65.9 87.3
44 71
6.30, d.f. = 1, p < 0.05, relative
to operate was made by the surgeons of the department. Two patients were excluded from the study, as the indication for surgery did not include pain. Gallstones were preoperatively demonstrated either by oral cholecystography or ultrasonography and confirmed during surgery. A structured interview was administered preoperatively to all patients. They provided information about abdominal pain including location, possible radiation, and description of the pain with regard to character, duration, severity, concomitant symptoms, and provoking and relieving factors. Localized pain in the upper right quadrant (Table 11) means pain under the right curvature, pain in the epigastrium, or upper right transverse abdominal pain, whereas diffuse pain indicates two or more locations in upper right quadrant. Radiation refers to radiation to the back and/ or right shoulder/shoulderblade. Furthermore, record was made of surgical procedures, intraoperative findings, histology, and postoperative hospital stay. Twenty-eight (23%) were operated on subacutely owing t o nonemergency acute cholecystitis, normally the day after the diagnosis was established; the others had elective cholecystectomy. In all cases intraoperative cholangiography was performed. T h e choledochus was explored in 27 patients. In case of choledochotomy, T-tube drainage and postoperative cholangiography were performed after 5-7 days. Four patients had wound sepsis, and a further two were reoperated o n because of complications. Twothirds of the patients were female. T h e median age was 58 years (range, 18-86 years). A test of psychic vulnerability was administered to all patients preoperatively. Psychic vulnerability is a reaction readiness defined by a low
125
threshold of being influenced and a risk of inexpedient reactions in social interaction and healthrelated behaviour. The test is a statistically evaluated rating scale with questions concerning psychosomatic and neurotic symptoms. It provides a semi-quantitative measure of each individual’s psychologic state (8). The score distribution (PV score) may either be interpreted as a ranked order measuring the degree of psychic vulnerability or be dichotomized with a cutting point between 2 and 3 (8). Population studies have shown that increasing scores correlate well with measures of psychic and somatic illness and increased use of the National Health Services and Social Services System (9). The test resembles closely several other such instruments (10, 11). Follow-up interviews were performed in the outpatient clinic 6-12 months postoperatively. One hundred and fifteen (94%) patients were interviewed. Patients not attending the follow-up were dead ( n = 3), had immigrated ( n = l), or refused to participate ( n = 3). The outcome was evaluated from the patients’ statements o n abdominal pain. T h e outcome was considered satisfactory in patients stating that they were relieved of the pain they had before the operation. In case of persisting pain, a full record of pain characteristics and abdominal symptoms was obtained, and intravenous biligraphy was performed. Additional paraclinical examinations were performed as appropriate, normally including gastroscopy. The study was approved by the ethical committee of Roskilde County. Statistical tests were the chi-square test, the Mann-Whitney rank sum test, and Spearman’s rank correlation coefficient. To check for confounding from internal cohesions between covariables, a Mantel-Haenszel summary chisquare test (12) was used. The risk ratios in Table I1 are estimates of the relative risk attributable t o psychic vulnerability. Level of significance was 5%. RESULTS One hundred and fifteen patients were available for analyses. Twenty-five patients complained of
126
T. J@rgensen et al.
Table 11. Proportion of patients with unsatisfactory outcome according to PV score and various variables
PV score
