|Year : 2017 | Volume
| Issue : 2 | Page : 104-109
Male gender as an independent risk factor for laparoscopic cholecystectomy: An outcome analysis at a teaching institute
Jitendra Kumar1, Pawan Kumar2, Kusum Meena2, Aizaz Akhtar Siddiqui2
1 Department of Surgery, Dr Baba Saheb Ambedkar Medical College and Hospital, Rohini, New Delhi, India
2 Department of Surgery, Lady Hardinge Medical College and Smt. S.K. Hospital, New Delhi, India
|Date of Web Publication||15-Sep-2017|
D-15/103, Sector-7, Rohini, New Delhi - 110 085
Source of Support: None, Conflict of Interest: None
Background: Laparoscopic cholecystectomy (LC) is one of the most common surgeries performed by the surgeons on a daily basis. Male gender patients have always been considered as an independent risk factor which adversely affects the surgical outcome of LC. However, in recent time, so many conflicting reports have been published which have started to challenge this notion. The aim of this study is to analyze the effect of male gender on an outcome of LC after doing proper adjustment of other risk factors and different variables. Materials and Methods: This is a retrospective observational study for which data collected in respect to elective LC performed at Lady Hardinge Medical College, New Delhi, of the period from April 20, 2014, to April 30, 2016, have been analyzed. Results: The total number of cases found to be suitable was 670 (n = 670) out of which the number of females was 597 (89.10%) and males was 73 (10.89%). Mean/median age of males was 39.30 (±1.23) and females was 36.00 (±20). Median duration of operating time was 60 min and it was same (interquartile range - male = 45/female = 40) for both male and female groups (P = 0.035). In male group, 08.10% and in female group, 05.01% undergone conversion (P = 0.188). In both groups, median duration of postoperative hospital stay was 1 (±1) day (P = 0.137). Conclusion: After exclusion of all other risk factors said to affect the surgical outcome of LC, statistically, we have not found any significant difference between male and female gender in term of influencing the outcome of LC.
Keywords: Conversion, difficult cholecystectomy, gallstone disease, laparoscopic cholecystectomy, male gender risk factor
|How to cite this article:|
Kumar J, Kumar P, Meena K, Siddiqui AA. Male gender as an independent risk factor for laparoscopic cholecystectomy: An outcome analysis at a teaching institute. Saudi J Health Sci 2017;6:104-9
|How to cite this URL:|
Kumar J, Kumar P, Meena K, Siddiqui AA. Male gender as an independent risk factor for laparoscopic cholecystectomy: An outcome analysis at a teaching institute. Saudi J Health Sci [serial online] 2017 [cited 2021 Jan 28];6:104-9. Available from: https://www.saudijhealthsci.org/text.asp?2017/6/2/104/214854
| Introduction|| |
Gallstone disease is one among commonly encountered surgical problem which has always been generated great interest for surgical fraternity. With its immense advantages of noninvasive approach, laparoscopic cholecystectomy (LC) has now become a gold standard treatment for gallstone disease and is widely being practiced all over the world even as a day-care surgery. With increased frequency of LC, which is being performed world over, surgeon's experiences are also growing very fast. Factors that adversely affect surgical outcomes are of particular interest for the surgeon as this way they can prepare themselves in better way and prevents the complications.
There are so many factors reported so far, which have been considered as an independent risk factor in term of surgical outcome for LC., These are age, male gender, obesity, comorbid illness, American Society of Anesthesiologists (ASA) class, gallbladder wall thickness, contracted gallbladder, history of upper abdominal surgery and endoscopic retrograde cholangiopancreatography, emergency surgery, etc. Among these factors, factor of male gender has always been a subject of debate and still controversies surround it.
Although few studies have been published highlighting the issue of effect of male sex as an independent factor on the surgical outcome of LC, most of them are done either on small sample size or without taking into the consideration of different biases and variables. The aim of this study is to evaluate further and determine the effect of male gender on the surgical outcome of LC in term of intra- and post-operative morbidity of the patients.
| Materials and Methods|| |
For this retrospective observational study, data in respect to all the LCs performed as an elective case in routine operation theater of Lady Hardinge Medical College, New Delhi, during the period from April 20, 2014, to April 30, 2016, has been collected. To reduce the observer biased to possible minimum, all individual case sheets of above-mentioned period were scrutinized and recorded at medical record department of hospital by first two authors themselves only. To reduce the operator bias, cases operated by trainee residents were not included and only cases operated by experienced faculty surgeon were included in this study.
All the other known risk factors which could have affected the surgical outcome of LC, for example, emergency cases, patients with a history of upper abdominal surgery, empyema of the gallbladder, very obese, and patient with ASA grade III and above were also excluded from this study. Data which were collected include age, sex, body weight, preexisting associated comorbidity, duration of symptoms with number of acute attack if any, obstructive jaundice, history of abdominal surgery, total duration of surgery (from making first incision to taking last suture), intraoperative findings, conversion to open and its reason, all perioperative events or complications, and total duration of postoperative hospital stay.
We performed the statistical analysis of the data using the Statistical Package for the Social Sciences (SPSS Versions 16.0, IBM corporation, USA) for Windows. A comparative study between male and female population was done after setting up the background of our null hypothesis that male gender, as an isolated risk factor, has no impact on the outcomes of LC. The data were collected using tabulation of descriptive statistics. The Kolmogorov–Smirnov test applied to test the normality of data. Variables which were normally distributed expressed as means (standard deviation). Variables which were not distributed normally expressed as the median and interquartile range (IQR). Overall study population was statistically described using absolute number of cases, percentages, and ranges. As in this case, the Kolmogorov–Smirnov test was significant for most of the variable, significances were calculated using the Mann–Whitney U-test with level of significance at P > 0.05. Association between two categorical variables was evaluated using Chi-square test.
All elective cases medically fit from anesthesia point of view and were operated under general anesthesia. Standard four-port technique with 30° telescope was used in all cases in conventional manner. For the creation of pneumoperitoneum, both closed and open techniques were used as per preference of an individual surgeon. Rest of the procedure and operative techniques has been followed as per standard prescribed protocols and recommended guidelines. In most of the cases, indications for conversion were unable to define the anatomy of Calot's triangle, excess uncontrolled bleeding, bile duct, or other visceral injuries, and very rarely discovery of malignancy. The placement of subhepatic drain was based on either confidence of a surgeon in respect to hemostasis or different intraoperative events, especially in difficult cases with prolonged dissection, but drain was put in all cases that had been converted to open.
| Results|| |
During the total period of 2 years and 10 days (from April 20, 2014, to April 30, 2016), after applying the inclusion and exclusion criteria, six hundred and seventy (n = 670) cases of LCs are found to be suitable for study. Out of these, little above the 89% (n = 597) were found to be females and just under the 11% (n = 73) were males. Mean age of male population of the cohort was 39.30 ± 11.23 years (range 14–70) while median age with IQR of females was 36.00 ± 20 years (range 17–95). There was no significant difference in respect to age distribution between male and female groups (P = 0.287), but significant difference was observed in the distribution of body weight of the patients between male and female groups (P = 0.01). Summary of epidemiological details is depicted in [Table 1].
|Table 1: Epidemiological parameters and other baseline preoperative characteristics of both groups|
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In spite of proportional low share of male gender in the study population, overall percentage of person with comorbid illnesses was found slightly more in male group (24% in males vs. 21.94% in females), but this difference was not statistically significant (P = 0.346). In both male and female groups, hypertension turned out as a most common associated comorbid illness, but second common associated comorbidity was hypothyroidism in female and diabetes mellitus Type-II in male group [Table 1].
As far as previous history of abdominal surgery is concerned, there was a significant difference in male and female group (P = 0.01). As cases with previous history of upper abdominal surgeries were already excluded from the study, all the cases with previous history of surgery were involving lower abdomen only. Among male group, only 2% of cases found to have previous surgery and all of them were operated for appendectomy while about 24% of female population had a history of surgery and most of them for gynecological and obstetric purpose [Table 1].
There was no evidence of complication on the record during creation of pneumoperitoneum or because of anesthesia in either male or female group. Median time duration of surgery for both male and female groups was surprisingly same and it was 60 min with IQR with 45 min for males (range = 25–210 min) and 40 min for females (range = 20–300 min) [Table 2]. Overall percentage of conversion from laparoscopic to open was relatively higher in male group (08.10% in males vs. 05.01% in females), but statistically, this was not a significant difference (P = 0.188) [Table 2].
|Table 2: Summary of baseline surgical outcome and factors associated with conversion|
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In females, the most common cause for conversion to open was dense adhesion (66.66%) followed by difficult anatomy and cholecystoduodenal fistula in each 10% of total conversion. Another reason for conversion in female patients in 6.66% of cases were common bile duct (CBD) injury and in 03.33% of equal cases were because of dense adhesion with Mirizzi syndrome and iatrogenic transverse colon injury. In males, again, except in one case (16.66%) where reason for conversion was suspicion of malignancy, rest of all cases (83.33%) were converted because of dense adhesion in Calot's area and unable to proceed laparoscopically further [Table 2].
Median duration of postoperative hospital stays in both male and female groups was 1 day [Table 2]. Maximum duration of postoperative hospital stay for a female was 28 days and it was a case in which resurgery within same hospital stay was performed as histopathology report of gallbladder turned out as a malignant. Next longest stay of 25 days was for a 95-year-old patient because of prolonged medical morbidity, followed by 20-day stay for a patient in whom re-exploration had to be done on the 3rd postoperative days for iatrogenic jejunal perforation peritonitis. In male group, maximum duration of postoperative hospital stay of 22 days was for a patient with complication of postoperative bilioma because of bile leakage followed by 21-day stay of a patient required re-exploration for postoperative acute intestinal obstruction.
The total number of cases in which intraoperative bleeding required some additional measure, for example, placement of pack, local hemostatic (surgicel), or drain placement was 06.84% in males and 04.85% in females. Overall percentage of all other intraoperative problems, for example, dense adhesions, bile spillage, Mirizzi syndrome, bile duct injury, and placement of drain was recorded comparatively more in male group, but again statistically, there was no significant difference. Evidence of bowel injuries was found only in female group. Details of all the intra- and post-operative complications are summarized in [Table 3].
| Discussion|| |
At the beginning, when LC was still evolving, surgeons were very cautious in case selection and topics dealing with the associated factors affecting the surgical outcome directly or indirectly used to be of huge interest. With time and experience, lot of such factors which have long been considered as a negative or even contraindicated for LC, for example, acute cholecystitis, morbid obesity, elderly, severe cardiovascular disease, pregnancy, previous abdominal surgery, liver cirrhosis, etc., now no longer considered to have any negative impact on the outcome of LC.,, Most of the studies reported male gender as a risk factor for LC in term of adverse surgical outcome.,,
Under this background and formulated hypothesis, when we started analyzing result of our study, it was not only surprising but also quite interesting. Although epidemiological variables of sample have never been direct causative factors in respect to any outcome, strong association of it with the result of study has always been considered important. In our study, proportionate population of males (10.89%) in comparison to females (89.10%) was relatively less (M:F ratio = 1:8.17) as other case series in respect to LC, based even on Indian population, reported their male percentage of at least 25% or more.,
Mean/median age of patients in both male and female groups in our study was under 40 years, which was comparatively younger in comparison to mean age reported in other reports, especially of sample belongs to the Western community. In most of other reported series of the Western background, mean age of the patients found to be above 50 years for females and above 60 years for males.,, In our result, finding of mean age of male population comparatively older than females followed the general trend as reported in most of studies, but in contrast to such general trend, median weight of our male population was higher than the median weight of females with statistically significant difference. Probably younger age and under nutritional status of female gender in comparison to males can explain this to some extent.
Associated comorbid illnesses with the patient of gallstone diseases have always been considered risk factors for LC in term of its surgical outcome and conversion., In our study, this risk factor has already been nullified as statistically there was no significant difference between male and female groups in term of associated comorbidities. In respect to previous history of abdominal surgery, only upper abdominal surgeries are found to have negative influence on the surgical outcome of LC. This is the reason that's why we have excluded the cases with previous history of surgery involving the area of the abdomen above the umbilical line. Hence, in our study, even if the both male and female groups have a significant difference in term of previous history of lower abdominal surgery, it is not going to influence the outcome of our study.
Surprisingly, our result in respect to median duration of surgery in both male and female groups was found to be of the same length of time (median = 60 min), and it was quite comparative with result of other studies, which varies between 45 and 85 min.,,, Combined in both groups, overall percentage of conversion to open was 05.37%, which is at lower side and well acceptable, especially if we compare this with the result of other series reported in recent time. Conversion rate in most of the case series found to be between 6% and 8%.,, However, few of them reported decreasing trend across the years, and in some cases, it reached up to 1.2%–2.3%.,
Even though percentage of conversion in male group (08.10%) was relatively higher in comparison to female group (05.01%), statistically, it was not found significant. So far result of conversion rate in respect to different genders reported by different studies is quite mixed and it varies in males from 02.8% to 09.03% and, in females, it ranges from 01.4% to 08.40%.,,,, As reported in other series, in our study, also the most common reason for conversion was dense adhesion around Calot's area and unable to proceed further because of difficulty in identifying the anatomy, but percentage-wise incidence of adhesions in our result was comparatively more than other reported series.,,, Percentage of rest of the intraoperative events and complications noted in both groups, for example, bile spillage, CBD injury, etc., was quite comparable to result reported earlier.,,,
Among postoperative complications, pertaining to mention here is postoperative bile leakage (bilioma) and wound infection, incidence of which in our study in both groups found to be comparatively in less number of patient., Result of median duration of hospital stay in most of the study has been reported between 1 and 3 days (range 1–100) with relatively longer duration of stay for male gender.,,,,, Our result in respect to median postoperative hospital stay was surprisingly same for both male and female groups and it was 1 day.
On reviewing the literature published in the past, we found that male gender has long been considered as an independent risk factor for LC., Even in the current scenario, most of the study found the male gender as an independent risk factor for LC.,,,,,, A recently published systematic review and meta-analysis in respect to preoperative risk factors for conversion of LC, by Philip Rothman et al. which included 32 studies and covered large number of 460,995 patients found male gender as a risk factor, but at the same time, they found quality of evidence of all these studies were very low as well as there was moderate degree of heterogeneity in their analysis.
Furthermore, there are few studies which came out with result that found no impact of male gender on surgical outcome of LC., Among these reports, one study found a significantly longer postoperative hospital stay in case of male patient  and another found duration of operative time 12 min longer in males than females. While result of our study has been done after proper risk adjustment and taking care of all the biases and confounding factor, it did not find any significant difference at every level in term of surgical outcome between male and female gender undergone LC.
| Conclusion|| |
In respect to surgical outcome of LC, operating time (duration of surgery), rate of conversion, and length of hospital stay are usually considered most important of all as these are highly sensitive and direct reflection of many factors that affect it adversely. After analyzing the result of our study, it is clear beyond doubt that after the removal of all additional risk factors associated with adverse outcome of LC, statistically, male gender cannot be considered as an independent risk factor for LC. However, this is the first such study in India, and further study is required so that it may put more light on this issue in an Indian scenario.
The authors would like to convey their heartiest thankfulness and gratitude to Mrs Bobby and Mr. Puran Singh, MRO, Medical Record Department of LHMC, for their huge support and cooperation in collecting the data of the patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]