2021, Number 1
Irritable bowel syndrome following laparoscopic cholecystectomy. A prospective cohort study
Full text
10.35366/103911
Language: English/Spanish [Versi?n en espa?ol]
References: 24
Page: 30-35
PDF size: 177.82 Kb.
ABSTRACT
Introduction: Laparoscopic cholecystectomy is one of the most frequently performed digestive surgical procedures in the world. Irritable bowel syndrome has been reported to occur more frequently in patients submitted to cholecystectomy, especially the diarrhea-predominant subtype. Objectives: To evaluate the presence of irritable bowel syndrome before and after laparoscopic cholecystectomy. Material and methods: A prospective cohort study, with control group. Irritable bowel syndrome was defined according to ROMA IV criteria, and was followed up at one, three, six, and 12 months postoperatively in search of symptomatology. The statistical analysis was performed with Fisher's exact one-way test. Results: Out of 166 patients, six presented an irritable bowel syndrome beyond six months postoperatively. In the control group there was two new cases at the end of follow-up. There were eight cases of post-cholecystectomy syndrome. Conclusions: It was not possible to establish a relationship different from chance between patients who underwent laparoscopic cholecystectomy and the presence of irritable bowel syndrome in any of its variants.ABBREVIATIONS:
- BLD = bladder lithiasis disease
- LC = laparoscopic cholecystectomy
- IBS = irritable bowel syndrome
- IBS-D = irritable bowel syndrome-subtype diarrhea
- IBS-C = irritable bowel syndrome-constipation subtype
- IBS-M = irritable bowel syndrome-mixed subtype
- PCS = post-cholecystectomy syndrome
INTRODUCTION
Bladder lithiasis disease (BLD) is highly prevalent in the western population.1 Laparoscopic cholecystectomy (LC) is one of the most performed digestive surgical procedures worldwide; in the United States it exceeds 750,000 procedures per year.2 Irritable bowel syndrome (IBS) is a common functional digestive disorder in general practice and in gastroenterology characterized by abdominal discomfort and pain and abnormal bowel habits, among other nonspecific symptoms.3 Ryle noted that multiple abdominal surgical procedures are notably more common in patients with this syndrome, such as hysterectomy, appendectomy and cholecystectomy.4 The multicenter collaborative study by Corazziari et al (MICOL) concluded that patients with IBS are more prone to cholecystectomy than the general population.5 A retrospective study by the Amieva-Balmori team,6 evaluated the presence of IBS and its subtypes according to the ROME IV criteria in a group of patients with a history of cholecystectomy, finding that irritable bowel syndrome subtype diarrhea (IBS-D) occurred more frequently in patients submitted to cholecystectomy patients. There are abdominal pain/discomfort7 in a non-negligible number of patients after cholecystectomy, and diarrhea stands out; however, there are no prospective studies that demonstrate this association, which is why we conducted the present prospective cohort study.
MATERIAL AND METHODS
This was a comparative, prospective, dynamic cohort, controlled study conducted at the Hospital Regional de Monterrey of the Instituto para la Salud y Seguridad Social de los Trabajadores del Estado (ISSSTE) in patients surgically intervened during 2017 and followed up during 2018. The study was approved by the ethics and research committee of hospital (folio 042, October 2016). According to probability sampling (10% difference in proportions, 5% adjusted for losses), 171 study subjects were included. Patients were not informed about the follow-up objective and were not given postoperative dietary recommendations different from those usually given for a healthy diet, with the aim of decreasing the Hawthorne effect. Patients with GBD diagnosis scheduled for CL and not having gastrointestinal alarm data suggesting other more serious disorders were randomly included (through a simple table of numbers). Patients with diagnosis of digestive malignancies, liver cirrhosis, upper or lower GI bleeding, chronic renal failure, uncontrolled diabetes, or psychiatric conditions that prevented a reliable direct questioning were excluded. Cases with IBS prior to surgery were also excluded from the analysis if they had been converted to open surgery and had presented any of the previously described situations during the intraoperative, immediate postoperative, and follow-up periods. The follow-up in search of IBS according to ROMA IV criteria (Table 1) was performed at one, three, six and 12 postoperative months. The investigator who performed the initial assessment was different from the surgeon, as well as the investigator of the subsequent follow-up. At the same time, an age- and sex-matched control group was included, randomly obtained from the general medical practice of two of the investigators, who were followed up in person and by telephone during the same periods of time, in search of symptoms compatible with IBS according to ROMA IV. This was done for both groups in these periods.8 Data were collected in an electronic data sheet, from the patient's clinical history that included all the questionnaires both preoperatively and at follow-up. The data obtained were tabulated to calculate the relative risk, absolute increase in risk, and one-way Fisher's exact test, taking as significant a p-value < 0.05.
RESULTS
Of a total of 171 patients with GBD sent to surgery during the study period, two were eliminated due to loss to follow-up, and one more due to the finding of gallbladder cancer, and for the statistical analysis, two with IBS prior two surgery were also eliminated (total losses: five cases, 2.92%). Of the total number of patients (166) who underwent surgery, 91.57% (152) were elective; 8.43% (14) were admitted through the emergency department for early LC for acute cholecystitis. The mean surgical time was 92 ± 51 minutes and there were no cases of open-surgery conversion (Table 2). At initial assessment, two cases of diarrhea subtype IBS were found in the group of cases that were to undergo LC; six more cases of diarrhea subtype IBS occurred during follow-up in the surgically operated group, with persistent symptoms even 12 months postoperatively (specifically IBS-D) (Table 3). It should be noted that eight patients presented symptoms (including diarrhea) from the first postoperative days compatible with post-cholecystectomy syndrome (PCS), which subsided within the first four postoperative weeks, and were different from those who presented IBS. In the control group, two cases were initially found, one diarrhea subtype and one mixed subtype; and during the follow-up period, two new cases were found, equally distributed. The statistical analysis showed a relative risk of 3.00 (0.61-14.54), the absolute risk increase (ARI) was 2.41 for IBS-D, with a p-value = 0.0875 (not statistically significant). Considering patients who presented with diarrhea, within the spectrum of symptoms of PCS, compared to the open population, their relative risk (RR) was 4 (0.86-18.55), the absolute risk increase was 4.05, with a p-value = 0.032 (statistically significant), with 28.5 as the number needed for harm (NNH). Although the RR seems to be high, it was not statistically significant, and that association seems to be given by chance (other variables). For post-cholecystectomy syndrome, the RR was four times higher; and the NNH leads us to conclude that up to one in 28 patients undergoing LC may develop this syndrome, which will be transient, and a limited number of patients will develop chronic diarrhea apparently without a direct and complete relationship to the lack of gallbladder. There are other variables that should be studied.
DISCUSSION
The evidence5,6 derived from retrospective studies suggests that patients who develop IBS, mainly the diarrhea subtype (IBS-D), have a history of cholecystectomy,9 with no difference between conventional or laparoscopic. In the classic surgical literature,10,11 has mentioned the existence of diarrhea derived from the surgical procedure itself as a possible complication, even chronic, and hence the recommendations of restricting fatty foods in the diet after the surgical procedure, information that has passed from generation to generation in surgical teaching, although without substantial evidence. We consider that there is no solid evidence to support this practice, as demonstrated in this work. An epidemiological study reported a higher frequency of IBS in patients who underwent hysterectomy and cholecystectomy;12 and another study performed at the Mayo Clinic concludes that patients with cholecystectomy have a 2.2 higher risk of developing and irritable bowel syndrome.13 Manríquez and collaborators, in a study of 100 patients (non-probabilistic sample), found that 15% presented postoperative diarrhea and 8% had chronic diarrhea, and in the rest of their population it subsided within the first 28 days.14 We obtained similar data in our group, but with a probabilistic sample. The theory that supports the current conclusions is the result of some experiments in which the retention of some radiolabeled bile acids was evaluated in patients with IBS, which correlate with the severity of symptoms, especially in the mixed alternating and diarrhea-predominant varieties.15 Post-cholecystectomy syndrome has also been described,7 which should be differentiated from IBS-D by morning predilection of symptoms, intolerance to fatty foods, nausea, vomiting, aerophagia, aero-coly and, in some cases, fecal urgency16 that is clearly relieved by evacuation. The physiopathology of this syndrome was excellently described by Jaramillo and Otero.17 They stated that malabsorption of bile acids or their contribution increases the concentrations of these bile acids in the colon, which modifies the displacement of water and electrolytes, causing osmotic diarrhea, which could be due to a poorly diagnosed chronic cause, especially in patients with cholecystectomy cases18 and its possible treatment with bile acid sequestrants.19 However, the evidence from clinical studies not specifically designed has failed to demonstrate causality;6,7,20,21 therefore, there must be other variables besides bile acids in the pathophysiology of chronic diarrhea. Reviews on IBS continue to place a history of cholecystectomy in a statistically significant association with IBS according to ROMA criteria.22-24
CONCLUSIONS
Our team concluded that there is no a randomly different association between laparoscopic cholecystectomy and the development of symptoms of abdominal pain and chronic intermittent diarrhea compatible with the diagnosis of IBS-D.
REFERENCES
AFFILIATIONS
1 Department of General Surgery. Monterrey Regional Hospital, ISSSTE, Monterrey, N.L. Mexico.
2 Medical Attention Center, Universidad de Monterrey, Monterrey, N.L. Mexico.
Ethical considerations and responsibility: The procedures in humans must comply with the principles established in the Declaration of Helsinki of the World Medical Association (WMA) and with the provisions of the General Health Law Title Five and Regulations of the General Health Law on Research for Health, and NOM-012SSA3-2012, which establishes the criteria for the execution of research projects for health in human beings, as well as with the rules of the Research Ethics Committee of the institution where they are carried out. In case of having a registration number, please provide it.
Funding: Authors\' own resources.
Disclosure: The authors stated that they did not have any conflict of interest.
CORRESPONDENCE
Francisco Cabrera-Mendoza. E-mail: cabrera_md@icloud.comReceived: 08/13/2019. Accepted: 06/06/2020