European Journal of Cardiovascular Medicine

As we know that in recent times, Laparoscopic Cholecystectomy (LC) is the gold standard surgery for symptomatic cholelithiasis with low mortality and morbidity.1,2 However, 1% to 15% of conversion rate to Open Cholecystectomy (OC) during laparoscopic cholecystectomy has been reported.3 Converted cases were associated with increased perioperative time, complication rates, perioperative costs, the length of hospital stay, and a higher 30-day readmission rate.3,4

Conversion was also associated with complications including bile leak, bile duct injury, or bleeding, requiring reoperation or transfusion, and death. A recent detailed critical review found that preoperative variables like male gender, older age, high body mass index, previous abdominal surgery, the severity of cholecystitis, and gallbladder wall thickness were associated with the higher rate of conversion to OC.4 However, data regarding its prevalence lacking in our setting.

The aim of this study is to find out the prevalence of open cholecystectomy among patients undergoing laparoscopic cholecystectomy in a tertiary care centre.

MATERIALS AND METHODS

It was a descriptive cross-sectional study conducted among 200 patients at the Department of Surgery in a tertiary teaching Hospital in Central India from June, 2022 to May, 2024. Convenience sampling was done. All the cases of elective LC admitted during the study period were included. Age <10 years, gall bladder malignancy, adults with preoperative choledocholithiasis, and perforated gall bladder were excluded. The sample size was calculated using the formula,

n = (Z2 × p × q) / e2

  = (1.962 × 0.049 × 0.951) / 0.032

  = 199

Where,

n = minimum required sample size

Z = 1.96 at 95% Confidence Interval (CI)

p = prevalence of open cholecystectomy among patients undergoing laparoscopic cholecystectomy, 4.9% 5

q = 1-p

e = margin of error, 3%

Thus, a sample size of 200 was taken and convenience sampling was done. Criteria for the diagnosis of symptomatic cholelithiasis are in accordance with the European Association for the Study of the Liver (EASL) Guideline 2016.6 LC was performed by the surgeons with an experience of more than 5 years in LC. Standard 4 port laparoscopic technique was used for the laparoscopic cholecystectomy and sub-costal Kocher incision was used for the open cholecystectomy respectively. Informed consent was obtained from every patient before enrolment into the study.

Data regarding demographic details, previous attack of biliary pathology, underlying condition, Huang classification of the biliary system,7 and outcome were collected. The data were entered and analysed in Microsoft Excel 2016. Point estimate at a 95% Confidence Interval was calculated along with frequency and percentages for binary data.

Out of 200 patients, the prevalence of open cholecystectomy among patients undergoing laparoscopic cholecystectomy was 5 (2.5%) (0.65-4.11 at 95% Confidence Interval). The study showed a male preponderance with a M:F ratio of 4:1 was seen.

The majority of the patients 4 (80%) were between the age of 20 and 60 years (Table 1).

Table 1: Demographic profile of the patients and conversion rate (n = 5).

In total of 5 patients undergoing OC, males were 4 (80%) and females were 1 (20%) in number. Two (40%) of them had dense adhesion at the Calot's triangle with a previous attack of cholecystitis and biliary pancreatitis. One (20%) of them had acute calculus cholecystitis with concomitant Common Bile Duct (CBD) stone and adhesion at the Calot's triangle. Another one (20%) had Mirizzi syndrome type I and finally, the last one (20%) had the aberrant insertion of the right hepatic duct into the cystic duct. (Table 2).

Table 2: Underlying conditions in the patients undergoing open cholecystectomy (n = 5).

The present clinical study of hypertensive emergencies and its clinical presentation was performed at the tertiary care hospital SSIMSRC Davangere from December 2012 to June 2014 over a period of one and half years.

In the present study, the number of males presenting with hypertensive emergencies was greater than that of females. 70% of the patients were males and 30% were females. In a study on hypertensive crisis, 55% of patients were males among patients with hypertensive emergencies13. The proportion of males in hypertensive emergencies was also higher in another study3. This is probably due to the increased susceptibility of males compared with females to hypertension related target end-organ damage. The decade-wise distribution of age shows that the largest groups belong to the fifth and sixth decades at the time of presentation, with 28% and 26% respectively. This possibility was revealed in the Framingham study, which showed that the incidence of coronary artery disease in men increased in an almost linear manner as age increased. The proportion of males was higher when studying the group of patients aged < 50 years. The majority of female patients belonged to the postmenopausal age group which shows susceptibility of postmenopausal age to end organ damage. This is also due to the fact that postmenopausal female haemodynamics is not very much different from the male profile with regard to blood pressure 15, 16. Analyzing the presenting symptoms, the largest group of patients in the present study presented with the neurological deficit (50%), followed by dyspnea (25%) and chest pain (14%). This was similar to the study by Martin et al., who reported presenting symptoms of neurological deficits, dyspnoea and chest pain in 48%, 25% and 18% of their patients 13. Another report also indicated that more patients presented with chest pain (27%), dyspnoea (22%) and neurological deficits (21%) 3. Neurological deficits in the present study included hemiparesis (40%), altered sensorium(48%), convulsions (6%) and visual deficits (4%). Altered sensorium, followed by hemiparesis, accounted for the largest group of patients with neurological deficits. Most patients in the present study had previously.

known hypertension (60%). Martin et al noticed a large number of patients (83%) in their study to be previously diagnosed hypertensives 13. It has also been reported that a large proportion (92%) of known hypertension prevails among patients. This evidence confirms that the number of hypertensive emergencies was higher in patients with previously known hypertension 3. This also shows that patients with hypertension are at a higher risk of developing a hypertensive emergency if they do not adhere to antihypertensive therapy. In the present study, 40% of the known hypertensives ignored their hypertensive status and discontinued antihypertensive medications which would have put them at a higher risk for acute target end-organ damage and hypertensive emergencies. Diabetes mellitus and dyslipidaemia were other risk factors in the present group of patients. In this study, 12% and 36% of the patients had diabetes mellitus and dyslipidaemia, respectively. The percentage of patients with diabetes mellitus was 26% in a previous reported study 13. These risk factors could have added to premature atherosclerosis and coronary artery disease, predisposing them to acute target end-organ damage. The prevalence of arterial hypertension in diabetic patients (40-50%) is greater than that in non-diabetic patients (20%) 17. Metabolic abnormalities ( hyperglycaemia, hyperinsulinaemia and dyslipidaemia) may play a role in the pathogenesis and complications of arterial hypertension, as observed in the present study. The highest recorded SBP was 280 mm Hg, with a mean SBP of 216+25 mmHg. The highest recorded DBP was 180 mmHg, with a mean of 126+18 mmHg. This is in conformity with the findings of Martin et al., who reported a mean SBP of 193+26 mmHg in their patients and a mean DBP of 129+12 mmHg 13. The mean reduction in blood pressure one hour after admission to the hospital was 19 mmHg for SBP and 14 mmHg for DBP. Blood pressure levels at admission were higher in the group of patients who died than in those who were discharged from the hospital. Higher blood pressure levels would have added to more severe target organ damage in these patients with adverse outcomes. This indicates a worse prognosis with higher blood pressure at presentation. Evaluation of the fundus revealed changes ranging from hypertensive retinopathy to papilloedema in 68% of the patients. Papilloedema was observed in 24% of the patients which is evidence of ongoing target organ damage in these patients. Renal dysfunction in the form of elevated serum urea and creatinine levels was observed in 24% and 18% of patients respectively. Renal changes amounting to hypertensive target end-organ damage were seen in five patients. Hyponatremia was observed in 32% of patients, 12% of the patients had hypokalemia compared to 4% with hyperkalemia, reflecting secondary aldosteronism from increased rennin secretion induced by intra renal ishaemia. Microalbuminuria was seen in 36% of the patients which puts these patients at a higher risk for hypertension-related renal disease than patients without proteinuria. Computed tomography of the brain showed intracerebral haemorrhage (56%) as the most common cause of neurological target organ damage, followed by cerebral infarction (16%) and subarachnoid haemorrhage (10%). Voltage criteria suggestive of left ventricular hypertrophy on ECG were seen in 38% of the patients and 76% had left ventricular hypertrophy on echocardiography. A study conducted by Lip et al. on complications and survival of 315 patients with malignant hypertension found a low median survival time in patients with proteinuria and high serum urea & creatinine levels at presentation and if left ventricular hypertrophy was detected on echocardiogram14. These findings in a patient in a hypertensive emergency may help in prognosticating these patients.

Evaluation of target organ damage in the present study showed intracerebral haemorrhage as the common cause (25%), followed by left ventricular failure (20%), unstable angina (12%), acute myocardial infarction (10%), acute ischaemic stroke (10%), subarachnoid haemorrhage (8%), malignant hypertension (6%), acute myocardial infarction with left ventricular failure (4%) and hypertensive encephalopathy (16%). Zampglione et al in their study observed target end organ damage in the form of intracerebral haemorrhage (45%), left ventricular failure (23%), acute ishaemic stroke (24%) in their patients 3. Another study revealed intracerebral haemorrhage (17%), left ventricular failure (25%), acute ischaemic stroke (39%) and acute myocardial infarction 8% in patients13.

The present study showed an in-hospital mortality rate of 22% in these patients. Among the 22 patients, 16 were males and 6 females. Of the 16 males, all were known hypertensives and 8 were diabetic patients. Of the six females, all were known to have hypertension and only four had diabetes mellitus.

This study showed that the prevalence of open cholecystectomy among patients undergoing laparoscopic cholecystectomy was lower when compared to similar studies conducted in similar settings and was common in males. With recent advances in the laparoscopic technique, conversion rate and complications like damage to major structures could be brought down to a minimum.

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