GENDER DIFFERENCE IN ELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY FOR CHRONIC CHOLECYSTITIS

Laparoscopic cholecystectomy is now considered as a treatment of choice for symptomatic gall stones. Although the difference in the outcome, including conversion rate, operation time, hospital stay, complications and the effect of gender, is emphasized, but no enough data could be found in the literature regarding the effect of gender on the outcome of elective laparoscopic cholecystectomy for chronic cholecystitis. This study aimed to define the effect of gender on the laparoscopic cholecystectomy for Chronic Cholecystitis. A randomized, coherent and prospective clinical trial was carried out at Hatwan Private Hospital for Endoscopic Surgery and Al Sulaimania Teaching Hospital to evaluate the sex difference as predictor for difficult laparoscopic cholecystectomy. From a total number of 712 patients, who were underwent laparoscopic cholecystectomy for Chronic Cholecystitis from 1st June 2002 to 1st of January 2011) three hundred and eighty eight patients were excluded according to exclusion criteria and the remaining 313 patients were included. All the operation were done by the same team and by the same surgeon , Standard four-port technique through a 'closed' method, was used, with first entry port in the periumblical region. Anesthetic technique and peri-operative management were not modified during the study period. Patients who were candidates for elective cholecystectomy, were mostly females with (F:M ratio= 3/1), mean age 28 years (range 20-50 years) with mean age of 34 years(range 20-49 years) for the females, 37years (range 20-50 years) for the males. There were more difficult cholecystectomies in males in comparison to female patients for chronic cholecystitis. In conclusion, male gender is a predictor for difficult laparoscopy for symptomatic gallstones presented as chronic cholecystitis.


Introduction
aparoscopic cholecystectomy is considered as a treatment of choice of symptomatic gall stones [1][2][3][4][5][6][7][8][9] .Although the difference in the outcome, including conversion rates, operation time, hospital stay, complications and the effect of gender, is emphasized, but the definition of difficult laparoscopic cholecystectomy (LC) is inconsistent 10 , at the same time some authors tried to describe these difficulties, as cholecystectomy "that places the patient at significant risk" 7 .Also may be described on basis of time as difficult LC needs (>120 minutes) or conversion to open surgery 11 .Yet with all these potential risks; laparoscopy "is the preferred method for cholecystectomy even in difficult cases" 2 , and laparoscopic management of difficult gallbladder problems is safe and effective 5 .Most detailed description of difficult laparoscopic cholecystectomy was done by (Kuldip Singh) as laparoscopic cholecystectomy whenever "there are (dense adhesions at the triangle of Calot, contracted and fibrotic gallbladder, L gangrenous gallbladder , acutely inflamed gallbladder, empyema gallbladder (including Mirrizi syndrome Type II), and cholecystogastric or cholecystoduodenal fistula, previous abdominal surgery, those patients who need conversion rate to open surgery" 7 , also difficulties in accessing the peritoneal cavity, creating a pneumoperitoneum, dissecting the gall bladder (GB), or extracting the excised GB 12 .Preoperative identification of difficult Laparoscopic cholecystectomy (DLC) and helps in better preparation of the patient, detailed discussion in the consent with the patients, regarding potential difficulties and possibility of conversion ,longer hospital stay, morbidity and mortality 6,[12][13][14][15] gender, age in clinical features and investigations and ultrasonography may help in the prediction of the difficulties 13,14 and referral of these patients for more experience surgeons and or specific centers of laparoscopic surgery 15,16 .There are very few reports which have discussed the effect of gender on the course of LC in AC and CC 1,9,12,13 , but no literature was found concerning sex difference in elective (LC) for chronic cholecystitis (CC), It is reported that "this relationship remains unclear" 17 .The present work is a trail to define the effect of gender on the LC for CC

Patients & methods
A randomized, coherent and prospective clinical trial was carried out at Hatwan Private Hospital for Endoscopic Surgery and Al Sulaimania Teaching Hospital to evaluate the sex difference as predictor for difficult laparoscopic cholecystectomy.From a total number of 712 patients, who underwent laparoscopic cholecystectomy (LC) for chronic cholecystitis (CC) from 1st June 2002 to 1st of January 2011) three hundred and eighty eight patients were excluded according to exclusion criteria and the remaining 313 patients were included.All the operations were done by the same team and by the same surgeon, Standard four-port technique through a 'closed' method, was used, with first entry port in the periumblical region.Anesthetic technique and peri-operative management were not modified during the study period: According to gender, the patients were categorized in to two groups.Group A; 88 patients, were male.Group B; 243 patients, were females.Exclusion criteria: to eliminate other variables which may affect difficulty of LC for CC, we excluded those turned out to have gallbladder carcinoma, or were not reported for reevaluation in the follow up as well as the following groups of patients ((morbid obesity, previous surgery, Diabetes Mellitus (DM), previous acute pancreatitis, cholecystitis, previous history of acute cholecystitis, multiple attacks (ten or more), who were jaundiced, Fever, palpable gall bladder, white blood cells account (WBC), liver function test.ultrasonographic signs of contracted gall bladder, gall bladder wall thickness more than 3mm, inflammation, shrunken or acute cholecystitis and who had common bile duct (CBD) stones, or cancer, Age above 50 years 6,8,14,15,18,19

Test of Hypotheses by Confidence
Interval: There are statistically significant differences between the frequency of various difficulties faced during LC, which were more frequent in male versus female patients (P value =0.0004).Male patients needed longer time in minutes for dissection of the gallbladder from its bed with overall longer operative time (Table III).Test of Hypotheses by Confidence Interval: There is very strong evidence against the null hypothesis (P value =0.0004), which was assuming that there is no difference between the time needed in each gender for dissection of the gallbladder or aver all operation time.

Discussion
As the experience of the surgeon will affect the conversion rates and complications in laparoscopic cholecystectomy, we selected the laparoscopies done by the same surgeon and team after completing his learning curve (his first 50 laparoscopy) [18][19][20] .Conversion rate was necessary in three male (3.4%) and one female patient (0.4 %), with overall conversion rates of 4  24 .This may be because other studies were about difficult cholecystectomies in both acute and chronic cholecystitis, while present paper is about chronic cholecystitis alone.Conversion rates of this paper is comparable with literature as in males 1,9,14,22 , which was difficult the rate was (3.4 %) and in females which was easy the rate was (0.41 %) in comparison to the literature , in which reported 6.1% (55 patients) in difficult laparoscopic cholecystectomy and (3.2% ) in "easy" cholecystectomy 24 .Since surgeons are reluctant to publish their own rate of complications, and since the complications of LC are treated in tertiary care centers, the precise magnitude of the problem remains uncertain 18 regarding gender difference, there are different ideas in the literature; i.e.: Gronroos et al., reported that women were at a higher risk for severe bile duct injuries during LC 22 .While other authors have opposite ideas, most are claiming that gender is not a risk factor in the difficulty of LC or conversion 21,23 , only preoperative diagnosis correlating significantly with LC difficulty 2,22 .In mean time there are papers which insist on the effect of gender on the difficulty of the LC 4,6,21 , in the point view of difficulty and time consuming, and conversion to open surgery 6 which is more in men than in women 9 .The results of the current study are comparable with the last group, as we found more difficulties in male patients (table 2), who need longer time for dissection of the bed of the gallbladder (17±4 minutes) for males and (7±3) minutes for female patients, and overall operative time of (49±10) minutes and (35±7) minutes for male and female patients respectively.Which is relatively comparable with a literature, as the mean time in a study was longer in men than women (80.3 vs. 70.4min) 22 , There are many speculations and explanations; why it is more common in males?On one hand male patients were delayed in seeking medical advice 1 , has a longer duration of symptoms before consultation 6 , by the time these patients seek treatment the stage has been set for a difficult laparoscopic cholecystectomy 9 .On the other hand there are more extensive inflammation and fibrosis that occur in men than in women 9 , there is higher amount of hydroxyproline (collagen component) and macrophages, mast cells, and eosinophilic granulocytes in the connective tissues of the gallbladder wall and in the pericholecystic tissues than women 6,16,17 .

Conclusion
Male gender is a predictor for difficult laparoscopy for symptomatic gallstones presented as chronic cholecystitis.

Table I :
Age and Gender of the patients.

Table II :
The rate of difficulties during surgery

Table III :
Comparing the time of gallbladder dissection and overall time of the operations in males versus female patients.