Hemorrhagic and thromboembolic complications following cholecystectomy

Abstract: Laparoscopic cholecystectomy for gallstone disease is one of the most common procedures in the Western world. The overall complication rate is 10%. Whereas most complications are easily managed, bile duct injuries may have devastating consequences. However, less described are haemorrhagic complications that cause morbidity and, in some cases, mortality. In addition, the use of thromboembolism prophylaxis (TP) is still questioned although in some institutions used routinely to prevent venous thromboembolism (VTE). The aims of this thesis were to evaluate the need for TP administration in patients undergoing cholecystectomy, and to determine the incidence and risk factors associated with haemorrhagic and thromboembolic complications in gallstone surgery. In Paper I, we included 48,010 patients from the Swedish Register for Gallstone Surgery and ERCP (GallRiks). The aim of the study was to evaluate the impact of TP on haemorrhagic complications in cholecystectomy. We found that the cumulative incidence of perioperative haemorrhagic complications doubled and that postoperative bleeding increased by 50% in patients receiving TP. Furthermore, in multivariable analysis, TP significantly predicted the risk for haemorrhage. In Paper II, data from GallRiks were cross-matched with the Swedish National Patient Register (NPR) to determine the incidence and risk factors for postoperative venous thromboembolism (VTE). The incidence of VTE in the cohort of 62,488 patients was 0.25%. A previous VTE event was the predominant risk factor for developing a thromboembolic complication following cholecystectomy. In Paper III, data from GallRiks were linked with the NPR to extract information regarding patients with liver cirrhosis (n=77) undergoing cholecystectomy. In our study we found that, compared to non-cirrhotic patients, those with liver cirrhosis were older and more often had complicated gallstone disease (cholecystitis or pancreatitis) at the time of surgery. Furthermore, patients with cirrhosis were more likely to receive a blood transfusion, and the number of postoperative complications was significantly higher than in non-cirrhotic patients. Paper IV assessed the impact of comorbidity and prescription drugs on haemorrhagic complications in cholecystectomy. A total of 94,557 patients were included from GallRiks and cross-matched with the NPR for data on comorbidity. In the second part of the study, data were cross-matched with the Swedish Prescribed Drug Register (PDR) for information regarding drugs prescribed within 90 days prior to surgery. We found that renal disease, previous myocardial infarction, heart failure, cerebrovascular disease and obesity were associated with an increased risk for haemorrhagic complications. Furthermore, perioperative haemorrhage increased the risk for bile duct injury/leakage as well as mortality. In conclusion, TP increases the risk for haemorrhagic complications in cholecystectomy. The incidence of VTE following cholecystectomy is low and TP should only be considered in patients with risk factors for VTE. Furthermore, patients with liver cirrhosis have a higher risk for developing perioperative complications. Finally, comorbidity must be considered when assessing the risk for haemorrhagic complications in patients undergoing cholecystectomy.