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Editor,—I read with great interest the article by Luman et al (Gut 1996; 39:863–6) on the incidence of persistent symptoms after laparoscopic cholecystectomy.
I would like to point out that their statement that no study has analysed prospectively symptoms before and after laparoscopic cholecystectomy is not quite true. Although in a much smaller patient population, we published a paper on the same subject in 1995.1 In our study, we found that cholecystectomy significantly improved quality of life, and cured nausea, fatty food upset, abdominal distension, and biliary pain. We also found that laparoscopic cholecystectomy improved quality of life and symptomatology at an earlier stage than conventional cholecystectomy.
Furthermore, I would like to stress that, although Luman et al’s study provides us with lots of interesting data and recommendations, it also leaves us with many unanswered questions. How many patients were excluded from the study because of planned open cholecystectomy and inability to answer the questionnaire? What were the reasons for treating patients by open cholecystectomy? How many patients underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) and did all of them undergo sphincterotomy? Were there any differences in symptoms between patients with or without sphincterotomy? Why is ERCP not mentioned in the analysis of preoperative investigations (Table IV)? Was there symptomatic relief of heartburn in patients from the uncomplicated group? I would be grateful if the authors would answer some of these questions.
Editor,—We thank Dr Plaisier for the interest he has expressed in our paper and for his thoughtful comments. We are grateful to him for pointing out his group’s published work. We agree with Dr Plaisier that laparoscopic cholecystectomy carries significantly less morbidity than open surgery.1-1-1-3
Our paper assessed symptoms after laparoscopic cholecystectomy and patients undergoing open surgery were not considered. Five per cent of patients undergo open cholecystectomy in our institution each year. No patients were excluded from the study because they were unable to answer the questionnaire.
As mentioned in our paper, patients with a history of jaundice, abnormal liver function tests, dilated common bile duct, or pancreatitis underwent preoperative ERCP. Ten patients had preoperative ERCP, five of whom required sphincterotomy for removal of common bile duct stones. All of them had successful symptomatic outcome from laparoscopic cholecystectomy. ERCP was not mentioned in the analysis of preoperative investigation as it was carried out for complications of choledocholithiasis—that is, pancreatitis or obstructive jaundice, and not for elucidation of causes of abdominal pain. There were preoperative differences in symptoms in patients who had choledocholithiasis as indicated in the first sentence of this paragraph.
In Table V, we showed that heartburn was relieved by laparoscopic cholecystectomy in only 3% of patients. None of the patients developed heartburn after surgery.
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