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ORIGINAL ARTICLE

Health-related quality of life in patients undergoing

cholecystectomy

Li-Na Hsueh

a

, Hon-Yi Shi

b

, Tsai-Fan Wang

a

, Chiung-Ying Chang

c

, King-Teh Lee

b,d,

*

a

Division of Operation Room, Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Taiwan

b

Graduate Institute of Healthcare Administration, Kaohsiung Medical University, Kaohsiung, Taiwan

c

Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Taiwan

d

Division of Hepatobiliary Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

Received 6 October 2010; accepted 21 January 2011 Available online 22 April 2011

KEYWORDS Cholecystectomy; Gastrointestinal Quality of Life Index; Health-related quality of life; Short-Form 36 Health Survey

Abstract This large-scale prospective cohort study of a Taiwan population applied general-ized estimating equations to evaluate predictors of health-related quality of life (HRQOL) after open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) procedures per-formed between February 2007 and November 2008. The Gastrointestinal Quality of Life Index and Short Form-36 were used in a preoperative assessment and in 3rdmonth and 6th month postoperative assessments of 38 OC and 259 LC patients. The HRQOL of the cholecys-tectomy patients were significantly improved at 3 months and 6 months postsurgery (p< 0.05). At 3 months postsurgery, HRQOL improvement was significantly larger in LC patients than in OC patients. Patient characteristics, clinical characteristics, and health care quality were also significantly related to HRQOL improvement (p< 0.05). Additionally, after controlling for related variables, preoperative health status was significantly and positively associated with each subscale of the Gastrointestinal Quality of Life Index and Short Form-36 throughout the 6 months (p< 0.05). Patients should be advised that their postoperative HRQOL may depend not only on their postoperative health care but also on their preoperative functional status.

Copyrightª 2011, Elsevier Taiwan LLC. All rights reserved.

* Corresponding author. Division of Hepatobiliary Surgery, Department of Surgery, Kaohsiung Medical University Hospital, 100, Zihyou 1stRoad, Kaohsiung 807, Taiwan.

E-mail address:hshi@kmu.edu.tw(K.-T. Lee).

a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m

j o u r n a l h o m e p a g e : h t t p : / / w w w . k j m s - o n l i n e . c o m Kaohsiung Journal of Medical Sciences (2011) 27, 280e288

1607-551X/$36 Copyrightª 2011, Elsevier Taiwan LLC. All rights reserved. doi:10.1016/j.kjms.2011.03.002

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Introduction

Cholecystectomy can be categorized as open cholecystec-tomy (OC) or laparoscopic cholecysteccholecystec-tomy (LC). The first LC was performed by Pillipe Mouret in France in 1987. In Western countries, more than 75% of patients who suffer from cholelithiasis combined with acute or chronic chole-cystitis undergo LC surgery [1], and about 6,000 patients undergo LC surgery annually in Taiwan. This procedure is now a standard treatment for cholelithiasis because of its short operation time, minimal invasiveness, good patient tolerance, rapid recovery, and short hospitalization time

[2e4].

Health-related quality of life (HRQOL) is a critical consideration when evaluating treatment options for cholelithiasis. Therefore, understanding the postoperative physical, psychological, and social outcomes associated with cholecystectomy is essential [5,6]. When evaluating HRQOL outcomes, especially after cholecystectomy, accu-rate data collection by longitudinal survey is essential

[5e7]. Accurately evaluating treatment efficacy generally requires a generic outcome measure, such as a general HRQOL improvement and a disease-specific measure of clinical improvement.

Until now, most studies of cholecystectomy outcome have only evaluated patients at 3 months postoperatively after they had received only one or two postoperative assessments[4e6]. Additionally, studies of treatment effi-cacy in patients who have received cholecystectomy in countries elsewhere have been limited to procedures per-formed in only one medical institution [7]. Hence, this follow-up study focused on dimensions, such as patient demographics, clinical characteristics, health care quality, and preoperative health status to provide guidance in performing related medical treatments and to establish reliable HRQOL measures. Longitudinal changes in each HRQOL subscale were evaluated in terms of predictive value for cholecystectomy outcome. This study is, to our knowledge, the first to apply generalized estimating equations (GEEs) in a large-scale prospective cohort study of HRQOL change and predictors in a Taiwan population of cholecystectomy patients.

Materials and methods

Participants and data collection

The participants of this study were patients who had received OC or LC at two southern Taiwan medical centers between February 2007 and November 2008. For accurate assessment of postoperative outcome measures, only patients who had been treated by highly experienced surgeons were analyzed[8]. That is, the participants were patients who had undergone cholecystectomy performed by directors of surgery in a medical institution or by senior attending doctors specializing in cholecystectomy surgery or treatment. Inclusion criteria were the following: (1) history of OC or LC after initial diagnosis of cholelithiasis alone; (2) ability to communicate in Chinese and Taiwa-nese; and (3) agreement to participate in questionnaire survey in the hospital ward or by telephone. Exclusion

criteria were postoperative diagnosis of any disease other than cholelithiasis or polyp and failure to complete post-operative questionnaires. The final study population of 297 patients included 38 OC patients and 259 LC patients.

Patient characteristics (including age, gender, education level, marital status, and body mass index (BMI), Charlson comorbidity index (CCI), history of abdominal surgery, duration of illness, reason for surgery, administration type, history of tobacco, and alcohol use), clinical characteristics (including duration of surgery and classification of anes-thetic risk), health care quality [including rehospitalization within 30 days postsurgery, average length of stay (ALOS), and complications], and preoperative health status were collected through structured questionnaires and by review of patient records. All involved institutions approved this study of human subjects before initiating the survey. Measures of HRQOL

The Gastrointestinal Quality of Life Index (GIQLI) was administered to evaluate social function and psychological and physical symptoms. The Short Form-36 (SF-36) Health Survey was administered to assess self-reported general health preoperatively and at 3 months and 6 months postsurgery.

The GIQLI gives a total score based on scores for four dimensions: symptoms, emotional function, physical func-tion, and social function. The index includes 35 four-point questions with a maximum score of 140, where higher scores represent better health conditions postoperatively. The SF-36 measures eight dimensions: physical (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role emotional (RE), and mental health (MH). The maximum score for each dimen-sion is 100, and higher scores indicate better postoperative health conditions. The SF-36 also includes a physical component summary dimension and a mental component summary dimension. Based on the formula suggested by Ware[9]and on nationwide data collected by researchers in Taiwan[10], each score was converted to obtain a mean of 50 and a standard deviation of 10. Briefly, physical component summary or mental component summary scores higher than 50 and lower than 50 indicated better and worse general bodily or psychological function, respec-tively, compared with the “nationwide” normal group. Statistical analysis

The unit of analysis in this study was the individual patient. The data structure of the sample was first established by statistical analysis of demographic data. Improved post-operative outcomes in different dimensions were then assessed by calculating effect size (ES). Improved post-operative HRQOL at each time point was analyzed by GEE modeling. Risk factors that significantly correlated with outcome dimensions or variables were identified by univariate analysis. The related risk factors were then entered into the GEE model for multivariate regression analysis as described in the literatures[11e13].

The model was constructed by first performing multiple regression analyses to find the best predictors of HRQOL at

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different time points when using preoperative measures as baseline. Dependent variables (mean value of each GIQLI and SF-36 subscale) were modeled as a function of time and effect predictors. These significant independent variables

were further included in the longitudinal analysis. Resta-ted, these effective predictive variables were included as covariates in the GEE approach because they were statis-tically significant in the multivariable models and are the

Table 1 Demographic and clinical characteristics of participants

Characteristics OC (nZ 38) LC (nZ 259) Total (nZ 297) Characteristics, mean (SD) Age 61.47 (15.32) 53.27 (14.78) 54.32 (15.08) BMI 24.79 (3.78) 24.53 (3.67) 24.56 (3.67) Duration of symptoms 5.33 (11.49) 14.45 (34.10) 13.30 (32.27) Number of comorbidities 1.58 (1.65) 0.89 (1.48) 0.98 (1.52) Gender, n (%) Male 28 (73.68) 105 (40.54) 13 (44.78) Female 10 (26.32) 154 (59.46) 164 (55.21) Education, n (%) No formal education 6 (15.79) 30 (21.62) 36 (12.12) Primary school 11 (28.95) 56 (21.62) 67 (22.55)

Junior high school 4 (10.53) 35 (13.51) 39 (13.13)

Senior high school 4 (10.53) 87 (33.59) 91 (30.64)

College 13 (34.21) 51 (19.69) 64 (21.55)

Marital status, n (%)

Single d 36 (13.90) 36 (12.12)

Married 38 (100.00) 223 (86.10) 164 (87.88)

Previous abdominal surgery, n (%)

Yes 15 (39.47) 84 (32.43) 99 (33.33)

No 23 (60.53) 175 (67.57) 198 (66.67)

Surgical factors, n (%)

Symptomatic gallstones 20 (52.63) 162 (62.55) 182 (61.28)

Acute cholecystitis with gallstones 18 (47.37) 97 (37.45) 115 (38.72)

Administration type, n (%) OPD 28 (73.68) 195 (75.29) 223 (75.08) ED 10 (26.32) 64 (24.71) 74 (24.92) Current drinker, n (%) Yes 8 (21.05) 34 (13.13) 42 (14.14) No 30 (78.95) 225 (86.87) 255 (85.86) Current smoker, n (%) Yes 9 (23.68) 39 (15.06) 48 (16.16) No 29 (76.32) 220 (84.94) 249 (83.84)

Quality of care, mean (SD)

ALOS 9.43 (4.89) 4.54 (3.28) 5.16 (3.87)

Rehospitalization within 30 days, n (%)

Yes d 10 (3.86) 10 (3.37)

No 38 (100.00) 249 (96.14) 287 (96.63)

Current complications, n (%)

0 38 (100.00) 234 (90.35) 272 (91.58)

1 d 25 (9.65) 25 (8.42)

Clinical characteristics, mean (SD)

Operation time 138.68 (62.78) 85.33 (41.76) 92.15 (48.29)

ASA score 2.43 (0.60) 2.04 (0.64) 2.09 (0.65)

ASAZ American Society of Anesthesiologists; ALOS Z average lengths of stay; BMI Z body mass index; ED Z emergency department; LCZ laparoscopic cholecystectomy; OC Z open cholecystectomy; OPD Z outpatient department; SD Z standard deviation.

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Table 2 HRQOL before and after cholecystectomy (mean SD)

Variable OC LC

Preoperation 3-mo postsurgery (p) 6-mo postsurgery (p) Preoperation 3-mo postsurgery (p) 6-mo postsurgery (p)

GIQLI Symptom 63.11 2.82 58.90 3.93 (0.290) 72.68 4.33 (0.001) 58.17 0.63 68.42 0.77 (<0.001) 71.14 0.89 (<0.001) Emotion 14.92 0.82 14.91 0.99 (0.994) 18.52 1.11 (0.001) 13.21 0.24 17.47 0.29 (<0.001) 18.02 0.33 (0.095) Physical 17.89 1.22 16.60 1.40 (0.357) 22.96 1.57 (<0.001) 18.17 0.32 20.54 0.42 (<0.001) 24.31 0.48 (<0.001) Social 13.39 0.86 11.17 0.99 (0.026) 16.48 1.12 (<0.001) 8.83 0.16 10.57 0.18 (<0.001) 10.98 0.21 (<0.001) Total 110.74 5.12 103.49 6.88 (0.292) 132.09 7.60 (<0.001) 100.92 1.26 120.49 1.51 (<0.001) 128.08 1.74 (<0.001) SF-36 PF 84.53 1.88 89.34 2.46 (0.050) 92.48 2.46 (<0.001) 76.56 1.15 91.13 1.46 (<0.001) 96.27 1.46 (<0.001) RP 57.61 6.30 57.84 8.62 (0.979) 92.51 8.62 (<0.001) 56.37 1.99 86.49 2.60 (<0.001) 92.02 2.60 (0.033) RE 72.43 5.26 83.83 6.86 (0.096) 95.17 6.86 (0.098) 54.01 2.10 86.06 2.77 (<0.001) 92.49 2.77 (<0.001) SF 89.14 2.88 81.58 3.70 (<0.001) 94.52 3.70 (<0.001) 74.61 1.14 87.66 1.34 (<0.001) 91.55 1.34 (<0.001) BP 52.03 3.23 84.48 4.12 (<0.001) 92.63 4.12 (<0.001) 57.76 1.06 84.06 1.42 (<0.001) 93.26 1.42 (<0.001) VT 64.47 2.86 69.10 3.57 (0.194) 78.61 3.57 (<0.001) 56.31 1.08 65.99 1.28 (<0.001) 67.36 1.07 (0.285) MH 75.79 2.54 84.33 2.91 (<0.001) 82.91 2.91 (0.625) 60.73 1.12 70.15 1.17 (<0.001) 73.19 1.17 (<0.001) GH 57.45 3.05 66.52 3.23 (<0.001) 68.13 3.23 (0.618) 59.60 1.12 66.27 1.19 (<0.001) 73.52 1.19 (<0.001) PCS 45.15 1.00 51.22 1.38 (<0.001) 51.38 1.38 (0.906) 48.80 0.44 53.95 0.56 (<0.001) 56.47 0.56 (<0.001) MCS 44.08 2.38 51.00 3.02 (0.022) 48.89 3.02 (0.486) 29.24 1.04 43.07 1.19 (<0.001) 45.96 1.19 (0.015)

BPZ bodily pain; GH Z general health; GIQLI Z gastrointestinal quality of life index; HRQOL Z health-related quality of life; LC Z laparoscopic cholecystectomy; MCS Z mental component summary; MHZ mental health; OC Z open cholecystectomy; PCS Z physical component summary; PF Z physical function; RE Z role emotional; RP Z role physical; SFZ social function; SF-36 Z Short-Form 36 Health Survey; VT Z vitality.

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conventional HRQOL predictors applied in the literature

[11e13]. The GEE procedure under XTGEE in Stata, version

9.0 (StataCorp, College Station, TX, USA), was used for statistical analyses in this study.

Results

In the 297 cholelithiasis patients analyzed in this study, average age was 54.32 15.08 years, average BMI was 24.56 3.67 kg/m2, average illness duration was 13.30 32.27 months, and average CCI was 0.98 1.52. Of the analyzed patients, 55.21% were female, 30.64% had a high school education or above, 87.88% were married, 66.67% had a history of abdominal surgery, 61.28% had a history of surgery for symptomatic cholelithiasis, 75.08% had been treated in clinics, 85.86% were drinkers, 83.84% were smokers, 96.63% did not require rehospitalization within 30 days, and 91.58% had no complications. ALOS was 5.16 3.87 days, average surgery duration was 92.15 48.29 minutes, and average anesthetic risk classification was 2.09 0.65 (Table 1).

By 3 months postsurgery, the OC patients had signifi-cantly (p< 0.05) improved in GIQLI social score; and, by 6 months postsurgery, they had significantly (p< 0.05) improved in other dimensions as well. The LC patients, however, exhibited significant improvement in all dimen-sions at both 3 months and 6 months postsurgery (p< 0.05)

(Table 2). By 3 months postsurgery, the OC patients had

significantly improved in all SF-36 dimensions except for RP, VT, and RE. By 6 months postsurgery, the OC patients had significantly (p< 0.05) improved in all dimensions. The LC patients, however, exhibited significant improvement in all dimensions at both 3 months and 6 months postsurgery

(p< 0.05). Additionally, patients who had complications in LC and those who did not have any complications throughout the 6 months did not statistically differ in preoperative or in any of the aforementioned postoperative HRQOL parameters (data not shown).

Table 3compares the HRQOL improvement between OC

and LC in different dimensions and time points. The OC patients exhibited negative change in all GIQLI dimensions at 3 months postsurgery with ES ranging from 0.01 (psychological function) to 2.58 (social function), whereas all changes were positive at 6 months postsurgery with ES ranging from 3.51 (symptoms) to 5.36 (social function). Additionally, the HRQOL changes in LC patients were uniformly positive at 3 months postsurgery with ES ranging from 7.41 (physical function) to 17.75 (psychological func-tion) and also uniformly positive at 6 months postsurgery with ES ranging from 1.90 (psychological function) to 8.98 (physical function). Analysis of total GIQLI indicated that the largest HRQOL change occurred at 6 months postsurgery in OC patients and at 3 months postsurgery in LC patients. Except for the SF dimension of the SF-36, HRQOL changes in the OC patients were uniformly positive at 3 months post-surgery with ES ranging from 2.63 (SF) to 10.05 (BP). Except for the MH dimension of the SF-36, HRQOL changes in OC patients were uniformly positive at 6 months post-surgery with ES ranging from 0.49 (PF) to 4.02 (RP). Meanwhile, the HRQOL changes in LC patients were uniformly positive at both 3 months and 6 months post-surgery with ES ranging from 5.96 (GH) to 24.81 (BP) and from 1.07 (VT) to 6.48 (BP), respectively.

Table 4 shows the results of multivariate analysis of

effective HRQOL predictors. Each time point was signifi-cantly related to the GIQLI subscales throughout the

Table 3 Effect sizes of HRQOL in different time sequences before and after cholecystectomy

Variables OC LC Preoperatively vs. 3-mo postsurgery 3-mo postsurgery vs. 6-mo postsurgery Preoperatively vs. 3-mo postsurgery 3-mo postsurgery vs. 6-mo postsurgery GIQLI Symptom 1.49 3.51 16.27 3.53 Emotion 0.01 3.65 17.75 1.90 Physical 1.06 4.54 7.41 8.98 Social 2.58 5.36 10.88 2.28 Total 1.42 4.16 15.53 5.03 SF-36 PF 2.56 1.28 12.67 3.52 RP 0.04 4.02 15.14 2.22 RE 2.17 1.65 15.26 2.32 SF 2.63 3.50 11.45 2.55 BP 10.05 1.98 24.81 6.48 VT 1.62 2.66 8.96 1.07 MH 3.36 0.49 8.41 2.60 GH 2.97 0.50 5.96 6.09 PCS 6.07 0.11 11.7 4.50 MCS 2.91 0.70 13.3 2.43

BPZ bodily pain; GH Z general health; GIQLI Z gastrointestinal quality of life index; HRQOL Z health-related quality of life; LCZ laparoscopic cholecystectomy; MCS Z mental component summary; MH Z mental health; OC Z open cholecystectomy; PCSZ physical component summary; PF Z physical function; RE Z role emotional; RP Z role physical; SF Z social function; SF-36Z Short-Form 36 Health Survey; VT Z vitality.

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Table 4 Multivariate regression analysis: factors affecting postoperative HRQOL of patients receiving OC and LC (GIQLI) Variables OC LC Symptom coefficient Emotion coefficient Physical coefficient Social coefficient Total coefficient Symptom coefficient Emotion coefficient Physical coefficient Social coefficient Total coefficient Intercept 55.21* 15.10* 21.11* 12.94* 104.81* 69.48* 17.14* 24.01* 11.80* 125.67* Timea 3-mo postsurgery 4.43* 0.12 1.39 2.20* 7.66* 10.27* 4.26* 2.38* 1.74* 19.60* 6-mo postsurgery 9.64* 3.58* 5.22* 3.04* 21.66* 13.23* 4.89* 6.23* 2.18* 27.61* Gendera Female 0.86 0.18 2.03 0.67 2.43 1.85 0.71* 0.82 0.40 3.89* 0.5 Age 0.13 0.01 0.03 0.01 0.11 0.05 0.02 0.03* 0.01 0.12

Reason for surgerya

Cholelithiasis combined with acute cholecystitis d d d d d 5.58 1.81* 2.64* 1.61* 12.10* CCI d d d d d 0.55 0.40* 0.24 0.15 1.38 Type of admissiona Emergency 4.00 0.16 1.53 0.34 5.91 d d d d d Complicationsa 1 d d d d d 4.30* 1.93 1.07 0.56 8.10*

Average length of stay (d) 0.15 0.04 0.26 0.16 0.36 d d d d d

Anesthesia risk classification 0.01 0.01 0.01 0.01 0.01 d d d d d

Preoperative health status (GIQLI score)

63.11* 14.92* 17.89* 13.39* 110.74* 58.17* 13.21* 18.17* 8.83* 100.92*

a Reference group: preoperative, male, symptomatic cholelithiasis, clinics, with no complication. *A p value<0.05.

CCIZ Charlson comorbidity index; GIQLI Z gastrointestinal quality of life index; HRQOL Z health-related quality of life; LC Z laparoscopic cholecystectomy; OC Z open cholecystectomy.

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Table 5 Multivariate regression analysis: factors affecting postoperative QOL in patients receiving OC and LC (SF-36) Variables OC LC PF coefficient RP coefficient RE coefficient SF coefficient BP coefficient VT coefficient MH coefficient GH coefficient PF coefficient RP coefficient RE coefficient SF coefficient BP coefficient VT coefficient MH coefficient GH coefficient Intercept 108.45* 75.99* 122.34* 83.31* 47.77* 63.71* 83.06* 33.49* 99.05* 71.53* 67.99* 83.23* 63.41* 55.99* 64.95* 54.54* Timea 3-mo postsurgery 4.99* 0.23 11.71 7.09 32.71* 5.43 9.31* 9.72* 14.75* 31.33* 33.74* 13.42* 26.64* 9.91* 9.58* 6.54* 6-mo postsurgery 8.27* 33.35* 23.56* 5.41 40.56* 14.86* 7.49* 10.53* 19.87* 36.32* 38.80* 17.42* 35.95* 11.25* 12.47* 13.38* Gendera Female 0.47 0.22 14.72 3.21 1.01 2.07 7.61 5.95 5.45* 9.14* 7.55* 5.72 3.19* 1.74 3.63* 5.02* Age 0.23* 0.13 0.38 0.13 0.19 0.05 0.09 0.44* 0.25* 0.02 0.06 0.02 0.09 0.12 0.09 0.07

Previous abdominal surgerya

No d d d d d d d d 0.60 0.01 1.53 4.78* 1.52 3.16 1.29 3.61 Reason for surgerya d d d d d d d d Cholelithiasis combined with acute cholecystitis d d d d d d d d 4.69* 2.41 2.37 1.38 0.63 2.03 4.55* 1.10 BMI 0.01 0.02 0.04* 0.04* 0.02 0.01 0.01 0.01 d d d d d d d d Educationa Primary 3.18 5.17 10.74 2.01 10.15 5.35 5.47 7.72 d d d d d d d d Junior high 1.15 2.89 1.69 0.39 5.14 4.25 4.10 5.89 d d d d d d d d Senior high 1.97 1.37 0.75 7.37 9.09 16.10* 7.94 27.08* d d d d d d d d College and above 5.61 20.83 21.94* 6.48 3.07 4.71 4.96 19.35* d d d d d d d d Illness duration d d d d d d d d 0.04 0.04 0.09* 0.05* 0.03 0.04 0.08* 0.03 CCI 0.25 2.73 0.75 0.36 2.51 1.04 0.67 3.85* 0.35 1.12* 0.38 0.37 0.84 0.16 0.57 1.16* Rehospitalization in 30 da No d d d d d d d d 2.66 4.68 4.26 8.65* 5.37 10.48* 11.07* 7.97 Average length of stay (d) 0.74* 1.14 0.97 0.23 0.04 0.01 0.20 1.42* 0.41 0.51 0.67 0.16* 0.06 0.09 0.29 0.01 Surgery duration d d d d d d d d 0.01 0.12* 0.08* 0.10 0.04* 0.02 0.07* 0.02 Preoperative health status (SF-36 score) 84.53* 57.61* 72.43* 89.14* 52.03* 64.47* 75.79* 57.45* 76.56* 56.37* 54.01* 74.61* 57.76* 56.31* 60.73* 59.60*

a Preoperative characteristics of reference group: male, with history of abdominal surgery, current symptomatic cholelithiasis, no formal education, with rehospitalization in 30 days. *A p value<0.05.

BMIZ body mass index; BP Z bodily pain; CCI Z Charlson comorbidity indexGH Z general health; LC Z laparoscopic cholecystectomy; MH Z mental health; OC Z open cholecystectomy; PFZ physical function; QOL Z quality of life; RE Z role emotional; RP Z role physical; SF Z social function; SF-36 Z Short-From 36 Health Survey; VT Z vitality.

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6 months (p< 0.05). After controlling for related variables, HRQOL revealed a significant and negative association with female gender, current cholelithiasis combined with acute cholecystitis, and any current complication. Additionally, preoperative health status was significantly and positively associated with each subscale of the GIQLI throughout the 6 months (p< 0.05). Table 5 shows the results. Each time point was significantly related to the SF-36 subscales throughout the 6 months (p< 0.05). Female gender; advanced age; current cholelithiasis combined with acute cholecystitis; education level lower than junior high school; rehospitalization within 30 days; and high values for BMI, CCI, ALOS, and surgery duration were significantly and negatively associated with HRQOL. Additionally, preopera-tive health status was significantly and posipreopera-tively associated with each subscale of the SF-36 throughout the 6 months (p< 0.05).

Discussion

Comparison of HRQOL improvements between different time points indicated that the GIQLI and SF-36 scores for LC patients were significantly improved by 6 months post-surgery. The improvement in LC patients after 6 months was also much larger than that in OC patients after 6 months, which is consistent with the literatures[11e13]. At 3 months postsurgery, the ES for all GIQLI dimensions correlated negatively with improvements in OC patients, which suggests that their health status was relatively poorer than that at baseline. Possible explanations for the relatively poorer health status of the OC patients include their relatively older average age, the larger percentage of males, the larger percentage of patients with only primary school education level, and the larger average wound size

[11e13]. The older average age of the OC patients (61.47

years vs. 53.27 years in LC patients) correlated with slower recovery from surgery, which is consistent with reports that age is a significant factor in HRQOL[7,11e13].

The baseline scores for the disease-specific measure (GIQLI) were lower in LC patients than in OC patients. The average total scores for LC patients were higher than those of OC patients at 3 months postsurgery, indicating that LC improvement in general gastrointestinal function is faster in LC patients than in OC patients. Pain relief and symptom improvement may also improve bodily function and emotional function, which may in turn improve social function[7,12].

Unlike previous reports[11e14], the average duration of illness in LC patients (14.45 months) was longer than that in OC patients (5.33 months). Duration of gall bladder disease is also reportedly shorter after LC than after OC. The data in this study suggest that gall bladder disease, which is often accompanied by abdominal pain, is easily mis-diagnosed as stomach disease, which delays treatment time. Another possibility is that the poorer health status of females compared with males causes a cognitive discrep-ancy in these patients[15,16].

ALOS (9.43 days) for the OC patients in this study was also longer than that reported in the literature[17]. Car-bonell et al.[17]found that, compared with females, males have a longer ALOS (6.6 days) after OC; Steven et al.[18]

reported a 7.4-day ALOS after OC whereas Rosenmu¨ller et al.[19]reported a 7.9-day ALOS after OC. Differences in national health conditions may explain the discrepancy. An earlier Taiwan study of cholecystectomy patients reported that percutaneous transhepatic gallbladder drainage may be a major cause of increased ALOS [20]. A longer pre-operation hospital day may also increase ALOS. A final possibility is that ALOS is longer in Taiwan populations than in Western populations because of different treatment protocols or cultural differences.

Although all research questions were satisfactorily addressed, one limitation should be noted. Prospective data were collected for a cohort in which the earliest patients were enrolled in 2007. Therefore, varying follow-up periods may have caused selection bias. Nonetheless, HRQOL did not significantly differ between patients who did and did not complete the entire 6-month study (data not shown). Additionally, without analyzing long-term HRQOL, it is unclear whether short-term benefits yield improved long-term outcomes. Previous studies indicate that sustained evaluations exceeding 1 year[21,22]are needed to accu-rately appraise patients who receive cholecystectomy.

The HRQOL improvement was generally larger in LC patients than in OC patients at 3 months postsurgery, but both groups had significantly improved by 6 months postsurgery. In conclusion, factors other than surgical outcome should be considered when evaluating post-cholecystectomy quality of life. All the significant factors identified in this study can be addressed in preoperative consultations to educate cholecystectomy candidates regarding the expected course of recovery and functional outcomes. Medical professionals and families of patients must also be advised that the HRQOL improvement for patients who receive such surgeries is determined not only by the clinical characteristics of the patient and by the quality of healthcare received but also by preopera-tive health status. Patients should be advised that post-operative HRQOL depends on prepost-operative functional status and demographic profile.

References

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數據

Table 1 Demographic and clinical characteristics of participants
Table 2 HRQOL before and after cholecystectomy (mean  SD)
Table 3 compares the HRQOL improvement between OC
Table 4 Multivariate regression analysis: factors affecting postoperative HRQOL of patients receiving OC and LC (GIQLI) Variables OC LC Symptom coefficient Emotion coefficient Physical coefficient Social coefficient Total coefficient Symptom coefficient Em
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參考文獻

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