Comparison of quality of life in postoperative patients with cholecystolithiasis and choledocholithiasis. The difference between open and laparoscopic treatment

Gallstone disease is quite common in the adult population and can quickly cause lifethreatening conditions that require extensive surgical treatment. In recent years, the assessment of quality of life is becoming increasingly important in world medicine as an indicator of the general condition of the patient and the effectiveness of treatment and rehabilitation measures. The aim of this work to collect and calculate indicators of quality of life in postoperative patients with gallstones of gall bladder and common bile duct; to compare data from patients with open and laparoscopic treatment; to determine the advantages of the treatment methods. For rating quality of life 36-Item Short-Form Health Status (SF-36) was used. The statistic was collected using retrospective analysis of worked out data in laparoscopic surgery unit in Volynian regional state hospital during 2016-2019 (191 patients). Patients of group I (113 patients) underwent laparoscopic treatment, patients of group II used open surgical treatment (78 people). Statistical processing was performed using the program "Statistica 6.0" (Statsoft Inc., USA). In group I pain level in first two hours was significantly lower than in group II (6.2 vs 8.4 in 10 point scale), in addition, pain relief became faster reaching low pain level of abdomen in 2.48 days. In group II pain level was higher (8.4 points) and pain relief was reached in 5.11 days. Oral nutrition and verticalisation were renewed in 14.7±3.1 hours in group I, and in 22.9±5,5 hours in group II and 6.1±1,9 hours in group I vs 19.7±3,3 hours in group II. Also, according the results SF-36, quality of life indicators indicate faster recovery in the group of laparoscopic treatment compared to the group with the classic version of the operation. The physical functioning and physical performance of the role differed significantly in favor of laparoscopic treatment throughout the follow-up period. Pain indicators in the first group were satisfactory after 1 month of rehabilitation, while in the second group such indicators were achieved only after 6 months 91/94/94 vs. 74/89/94. Although psychological well-being differed between 1 and 3 months, in favor of minimally invasive treatment, after 6 months the data were comparable in both groups.


Introduction
In recent years, the assessment of quality of life is becoming increasingly important in world medical practice as an indicator of the general condition of the patient, the effectiveness of treatment and rehabilitation measures, and is used as a prognostic criterion for disease resolution [3].
As early as 1948, the WHO defined health not only as the absence of disease, but also as the presence of physical, psychological and social well-being [18]. Since then, medical practice has increasingly begun to pay attention to quality of life.
Gallstone disease is quite common in the adult population of Western countries, due to the specifics of lifestyle, nutrition [18]. The most common manifestation is cholecystolithiasis. According to various data, it affects 30 % of the adult population [18]. Choledocholithiasis is also a frequent complication of cholecystolithiasis [2]. Choledocholithiasis itself can cause serious complications, such as biliary pancreatitis, gallbladder, mechanical jaundice, which is quite life-threatening [16]. Disruption of the bile duct can quickly cause life-threatening conditions that will require extensive surgical treatment [8]. One of the most formidable complications is acute pancreatitis, which in 35 % of cases is caused by a violation of the passage of bile [11,17]. That is why the study of surgical treatment of this pathology is relevant.
This article presents a comparative assessment of the simultaneous treatment of gallstone disease (GD), namely open cholecystectomy with choledocholithotomy and laparoscopic cholecystectomy with laparoscopic choledocholithotomy.
The purpose of the work -to determine the quality of life in postoperative patients with gallstones and common bile duct in 1, 3 and 6 months after surgery; to compare time indicators of verticalization, reduction of a pain syndrome, restoration of oral food, time of hospitalization at patients; identify the benefits of the methods.

Materials and methods
Strategies were evaluated by determining and comparing the postoperative period in patients who underwent surgical treatment, namely by assessing the time of hospitalization, time of verticalization and recovery of oral nutrition as important indicators for assessing the postoperative condition of patients [10] who underwent laparoscopic and open surgery, and also levels of quality of life. The main tool for numerical determination of quality of life is a questionnaire. In our work, we used the SF-36 questionnaire, as we believe it is effective for assessing the quality of life of patients after surgery [7], with its help you can quickly and accurately determine the quality of life and obtain this indicator through numerical expression. Also, the questionnaire is easy to understand and interpret for patients themselves, which is also important enough to form a true statistical base. SF-36 has 36 questions that form 8 scales (PF -physical component, RP -the ability to physically perform a social role, BP -pain, GH -general condition, VT -vital activity, SF -social functioning, RE -the ability to emotionally perform social role, MH -mental health). The higher the score on the SF36 questionnaire scale, the better the quality of life. Testing took place after 1, 3 and 6 months with prior voluntary consent. Statistical analysis included descriptive statistics and assessment of differences. The obtained data were checked, processed and analyzed using a computer program. Statistical processing was performed using the program "Statistica 6.0" (Statsoft Inc., USA).
To develop the statistical base, we developed case histories of patients operated in the department of invasive methods of diagnosis and treatment of Volyn Regional Clinical Hospital ( The latter point to the critical importance of rapid recovery of oral nutrition and self-verticalization of postoperative patients, to reduce the level of postoperative complications, as well as to improve the quality of care [10]. In both groups the number of concomitant pathologies was comparable, but did not differ from that expected in surgical patients [5], on average -2 (most often it is gastroesophageal reflux disease -38 people (19.9 %), erosive gastritis -52 people (27.2 %), hypertension -101 people (52.9 %)).

Results
The analysis of the results of the obtained data showed that the pain syndrome in patients of group I was present only in the first 2 days (average 2.48 days), and on the second day after surgery it was observed only during active movement. In the first 2 hours, the pain, assessed by patients on points from 1 to 10, averaged 6.2 points, after 48 hours -2.8. In group II, the pain lasted from 4 to 7 days (average 5.11 days), in the first two hours the pain rating was 8.4, after 48 hours -5.3 points. Independent getting up of patients in the first group was possible in 6.1±1.9 hours, in the second group -in 19.7±3.3 hours after the operation is completed.
Oral nutrition was resumed in patients of the first group after 14.7±3.1 hours, in the second group -after 22.9±5.5 hours after the operation is completed. The average quality of life of the operated patients is shown in

Discussion
The World Community for Enhanced Recovery After Surgery (ERAS) recommends in all its recommendations to prefer minimally invasive interventions, especially in general surgery, where laparoscopy has developed the most [14]. Endocrine-metabolic stress resulting from tissue damage slows recovery [15]. The greater the damage, the longer the operation, the more interleukin-6 is released, the more stress develops in response [5]. A larger incision causes more pain and prevents early verticalization, which is a very important factor in the patient's recovery, return to normal functioning and reduction of postoperative complications [12]. Also, the restoration of oral nutrition minimizes the effect of stress diabetes, which is a leading factor in the healing of surgical wounds, the development of infectious postoperative complications [1,19]. The results of the study suggest a more appropriate use of laparoscopic simultaneous techniques for the treatment of cholecystolithiasis in combination with choledocholithiasis. It is clear that to perform such operations, in comparison with the open method of treatment, it is necessary to provide the doctor with additional equipment, and the specialist must have the appropriate qualifications and surgical skills. But less trauma to the patient significantly affects the rehabilitation and postoperative period not only during hospitalization, but also 6 months after discharge [13], which is an important indicator of the effectiveness of the method [6]. The difference between the level of pain and the time during which the patient can eat and get out of bed, ie self-care, significantly affects not only the physical but also the psychological state of the patient. These indicators differ favorably in the group of laparoscopic treatment, compared with open. The use of minimally invasive methods is also recommended by the ERAS community as one of the main factors influencing the patient's recovery and recovery, hospital stay and economic feasibility.
After open surgery, rehabilitation of patients is slower than after laparoscopic, sometimes it is not possible to restore functional activity of the patient after six months of rehabilitation. Estimates of indicators such as pain or physical functioning differ significantly not only in the short term, but also in 6 months, although the difference becomes less critical over time. Although the pain component did not differ in both groups, the physical role and the physical component in the open surgery group recovered less. According to the SF-36 quality of life questionnaire, the data indicate not only better physical performance, but also a much better mental health status in patients who were treated minimally invasively. This is due to the absence of severe pain and exhaustion after major surgery, and the absence of a cosmetic defect contributes to a psychologically easier perception of small accesses over a large incision, as well as faster rehabilitation with recovery, which helps patients realize their recovery.
The technique of simultaneous laparoscopic interventions has many opportunities for development, because comorbidity in surgical patients is not uncommon. The most common combinations of surgical pathologies within the abdominal cavity are cholecystolithiasis and diaphragmatic esophageal hernia, cholecystolithiasis and inguinal hernia, cholecystolithiasis and liver tumors, cholecystolithiasis and kidney tumors [12]. Therefore, the implementation of simultaneous surgical treatment for these groups of patients is promising.