Osteopathic Manipulative Treatment for a Recognizable Pattern of Somatic Dysfunction Following Laparoscopic Cholecystectomy

Methods

The Metro Health-University of Michigan Health Institutional Review Board (IRB) reviewed the protocol for this study and determined it to be a quality improvement project. Approval for the study was granted. Based on the IRB exemption, no consent was indicated or required.

We retrospectively reviewed billing records for patients older than 18 years who underwent laparoscopic cholecystectomy with a single osteopathic general surgeon (K.S.) between 2006 and 2018 at a community hospital in Grand Rapids, Michigan; 981 records were found. After searching those records for subsequent OMT by the same surgeon (K.S.), 22 patients remained. Patients who underwent open cholecystectomy, who did not have documented somatic dysfunction, or who had OMT for an unrelated disease (ie, extremity strain) were excluded. No prisoners, pregnant women, or children were evaluated in the study. After preliminary review of de-identified patient charts and application of exclusion criteria, 9 cases were selected for this case series.

Chart review was performed by the attending physician (K.S.) and 2 resident physicians in the Metro Health system. Patient demographics and diagnoses are presented in Table 1. OMT used in the treatment of somatic dysfunction included high-velocity, low-amplitude (HVLA), muscle energy, and myofascial techniques.

Results

The 9 patients evaluated in this series represented approximately 1% of all patients treated with laparoscopic cholecystectomy by the attending surgeon. All patients had a documented diagnosis of somatic dysfunction postoperatively and had documented treatment with OMT. Of the 9 patients evaluated, all were women with a mean age of 33.3 years (range, 25 to 53 years). Each patient demonstrated similar somatic disease, with all 9 patients (100%) reporting pain in the right upper quadrant. Eight of 9 patients (89%) exhibited a rib or a thoracic spine dysfunction; 1 had lumbar dysfunction. Examination findings in the reviewed cases demonstrated posterior lower rib involvement and rotated right/sidebent left thoracic spine dysfunctions between T5 and T11. In addition to pain, 7 patients (77%) had nausea, 3 (33%) had vomiting, 2 (22%) had bloating, 3 (33%) had stool changes, 3 (33%) had food intolerance, and 1 (11%) had acid reflux.

All patients who demonstrated somatic dysfunction at their postoperative appointment were treated with OMT: 4 patients with HVLA alone, 3 patients with muscle energy alone, 1 with muscle energy and myofascial release, and 1 with a combination of muscle energy, HVLA, facilitated positional release (FPR), and articulatory techniques. The technique selected was dependent on patient tolerance and physician preference.

Eight patients (88%) verbally reported symptom improvement following treatment with OMT. One patient was treated by the attending physician without significant relief and was referred for a gastroenterology evaluation of persistent symptoms. Three additional patients without full relief of pain (despite reporting improvement in somatic dysfunction) were referred to an OMT specialist clinic for recurrent dysfunction following initial treatment. One patient initially reported partial relief of symptoms after OMT but was treated with additional supportive care and stretching exercises without specialist referral. Table 2 shows a summary of case findings, treatment, and results.

The patients in the case series who reported immediate symptomatic relief following OMT were not scheduled for follow-up because their symptoms had resolved. The patient who reported partial relief of symptoms initially after OMT but was treated additionally with supportive care and stretching exercises without specialist referral reported improvement in symptoms, as confirmed during a short-term follow up appointment. Long-term pain relief for patients who were referred to OMT or gastroenterology specialists is unknown, as this group did not follow up with the surgeon after these referrals. All patients were instructed to follow-up as needed with the operating surgeon. No complications or adverse events were noted following application of OMT.

Discussion

Postoperative pain is an important subject because of the significant effect it has on patients’ health, finances, and psychological states. Careful history and physical examination must be performed when evaluating someone with persistent postoperative pain to rule out serious complications such as biliary obstruction, bile leak, common bile duct injury, and bleeding. Additional testing should be ordered as clinically warranted. Once urgent diseases have been ruled out, care must be taken to identify other sources of postoperative pain to target treatment.

The patients in our retrospective series exhibited similar patterns of somatic dysfunction on their right sides, particularly in the thoracic vertebrae. The sympathetic viscerosomatic reflex of the liver and biliary tree is associated with T5-10 on the right and with the gallbladder at T6 on the right. The Chapman point for the gallbladder is underlying anterior right 6^th rib.¹⁷ While some of the somatic dysfunctions documented in the cases are consistent with a viscerosomatic response, there were additional findings that could indicate alternative causes—specifically in the patient with lumbar somatic dysfunction. Postoperative pain can result from a variety of factors, including incisional pain, nerve injury or entrapment, pneumoperitoneum, intraoperative positioning, tissue manipulation, and metabolic changes, among others. Any of these can lead to physiologic derangements and anatomic or postural changes to compensate for acute pain. Preoperative pain from biliary disease, pain from surgery, and decreased postoperative mobility and respiratory excursion can also contribute to somatic dysfunction. Early recognition and timely treatment can increase mobility, recover respiratory excursion, and improve quality of life in addition to decreasing the duration of analgesic use and risk of chronic pain.^1,18,19 Due to the acute nature of the pain, the dysfunctions identified in this series responded well to HVLA. If a postoperative patient is unable to tolerate HVLA, muscle energy, and myofascial techniques are an acceptable alternative. Four patients in our study were unable to tolerate HVLA and were instead treated with the muscle energy technique.

Limitations to our retrospective case series include the low number of patients and the fact that all patients were treated in a single hospital system by a single provider. As mentioned previously, only 1% to 2% of patients who had laparoscopic cholecystectomies by the surgeon underwent OMT in this review. This may be in part due to low prevalence of somatic dysfunction, but it may also reflect underdiagnosis of somatic dysfunction in this patient population. These conjectures would be good topics for future studies.

An additional limitation was that there were no men who fit the inclusion criteria for the series. This may indicate higher incidence of somatic dysfunction in female patients; however, with low statistical power, this cannot be inferred from our data without additional investigation. Gallbladder disease is also more common in women, which may at least partially explain the absence of men in our sample. Retrospective analysis can also be subject to researcher bias and objective differences in examination or treatment compared with other osteopathic physicians. However, this study was designed to assist in developing preliminary data to identify common patterns of somatic dysfunction in laparoscopic cholecystectomy patients with persistent pain. The next step is to develop a prospective study with preoperative screening of a group of laparoscopic cholecystectomy patients to establish a baseline of somatic dysfunction. Patients will then be examined postoperatively to see whether and how their somatic dysfunction might have changed.

Conclusion

While somatic dysfunction is not a leading cause of persistent postoperative pain following laparoscopic cholecystectomy, it is an easily manageable cause. This retrospective case series documenting postoperative pain treatment with OMT serves to encourage surgeons to include this etiology in the differential diagnosis and initiate timely management. Early treatment of reversible causes of pain particularly in the acute setting can decrease pain, lead to earlier return of baseline function, and improve quality of life.

Author Contributions

All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.