Assessing the Impact of Laparoscopic Cholecystectomy on Satisfaction, Quality of Life, and Cost-Effectiveness in Saudi Patients With Gallstone Disease: A Comprehensive Cross-Sectional Analysis

Introduction: Cholelithiasis, or gallstone disease, is a prevalent medical condition with substantial global implications. Laparoscopic cholecystectomy (LC) has become the dominant surgical solution for treating various biliary conditions in affluent countries due to its numerous benefits, such as shorter hospital stays and reduced costs. An assessment of postoperative recovery, patient satisfaction, and quality of life (QoL) is crucial to judge the success of any medical procedure regarding long-term patient well-being. Given the scarcity of research on the satisfaction, QoL, and cost-effectiveness of LC among Saudi patients, this study seeks to fill this gap. Methods: To achieve the study's objectives, a cross-sectional research study was conducted from January to December 2023, focusing on Saudi patients who had received LC for gallstone disease. We utilized an extensive questionnaire to determine patient satisfaction, QoL, and the perceived value of LC, which combined closed and open-ended questions to provide a holistic understanding. Additionally, an in-depth literature review was performed to compare our findings with existing research. Results: Our survey received answers from 886 Saudi LC patients. Generally, participants showed satisfaction with LC, though complications were reported in a significant number of cases. However, a minority of participants were dissatisfied. Most respondents indicated a moderate enhancement in their QoL postsurgery. Notably, demographic factors like gender, age, and employment status had profound effects on satisfaction and QoL, with male participants more likely to report higher satisfaction and QoL than females. Conclusion: Our data firmly support the ongoing use of LC as the preferred surgical technique for treating biliary diseases in Saudi Arabia. They emphasize the benefits of personalizing care based on patient demographics to improve the overall experience. Proper communication, thorough preoperative planning, and attentive postoperative care are essential for achieving the best outcomes. Despite these findings, more research is needed, focusing on different patient demographics and comparing LC with other treatment methods to enhance our understanding of gallstone disease management in the Saudi context.


Introduction
Gallstone disease, or cholelithiasis, covers a variety of conditions, such as asymptomatic cholelithiasis, biliary colic, and complicated gallstones like empyema gallbladder, gangrene, and even peritonitis [1].The inflammation of the gallbladder, cholecystitis, stands as the primary reason for right upper quadrant (RUQ) pain, leading it to be one of the foremost causes for emergency surgical admissions [2].With the evolution of medical procedures, laparoscopic cholecystectomy (LC), a minimally invasive surgery for removing a diseased gallbladder, has overtaken the traditional open technique since the early 1990s [3].This procedure is now the first choice for a range of conditions, from symptomatic cholelithiasis and chronic cholecystitis to more serious conditions like gallstone pancreatitis [4].In high-income countries, LC's dominance is evident due to the numerous benefits it offers [5], such as reduced hospital stays, quicker recovery, and cost savings [6].With an impressively low mortality rate of 0.22-0.4%,its safety is largely affirmed [7].A vital area of focus in medical research nowadays is the health-related quality of life (HRQoL).While its definition might remain broad, encompassing physical, emotional, and social dimensions, its relevance has surged, especially when assessing medical interventions [8].The outcomes as reported by patients, including pain and quality of life (QoL), become pivotal for a surgeon when considering a procedure [9].Notably, the gastrointestinal quality of life index (GIQLI) is frequently employed to measure QoL for biliary tract diseases, indicating an improvement in gastrointestinal symptoms post-LC [10].
In the context of Saudi patients, we posit two hypotheses.First, we anticipate that those undergoing LC will exhibit greater satisfaction compared to patients subjected to other treatments.Additionally, LC is expected to bring about a marked enhancement in the QoL of these patients vis-à-vis alternative treatment modalities.To validate these hypotheses, we will employ a slew of statistical techniques, from correlation and regression analysis to the chi-square test.
Guided by the above, the core objectives of this study center around gauging patient satisfaction post-LC for gallstone disease, understanding its impact on Saudi patients' QoL, and weighing its cost-effectiveness relative to other treatment options.

Study location
The research was conducted in Saudi Arabia, specifically in areas known for high gallstone disease incidence and frequent LC interventions.

Study design and duration
A cross-sectional approach was adopted from the first of January to the 15th of August 2023.Data were primarily gathered via questionnaires distributed to Saudi patients who had experienced LC due to gallstone disease.

Participants
The subjects of interest were Saudi patients who had received LC across various hospitals in Saudi Arabia.

Sample size and selection
A power analysis determined the necessary sample size, factoring in a 95% confidence level and a 5% margin of error.Through convenience sampling, patients were selected based on their availability and consent to participate.

Inclusion criteria
Saudi patients, aged 18 and above, who had previously undergone LC for gallstone disease were included.

Exclusion criteria
Those who underwent open cholecystectomy, declined participation, or could not provide informed consent were omitted.

Data gathering instruments
A standardized questionnaire was the principal tool, aimed at assessing patient satisfaction, QoL postprocedure, and perceived cost-effectiveness of LC.This questionnaire incorporated both open-ended and closed questions for an exhaustive grasp of the patients' views.

Independent Variables
Variables such as age, gender, educational attainment, and employment status were deemed independent.

Dependent Variables
Key outcomes included patient satisfaction, postoperative QoL, and perceived cost-effectiveness.

Preliminary study
To evaluate the reliability and validity of the questionnaire, a pilot study with 30 participants was conducted.For validity, feedback from participants prompted minor adjustments to enhance clarity and organization of some questions.
For reliability, we assessed the internal consistency of the 'Satisfaction' and 'Quality of Life' sections using Cronbach's alpha.The results, as illustrated in    The outcomes suggest that our questionnaire exhibits both satisfactory validity and reliability.

Constraints
This study faced potential limitations, such as the possibility of biased self-reported data.Due to the specific sampling technique and regional emphasis, results may not represent the entire Saudi patient population.

Data analysis
IBM SPSS Statistics for Windows, Version 28 (Released 2021; IBM Corp., Armonk, New York, United States) facilitated the analysis.Descriptive statistics, like frequencies and percentages, portrayed the demographics of the 886 respondents.Age, gender, educational background, employment status, and regional data were analyzed.Quantitative responses on satisfaction and postsurgery QoL were articulated using means and standard deviations.Inferential statistics, especially logistic regression models, probed the connection between demographic attributes and central outcomes.The questionnaire's reliability was confirmed by computing the Cronbach's alpha for the Satisfaction and Quality of Life portions, thus guaranteeing internal consistency.

Results
Among 886 participants in

General information regarding LC
Table 3 shows that participants' overall satisfaction with the procedure was quite favorable, with 61.6% reporting satisfaction and an additional 25.4% being very satisfied.However, a minority expressed dissatisfaction (2.3%).Complications or adverse effects were experienced by 39.5% of participants.Notably, 64.4% did not experience recurrence of gallstone-related symptoms after the procedure.Table 4 displays participants rated their overall satisfaction with the communication between them and the surgical team before the procedure, with a mean score of 4.12 (SD = 1.2) indicating a very high satisfaction of the procedure.The clarity of instructions provided for postoperative care was rated as 3.88 (SD = 0.983).Satisfaction with nursing care during the hospital stay was reported as 3.57 (SD = 1.049).Importantly, the majority of participants would recommend LC to others based on their personal experience (mean = 3.79, SD = 0.954).

TABLE 5: Satisfaction scale
This table outlines participants' ratings on various aspects related to their experience with laparoscopic cholecystectomy.

Factors influencing satisfaction
Tables 6, 7 demonstrate that gender (p = 0.01), age (p = 0.008), education level (p < 0.001), employment status (p = 0.001), and city of residence (p = 0.031) were found to significantly influence overall satisfaction levels.Notably, male participants had higher odds of being satisfied compared to females (OR = 1.24, 95% CI = 1.20 -1.91).Participants with a master's degree had significantly lower odds of being satisfied compared to those with a high school or lower education (OR = 1.30, 95% CI = 0.42 -1.88).Employment status also played a significant role, with employed full-time participants having lower odds of satisfaction compared to other employment categories (OR = 0.30, 95% CI = 0.42 -0.88).

TABLE 7: Factors influencing satisfaction
This table presents the association between demographic factors (gender, age, education level, employment status, city of residence) and overall satisfaction with the laparoscopic cholecystectomy procedure.The chi-square test was used to explore the statistical significance of potential comparisons according to the level of satisfaction, a p-value less than 0.05 is significant.

Self-reported QoL after the procedure
Table 8 shows the overall physical well-being after the procedure received a mean score of 3.92 (SD = 0.974).
The majority reported moderate improvement (62.1%) and significant improvement (27.7%) in their quality of life.Satisfaction with the ability to engage in physical activities was generally high (mean = 4.00, SD = 1.000).

TABLE 8: Logistic regression model of factors influencing the overall satisfaction level
This table shows the odds ratios and confidence intervals for the logistic regression model exploring the impact of demographic factors on overall satisfaction with the laparoscopic cholecystectomy procedure.

Factors influencing QoL
Tables 9-11 show that gender (p = 0.04), age (p <0.001), education level (p < 0.001), employment status (p = 0.001), and city of residence (p <0.001) were found to significantly influence overall satisfaction levels.Gender (p < 0.001), education level (p < 0.001), employment status (p < 0.001), and city of residence (p < 0.001) were found to significantly influence self-reported QoL.Male participants had higher odds of reporting a higher quality of life compared to females (OR = 1.54, 95% CI = 1.20 -1.98).Participants with a master's degree had significantly higher odds of reporting a higher quality of life (OR = 0.60, 95% CI = 0.42 -0.85).This table presents the odds ratios and confidence intervals for the logistic regression model investigating the impact of demographic factors on selfreported quality of life after the laparoscopic cholecystectomy procedure.

Discussion
The purpose of this cross-sectional study was to look into the QoL and satisfaction levels of Saudi patients who had LC for gallstone disease.The questionnaire, primarily divided into four sections, demographic information, general questions, satisfaction level, and quality of life, can be found in Table 12 present in the appendices.Our research findings substantially confirm the hypotheses that LC improves patients' QoL and satisfaction levels significantly more than alternative treatments.These findings are consistent with both international and regional literature, indicating that LC improves patients' QoL [6,8].Gallstone disease is one of the most common medical issues, with different degrees of severity and complications.LC, a minimally invasive surgical operation that removes the damaged gallbladder, is the standard treatment for symptomatic cholelithiasis and chronic cholecystitis, offering advantages such as a reduced hospital length of stay and lower perioperative morbidity and mortality.However, little evidence has been reported on postoperative changes in QoL following LC.To test these hypotheses, appropriate statistical methods, including correlation analysis, and Chi-square test, were utilized.
Interestingly, the study discovered no significant relationship between patients' age and their evaluation of postsurgery QoL.This finding contrasts with previous research that showed older age was related to worse results from surgery [7].
It is worth noting that the Middle East results indicate a female majority in the patient distribution undergoing LC.However, our study found no significant gender differences in postsurgery satisfaction.
Although a previous study has suggested that women may have more severe QoL and gallstone symptoms and recover more slowly than men [8], our data suggest that gender has no effect on reported QoL after LC.
Our review of Saudi Arabian data revealed a need for more comprehensive and localized research on LC's cost-effectiveness.While early laparoscopic cholecystectomy appears to be more cost-effective than delayed laparoscopic cholecystectomy in high-income countries, there is a gap in the literature regarding other economies, including Saudi Arabia [9].Such research could provide valuable insights for health policy and planning and management.
The findings of the study highlight the importance of patient-reported outcomes in evaluating surgical treatments.While standard measurements of outcomes like mortality and complication rates provide important information regarding the safety and efficacy of surgery, patient-reported outcomes can shed information on the procedure's effect on patients' everyday lives and general well-being.
Furthermore, our findings indicate that the minimally invasive procedure of cholecystectomy, particularly LC, should stay the primary line of surgical care in Saudi Arabia for simple and complex biliary diseases.This is because it is associated with a shorter hospital stay, decreased perioperative morbidity and mortality, a faster return to work, and lower total hospital costs [10].
In conclusion, while this study provides useful insights into the QoL after LC among Saudi patients, more research is needed to comprehensively investigate the experiences of different patient demographics and compare LC with alternative treatment options.To further optimize patient care, future research could look into the elements that affect the perceived QoL after surgery, such as physical, emotional, and social factors.

Conclusions
In conclusion, this cross-sectional study underscores the positive impact of LC on the QoL and satisfaction levels among Saudi patients with gallstone disease.Notably, while our findings concur with global and regional literature that LC enhances QoL, they also illuminate that factors such as age and gender may not significantly influence post-operative QoL perceptions in the Saudi context.Despite LC's evident benefits, such as reduced hospital stays and lower costs, there remains an evident gap in localized research concerning its cost-effectiveness in economies like Saudi Arabia.The results accentuate the value of patientreported outcomes, going beyond conventional metrics like mortality rates to understand a procedure's holistic influence on a patient's life.Looking forward, as LC continues to be the preferred surgical approach for biliary diseases in Saudi Arabia, further investigations are essential to delve deeper into various patient experiences and holistically evaluate LC against other treatments.The ultimate goal should be to continuously refine and enhance patient care by understanding the multifaceted factors affecting postsurgical QoL.

Appendices
Table 12 reflects the questionnaire used in this study.have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Section 1 :
Demographics 1. Age Under 18 | 18-24 | 25-34 | 35-44 | 45-54 | 55-64 | Above 65 2. Gender Male | Female 3. Education level High school or less | Diploma | Bachelor's degree | Master's degree | Doctorate or higher 4. Employment status Employed full-time | Employed part-time | Unemployed | Student | Retired | Other 5. City of residence Middle Province | Eastern Province | Northern Province | South Province | Western province | Others 6. Geographic location Urban | Suburban | Rural Section 2: General Questions How would you rate your overall satisfaction with the laparoscopic cholecystectomy procedure?Very Satisfied | Satisfied | Neutral | Dissatisfied | Very Dissatisfied Did you experience any complications or adverse effects?Yes | No How would you rate the improvement in your quality of life?Significant Improvement | Moderate Improvement | Slight Improvement | No Change | Decline Compared to your expectations, how would you rate the postoperative pain?Much Less Than Expected | Less Than Expected | As Expected | More Than Expected | Much More Than Expected Did you experience any limitations in daily activities?Yes | No 2023 Aleid et al.Cureus 15(9): e45288.DOI 10.7759/cureus.45288

TABLE 1 : Internal consistency of questionnaire sections
Ethical clearance was secured from pertinent local ethics committees.All participants were briefed on the study's objectives and offered informed consent.Ensuring anonymous responses upheld confidentiality.No conflicts of interest were detected in this study.

TABLE 2 : Demographic characteristics
This table provides an overview of the key demographic characteristics of the study participants, including age, gender, education level, employment status, and geographic distribution.

TABLE 3 : General information regarding laparoscopic cholecystectomy
This table presents participants' responses to general questions about their satisfaction with the laparoscopic cholecystectomy procedure, complications 2023 Aleid et al.Cureus 15(9): e45288.DOI 10.7759/cureus.452885 of 16 experienced, improvement in quality of life, postoperative pain, limitations in daily activities, and perceived financial burden.
How well were you informed about the potential risks and benefits of laparoscopic cholecystectomy before 2023 Aleid et al.Cureus 15(9): e45288.DOI 10.7759/cureus.452886 of 16 Did you have any pre-existing conditions that affected your recovery after laparoscopic cholecystectomy?

TABLE 4 : General information regarding laparoscopic cholecystectomy
This table presents participants' responses to general questions about their satisfaction with the laparoscopic cholecystectomy procedure, complications experienced, improvement in quality of life, postoperative pain, limitations in daily activities, and perceived financial burden.

Table 5
categorizes the participants' satisfaction levels.The majority of participants (63.6%) reported being very satisfied with the LC procedure, while 29.8% indicated being satisfied.A smaller proportion (9.5%) expressed not being satisfied.

TABLE 9 : Self-reported quality of life after the procedure
N Minimum Maximum Mean SDHow would you rate your overall physical well-being after laparoscopic cholecystectomy?This table displays participants' self-reported ratings on various aspects of their quality of life following the laparoscopic cholecystectomy.2023 Aleid et al.Cureus 15(9): e45288.DOI 10.7759/cureus.45288

TABLE 10 : Association between demographic characteristics and self-reported quality of life.
This table examines the relationship between demographic factors (gender, age, education level, employment status, city of residence) and self-reported quality of life after the laparoscopic cholecystectomy procedure.