How to predict difficult laparoscopic cholecystectomy? Proposal for a simple preoperative scoring system

Utilization of the modified Kama scoring system for predicting bail-out cholecystectomy: a valuable tool in the era of rising laparoscopic surgery prevalence

PURPOSE

Recently, bail-out cholecystectomy (BOC) during laparoscopic cholecystectomy to avoid severe complications, such as vasculobiliary injury, has become widely used and increased in prevalence. However, current predictive factors or scoring systems are insufficient. Therefore, in this study, we aimed to test the validity of existing scoring systems and determine a suitable cutoff value for predicting BOC.

METHODS

We retrospectively assessed 305 patients who underwent laparoscopic cholecystectomy and divided them into a total cholecystectomy group (n = 265) and a BOC group (n = 40). Preoperative and operative findings were collected, and cutoff values for the existing scoring systems (Kama's and Nassar's) were modified using a prospectively maintained database.

RESULTS

The BOC rate was 13% with no severe complications. A logistic regression analysis revealed that the Kama's score (odds ratio, 0.93; 95% confidence interval 0.91-0.96; P < 0.01) was an independent predictor of BOC. A cutoff value of 6.5 points gave an area under the curve of 0.81, with a sensitivity of 87% and a specificity of 67%.

CONCLUSIONS

Kama's difficulty scoring system with a modified cutoff value (6.5 points) is effective for predicting BOC.

Can Hemogram Parameters and Derived Ratios Predict Conversion From Laparoscopic to Open Cholecystectomy?

Backgrounds Laparoscopic cholecystectomy (LC) is the gold standard for surgical removal of gallbladder today. In challenging cholecystectomy cases, conversion to an open technique may be necessary. Therefore, the preoperative prediction of conversion to open technique holds significant importance for patient safety and surgical strategy. In the literature, conversion to open cholecystectomy has been associated with many contradictory predictive factors. The aim of this study is to identify and comprehensively evaluate the predictive laboratory parameters and ratios associated with the conversion from laparoscopic to open cholecystectomy. Methods In this historical cohort study, the data of patients who were scheduled for and underwent LC between January 1, 2018, and September 1, 2023, were retrospectively evaluated. The preoperative laboratory findings and surgical notes of the patients were reviewed retrospectively from the archives. The correlation between patient data and the cholecystectomy groups was analyzed, and comparisons were made between the groups. Results All 160 patients initially underwent a laparoscopic approach. In emergency cases, a statistically significant association was found between lymphocyte count (p = 0.017) and lymphocyte-to-monocyte ratio (LMR) (p = 0.041) with operations completed laparoscopically and between neutrophil-to-lymphocyte ratio (NLR) (p = 0.007) and Systemic Inflammatory Response Index (SIRI) (p = 0.031) with operations converted to open surgery. In elective cases, gamma-glutamyl transferase (GGT) (p = 0.024) and total bilirubin (TBIL) (p = 0.003) were found to have a statistically significant association with operations converted to open surgery. In the logistic regression analysis, hematological parameters and ratios were not found to have a statistically significant relationship in predicting the conversion to open surgery. Conclusion Although significant differences were observed in laboratory parameters and derived ratios such as the NLR and LMR, logistic regression analysis did not identify any of these measures as significant predictors of conversion from laparoscopic to open surgery. Further prospective studies with larger sample sizes are needed in this area.

Predicting Difficulty in Laparoscopic Cholecystectomies: An Evaluation of the Labbad-Vivas Score and Its Correlation With the Parkland Grading Scale

Background Difficult laparoscopic cholecystectomy (DLC) denotes the surgical extraction of the gallbladder under circumstances where associated conditions within the same organ, adjacent structures, or patient-specific conditions impede a smooth, expeditious, and comfortable dissection. It is imperative to utilize tools that aid in anticipating this challenging surgical scenario, enabling the implementation of appropriate measures. Objective This study aimed to assess the effectiveness of the Labbad-Vivas score (LVS) in predicting DLC and its correlation with the Parkland Grading Scale (PGS). Methodology A prospective study was conducted, including patients diagnosed with gallstone disease undergoing LC (laparoscopic cholecystectomy) at the "Dr. Luis Razetti" University Hospital in Barcelona, Venezuela, between September and December 2023. Results Forty patients were studied, with 80% (n=32) being female and 95% (n=38) under the age of 65; surgeries were elective in 72.5% (n=29) of cases; 35% (n=14) had an LVS ≥16 (difficult cholecystectomy); and 62.5% (n=25) of patients presented Grades 1 and 2 on the PGS. Total cholecystectomy was performed in 95% (n=38) of the patients. The LVS showed a sensitivity of 80%, specificity of 92%, positive predictive value of 85.7%, and negative predictive value of 88.5% to predict DLC, with an area under the receiver operating characteristic curve of 0.897 (95% confidence interval (CI) = 0.792-1.003). A Pearson correlation coefficient of 0.805 (95% CI = 0.656 - 0.904) was obtained between both scores. Conclusion The use of the LVS score in the preoperative setting is feasible as a predictor of DLC, given its effectiveness and high correlation with the PGS.

Predictive Factors for Difficult Laparoscopic Cholecystectomies in Acute Cholecystitis

Laparoscopic cholecystectomy (LC) is the gold standard treatment in acute cholecystitis. However, one in six cases is expected to be difficult due to intense inflammation and suspected adherence to and involvement of adjacent important structures, which may predispose patients to higher risk of vascular and biliary injuries. In this study, we aimed to identify the preoperative parameters with predictive value for surgical difficulties. A retrospective study of 255 patients with acute cholecystitis admitted in emergency was performed between 2019 and 2023. Patients in the difficult laparoscopic cholecystectomy (DLC) group experienced more complications compared to the normal LC group (33.3% vs. 15.3%, p < 0.001). Age (p = 0.009), male sex (p = 0.03), diabetes (p = 0.02), delayed presentation (p = 0.03), fever (p = 0.004), and a positive Murphy sign (p = 0.007) were more frequently encountered in the DLC group. Total leukocytes, neutrophils, and the neutrophil-to-lymphocyte ratio (NLR) were significantly higher in the DLC group (p < 0.001, p = 0.001, p = 0.001 respectively). The Tongyoo score (AUC ROC of 0.856) and a multivariate model based on serum fibrinogen, thickness of the gallbladder wall, and transverse diameter of the gallbladder (AUC ROC of 0.802) showed a superior predictive power when compared to independent parameters. The predictive factors for DLC should be assessed preoperatively to optimize the therapeutic decision.

Management of Intra-Abdominal Infections: The Role of Procalcitonin

Patients with intra-abdominal sepsis suffer from significant mortality and morbidity. The main pillars of treatment for intra-abdominal infections are (1) source control and (2) early delivery of antibiotics. Antibiotic therapy should be started as soon as possible. However, the duration of antibiotics remains a matter of debate. Prolonged antibiotic delivery can lead to increased microbial resistance and the development of nosocomial infections. There has been much research on biomarkers and their ability to aid the decision on when to stop antibiotics. Some of these biomarkers include interleukins, C-reactive protein (CRP) and procalcitonin (PCT). PCT's value as a biomarker has been a focus area of research in recent years. Most studies use either a cut-off value of 0.50 ng/mL or an >80% reduction in PCT levels to determine when to stop antibiotics. This paper performs a literature review and provides a synthesized up-to-date global overview on the value of PCT in managing intra-abdominal infections.

Defining Critical View of Safety During Laparoscopic Cholecystectomy: The Preoperative Predictors of Failure

Background Defining critical view of safety (CVS) is one of the most crucial steps during laparoscopic cholecystectomy (LC). This study aimed to determine the preoperative predictors of failure to achieve CVS during LC. Methods All patients undergoing LC from December 2020 to July 2022 were prospectively included. Results There were 180 females and 93 males. CVS was achieved during LC in 238 (87.2%) patients. Conversion to open surgery was performed for 11 patients. Bile leak occurred in three patients which resolved spontaneously. No patient developed bile duct injury. On univariate analysis, age, male sex, American Society of Anaesthesiologists (ASA) grading, Murphy's sign, emergency surgery, neutrophil percentage, lymphocyte percentage, gallbladder wall thickness > 3mm, and impacted gallstone on abdominal ultrasound were predictors of failure to achieve CVS. On multivariate analysis, neutrophil and lymphocyte percentages were independent predictors of failure to achieve CVS. Patients in whom CVS could not be achieved had significantly longer operative time, higher blood loss, complications, and hospital stays. Discussion Inability to achieve CVS during LC can be predicted preoperatively using various parameters including neutrophil and lymphocyte percentages. Such cases must be operated by senior surgeons or referred to experienced general or hepatobiliary surgeons for cholecystectomy to avoid bile duct injury. The proposed algorithm can help in intraoperative decision-making in difficult cases.

Intraoperative complexity and risk factors associated with conversion to open surgery during laparoscopic cholecystectomy in eight hospitals in Mexico City

BACKGROUND

The conversion to open surgery (COS) during the Laparoscopic Cholecystectomy (LC) is reported to occur at a rate of 10-15%. Some preoperative risk factors (RF) have been postulated; however, few studies have evaluated these factors and the intraoperative complexity with the COS rate. The aim of the study was to evaluate the preoperative RF and intraoperative complexity using the Parkland grading scale (PGS) with the COS rate in LC.

METHODS

A retrospective study was done evaluating the demographic and surgical variables from the patients and LC videos from 8 different hospitals of Mexico City from December 2018 to January 2020. The evaluation of the PGS was done by 2 surgeons (one MI and one HPB surgeon); the PGS was also categorized as Non-Complex LC (nCLC, PGS1-2) and Complex LC (CLC, PGS 3-5). Logistic regression was used to evaluate the association of this factors with the COS rate.

RESULTS

430 LC were analyzed; 358 (78.61%) were women, 261 (60.7%) were elective and 169(39.3%) urgent LC, the mean age was 44.06 (SD ± 13.16) years. 21 (4.8%) LC were COS; the mean age of this group was 55 (SD ± 12.95), 3 (0.7%) were nCLC and 18 (4.19%) CLC, mean PGS of 3.76 (SD ± 1.09), the mean time to COS was 48.67 (SD ± 41.9), the estimated blood loss (EBL) was 258 (SD ± 260.22) and 6 (1.4%) intraoperative BDI were recognized on this group. Univariate analysis showed a significant association with the COS with male sex, older age, age > 45 years, presence of comorbidities, a higher PGS, a CLC, higher EBL and possible BDI; multivariate analysis produced a model using male sex, age, presence of comorbidities and a CLC with a 0.809 area under the ROC curve.

CONCLUSION

The recognition of the associated RF and a CLC can guide the surgeon to establish preoperative and bailout strategies during the procedure, recognizing a higher risk of COS and its higher morbidity.

A novel machine learning model and a public online prediction platform for prediction of post-ERCP-cholecystitis (PEC)

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is an established treatment for common bile duct (CBD) stones. Post- ERCP cholecystitis (PEC) is a known complication of such procedure and there are no effective models and clinical applicable tools for PEC prediction.

METHODS

A random forest (RF) machine learning model was developed to predict PEC. Eligible patients at The First Hospital of Lanzhou University in China with common bile duct (CBD) stones and gallbladders in-situ were enrolled from 2010 to 2019. Logistic regression analysis was used to compare the predictive discrimination and accuracy values based on receiver operation characteristics (ROC) curve and decision and clinical impact curve. The RF model was further validated by another 117 patients. This study was registered with ClinicalTrials.gov, NCT04234126.

FINDINGS

A total of 1117 patients were enrolled (90 PEC, 8.06%) to build the predictive model for PEC. The RF method identified white blood cell (WBC) count, endoscopic papillary balloon dilatation (EPBD), increase in WBC, residual CBD stones after ERCP, serum amylase levels, and mechanical lithotripsy as the top six predictive factors and has a sensitivity of 0.822, specificity of 0.853 and accuracy of 0.855, with the area under curve (AUC) value of 0.890. A separate logistic regression prediction model was built with sensitivity, specificity, and AUC of 0.811, 0.791, and 0.864, respectively. An additional 117 patients (11 PEC, 9.40%) were used to validate the RF model, with an AUC of 0.889 compared to an AUC of 0.884 with the logistic regression model.

INTERPRETATION

The results suggest that the proposed RF model based on the top six PEC risk factors could be a promising tool to predict the occurrence of PEC.

Predicting the difficult laparoscopic cholecystectomy based on a preoperative scale

It is important to establish the difficulty of a cholecystectomy preoperatively to improve the outcomes. There are multiple risk factors for a difficult cholecystectomy that may depend on the patient, the disease, or extrinsic factors. The aim of this study is to evaluate the predictive capacity of a difficult cholecystectomy with a preoperative scale. A diagnostic trial study was designed to evaluate the performance of a scale to predict the difficulty of laparoscopic cholecystectomy, considering as a reference standard the intraoperative findings evaluated according to an intraoperative difficulty scale. A ROC curve was performed and used to estimate predictive value of the preoperative score to predict the difficulty of a cholecystectomy preoperatively. The ROC curve shows an area of 0.88 under the curve. The calculated ideal cutoff was 8, with a sensitivity, specificity, positive predictive value and negative predictive value of 75.15%, 88.31%, 87.32 and 76.83%, respectively. It was demonstrated that, as the difficulty predicted by the preoperative scale increases, the rate of conversion to open procedure, the rate of subtotal cholecystectomies, the rate of complication and the rate of a critical view of safety failed increase. We suggest implementing the preoperative scale in all patients who are planning laparoscopic cholecystectomy, considering it a simple and easy tool to perform. This to inform the patient, organize the surgery schedule, select personnel, request support and have adequate pre-operative planning.

Statistical models to preoperatively predict operative difficulty in laparoscopic cholecystectomy: A systematic review

BACKGROUND

Laparoscopic cholecystectomy operative difficulty is highly variable and influences outcomes. This systematic review analyzes the performance and clinical value of statistical models to preoperatively predict laparoscopic cholecystectomy operative difficulty.

METHODS

PRISMA guidelines were followed. PubMed, Embase, and the Cochrane Library were searched until June 2020. Primary studies developing or validating preoperative models predicting laparoscopic cholecystectomy operative difficulty in cohorts of >100 patients were included. Studies not reporting performance metrics or enough information for clinical implementation were excluded. Data were extracted according to CHARMS, and study quality was assessed using the PROBAST tool.

RESULTS

In total, 2,654 articles were identified, and 22 met eligibility criteria. Eighteen were model development, whereas 4 were validation studies. Eighteen studies were at high risk of bias. However, 11 studies showed low concern for applicability. Identified models predict 9 definitions of laparoscopic cholecystectomy operative difficulty, the most common being conversion to open surgery and operating time. The most validated models predict an intraoperative difficulty scale and procedures >90 minutes with an area under the curve of >0.70 and >0.76, respectively. Commonly used predictors include demographic variables such as age and gender (9/18 models) and ultrasound findings such as gallbladder wall thickness (11/18). Clinical implementation was never studied.

CONCLUSION

There is a longstanding interest in estimating laparoscopic cholecystectomy operative difficulty. Models to preoperatively predict laparoscopic cholecystectomy operative difficulty have generally good performance and seem applicable. However, an unambiguous definition of operative difficulty, validations, and clinical studies are needed to implement patients' stratification in laparoscopic cholecystectomy.

How to Predict Postoperative Complications After Early Laparoscopic Cholecystectomy for Acute Cholecystitis: the Chole-Risk Score

BACKGROUND

Early laparoscopic cholecystectomy (ELC) is the gold standard treatment for patients with acute calculous cholecystitis (ACC); however, it is still related to significant postoperative complications. The aim of this study is to identify factors associated with an increased risk of postoperative complications and develop a preoperative score able to predict them.

METHODS

Multicentric retrospective analysis of 1868 patients with ACC submitted to ELC. Included patients were divided into two groups according to the presentation of increased postoperative complications defined as postoperative complications ≥ Clavien-Dindo IIIa, length of stay greater than 10 days and readmissions within 30 days of discharge. Variables that were independently predictive of increased postoperative complications were combined determining the Chole-Risk Score, which was validated through a correlation analysis.

RESULTS

We included 282 (15.1%) patients with postoperative complications. The multivariate analysis predictors of increased morbidity were previous percutaneous cholecystostomy (OR 2.95, p=0.001), previous abdominal surgery (OR 1.57, p=0.031) and diabetes (OR 1.62, p=0.005); Charlson Comorbidity Index >6 (OR 2.48, p=0.003), increased total bilirubin > 2 mg/dL (OR 1.88, p=0.002), dilated bile duct (OR 1.79, p=0.027), perforated gallbladder (OR 2.62, p<0.001) and severity grade (OR 1.93, p=0.001). The Chole-Risk Score was generated by grouping these variables into four categories, with scores ranging from 0 to 4. It presented a progressive increase in postoperative complications ranging from 5.8% of patients scoring 0 to 47.8% of patients scoring 4 (p<0.001).

CONCLUSION

The Chole-Risk Score represents an intuitive tool capable of predicting postoperative complications in patients with ACC.

Simple Blood Tests May Be Used to Predict the Increased Risk of Conversion in Elective Laparoscopic Cholecystectomy Surgery

Background: In this study, we aimed to evaluate the possibility if simple blood tests that can be made in majority of hospitals may be used predict to risk of conversion to laparoscopic surgery to an open approach. Patients and Methods: The hospital records of 636 patients who underwent elective laparoscopic cholecystectomy (L-C) were retrospectively reviewed, and 583 patients included in the study protocol. Preoperative laboratory tests of all patients and data of patients who underwent conversion from laparoscopic surgery to open surgery were examined. Results: Of the 583 patients who were included in the study, 404 (69.29%) were female and the mean age was 50.02 ± 12.84 (19-89) years. The cholecystectomy was completed laparoscopically in 559 (89.5%) patients. The most common symptoms seen in the patients were epigastric discomfort and right upper quadrant pain. The high level of white blood cell (WBC) count and c-reactive protein (CRP) were found to be statistically significant before surgery in patients who had a conversion to open cholecystectomy (P < .001). Conclusion: Elevation of WBC count and CRP value before elective L-C may be useful in the prediction of a high risk of conversion from laparoscopic to open approach. This finding will help the surgeon to plan the treatment and inform the patient of the possibility before surgery.

Efficacy of Thiol Disulfide Homeostasis and Ischemia Modified Albumin Values in Estimating the Degree of Difficulty for Laparoscopic Cholecystectomy

Aim:

The aim of this study was to investigate the efficacy of thiol disulfide homeostasis and Ischemia Modified Albumin (IMA) values in predicting the technical difficulties that might be encountered during laparoscopic cholecystectomy.

Materials and Methods:

The study included 65 patients who underwent laparoscopic cholecystectomy due to cholelithiasis at the General Surgery Clinic of Ankara Numune Training and Research Hospital. All patients’ demographic data, previous history of cholecystitis, a history of chronic illness, preoperative white blood count (WBC), liver function tests (AST, ALT), amylase and lipase levels, intra-operative adhesion score, the ultrasonographic appearance of gall bladder, duration of hospital stay, duration of operation, thiol disulfide and IMA values were evaluated.

Results:

Native thiol and total thiol averages were higher in patients without a history of cholecystitis, and on the other hand, disulfide, disulfide/native thiol rate, disulfide/total thiol rate, native thiol/total thiol rate and IMA averages were higher in patients with a history of cholecystitis. While there was a statistically significant negative correlation between native and total thiol values and age, duration of surgery and duration of hospital stay; IMA, disulfide, disulfide/Total thiol, Native/Total thiol and disulfide/Native thiol rates were higher in older patients with a longer duration of surgery and hospital stay. In addition, preoperative IMA, disulfide, disulfide/Total thiol, Native/Total thiol and disulfide/Native thiol were observed to increase as the degree of intraoperative pericholecystic adhesion increased.

Conclusion:

We believe that the evaluation of thiol disulfide homeostasis and IMA parameters prior to laparoscopic cholecystectomy can be used as an effective method for predicting intraoperative difficulties.

Difficult laparoscopic cholecystectomy and preoperative predictive factors

Laparoscopic cholecystectomy (LC) is the standard technique for treatment of gallbladder disease. In case of acute cholecystitis we can identify preoperative factors associated with an increased risk of conversion and intraoperative complications. The aim of our study was to detect preoperative laboratory and radiological findings predictive of difficult LC with potential advantages for both the surgeons and patients in terms of options for management. We designed a retrospective case-control study to compare preoperative predictive factors of difficult LC in patients treated in emergency setting between January 2015 and December 2019. We included in the difficult LC group the surgeries with operative time > 2 h, need for conversion to open, significant bleeding and/or use of synthetic hemostats, vascular and/or biliary injuries and additional operative procedures. We collected 86 patients with inclusion criteria and difficult LC. In the control group, we selected 86 patients with inclusion criteria, but with no operative signs of difficult LC. The analysis of the collected data showed that there was a statistically significant association between WBC count and fibrinogen level and difficult LC. No association were seen with ALP, ALT and bilirubin values. Regarding radiological findings significant differences were noted among the two groups for irregular or absent wall, pericholecystic fluid, fat hyperdensity, thickening of wall > 4 mm and hydrops. The preoperative identification of difficult laparoscopic cholecystectomy provides an important advantage not only for the surgeon who has to perform the surgery, but also for the organization of the operating block and technical resources. In patients with clinical and laboratory parameters of acute cholecystitis, therefore, it would be advisable to carry out a preoperative abdominal CT scan with evaluation of features that can be easily assessed also by the surgeon.

Utilization of an Intraoperative Grading Scale in Laparoscopic Cholecystectomy: A Nepalese Perspective

INTRODUCTION

Difficult geographic diversity and late presentation to medical attention often make the laparoscopic cholecystectomy difficult and chances of conversion and complication remains. Various preoperative grading scales have been developed for predicting the difficulty of surgery in cholecystitis patients; however, intraoperative assessment of anatomical status and inflammation of the gall bladder has not been assessed till date except for some guidelines like the Parkland grading scale (PGS). We aimed to utilise this guideline in patients undergoing laparoscopic cholecystectomy in rural community of the developing nation.

METHODS

PGS was applied for all the patients undergoing laparoscopic cholecystectomy and laboratory and outcome factors like preoperative white blood cells (WBC), open conversion, subtotal cholecystectomy, length of surgery, and bile leaks postoperatively were assessed.

RESULTS

Among 178 patients who underwent cholecystectomy, there were 40 grade one GBs, 90 grade two GBs, 26 grade three GBs, 16 grade four GBs, and six grade five GBs. With a conversion rate of 6.74%, eight patients underwent subtotal cholecystectomy. Among them, four patients were graded as 5th grade, two as 4th grade, and two as 3rd grade according to PGS system. Postoperative bile leak was seen in three patients among which two were grade five GBs and one was grade four. Preoperative WBC, conversion to open, subtotal cholecystectomy, length of surgery, and postoperative bile leak all significantly increased with increasing grades (p < 0.05).

CONCLUSION

PGS can be applied in patients undergoing laparoscopic cholecystectomy in the rural setting of a developing nation. With its application, postoperative course could be predicted and adequate counselling can be done about the possibilities of the outcome.

Grading operative findings at laparoscopic cholecystectomy following the new scoring system in Duhok governorate: Cross sectional study

Introduction

Numerous preoperative scoring systems predict difficult laparoscopic cholecystectomy. Recently, the intraoperative difficulties which are facing surgeons are studied. A new scoring system categorize patients according to many intraoperative findings with a final outcome whether converting to open cholecystectomy or continuing laparoscopically.

Patients and methods

This prospective study included 120 patients admitted for laparoscopic cholecystectomy for symptomatic gallstones from October 2019 to August 2020. Intraoperative difficulties were evaluated and patients were categorized according to intraoperative scoring for cholecystitis severity and compared depending to the rate of conversion to the open technique.

Results

Most patient were middle aged females having multiple gallstones, the mean operation time was 35 min and 7.8% of patients were converted to open cholecystectomy because of intraoperative difficulty.

There was a significant correlation between the conversion rate and each of distended and/or contracted gall bladder, inability to grasp the gall bladder with traumatic forceps, stone ≥1 cm impacted in Hartman's pouch, and bile or pus outside gallbladder (P values: 0.002, 0.000, 0.008 and 0.015) respectively, and no significant correlation with gallbladder adhesions, adhesions from previous upper abdominal surgery, BMI>30, and Time to identify cystic artery and duct >90 min (P values: 0.123, 1, 1, 0.078) respectively.

Conclusion

New intraoperative scoring systems are valuable in predicting difficulties and preventing increase operation time and possible injuries. The main points of difficulties are distended or contracted gallbladder, large stone impaction, difficult grasping the wall of the gall bladder and the presence of bile or pus outside the gall bladder.

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Laparoscopic cholecystectomy is a safe procedure with some difficulties.

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The definition of difficult LC is not well established until now.

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Recently intraoperative difficulties facing the surgeons are studied.

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Inflammation, adhesions, and obesity are some factors for difficulty.

Predicting the difficult laparoscopic cholecystectomy: development and validation of a pre-operative risk score using an objective operative difficulty grading system

BACKGROUND

The prediction of a difficult cholecystectomy has traditionally been based on certain pre-operative clinical and imaging factors. Most of the previous literature reported small patient cohorts and have not used an objective measure of operative difficulty. The aim of this study was to develop a pre-operative score to predict difficult cholecystectomy, as defined by a validated intra-operative difficulty grading scale.

METHOD

Two cohorts from prospectively maintained databases of patients who underwent laparoscopic cholecystectomy were analysed: the CholeS Study (8755 patients) and a single surgeon series (4089 patients). Factors potentially predictive of difficulty were correlated to the Nassar intra-operative difficulty scale. A multivariable binary logistic regression analysis was then used to identify factors that were independently associated with difficult laparoscopic cholecystectomy, defined as operative difficulty grades 3 to 5. The resulting model was then converted to a risk score, and validated on both internal and external datasets.

RESULT

Increasing age and ASA classification, male gender, diagnosis of CBD stone or cholecystitis, thick-walled gallbladders, CBD dilation, use of pre-operative ERCP and non-elective operations were found to be significant independent predictors of difficult cases. A risk score based on these factors returned an area under the ROC curve of 0.789 (95% CI 0.773-0.806, p < 0.001) on external validation, with 11.0% versus 80.0% of patients classified as low versus high risk having difficult surgeries.

CONCLUSION

We have developed and validated a pre-operative scoring system that uses easily available pre-operative variables to predict difficult laparoscopic cholecystectomies. This scoring system should assist in patient selection for day case surgery, optimising pre-operative surgical planning (e.g. allocation of the procedure to a suitably trained surgeon) and counselling patients during the consent process. The score could also be used to risk adjust outcomes in future research.

Early versus delayed cholecystectomy for cholecystitis at high risk of operative difficulties: A propensity score-matching analysis

BACKGROUND

Numerous studies have demonstrated the superiority of early (EC) over delayed (DC) cholecystectomy for acute cholecystitis (AC). However, none have assessed the effect of operative difficulty when reporting on treatment outcomes.

METHODS

Outcomes of patients who underwent EC or DC between 2010 and 2019 were compared taking into account the operative difficulty evaluated by the Difficult Laparoscopic Cholecystectomy score (DiLC). For each patient, the DiLC score was retrospectively calculated and corresponded to the foreseeable operative difficulty measured on admission for AC. A propensity score was used to account for confounders. Primary endpoints were the length of stay (LOS) and the occurrence of a serious operative/post-operative event (SOE).

RESULTS

DC in patients with DiLC≥10 reduced the risk of SOE without increasing the LOS. Conversely, DC in patients with DiLC<10 increased the LOS without improving outcomes. Multivariate analysis found EC in patients with DiLC≥10 as the main independent predictor of SOE.

CONCLUSIONS

Provided prospective validation, DC for AC in patients with DiLC≥10 seems safer than EC and is not hospital-stay consuming.

¿Es más difícil la colecistectomía laparoscópica después de una colangiopancreatografía retrógrada endoscópica? Experiencia en un hospital de tercer nivel

Introducción. La colecistectomía laparoscópica es el tratamiento estándar para la colecistitis aguda. En pacientes con coledocolitiasis, la colangiopancreatografía retrógrada endoscópica es el tratamiento de elección. Se ha reportado que, después de este procedimiento endoscópico, la colecistectomía laparoscópica es más difícil y son mayores las tasas de conversión, hemorragia y tiempo operatorio. El objetivo de este estudio fue determinar si en nuestro medio las colecistectomías laparoscópicas posteriores a este procedimiento endoscópico presentan más complicaciones posquirúrgicas y mayor dificultad técnica. Métodos. Estudio de cohorte prospectivo, en el que se comparó un grupo de pacientes sometidos a colecistectomía laparoscópica previa colangiopancreatografía retrógrada endoscópica, contra un grupo homogéneo de pacientes sin colangiografía previa, para evaluar la dificultad en la colecistectomía laparoscópica, la conversión, la reintervención y las complicaciones. Resultados. El 45,4 % de las cirugías fueron difíciles. No hay relación entre la realización previa de colangiopancreatografía retrógrada endoscópica y la dificultad de la colecistectomía laparoscópica. Con el modelo de regresión logística, se encontraron como factores predictores para una cirugía difícil, la edad, el sexo masculino, la cirugía abdominal previa, la colecistitis aguda y la mayor gravedad de la colecistitis aguda.  Conclusión. La colangiopancreatografía retrógrada endoscópica en nuestro medio no constituye un factor de riesgo para dificultad en la colecistectomía laparoscópica. Debe prestarse especial cuidado al sexo masculino, la gravedad de la colecistitis aguda, los antecedentes de cirugía abdominal y la presencia de comorbilidades a la hora de planear una colecistectomía laparoscópica, tomando precauciones adicionales en estos casos para prevenir complicaciones.

Usefulness of preoperative drip infusion cholangiography with computed tomography for predicting surgical difficulty during laparoscopic cholecystectomy

BACKGROUND

Drip infusion cholangiography with computed tomography (DIC-CT) is a major preoperative modality used for patients undergoing laparoscopic cholecystectomy (LC).

METHODS

This study included 218 patients for whom preoperative DIC-CT images were obtained prior to undergoing LC. The association between gallbladder (GB) opacification in DIC-CT and the operative time was assessed.

RESULTS

The GB opacification on the DIC-CT images was classified as follows: Grade 0, homogeneous opacification; Grade 1, heterogeneous opacification; Grade 2, only cystic duct can be identified; and Grade 3, no opacification. Images obtained for the 218 patients showed 41 (18.8%) with Grade 0, 91 (41.7%) with Grade 1, 54 (24.8%) with Grade 2, and 32 (14.7%) with Grade 3. The operative time and intraoperative blood loss were significantly longer and larger, respectively, in cases classified as Grade 2 or 3 (GB negative) compared with cases classified as Grade 0 or 1 (GB positive). We created an LC difficulty score based on the following variables that were significant independent predictors of increased operative time: GB negativity in DIC-CT (P = .002, 2 points), GB wall thickness (P = .002, 2 points), body mass index (P = .015, 1 point), preoperative alkaline phosphatase value (P = .018, 1 point), and preoperative C-reactive protein value (P = .04, 1 point). The LC difficulty score (Grade A, score 0-2; Grade B, score 3-5; and Grade C, score 6-7) was significantly associated with a prolonged operative time.

CONCLUSION

Drip infusion cholangiography with computed tomography is useful for predicting the surgical difficulty of LC.

Acute cholecystitis or simple biliary colic after an emergency presentation: why it matters

BACKGROUND

Laparoscopic cholecystectomy (LC) is often performed during the index admission after emergency presentation for acute biliary pain. Many patients have acute cholecystitis (AC) that may increase operative difficulty and complications. Our primary aim was to assess the validity of Tokyo Guidelines (TG18) for diagnosing AC by comparison with the admitting team diagnosis, operative findings and histopathology. The secondary aim was to assess outcomes after same-admission or delayed LC.

METHODS

Retrospective analysis of patients who underwent LC after presenting to a tertiary hospital emergency department over a 12-month period was conducted.

RESULTS

A total of 139 patients underwent LC with no mortality or bile duct injury. A diagnosis of AC made by the admitting surgical team had sensitivity of 84% and specificity of 57%. The TG18 diagnosis had sensitivity of 84% and specificity of 53%. A diagnosis of AC by the admitting surgical team correlated well with TG18 criteria diagnosis. There was poor correlation between clinical and histopathological diagnoses. Nine percent of patients had complications and 4% required conversion to open procedure. Patients with a clinical diagnosis of AC had longer post-operative length of stay and more complications compared with those who had non-AC diagnosis. There was no difference in outcomes between same-admission LC or delayed LC.

CONCLUSION

TG18 diagnosis of AC does not improve accuracy of diagnosis or predictability of a poor outcome over the admitting surgical team diagnosis. Same-admission LC for patients with AC is associated with similar outcomes compared to those who undergo delayed LC.

Predicting operative difficulty of laparoscopic cholecystectomy in patients with acute biliary presentations

BACKGROUND

Early laparoscopic cholecystectomy (LC) is advocated in patients with an acute biliary presentation but may require some precaution. We aimed to assess the intra-operative difficulty of cholecystectomy in patients who underwent early intervention, and to establish a prediction model for a 'complicated' LC.

METHODS

Retrospective analysis of prospectively collected data from patients presenting to the emergency department with acute biliary symptoms, and who subsequently underwent early LC between 2015 and 2018. Operative difficulty was assessed by standardized grading of intra-operative findings (grades 1-4). Pre-operative predictors for a 'complicated' LC (grades 3/4) were assessed using univariable and multivariable logistic regression analysis. A prediction model was created using variable regression coefficients. Cut-off and accuracy of the model were assessed using a receiver operating characteristic curve.

RESULTS

A total of 185 patients were included and 59% presented with acute cholecystitis. In this cohort 113 (61%) patients underwent a 'complicated' LC. A prediction model for a 'complicated' LC (0-4.5 points) included: clinical diagnosis of acute cholecystitis (2 points), C-reactive protein >10.5 mg/L (1.5 points) and pericholecystic fluid on pre-operative imaging (1 point). A score ≥2.5 had a sensitivity of 77.7%, specificity of 81.7% and positive and negative predictive values of 87.0% and 69.9%, respectively.

CONCLUSION

Early LC may be 'complicated' in up to 60% of cases. The presented prediction model uses readily available information in the emergency department and is a simple but accurate way to predict a likely 'complicated' LC in patients with acute biliary presentations.

Role of procalcitonin as a predictor in difficult laparoscopic cholecystectomy for acute cholecystitis case: A retrospective study based on the TG18 criteria

Difficult laparoscopic cholecystectomy (DLC) is difficult to precisely predict before operation. This observational cohort study aimed to evaluate the predictive value of procalcitonin (PCT) for DLC in patients with acute cholecystitis (AC). A total of 115 patients were included in the study from January 2017 to April 2018. Multiple logistic regression and receiver-operating characteristic (ROC) were performed to evaluate the predictive value of PCT levels in DLC. Patients with DLC had significantly higher Tokyo Guidelines 2018 (TG18) grade (P = 0.002) and levels of C-reactive protein (CRP) (P = 0.007) and PCT (P < 0.001). The cut-off value of PCT for predicting DLC was 1.50 ng/ml. The sensitivity and specificity were 91.3% (95% CI 78.3–97.1) and 76.8% (95% CI 64.8–85.8), respectively. The area under ROC curve was 92.7% (95% CI 88.2–97.3, P < 0.001). Our results suggested that PCT was a good predictor for DLC in the AC patients, but further research is necessary. Monitoring of PCT trends in AC patients may be useful for preoperative risk assessment.

Correlation between port-to-target distance and procedural difficulty in single-incision laparoscopic cholecystectomy: An observational study

INTRODUCTION

Single-incision laparoscopic cholecystectomy (SILC) is more challenging than conventional (multiport) laparoscopic cholecystectomy (CLC) because of the increased likelihood of instrument collision and the limited surgical workspace. In SILC, procedural difficulties may increase when the port-to-target distance is long. We aimed to assess the correlation between port-to-target distance and procedural difficulty.

METHODS

Thirty-six consecutive patients who underwent SILC at our hospital were included in this study. The umbilicus-to-Calot's triangle distance (UCD) was measured intraoperatively. The correlations between the UCD and operative time were analyzed, and for comparison, CLC cases during the same period (n = 28) were similarly analyzed. Moreover, UCD was estimated from preoperative CT (UCD-CT), and the usefulness of UCD-CT was assessed during SILC and CLC.

RESULTS

Thirty-four patients successfully underwent SILC. There were positive correlations between the UCD and pneumoperitoneum time. Multivariate linear regression analysis, including BMI and height, which were previously reported to have a correlation with longer operative time in SILC, showed that UCD is an independent predictive factor for prolonged operative duration. However, BMI and height were not independent predictive factors. UCD and UCD-CT had a very strong positive correlation; therefore, UCD was estimated from CT. UCD-CT had a strong positive correlation with operative time in SILC, but not in CLC.

CONCLUSIONS

A longer UCD is an important predictive factor for difficult cases of SILC, but this finding is not applicable in CLC. The usefulness of UCD is specific to SILC.

Outcomes of laparoscopic cholecystectomy in patients with and without COPD

Objective: The aim of this study was to investigate the outcomes of patients with COPD after laparoscopic cholecystectomy (LC).

Patients and methods: All COPD patients who underwent LC from 2000 to 2010 were identified from the Taiwanese National Health Insurance Research Database. The outcomes of hospital stay, intensive care unit (ICU) stay, and use of mechanical ventilation and life support measures in COPD and non-COPD populations were compared.

Results: A total of 3,954 COPD patients who underwent LC were enrolled in our study. There were significant differences in the hospitalization period, ICU stay, and use of mechanical ventilation and life support measures between the COPD and non-COPD populations. The mean hospital stay, ICU stay and number of mechanical ventilation days in the COPD and non-COPD groups were 7.81 vs 6.01 days, 5.5 vs 4.5 days and 6.40 vs 4.74 days, respectively. The use of life support measures, including vasopressors and hemodialysis, and the rates of hospital mortality, acute respiratory failure and pneumonia were also increased in COPD patients compared with those in non-COPD patients.

Conclusion: COPD increased the risk of mortality, lengths of hospital and ICU stays, ventilator days and poor outcomes after LC in this study.

A Retrospective and Prospective Study to Develop a Pre-operative Difficulty Score for Laparoscopic Cholecystectomy

BACKGROUND

The objectives of this study were to develop a grading system to enable pre-operative prediction of technical difficulty of laparoscopic cholecystectomy using retrospective data and to attempt to validate our scoring system prospectively.

METHODS

Retrospective analysis was conducted of 100 consecutive patients. Pre-operative variables were collected based on a template devised by the American College of Surgeons. Outcomes were duration of surgery, conversion to open and post-operative complications. Multivariate analysis with subsequent measurement of hazard ratios was used to formulate a weighted grading system. Prospective analysis was performed of 100 consecutive patients who were scored pre-operatively. Outcomes were duration of surgery and length of stay.

RESULTS

Retrospective univariate analysis identified four variables associated with an increase in duration of surgery: male gender (p = 0.023), age (p = 0.000), body mass index (BMI) (p = 0.000) and pre-operative endoscopic retrograde cholangiopancreatography (ERCP) (p = 0.001). Prospective analysis revealed weak positive correlations between the scoring system and duration of surgery (0.34) and length of stay (0.40).

CONCLUSION

We have identified four pre-operative variables that predicted a longer duration of surgery. Preliminary results suggest a positive correlation between this scoring system and duration of surgery. An adequately powered prospective multi-centre study is needed to validate our findings.

2017 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population

Background

Gallstone disease is very common afflicting 20 million people in the USA. In Europe, the overall incidence of gallstone disease is 18.8% in women and 9.5% in men. The frequency of gallstones related disease increases by age. The elderly population is increasing worldwide.

Aim

The present guidelines aims to report the results of the World Society of Emergency Surgery (WSES) and Italian Surgical Society for Elderly (SICG) consensus conference on acute calcolous cholecystitis (ACC) focused on elderly population.

Material and methods

The 2016 WSES guidelines on ACC were used as baseline; six questions have been used to investigate the particularities in elderly population; the answers have been developed in terms of differences compared to the general population and to statements of the 2016 WSES Guidelines. The Consensus Conference discusses, voted, and modified the statements. International experts contributed in the elaboration of final statements and evaluation of the level of scientific evidences.

Results

The quality of the studies available decreases when we approach ACC in elderly. Same admission laparoscopic cholecystectomy should be suggested for elderly people with ACC; frailty scores as well as clinical and surgical risk scores could be adopted but no general consensus exist. The role of cholecystostomy is uncertain.

Discussion and conclusions

The evaluation of pro and cons for surgery or for alternative treatments in elderly suffering of ACC is more complex than in young people; also, the oldest old age is not a contraindication for surgery; however, a larger use of frailty and surgical risk scores could contribute to reach the best clinical judgment by the surgeon. The present guidelines offer the opportunity to share with the scientific community a baseline for future researches and discussion.

Combination of serum gamma-glutamyltransferase and alkaline phosphatase in predicting the diagnosis of asymptomatic choledocholithiasis secondary to cholecystolithiasis

BACKGROUND

Gamma-glutamyltransferase (GGT) is one of the most important laboratory tests for the evaluation of liver damage. Through a long-term clinical observation of patients with secondary asymptomatic choledocholithiasis, we found that most patients had abnormal GGT serum levels.

AIM

To investigate the combination of serum GGT and alkaline phosphatase (ALP) in predicting the diagnosis of asymptomatic choledocholithiasis secondary to cholecystolithiasis.

METHODS

In this retrospective cohort study, the clinical data of 829 patients with cholecystolithiasis admitted to the Third Affiliated Hospital of Zunyi Medical College from August 2014 to August 2017 were collected. Among these patients, 151 patients had secondary asymptomatic choledocholithiasis and served as the observation group, and the remaining 678 cholecystolithiasis patients served as the control group. Serum liver function indexes were detected in both groups, and the receiver operating characteristic (commonly known as ROC) curves were constructed for markers showing statistical significances. The cutoff value, sensitivity, and specificity of each marker were calculated according to the ROC curves.

RESULTS

The overall incidence of asymptomatic choledocholithiasis secondary to cholecystolithiasis was 18.2%. The results of liver function indexes including serum aspartate aminotransferase, alanine aminotransferase, direct bilirubin and total bilirubin levels showed no significant differences between the two groups (P > 0.05). However, the serum GGT and ALP levels were significantly higher in the observation group than in the control group (P < 0.05). The ROC curve analysis showed that the area under the curve was 0.881 (95%CI: 0.830-0.932), 0.647 (95%CI: 0.583-0.711) and 0.923 (95%CI: 0.892-0.953) for GGT, ALP, and GGT + ALP, respectively. The corresponding cut-off values of GGT and ALP were 95.5 U/L and 151.5 U/L, sensitivity were 90.8% and 65.1%, and specificity were 83.6% and 59.8%, respectively. The sensitivity and specificity of GGT + ALP were 93.5% and 85.1%, respectively.

CONCLUSION

An abnormally elevated serum GGT level has an important value in the diagnosis of asymptomatic choledocholithiasis secondary to cholecystolithiasis. The combination of serum GGT and ALP has better diagnostic performance. As a convenient, rapid and inexpensive test, it should be applied in secondary asymptomatic choledocholithiasis routine screening.

Routine versus difficult cholecystectomy: using predictive analytics to assess patient outcomes

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program^® (NSQIP) Surgical Risk. Calculator (SRC) estimates postoperative outcomes. The aim of this study was to develop and validate a specific predictive outcomes model for cholecystectomy procedures.

METHODS

Patients who underwent cholecystectomy between 2008 and 2016 and were deemed too high risk for acute care general surgery (GS) and had surgery performed by the Division of Hepatopancreatobiliary Surgery (HPB) were identified. Outcomes of the HPB cholecystectomies were matched against cholecystectomies performed by GS. New predictive models for postoperative outcomes were constructed. Area under the curve was used to assess predictive accuracy for both models and internal validation was performed using bootstrap logistic regression.

RESULTS

A total of 169/934 (18%) cholecystectomies were identified as too high risk for GS. These 169 patients were matched with 126 patients who had cholecystectomy performed by GS. For GS and HPB cholecystectomies, the proposed model demonstrated better discriminative ability compared to the SRC based on ROC curves (proposed model: 0.589-0.982; SRC: 0.570-0.836) for each of the predicted outcomes.

CONCLUSION

For patients undergoing cholecystectomy, customized models are superior for predicting individual perioperative risk and allow more accurate, patient-specific delivery of care.

Does surgical difficulty relate to severity of acute cholecystitis? Validation of the parkland grading scale based on intraoperative findings

BACKGROUND

The Parkland grading scale (PGS) was assessed to validate its correlation to severity of acute cholecystitis (AC).

METHODS

This study investigated the correlation between the PGS and Tokyo guidelines (TG) using multinomial logistic regression analysis in 177 patients with AC.

RESULTS

High PGS grades were related to higher C-reactive protein (p < 0.001) and frequent gangrenous cholecystitis (p < 0.001). The PGS and TG grades correlated with statistical significance (p < 0.001). Patients with PGS Grade 4 had a higher risk of moderate AC than those with Grade 3 (odds ratio: 4.4; 95% confidence interval [CI]: 1.2-15.6; p = 0.019). The PGS showed good predictive power for moderate or severe AC (area under the curve: 0.771; 95% CI: 0.700-0.842; p = 0.031).

CONCLUSION

The PGS is helpful to discriminate severity of AC. Patients with PGS Grade 4 or 5 have a high risk of moderate or severe AC.

Tokyo Guidelines 2013 may be too restrictive and patients with moderate and severe acute cholecystitis can be managed by early cholecystectomy too

OBJECTIVE

The aim of this study was to determine whether early laparoscopic cholecystectomy (LC) is safe and feasible for patients diagnosed with moderate (grade 2) and severe (grade 3) acute cholecystitis (AC) according to the Tokyo Guidelines 2013 (TG13).

BACKGROUND

Early cholecystectomy is the current accepted standard of care for patients with mild (grade 1) and selected grade 2 AC based on TG13. For selected grade 2 and grade 3 AC, early percutaneous cholecystostomy (PC) followed by delayed cholecystectomy is recommended.

METHODS

Patients diagnosed with AC over a 14-month period were identified and divided into three grades of AC based upon chart review using the grading and severity indicators according to TG13.

RESULTS

A total of 149 patients underwent emergency LC. Eighty-two (55 %) patients were male. Eighty-four (56.4 %) patients were classified as grade 1 AC, 49 (32.9 %) as grade 2, and 16 (10.7 %) as grade 3. Eighty-three (98.8 %) patients with grade 1 AC underwent emergency LC, and 1 patient (1.2 %) underwent PC followed by emergency LC. The median length of hospital stay for grade 1 AC patients was 2 (1-11) days. There were 2 (2.4 %) readmissions with fever and no additional complications. Among the 65 patients identified with grade 2 or 3 AC, 6 (9.2 %) underwent PC followed by emergency LC. Fifty-nine (90.8 %) patients underwent emergency cholecystectomy: 58 (98.3 %) LC and one (1.7 %) open cholecystectomy. Among the 58 patients with LC, 3 (5.2 %) patients had open conversion and 10 (17.2 %) patients required subtotal cholecystectomy. One patient was converted to open due to bile duct injury and had hepaticojejunostomy repair. Two other patients were converted due to dense adhesions and inability to safely dissect Calot's triangle. The median length of hospital stay was 4 (1-28) days. There was one readmission for ileus.

CONCLUSION

Severity grading of AC is not the sole determinant of early LC. Patient comorbidity also impacts clinical decision. Confirmation in a larger cohort is warranted.

Ninety-day readmissions after inpatient cholecystectomy: A 5-year analysis

AIM

To determine the incidence of readmission after cholecystectomy using 90 d as a time limit.

METHODS

We retrospectively reviewed all patients undergoing cholecystectomy at the General Surgery and Digestive System Service of the University Hospital of Guadalajara, Spain. We included all patients undergoing cholecystectomy for biliary pathology who were readmitted to hospital within 90 d. We considered readmission to any hospital service as cholecystectomy-related complications. We excluded ambulatory cholecystectomy, cholecystectomy combined with other procedures, oncologic disease active at the time of cholecystectomy, finding of malignancy in the resection specimen, and scheduled re-admissions for other unrelated pathologies.

RESULTS

We analyzed 1423 patients. There were 71 readmissions in the 90 d after discharge, with a readmission rate of 4.99%. Sixty-four point seven nine percent occurred after elective surgery (cholelithiasis or vesicular polyps) and 35.21% after emergency surgery (acute cholecystitis or acute pancreatitis). Surgical non-biliary causes were the most frequent reasons for readmission, representing 46.48%; among them, intra-abdominal abscesses were the most common. In second place were non-surgical reasons, at 29.58%, and finally, surgical biliary reasons, at 23.94%. Regarding time for readmission, almost 50% of patients were readmitted in the first week and most second readmissions occurred during the second month. Redefining the readmissions rate to 90 d resulted in an increase in re-hospitalization, from 3.51% at 30 d to 4.99% at 90 d.

CONCLUSION

The use of 30-d cutoff point may underestimate the incidence of complications. The current tendency is to use 90 d as a limit to measure complications associated with any surgical procedure.