[Design of a preoperative predictive score for choledocholithiasis]

Development and validation of a predictive model for choledocholithiasis

BACKGROUND

Gallstone-related conditions affect a significant portion of the population, with varying prevalence among different ethnic groups. Complications such as pancreatitis and cholangitis are associated with the presence of common bile duct (CBD) stones. Existing guidelines for diagnosing choledocholithiasis lack precision, leading to excessive use of invasive procedures like endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

A prospective study was conducted at Hospital Central "Dr. Ignacio Morones Prieto," involving 374 patients in the development cohort and 154 patients in the validation cohort. Patients meeting inclusion criteria underwent biochemical testing and ultrasonography. A predictive scoring system was developed using logistic regression and validated in an independent cohort. Clinical and laboratory variables were collected, and model performance was assessed using receiver-operator characteristic (ROC) curves.

RESULTS

The predictive model incorporated variables such as age, pancreatitis, cholangitis, bilirubin levels, and CBD stone presence on ultrasound. The model demonstrated an area under the ROC curve (AUC) of 93.81% in the validation dataset. By adjusting the threshold defining high-risk probability to 40%, the model improved specificity and sensitivity compared to existing guidelines. Notably, the model reclassified patients, leading to a more accurate risk assessment.

CONCLUSIONS

The developed algorithm accurately predicts choledocholithiasis non-invasively in patients with symptomatic gallstones. This tool has the potential to reduce reliance on costly or invasive procedures like magnetic resonance cholangiopancreatography and ERCP, offering a more efficient and cost-effective approach to patient management. The user-friendly calculator developed in this study could streamline diagnostic procedures, particularly in resource-limited healthcare settings, ultimately improving patient care.

Bilirubin Correlation May Preclude MRCP in Acute Cholecystitis Patients With Normal Common Bile Duct Diameter

OBJECTIVE. In patients with acute cholecystitis (AC), accurate identification of a common bile duct (CBD) stone before cholecystectomy is of concern for surgeons, gastroenterologists, and radiologists. This study evaluates the utility of preoperative MRCP taking into consideration both sonographic findings and biochemical predictors for choledocholithiasis. MATERIALS AND METHODS. Fifty-seven patients (58% women; mean age, 54 years old) with signs of AC on right upper quadrant (RUQ) ultrasound (US) who underwent subsequent MRCP from 2007 to 2017 were identified using a text-based search and retrospectively analyzed, using ERCP as the reference standard. RESULTS. For patients with AC who had a normal CBD diameter on initial RUQ US, we found a significant difference in the total and direct bilirubin levels of patients who had positive (1.94 vs 4.02 mg/dL, respectively; p = 0.013) and negative (0.71 vs 2.13 mg/dL, respectively; p = 0.02) findings for CBD stone on MRCP. ROC curve analysis showed an increased total bilirubin threshold of > 2.3 mg/dL (standard threshold, 1.2 mg/dL), which yielded a negative predictive value (NPV) of 95%. An increased direct bilirubin threshold of > 0.9 mg/dL (standard threshold, 0.2 mg/dL) yielded an NPV of 100%. CONCLUSION. In patients with AC who have a normal CBD diameter on RUQ US, normal or even mildly elevated bilirubin levels below a calculated threshold may obviate preoperative MRCP. Radiologists should be active participants in clinical decision-making; discussion between referring physicians and radiologists regarding biochemical markers and sonographic findings will lead to more appropriate use of preoperative imaging.

[Efficiency of laparoscopic vs endoscopic management in cholelithiasis and choledocholithiasis. Is there any difference?]

BACKGROUND

Concomitant cholelithiasis and choledocholithiasis is a disease where incidence increases with age and can have serious complications such as pancreatitis, cholangitis and liver abscesses, but its management is controversial, because there are minimally invasive laparoscopic and endoscopic surgical procedures.

OBJECTIVE

To compare the efficiency in the management of cholelithiasis and choledocholithiasis with laparoscopic cholecystectomy with common bile duct exploration vs cholangiopancreatography endoscopic retrograde+laparoscopic cholecystectomy.

MATERIAL AND METHOD

Retrospective analysis of a five year observational, cross sectional multicenter study of patients with cholelithiasis and concomitant high risk of choledocholithiasis who were divided into two groups and the efficiency of both procedures was compared. Group 1 underwent laparoscopic cholecystectomy with common bile duct exploration and group 2 underwent cholangiopancreatography endoscopic retrograde+laparoscopic cholecystectomy.

RESULTS

40 patients, 20 were included in each group, we found p=0.10 in terms of operating time; when we compared hospital days we found p=0.63; the success of stone extraction by study group we obtained was p=0.15; the complications presented by group was p=0.1 and the number of hospitalizations by group was p ≤ 0.05 demonstrating statistical significance.

CONCLUSIONS

Both approaches have the same efficiency in the management of cholelithiasis and choledocholithiasis in terms of operating time, success in extracting stone, days of hospitalization, postoperative complications and conversion to open surgery. However the laparoscopic approach is favourable because it reduces the number of surgical anaesthetic events and the number of hospital admissions.

Regression tree for choledocholithiasis prediction

OBJECTIVES

The aim of this study was to develop and compare the predictive accuracy of classification and regression tree (CART) analysis with logistic regression (LR) for predicting common bile duct stones (CBDS) in patients subjected to laparoscopic cholecystectomy.

PATIENTS AND METHODS

We prospectively collected preoperative (demographic, biochemical, ultrasonographic) and intraoperative (intraoperative cholangiography, cystic duct diameter) data for 154 patients considered for elective laparoscopic cholecystectomy at the department of General Surgery at Gornji Milanovac from 2013 through 2014. Univariate and multivariate regression analyses were used to determine independent predictors of CBDS. The CART analysis was carried out using the predictors identified by LR analysis. Various measures for the assessment of risk prediction models were determined, such as predictive ability, accuracy, the area under the receiver operating characteristic curve, and clinical utility using decision curve analysis.

RESULTS

The most decisive variable at the time of classification was the cystic duct diameter category, the alkaline phosphatase, and dangerous stones. The CART model was shown to have good discriminatory ability (93.9%). Accuracy was similar in both models, ranging from 92.9% in the CART model and 93.5% in the LR model. In decision curve analysis, the CART model outperformed the LR model.

CONCLUSION

We developed a user-friendly risk model that can successfully predict the presence of choledocholithiasis in patients planned for elective cholecystectomy. However, before recommending its use in clinical practice, a larger and more complete database should be used to further clarify the differences between models in terms of prediction of the CBDS.