C-reactive Protein is an Independent Predictor of Difficult Emergency Cholecystectomy

Role of C-Reactive Protein as a Predictor of Difficult Laparoscopic Cholecystectomy

INTRODUCTION

Cholelithiasis is one of the most common diseases encountered in gastroenterology. Laparoscopic cholecystectomy can be labelled as difficult if the surgery continues for more than 60 minutes or if the cystic artery is injured before ligation or clipping. Predicting difficult laparoscopic cholecystectomy can help the surgeon to be prepared for intraoperative challenges such as adhesions in triangle of Calot, injury to cystic artery or gall stone spillage; and improve patient counseling.

METHODS

In this cross-sectional study, we evaluated 269 patients with diagnosed cholelithiasis and planned for laparoscopic cholecystectomy in the general surgery department of Civil Hospital Karachi. After approval of the institution review board of the Civil Hospital, the data of all the patients was collected along with informed consent. The patients were selected via nonprobability, consecutive sampling.

RESULTS

The prevalence of difficult LC during procedure was 14.5% (39/269). Contingency table showed the true positive, negative and false positive and negative observation and using these observation to compute accuracy. Sensitivity, specificity, PPV, NPV and accuracy of serum c-reactive protein (CRP) in predicting the difficult laparoscopic cholecystectomy in patients of cholelithiasis was 87.2%, 97%, 82.9%, 97.8% and 95.5% respectively. Effect modifiers like age, gender and BMI were controlled by stratification analysis and observed that diagnostic accuracy was above 90% in all stratified groups as presented in the following tables. 175 (65.06%) of 279 patients were females indicating female predominance. In general, 41 patients (15.05%) had CRP serum levels greater than 11 mg/dL out of which 34 patients had to undergo difficult laparoscopic cholecystectomy (DLC), while 223 out of 228 patients with serum CRP levels of less than 11 mg/dL did not face any difficulty during their cholecystectomy. Similar results have been acquired across all age groups and both genders.

CONCLUSION

C Reactive Protein is a potent predictor of difficult laparoscopic cholecystectomy and its conversion preoperatively. Patients with preoperatively high C Reactive Protein CRP levels in serum have more chances of complication intraoperatively and increased chances of conversion from laparoscopic to open surgery. Preoperative C Reactive Protein (CRP) with values >11 mg/dL was associated with the highest odds of presenting difficult laparoscopic cholecystectomy (DLC) in our study. This value possesses good sensitivity, specificity, PPV, and NPV for predicting DLC in our population.

Association of Serum C-Reactive Protein Level and Treatment Duration in Acute Cholecystitis Patients Treated Conservatively

Background: Acute cholecystitis (AC) is one of the most common gastrointestinal diseases that require hospitalization and surgical treatment. The treatment of the disease depends upon the severity of the disease and the patients’ medical status.

Objective: In this study, we aimed to investigate if there is an association between the serum C-reactive protein (CRP) value and treatment response and the duration and length of hospital stay in AC patients who are treated conservatively.

Methodology: The medical records of all patients with the diagnosis of AC who were treated with conservative management were included in the study. The demographic and laboratory data including CRP level at first admission to hospital, length of hospital stay, and complications during the conservative treatment were obtained from the patients’ records. Patients were divided into two groups according to the treatment response and length of hospital stay. Group 1 patients were defined as patients who responded to the medical treatment in less than three days, and Group 2 patients were defined as patients who did not respond to the medical treatment in three days and stayed at the hospital for more than three days.

Results: We identified 101 patients with AC treated medically. Mean age (51.3 ± 16.3, 59.5 ± 15.7; p = 0.013), total leukocyte count (11.8 ± 4.4, 8.2 ± 2.8; p = 0.0005), and CRP value (19.3 ± 13.9, 9.6 ± 5.2; p = 0.0003) were higher in Group 2 compared to Group 1. Correlation analyses demonstrated a significant positive association between the length of hospital stay, total leukocyte count (r = 0.35; p = 0.0002), and CRP value (r = 0.59; p = 0.0004).

Conclusion: We found that CRP level is associated with treatment duration and hospital stay in AC patients. However, large-scale, prospective further studies are needed to confirm our results and to determine whether CRP levels can be used to discriminate which patient would benefit from medical treatment.

Patient and surgeon factors contributing to bailout cholecystectomies: a single-institutional retrospective analysis

BACKGROUND

Laparoscopic cholecystectomies continue to pose trouble for surgeons in the face of severe inflammation. In the advent of inability to perform an adequate dissection, a "bailout cholecystectomy" is advocated. Conversion to open or subtotal cholecystectomy is among the standard bailout procedures in such instances.

METHODS

We performed a retrospective single institution review from January 2016 to August 2019. All patients who underwent a cholecystectomy were included, while those with a concurrent operation, malignancy, planned as an open cholecystectomy, or performed by a low volume surgeon were excluded. Patient characteristics, operative reports, and outcomes were collected, as were surgeon characteristics such as years of experience, case volume, and bailout rate. Univariable and multivariable analysis were performed.

RESULTS

2458 (92.6%) underwent laparoscopic total cholecystectomy (LTC) and 196 (7.4%) underwent a bailout cholecystectomy (BOC). BOC patients tended to be older (p < 0.001), male (p < 0.001), have a longer duration of symptoms (p < 0.001), and higher ASA class (p < 0.001). They also had more signs of biliary inflammation, as evidenced by increased leukocytosis (p < 0.001), tachycardia (p < 0.001), bilirubinemia (p = 0.003), common bile duct dilation (p < 0.001), and gallbladder wall thickening (p < 0.001). The BOC cohort also had increased rates of complications, including bile leak (16%, p < 0.001), retained stone (5.1%, p = 0.005), operative time (114 min vs 79 min, p < 0.001), and secondary interventions (22.7%, p < 0.001). Male gender (aOR = 2.8, p < 0.001), preoperative diagnosis of acute cholecystitis (aOR = 2.2, p = 0.032), right upper quadrant tenderness (aOR = 3.0, p = 0.008), Asian race (aOR = 2.7, p = 0.014), and intraoperative adhesions (aOR = 13.0, p < 0.001) were found to carry independent risk for BOC. Surgeon bailout rate ≥ 7% was also found to be an independent risk factor for conversion to BOC.

CONCLUSIONS

Male gender, signs of biliary inflammation (tachycardia, leukocytosis, dilated CBD, and diagnosis of acute cholecystitis), as well as surgeon bailout rate of 7% were independent risk factors for BOC.

The predictive significance of neutrophil-to-lymphocyte ratio in cholecystitis: a systematic review and meta-analysis

PURPOSE

The aim of this review was to examine whether neutrophil-to-lymphocyte ratio (NLR) can predict the presence of cholecystitis and distinguish between simple and severe cholecystitis.

METHODS

A systematic literature search was performed. Risk of bias was assessed using the Newcastle-Ottawa Scale. Random effects model was used to calculate mean difference (MD) in two situations: (a) no cholecystitis versus cholecystitis and (b) simple versus severe cholecystitis. Receiver operating characteristic (ROC) curve analysis was performed to determine cut-off values of NLR for the above situations.

RESULTS

Ten retrospective studies comprising of 2827 patients were included. Three hundred twenty-seven had no cholecystitis, 2100 had simple cholecystitis and the remaining 400 had severe cholecystitis. NLR was significantly higher in acute cholecystitis compared to "no cholecystitis" (MD = 8.05 (95% CI 7.71-8.38), p < 0.01) and in severe cholecystitis when compared with simple cholecystitis (MD = 3.14 (95% CI 1.26-5.02), p < 0.01). For patients with cholecystitis compared to those without cholecystitis, an NLR cut-off value of 2.98 was identified (AUC = 0.90). Logistic regression analysis confirmed an NLR > 2.9 was an independent predictor of cholecystitis (OR 36.0, p = 0.006). In simple versus severe cholecystitis, an NLR cut-off value of 8.5 was identified (AUC = 0.73). Binary logistic regression analysis suggested an NLR > 8.5 was not an independent predictor of severe cholecystitis (OR 6.5 p = 0.090).

CONCLUSION

NLR is significantly higher in patients with cholecystitis of any severity compared to patients without cholecystitis. Moreover, NLR can predict acute cholecystitis. However, NLR cannot predict the severity of disease due to inadequately powered studies. Future research is required.