External Validation of Two Scoring Tools to Predict the Operative Duration and Open Conversion of Elective Laparoscopic Cholecystectomy in a Mexican Population

INTRODUCTION

This study aimed to evaluate the use of laparoscopic cholecystectomy (LC) operative time (CholeS score) and conversion to an open procedure (CLOC score) outside their validation dataset in Mexican population.

METHODS

Patients >18 years who underwent elective LC were analyzed in a single-center retrospective chart review study. Association between scores (CholeS and CLOC) with operative time and conversion to open procedures was assessed with Spearman correlation. The predictive accuracy of the CholeS score and CLOC score was evaluated by receiver operator characteristic.

RESULTS

200 patients were included in the study (33 excluded for emergency case or missing data). Spearman coefficient correlations between CholeS or CLOC score and operative time were 0.456 (p < 0.0001) and 0.356 (p < 0.0001), respectively. Area under the curve (AUC) for operative prediction time (>90 min) by CholeS score was 0.786 with a 3.5-point cutoff (80% sensitivity and 63.2% specificity). AUC for open conversion (CLOC score) was 0.78 with a 5-point cutoff (60% sensitivity and 91% specificity). The CLOC score had a 0.740 AUC (64% sensitivity and 72.8% specificity) for operative time >90 min.

CONCLUSIONS

The CholeS and the CLOC scores predicted LC long operative time and risk for conversion to an open procedure, respectively, outside their original validation set.

Performance of the American College of Surgeons National Surgical Quality Improvement calculator for early postoperative outcomes following bile duct repair hepaticojejunostomy

PURPOSE

A Roux-en-Y hepaticojejunostomy (HJ) is the preferred method for repairing bile duct injuries (BDIs). The American College of Surgeons (ACS) established the National Surgical Quality Improvement Program (NSQIP) online risk calculator to predict risks for morbidity and mortality. The objective of the study is to assess the use of the ACS NSQIP calculator for patients undergoing HJ for BDI repairs outside the NSQIP cohort.

METHODS

An IRB-approved retrospective study of Bismuth-Strasberg type E BDI HJ (2008-2020) was performed. Clinical data was introduced in the NSQIP calculator, and morbidity and mortality were determined. Perioperative risk factors were obtained. Comparisons of postoperative complications and NSQIP-predicted complication rate were carried out.

RESULTS

Eighty-two patients were included (age: 42.2 ± 15.7 years; 81% female; BMI 27.1 ± 4.4 kg/m2). The most common injury was E4 (36.3%). A total of 40.2% patients had a 30-day complication. Mortality was 2.4%. Preoperative sepsis and high body mass index (p = 0.01) were significantly related to complications (p = 0.01) (univariate analysis). Older age (p = 0.01) and higher ASA class (p = 0.02) were significantly related to mortality (univariate analysis). None was statistically significant in multivariate analysis. Comparison between morbidity and mortality and the calculated NSQIP was not statistically significant. Postoperative mortality had a statistically significant trend (C-value = 0.72, p = 0.055).

CONCLUSION

Preoperative sepsis, high body mass index, age, and ASA classification were associated with worse outcomes in HJ BDI repair. The ACS NSQIP calculator did not have a good performance in a population outside the NSQIP data. Further larger studies will need to corroborate these results.

Factors associated with patency loss and actuarial patency rate following post-cholecystectomy bile duct injury repair: long-term follow-up

PURPOSE

Several factors may contribute to bile duct injury (BDI) repair failure. The objective of our study was to evaluate factors that contribute to the loss of patency and influence the actuarial patency rate of BDI repairs in an 11-year period.

METHODS

Retrospective review study of patients who underwent a hepaticojejunostomy for a type E Bismuth-Strasberg BDI (2008-2019). The outcomes are the following: primary patency attained, loss of primary patency, and actuarial primary patency rate. Logistic regression for loss of patency and Cox regression for actuarial patency rate were used.

RESULTS

Seventy-nine patients (age 42.3 ± 15.8 years, 81% female) were studied. Most common index operation was open cholecystectomy (60.8%). Most common Bismuth-Strasberg lesion was E4 (38%). Primary patency was 93.4%. Mean follow-up was 36 ± 34 months. Ten-year actuarial patency was 53.9%. Factors associated with loss of patency were vasculobiliary injury, biliary stents, and 90-day biliary complications (univariate); number of surgeries before repair and postoperative cholangitis (univariate and multivariate) (p < 0.05). Factors that impacted actuarial patency rate were (univariate analysis) 90-day biliary complications; postoperative cholangitis and index treatment period stenosis (p < 0.05). No factors impacted actuarial patency rate in multivariate analysis.

CONCLUSION

Postoperative cholangitis is associated with loss of patency and had potentially detrimental effect on the actuarial patency rate in BDI repair.

Differences in Post-Cholecystectomy Bile Duct Injury Care: A Comparative Analysis of 2 Different Health-Care Public Institutions in a Low- and Middle-Income Country: Southeast Mexico

BACKGROUND

Mexican health system structure allows us to study the differences in bile duct injury (BDI) management. The study aimed to assess the differences in patients with complex BDI in 2 different public sector institutions using a new proposed standard terminology.

METHODS

Retrospective review (2008-2019) in 2 public institutions (IMSS/SESVER). Bismuth-Strasberg E injuries with hepaticojejunostomy were included. Data are presented in a tabular reporting system. The outcomes were percent of patients attaining primary patency, loss of primary patency, and actuarial primary patency rate.

RESULTS

Seventy-eight patients (IMSS: n = 37; SESVER: n = 41) without differences in demographic and preoperative assessment were studied. BDI occurred mostly in outside hospitals. Open cholecystectomy was the most common index operation in SESVER (73%, p = 0.02). IMSS had more surgeries (p = 0.007) and repair attempts (p = 0.06) prior to referral. Magnetic resonance cholangiopancreatography was more commonly used in IMSS patients. Biliary stents (45%) and cholangitis (29%) were more common in IMSS (p < 0.05). IMSS patients had longer follow-up than SESVER (p < 0.05). No differences in primary patency rates (IMSS: 89%, SESVER: 97%) and actuarial patency rates were noted.

DISCUSSION

Despite differences in referral, preoperative, and operative events, good BDI repair outcomes can be achieved. Longer follow-up is needed to monitor these outcomes.