The pre-operative predictive model for difficult elective laparoscopic cholecystectomy: A modification

Development and validation of a radiologically-based nomogram for preoperative prediction of difficult laparoscopic cholecystectomy

Background

Preoperative prediction of difficult laparoscopic cholecystectomy (DLC) remains challenging, as intraoperative anatomical complexity significantly increases complication risks. Current studies have not reached consensus on definitive risk factors for DLC.

Materials and methods

This retrospective study aimed to identify DLC risk factors and develop a predictive model. We analyzed clinical data from 265 patients undergoing laparoscopic cholecystectomy (LC) at the Department of General Surgery, Shijiazhuang People's Hospital, between September 2022 and June 2024. Risk factors were explored through least absolute shrinkage and selection operator (LASSO) regression, multivariate analysis, and receiver operating characteristic (ROC) curves, with a nomogram constructed for prediction.

Results

Among 265 eligible patients, four independent risk factors were identified: thickness of gallbladder wall (p = 0.0007), cystic duct length (p < 0.0001), cystic duct diameter (p < 0.0001), and gallbladder neck stones (p = 0.0002). The nomogram demonstrated strong predictive performance, with an area under the curve (AUC) of 0.915 in the training cohort and 0.842 in the validation cohort. Calibration curves indicated excellent model fit.

Conclusion and discussion

The proposed predictive model integrating gallbladder neck stones, thickness of gallbladder wall, cystic duct length, and cystic duct diameter may assist surgeons in preoperative DLC risk stratification. Further validation through multicenter prospective studies is warranted.

Development and validation of a nomogram to predict the need for bailout procedure in laparoscopic cholecystectomy: A multicenter study of 1,898 cases

BACKGROUND

Laparoscopic cholecystectomy is the standard treatment for benign gallbladder disease. A bailout procedure is recommended for patients with severe inflammation. This study identified the preoperative factors that predict bailout procedures and developed a predictive nomogram.

METHODS

A total of 1,898 patients with laparoscopic cholecystectomy from 5 institutions (2015-2020) were divided into training (n = 1,518) and validation (n = 380) sets. Logistic regression was employed to predict bailout procedures and to develop a nomogram on the basis of the training set. The accuracy of the nomogram was evaluated using receiver operating characteristic curve analysis of the validation set. Postoperative outcomes were compared between qualified surgeons certified by the Japanese Society for Endoscopic Surgery and residents who had graduated from a medical university within the past 5 years.

RESULTS

Bailout procedures were performed in 262 (13.8%) patients. Multivariate analysis identified several significant predictors, including sex, age, gallbladder drainage, severity of acute cholecystitis, stone impaction of the gallbladder neck, and serum C-reactive protein. The nomogram achieved an area under the curve of 0.788 in the training set and 0.769 in the validation set. Intraoperative complications were significantly fewer in the qualified surgeon group than in the nonqualified surgeon group.

CONCLUSION

The nomogram aids surgeons in identifying high-risk patients and making informed decisions about bailout procedures, thereby ensuring patient safety. Involving qualified surgeons in case predicted to be difficult cholecystectomies may help prevent help to avoid intraoperative complications.

Prospective validation of a preoperative scoring system for difficult laparoscopy cholecystectomy

Difficult laparoscopic cholecystectomy (LC) is defined by its surgical outcomes, including operative time, conversion to open surgery, bile duct and/or vascular injury. Difficult LC can be graded based on intraoperative findings. The main objective of this study is to apply and validate the reliability of their proposed risk score to predict the operative difficulty of an LC, based on their own validated intraoperative scale. Single-center prospective cohort study from 01/2020-12-2023. 367 patients > 18 years who underwent LC were included. The preoperative risk scale and intraoperative grading system were registered. Surgical outcomes were determined. Predictive accuracy was evaluated by the Receiver Operator Characteristic curve, sensitivity, specificity, positive, and negative predictive values, and Youden's Index (J). Patients' mean age was 44.1 ± 15.3 years. According to the risk score, 39.5% LC were "low" risk difficulty, 49.3% were "medium" risk, and 11.2% were "high" risk difficult LC. Based on the intraoperative grading system, 31.9% were difficult LC (Nassar grades 3-4) and 68.1% were easy LC (Nassar grades 1-2). There was a statistically significant correlation (0.428, p < 0.05) between the preoperative risk score and the intraoperative grading system. The AUC for the preoperative risk score scale and intraoperative difficult LC was 0.735 (95% CI 0.687-0.779) (J: 0.34). A preoperative risk score > 1.5 had an 83.7% sensitivity and a 50.8% specificity for intraoperative difficult LC. A predictive preoperative score for difficult LC and a routine collection of the intraoperative difficulty should be implemented to improve surgical outcomes and surgical planning.

New Proposed Classification of Difficulty in Laparoscopic Cholecystectomy

Background: Difficult laparoscopic cholecystectomy (LC) has been challenging for surgeons. Randhawa's system used operative time, complications, and conversion to define three difficulty grades. However, using fixed numbers of operative time as dividers among three groups might not be applicable universally. This study aimed to propose new classification with more flexible parameters. Methods: This retrospective cohort study was conducted with patients who underwent LC because of gallstone-related diseases between January 2017 and December 2021 at Thammasat University Hospital. The exclusion criteria were (1) emergent LC for acute cholecystitis, (2) other procedures performed in the same setting of LC, (3) incomplete information, and (4) LC converted to open cholecystectomy. Patients were categorized into three groups using Randhawa's classification. Thereafter, new classification using mean and standard deviation was applied to reclassify patients into three new groups. The comparison between two grading results was performed to prove the advantage of new classification. Results: Total of 523 patients who underwent LC were included with median age 59.3 years old and 60.8% female. By Randhawa classification, proportions of easy, difficult, and very difficult groups were 39%, 53.7%, and 7.3%, respectively. Then, the new operative-time dividers among three groups were changed from 60 and 120 minutes to mean and mean + 2SD, respectively. Reclassified three difficult groups were 38.9%, 57.1%, and 4%. The comparison demonstrated new classification as more flexible and more compatible with each individual surgeon. Conclusions: New surgeon-referenced grading system of difficult LC included surgeon's factors, not only unfavorable operative findings. This classification should be more flexible than the previous criterion-referenced one. Thai Clinical Trials Registry at https://www.thaiclinicaltrials.org with Number TCTR20220426003.

Preoperative diagnostic criteria for scleroatrophic gallbladder: A systematic review protocol

BACKGROUND

Although scleroatrophic gallbladder is a rare condition, it presents significant clinical challenges in diagnosis and management. More agreement is needed on this disorder's diagnostic criteria and optimal management approach. We will conduct a systematic review to summarise the scleroatrophic gallbladder's preoperative diagnostic criteria, including imaging modalities.

METHODS

A systematic review will be undertaken using the PRISMA guidelines. The protocol has been registered in PROSPERO (CRD42024503701). We will search in Medline (via PubMed), Embase, SCOPUS, the Cochrane Library, and Web of Science to find original studies reporting about scleroatrophic gallbladder or synonymous. Two reviewers will independently screen the titles and abstracts following the eligibility criteria. We will include all types of studies that describe any diagnostic criteria or tools. After retrieving the full text of the selected studies, we will conduct a standardised data extraction. Finally, a narrative synthesis will be performed. The quality of the identified studies will be assessed using the Quality Assessment of Diagnostic Accuracy Studies- 2 tool.

DISCUSSION

This systematic review will provide information on the preoperative diagnostic criteria of the scleroatrophic gallbladder and the value of imaging studies in its diagnosis. In addition, this work will aid doctors in the decision-making process for diagnosing scleroatrophic gallbladder and propose treatment approaches to this condition.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered in PROSPERO (CRD42024503701).

Risk Factors and Prevalence Associated With Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy: A Tertiary Care Hospital Experience in Western Mexico

Introduction Laparoscopic cholecystectomy (LC) is a common procedure used for the treatment of different pathologies caused by gallstones in the gallbladder, and one of the most common indications is acute cholecystitis. The definitive treatment for acute cholecystitis is surgery, and LC is the gold standard. Nevertheless, transoperative complications (like intraoperative bleeding, anatomical abnormalities of the gallbladder, etc.) of LC and some other preoperative factors (like dilatation of bile duct, increased gallbladder wall thickness, etc.) can cause or be a risk factor for conversion to open cholecystectomy (OC). The objective of this study was to determine the risk factors and prevalence associated with the conversion from LC to OC in patients with gallbladder pathology and the indication for LC. Materials and methods This was a prospective cohort study. We included patients of both sexes over 18 years of age with gallbladder disease. To determine the risk factors associated with conversion, we performed a bivariate analysis and then a multivariate analysis. Results The rate of conversion to OC was 4.54%. The preoperative factors associated with conversion, in the bivariate analysis, were common bile duct dilatation (p=0.008), emergency surgery (p=0.014), and smoking (p=0.001); the associated intraoperative variables were: laparoscopic surgery duration (p <0.0001), Calot triangle edema (p=0.033), incapacity to hold the gallbladder with atraumatic laparoscopic tweezers (p=0.036), and choledocholithiasis (p=0.042). Laparoscopic Surgery duration was the only factor with a significant association in the multivariate analysis (p=0.0036); we performed a receiver operating characteristic (ROC) curve analysis and found a cut-off point of 120 minutes for the duration of laparoscopic surgery with a sensitivity and a specificity of 67 and 88%, respectively. Conclusion The prevalence of conversion from LC to OC is similar to that reported in the international literature. The risk factors associated with conversion to OC, in this study, should be confirmed in future clinical studies, in this same population, with a larger sample size.

The Modification of a Preoperative Scoring System to Predict Difficult Elective Laparoscopic Cholecystectomy

Background: Laparoscopic cholecystectomy (LC) is one of the most common abdominal operations. The difficult cases are still challenging for surgeons. There had been many studies providing several preoperative models to predict difficult LC or conversion. Randhawa's scoring system was a simple and practical predictive model for clinicians. The modification was reported to be more preferable for delayed LC. This study aimed to confirm the advantage of modified predictive model in larger sample size. Materials and Methods: This retrospective cohort study reviewed medical records of patients who underwent LC since January 2017 to December 2021. The difficulty of operation was categorized into three groups: easy, difficult, and very difficult. Multivariate analysis was performed to define significant factors of very difficult and converted cases. The predictive scores were calculated by using the original Randhawa's model and the modification, then compared with actual outcome. Results: There were 567 cases of delayed LC in this study, with 44 cases (7.8%) converted to open cholecystectomy. Four factors (previous cholecystitis, previous endoscopic retrograde cholangiopancreatography, higher ALP, and gallbladder wall thickening) for very difficult group and five factors (previous cholecystitis, previous cholangitis, higher white blood cell count, gallbladder wall thickening, and contracted gallbladder) for conversion were significant. The modification provided the better correlation and higher area of receiver operating characteristic (ROC) curve comparing with the original model. Conclusion: The modification of Randhawa's model was supposed to be more preferable for predicting the difficulty in elective LC. Thai Clinical Trials Registry No. 20220712006.

Preoperative Risk Factors for Conversion from Laparoscopic to Open Cholecystectomy: A Systematic Review and Meta-Analysis

Laparoscopic cholecystectomy is a standard treatment for patients with gallstones in the gallbladder. However, multiple risk factors affect the probability of conversion from laparoscopic cholecystectomy to open surgery. A greater understanding of the preoperative factors related to conversion is crucial to improve patient safety. In the present systematic review, we summarized the current knowledge about the main factors associated with conversion. Next, we carried out several meta-analyses to evaluate the impact of independent clinical risk factors on conversion rate. Male gender (OR = 1.907; 95%CI = 1.254−2.901), age > 60 years (OR = 4.324; 95%CI = 3.396−5.506), acute cholecystitis (OR = 5.475; 95%CI = 2.959−10.130), diabetes (OR = 2.576; 95%CI = 1.687−3.934), hypertension (OR = 1.931; 95%CI = 1.018−3.662), heart diseases (OR = 2.947; 95%CI = 1.047−8.296), obesity (OR = 2.228; 95%CI = 1.162−4.271), and previous upper abdominal surgery (OR = 3.301; 95%CI = 1.965−5.543) increased the probability of conversion. Our analysis of clinical factors suggested the presence of different preoperative conditions, which are non-modifiable but could be useful for planning the surgical scenario and improving the post-operatory phase.

[Measures for preventing bile duct injuries during difficult cholecystectomies-Bail-out procedures]

BACKGROUND

Cholecystectomies can sometimes be very complex operations, which place high demands on the surgeon.

OBJECTIVE

Are there preoperative and intraoperative procedures available for reducing the risk of intraoperative bile duct injuries during a complex cholecystectomy?

RESULTS

The complexity of the operation should be estimated preoperatively. Extended diagnostic examinations, preoperative biliary stenting and the performance of the operation by an experienced surgeon may help to reduce the operative risk. In high-risk patients, postponing the cholecystectomy may be indicated. The timely intraoperative recognition of the impossibility to perform a regular cholecystectomy is of decisive importance. In this situation, so-called bail-out procedures, such as fundus-down cholecystectomy or subtotal cholecystectomy are warranted. Conversion from laparoscopic to open surgery is not always necessary.

CONCLUSION

Bail-out procedures are useful to reduce the risk of bile duct injuries during complex cholecystectomy and can enable a safe completion of the operation.