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Stoica PL, Serban D, Bratu DG, Serboiu CS, Costea DO, Tribus LC, Alius C, Dumitrescu D, Dascalu AM, Tudor C, Simion L, Tudosie MS, Comandasu M, Popa AC, Cristea BM. Predictive Factors for Difficult Laparoscopic Cholecystectomies in Acute Cholecystitis. Diagnostics (Basel) 2024; 14:346. [PMID: 38337862 PMCID: PMC10855974 DOI: 10.3390/diagnostics14030346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/02/2024] [Accepted: 02/03/2024] [Indexed: 02/12/2024] Open
Abstract
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.
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Affiliation(s)
- Paul Lorin Stoica
- Doctoral School, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania;
| | - Dragos Serban
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania;
| | - Dan Georgian Bratu
- Faculty of Medicine, University Lucian Blaga Sibiu, 550169 Sibiu, Romania
- Department of Surgery, Emergency County Hospital Sibiu, 550245 Sibiu, Romania
| | - Crenguta Sorina Serboiu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
| | - Daniel Ovidiu Costea
- Faculty of Medicine, Ovidius University Constanta, 900470 Constanta, Romania
- General Surgery Department, Emergency County Hospital Constanta, 900591 Constanta, Romania
| | - Laura Carina Tribus
- Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania;
- Department of Internal Medicine, Ilfov Emergency Clinic Hospital Bucharest, 022104 Bucharest, Romania
| | - Catalin Alius
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania;
| | - Dan Dumitrescu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania;
| | - Ana Maria Dascalu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
| | - Corneliu Tudor
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania;
| | - Laurentiu Simion
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
- Department of Surgical Oncology, Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Mihail Silviu Tudosie
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
| | - Meda Comandasu
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania;
| | - Alexandru Cosmin Popa
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
- Department of General Surgery, Colentina Clinic Hospital, 020125 Bucharest, Romania
| | - Bogdan Mihai Cristea
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
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Serban D, Stoica PL, Dascalu AM, Bratu DG, Cristea BM, Alius C, Motofei I, Tudor C, Tribus LC, Serboiu C, Tudosie MS, Tanasescu D, Vancea G, Costea DO. The Significance of Preoperative Neutrophil-to-Lymphocyte Ratio (NLR), Platelet-to-Lymphocyte Ratio (PLR), and Systemic Inflammatory Index (SII) in Predicting Severity and Adverse Outcomes in Acute Calculous Cholecystitis. J Clin Med 2023; 12:6946. [PMID: 37959411 PMCID: PMC10648653 DOI: 10.3390/jcm12216946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 10/31/2023] [Accepted: 11/03/2023] [Indexed: 11/15/2023] Open
Abstract
The prediction of severity in acute calculous cholecystitis (AC) is important in therapeutic management to ensure an early recovery and prevent adverse postoperative events. We analyzed the value of the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic inflammatory index (SII) to predict advanced inflammation, the risk for conversion, and postoperative complications in AC. Advanced AC was considered the cases with empyema, gangrene, perforation of the gallbladder, abscesses, or difficulties in achieving the critical view of safety. A 3-year retrospective was performed on 235 patients admitted in emergency care for AC. The NLR was superior to the PLR and SII in predicting advanced inflammation and risk for conversion. The best predictive value was found to be at an NLR "cut-off" value of >4.19, with a sensitivity of 85.5% and a specificity of 66.9% (AUC = 0.824). The NLR, SII, and TG 13/18 correlate well with postoperative complications of Clavien-Dindo grade IV (p < 0.001 for all variables) and sepsis. For predicting early postoperative sepsis, TG 13/18 grading >2 and NLR > 8.54 show the best predicting power (AUC = 0.931; AUC = 0.888, respectively), although not significantly higher than that of the PLR and SII. The NLR is a useful biomarker in assessing the severity of inflammation in AC. The SII and PLR may be useful in the prediction of systemic inflammatory response.
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Affiliation(s)
- Dragos Serban
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (D.S.); (B.M.C.); (C.A.); (I.M.); (C.S.); (G.V.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Paul Lorin Stoica
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (D.S.); (B.M.C.); (C.A.); (I.M.); (C.S.); (G.V.)
| | - Ana Maria Dascalu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (D.S.); (B.M.C.); (C.A.); (I.M.); (C.S.); (G.V.)
| | - Dan Georgian Bratu
- Faculty of Medicine, University Lucian Blaga Sibiu, 550169 Sibiu, Romania;
- Department of Surgery, Emergency County Hospital Sibiu, 550245 Sibiu, Romania
| | - Bogdan Mihai Cristea
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (D.S.); (B.M.C.); (C.A.); (I.M.); (C.S.); (G.V.)
| | - Catalin Alius
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (D.S.); (B.M.C.); (C.A.); (I.M.); (C.S.); (G.V.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Ion Motofei
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (D.S.); (B.M.C.); (C.A.); (I.M.); (C.S.); (G.V.)
- Department of General Surgery, Emergency Clinic Hospital “Sf. Pantelimon” Bucharest, 021659 Bucharest, Romania
| | - Corneliu Tudor
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (D.S.); (B.M.C.); (C.A.); (I.M.); (C.S.); (G.V.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Laura Carina Tribus
- Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania
- Department of Internal Medicine, Ilfov Emergency Clinic Hospital Bucharest, 022104 Bucharest, Romania
| | - Crenguta Serboiu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (D.S.); (B.M.C.); (C.A.); (I.M.); (C.S.); (G.V.)
| | - Mihail Silviu Tudosie
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (D.S.); (B.M.C.); (C.A.); (I.M.); (C.S.); (G.V.)
| | - Denisa Tanasescu
- Department of Nursing and Dentistry, Faculty of General Medicine, University Lucian Blaga Sibiu, 550169 Sibiu, Romania;
| | - Geta Vancea
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (D.S.); (B.M.C.); (C.A.); (I.M.); (C.S.); (G.V.)
- Clinical Hospital of Infectious and Tropical Diseases “Dr. Victor Babes”, 030303 Bucharest, Romania
| | - Daniel Ovidiu Costea
- Faculty of Medicine, Ovidius University Constanta, 900470 Constanta, Romania;
- General Surgery Department, Emergency County Hospital Constanta, 900591 Constanta, Romania
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Alius C, Serban D, Bratu DG, Tribus LC, Vancea G, Stoica PL, Motofei I, Tudor C, Serboiu C, Costea DO, Serban B, Dascalu AM, Tanasescu C, Geavlete B, Cristea BM. When Critical View of Safety Fails: A Practical Perspective on Difficult Laparoscopic Cholecystectomy. Medicina (Kaunas) 2023; 59:1491. [PMID: 37629781 PMCID: PMC10456257 DOI: 10.3390/medicina59081491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/12/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023]
Abstract
The incidence of common bile duct injuries following laparoscopic cholecystectomy (LC) remains three times higher than that following open surgery despite numerous attempts to decrease intraoperative incidents by employing better training, superior surgical instruments, imaging techniques, or strategic concepts. This paper is a narrative review which discusses from a contextual point of view the need to standardise the surgical approach in difficult laparoscopic cholecystectomies, the main strategic operative concepts and techniques, complementary visualisation aids for the delineation of anatomical landmarks, and the importance of cognitive maps and algorithms in performing safer LC. Extensive research was carried out in the PubMed, Web of Science, and Elsevier databases using the terms "difficult cholecystectomy", "bile duct injuries", "safe cholecystectomy", and "laparoscopy in acute cholecystitis". The key content and findings of this research suggest there is high intersocietal variation in approaching and performing LC, in the use of visualisation aids, and in the application of safety concepts. Limited papers offer guidelines based on robust data and a timid recognition of the human factors and ergonomic concepts in improving the outcomes associated with difficult cholecystectomies. This paper highlights the most relevant recommendations for dealing with difficult laparoscopic cholecystectomies.
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Affiliation(s)
- Catalin Alius
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Dragos Serban
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Dan Georgian Bratu
- Faculty of Medicine, University “Lucian Blaga”, 550169 Sibiu, Romania; (D.G.B.)
- Department of Surgery, Emergency County Hospital Sibiu, 550245 Sibiu, Romania
| | - Laura Carina Tribus
- Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021Bucharest, Romania;
- Department of Internal Medicine, Ilfov Emergency Clinic Hospital Bucharest, 022104 Bucharest, Romania
| | - Geta Vancea
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
- Third Clinical Infectious Disease Department, Clinical Hospital of Infectious and Tropical Diseases “Dr. Victor Babes”, 030303 Bucharest, Romania
| | - Paul Lorin Stoica
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Ion Motofei
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
- Department of General Surgery, Emergency Clinic Hospital “Sf. Pantelimon” Bucharest, 021659 Bucharest, Romania
| | - Corneliu Tudor
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Crenguta Serboiu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
| | - Daniel Ovidiu Costea
- Faculty of Medicine, Ovidius University Constanta, 900470 Constanta, Romania;
- General Surgery Department, Emergency County Hospital Constanta, 900591 Constanta, Romania
| | - Bogdan Serban
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
| | - Ana Maria Dascalu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
| | - Ciprian Tanasescu
- Faculty of Medicine, University “Lucian Blaga”, 550169 Sibiu, Romania; (D.G.B.)
- Department of Surgery, Emergency County Hospital Sibiu, 550245 Sibiu, Romania
| | - Bogdan Geavlete
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
| | - Bogdan Mihai Cristea
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
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