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.

Overcoming Anatomical Challenges: Laparoscopic Cholecystectomy in Situs Inversus Totalis

Situs inversus totalis (SIT) is a rare genetic condition characterized by the sagittal inversion of thoracoabdominal organs. Surgeons may face substantial challenges when dealing with surgical pathologies in SIT patients, particularly those involving the gallbladder and bile ducts, such as cholelithiasis and acute cholecystitis. In this report, we present the case of a 46-year-old male with a previously known diagnosis of SIT, who presented with recurrent episodes of atypical abdominal pain. Cholelithiasis was diagnosed through ultrasound and as a result, elective surgery was scheduled. In addition, we detail the adjustments implemented by our surgical team in the laparoscopic cholecystectomy procedure, which contributed to a successful surgical outcome. Nevertheless, like any patient, those with SIT are not exempt from postoperative complications, as detailed in this case. Hence, we emphasize the importance of comprehensive preoperative diagnostics to reduce the risk of perioperative complications in this group of patients.

Difficult Laparoscopic Cholecystectomy Predictors and its Significance: Our Experience

Background

Laparoscopic cholecystectomy (LC) has become the procedure of choice for the management of symptomatic gallstone disease. In LC, the surgeons encountered difficulties with acutely inflamed or gangrenous gallbladder (GB), dense adhesions at Calot's triangle, fibrotic and contracted GB, and cholecystoenteric fistula. Depending on the difficulty faced during the surgery, the outcome of LC may vary from abandoning the procedure or partial cholecystectomy to conversion into open cholecystectomy. Complications related to biliary tract or adjoining structures or vessels may also occur. Our aim was to assess the different preoperative factors in patients of cholelithiasis and ascertain the validity of the scoring system devised by Randhawa and Pujahari in preoperatively predicting the difficult LC in our hospital scenario.

Materials and Methods

This hospital-based observational study was conducted in the Department of General Surgery for a period of 2 years. All diagnosed cases of cholelithiasis admitted for elective LC during the study period in our hospital were included in the study.

Results

In total, 154 patients, aged≥50 years, history of hospitalization for acute cholecystitis (AC), body mass index of 25 kg/m2 and more, abdominal scar, palpable GB, GB wall thickness ≥4 mm, pericholecystic collection, impacted stone found to be significant factors to predict difficult LC preoperatively. Endoscopic retrograde cholangiopancreatography and pancreatitis were found as independent risk factor for difficult LC.

Conclusion

We recommend that the scoring system should be regularly used as a protocol for predicting difficulty levels preoperatively in LC. It can help to decide the surgical approach, counsel the patients, and reduce the complication rate, rate of conversion, and overall medical cost. The scoring system proposed by Randhawa and Pujahari is effective but has some lacunae.

Preoperative Ultrasonography as a Predictor of Difficult Laparoscopic Cholecystectomy that Requires Conversion to Open Procedure

AIM

The present study was conducted to see whether preoperative ultrasonography can be used as a predictor of difficult lapariscopic cholecystectomy or not.

METHODS

50 patients of cholelithiasis, selected from surgical OPD of Rajindra Hospital Patiala, who fulfilled all inclusion and exclusion criteria for the study underwent elective cholecystectomy. Ultrasonography was done pre-operatively on all cases in the same setup and with same probe and patients underwent laparoscopic cholecystectomy in same setup.

RESULTS

A significant prediction was found between ultrasonographic parameters and conversion of the procedure to open cholecystectomy which proved that pre-operative ultrasonography is a good predictor of difficulty in laparoscopic cholecystectomy in majority of the cases and should be used as a screening procedure.

CONCLUSION

Preoperative ultrasonography should be used as a screening procedure as it is a good predictor of difficulty in laparoscopic cholecystectomy in majority of the cases. It can help surgeon to get an idea of potential difficulty that he can face in the particular patient.