Preoperative predictors of difficult early laparoscopic cholecystectomy among patients with acute calculous cholecystitis in Egypt

Abstract

Background: Early laparoscopic cholecystectomy (ELC) in the setting of acute calculous cholecystitis (ACC) requires to be performed by highly-skilled surgeons to avoid complications. The purpose of this study is to identify preoperative factors that would predict difficult ELC among patients with ACC prior to proceeding with surgery.

Methods: We retrospectively reviewed all patients who received ELC within 10 days from the onset of symptoms of ACC between August 1, 2018, and December 31, 2022. They were divided into 2 groups according to the difficulty of surgery.

Results: 149 patients with ACC received ELC during the study period. ELC was considered difficult in 52 patients (35%). Five preoperative factors were identified as significant predictors of difficult ELC (DELC) on multivariate analysis: duration of acute attack ≥ 4 days from the onset of symptoms till surgery (OR 34.4, P < 0.001), ultrasound showing largest gallstone size > 20 mm (OR 20.2, P = 0.029), ultrasound showing gallstone impaction in Hartmann's pouch (OR 7.2, P = 0.017), history of prior episode(s) of acute attack (OR 6.8, P = 0.048), and diabetes mellitus (OR 5.8, P = 0.046).

Conclusion: Careful preoperative assessment of patients with ACC is crucial among junior surgeons with limited surgical expertise prior to proceeding with ELC to identify those at risk of DELC to potentially reduce postoperative morbidity and mortality. If encountered, a management plan should be made, and surgery should proceed only upon confirming the availability of experienced surgeons in the field of biliary and laparoscopic surgery to supervise or assist in the procedure. Alternatively, such group of patients should rather be transferred to more advanced surgical centers which offer higher level of care to maintain patient safety and optimal surgical outcomes. More importantly, bail-out procedures should always be resorted to whenever DELC is encountered intraoperatively to prevent further surgical damage.

Keywords: Acute calculous cholecystitis; Difficult early laparoscopic cholecystectomy; Predictors; Risk factors.

Fig. 1

Intraoperative findings during ELC showing GB concealed by dense omental adhesions (A); dense visceral adhesions (duodenum) with the GB (B); GB difficult to grasp due to marked distension necessitating percutaneous needle aspiration (C); and acute cholecystitis difficult to grasp due to marked wall thickness and edema (D)

Fig. 2

Intraoperative findings during ELC showing GB wall gangrene (A); frozen Calot’s triangle by dense adhesions (B); large stone impaction in Hartmann’s pouch (C); and large stone impacted in gallbladder neck with very short and wide cystic duct requiring suture-ligation (D)

Fig. 3

Flow chart showing study design and the population of patients included in the analysis over 53-month-period

Fig. 4

ROC curve showing goodness-of-fit of the model with AUROC = 0.97 (95% CI 0.95–0.99, P < 0.001)