Intra-operative gallbladder scoring predicts conversion of laparoscopic to open cholecystectomy: a WSES prospective collaborative study

Michael Sugrue, Federico Coccolini, Magda Bucholc, Alison Johnston, Contributors from WSES, Dimitrios Manatakis, Orestis Ioannidis, Stefano Bonilauri, Mahir Gachabayov, Arda Isik, Wagih Ghnnam, Vishal Shelat, Muyiwa Aremu, Rajashekar Mohan, Giulia Montori, Maciej Walędziak, Magdalena Pisarska, Victor Kong, Marcin Strzałka, Paola Fugazzola, Gabriela Elisa Nita, Matteo Nardi, Piotr Major, Ionut Negoi, Andrea Allegri, Georgios Konstantoudakis, Isidoro Di Carlo, Damien Massalou, Giuseppe D'Amico, Leonardo Solaini, Marco Ceresoli, Roberto Bini, Martin Zielinski, Matteo Tomasoni, Andrey Litvin, Belinda De Simone, Eftychios Lostoridis, Fernando Hernandez, Gabor Panyor, Gustavo M Machain V, Ioanna Pentara, Luca Baiocchi, Kin Cheung Ng, Luca Ansaloni, Massimo Sartelli, Miguel Leon Arellano, Natalia Savala, Neville Couse, Sarah McBride, Michael Sugrue, Federico Coccolini, Magda Bucholc, Alison Johnston, Contributors from WSES, Dimitrios Manatakis, Orestis Ioannidis, Stefano Bonilauri, Mahir Gachabayov, Arda Isik, Wagih Ghnnam, Vishal Shelat, Muyiwa Aremu, Rajashekar Mohan, Giulia Montori, Maciej Walędziak, Magdalena Pisarska, Victor Kong, Marcin Strzałka, Paola Fugazzola, Gabriela Elisa Nita, Matteo Nardi, Piotr Major, Ionut Negoi, Andrea Allegri, Georgios Konstantoudakis, Isidoro Di Carlo, Damien Massalou, Giuseppe D'Amico, Leonardo Solaini, Marco Ceresoli, Roberto Bini, Martin Zielinski, Matteo Tomasoni, Andrey Litvin, Belinda De Simone, Eftychios Lostoridis, Fernando Hernandez, Gabor Panyor, Gustavo M Machain V, Ioanna Pentara, Luca Baiocchi, Kin Cheung Ng, Luca Ansaloni, Massimo Sartelli, Miguel Leon Arellano, Natalia Savala, Neville Couse, Sarah McBride

Abstract

Introduction: Laparoscopic cholecystectomy, the gold-standard approach for cholecystectomy, has surprisingly variable outcomes and conversion rates. Only recently has operative grading been reported to define disease severity and few have been validated. This multicentre, multinational study assessed an operative scoring system to assess its ability to predict the need for conversion from laparoscopic to open cholecystectomy.

Methods: A prospective, web-based, ethically approved study was established by WSES with a 10-point gallbladder operative scoring system; enrolling patients undergoing elective or emergency laparoscopic cholecystectomy between January 2016 and December 2017. Gallbladder surgery was considered easy if the G10 score < 2, moderate (2 ≦ 4), difficult (5 ≦ 7) and extreme (8 ≦ 10). Demographics about the patients, surgeons and operative procedures, use of cholangiography and conversion rates were recorded.

Results: Five hundred four patients, mean age 53.5 (range 18-89), were enrolled by 55 surgeons in 16 countries. Surgery was performed by consultants in 70% and was elective in (56%) with a mean operative time of 78.7 min (range 15-400). The mean G10 score was 3.21, with 22% deemed to have difficult or extreme surgical gallbladders, and 71/504 patients were converted. The G10 score was 2.98 in those completed laparoscopically and 4.65 in the 71/504 (14%) converted. (p < 0.0001; AUC 0.772 (CI 0.719-0.825). The optimal cut-off point of 0.067 (score of 3) was identified in G10 vs conversion to open cholecystectomy. Conversion occurred in 33% of patients with G10 scores of ≥ 5. The four variables statistically predictive of conversion were GB appearance-completely buried GB, impacted stone, bile or pus outside GB and fistula.

Conclusion: The G10 operative scores provide simple grading of operative cholecystectomy and are predictive of the need to convert to open cholecystectomy. Broader adaptation and validation may provide a benchmark to understand and improve care and afford more standardisation in global comparisons of care for cholecystectomy.

Keywords: Cholecystitis; Conversion to open cholecystectomy; Index surgery; Operative severity scoring system; Surgical outcomes.

Conflict of interest statement

Not applicableEthical approval for the audit was obtained from each contributor’s individual institution. Consent to participate was not applicable.Not applicableMichael Sugrue is a consultant with Smith & Nephew and Acelity.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
The relationship between the number of cholecystectomies performed and conversion, (rho = −0.17)

References

    1. Lombardo S, Rosenberg J, Kim J, Erdene S, Sergelen O, Nellermoe J, Finlayson S, Price R. Cost and outcomes of open versus laparoscopic cholecystectomy in Mongolia. J Surg Res. 2018;229:186–191. doi: 10.1016/j.jss.2018.03.036.
    1. van de Graaf F, van den Bos J, Stassen L, Lange J. Lacunar implementation of the critical view of safety technique for laparoscopic cholecystectomy: results of a nationwide survey. Surgery. 2018;164(1):31–39. doi: 10.1016/j.surg.2018.01.016.
    1. Pitt HA. Patient value is superior with early surgery for acute cholecystitis. Ann Surg. 2014;259:16–17. doi: 10.1097/SLA.0000000000000428.
    1. Sugrue M, Maier R, Moore E, Boermeester M, Catena F, Coccolini F, Leppaniemi A, Peitzman A, Velmahos G, Ansaloni L, Abu-Zidan F. Proceedings of resources for optimal care of acute care and emergency surgery consensus summit Donegal Ireland. World J Emerg Surg. 2017;12(1):47. doi: 10.1186/s13017-017-0158-x.
    1. Wakabayashi G, Iwashita Y, Hibi T, Takada T, Strasberg S, Asbun H, Endo I, Umezawa A, Asai K, Suzuki K, Mori Y. Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos) J Hepatobiliary Pancreat Sci. 2018;25(1):73–86. doi: 10.1002/jhbp.517.
    1. Vera K, Pei K, Schuster K, Davis K. Validation of a new American Association for the Surgery of Trauma (AAST) anatomic severity grading system for acute cholecystitis. J Trauma Acute Care Surg. 2018;84(4):650–654. doi: 10.1097/TA.0000000000001762.
    1. Sugrue M, Sahebally S, Ansaloni L, Zielinski M. Grading operative findings at laparoscopic cholecystectomy- a new scoring system. World J Emerg Surg. 2015;10:14. doi: 10.1186/s13017-015-0005-x.
    1. Bharamgoudar R, Sonsale A, Hodson J, Griffiths E, CholeS Study Group, West Midlands Research Collaborative. The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy. Surg Endosc 2018; 32(7):3149–3157.
    1. Sutcliffe R, Hollyman M, Hodson J, Bonney G, Vohra R, Griffiths E, Fenwick S, Elmasry M, Nunes Q, Kennedy D, Khan R. Preoperative risk factors for conversion from laparoscopic to open cholecystectomy: a validated risk score derived from a prospective UK database of 8820 patients. J Hepatobiliary Pancreat Sci. 2016;18(11):922–928.
    1. Madni T, Leshikar D, Minshall C, Nakonezny P, Cornelius C, Imran J, Clark A, Williams B, Eastman A, Minei J, Phelan H. The Parkland grading scale for cholecystitis. Am J Surg. 2018;215(4):625–630. doi: 10.1016/j.amjsurg.2017.05.017.
    1. Hernandez M, Murphy B, Aho J, Haddad N, Saleem H, Zeb M, Morris D, Jenkins D, Zielinski M. Validation of the AAST EGS acute cholecystitis grade and comparison with the Tokyo guidelines. Surgery. 2018;163(4):739–746. doi: 10.1016/j.surg.2017.10.041.
    1. Yokoe M, Takada T, Strasberg S, Solomkin J, Mayumi T, Gomi H, Pitt H, Gouma D, Garden O, Büchler M, Kiriyama S. New diagnostic criteria and severity assessment of acute cholecystitis in revised Tokyo Guidelines. J Hepatobiliary Pancreat Sci. 2012;19(5):578–585. doi: 10.1007/s00534-012-0548-0.
    1. World Society of Emergency Surgery Trials Registry. G10-Trial.2016. Available on-line at
    1. Ansaloni L, Pisano M, Coccolini F, Peitzmann A, Fingerhut A, Catena F, Agresta F, Allegri A, Bailey I, Balogh Z, Bendinelli C. 2016 WSES guidelines on acute calculous cholecystitis. World J Emerg Surg. 2016;11(1):25. doi: 10.1186/s13017-016-0082-5.
    1. Griffiths E. Two operative grading systems to define the difficulty of cholecystectomy. Comment in response to: Sugrue M, Sahebally S, Ansaloni L, Zielinski M. Grading operative findings at laparoscopic cholecystectomy- a new scoring system. World J Emerg Surg. 2015;10:14. doi: 10.1186/s13017-015-0005-x.
    1. Sheffield K, Ramos K, Djukom C, Jimenez C, Mileski W, Kimbrough T, Townsend C, Jr, Riall T. Implementation of a critical pathway for complicated gallstone disease: translation of population-based data into clinical practice. J Am Coll Surg. 2011;212(5):835–843. doi: 10.1016/j.jamcollsurg.2010.12.047.
    1. Litynski G. Erich Mühe and the rejection of laparoscopic cholecystectomy (1985): a surgeon ahead of his time. J Soc Laparoendosc Surg. 1998;2(4):341.
    1. Ogola G, Crandall M, Shafi S. Variations in outcomes of emergency general surgery patients across hospitals: a call to establish emergency general surgery quality improvement program. J Trauma Acute Care Surg. 2018;84(2):280–286. doi: 10.1097/TA.0000000000001755.
    1. Hanna G, Shimi S, Cuschieri A. Randomised study of influence of two-dimensional versus three-dimensional imaging on performance of laparoscopic cholecystectomy. Lancet. 1998;351(9098):248–251. doi: 10.1016/S0140-6736(97)08005-7.
    1. Nassar A, Ashkar K, Mohamed A, Hafiz A. Is laparoscopic cholecystectomy possible without video technology? Min Invas Ther. 1995;4(2):63–65. doi: 10.3109/13645709509152757.
    1. Guan G, Sun C, Ren Y, Zhao Z, Ning S. Comparing a single-staged laparoscopic cholecystectomy with common bile duct exploration versus a two-staged endoscopic sphincterotomy followed by laparoscopic cholecystectomy. Surgery. 2018;164(5):1030–1034. doi: 10.1016/j.surg.2018.05.052.
    1. Pan L, Chen M, Ji L, Zheng L, Yan P, Fang J, Zhang B, Cai X. The safety and efficacy of laparoscopic common bile duct exploration combined with cholecystectomy for the management of cholecysto-choledocholithiasis: an up-to-date meta-analysis. Ann Surg. 2018;268(2):247–253. doi: 10.1097/SLA.0000000000002731.
    1. Noel R, Arnelo U, Enochsson L, Lundell L, Nilsson M, Sandblom G. Regional variations in cholecystectomy rates in Sweden: impact on complications of gallstone disease. Scand J Gastroenterol. 2016;51(4):465–471. doi: 10.3109/00365521.2015.1111935.
    1. CholeS Study Group, West Midlands Research Collaborative. Vohra R, Pasquali S, Kirkham A, Marriott P, Johnstone M, Spreadborough P, Alderson D, Griffiths E, Fenwick S, Elmasry M. Population-based cohort study of outcomes following cholecystectomy for benign gallbladder diseases. Br J Surg. 2016;103(12):1704–1715. doi: 10.1002/bjs.10287.
    1. Hu A, O’Donohue P, Gunnarsson R, de Costa A. External validation of the Cairns Prediction Model (CPM) to predict conversion from laparoscopic to open cholecystectomy. Am J Surg. 2018;216(5):949–954. doi: 10.1016/j.amjsurg.2018.03.016.
    1. Törnqvist B, Strömberg C, Persson G, Nilsson M. Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study. BMJ. 2012;345:e6457. doi: 10.1136/bmj.e6457.
    1. Hall B, Armijo P, Krause C, Burnett T, Oleynikov D. Emergent cholecystectomy is superior to percutaneous cholecystostomy tube placement in critically ill patients with emergent calculous cholecystitis. Am J Surg. 2017;216(1):116–119. doi: 10.1016/j.amjsurg.2017.11.002.
    1. Yeo C, Tay V, Low J, Woon W, Punamiya S, Shelat V. Outcomes of percutaneous cholecystostomy and predictors of eventual cholecystectomy. J Hepatobiliary Pancreat Sci. 2016;23(1):65–73. doi: 10.1002/jhbp.304.
    1. Cherng N, Witkowski E, Sneider E, Wiseman J, Lewis J, Litwin D, Santry H, Cahan M, Shah S. Use of cholecystostomy tubes in the management of patients with primary diagnosis of acute cholecystitis. J Am Coll Surg. 2012;214(2):196–201. doi: 10.1016/j.jamcollsurg.2011.11.005.
    1. Goonawardena J, Gunnarsson R, De Costa A. Predicting conversion from laparoscopic to open cholecystectomy presented as a probability nomogram based on preoperative patient risk factors. Am J Surg. 2015;210(3):492–500. doi: 10.1016/j.amjsurg.2015.04.003.
    1. van den Boom A, de Wijkerslooth E, Mauff K, Dawson I, van Rossem C, Toorenvliet B, Wijnhoven B. Interobserver variability in the classification of appendicitis during laparoscopy. Br J Surg. 2018;105(8):1014–1019. doi: 10.1002/bjs.10837.
    1. Peponis T, Baekgaard J, Bohnen J, Han K, Lee J, Saillant N, Fagenholz P, King D, Velmahos G, Kaafarani H. Are surgeons reluctant to accurately report intraoperative adverse events? A prospective study of 1,989 patients. Surgery. 2018. Article in press; available online at. 10.1016/j.surg.2018.04.035.
    1. Amirthalingam V, Low J, Woon W, Shelat V. Tokyo Guidelines 2013 may be too restrictive and patients with moderate and severe acute cholecystitis can be managed by early cholecystectomy too. Surg Endosc. 2017;31(7):2892–2900. doi: 10.1007/s00464-016-5300-4.
    1. Sugrue M, Sahebally S, Ansaloni L, Zielinski M, Coccolini F. In response to the article entitled “The Parkland grading scale for cholecystitis” by Madni et al. In Madni T, Leshikar D, Minshall C, Nakonezny P, Cornelius C, Imran J, Clark A, Williams B, Eastman A, Minei J, Phelan H. The Parkland grading scale for cholecystitis. In Am J Surg; 2017 Jun 6. doi. org/10.1016/j. amjsurg. 2017.05. 017. Am J Surg. 2018. 10.1016/j.amjsurg.2018.01.029.
    1. Lee W, Jang J, Cho J, Hong S, Jeong C. Does surgical difficulty relate to severity of acute cholecystitis? Validation of the Parkland grading scale based on intraoperative findings. Am J Surg. 2018; Article in press; available online at 10.1016/j.amjsurg.2018.12.005.
    1. Lal P, Agarwal P, Malik V, Chakravarti A. A difficult laparoscopic cholecystectomy that requires conversion to open procedure can be predicted by preoperative ultrasonography. J Soc Laparoendosc Surg. 2002;6:59–63.

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