Predicting the difficult laparoscopic cholecystectomy: development and validation of a pre-operative risk score using an
- PDF / 1,052,552 Bytes
- 13 Pages / 595.276 x 790.866 pts Page_size
- 38 Downloads / 203 Views
and Other Interventional Techniques
Predicting the difficult laparoscopic cholecystectomy: development and validation of a pre‑operative risk score using an objective operative difficulty grading system Ahmad H. M. Nassar1 · James Hodson2 · Hwei J. Ng1 · Ravi S. Vohra3 · Tarek Katbeh1 · Samer Zino1 · Ewen A. Griffiths4,5,6 on behalf of the CholeS Study Group, West Midlands Research Collaborative Received: 16 July 2019 / Accepted: 28 October 2019 © Springer Science+Business Media, LLC, part of Springer Nature 2019
Abstract Background The prediction of a difficult cholecystectomy has traditionally been based on certain pre-operative clinical and imaging factors. Most of the previous literature reported small patient cohorts and have not used an objective measure of operative difficulty. The aim of this study was to develop a pre-operative score to predict difficult cholecystectomy, as defined by a validated intra-operative difficulty grading scale. Method Two cohorts from prospectively maintained databases of patients who underwent laparoscopic cholecystectomy were analysed: the CholeS Study (8755 patients) and a single surgeon series (4089 patients). Factors potentially predictive of difficulty were correlated to the Nassar intra-operative difficulty scale. A multivariable binary logistic regression analysis was then used to identify factors that were independently associated with difficult laparoscopic cholecystectomy, defined as operative difficulty grades 3 to 5. The resulting model was then converted to a risk score, and validated on both internal and external datasets. Result Increasing age and ASA classification, male gender, diagnosis of CBD stone or cholecystitis, thick-walled gallbladders, CBD dilation, use of pre-operative ERCP and non-elective operations were found to be significant independent predictors of difficult cases. A risk score based on these factors returned an area under the ROC curve of 0.789 (95% CI 0.773–0.806, p 6 mm) on pre-operative ultrasound were also recorded, as well as whether CT scans, MRCP or ERCP had been performed preoperatively [19]. The remaining factors related to the admission, namely whether the patient had previous admissions, the type of admission (elective, delayed or emergency), and the number of days from admission to surgery.
Nassar difficultly grading scale In both datasets, surgeons were asked prospectively to grade the difficulty of the procedure using the Nassar scale [17]. This scale graded operative findings from the gallbladder, cystic pedicle and associated adhesions (Supplementary Table 1). The grading system is designed to be used as an
Surgical Endoscopy
overall summary of the operative conditions found; and the worst factor found in the individual aspect of either the ‘Gallbladder’, ‘Cystic Pedicle’ or ‘Adhesions’ should be used to define the final overall grade. The scale was originally published in 1995, with grades of 1–4, and subsequently modified in 1996 with the addition of a grade 5. However, whilst the reference cohort used the modifie
Data Loading...
