Maximum Diameter of the Gallbladder Determined Presurgically Using Computed Tomography as a Risk Factor for Difficult Emergency Laparoscopic Cholecystectomy in Patients With Mild to Moderate Acute Cholecystitis.

Abstract

Early or emergency laparoscopic cholecystectomy (LC) was recommended in the 2018 Tokyo Guidelines for patients with mild to moderate acute cholecystitis (AC). Although surgical difficulty is frequently encountered during these surgeries, risk factors for predicting surgical difficulties have not been fully investigated, especially based on computed tomography (CT) findings. We investigated 72 patients who underwent emergency LC with mild (n=45) to moderate (n=27) AC. Patients who previously underwent presurgical percutaneous or endoscopic biliary drainage were excluded from this study. Difficult LC was defined using any of the following surgical factors: surgical duration ≥180 minutes, blood loss ≥300g, or a conversion to open cholecystectomy. Subsequently, several presurgical clinical factors were analyzed, including sex, age at surgery, experience of the surgeon, interval between symptom onset and surgery, body mass index, diabetes history, presurgical white blood cell count, and C-reactive protein level. Moreover, stones in the cystic duct or perigallblader fluid and the maximum thickness and diameter of the gallbladders were evaluated via presurgical CT. Finally, logistic regression analysis was performed to compare the relationship between surgical difficulty and each clinical factor. The average age at surgery of the included patients was 60.3 (range: 25 to 88y), surgical duration was 112.2 (range: 29 to 296min), and surgical blood loss was 55.2 (range: 0 to 530g). Furthermore, 4 (5.6%) had to undergo open cholecystectomy, whereas postsurgical complications occurred in 5 (6.9%) patients. In addition, the mean postsurgical admission duration was 7 (range: 3 to 63d). Thus, 12 patients experienced difficult LC, whereas 60 experienced nondifficult LC. Of the evaluated clinical factors, patients who experienced difficult LC showed higher presurgical C-reactive protein levels (10.78 vs. 6.76mg/dL, P =0.01) and wider gallbladder diameters (48.4 vs. 41.8mm, P <0.01) than those who experienced nondifficult LC. By univariate logistic regression analysis, results also showed that patients with a maximum gallbladder diameter had a higher risk of experiencing difficulty during emergency LC ( P =0.02). Moreover, the gallbladder diameter's cutoff value was 43mm after the receiver operating characteristic curve analysis. In patients with mild to moderate AC, emergency LC can safely be performed. However, performing LC might be technically difficult in patients with AC after the identification of severe gallbladder swelling during presurgical CT.