Predictive Factors for Difficult Surgery in Laparoscopic Cholecystectomy for Chronic Cholecystitis

摘要

Introduction: Conversion rate in laparoscopic cholecystectomy is still 1.5-19%. Our aim was to look for various factors and to make a predictive index which can predict the chances of conversion. Methods: We included 536 patients with laparoscopic cholecystectomy during July 2002 to April 2006. A total of 64 patients needed conversion. Twenty four patients who underwent conversion because of non-surgical reasons were excluded. Criteria of exclusion were: history of jaundice, cholangitis, raised alkaline phosphatase, dilated common bile duct (CBD) and patients with CBD stones. Patients were evaluated in terms of clinical, hematological, biochemical and ultrasonographic parameters.Results: Overall conversion rate was 7.81%. Univariate analysis showed that body mass index (BMI), fever at the time of attack, number of stones, number of attacks, previous history of acute cholecystitis, presence of tenderness, gall bladder wall thickness on ultrasonography (USG) and raised total leucocyte counts (TLC) were significant for conversion. Stepwise logistic regression showed that only number of attacks, TLC & wall thickness were significant. Probability of prediction: P = ey/(1+ey) and Y = -9.2015 + (0.3623 × Number of Attacks) + (0.0003 x TLC) + (0.8633 × Wall Thickness), where 'e' is the exponential constant -2.7182, number of attacks is '1' if > 5 and '0' for < 5, TLC = '1' if counts are > 11,000/cu.mm and '0' if within normal range, and wall thickness is '1' if > 4 mm and '0' for < 4 mm on USG. Conclusion: Yes, it is possible to predict the risk of conversion and patients can be informed preoperatively. Introduction Since its advent in 1987, laparoscopic cholecystectomy (LC) has become the gold standard for symptomatic gall stones. In spite of increasing expertise and advances in technology conversion rate is still 1.5-19% in different centers 1 . The incidence of conversion is less in centers where LC is attempted in a selected group of patients. This conversion is neither a failure nor a complication, but an attempt to avoid complications. It would be useful to have some reliable predictive factors for conversion in LC so that patients may be informed appropriately and they have chance to make arrangements regarding their work and family. Similarly, the surgeon may schedule the time and team for surgery, because these high-risk patients are not candidates for routine resident training. Studies have shown that there are higher incidences of post-operative complications and longer hospital stays in converted patients when compared with both the laparoscopic and the open cholecystectomy group 2 . Scoring systems are designed in some studies for better understanding and for easy prediction of conversion 1,3 . The risk factors had been reviewed recently 4 . Our aim was to look for the various factors and to make a predictive index which can predict which patient may need to be converted, thus suitably opting for the operating procedure. Methods We included 536 patients who underwent LC from July 2002 to April 2006 in our university hospital in North India. A total of 64 patients needed conversion. Twenty-four patients who underwent conversion because of anesthetic complications and presence of other co-morbidities were excluded from the study. Patients with history of jaundice, cholangitis, raised alkaline phosphatase or dilated common bile duct (CBD) were evaluated further by ERCP and patients with CBD stones were excluded. All cases were operated by a single experienced senior surgeon. All patients were evaluated in terms of clinical, hematological, biochemical and ultrasonographic parameters (Table 1). Conversion rate and reasons for conversions were also noted.