Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 51, Num. 1, 2005, pp. 21-22

Journal of Postgraduate Medicine, Vol. 51, No. 1, January-March, 2005, pp. 21-22

Expert's Comments

Prediction of unsuccessful laparoscopic cholecystectomy

Hammarstrom Lars-Erik

Department of Surgery, Angelholms Sjukhus, S-262 81 Angelholm

Correspondence Address:Department of Surgery, Angelholms Sjukhus, S-262 81 Angelholm, le.hammarstrom@lund.mail.telia.com

Code Number: jp05007

The quest for predicting the probability of conversion of laparoscopic cholecystectomy in unselected groups of patients with calculous gall bladder disease has been extensive. The outcome in the present study by Tayeb et al[1] lends support to acquired knowledge, that the major and independent risk factors for conversion are acute cholecystitis and advanced age.

Assessment of risk factors/constructing prognostic indices is merely an adjunct to qualified surgical judgment. Thus, Tayeb et al[1] prudently point out that conversion should be considered early if difficulties are encountered intraoperatively, and that open surgery should be scheduled in patients with additive risk factors.

Consequently, the prospect of preoperatively predicting conversion is important, in order to ′a priori′ schedule open surgery or take appropriate measures if laparoscopy is scheduled. Intraoperative findings (adhesions, obscure anatomy) are left to the surgeon′s experience and when dealt with qualified judgment and are less important predictors.[2] Male gender is frequently reported to be a risk factor for conversion,[2],[3],[4] a finding contradicted in the present study (23.3% males)[1] and elsewhere.[5]

Without concomitant cholecystitis, gall bladder wall thickness alone cannot be expected to be a strong predictor of conversion. Although associated with a conversion rate of 58% in this study, it was weak compared to the actual signs of inflammation (oedematous wall and pericholecystic fluid), which were associated with a conversion rate of about 90%. These findings highlight cholecystitis as a major predictor for conversion, but unfortunately, patients with acute cholecystitis have been studied less extensively, and results are inconsistent, with a potentially low impact on management.[2],[3],[5] Thus, this patient category deserves to be investigated further in prospective studies, in order to construct a refined prognostic index, and to improve the accuracy of the overall prediction of conversion of laparoscopic cholecystectomy.

Reportedly, superimposed bacterial infection (indicated by high C-reactive protein and leucocyte count, duration of inflammation, and positive bile cultures), which is known to increase with age, might be the most important cause of conversion in patients with acute cholecystitis.[2],[3],[4],[5],[6],[7]

In clinical practice, the important issue would be to define the probability of an event in terms of (arbitrary) ′high-risk′(>80%) or ′low-risk′ (<10-15%). In this context, those figures for risk of conversion should lead to open and laparoscopic approach, respectively. An intermediate probability of conversion would imply that the best available expertise is engaged when laparoscopy is scheduled, and that it hardly matters whether the risk of conversion is estimated to 30% or 50%.

Moreover, in order to proceed by improving/refining models for prediction of conversion, discrete variables (for example ultrasonographic and physical findings) are less reliable and reproducible, and "cut-off" points for continuous variables might be useful but blunt, suggesting that the construction of prognostic indices from continuous variables should be investigated further, especially in patients with acute cholecystitis.

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