C-reactive Protein is an Independent Predictor of Difficult Emergency Cholecystectomy

Abstract

Purpose The objective of this study was to identify variables that predict a difficult laparoscopic cholecystectomy performed in an emergency setting. The secondary aim was to devise a pathway for patients admitted acutely that required a cholecystectomy. Methods Patients admitted to the Emergency General Surgery Department at Nottingham, the United Kingdom that had an emergency cholecystectomy performed during the one-year period from May 2016 to June 2017 were identified. Collected data included patient demographics, clinical presentation, biochemical analysis, radiological findings, subsequent interventions, surgical data, and clinical outcome. A difficult cholecystectomy was defined as operative time >60 minutes, conversion to an open procedure, or sub-total cholecystectomy performed. Results A total of 149 patients were included. Cholecystitis was the most common diagnosis ( n = 86, 57.7%), followed by acute pancreatitis ( n = 36, 24.1%). Fifty-five (36.9%) patients had an elevated C-reactive protein (CRP) >100 mg/dL. One hundred and twenty-one (81.2%) patients who had an emergency cholecystectomy were defined as “difficult”. The overall morbidity rate was 15.4% ( n = 23), and there was no post-operative in-hospital mortality. Univariate analysis showed that age >60 years ( p = 0.012), underlying diagnosis ( p = 0.010), presence of heart rate >90 ( p = 0.027), and an elevated pre-surgery CRP >100 ( p < 0.001) was associated with a difficult emergency cholecystectomy. Multi-variate analysis demonstrated that an elevated pre-surgery CRP >100 was an independent predictor of a difficult emergency cholecystectomy ( p = 0.041). Conclusions An elevated pre-operative CRP is an independent predictor of a technically more difficult cholecystectomy in the emergency setting.

Acute cholecystitis: Delayed cholecystectomy has lesser perioperative morbidity compared to emergency cholecystectomy

“…This further supports the benefit of performing a delayed laparoscopic cholecystectomy after a "cooling off" period. 22,23 The readmission risk before DLC is significant (13.5% over 2 months; 22.5% over the median waiting time [5 months, 9 days]) and must be minimized. Recurrent admissions ultimately result in increased morbidity that may actually outweigh the benefit of DLC.…”

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

“…Among these reports, Inoue et al 14 and Hayama et al 19 defined surgical difficulty as the following: surgical duration ≥ 180 minutes, intrasurgical blood loss ≥ 300 g, or conversion to open cholecystectomy. However, Gregory et al 11 defined surgical difficulty as surgical duration > 60 minutes, in addition to the conversion to open or subtotal cholecystectomy. In this study, we adopted the criteria of Inoue et al 14 and Hayama et al 19 for assessing the difficulty experienced during emergency LC in patients with AC.…”

C-reactive protein in gallbladder diseases: diagnostic and therapeutic insights

“…The delay of elective cholecystectomy from the time of diagnosis has not been shown to increase risk of complications from either surgery or acute cholecystitis. Cholecystectomies are relatively safe procedures and provide symptom relief in 75%-90% of patients (Elwood 2008;Greenberger and Paumgartner 2018;Lee and Boll 2018;Okamoto et al 2018).…”

“…Chronic cholecystitis can be complicated by many concomitant issues, such as empyema, hydrops, gangrene, fistulas, or limey bile. Calcium may also deposit and harden in the walls of the gallbladder, causing extensive scarring (Elwood 2008;Greenberger and Paumgartner 2018;Lee and Boll 2018).…”