Predicting operative difficulty of laparoscopic cholecystectomy in patients with acute biliary presentations

Background Early laparoscopic cholecystectomy (LC) is advocated in patients with an acute biliary presentation but may require some precaution. We aimed to assess the intra‐operative difficulty of cholecystectomy in patients who underwent early intervention, and to establish a prediction model for a ‘complicated’ LC. Methods Retrospective analysis of prospectively collected data from patients presenting to the emergency department with acute biliary symptoms, and who subsequently underwent early LC between 2015 and 2018. Operative difficulty was assessed by standardized grading of intra‐operative findings (grades 1–4). Pre‐operative predictors for a ‘complicated’ LC (grades 3/4) were assessed using univariable and multivariable logistic regression analysis. A prediction model was created using variable regression coefficients. Cut‐off and accuracy of the model were assessed using a receiver operating characteristic curve. Results A total of 185 patients were included and 59% presented with acute cholecystitis. In this cohort 113 (61%) patients underwent a ‘complicated’ LC. A prediction model for a ’complicated’ LC (0–4.5 points) included: clinical diagnosis of acute cholecystitis (2 points), C‐reactive protein >10.5 mg/L (1.5 points) and pericholecystic fluid on pre‐operative imaging (1 point). A score ≥2.5 had a sensitivity of 77.7%, specificity of 81.7% and positive and negative predictive values of 87.0% and 69.9%, respectively. Conclusion Early LC may be ‘complicated’ in up to 60% of cases. The presented prediction model uses readily available information in the emergency department and is a simple but accurate way to predict a likely ‘complicated’ LC in patients with acute biliary presentations. Sixty percent of patients with acute biliary disease who underwent early surgical intervention have a ‘complicated’ laparoscopic cholecystectomy (LC) and this is associated with worse post‐operative outcomes compared with ‘straightforward’ procedures. In order to schedule operations accurately and provide appropriate resources, the expected difficulty of an early LC can be assessed pre‐operatively using a simple prediction model based on the clinical diagnosis of acute cholecystitis, a positive Murphy's sign, C‐reactive protein level >10.5 mg/L and radiological findings of pericholecystic fluid and stone impaction at the gallbladder neck.