Preoperative MRI for predicting pathological changes associated with surgical difficulty during laparoscopic cholecystectomy for acute cholecystitis

Abstract

Background: Severe inflammation with necrosis and fibrosis of the gallbladder in acute cholecystitis increases operative difficulty during laparoscopic cholecystectomy. This study aimed to assess the use of preoperative MRI in predicting pathological changes of the gallbladder associated with surgical difficulty. Methods: Patients who underwent both preoperative MRI and early cholecystectomy for acute cholecystitis between 2012 and 2018 were identified retrospectively. On the basis of the layered pattern of the gallbladder wall on MRI, patients were classified into three groups: high signal intensity (HSI), intermediate signal intensity (ISI), and low signal intensity (LSI). The endpoint was the presence of pathological changes of the gallbladder associated with surgical difficulty, such as necrosis, abscess formation and fibrosis. Results: Of 229 eligible patients, pathological changes associated with surgical difficulty were found in 17 (27 per cent) of 62 patients in the HSI group, 84 (85 per cent) of 99 patients in the ISI group, and 66 (97 per cent) of 68 patients in the LSI group (P < 0⋅001). For detecting these changes, intermediate to low signal intensity of the gallbladder wall had a sensitivity of 90 (95 per cent c.i. 84 to 94) per cent, specificity of 73 (60 to 83) per cent and accuracy of 85 (80 to 90) per cent. Conclusion: Preoperative MRI predicted pathological changes associated with surgical difficulty during laparoscopic cholecystectomy for acute cholecystitis.

Preoperative Magnetic Resonance Cholangiopancreatography for Detecting Difficult Laparoscopic Cholecystectomy in Acute Cholecystitis

“…As we hypothesized, LSI broadening in the gallbladder wall on preoperative MRI was significantly associated with a higher bailout procedure rate and longer operating time in early LC for AC. These results can be explained by the results of our previous study, which showed that the rate of inflammatory pathological changes such as necrosis, abscess formation, and fibrosis of the gallbladder wall significantly increased as LSI in the gallbladder wall broadened (27.4%, 84.8%, and 97.1% in the HSI, ISI, and LSI groups, respectively) [12]. There was a significant difference in operative outcomes between the HSI and LSI groups (bailout procedure rate: 6.8% vs. 40.2%; open conversion rate: 0% vs. 26.5%; operating time: 95 min vs. 138 min).…”

“…Although MRI is more expensive than other examinations, such as abdominal ultrasonography [37], it provides much information at once. Our MRI assessment method is available using the HASTE sequence captured during routine MRCP, as some studies have already reported [11,12,38,39], and can be quickly introduced as part of daily radiological studies. In conclusion, MRCP/MRI could be a useful option for the comprehensive surgical management of acute cholecystitis and decision making in emergencies.…”

“…The gallbladder wall thickness was measured from the section showing the thickest part of the wall. Based on the layered pattern of the thickened wall, patients were divided into three groups as follows ( Figure 1): This classification scheme was the same as that used in our previous study [12]. We determined the signal intensities by adopting standardized regions of interest.…”

“…We judged LSI lesions of the gallbladder wall relative to the renal parenchyma's signal intensity level. This classification scheme was the same as that used in our previous study [12]. We determined the signal intensities by adopting standardized regions of interest.…”

“…Meanwhile, Jung et al [11] have highlighted that half-Fourier acquisition single-shot turbo spin-echo (HASTE) magnetic resonance imaging (MRI) of AC captured during MRCP typically reveals two layers in the gallbladder wall: A low signal inner layer of mucosa and muscle and a high signal outer layer of serosal edema. Our previous study revealed that the thickening of the inner layer with a low signal was associated with significant inflammatory pathological changes in the gallbladder wall, such as necrosis and fibrosis, which substantially impact the surgical difficulty of LC [12]. Thus far, using rates of bailout procedures (such as open conversion and laparoscopic subtotal cholecystectomy) and the operating time as indicators, numerous studies have identified predictors for surgical difficulty during early LC for AC.…”