The value of percutaneous ultrasound in predicting conversion from laparoscopic to open cholecystectomy due to acute cholecystitis

Abstract

BackgroundLaparoscopic cholecystectomy has become the treatment of choice for gallstone disease. Advantages of the laparoscopic approach include lower morbidity and mortality rates, reduced length of hospital stay, and earlier return to work. In acute cholecystitis, severe inflammation makes laparoscopic dissection technically more demanding, with a higher risk of related complications that require conversion to open cholecystectomy.MethodsWe reviewed the records of 5,596 patients who underwent cholecystectomy between 1993 and 2011 in a single institution. A laparoscopic approach was undertaken in 4,105 patients (73.4 %). The ultrasound signs of acute cholecystitis were found in 542 patients (13.2 %) who underwent laparoscopic cholecystectomy. We analyzed the ultrasound presentations of acute cholecystitis in patients who required conversion to open cholecystectomy and compared them with the ultrasound signs of acute cholecystitis in patients who had a completed laparoscopic cholecystectomy.ResultsA conversion to open cholecystectomy in patients with acute cholecystitis was necessary in 24 % (n = 130) of the patients compared to 3.4 % of the patients with uncomplicated gallstone disease. The most frequent ultrasound findings in patients requiring conversion were a pericholecystic exudate in 42 %, a difficult identification of anatomical structures due to local severe inflammation in 34 %, and gallbladder wall thickening of >5 mm in 31 %. Additionally, when the duration of symptoms exceeded 3 days, more than half of the patients required conversion to open cholecystectomy and the conversion rate was fivefold higher than for those with a shorter duration of acute cholecystitis.ConclusionsIn patients with severe acute cholecystitis found on ultrasound, combined with gallbladder wall thickening to >5 mm, pericholecystic exudates or abscess adjacent to the gallbladder, difficulty identifying anatomical structures within Calot’s triangle, specifically when the duration of symptoms exceeds 3 days, cholecystectomy should be done as an open approach because of the high risk of conversion.

Risk Factors and Predictive Models for Conversion of Laparoscopic Cholecystectomy to Open Surgery, and Surgical Quality Outcome Measures

“…The risk of CTO doubles with every millimetre increase in gallbladder wall thickness (OR = 2; 95% CI: 1.7-2.3; P < 0.001) [52]. Patients with GB wall thickness >5 mm on transabdominal US have a 16 times higher risk of CTO than those with GB wall thickness 3-5 mm (OR = 16.3; 95% CI: 8.1-33.3; P < 0.00005) [35]. GB wall thickness >4 mm on US is not only a radiological marker for AC but also associated with greater operational difficulty [40,61].…”

“…Diagnostic criteria for AC are presented in Table 2 [34]. AC patients have eight times higher risk of CTO than patients with uncomplicated gallstone disease (OR = 8.01; 95% CI: 6.1-10.5; P < 0.00005) [35]. Severity grades of AC, as defined by the 2013 Tokyo Guidelines, are associated with an increased rate of CTO [36,37].…”

“…Some authors report their institutional policy of avoidance of difficult dissections during LC and making a decision of CTO if there is a lack of dissection progress for 15-30 min [27]. Intense inflammatory infiltrate in the Calot's triangle makes identification of the cystic duct and cystic artery very challenging predisposing patients to iatrogenic BDI and uncontrollable bleeding [32,35]. To prevent BDI, CTO is directed when one of three fundamentals of the critical view of safety cannot be ascertained [30,68].…”

Role of Ultrasonography (USG) in Evaluation of Pericholecystic Adhesions in Gallstone Disease (GSD)

“…Aslam HMet al (2013) described the relative importance of clinical, [11] biochemical and ultrasonographic parameters in preoperative assessment for GB surgery. Cwik G et al (2013) found that many USG factors were more common in OC group vs LC group. [12] Out of these, presence of exudates around GB, suboptimal visualization of the pericholecystic anatomy on and GB wall thickening of >5 mm were significant predictors of OC.…”

“…Cwik G et al (2013) found that many USG factors were more common in OC group vs LC group. [12] Out of these, presence of exudates around GB, suboptimal visualization of the pericholecystic anatomy on and GB wall thickening of >5 mm were significant predictors of OC. Pinto Aet al (2013) & Melamud Ket al (2014) studied significant predictors of OC.…”