Multivariate Analysis for Preoperative Prediction on Intraoperative Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy
Background: Intraoperative conversion of laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) to avoid biliovascular injury is considered a strategy, not a failure. But conversion from LC to OC causes significant postoperative morbidity. Preoperative prediction of conversion, using clinical, laboratory and imaging parameters, can help the patient and the surgeon for better preoperative preparations.
Objective: To identify preoperative predictors for intraoperative conversion of LC to OC by multivariate analysis of clinical, laboratory and imaging parameters.
Methods: Single centre retrospective comparative study was done using the database in the Department of Surgical Gastroenterology, Medical College, Trivandrum; on patients taken up for LC during the period from 01/01/2010 to 30/09/2016. Inclusion criteria were symptomatic gall stone patients confirmed by imaging whose surgical treatment is planned as LC. Exclusion criteria were LC-converted-OC before dissection (suspected carcinoma / hemodynamic instability / technical problems). Data collection was done using a proforma structured for prediction analysis using clinical, laboratory and imaging parameters. Statistical analysis was done by stratifying the patients as Group-I (LC) and Group II (LC-converted-OC). Univariate analysis (Chi- squared test) was done for factors favouring conversion, with which multivariate logistic regression analysis performed for OR and 95% CI (SPSS; statistical significance=p<0.05).
Results: Total 502 patients were enrolled (Group-I=428; Group-II=74). Age range was 13-78 years (mean age, Group-I=43.4; Group-II=52.6 (p<0.001). 79.9% males in Group-I; 20.1% in Group-II (p=0.008). Among diabetics; Group-I=76.7%; Group-II=23.3% (p<0.05). Jaundice was 61.7% Group-I and 38.3% Group-II (p<0.001). Pre-operative biliary stenting was done in 62.7% Group-I; 37.3% Group-II (P<0.001). Stone size of >20 mm observed in 66.7% Group-I; 33.3% Group-II (p<0.001). Serum alkaline phosphatase was >120 in 72.7% Group-I; 27.3% Group-II (p<0.05). 18.9% LC done by consultants and 6.5% LC by residents under supervision of consultants were converted to OC. Logistic regression analysis showed significant correlation regarding prediction of conversion to OC with male gender (OR 3.826;95%CI0.419-1.313), age>40 (OR3.826;95%CI1.869-7.831), diabetes (OR1.223;95%CI0.628-2.383), jaundice (OR4.954; 95%CI0.905-7.113), biliary stenting (OR2.684;95%CI0.254-8.382), interval after stenting >8 weeks (OR0.482;95%CI0.078-2.979) and single large stone (OR 2.540; 95%CI1.634-3.947). Among these age >40 years, jaundice and single large stone are observed as the most correlating factors.
Conclusion: Logistic regression analysis showed significant correlation between converted laparoscopic cholecystectomy and parameters including male gender, age above 40 years, diabetes, jaundice, biliary stenting, interval after biliary stenting >8 weeks and single large stone. These could be further utilised for formulating a simple bedside numerical prediction score using statistical software.
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