To Validate A Scoring System to Predict Difficult Laparoscopic Cholecystectomy: A One-Year Cross-Sectional Study at KLES Dr. Prabhakar Kore Hospital and MRC, Belagavi

Abstract

BACKGROUND AND OBJECTIVES: Laparoscopic cholecystectomy is one of the most common surgical procedures performed in recent times in surgical practice. Various patient and disease related factors can be associated with difficult laparoscopic cholecystectomy. Identifying these patients in the preoperative period, may aid the surgeon in effective risk communication and preoperative preparation to deal with the situation. There are various structured scoring systems in use across the globe, but their utility on Indian subjects is yet to be studied extensively. The current study has attempted to validate a new scoring system, for its utility in risk stratification of people undergoing laparoscopic cholecystectomy. MATERIALS & METHODS: The current prospective observational study was conducted in the department of General Surgery at KLES Dr. Prabhakar Kore Hospital and Medical Research centre, Jawaharlal Nehru Medical College, KAHER, Belagavi. All the eligible patients undergoing laparoscopic cholecystectomy between January 2017 to December 2017 were considered as study population. The study had excluded people with jaundice, cholangitis, raised alkaline phosphatase, dilated common bile duct, common bile duct stones, empyema of gall bladder, acalculous cholecystitis, LC done along with common bile duct exploration, LC with other intervention at the same setting, patients with anesthetic complications and patients with co-morbid diseases were excluded from the study. The scoring system used has considered age, gender, history of hospitalization, BMI, abdominal scar, palpable gall bladder and three ultrasonographic features (thick gallbladder, pericholecystic collection and impacted stone) for risk stratification. Sensitivity, specificity and predictive values of the preoperative scoring system were calculated. p value < 0.05 was considered statistically significant. IBM SPSS version 22 was used for statistical analysis. RESULTS: A total 50 people were included in the final analysis., with the mean age of 43.36 ± 9.84 years. Females constituted 82% of the study population. Among the study population 12(24%) people had difficult intraoperative outcome. The proportion of difficult intraoperative outcome was much higher among males, as compared to females. The other factors associated with intraoperative difficulty were prior hospitalization and impacted stone. Age of the person, presence of abdominal scar, palpable gall bladder, thick gallbladder, pericholecystic collection and BMI had no association with difficult intraoperative outcome in study population. Among the 36 people with preoperative score between 0 to 5, 3(8.3%) people had difficult intraoperative outcome. Among the 14 people with preoperative score between 6 to 10, 9(64.3%) people had difficult intraoperative outcome. The difference between preoperative score and intraoperative outcome was statistically significant, (p value<0.001). To predict Intra operative difficulty, pre operative score had sensitivity of 75.00% (95% CI 42.81% to 94.51%). The specificity was 86.84% (95 CI 71.91% to 95.59%), false positive rate was 13.16% (95 CI 4.41% to 28.09%), false negative rate was 25.00% (95 CI 5.49% to 57.19%), positive predictive value was 64.29% (95 CI 35.14% to 87.24%), negative predictive value was 91.67% (95 CI 77.53% to 98.25%), and the total diagnostic accuracy was 84.00% (95 CI 70.89% to 92.83%). CONCLUSION: The current scoring system had a sensitivity of 75% and specificity of 86.84% in predicting difficult laparoscopic cholecystectomy, which makes it a reasonably good scoring system for preoperative risk stratification of subjects.