Preoperative factors associated with technical difficulties of laparoscopic cholecystectomy in acute cholecystitis

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Changes characteristics of recent surgery. (a) Sagittal T1-weighted SPIR image. On the upper edge, we can see the hypophyseal stalk (arrow), and normal hypophyseal gland remains. (b and c) Sagittal and coronal T1-weighted images after the administration of IV contrast, with hypointense filling of the cavity with Surgicel®, and the hyper-uptake edge, without signs indicative of adenoma. (d) Preoperative study images. (e) Control MRI after 3 months." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Taberner López, M. Vañó Molina, J. Calatayud Gregori, M. Jornet Sanz, J. Jornet Fayos, A. Pastor del Campo, A. Caño Gómez, E. Mollá Olmos" "autores" => array:8 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Taberner López" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Vañó Molina" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Calatayud Gregori" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Jornet Sanz" ] 4 => array:2 [ "nombre" => "J." 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Bilateral breast MRI with contrast. (a) T1-weighted sequence without contrast. One ROI is placed within the mass showing the area in square centimeters, the mean, and the standard deviation of the signal intensity in the area measured by the ROI. (b) T1-weighted sequence with contrast during the first time of acquisition (T1) after the administration of contrast. ROI placement in the area of the lesion that has the highest enhancement of all. (c) T1-weighted sequence with contrast during the second time of acquisition (T2). (d) T1-weighted sequence with contrast during the third time of acquisition T3. (e) T1-weighted sequence with contrast during the fourth time of acquisition T4. (f) T1-weighted sequence during the fifth and last time of acquisition T5. The ROI is maintained in the same location during the entire study. 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Izquierdo, N.E. Díaz Díaz, N. Muñoz, O.E. Guzmán, I. Contreras Bustos, J.S. Gutiérrez" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Y.E." "apellidos" => "Izquierdo" "email" => array:1 [ 0 => "yeaguirrei@unal.edu.co" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "N.E." "apellidos" => "Díaz Díaz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "N." "apellidos" => "Muñoz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "O.E." "apellidos" => "Guzmán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "I." 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"apellidos" => "Gutiérrez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Facultad de Medicina, Universidad Nacional de Colombia, Bogotá D.C, Colombia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Radiología, ESE Hospital El Tunal nivel III, Bogotá D.C, Colombia" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Cirugía, ESE Hospital El Tunal nivel III, Bogotá D.C, Colombia" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Factores prequirúrgicos asociados con dificultades técnicas de la colecistectomía laparoscópica en la colecistitis aguda" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1048 "Ancho" => 1549 "Tamanyo" => 46904 ] ] "descripcion" => array:1 [ "en" => "Causes for conversion from laparoscopic cholecystectomy to open surgery." ] ] ] "textoCompleto" => "IntroductionAcute cholecystitis (AC) is the acute inflammatory process of the gallbladder wall that is secondary to lithiasis in 95 per cent of the cases.<a class="elsevierStyleCrossRefs" href="#bib0125">1,2</a> According to the 2013 Tokyo guidelines for the management of cholangitis and AC,<a class="elsevierStyleCrossRef" href="#bib0135">3</a> the concomitant presence of local inflammatory sings in the upper right abdominal quadrant; the signs of systemic inflammatory response; and the typical AC imaging findings are considered definitive diagnosis of AC.The initial approximation image in cases of diagnostic suspicion of AC is the ultrasound scan (US). The diagnosis of AC through an ultrasound scan is based on the combination of ultrasound findings, given that there is no pathognomonic sign.<a class="elsevierStyleCrossRef" href="#bib0140">4</a> The findings typically described in AC are the presence of an impacted gallstone or peri-gallbladder fluid; overdistended gallbladder; thickening or flow increase of the gallbladder wall; and the positive sonographic Murphy sign.<a class="elsevierStyleCrossRef" href="#bib0140">4</a> The concomitance of several of these ultrasound findings reaches an 88 per cent sensitivity and an 80 per cent specificity in the diagnosis of AC.<a class="elsevierStyleCrossRef" href="#bib0145">5</a>The treatment of choice for the management of AC is the laparoscopic cholecystectomy (LC) procedure, since there is less postoperative pain: hospital stays are shorter and is more cost-effective compared to open surgery.<a class="elsevierStyleCrossRefs" href="#bib0150">6,7</a> One of the setbacks of LC compared to open surgery is the higher risk of biliary duct injury;<a class="elsevierStyleCrossRef" href="#bib0160">8</a> as a matter of fact, avoiding the appearance of iatrogenic lesions is the main reason for LC to open surgery conversion.<a class="elsevierStyleCrossRefs" href="#bib0160">8–11</a>The conversion rate from LC to open surgery ranges from 5 per cent to 29.4 per cent,<a class="elsevierStyleCrossRefs" href="#bib0180">12,13</a> and it is based on two (2) types of conditions: those non-associated with the patient, such as the surgeon's experience, and patient-inherent conditions, such as the significant inflammation of the gallbladder bed that increases the difficulty to identify or dissect anatomical structures. Defining the impact of these conditions prior to the LC is the first step to be able to establish strategies aimed at reducing the conversion rate of LC to open surgery in all hospitals.<a class="elsevierStyleCrossRef" href="#bib0185">13</a>The goal of this work was to identify, in patients with AC, the preoperative factors associated with an extended surgical time, or conversion from LC to open surgery.MethodAfter obtaining authorization from the hospital ethics committee, one observational, analytical and retrospective study was conducted, which is why no informed consent was required.PatientsThe medical histories of all the patients who underwent LC procedures in our center between September 15th, 2015 through October 15th, 2016 were reviewed. The following were defined as inclusion criteria: being over 17 years of age, and having a definitive diagnosis of AC according to the 2013 Tokyo guidelines for the management of cholangitis and AC<a class="elsevierStyleCrossRefs" href="#bib0135">3,14</a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Those individuals who underwent intraoperative cholangiography procedures were excluded, since this procedure involves extra surgical time non-associated with the technical difficulties of LC. Also, patients operated between 19:00h and 06:59h (the night shift) were ruled out to avoid confusion bias associated with the extended surgery time secondary to the effect of fatigue on the surgeon performance. Following the local protocol, all individuals with a definitive diagnosis of AC are treated with LC.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Ultrasound scanAll studies were conducted using a ALOKA PROSOUND F75 machine (Model IPF-1904 SN M00159 series M00159) with a 7.5MHz convex transducer operated by, at least, one of the four radiologists from our hospital, with between 4 and 12 years of experience working with this diagnostic modality. The gallbladder volume was estimated using the ellipsoid volume formula. The presence of one 1mm wide anechoic band around the gallbladder was considered peri-gallbladder fluid. The existence of amorphous and mobile echogenic material inside the gallbladder was defined as biliary mud. Multiple cholelithiasis was established as the presence of two (2) or more stones followed by posterior acoustic shadowing. Microlithiasis was defined as the presence of mobile echogenic images without posterior acoustic shadowing with a diameter smaller than 5mm. The gallbladder wall thickness was measured on the longitudinal section of the gallbladder on the contact area with the hepatic parenchyma. A detailed description of the measurements of the gallbladder wall is described in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. All measurements were taken directly on the machine while the ultrasound scan was being conducted.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The cases meeting, at least, three (3) of the following criteria were considered imaging diagnosis of AC:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Gallbladder wall thickness >3mm.</li><li class="elsevierStyleListItem" id="lsti0010">•Presence of peri-gallbladder fluid.</li><li class="elsevierStyleListItem" id="lsti0015">•Positive sonographic Murphy sign.<a class="elsevierStyleCrossRef" href="#bib0195">15</a></li><li class="elsevierStyleListItem" id="lsti0020">•Gallbladder volume >100cc.</li><li class="elsevierStyleListItem" id="lsti0025">•Gallbladder stone impacted at gallbladder neck level.</li></ul>Surgical procedureThe LC procedures were conducted under general anesthesia through orotracheal intubation performed by, at least, one (1) member from the hospital general surgery team with between 1 and 15 years of experience doing laparoscopic procedures. STORZ laparoscopic machines were used with the surgical technique of three or four ports.Assessed variablesWe recorded the patients’ age; sex; duration of symptoms; body mass index; and laboratory markers (total leukocyte recount and C-reactive protein) measured in the blood samples taken when they were admitted to the hospital.The ultrasound scan variables were recorded from the ultrasound reports including the gallbladder volume and the presence of peri-gallbladder fluid; biliary mud; microlithiasis; or multiple lithiasis; length of the largest gallstones; and gallbladder wall thickness.Total surgical time and the need for conversion to open surgery were considered indicators of technical difficulties associated with the LC procedure.Managing the confusion biasTo assess the impact of surgeon experience on the results obtained, a comparison was made between the percentage of LC procedures converted to open surgery and the mean surgical time used by each and every one of the surgeons who participated in this research.The homogeneity of conditions prior to the surgery between the groups of converted and unconverted LC procedures was determined by assessing the mean time elapsed between the US diagnosis and the beginning of the LC procedure (US–LC time), and the average days spent with symptoms in each group.Statistical analysisIn the descriptive analysis of the continuous variables the average±standard deviation or median and interquartile range (IQR) was used, depending on the nature of the distribution according to the Kolmogorov–Smirnov normality test. The nominal variables were expressed in absolute and relative frequencies using percentages.The descriptive analysis was conducted independently for the groups of LC procedures converted to open surgery and non-converted LC procedures, and their results were compared using the square chi test or the exact Fisher test for the categorical variables, and the Student t or Mann–Whitney U test for quantitative variables. To establish the relation between two continuous variables, the Spearman or Pearson’ correlations were used.Those parameters with statistically significant associations (p≤0.05) were incorporated into the multivariate models of binary logistic regression using the need for conversion to open surgery as a dependent variable. To estimate the percentage of variation explained and its goodness-of-fit, the Nagelkerke R square and the Hosmer–Lemeshow test were used, respectively.Finally, the ROC (Receiver Operating Characteristic) curves were conducted in order to determine the cutoff points of those variables with statistically significant associations and their capacity to predict the need for conversion to open surgery. The cutoff point with the best performance for each variable was determined using the Youden Index. The operative characteristics were calculated as well as the odds ratio (OR), and the 95 per cent confidence interval (95 per cent CI) of the cutoff points found. The entire data analysis was conducted using the software package IBM SPSS Statistics for Windows, version 22.0.ResultsNinety-nine (99) patients were included with an average age of 49.7±16.8 years old–68 women (68.7 per cent) and 31 males (31.3 per cent). The median time with abdominal pain was 3 days (IQR: 4) and the US-LC mean time was 70.9hours (IQR: 125.6).At our center, every individual with a definitive diagnosis of AC is treated with LC; however, in the period studied eight (8) individuals were taken directly to open surgery: three (3) with suspicion of pyocholecyst with severe adherences, one (1) due to an apparent biliary peritonitis, one (1) due to a history of biliary pancreatitis, one (1) pregnant woman with severe thrombocytopenia, and one (1) patient with severe pulmonary hypertension, which relatively contraindicated the use of pneumoperitoneum for the LC procedure.Risk prediction of conversion to open surgeryConversion to open surgery was necessary in eight (8) patients (8 per cent). <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> shows the reasons for conversion from LC procedures. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> summarizes the clinical, laboratory and ultrasound scan variables for the converted LC and non-converted LCs groups, as well as their association with the conversion represented by the p values.<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>One logistic regression model using the gallbladder wall thickness as the single variable explained 13 per cent of the variance associated with the need for conversion to open surgery (Nagelkerke R square: 0.13), with good goodness-of-fit (Hosmer–Lemeshow test, p=0–41).<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> represents the ROC curve for the gallbladder wall thickness, with an area under the curve (AUC) of 0.82. According to Youden Index, the cutoff point with the best performance in our sample was 6mm, with a 87.5 per cent sensitivity and a 62.6 per cent specificity (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). The ≥6mm thickness confirmed through US scan had an OR of 11.71 (95 per cent CI: 1.38–99; p=0.008) for conversion to open surgery.<elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Prediction of surgical timeThere was no statistically significant association between the preoperative variables assessed and the total time of the LC procedure. <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> shows the p values documented for each variable.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Managing the confusion biasThe LC procedures included were performed by 13 surgeons. <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> summarizes the data obtained for each one of them. No statistically significant associations were found between the surgeon who performed the surgical procedure and the prevalence of LC conversion. The mean surgical time was 87.2±34minutes; in none of the cases the surgeons’ mean surgical times surpassed in two (2) standard deviations the group's mean surgical time.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>There was no statistically significant association between the US-LC time and the total surgical time, or between the US-LC time, or between the converted LC group and the non-converted LC group.DiscussionThe only variable with statistically significant association for conversion of LC procedure to open surgery was the gallbladder wall thickness documented by the US scan. Thickness ≥6mm had a 87.5 per cent sensitivity and a 62.6 per cent specificity, with an OR of 11.71 (95 per cent CI: 1.38–99; p=0.008) for conversion to open surgery. Other authors had already described the gallbladder wall thickness on the US scan as a risk factor for conversion to open surgery. For example, Stanisic et al.<a class="elsevierStyleCrossRef" href="#bib0200">16</a> documented a >4mm thickness, but, in their study, they included patients with AC and chronic cholecystitis. Cwik et al.<a class="elsevierStyleCrossRef" href="#bib0205">17</a> reported thicknesses >5mm as risk factor, but they did not make any comments on the sensitivity or specificity of their findings; a similar problem is found in the study by Cho et al.,<a class="elsevierStyleCrossRef" href="#bib0210">18</a> who used 3mm as the cutoff point.The proportion of conversion from LC procedure to open surgery in individuals with cholelithiasis without AC is not over 10 per cent,<a class="elsevierStyleCrossRefs" href="#bib0185">13,19</a> while in patients with AC, it goes from 5 per cent to 29.4 per cent.<a class="elsevierStyleCrossRefs" href="#bib0180">12,13</a> In our sample, the prevalence of conversion (8 per cent) was consistent with this range. The main reason for conversion in our study was the poor visualization of the biliary anatomy and the difficulty dissecting the structures of Calot's triangle, which is consistent with what has been reported by other authors.<a class="elsevierStyleCrossRefs" href="#bib0160">8,20–22</a> Other intraoperative findings that determine the greater technical difficulty of LC procedures are cholecystoenteric fistulas and the presence of collateral veins in a cirrhotic liver, circumstances that did not occur in our patients.Other US descriptors have been associated with surgical conversion in AC. Cwik et al.<a class="elsevierStyleCrossRef" href="#bib0205">17</a> reported the presence of peri-gallbladder fluid as a risk factor for conversion. Both in our study and in the study published by these authors, the prevalence of peri-gallbladder fluid was 22 per cent, which is why we believe that this association was the result of a conversion rate to open surgery three times higher than that reported by our group.More complex statistic models to predict the conversion of LC procedures to open surgery have been described. In benign conditions of the biliary duct, Beksac et al.<a class="elsevierStyleCrossRef" href="#bib0235">23</a> designed a score including age; sex; history of prior surgery; and alkaline phosphatase values, with a 70 per cent sensitivity; a 79 per cent specificity; and an AUC of 0.77. However, these authors did not discriminate individuals with AC, an important consideration given that Stanisic et al.<a class="elsevierStyleCrossRef" href="#bib0200">16</a> and Kama et al.<a class="elsevierStyleCrossRef" href="#bib0220">20</a> have reported AC as a risk factor for conversion to open surgery.The risk of conversion depends on factors associated with the patient, the machine used and the surgeon (experience, degree of fatigue).<a class="elsevierStyleCrossRefs" href="#bib0160">8,20</a> This study intended to evaluate only those variables associated with the patient, which is why the other elements were considered sources of bias. The difference in terms of the surgeon experience did not make an impact on the results reported.The report on the conversion rate from LC to open surgery is considered a quality indicator of surgery services.<a class="elsevierStyleCrossRef" href="#bib0240">24</a> In this sense, our results can help discriminate retrospectively the cases of conversion for causes that are not modifiable, such as gallbladder wall thickness >6mm, and causes that can be fixed such as the surgeon experience or the equipment malfunction in an effort to reduce conversion rates.Our study is one of the first ones to include exclusively individuals with a diagnosis of AC, but it has several limitations though. In the first place, the data mining was conducted retrospectively from the medical histories, hence the data loss was significant, especially for the laboratory variables, which is why our conclusions on this issue are limited. When it comes to the diagnosis of AC through ultrasound scans only five (5) typical elements were taken into consideration; other findings such as the gallbladder mobility or the striated thickening of the gallbladder wall were not assessed since their clinical utility has not been entirely validated. Finally, although our conversion rate was within the range reported in the medical literature, we only had eight (8) patients who required conversion to open surgery.In sum, the gallbladder wall thickness confirmed by US scans is associated with the need for conversion of LC procedure to open surgery in patients with AC; also, it warns surgeons on the complications they may find with a given patient.Authors<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030">1.Manager of the integrity of the study: YEI.</li><li class="elsevierStyleListItem" id="lsti0035">2.Study Idea: YEI, NEDD and NM.</li><li class="elsevierStyleListItem" id="lsti0040">3.Study Design: YEI and OEG.</li><li class="elsevierStyleListItem" id="lsti0045">4.Data Mining: YEI and OEG.</li><li class="elsevierStyleListItem" id="lsti0050">5.Data Analysis and Interpretation: YEI, ICB and JSG.</li><li class="elsevierStyleListItem" id="lsti0055">6.Statistical Analysis: YEI.</li><li class="elsevierStyleListItem" id="lsti0060">7.Reference: OEG, ICB and JSG.</li><li class="elsevierStyleListItem" id="lsti0065">8.Writing: YEI, OEG, ICB and JSG.</li><li class="elsevierStyleListItem" id="lsti0070">9.Critical review of the manuscript with intellectually relevant remarks: NEDD and NM.</li><li class="elsevierStyleListItem" id="lsti0075">10.Approval of final version: YEI, NEDD, NM, OEG, ICB and JSG.</li></ul>Conflicts of interestsThe authors declare no conflict of interests associated with this article whatsoever." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres976653" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec946426" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres976654" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec946427" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Method" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Ultrasound scan" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Surgical procedure" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Assessed variables" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Managing the confusion bias" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0045" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Risk prediction of conversion to open surgery" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Prediction of surgical time" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Managing the confusion bias" ] ] ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Authors" ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflicts of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-03-07" "fechaAceptado" => "2017-10-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec946426" "palabras" => array:5 [ 0 => "Cholecystectomy" 1 => "Laparoscopic" 2 => "Conversion to open surgery" 3 => "Ultrasonography" 4 => "Cholecystitis, acute" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec946427" "palabras" => array:4 [ 0 => "Colecistectomía laparoscópica" 1 => "Conversión a cirugía abierta" 2 => "Ultrasonido" 3 => "Colecistitis aguda" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo identify preoperative factors associated with surgical time and conversion of the laparoscopic cholecystectomy (LC) to open surgery in subjects with acute cholecystitis (AC). MethodWe developed a cross-sectional study that included 99 subjects older than 17 years with definitive diagnosis of AC who had undergone to LC. Preoperative variables such as clinical data, laboratory markers and ultrasound findings as wall thickness, the size of the major calculus and the presence of: perivesicular fluid, multiple cholelithiasis, biliary mud or microlithiasis were registered. We consider indirect measures of technical difficulties of LC the total surgical time and the need for conversion to open surgery. We used the square chi and Mann–Whitney U test to stablish the correlation between preoperative variables and the technical difficulties of LC. We build ROC curves of the variables with significant statistical association (p≤0.05 and 95% confidence interval) to determine the cut-off points of better sensitivity and specificity to predict conversion of LC to open surgery. ResultsA gallbladder wall thickness ≥6mm detected by ultrasound has a sensitivity of 87.5% and a specificity of 62.6% with OR 11.71 (95%CI: 1.38–99; p=0.008) for predict conversion to open surgery. There was no relationship between surgical time and the preoperative evaluated variables. ConclusionThe gallbladder wall thickness detected by the ultrasound is associated with the need of conversion of LC to open surgery in subjects with AC, furthermore this finding could warn the surgeon on the complexity with a particular patient." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoIdentificar en pacientes con colecistitis aguda (CoA) los factores preoperatorios asociados con el tiempo quirúrgico y con la conversión de colecistectomía laparoscópica (CL) a cirugía abierta. MétodoSe realizó un estudio transversal que incluyó 99 pacientes mayores de 17 años con diagnóstico definitivo de CoA tratados con CL. Se registraron variables prequirúrgicas, como datos clínicos, valores de laboratorio y hallazgos ecográficos como el grosor de la pared de la vesícula, el volumen vesicular y la presencia de: líquido perivesicular, colelitiasis múltiple o barro biliar. Se consideraron medidas indirectas de dificultad técnica de la CL, el tiempo quirúrgico empleado y la necesidad de conversión a cirugía abierta. Se utilizaron las pruebas de ji-cuadrado o U de Mann-Whitney para establecer la relación entre las variables prequirúrgicas y aquellas indicativas de dificultad técnica. Se construyeron curvas ROC (Receiver Operating Characteristic) de las variables con asociación estadística significativa (p ≤0,05 e intervalo de confianza del 95%) para determinar los puntos de corte de mejor rendimiento para predecir la conversión de CL a cirugía abierta. ResultadosUn grosor de la pared vesicular ≥6mm detectado por ultrasonido tiene una odds ratio de 11,71 (IC95%: 1,38-99; p=0,008), con una sensibilidad del 87,5% y una especificidad del 62,6% para predecir la conversión a cirugía abierta. No hubo relación entre el tiempo quirúrgico y las variables prequirúrgicas evaluadas. ConclusiónEl grosor de la pared de la vesícula biliar detectado por ultrasonido se asocia con la necesidad de conversión de la CL a cirugía abierta en pacientes con CoA." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Izquierdo YE, Díaz Díaz NE, Muñoz N, Guzmán OE, Contreras Bustos I, Gutiérrez JS. Factores prequirúrgicos asociados con dificultades técnicas de la colecistectomía laparoscópica en la colecistitis aguda. Radiología. 2018:60;57–63." ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 901 "Ancho" => 2500 "Tamanyo" => 256476 ] ] "descripcion" => array:1 [ "en" => "Image of the gallbladder. (A) Longitudinal cut of the gallbladder. The continuous yellow line represents the line that is tangent to the gallbladder thickest point. The red line represents the line that is perpendicular to the continuous yellow line; the gallbladder wall thickness was measured over this perpendicular line. Dotted yellow line: length of gallstone. Yellow arrow: biliary mud. Purple arrow: acoustic shadow generated by the gallstone. (B) Gallbladder transverse cut. Blue line: gallbladder diameters used to estimate the volume." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1048 "Ancho" => 1549 "Tamanyo" => 46904 ] ] "descripcion" => array:1 [ "en" => "Causes for conversion from laparoscopic cholecystectomy to open surgery." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1016 "Ancho" => 1461 "Tamanyo" => 59121 ] ] "descripcion" => array:1 [ "en" => "ROC curve for gallbladder wall thickness on the ultrasound scan and conversion to open surgery." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">A. Local inflammatory signs: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(1) Murphy's sign \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(2) Mass, pain or sensitivity in right upper quadrant \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">B. Systemic inflammatory signs: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(1) Fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(2) High C-reactive protein levels \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(3) Leukocytosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C. Imaging findings: findings characteristic of acute cholecystitis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> Diagnostic suspicion: 1 item from A+1 item from B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Definitive diagnosis: 1 item from A+1 item from B+C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">*Acute hepatitis and other causes for abdominal pain and chronic cholecystitis should be excluded. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adapted from Ref.<a class="elsevierStyleCrossRef" href="#bib0135">3</a>. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1654412.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Diagnostic criteria for acute cholecystitis." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "LC: laparoscopic cholecystectomy; IQR: interquartile range; NA: non-applicable; US-LC time: time elapsed between the US and the beginning of the LC procedure." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Variables</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LC converted to open surgery n=8 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LC not converted n=91 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Clinical</td><td class="td" title="table-entry " align="left" valign="top">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62.5 IQR 10.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">48.8±17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.069 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Feminine Sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (50 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64 (70.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Days with symptomatology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 IQR 3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 IQR 3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.52 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">US-LC time (h) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">97.1 IQR 182.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">70 IQR 122.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.69 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI (kg/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25.71 IQR NA (n=3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25.95 IQR 7.04 (n=53) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Laboratory</td><td class="td" title="table-entry " align="left" valign="top">Leukocytes (No./mm3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12,290 IQR 5317 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12,330 IQR 6717 (n=90) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.71 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RCP (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27 IQR NA (n=3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">102 IQR 255.3 (n=22) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Ultrasound scan</td><td class="td" title="table-entry " align="left" valign="top">Wall thickness (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.5 IQR 1.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 IQR 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.005<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Length of gallstone (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17.5 IQR 19.75 (n=6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 IQR 9.5 (n=60) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.19 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Peri-gallbladder fluid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3/6 (50 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20/90 (22 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.61 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Biliary mud \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1/8 (12.5 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23/90 (12.5 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.42 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Multiple cholelithiasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6/8 (75 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62/91 (68.1 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.17 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1654413.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "Statistically significant value." ] ] ] "descripcion" => array:1 [ "en" => "Relation between the variables and the need for conversion to open surgery." ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Sensitivity=(a)/(a)+(c): 7/7+1=0.875.Specificity=(d)/(c)+(d): 57/57+34=0.626.OR=(a)×(d)/(b)×(c)=7×57/1×34=11.71." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Conversion to open surgery</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wall thickness ≥6mm confirmed through ultrasound scan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="center" valign="top">Yes</td><td class="td" title="table-entry " colspan="2" align="center" valign="top">No</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(a) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(b) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(c) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(d) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1654414.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Table 2 × 2 on the association between gallbladder wall thickness and conversion to open surgery." ] ] 6 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "BMI: Body mass index; CRP: C-reactive protein." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Variable</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Clinical</td><td class="td" title="table-entry " align="left" valign="top">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.086 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Feminine sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Days in pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.37 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI (kg/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Laboratory</td><td class="td" title="table-entry " align="left" valign="top">Leukocytes (No./mm3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.69 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CRP (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.42 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Ultrasound scan</td><td class="td" title="table-entry " align="left" valign="top">Wall thickness (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.734 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Length of gallstone (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.08 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Peri-gallbladder fluid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.143 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Biliary mud \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.151 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Multiple cholelithiasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.37 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1654415.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Association between the variables and the surgical time used in laparoscopic cholecystectomy procedures." ] ] 7 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Surgeon \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Conversion of the LC procedure</th><th class="td" title="table-head " align="left" valign="top" scope="col">Surgical time (min) \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of LC procedures conducted \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of LC procedures converted \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90±41 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (13.3 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78±24 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (8.6 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81±36 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65±12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">102±31 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89±27 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60±14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84±34 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100±53 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (28 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89±43 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (25 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92±42 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">105±14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (8 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87.2±34 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1654416.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Results of conversion of the laparoscopic cholecystectomy procedure and the surgical time per surgeon." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0125" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Definitions, pathophysiology and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y. 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Factores prequirúrgicos asociados con dificultades técnicas de la colecistectomía laparoscópica en la colecistitis aguda

Y.E. Izquierdoa,

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yeaguirrei@unal.edu.co

Corresponding author.

, N.E. Díaz Díazb, N. Muñozc, O.E. Guzmána, I. Contreras Bustosa, J.S. Gutiérreza

a Facultad de Medicina, Universidad Nacional de Colombia, Bogotá D.C, Colombia

b Servicio de Radiología, ESE Hospital El Tunal nivel III, Bogotá D.C, Colombia

c Servicio de Cirugía, ESE Hospital El Tunal nivel III, Bogotá D.C, Colombia

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Acute cholecystitis &#40;AC&#41; is the acute inflammatory process of the gallbladder wall that is secondary to lithiasis in 95 per cent of the cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;2</span></a> According to the 2013 Tokyo guidelines for the management of cholangitis and AC&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a> the concomitant presence of local inflammatory sings in the upper right abdominal quadrant&#59; the signs of systemic inflammatory response&#59; and the typical AC imaging findings are considered definitive diagnosis of AC&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The initial approximation image in cases of diagnostic suspicion of AC is the ultrasound scan &#40;US&#41;&#46; The diagnosis of AC through an ultrasound scan is based on the combination of ultrasound findings&#44; given that there is no pathognomonic sign&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> The findings typically described in AC are the presence of an impacted gallstone or peri-gallbladder fluid&#59; overdistended gallbladder&#59; thickening or flow increase of the gallbladder wall&#59; and the positive sonographic Murphy sign&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> The concomitance of several of these ultrasound findings reaches an 88 per cent sensitivity and an 80 per cent specificity in the diagnosis of AC&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The treatment of choice for the management of AC is the laparoscopic cholecystectomy &#40;LC&#41; procedure&#44; since there is less postoperative pain&#58; hospital stays are shorter and is more cost-effective compared to open surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">6&#44;7</span></a> One of the setbacks of LC compared to open surgery is the higher risk of biliary duct injury&#59;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a> as a matter of fact&#44; avoiding the appearance of iatrogenic lesions is the main reason for LC to open surgery conversion&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">8&#8211;11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The conversion rate from LC to open surgery ranges from 5 per cent to 29&#46;4 per cent&#44;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">12&#44;13</span></a> and it is based on two &#40;2&#41; types of conditions&#58; those non-associated with the patient&#44; such as the surgeon&#39;s experience&#44; and patient-inherent conditions&#44; such as the significant inflammation of the gallbladder bed that increases the difficulty to identify or dissect anatomical structures&#46; Defining the impact of these conditions prior to the LC is the first step to be able to establish strategies aimed at reducing the conversion rate of LC to open surgery in all hospitals&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The goal of this work was to identify&#44; in patients with AC&#44; the preoperative factors associated with an extended surgical time&#44; or conversion from LC to open surgery&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Method</span><p id="par0030" class="elsevierStylePara elsevierViewall">After obtaining authorization from the hospital ethics committee&#44; one observational&#44; analytical and retrospective study was conducted&#44; which is why no informed consent was required&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0035" class="elsevierStylePara elsevierViewall">The medical histories of all the patients who underwent LC procedures in our center between September 15th&#44; 2015 through October 15th&#44; 2016 were reviewed&#46; The following were defined as inclusion criteria&#58; being over 17 years of age&#44; and having a definitive diagnosis of AC according to the 2013 Tokyo guidelines for the management of cholangitis and AC<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">3&#44;14</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Those individuals who underwent intraoperative cholangiography procedures were excluded&#44; since this procedure involves extra surgical time non-associated with the technical difficulties of LC&#46; Also&#44; patients operated between 19&#58;00<span class="elsevierStyleHsp" style=""></span>h and 06&#58;59<span class="elsevierStyleHsp" style=""></span>h &#40;the night shift&#41; were ruled out to avoid confusion bias associated with the extended surgery time secondary to the effect of fatigue on the surgeon performance&#46; Following the local protocol&#44; all individuals with a definitive diagnosis of AC are treated with LC&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Ultrasound scan</span><p id="par0040" class="elsevierStylePara elsevierViewall">All studies were conducted using a ALOKA PROSOUND F75 machine &#40;Model IPF-1904 SN M00159 series M00159&#41; with a 7&#46;5<span class="elsevierStyleHsp" style=""></span>MHz convex transducer operated by&#44; at least&#44; one of the four radiologists from our hospital&#44; with between 4 and 12 years of experience working with this diagnostic modality&#46; The gallbladder volume was estimated using the ellipsoid volume formula&#46; The presence of one 1<span class="elsevierStyleHsp" style=""></span>mm wide anechoic band around the gallbladder was considered peri-gallbladder fluid&#46; The existence of amorphous and mobile echogenic material inside the gallbladder was defined as biliary mud&#46; Multiple cholelithiasis was established as the presence of two &#40;2&#41; or more stones followed by posterior acoustic shadowing&#46; Microlithiasis was defined as the presence of mobile echogenic images without posterior acoustic shadowing with a diameter smaller than 5<span class="elsevierStyleHsp" style=""></span>mm&#46; The gallbladder wall thickness was measured on the longitudinal section of the gallbladder on the contact area with the hepatic parenchyma&#46; A detailed description of the measurements of the gallbladder wall is described in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; All measurements were taken directly on the machine while the ultrasound scan was being conducted&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The cases meeting&#44; at least&#44; three &#40;3&#41; of the following criteria were considered imaging diagnosis of AC&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Gallbladder wall thickness &#62;3<span class="elsevierStyleHsp" style=""></span>mm&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Presence of peri-gallbladder fluid&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Positive sonographic Murphy sign&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Gallbladder volume &#62;100<span class="elsevierStyleHsp" style=""></span>cc&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Gallbladder stone impacted at gallbladder neck level&#46;</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Surgical procedure</span><p id="par0075" class="elsevierStylePara elsevierViewall">The LC procedures were conducted under general anesthesia through orotracheal intubation performed by&#44; at least&#44; one &#40;1&#41; member from the hospital general surgery team with between 1 and 15 years of experience doing laparoscopic procedures&#46; STORZ laparoscopic machines were used with the surgical technique of three or four ports&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Assessed variables</span><p id="par0080" class="elsevierStylePara elsevierViewall">We recorded the patients&#8217; age&#59; sex&#59; duration of symptoms&#59; body mass index&#59; and laboratory markers &#40;total leukocyte recount and C-reactive protein&#41; measured in the blood samples taken when they were admitted to the hospital&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The ultrasound scan variables were recorded from the ultrasound reports including the gallbladder volume and the presence of peri-gallbladder fluid&#59; biliary mud&#59; microlithiasis&#59; or multiple lithiasis&#59; length of the largest gallstones&#59; and gallbladder wall thickness&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Total surgical time and the need for conversion to open surgery were considered indicators of technical difficulties associated with the LC procedure&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Managing the confusion bias</span><p id="par0095" class="elsevierStylePara elsevierViewall">To assess the impact of surgeon experience on the results obtained&#44; a comparison was made between the percentage of LC procedures converted to open surgery and the mean surgical time used by each and every one of the surgeons who participated in this research&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The homogeneity of conditions prior to the surgery between the groups of converted and unconverted LC procedures was determined by assessing the mean time elapsed between the US diagnosis and the beginning of the LC procedure &#40;US&#8211;LC time&#41;&#44; and the average days spent with symptoms in each group&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0105" class="elsevierStylePara elsevierViewall">In the descriptive analysis of the continuous variables the average<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation or median and interquartile range &#40;IQR&#41; was used&#44; depending on the nature of the distribution according to the Kolmogorov&#8211;Smirnov normality test&#46; The nominal variables were expressed in absolute and relative frequencies using percentages&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The descriptive analysis was conducted independently for the groups of LC procedures converted to open surgery and non-converted LC procedures&#44; and their results were compared using the square chi test or the exact Fisher test for the categorical variables&#44; and the Student <span class="elsevierStyleItalic">t</span> or Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test for quantitative variables&#46; To establish the relation between two continuous variables&#44; the Spearman or Pearson&#8217; correlations were used&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Those parameters with statistically significant associations &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; were incorporated into the multivariate models of binary logistic regression using the need for conversion to open surgery as a dependent variable&#46; To estimate the percentage of variation explained and its goodness-of-fit&#44; the Nagelkerke <span class="elsevierStyleItalic">R</span> square and the Hosmer&#8211;Lemeshow test were used&#44; respectively&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Finally&#44; the ROC &#40;Receiver Operating Characteristic&#41; curves were conducted in order to determine the cutoff points of those variables with statistically significant associations and their capacity to predict the need for conversion to open surgery&#46; The cutoff point with the best performance for each variable was determined using the Youden Index&#46; The operative characteristics were calculated as well as the odds ratio &#40;OR&#41;&#44; and the 95 per cent confidence interval &#40;95 per cent CI&#41; of the cutoff points found&#46; The entire data analysis was conducted using the software package IBM SPSS Statistics for Windows&#44; version 22&#46;0&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0125" class="elsevierStylePara elsevierViewall">Ninety-nine &#40;99&#41; patients were included with an average age of 49&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;8 years old&#8211;68 women &#40;68&#46;7 per cent&#41; and 31 males &#40;31&#46;3 per cent&#41;&#46; The median time with abdominal pain was 3 days &#40;IQR&#58; 4&#41; and the US-LC mean time was 70&#46;9<span class="elsevierStyleHsp" style=""></span>hours &#40;IQR&#58; 125&#46;6&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">At our center&#44; every individual with a definitive diagnosis of AC is treated with LC&#59; however&#44; in the period studied eight &#40;8&#41; individuals were taken directly to open surgery&#58; three &#40;3&#41; with suspicion of pyocholecyst with severe adherences&#44; one &#40;1&#41; due to an apparent biliary peritonitis&#44; one &#40;1&#41; due to a history of biliary pancreatitis&#44; one &#40;1&#41; pregnant woman with severe thrombocytopenia&#44; and one &#40;1&#41; patient with severe pulmonary hypertension&#44; which relatively contraindicated the use of pneumoperitoneum for the LC procedure&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Risk prediction of conversion to open surgery</span><p id="par0135" class="elsevierStylePara elsevierViewall">Conversion to open surgery was necessary in eight &#40;8&#41; patients &#40;8 per cent&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows the reasons for conversion from LC procedures&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> summarizes the clinical&#44; laboratory and ultrasound scan variables for the converted LC and non-converted LCs groups&#44; as well as their association with the conversion represented by the <span class="elsevierStyleItalic">p</span> values&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">One logistic regression model using the gallbladder wall thickness as the single variable explained 13 per cent of the variance associated with the need for conversion to open surgery &#40;Nagelkerke <span class="elsevierStyleItalic">R</span> square&#58; 0&#46;13&#41;&#44; with good goodness-of-fit &#40;Hosmer&#8211;Lemeshow test&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#8211;41&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> represents the ROC curve for the gallbladder wall thickness&#44; with an area under the curve &#40;AUC&#41; of 0&#46;82&#46; According to Youden Index&#44; the cutoff point with the best performance in our sample was 6<span class="elsevierStyleHsp" style=""></span>mm&#44; with a 87&#46;5 per cent sensitivity and a 62&#46;6 per cent specificity &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; The &#8805;6<span class="elsevierStyleHsp" style=""></span>mm thickness confirmed through US scan had an OR of 11&#46;71 &#40;95 per cent CI&#58; 1&#46;38&#8211;99&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41; for conversion to open surgery&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Prediction of surgical time</span><p id="par0150" class="elsevierStylePara elsevierViewall">There was no statistically significant association between the preoperative variables assessed and the total time of the LC procedure&#46; <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> shows the <span class="elsevierStyleItalic">p</span> values documented for each variable&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Managing the confusion bias</span><p id="par0155" class="elsevierStylePara elsevierViewall">The LC procedures included were performed by 13 surgeons&#46; <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> summarizes the data obtained for each one of them&#46; No statistically significant associations were found between the surgeon who performed the surgical procedure and the prevalence of LC conversion&#46; The mean surgical time was 87&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>34<span class="elsevierStyleHsp" style=""></span>minutes&#59; in none of the cases the surgeons&#8217; mean surgical times surpassed in two &#40;2&#41; standard deviations the group&#39;s mean surgical time&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">There was no statistically significant association between the US-LC time and the total surgical time&#44; or between the US-LC time&#44; or between the converted LC group and the non-converted LC group&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0165" class="elsevierStylePara elsevierViewall">The only variable with statistically significant association for conversion of LC procedure to open surgery was the gallbladder wall thickness documented by the US scan&#46; Thickness &#8805;6<span class="elsevierStyleHsp" style=""></span>mm had a 87&#46;5 per cent sensitivity and a 62&#46;6 per cent specificity&#44; with an OR of 11&#46;71 &#40;95 per cent CI&#58; 1&#46;38&#8211;99&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41; for conversion to open surgery&#46; Other authors had already described the gallbladder wall thickness on the US scan as a risk factor for conversion to open surgery&#46; For example&#44; Stanisic et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> documented a &#62;4<span class="elsevierStyleHsp" style=""></span>mm thickness&#44; but&#44; in their study&#44; they included patients with AC and chronic cholecystitis&#46; Cwik et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> reported thicknesses &#62;5<span class="elsevierStyleHsp" style=""></span>mm as risk factor&#44; but they did not make any comments on the sensitivity or specificity of their findings&#59; a similar problem is found in the study by Cho et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a> who used 3<span class="elsevierStyleHsp" style=""></span>mm as the cutoff point&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The proportion of conversion from LC procedure to open surgery in individuals with cholelithiasis without AC is not over 10 per cent&#44;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">13&#44;19</span></a> while in patients with AC&#44; it goes from 5 per cent to 29&#46;4 per cent&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">12&#44;13</span></a> In our sample&#44; the prevalence of conversion &#40;8 per cent&#41; was consistent with this range&#46; The main reason for conversion in our study was the poor visualization of the biliary anatomy and the difficulty dissecting the structures of Calot&#39;s triangle&#44; which is consistent with what has been reported by other authors&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">8&#44;20&#8211;22</span></a> Other intraoperative findings that determine the greater technical difficulty of LC procedures are cholecystoenteric fistulas and the presence of collateral veins in a cirrhotic liver&#44; circumstances that did not occur in our patients&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Other US descriptors have been associated with surgical conversion in AC&#46; Cwik et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> reported the presence of peri-gallbladder fluid as a risk factor for conversion&#46; Both in our study and in the study published by these authors&#44; the prevalence of peri-gallbladder fluid was 22 per cent&#44; which is why we believe that this association was the result of a conversion rate to open surgery three times higher than that reported by our group&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">More complex statistic models to predict the conversion of LC procedures to open surgery have been described&#46; In benign conditions of the biliary duct&#44; Beksac et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> designed a score including age&#59; sex&#59; history of prior surgery&#59; and alkaline phosphatase values&#44; with a 70 per cent sensitivity&#59; a 79 per cent specificity&#59; and an AUC of 0&#46;77&#46; However&#44; these authors did not discriminate individuals with AC&#44; an important consideration given that Stanisic et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> and Kama et al&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a> have reported AC as a risk factor for conversion to open surgery&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The risk of conversion depends on factors associated with the patient&#44; the machine used and the surgeon &#40;experience&#44; degree of fatigue&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">8&#44;20</span></a> This study intended to evaluate only those variables associated with the patient&#44; which is why the other elements were considered sources of bias&#46; The difference in terms of the surgeon experience did not make an impact on the results reported&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">The report on the conversion rate from LC to open surgery is considered a quality indicator of surgery services&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a> In this sense&#44; our results can help discriminate retrospectively the cases of conversion for causes that are not modifiable&#44; such as gallbladder wall thickness &#62;6<span class="elsevierStyleHsp" style=""></span>mm&#44; and causes that can be fixed such as the surgeon experience or the equipment malfunction in an effort to reduce conversion rates&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Our study is one of the first ones to include exclusively individuals with a diagnosis of AC&#44; but it has several limitations though&#46; In the first place&#44; the data mining was conducted retrospectively from the medical histories&#44; hence the data loss was significant&#44; especially for the laboratory variables&#44; which is why our conclusions on this issue are limited&#46; When it comes to the diagnosis of AC through ultrasound scans only five &#40;5&#41; typical elements were taken into consideration&#59; other findings such as the gallbladder mobility or the striated thickening of the gallbladder wall were not assessed since their clinical utility has not been entirely validated&#46; Finally&#44; although our conversion rate was within the range reported in the medical literature&#44; we only had eight &#40;8&#41; patients who required conversion to open surgery&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">In sum&#44; the gallbladder wall thickness confirmed by US scans is associated with the need for conversion of LC procedure to open surgery in patients with AC&#59; also&#44; it warns surgeons on the complications they may find with a given patient&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Authors</span><p id="par0205" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">1&#46;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Manager of the integrity of the study&#58; YEI&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">2&#46;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Study Idea&#58; YEI&#44; NEDD and NM&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">3&#46;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Study Design&#58; YEI and OEG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">4&#46;</span><p id="par0225" class="elsevierStylePara elsevierViewall">Data Mining&#58; YEI and OEG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">5&#46;</span><p id="par0230" class="elsevierStylePara elsevierViewall">Data Analysis and Interpretation&#58; YEI&#44; ICB and JSG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">6&#46;</span><p id="par0235" class="elsevierStylePara elsevierViewall">Statistical Analysis&#58; YEI&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">7&#46;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Reference&#58; OEG&#44; ICB and JSG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">8&#46;</span><p id="par0245" class="elsevierStylePara elsevierViewall">Writing&#58; YEI&#44; OEG&#44; ICB and JSG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">9&#46;</span><p id="par0250" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant remarks&#58; NEDD and NM&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">10&#46;</span><p id="par0255" class="elsevierStylePara elsevierViewall">Approval of final version&#58; YEI&#44; NEDD&#44; NM&#44; OEG&#44; ICB and JSG&#46;</p></li></ul></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interests</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests associated with this article whatsoever&#46;</p></span></span>"
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              "titulo" => "Risk prediction of conversion to open surgery"
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            0 => "Cholecystectomy"
            1 => "Laparoscopic"
            2 => "Conversion to open surgery"
            3 => "Ultrasonography"
            4 => "Cholecystitis&#44; acute"
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          "palabras" => array:4 [
            0 => "Colecistectom&#237;a laparosc&#243;pica"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To identify preoperative factors associated with surgical time and conversion of the laparoscopic cholecystectomy &#40;LC&#41; to open surgery in subjects with acute cholecystitis &#40;AC&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We developed a cross-sectional study that included 99 subjects older than 17 years with definitive diagnosis of AC who had undergone to LC&#46; Preoperative variables such as clinical data&#44; laboratory markers and ultrasound findings as wall thickness&#44; the size of the major calculus and the presence of&#58; perivesicular fluid&#44; multiple cholelithiasis&#44; biliary mud or microlithiasis were registered&#46; We consider indirect measures of technical difficulties of LC the total surgical time and the need for conversion to open surgery&#46; We used the square chi and Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test to stablish the correlation between preoperative variables and the technical difficulties of LC&#46; We build ROC curves of the variables with significant statistical association &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;05 and 95&#37; confidence interval&#41; to determine the cut-off points of better sensitivity and specificity to predict conversion of LC to open surgery&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A gallbladder wall thickness &#8805;6<span class="elsevierStyleHsp" style=""></span>mm detected by ultrasound has a sensitivity of 87&#46;5&#37; and a specificity of 62&#46;6&#37; with OR 11&#46;71 &#40;95&#37;CI&#58; 1&#46;38&#8211;99&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41; for predict conversion to open surgery&#46; There was no relationship between surgical time and the preoperative evaluated variables&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The gallbladder wall thickness detected by the ultrasound is associated with the need of conversion of LC to open surgery in subjects with AC&#44; furthermore this finding could warn the surgeon on the complexity with a particular patient&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Identificar en pacientes con colecistitis aguda &#40;CoA&#41; los factores preoperatorios asociados con el tiempo quir&#250;rgico y con la conversi&#243;n de colecistectom&#237;a laparosc&#243;pica &#40;CL&#41; a cirug&#237;a abierta&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio transversal que incluy&#243; 99 pacientes mayores de 17 a&#241;os con diagn&#243;stico definitivo de CoA tratados con CL&#46; Se registraron variables prequir&#250;rgicas&#44; como datos cl&#237;nicos&#44; valores de laboratorio y hallazgos ecogr&#225;ficos como el grosor de la pared de la ves&#237;cula&#44; el volumen vesicular y la presencia de&#58; l&#237;quido perivesicular&#44; colelitiasis m&#250;ltiple o barro biliar&#46; Se consideraron medidas indirectas de dificultad t&#233;cnica de la CL&#44; el tiempo quir&#250;rgico empleado y la necesidad de conversi&#243;n a cirug&#237;a abierta&#46; Se utilizaron las pruebas de ji-cuadrado o U de Mann-Whitney para establecer la relaci&#243;n entre las variables prequir&#250;rgicas y aquellas indicativas de dificultad t&#233;cnica&#46; Se construyeron curvas ROC &#40;Receiver Operating Characteristic&#41; de las variables con asociaci&#243;n estad&#237;stica significativa &#40;p &#8804;0&#44;05 e intervalo de confianza del 95&#37;&#41; para determinar los puntos de corte de mejor rendimiento para predecir la conversi&#243;n de CL a cirug&#237;a abierta&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Un grosor de la pared vesicular &#8805;6<span class="elsevierStyleHsp" style=""></span>mm detectado por ultrasonido tiene una odds ratio de 11&#44;71 &#40;IC95&#37;&#58; 1&#44;38-99&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;008&#41;&#44; con una sensibilidad del 87&#44;5&#37; y una especificidad del 62&#44;6&#37; para predecir la conversi&#243;n a cirug&#237;a abierta&#46; No hubo relaci&#243;n entre el tiempo quir&#250;rgico y las variables prequir&#250;rgicas evaluadas&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El grosor de la pared de la ves&#237;cula biliar detectado por ultrasonido se asocia con la necesidad de conversi&#243;n de la CL a cirug&#237;a abierta en pacientes con CoA&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Izquierdo YE&#44; D&#237;az D&#237;az NE&#44; Mu&#241;oz N&#44; Guzm&#225;n OE&#44; Contreras Bustos I&#44; Guti&#233;rrez JS&#46; Factores prequir&#250;rgicos asociados con dificultades t&#233;cnicas de la colecistectom&#237;a laparosc&#243;pica en la colecistitis aguda&#46; Radiolog&#237;a&#46; 2018&#58;60&#59;57&#8211;63&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Image of the gallbladder&#46; &#40;A&#41; Longitudinal cut of the gallbladder&#46; The continuous yellow line represents the line that is tangent to the gallbladder thickest point&#46; The red line represents the line that is perpendicular to the continuous yellow line&#59; the gallbladder wall thickness was measured over this perpendicular line&#46; Dotted yellow line&#58; length of gallstone&#46; Yellow arrow&#58; biliary mud&#46; Purple arrow&#58; acoustic shadow generated by the gallstone&#46; &#40;B&#41; Gallbladder transverse cut&#46; Blue line&#58; gallbladder diameters used to estimate the volume&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">A&#46; Local inflammatory signs&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#40;1&#41; Murphy&#39;s sign&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#40;2&#41; Mass&#44; pain or sensitivity in right upper quadrant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">B&#46; Systemic inflammatory signs&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#40;1&#41; Fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#40;2&#41; High C-reactive protein levels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#40;3&#41; Leukocytosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">C&#46; Imaging findings&#58; findings characteristic of acute cholecystitis&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span> Diagnostic suspicion&#58; 1 item from A<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 item from B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Definitive diagnosis&#58; 1 item from A<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 item from B<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#42;Acute hepatitis and other causes for abdominal pain and chronic cholecystitis should be excluded&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Adapted from Ref&#46;</span><a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleItalic">3</span></a>&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Diagnostic criteria for acute cholecystitis&#46;</p>"
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">LC&#58; laparoscopic cholecystectomy&#59; IQR&#58; interquartile range&#59; NA&#58; non-applicable&#59; US-LC time&#58; time elapsed between the US and the beginning of the LC procedure&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Variables</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LC converted to open surgery<br>n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LC not converted<br>n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Clinical</span></td><td class="td" title="table-entry  " align="left" valign="top">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&#46;5 IQR 10&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;069&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Feminine Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;50 per cent&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64 &#40;70&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Days with symptomatology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 IQR 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 IQR 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">US-LC time &#40;h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">97&#46;1 IQR 182&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70 IQR 122&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#46;71 IQR NA &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#46;95 IQR 7&#46;04 &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Laboratory</span></td><td class="td" title="table-entry  " align="left" valign="top">Leukocytes &#40;No&#46;&#47;mm<span class="elsevierStyleSup">3</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#44;290 IQR 5317&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#44;330 IQR 6717 &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RCP &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27 IQR NA &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">102 IQR 255&#46;3 &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Ultrasound scan</span></td><td class="td" title="table-entry  " align="left" valign="top">Wall thickness &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;5 IQR 1&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 IQR 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;005<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Length of gallstone &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#46;5 IQR 19&#46;75 &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11 IQR 9&#46;5 &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Peri-gallbladder fluid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#47;6 &#40;50 per cent&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#47;90 &#40;22 per cent&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Biliary mud&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;8 &#40;12&#46;5 per cent&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&#47;90 &#40;12&#46;5 per cent&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Multiple cholelithiasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#47;8 &#40;75 per cent&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&#47;91 &#40;68&#46;1 per cent&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Statistically significant value&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Relation between the variables and the need for conversion to open surgery&#46;</p>"
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Sensitivity<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#40;a&#41;&#47;&#40;a&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>&#40;c&#41;&#58; 7&#47;7<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;875&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Specificity<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#40;d&#41;&#47;&#40;c&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>&#40;d&#41;&#58; 57&#47;57<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>34<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;626&#46;</p><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#40;a&#41;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>&#40;d&#41;&#47;&#40;b&#41;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>&#40;c&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>57&#47;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>34<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#46;71&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Conversion to open surgery</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Wall thickness &#8805;6</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mm confirmed through ultrasound scan</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="center" valign="top">Yes</td><td class="td" title="table-entry  " colspan="2" align="center" valign="top">No</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#40;a&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#40;b&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#40;c&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#40;d&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Peri-gallbladder fluid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;143&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Biliary mud&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;151&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Multiple cholelithiasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Surgeon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Conversion of the LC procedure</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Surgical time &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of LC procedures conducted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of LC procedures converted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;13&#46;3 per cent&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;8&#46;6 per cent&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">102<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;28 per cent&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;25 per cent&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">105<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;8 per cent&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:24 [
            0 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "1"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Definitions&#44; pathophysiology and epidemiology of acute cholangitis and cholecystitis&#58; Tokyo Guidelines"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "Y&#46; Kimura"
                            1 => "T&#46; Takada"
                            2 => "Y&#46; Kawarada"
                            3 => "Y&#46; Nimura"
                            4 => "K&#46; Hirata"
                            5 => "M&#46; Sekimoto"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00534-006-1152-y"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hepatobiliary Pancreat Surg"
                        "fecha" => "2007"
                        "volumen" => "14"
                        "paginaInicial" => "15"
                        "paginaFinal" => "26"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17252293"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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Article information

ISSN: 21735107
Original language: English

DOI:10.1016/j.rxeng.2017.10.005

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