Analysis of factors for conversion of laparoscopic to open cholecystectomy: A prospective study of 703 patients with acute cholecystitis

Abstract

Aims

Conversions to open surgery during laparoscopic cholecystectomy are performed in 20% of patients with acute cholecystitis, and are associated with increased morbidity and costs. The aim of this study was to identify predictive factors for conversion and to evaluate morbidity, mortality and hospital stay.

Methods

A prospective cohort of patients admitted to the emergency department with acute cholecystitis. We evaluated the statistical significance of the demographic, clinical, biochemical, imaging and surgical factors at admission, associated with conversion to open surgery using a univariate model. The associated factors evaluated during initial analysis were then included in a multivariate analysis. Finally a comparative analysis was made of the morbidity and mortality in both models.

Results

A total of 703 patients were included. Conversion rate was 13.8%. Univariate analysis identified as factors: male gender, previous ERCP, leucocytes > 12,000 mm³, age >70 years, hypertension, jaundice, cholangitis, total bilirubin >2 mg/dl, ASA III-IV, gallbladder wall enlargement and choledocholithiasis. Logistic regression identified as predictive factors: previous ERCP, leucocytes, age >70 years and male gender. Converted patients had a higher morbidity rate, further operations and longer hospital stays (P < 001). No difference was seen in mortality.

Discussion

It is important to recognise patients with a higher risk of conversion in order to optimise planning and performing of the surgical procedure, and to decrease the morbidity associated with laparotomy, given that the independent factors identified are not modifiable.

Resumen

Introducción

La conversión a cirugía abierta durante colecistectomía laparoscópica se presenta en el 20%. Este desenlace se relaciona con mayor morbilidad y costos. En este estudio se describen los factores predictivos de conversión, la estancia hospitalaria, morbimortalidad asociada.

Materiales y métodos

Cohorte prospectiva de pacientes sometidos a colecistectomía laparoscópica de urgencia con colecistitis aguda. Análisis uni- y multivariado de los factores predictivos de conversión a partir de variables socio-demográficas, clínicas, bioquímicas y de imágenes diagnósticas, identificación de la tasa de morbilidad, mortalidad y estancia hospitalaria en los dos grupos.

Resultados

703 pacientes fueron incluidos en el análisis. La tasa de conversión fue 13,8%. Los factores identificados en el análisis univariado fueron: género masculino, edad > 70 años, hipertensión arterial, colangitis, CPRE previa, coledocolitiasis, bilirrubina total > 2 mg/dl, ictericia, recuento de leucocitos > 12.000 mm3, ASA III-IV y engrosamiento de la pared de la vesícula por ecografía. Los factores independientes fueron: género masculino (p < 0,02), edad > 70 años (p < 0,02), CPRE previa (p < 0,05) y recuento de leucocitos> 12.000 mm³ (p < 0,04). Los pacientes convertidos presentaron mayor tasa de morbilidad, reoperación y estancia hospitalaria (p < 0,001). La mortalidad no mostró diferencias.

Conclusiones

Es importante reconocer al paciente con mayor riesgo de conversión para optimizar la planeación y ejecución del procedimiento quirúrgico y disminuir la morbilidad asociada a la laparotomía, dado que los factores independientes identificados no son modificables.