Department of Surgery, University Hospital Monklands, Lanarkshire, Scotland, UK.
Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
Surg Endosc. 2020 Oct;34(10):4549-4561. doi: 10.1007/s00464-019-07244-5. Epub 2019 Nov 15.
The prediction of a difficult cholecystectomy has traditionally been based on certain pre-operative clinical and imaging factors. Most of the previous literature reported small patient cohorts and have not used an objective measure of operative difficulty. The aim of this study was to develop a pre-operative score to predict difficult cholecystectomy, as defined by a validated intra-operative difficulty grading scale.
Two cohorts from prospectively maintained databases of patients who underwent laparoscopic cholecystectomy were analysed: the CholeS Study (8755 patients) and a single surgeon series (4089 patients). Factors potentially predictive of difficulty were correlated to the Nassar intra-operative difficulty scale. A multivariable binary logistic regression analysis was then used to identify factors that were independently associated with difficult laparoscopic cholecystectomy, defined as operative difficulty grades 3 to 5. The resulting model was then converted to a risk score, and validated on both internal and external datasets.
Increasing age and ASA classification, male gender, diagnosis of CBD stone or cholecystitis, thick-walled gallbladders, CBD dilation, use of pre-operative ERCP and non-elective operations were found to be significant independent predictors of difficult cases. A risk score based on these factors returned an area under the ROC curve of 0.789 (95% CI 0.773-0.806, p < 0.001) on external validation, with 11.0% versus 80.0% of patients classified as low versus high risk having difficult surgeries.
We have developed and validated a pre-operative scoring system that uses easily available pre-operative variables to predict difficult laparoscopic cholecystectomies. This scoring system should assist in patient selection for day case surgery, optimising pre-operative surgical planning (e.g. allocation of the procedure to a suitably trained surgeon) and counselling patients during the consent process. The score could also be used to risk adjust outcomes in future research.
传统上，预测困难的胆囊切除术一直基于某些术前临床和影像学因素。之前的大多数文献报告了小的患者队列，并且没有使用手术难度的客观衡量标准。本研究的目的是开发一种术前评分来预测困难的胆囊切除术，该评分由经过验证的术中难度分级量表定义。
分析了前瞻性维护的腹腔镜胆囊切除术患者数据库中的两个队列：CholeS 研究（8755 例患者）和单外科医生系列（4089 例患者）。将潜在的预测困难的因素与 Nassar 术中难度量表相关联。然后，使用多变量二项逻辑回归分析来确定与腹腔镜胆囊切除术困难独立相关的因素，定义为手术难度等级 3 至 5。然后将得到的模型转换为风险评分，并在内部和外部数据集上进行验证。
年龄和 ASA 分类增加、男性、CBD 结石或胆囊炎的诊断、厚壁胆囊、CBD 扩张、术前 ERCP 检查和非择期手术的使用被发现是困难病例的显著独立预测因素。基于这些因素的风险评分在外部验证中获得了 0.789（95%CI 0.773-0.806，p<0.001）的 ROC 曲线下面积，11.0%与 80.0%的患者被分类为低风险与高风险患者，其手术难度不同。
我们开发并验证了一种术前评分系统，该系统使用易于获得的术前变量来预测困难的腹腔镜胆囊切除术。该评分系统有助于选择日间手术患者，优化术前手术计划（例如，将手术分配给受过适当培训的外科医生）并在同意过程中为患者提供咨询。该评分还可用于在未来的研究中调整风险调整结果。
