Simple Blood Tests May Be Used to Predict the Increased Risk of Conversion in Elective Laparoscopic Cholecystectomy Surgery

Abstract

Background:

In this study, we aimed to evaluate the possibility if simple blood tests that can be made in majority of hospitals may be used predict to risk of conversion to laparoscopic surgery to an open approach.

Patients and Methods:

The hospital records of 636 patients who underwent elective laparoscopic cholecystectomy (L-C) were retrospectively reviewed, and 583 patients included in the study protocol. Preoperative laboratory tests of all patients and data of patients who underwent conversion from laparoscopic surgery to open surgery were examined.

Results:

Of the 583 patients who were included in the study, 404 (69.29%) were female and the mean age was 50.02 ± 12.84 (19–89) years. The cholecystectomy was completed laparoscopically in 559 (89.5%) patients. The most common symptoms seen in the patients were epigastric discomfort and right upper quadrant pain. The high level of white blood cell (WBC) count and c-reactive protein (CRP) were found to be statistically significant before surgery in patients who had a conversion to open cholecystectomy (P < .001).

Conclusion:

Elevation of WBC count and CRP value before elective L-C may be useful in the prediction of a high risk of conversion from laparoscopic to open approach. This finding will help the surgeon to plan the treatment and inform the patient of the possibility before surgery.

Introduction

The lifetime prevalence of gallstone disease in an adult Western population ranges between 10% and 15%.¹ And only 15% of the patients having gallstone will become symptomatic resulting in acute cholecystitis.² Laparoscopic cholecystectomy (L-C) has become the gold standard for symptomatic gallstones with minimized postoperative ache, short postoperative fasting period, faster discharge from the hospital, early resumption of routine-daily action, and superior cosmetic outcomes.³

The patients in whom laparoscopic procedure cannot be carried out are switched to open surgery because of technical trouble or intraoperative complications. The conversion frequency ranges between 0% and 20%.⁴ The conversion from laparoscopic to open surgery means an increment in the operating and hospitalization time and postoperative adverse outcomes. Several studies were performed to clarify the predictor factors for conversion, but no agreement has been reached so far.^5–7

In this study, we aimed to assess if there is a relationship between some laboratory results preoperatively used and the risk of conversion from laparoscopic to open surgery.

Materials and Methods

The data of 583 patients who underwent L-C because of benign gallbladder diseases in SisliEtfal Training and Research Hospital between January 2019 and March 2021 were retrospectively analyzed. The study was approved by the Ethics Committee of Health Sciences University, SisliEtfal Training and Research Hospital.

We classified individuals into two groups:

Group 1: Surgical procedure was completed laparoscopically.

Group 2: Surgical procedure was not completed laparoscopically and converted to open surgery.

We evaluated all patients in terms of age, gender, preoperative laboratory tests, body mass index, time since first complaint, dominant presenting symptoms, the mean hospital stay, and ultrasonography features.

Inclusion criteria

All patients who underwent elective cholecystectomy were included in the study.

Exclusion criteria

Emergency operated cases were excluded from the study. Also, patients with common bile duct stones or any other common bile duct pathology, jaundice, or abnormal liver function tests (serum glutamic-pyruvic transaminase >55 IU/L, serum glutamic-oxaloacetic transaminase >35 IU/L), elevated serum bilirubin levels (total bilirubin >1 mg/dL, direct bilirubin >0.5 mg/dL), acute cholecystitis, and patients who had undergone previous abdominal operations (upper abdominal) were excluded from the study.

Laboratory tests

From the preoperative laboratory values, which is above the normal range, the c-reactive protein (CRP) >5 mg/dL, white blood cell (WBC) count >10.2 × 10³/mL, neutrophil >80%, lymphocyte >50%, and red cell distribution width >17.2% were taken as positive.

Radiological evaluation

We applied transabdominal ultrasonography for imaging the gallbladder. Four ultrasonography parameters were studied, namely gallbladder wall thickness (>3 mm thick gallbladder wall thickness was accepted an increase in thickness); ultrasonography features (gallstones and gallbladder polyps); the diameter of the gallstone/gallstones (stones ≤1 cm and >1 cm); gallbladder size, whether gallbladder is hydropic or not.

Surgical procedure

Standard four trocar technique was used in all patients as an initial surgical procedure.⁸

Statistical analysis

Statistical analyses were performed with SPSS version 25.0 (SPSS, Inc., Chicago, IL). Descriptive statistical methods (mean, standard deviation, median, first quadrant, third quadrant, frequency, percentage, minimum, and maximum) were used when study data were evaluated. Analysis of variance or nonparametric Mann–Whitney U tests were used for continuous variables depending on the distribution of the variable. Categorical data were compared using the Fisher's exact test or chi-square test and statistical significance was accepted as P ≤ .05.

Results

Four hundred four (69.29%) patients were female, and 179 (30.7%) patients were male. Male gender ratio in group 2 was significantly higher than group 1 (P = .003). All individuals' mean age was 50.02 ± 12.84 (19–89) years. The mean age of group 2 was higher than group 1 (P < .001). The cholecystectomy was completed laparoscopically in 559 (95.8%) patients and converted to open cholecystectomy in 24 (4.1%) patients. The most common symptoms observed in the patients were epigastric right upper quadrant pain (57.63) and fatty food intolerance (20.24%). The mean hospital stay of the patients treated laparoscopically and conversion to open approach were 1.3 ± 1 (1–9) and 5.2 ± 3 (2–14) days, respectively (Table 1).

Table 1.

Patient Characteristics

		n (%)	P
Age (year)	Min–max (median) Average ± SD	19–89 (50) 50.02 ± 12.84	<.001
L-C	Min–max (median) Average ± SD	19–89 (50) 49.6 ± 12.61	<.001
Conversion to open cholecystectomy	Min–max (median) Average ± SD	32–84 (61) 59.67 ± 14.03
Gender
L-C	Female	394 (70.48)	.003
L-C	Male	165 (29.51)
Conversion to open cholecystectomy	Female	10 (41.66)
Conversion to open cholecystectomy	Male	14 (58.33)
BMI (kg/m²)
L-C	Min–max (median)Average ± SD	19.4–39.84 (27.8)25.85 ± 1.62	.08
Conversion to open cholecystectomy	Min–max (median)Average ± SD	23.6–39.6 (31.3)27.8 ± 4.83
Time since first complaint (days)
L-C	Average ± SD (min–max)	30 ± 21.5 (1–120)	.26
Conversion to open cholecystectomy	Average ± SD (min–max)	23.8 ± 42.8 (1–120)
Dominant presenting symptoms	Pain at the upper abdomen	336 (57.63)
	Food intolerance	118 (20.24)
	Nausea/vomiting	82 (14.06)
	Pain at the right shoulder	47 (8.06)
Hospitalization (day)
L-C	Average ± SD (min–max)	1.3 ± 1 (1–9)	<.001
Conversion to open cholecystectomy	Average ± SD (min–max)	5.2 ± 3 (2–14)

BMI, body mass index; L-C, laparoscopic cholecystectomy; SD, standard deviation.

The number of patients with gallbladder thickness of >3 mm is 97 in L-C and 16 in conversion to open cholecystectomy groups. The majority of the patients have healthy gallbladder in size in the L-C group (Table 2). In group 2, we detected higher CRP, WBC, and neutrophils than in the group 1 (P < .001) (Table 3).

Table 2.

Comparison of Ultrasonography Features of Laparoscopic Cholecystectomy and Conversion to Open Cholecystectomy Groups

	Laparoscopic cholecystectomy, n (%)	Conversion to open cholecystectomy, n (%)	P
The diameter of the gallstone(s)
>1 cm	201 (35.95)	6 (25)	.272
≤1 cm	358 (64.04)	18 (75)	.272
Ultrasonography features
Only gallstone	520 (93)	23 (95.83)	.594
Gallbladder polyp	39 (7)	1 (4.16)	.594
Size of the gallbladder
Normal	544 (97.31)	20 (83.3)	.006
Hydropic	15 (2.68)	4 (16.6)	.006
Gallbladder wall thickness
<3 mm	462 (82.64)	8 (33.3)	<.001
≥3 mm	97 (17.35)	16 (66.6)	<.001

Table 3.

Comparison of Ultrasonography Features of Laparoscopic Cholecystectomy and Conversion to Open Cholecystectomy Groups

	Laparoscopic cholecystectomy, n (%)	Conversion to open cholecystectomy, n (%)	P
C-reactive protein >5 mg/dL	136 (24.3)	19 (79.16)	<.001
White blood cell >10,200 × 10³/μL	26 (4.65)	9 (37.5)	<.001
Neutrophil >80%	4 (0.71)	8 (33.3)	<.001
Lymphocyte >50%	5 (0.89)	1 (4.16)	.912
RDW >17.2%	25 (4.4)	0 (0)	.280

RDW, red cell distribution width.

Discussion

In a crucial situation during the operation, the surgeon may convert to laparotomy for safety of the patient without hesitation. In previous studies, the surgical conversion rates range between 11% and 31%.^9,10 But the skyrocketing popularity of laparoscopic surgery and the increase in experience in laparoscopic applications decreased this rate between 2.6% and 11.9%.¹¹ In this retrospective study, the conversion rate was 4.1%, which is following the literature. Conversion to open surgery is not a setback but is a smart choice on the operating surgeon's part.

The leading factors for converting laparoscopy to an open approach have been discussed and, age, gender, obesity, duration of symptoms, WBC count, liver function tests, ultrasonography findings, previous cholangitis attacks, pancreatitis history, and preoperative endoscopic retrograde cholangiopancreatography are found to be related to increased conversion rates.¹² However, the most common cause of converting to open surgery is the inability to correctly identify Calot's triangle anatomy around the bile duct as a result of inflammation.¹³ The most common reasons for converting to open surgery were the frozen Calot's triangle, ambiguous anatomy, life-threatening bleeding, and bile duct injury in this study.

The male gender and advanced age could be an independent risk factor for conversion and postoperative complications and the laparoscopic approach is technically more demanding in these patients undergoing cholecystectomy. Similar to the literature, in this study, it was shown that male gender and increasing age are associated with difficult L-C and lead to higher conversion rates.^14–16

Gallstone disease is the primary reason for cholecystectomy.¹⁷ In this study, 93.1% of the cases operated due to gallstones. Ultrasound findings such as contracted gall bladder, single large stone, gall bladder thickness, and pericholecystic fluid collection are associated with difficult L-C.¹⁸ In this study, ultrasound findings revealed that healthy gallbladder in size and a wall thickness of <3 mm lead surgery to be completed laparoscopically. Vice versa, the absence of these findings in ultrasonography leads to conversion to open cholecystectomy. The reasons of gallbladder wall thickening are classified as inflammatory, neoplastic, and systemic. The differential diagnosis can be obtained by a combined evaluation of clinical and imaging findings. Apart from acute cholecystitis, different diseases that cause thickening of the gallbladder wall include pancreatitis, diverticulitis, heart failure, pyelonephritis, and hepatitis. The patients with malignant pathologies or acute cholecystitis were excluded from the study, but the patients with chronic cholecystitis and other systemic diseases that may also cause gallbladder wall thickening were included in the study. The diameter of the gallstones and presence of gallbladder polyps were found to be statistically insignificant for the prediction of cholecystectomies to be completed with laparoscopy. These findings are indirect, and this issue needs to be investigated more in studies with more extensive individual series.

Hematological parameters such as elevated WBC count and serum alkaline phosphatase are reported as risk factors for difficult L-C.^2,19–21 Harmonious with the literature, we found a relation between CRP, WBC, neutrophil blood levels, and conversion frequency. Similar to our outcomes, various studies.^2,22–24 reported that high CRP was a risk factor in switching to the open technique. Yacoub et al. also noted that elevated WBC count is associated with complications in the presence of gallstones.²⁵ Among studies reporting on the operative difficulty, Bourgouin et al. also identified neutrophil count as a strong predictor.²⁶ We believe the elevation of CRP, WBC, and neutrophil count should make the surgeon more alert for the possibility of conversion from the laparoscopic to open approach.

The retrospective nature is the main weakness of this study. Also, data regarding patients who were emergency operated or had bile duct stones, any other common bile duct pathology, jaundice, or abnormal liver function tests, bilirubin levels, acute cholecystitis, and patients who had undergone previous abdominal operations (upper abdominal) were outside the scope of this study.

Conclusion

L-C is accompanied by a significant rate of conversion to open procedure. Elevation in WBC, CRP, and neutrophil count may be the predictors for conversion. Also, ultrasound findings of healthy gallbladder in size and wall thickness <3 mm increase the chance of surgery to be completed laparoscopically.

Footnotes

Authors' Contributions

All authors have made substantial contributions to this article being submitted for publications. All authors critically reviewed the article and approved the final form.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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