Gastrointestinal
A proposal for a preoperative clinical scoring system for acute cholecystitis

https://doi.org/10.1016/j.jss.2015.09.010Get rights and content

Abstract

Background

Acute cholecystitis is a common diagnosis for which surgery is usually indicated. However, the heterogeneity of clinical presentation makes it difficult to standardize management. The variation in clinical presentation is influenced by both patient-dependent and disease-specific factors. A preoperative clinical scoring system designed to included patient-dependent and clinical factors might be a useful tool in clinical decision making.

Methods

The data of patients undergoing laparoscopic cholecystectomy for acute cholecystitis in a university hospital were retrospectively reviewed. Patient-dependent factors (age, sex, body mass index, and American Society of Anesthesiologists score) and disease-specific factors (history of biliary colics, white blood count, C-reactive protein, and gallbladder wall thickness) were used to compute a clinical score between zero and nine for each patient. Cholecystitis was classified as mild (score ≤ 3), moderate (4 ≤ score ≤ 6), or severe (score ≥ 7).

Results

Cholecystitis was mild in 45 cases, moderate in 105 cases, and severe in 27 cases.

Among patient-dependent factors, the male gender, age >65 y, and American Society of Anesthesiologists score >2 correlated significantly with high scores, P = 0.001. Equally, high white blood count, elevated C-reactive protein, and gallbladder wall thickness >4 mm correlated significantly with high scores, P = 0.001. These findings were confirmed on multivariate analyses. High scores correlated significantly with the duration of surgery (P = 0.007), the need of intensive care unit management (P = 0.001) and the length of stay (P = 0.001). However, there was no significant association between the preoperative score and the rate of conversion (P = 0.103) or the rate of complication (P = 0.209).

Conclusions

This preoperative clinical scoring system has a potential to select patients with severe cholecystitis and therefore might be a useful tool in clinical decision making.

Introduction

Acute cholecystitis (AC) is a frequent reason for a visit to the emergency department. Although surgery is generally accepted as the main stay of treatment, the divergence in the clinical presentation of AC renders the standardization of treatment difficult. Being able to determine the preoperative extent of gallbladder inflammation might facilitate the clinical decision making.

The clinical presentation, disease course and outcome of AC might be influenced by both patient-dependent and clinical factors. Advanced age at the time of surgery, male gender, concomitant conditions, body mass index (BMI), gallbladder wall thickness, recurrent biliary colics, elevated C-reactive protein (CRP), high white blood count (WBC), and the extent of gallbladder inflammation have been confirmed as risk factors for complications in patients undergoing laparoscopic cholecystectomy (LC) [1], [2], [3], [4], [5], [6], [7], [8], [9].

The Tokyo Guidelines of 2007 and the updated version of 2013 (TG13) provide recommendations for the diagnosis and severity grading of acute cholangitis and cholecystitis. The TG13 uses clinical data, findings from blood chemistry, and abdominal ultrasound sonography to classify AC into three severity grades [10], [11], [12]. Our experience with patients presenting with AC suggests that the clinical decision making should be individualized, owing to the heterogeneity of presentation. Therefore, a preoperative clinical severity grading system for AC should be designed to include both patient-dependent and clinical parameters.

The aim of this study was to design a preoperative clinical scoring system for acute cholecystitis. This preoperative clinical scoring system was designed by computing patient-dependent and clinical risk factors for complications after LC for AC and might be helpful in the clinical decision making and comparison of outcomes.

Section snippets

Methods

This study was approved by the ethics committee of the Witten–Herdecke University. A retrospective review of our departmental database for patients undergoing LC for AC within a 3-y period from January 2012 until December 2014 was performed. Patients were consecutively recorded after presentation in the emergency department. Findings from clinical examination, abdominal ultrasound sonography, and blood chemistry were used to diagnose AC as outlined in the Tokyo Guidelines [10], [11], [12].

As

Results

Within the period of investigation, 1024 cholecystectomies were performed in our department. The indication for surgery was AC in 405 cases. After excluding cases with negative pathology and incomplete files, 177 cases of AC including 78 female and 99 male patients were included for analysis.

Using the above-mentioned scoring system, mild cholecystitis was present in 45 patients (25.4%), group I. Cholecystitis was classified as moderate in 105 patients (59.3%), group II, whereas severe

Discussion

The aim of this study was to design a simple preoperative clinical scoring system for AC. This scoring system was designed to estimate the severity of gallbladder inflammation by computing patient-dependent risk factors and clinical parameters. The male gender, age >65 y, obesity, and concomitant conditions constituted patient-dependent risk factors. Gallbladder wall thickness, CRP, WBC, and history of biliary colics constituted the clinical parameters. These parameters were used to calculate a

Conclusion

Taken together, our preoperative clinical scoring system has a potential to select patients with severe cholecystitis. Significant results were recorded with respect to the duration of surgery, the need of ICU management, and the length of hospital stay. Therefore, this preoperative clinical scoring system might be a useful tool in clinical decision making.

Acknowledgments

Authors' contribution: P.C.A. performed the conception of the study. P.C.A., M.P., and H.Z. designed the study. P.C.A. and M.P. performed data acquisition and analysis. P.C.A., M.P., and H.Z. performed the interpretation of data. P.C.A. drafted the article. P.C.A., M.P., and H.Z. critically reviewed the article. P.C.A., M.P., and H.Z. contributed to the final approval of the study.

There was no grant or financial support for the study.

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