Hematological Ratios versus Disease Characteristics versus Surgeons’ Experience and Expertise: What Stands Out as Predictor of Conversion to Open Cholecystectomy? Hematological and Surgical Factors in Cholecystectomy

Maryam Afzal; Mehmood Ul Haq Farooqi; Sobia Ashraf; Muhammad Afzal

doi:10.54393/pjhs.v6i5.2881

Authors

Maryam Afzal Department of Pathology, University College of Medicine and Dentistry, The University of Lahore, Lahore, Pakistan
Mehmood Ul Haq Farooqi Department of Surgery, Surayya Azeem Hospital, Lahore, Pakistan
Sobia Ashraf Department of Hematology, University College of Medicine and Dentistry, The University of Lahore, Lahore, Pakistan
Muhammad Afzal Department of Surgery, University College of Medicine and Dentistry, The University of Lahore, Lahore, Pakistan

DOI:

https://doi.org/10.54393/pjhs.v6i5.2881

Keywords:

Laparoscopic Cholecystectomy, Systemic Inflammatory Ratios, Neutrophil to Lymphocyte Ratio, Monocyte to Lymphocyte Ratio, Platelet to Lymphocyte Count, Systemic Inflammatory Response Index, Systemic Immune Inflammation Index, Derived Neutrophil to Lymphocyte Ratio

Abstract

Conversion of laparoscopic to open cholecystectomy is often a surprise for the surgeon. Objective: To evaluate predictors like inflammatory ratios, gallbladder wall thickness and surgeons’ experience to see what predicts conversion best. Methods: Retrospective cohort study was done on adult patients diagnosed with acute cholecystitis (Tokyo guidelines) at Surayya Azeem Hospital from 2021 to 2024. Data collected included demographics, CBC findings, surgeons' experience, operation details and ultrasound findings. Patients with chronic cholecystitis, comorbidities and other gallbladder pathologies were excluded. Ratios like NLR, MLR, PLR, SIRI, SII, NLPR and d-NLR were calculated. Chi square, Mann Whittney U, binary logistic regression and ROC analysis were used as per requirement. P-value of less than 0.05 was considered significant. Results: 80% of 475 patients were females. 22 (4.8%) patients underwent conversion. Old age and male gender were associated with adverse outcome. WBC count, NLR, d-NLR, SIRI, SII and NLPR were higher in conversion group. Platelet count, PLR and MLR had no associations. Higher hemoglobin (>12.3 g/dL) and ALC (> 1.8x109/L) were predictive of successful laparoscopic procedure. Highest predictive value for conversion was found for NLR and d-NLR (AUC=0.84) followed SIRI (AUC=0.78) with cut-offs of 4.97, 3.76, and 1.69 respectively. Gallbladder wall thickness of >7mm (AUC=0.64) and inexperienced surgeons (AUC=0.69) also increase the probability of conversion. Conclusion: Systemic inflammatory indices predict conversion better than ultrasound findings and surgeons’ experience. Experienced laparoscopic surgeons should operate on patients with thick gallbladder wall and high inflammatory ratios to minimize the risk of conversion.

References

Delgado LM, Pompeu BF, Pasqualotto E, Magalhães CM, Oliveira AF, Kato BK et al. Robotic-assisted cholecystectomy versus conventional laparoscopic cholecystectomy for benign gallbladder disease: a systematic review and meta-analysis. Journal of Robotic Surgery. 2024 Jun; 18(1): 242. doi: 10.1007/s11701-024-01989-5.

Mannam R, Narayanan RS, Bansal A, Yanamaladoddi VR, Sarvepalli SS, Vemula SL et al. Laparoscopic cholecystectomy versus open cholecystectomy in acute cholecystitis: a literature review. Cureus. 2023 Sep; 15(9). doi: 10.7759/cureus.45704.

Zhao JJ, Syn NL, Chong C, Tan HL, Ng JY, Yap A et al. Comparative outcomes of needlescopic, single-incision laparoscopic, standard laparoscopic, mini-laparotomy, and open cholecystectomy: A systematic review and network meta-analysis of 96 randomized controlled trials with 11,083 patients. Surgery. 2021 Oct; 170(4): 994-1003. doi: 10.1016/j.surg.2021.04.004.

Da Costa DW, Schepers NJ, Bouwense SA, Hollemans RA, van Santvoort HC, Bollen TL et al. Predicting a 'difficult cholecystectomy'after mild gallstone pancreatitis. Hpb. 2019 Jul; 21(7): 827-33. doi: 10.1016/j.hpb.2018.10.015.

Bhandari TR, Khan SA, Jha JL. Prediction of difficult laparoscopic cholecystectomy: An observational study. Annals of Medicine and Surgery. 2021 Dec; 72: 103060. doi: 10.1016/j.amsu.2021.103060.

Magnano San Lio R, Barchitta M, Maugeri A, Quartarone S, Basile G, Agodi A. Preoperative risk factors for conversion from laparoscopic to open cholecystectomy: a systematic review and meta-analysis. International Journal of Environmental Research and Public Health. 2022 Dec; 20(1): 408. doi: 10.3390/ijerph20010408.

Stanisic V, Milicevic M, Kocev N, Stanisic B. A prospective cohort study for prediction of difficult laparoscopic cholecystectomy. Annals of Medicine and Surgery. 2020 Dec; 60: 728-33. doi: 10.1016/j.amsu.2020.11.082.

Kapoor A, Sidhu BS, Singh J, Brar N, Singh P, Kapur A. Adhesions detection and staging classification for preoperative assessment of difficult laparoscopic cholecystectomies: A prospective case-control study. Journal of Medical Ultrasound. 2023 Apr; 31(2): 137-43. doi: 10.4103/jmu.jmu_36_22.

Targońska-Stępniak B, Zwolak R, Piotrowski M, Grzechnik K, Majdan M. The relationship between hematological markers of systemic inflammation (neutrophil-to-lymphocyte, platelet-to-lymphocyte, lymphocyte-to-monocyte ratios) and ultrasound disease activity parameters in patients with rheumatoid arthritis. Journal of Clinical Medicine. 2020 Aug; 9(9): 2760. doi: 10.3390/jcm9092760.

Xia Z, Liu Y, Sun S, Shan E, Liu Y. The value of preoperative neutrophil/lymphocyte ratio in predicting the severity of cholecystolithiasis with cholecystitis in elderly patients. BioMed Central Surgery. 2023 Nov; 23(1): 360. doi: 10.1186/s12893-023-02267-1.

Şener K, Çakır A, Kılavuz H, Doğan S, Güven R, Korkut S. Diagnostic Value of the Systemic Immune-Inflammation Index in Diagnosing Acute Cholecystitis. Comprehensive Medicine. 2023 May; 15(2): 125-31. doi: 10.14744/cm.2023.18209.

Serban D, Stoica PL, Dascalu AM, Bratu DG, Cristea BM, Alius C et al. The significance of preoperative neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic inflammatory index (SII) in predicting severity and adverse outcomes in acute calculous cholecystitis. Journal of Clinical Medicine. 2023 Nov; 12(21): 6946. doi: 10.3390/jcm12216946.

Avci MA, Akgün C, Buk O, Karadan D, Karadan II D. Can Hemogram Parameters and Derived Ratios Predict Conversion From Laparoscopic to Open Cholecystectomy?. Cureus. 2024 Aug; 16(8). doi: 10.7759/cureus.68290.

Kartal M and Kalaycı T. Can neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, prognostic nutrition index, and albumin be used to predict cholecystectomy morbidity in super-elderly patients?. Turkish Journal of Trauma & Emergency Surgery. 2023 Aug; 29(8): 890. doi: 10.14744/tjtes.2023.31462.

Moloney BM, Waldron RM, O'Halloran N, Kelly ME, Myers E, Garvin JT et al. The clinical utility of pre-operative neutrophil-to-lymphocyte ratio as a predictor of outcomes in patients undergoing elective laparoscopic cholecystectomy. Irish Journal of Medical Science (1971-). 2018 Aug; 187: 755-60. doi: 10.1007/s11845-018-1749-6.

Efgan MG, Bora ES, Coşkun SM, Kırık S, Kayalı A. Predictive value of inflammatory indices in acute cholecystitis: a retrospective study of gallstone detection and outcome assessment. Signa Vitae. 2024 Aug; 1: 10. doi: 10.22514/sv.2024.134.

Durak D, Alkurt EG, Tutan MB. CRP, WBC and monocyte/lymphocyte ratio relation as a preoperative predictive factor for adhesions observed during laparoscopic cholecystectomy. Journal of Health Sciences and Medicine. 2021 Apr; 4(5): 686-91. doi: 10.32322/jhsm.952507.

Morales-Maza J, Rodríguez-Quintero JH, Santes O, Aguilar-Frasco JL, Romero-Vélez G, García-Ramos ES et al. Conversion from laparoscopic to open cholecystectomy: Risk factor analysis based on clinical, laboratory, and ultrasound parameters. Revista de Gastroenterología de México (English Edition). 2021 Oct; 86(4): 363-9. doi: 10.1016/j.rgmxen.2021.08.001.

Altıner S, Ergüder E, Altınok SH, Aydın SM, Barlas AM, Tuncal S. The role of preoperative ultrasound in predicting conversion from laparoscopic cholecystectomy to open surgery in acute cholecystitis. Turkish Journal of Trauma & Emergency Surgery. 2023 Sep; 29(10): 1109. doi: 10.14744/tjtes.2023.45469.

Kulkarni SV and Kumar SS. Preoperative predictors of a difficult laparoscopic cholecystectomy. International Journal of Surgery. 2018 Feb; 5(2): 608-13. doi: 10.18203/2349-2902.isj20180362.

Lee CE, Lee SJ, Moon JI, Choi IS, Yoon DS, Choi WJ et al. Acute cholecystitis in old adults: the impact of advanced age on the clinical characteristics of the disease and on the surgical outcomes of laparoscopic cholecystectomy. BioMed Central Gastroenterology. 2023 Sep; 23(1): 328. doi: 10.1186/s12876-023-02954-6.

Hobbs MS, Mai Q, Knuiman MW, Fletcher DR, Ridout SC. Surgeon experience and trends in intraoperative complications in laparoscopic cholecystectomy. Journal of British Surgery. 2006 Jul; 93(7): 844-53. doi: 10.1002/bjs.5333.

Riccardi M, Dughayli M, Baidoun F. Open Cholecystectomy for the New Learner-Obstacles and Challenges. JSLS: Journal of the Society of Laparoscopic & Robotic Surgeons. 2021 Apr; 25(2): e2021-00026. doi: 10.4293/JSLS.2021.00026.

Patel MD, Sill AP, Dahiya N, Chen F, Eversman WG, Kriegshauser JS et al. Performance of an algorithm for diagnosing acute cholecystitis using clinical and sonographic parameters. Abdominal Radiology. 2022 Feb; 47(2): 576-85. doi: 10.1007/s00261-021-03384-2.

Patel R, Tse JR, Shen L, Bingham DB, Kamaya A. Improving Diagnosis of Acute Cholecystitis with US: New Paradigms. RadioGraphics. 2024 Nov; 44(12): e240032. doi: 10.1148/rg.240032.