Preoperative ndings predict conversion from laparoscopic to open cholecystectomy

Jeremy M. Lipman, MD, Jeffrey A. Claridge, MD, Manjunath Haridas, MBBS, Matthew D. Martin, BS, David C. Yao, BS, Kevin L. Grimes, BS, and Mark A. Malangoni, MD, Cleveland, Ohio

Background. Previous studies evaluating predictive factors for conversion from laparoscopic to open cholecystectomy have drawn conicting conclusions. We evaluated objective preoperative variables to create an accurate, accessible risk score to predict conversion. Methods. A retrospective review was performed of laparoscopic cholecystectomy patients at an urban tertiary care center. Seventy characteristics were subjected to bivariate and multivariate logistic regression analysis to identify parameters that independently predict conversion to open cholecystectomy. A model was created based on this analysis. Results. Laparoscopic cholecystectomy was performed on 1377 patients for benign gallbladder disease over a 71-month period. There were 112 (8.1%) conversions to open cholecystectomy. The correlation between the preoperative clinical diagnosis and pathologic diagnosis for acute and chronic cholecystitis was 48.6% and 94.6%, respectively. Multivariate analysis identied male gender, elevated white blood cell count, low serum albumin, ultrasound nding of pericholecystic uid, diabetes mellitus, and elevated total bilirubin as independent predictors of conversion. These 6 factors were also associated with the pathologic diagnosis of acute cholecystitis. A model to calculate the risk for conversion was created with an area under the receiver operator curve of 0.83. The risk for conversion also can be estimated based on the number of factors identied present and ranged from 2% when 1 factor was present to 89% with 6 factors. Conclusions. These results demonstrate that conversion to open cholecystectomy can be predicted based on parameters available preoperatively. Conversion is more likely in patients who have acute cholecystitis; however, the correlation between its clinical and pathologic diagnosis is poor. Improvements in the ability to determine the risk for conversion have important implications for surgical care. (Surgery 2007;142:556-65.)
From the Department of Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Oh

Laparoscopic cholecystectomy is established as the primary procedure for the vast majority of patients with benign gallbladder disease. Conversion to open cholecystectomy is occasionally necessary to avoid or repair injury, delineate confusing anatomic relationships, or treat associated conditions. Conversion to open cholecystectomy has been associated with increased overall morbidity,
Presented at the 64th annual meeting of the Central Surgical Association, Chicago, Illinois, March 8-10, 2007. Accepted for publication July 26, 2007. Reprint requests: Mark A. Malangoni, MD, FACS, Chair, Department of Surgery, H914, MetroHealth Medical Center, Cleveland, Ohio 44109. E-mail: mmalangoni@metrohealth.org. 0039-6060/$ - see front matter 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2007.07.010

surgical site and pulmonary infections, and longer hospital stays.1,2 The ability to accurately identify an individual patients risk for conversion based on preoperative information can result in more meaningful and accurate preoperative counseling, improved operating room scheduling and efciency, stratication of risk for technical difculty, and appropriate assignment of resident assistance, may improve patient safety by minimizing time to conversion, and helps to identify patients in whom a planned open cholecystectomy is indicated. Previous reports have promulgated the use of scoring systems to predict conversion to open cholecystectomy.1-4 However, these systems presented incongruent data points, evaluated a limited number of factors, included subjective variables, and some were formulated early in the course of laparoscopic cholecystectomy before the operation became uni-

556 SURGERY

Surgery Volume 142, Number 4

Lipman et al 557

formly established. These scoring systems have not been widely incorporated into surgical practice for this purpose. We hypothesized that an accurate and useful scoring system could be created based on objective, available, preoperative data to predict conversion to open cholecystectomy. This information is useful in preoperative discussions with patients, addresses issues of patient safety, and optimizes operating room resource allocation and efciency. METHODS All patients who had cholecystectomy over the 71 months from January, 2000, through November, 2005, at MetroHealth Medical Center, a public, tertiary care, teaching hospital, were identied by Current Procedural Terminology (CPT-9) code search of the institutions electronic operating room data system (Surgical Information Systems, Alpharetta, GA; Table I). The hospital records of patients 18 years of age who had cholecystectomy for benign disease were reviewed. Patients were excluded if they were 18 years old, had an additional procedure planned at the time of cholecystectomy, or had a presumed diagnosis of biliary cancer. Seventy characteristics were evaluated, including demographics, preoperative and pathologic diagnosis, preoperative and intraoperative imaging, laboratory values, surgeon, postgraduate year of the participating resident, intraoperative and postoperative complications, American Society of Anesthesiologists (ASA) risk score, length of stay, comorbid diseases, and the relationship of the operation to the implementation of resident duty hours restrictions (July 2004). Patients were classied into three groups: Open, laparoscopic, or conversion. The preoperative clinical diagnosis and rationale for conversion to open cholecystectomy were obtained from the operative report. Patients were classied as having acute or chronic cholecystitis based on the pathology report. Radiology reports of preoperative and intraoperative imaging were reviewed. Laboratory values obtained immediately before the operation were recorded categorically based on whether the value was abnormal for our institution. Categorical data were used to facilitate the application of this model. An elevated white blood cell count (WBC) was dened as 11,000/L, low serum albumin as 3.5 g/dL, elevated total bilirubin as 1.5 g/dL, elevated alkaline phosphatase as 200 IU/L, elevated alanine aminotransferase as 40 IU/L, elevated creatinine as 1.5 mg/dL, elevated lipase as 128 U/L, and elevated amylase as 150 U/L. Patients were classied as obese if their body mass index was 30 kg/m2 or if they

Table I. CPT-9* codes and denitions

CPT code 47562 47563 47564 47600 47605 47610 47612 Description Laparoscopic cholecystectomy Laparoscopic cholecystectomy with cholangiography Laparoscopic cholecystectomy with exploration of common duct Cholecystectomy Cholecystectomy with cholangiography Cholecystectomy with exploration of common duct Cholecystectomy with exploration of common duct; with choledochoenterostomy Cholecystectomy with exploration of common duct; with trans-duodenal sphincterotomy or sphincteroplasty, with or without cholangiography

47620

*Current procedural terminology code.

had obesity as a current diagnosis in their medical record at the time of surgery, and as super-obese if their body mass index was 50 kg/m2. Percents are recorded as valid percent based on the number of patients with available data for each variable. If information was not available for a variable, it was excluded from analysis. A patient was categorized as having diabetes mellitus, liver disease, chronic obstructive pulmonary disease, congestive heart failure, myocardial infarction, or abdominal cancer if such a diagnosis was included in the patients medical record at the time of cholecystectomy. Intraoperative complications evaluated included common bile duct injury, bowel injury, vascular injury, transfusion requirement, and liver injury. Postoperative complications recorded included retained common bile duct stones, intraperitoneal bile leak, necessity for interventional procedure, or death. Data were analyzed using SPSS statistical software (SPSS Inc, Chicago, Ill). Discrete variables were compared using 2 analysis or the Fisher exact test. Continuous variables were compared using an unpaired 2-tailed Students t-test. Differences were considered signicant at P .05. Variables signicant at P .10 were retained in the backward stepwise logistic regression model for predicting conversion. Receiver operator characteristics were generated on the basis of various probabilities for conversion. This study was approved by the MetroHealth Medical Center Institutional Review Board. Patient condentiality was maintained in accordance with HIPAA.

558 Lipman et al

Surgery October 2007

Table II. Patient characteristics

Variable Female Mean age Age 65 Comorbid disease Diabetes mellitus Obese Super-obese Nicotine use Alcohol abuse Previous abdominal operation Mean ASA score ASA score 3 Preoperative diagnosis Chronic cholecystitis Acute cholecystitis Pathologic diagnosis Chronic cholecystitis Acute cholecystitis Before duty hours restrictions Low albumin Elevated WBC Elevated total bilirubin Pericholecystic uid on ultrasound n %* 1111 80.7 44.2 16.8 190 13.8 401 29.1 184 13.4 652 57.5 51 4.5 423 34.2 413 33.6 548 39.8 1.8 0.65 146 10.6 1120 257 1191 186 1027 298 202 138 96 81.3 18.7 86.5 13.5 74.6 25.4 17.9 11.6 8.0

Table III. Reasons for conversion to open cholecystectomy

Reason Adhesions Inammation Anatomy Injury Common bile duct stones Other Multiple reasons n (%) 39 (34.8) 36 (32.1) 33 (29.5) 13 (11.6) 6 (5.4) 4 (3.6) 19 (17.0)

ASA, American Society of Anesthesiologists; WBC, white blood cell count. *Expressed as valid percent where denominator is number of patients with available data. Mean value standard deviation.

RESULTS A total of 1421 patients met the inclusion criteria. Laparoscopic cholecystectomy was attempted on 1377 patients, which represented 97% of all cholecystectomies done during that time. Fortyfour patients underwent planned open cholecystectomy and were not included in our analysis. The patient characteristics of our study population are listed in Table II. A preoperative clinical diagnosis of chronic cholecystitis was made in 1120 patients (81.3%), and this correlated with the pathologic diagnosis in 94.6% of cases. In contrast, the clinical diagnosis of acute cholecystitis correlated with the pathologic diagnosis in only 48.6% of cases. Of the 186 patients with pathologic ndings of acute cholecystitis, 81 (43.5%) had an elevated WBC and 49 (26.3%) had both an elevated WBC and ultrasound ndings of pericholecystic uid, gallbladder wall thickness 3 mm, or emphysema. One hundred twelve patients (8.1%) required conversion to open cholecystectomy. The most frequent reasons for conversion were adhesions (n 39), inammation (n 36), and unclear anatomy (n 33; Table III). Forty-ve preoperative parameters were evaluated for their effect on conversion

from laparoscopic to open cholecystectomy and 20 were signicant on bivariate analysis (Table IV). Logistic regression analysis demonstrated that male gender, elevated WBC, low serum albumin, ultrasound ndings of pericholecystic uid, the presence of diabetes mellitus, and elevated total bilirubin were independent predictors of conversion (Table V). All 6 factors were more frequently identied in patients who had a pathologic diagnosis of acute cholecystitis (Fig 1). Factors evaluated but not found to be signicant on bivariate analysis included cholelithiasis on preoperative ultrasound (n 1079), timing of surgery relative to resident duty hours restrictions (n 1080 before, 367 after), obesity (n 670), previous abdominal surgery (n 539), nicotine use (n 423), alcohol abuse (n 413), chronic obstructive pulmonary disease (n 134), liver disease (n 106), super-obesity (n 51), pancreatitis (n 50), or a history of abdominal cancer (n 31). A model was created based on the clinically relevant preoperative characteristics found to be statistically signicant on multivariate analysis. The probability for conversion is calculated by the equation: PConversion e fx 1 e fx where f(x) 3.949 1.40 (male) 1.20 (low albumin) 1.06 (elevated WBC) 0.91(pericholecystic uid on ultrasound) 0.80 (diabetes mellitus) 0.57 (elevated total bilirubin). A 1 is inserted into the equation when the parameter is abnormal or the factor is present in the cases of male, pericholecystic uid on ultrasound, and diabetes mellitus. Receiver operator curve (ROC) analysis of the model demonstrated an area under the curve of 0.83. For simplication, an estimation of these results can be obtained by replacing the modier of each factor with 1 (Table VI). A comparison of the estimated and calculated likelihood for conversion is demonstrated in Fig 2. Intraoperative complications occurred in 1.3% of patients. These included common bile duct injury (n 7; 0.5%), all of which were recognized and converted to open cholecystectomy; minor

Surgery Volume 142, Number 4

Lipman et al 559

Table IV. Bivariate analysis of laparoscopic and converted patients

Factor Male Age 65 Comorbid disease Diabetes mellitus ASA score 3 Clinical diagnosis of acute cholecystitis Pathologic diagnosis of acute cholecystitis Elevated ALT Low albumin Gallbladder wall thickened on ultrasound Elevated WBC Elevated total bilirubin Pericholecystic uid on ultrasound Elevated alkaline phosphatase Congestive heart failure Elevated creatinine Myocardial infarction Postgraduate year 4-5* Common bile duct dilation on ultrasound Laparoscopic, n (%) 209 (16.5) 160 (12.6) 345 (27.3) 150 (11.9) 118 (8.1) 199 (15.7) 131 (10.4) 284 (26.9) 236 (18.6) 237 (18.7) 161 (5.8) 103 (9.5) 74 (6.7) 72 (5.7) 47 (3.7) 27 (2.1) 43 (3.4) 608 (48.1) 181 (14.3) Conversion, n (%) 57 (50.9) 30 (26.8) 56 (50.0) 34 (30.4) 28 (25) 58 (51.8) 55 (49.1) 49 (43.8) 62 (55.3) 45 (40.1) 41 (36.6) 35 (31.3) 22 (19.6) 19 (16.9) 11 (9.8) 9 (8.0) 10 (8.9) 68 (61.8) 24 (21.4) P .001 .001 .001 .001 .001 .001 .001 .001 .001 .001 .001 .001 .001 .001 .005 .008 .008 .013 .034

ASA, American Society of Anesthesiologists; ALT, alanine aminotransferase; WBC, white blood cell count. *Postgraduate year of resident.

Table V. Factors independently predictive of conversion to open cholecystectomy on multivariate analysis

Factor Male Elevated WBC Low albumin Pericholecystic uid on ultrasound Diabetes mellitus Elevated total bilirubin
WBC, White blood cell count.

Odds ratio 4.06 3.01 2.90 2.36 1.87 1.85

95% Condence interval 2.42-6.82 1.77-5.13 1.70-4.96 1.25-4.47 1.03-3.42 1.01-3.39

liver injury (n 6; 0.4%, no conversions); bowel injury (n 4; 0.3%; 2 conversions); and vascular injury (n 2; 0.1%; 2 conversions). Forty-four patients (3.2%) had unsuspected common bile duct stones; 27 of these (61.4%) were identied on intraoperative cholangiography. Twenty-one of these patients had laparoscopic cholecystectomy (77.8%) and 6 required conversion to treat choledocholithiasis. Laparoscopic common bile duct exploration was undertaken in 12 patients (57.1%) with successful duct clearance in 4. Of the remaining 34 patients with common bile duct stones, postoperative retrieval by endoscopic retrograde cholangiopancreatography was accomplished in 33. One patient passed a stone spontaneously.

Fig 1. Relationship between factors predicting conversion and pathologic diagnosis of acute and chronic cholecystitis. *P .001. P .025.

Cholangiography was performed more frequently in patients requiring conversion (27.7% vs 11.1%; P .001). Among converted patients who did not have a cholangiogram, conversion occurred before dissection of the cystic duct or attempted cholangiography was not successful. Postoperative complications included intra-abdominal abscess (n 8; 0.6%), all requiring drainage, and bile leak resulting in percutaneous drainage (n 6; 0.4%). Two patients with a bile leak also had retained common bile duct stones. Five patients died (0.4%), 4 of whom had laparoscopic cholecystectomy (0.3%), and 1 who re-

560 Lipman et al

Surgery October 2007

Table VI. Calculated versus estimated risk for conversion to open cholecystectomy based on risk factors
No. of factors 0 1 2 3 4 5 6 Estimated conversion rate (%) 1.9 5 12.5 27.9 51.3 74.1 88.6 Calculated conversion rate (%) 1.9 3.3-7.4 7-21.1 15.8-45.3 35-65.5 64.2-80.9 88.2

Fig 2. Comparison of estimated and calculated likelihood of conversion. *Estimated score is the percent of patients who will require conversion to open cholecystectomy assuming equal weight given to all factors in the equation. Calculated high and low represent the percent range of patients who will require conversion to open cholecystectomy based on the previously described formula.

quired conversion (0.9%). Four of these patients had a pathologic diagnosis of acute cholecystitis. Death was due to infection in all patients. No deaths occurred as a result of intraoperative complications. There was no association between the number of risk factors and death. DISCUSSION Conversion from laparoscopic to open cholecystectomy is required when safe completion of the laparoscopic procedure cannot be ensured. The identication of parameters predicting conversion improves preoperative patient counseling, provides for better perioperative planning, optimizes operating room efciency, and helps to avoid laparoscopic-associated complications by performing an open operation when appropriate. Our results demonstrate that male gender, elevated WBC, elevated total bilirubin, low albumin, diabetes mellitus, and ultrasound ndings of pericholecystic uid are associated with conversion to

open cholecystectomy. No subjective variables were included in an effort to improve the predictive value of our results. Conversion rates did not decline signicantly during the study period. Our analysis was performed during a steady state of laparoscopic cholecystectomy. Preoperative and intraoperative factors that predict or contribute to conversion have been evaluated previously, but no consensus has emerged. A recent review by Tang and Cuschieri5 identied 109 publications addressing this issue over 15 years. Among these studies, 4 scoring systems have been developed to predict conversion to open cholecystectomy.1-4 These scoring systems have demonstrated variable and conicting results and are affected by a small number of factors evaluated, inclusion of subjective variables, and collection of data early in the experience of laparoscopic cholecystectomy. None of these systems has been widely incorporated into surgical practice. Furthermore, the only study to be validated prospectively had a negative predictive value of 100%, but the positive predictive value was only 43%.6 Our model predicted conversion to open cholecystectomy based on 6 easily obtained parameters. To facilitate the clinical application of this information, however, a reasonable estimate of risk was made based on the number of factors identied. For example, a patient with 2 risk factors has an approximate conversion risk of 12.5%. A range of risk actually exists based on which factors are present owing to differences in the odds ratios of each parameter. If the 2 factors are diabetes mellitus and elevated total bilirubin, the conversion risk is only 7.0%; however, if the factors are male gender and low albumin, the risk increases to 21.1%. A patient with 4 risk factors has an estimated risk for conversion of 50%. Thus, depending on the situation, an approximation or more precise calculation of risk can be derived. The presence of acute cholecystitis has been shown to predict conversion to open cholecystectomy.2-4,7-11 In our analysis, the preoperative clinical diagnosis of acute cholecystitis was a signicant predictor of conversion on bivariate and multivariate analyses (data not shown). Despite the availability of ultrasound and leukocyte count to assist with the clinical diagnosis of acute cholecystitis, there was a poor correlation with the pathologic ndings; therefore, we excluded it from the multivariate analysis. Our data demonstrate that patients with the constellation of clinical symptoms typically associated with acute cholecystitis do not always demonstrate the pathologic ndings to support the diagnosis. To our knowledge, the correlation be-

Surgery Volume 142, Number 4

Lipman et al 561

tween the preoperative clinical and pathologic diagnosis of acute cholecystitis has not been evaluated previously. All 6 factors that independently predicted conversion to open cholecystectomy were found signicantly more frequently in patients with pathologic diagnosis of acute cholecystitis. Furthermore, the pathologic diagnosis of acute cholecystitis was associated with a 43% greater likelihood of the need for conversion to open cholecystectomy than the clinical diagnosis. The objective parameters identied by this analysis provide a more accurate prediction of the rate of conversion than the clinical suspicion of acute cholecystitis. Men have been identied to have a greater incidence of conversion to open cholecystectomy than women.1,3,4,8,9,12-16 The etiology of this association is unclear. Inammation and dense adhesions are frequently cited as reasons for conversion in men.12 Men had a greater frequency of the 5 other characteristics demonstrated to predict conversion and had a signicantly greater incidence of acute cholecystitis. The pathophysiologic differences between men and women with cholecystitis remain unclear. The association between an elevated WBC and conversion has been reported previously.2,4,8-10,13-17 This parameter likely reects the inammatory response associated with more acute diseases and is more commonly present with acute cholecystitis. Hypoalbuminemia has not been identied previously as a risk factor for conversion to open cholecystectomy. This may be due to exclusion of this parameter in prior investigations evaluating reasons for conversion. Low serum albumin has been shown to predict postoperative complications in general.13 Severe acute inammation as is associated with acute cholecystitis results in decreased albumin synthesis. Hypoalbuminemia also can result from protein-calorie malnutrition or reduced hepatic synthetic function owing to cirrhosis or other hepatic diseases. Pericholecystic uid results from the translocation of uid from the surrounding tissues owing to severe inammation of the gallbladder. This factor has been previously demonstrated to predict conversion.9,17 In our series, pericholecystic uid was the only radiographic nding predictive of conversion. Acute cholecystitis was 7 times more common among patients with pericholecystic uid on ultrasound. Diabetic patients undergoing laparoscopic cholecystectomy have been found to have signicantly increased rates of conversion as well as intraoperative and postoperative complications.9,18,19 The rea-

son for the greater conversion rate in this group of patients is unclear. One explanation may be the presence of more severe inammation among diabetic patients with acute cholecystitis compared with nondiabetics.19 Because of autonomic and peripheral neuropathy, some diabetic patients may not develop symptoms of gallbladder disease until later in the course of their illness. This may lead to delayed diagnosis, which can result in more advanced disease and a greater risk for conversion.20 An elevated bilirubin has been previously recognized as a signicant predictor of conversion to open cholecystectomy in acute cholecystitis.9,17 We have found that it is predictive of conversion for patients with both acute and chronic cholecystitis. Hyperbilirubinemia is most likely a marker for inammation in this setting rather than an indicator of biliary obstruction. Elevated bilirubin is also associated with Mirizzi syndrome, the presence of which may increase the probability of conversion.21 The postgraduate year of the resident performing the operation predicted conversion on bivariate analysis. This was likely due to selection bias; patients expected to present technical challenges are assigned to more senior residents. The inuence of the level of resident training on conversion has been evaluated by others and was not found to contribute to conversion, although longer operative times and more intraoperative complications were observed when junior residents were involved in these operations.22,23 We did not observe any change in the rate of conversion based on the implementation of resident duty hours restrictions in July 2004. We evaluated the effect of obesity and performed a subgroup analysis on super-obese patients. Neither parameter was found to have an increased risk for conversion. Obesity has been previously identied as a risk factor for conversion.1,3,4,10 More than 50% of patients in the present study were obese and this high incidence improves the accuracy of our analysis. The previously identied association between obesity and conversion may be due to the propensity for obese patients to develop diabetes mellitus. The lower conversion rates among obese patients in our study may also be attributed to the greater experience in the laparoscopic management of patients with this condition. Others have demonstrated that previous upper abdominal operations increase the risk for conversion to open cholecystectomy.4,5,7-9,11,17 This may be due to increased adhesion formation. It is possible that our analysis did not demonstrate this to be a risk factor for conversion because of the overwhelming effect of acute cholecystitis on this pa-

562 Lipman et al

Surgery October 2007

rameter. However, we did not evaluate the specic location of the previous operation because the location of the incision may not entirely predict the area of adhesion formation or chronic inammatory changes.5,8,9,11,17 The rate of complications in our series is similar to other reports.24,25 All injuries were treated at operation and there were no missed injuries. Cholecystectomy was able to be completed laparoscopically after injury repair in only 6 of 19 patients. The 30-day mortality rate of 0.4% in the present series is slightly higher than previously reported rates of 0.1%-0.2% for laparoscopic cholecystectomy and 0.7% for open cholecystectomy.24,25 There were 2 deaths in excess of expected in our series based on these rates. All deaths were the result of infection; 4 abdominal and 1 pulmonary (due to aspiration). Four patients died after operation for acute cholecystitis. There were no deaths owing to missed or intraoperative injury. It is difcult to compare mortality rates between reports without adjusting for risk. Although our scoring system has favorable characteristics to predict conversion from laparoscopic to open cholecystectomy, it has some limitations. Our results are based on retrospective data. We did not assess the impact of symptom duration on conversion rate. We chose not to include this factor in our analysis because of its subjective nature and the inherent inaccuracies associated with estimating the time of symptom onset. However, the duration of symptoms may be associated with the degree of inammation encountered at operation and thus would inuence the conversion rate.20 We also did not evaluate the time from hospital admission to operation. Patients with longer hospital stays before operation may have more severe inammation; however, the time from symptom onset to operation is likely to correlate with conversion rates. Because the reasons for conversion were taken from the operative note, it is not possible to denitively determine whether conversion was due to inammation or other causes unless specically stated in the report. It is possible that the utility of this model is that its parameters more accurately predict the pathologic diagnosis of acute cholecystitis. Based on the large number of factors assessed, the volume of patients reviewed and the adequacy of our models ROC, we are optimistic that prospective evaluation of this scoring system will conrm its validity. For patients with a high predicted rate of conversion, it may be advantageous to proceed with open cholecystectomy. This would negate the potential for trochar injuries, problems due to pneumo-

peritoneum, and other complications specically associated with laparoscopy. A high presumed risk for conversion was frequently cited as a reason for the use of a planned open approach. Because patients undergoing open cholecystectomy were not included in our analysis, the complication rate in patients who had conversion to open operation may be lower than would have been seen if all cholecystectomies were initially approached laparoscopically. Our results demonstrate that an accurate and easily derived estimation of risk for conversion from laparoscopic to open cholecystectomy can be obtained from readily available preoperative data. Recognizing when a patient is at increased risk for conversion would improve preoperative counseling, assist with appropriate allocation of resources in the operating room, may increase safety by limiting delay in conversion to open cholecystectomy, and can identify patients who might benet from a planned open approach. If validated, this scoring system may improve patient outcomes by reducing unnecessary injuries related to laparoscopy that is unlikely to succeed.
REFERENCES
1. Livingston E, Rege R. A nationwide study of conversion from laparoscopic to open cholecystectomy. Am J Surg 2004; 188:205-11. 2. Alponat A, Kum C, Koh B, Rajnakova A, Goh P. Predictive factors for conversion of laparoscopic cholecystectomy. World J Surg 1997;21:629-33. 3. Fried G, Barkun J, Sigman H, Joseph L, Clas D, Garzon J, et al. Factors determining conversion to laparotomy in patients undergoing laparoscopic cholecystectomy. Am J Surg 1994;167:35-9. 4. Kama N, Kologlu M, Doganay M, Reis E, Atli M, Dolapci M. A risk score for conversion from laparoscopic to open cholecystectomy. Am J Surg 2001;181:520-5. 5. Tang B, Cuschieri A. Conversions during laparoscopic cholecystectomy: risk factors and effects on patient outcome. J Gastrointest Surg 2006;10:1081-91. 6. Bulbuller N, Ilhan Y, Baktir A, Kirkil C, Dogru O. Implementation of a scoring system for assessing difcult cholecystectomies in a single center. Surg Today 2006; 36:37-40. 7. Wiebke E, Pruitt A, Howard T, Jacobson L, Broadie T, Goulet RJ Jr, et al. Conversion of laparoscopic to open cholecystectomy. An analysis of risk factors. Surg Endosc 1996;10:742-5. 8. Ibrahim S, Hean T, Ho L, Ravintharan T, Chye T, Chee C. Risk factors for conversion to open surgery in patients undergoing laparoscopic cholecystectomy. World J Surg 2006; 30:1698-704. 9. Simopoulos C, Botaitis S, Polychronidis A, Tripsianis G, Karayiannakis A. Risk factors for conversion of laparoscopic cholecystectomy to open cholecystectomy. Surg Endosc 2005;19:905-9. 10. Rosen M, Brody F, Ponsky J. Predictive factors for conversion of laparoscopic cholecystectomy. Am J Surg 2002;184: 254-8.

Surgery Volume 142, Number 4

Lipman et al 563

11. Zgraggen K, Wehrli H, Metzger A, Buehler M, Frei E, Klaiber C. Complications of laparoscopic cholecystectomy in Switzerland. A prospective 3-year study of 10,174 patients. Swiss Association of Laparoscopic and Thoracoscopic Surgery. Surg Endosc 1998;12:1303-10. 12. Zisman A, Gold-Deutch R, Zisman E, Negri M, Halpern Z, Lin G, et al. Is male gender a risk factor for conversion of laparoscopic into open cholecystectomy? Surg Endosc 1996;10:892-4. 13. Schafer M, Krahenbuhl L, Buchler M. Predictive factors for the type of surgery in acute cholecystitis. Am J Surg 2001;182:291-7. 14. Kanaan S, Murayama K, Merriam L, Dawes L, Prystowsky J, Rege R, et al. Risk factors for conversion of laparoscopic to open cholecystectomy. J Surg Res 2002;106:20-4. 15. Brodsky A, Matter I, Sabo E, Cohen A, Abrahamson J, Eldar S. Laparoscopic cholecystectomy for acute cholecystitis: can the need for conversion and the probability of complications be predicted? A prospective study. Surg Endosc 2000;14:755-60. 16. Halachmi S, DiCastro N, Matter I, Cohen A, Sabo E, Mogilner J, et al. Laparoscopic cholecystectomy for acute cholecystitis: how do fever and leucocytosis relate to conversion and complications? Eur J Surg 2000;166:136-40. 17. Schrenk P, Woisetschlager R, Rieger R, Wayand W. A diagnostic score to predict the difculty of a laparoscopic cholecystectomy from preoperative variables. Surg Endosc 1998;12:148-50. 18. Bedirli A, Sozuer E, Yuksel O, Yilmaz Z. Laparoscopic cholecystectomy for symptomatic gallstones in diabetic patients. J Laparoendosc Adv Surg Tech A 2001;11:281-4. 19. Shpitz B, Sigal A, Kaufman Z, Dinbar A. Acute cholecystitis in diabetic patients. Am Surg 1995;61:964-7. 20. Lau H, Lo C, Patil N, Yuen W. Early versus delayed-interval laparoscopic cholecystectomy for acute cholecystitis: a metaanalysis. Surg Endosc 2006;20:82-7. 21. Rohatgi A, Singh K. Mirizzi syndrome: laparoscopic management by subtotal cholecystectomy. Surg Endosc 2006; 20:1477-81. 22. Kauvar D, Braswell A, Brown B, Harnisch M. Inuence of resident and attending surgeon seniority on operative performance in laparoscopic cholecystectomy. J Surg Res 2006; 132:159-63. 23. Imhof M, Zacherl J, Rais A, Lipovac M, Jakesz R, Fuegger R. Teaching laparoscopic cholecystectomy: do beginners adversely affect the outcome of the operation? Eur J Surg 2002;168:470-4. 24. Shea J, Healey M, Berlin J, Clarke J, Malet P, Staroscik R, et al. Mortality and complications associated with laparoscopic cholecystectomy. A meta-analysis. Ann Surg 1996;224:609-20. 25. Shamiyeh A, Wayand W. Laparoscopic cholecystectomy: early and late complications and their treatment. Langenbecks Arch Surg 2004;389:164-71.

DISCUSSION Dr Thomas J. Howard (Indianapolis, Indiana): I rise to congratulate Drs Lipman and Malangoni and their colleagues at MetroHealth Medical Center on an important analysis of a large contemporary cohort of patients who underwent laparoscopic cholecystectomy at an urban tertiary care medical center for benign gallbladder disease. Their purpose was identifying objective clinical, radiographic, and pathologic factors that could be used to predict the

likelihood of conversion to an open cholecystectomy. Despite the ability to complete laparoscopic cholecystectomy in approximately 92% of patients given our current state of technological advancement, identifying the 8% who require open conversion remains a signicant issue in the lives of all general surgeons. The strengths of this analysis are its size, with 1377 patients, the post-learning curve period of analysis from 2000 to 2005, the large number of variables that they assessed in their model, and the use of strict denitions and careful outcome measurements in the application and constrained and appropriate statistical analysis. The authors tell us that 6 factorsmale gender, WBC 11,000, bilirubin 1.5, pericholecystic uid on preoperative ultrasound, diabetes mellitus, and serum albumin level 3.5were identied on their backward stepwise logistic regression analysis to predict conversion. These factors contribute sequentially, albeit with different power, to a probability equation such that 1 factor gives a 2% risk of conversion, whereas the presence of all 6 factors result in 89% risk of conversion. The data presented are sound and consistent with other published literature, yet the authors have taken the additional steps to simplify and distill these observations into risk factors even a Hoosier can understand and remember, namely, men with severe inammatory gallbladder disease. This simplicity should enhance the clinical applicability of their variables as a prospective tool to be used in a daily basis. Was the designation of the operation as an emergency versus an elective procedure 1 of the 70 characteristics that you used in the evaluation? Second, why in the 21st century is our preoperative clinical diagnosis of acute cholecystitis accurate less than half the time when correlated with nal histologic diagnosis? The authors have excluded this variable from their analysis owing to its subjective nature and poor correlation, but isnt the ability to make this diagnosis preoperatively the crux of their message in this paper? Dr J. M. Lipman (Cleveland, Ohio): In reference to your rst question about the inclusion of the designation of the operation as elective versus emergent, we did not include that in our analysis because of the subjective nature of the designation. A patient may end up going for an emergency operation after days of failed nonoperative management, whereas another patient may go to the operating room for an elective cholecystectomy the day they present to the emergency department just based on

564 Lipman et al

Surgery October 2007

the availability of the surgeon, the operating room, and so forth. As to the diagnosis of acute cholecystitis, I think that in part the discrepancy stems from our desire to do what is best for the patient. When someone comes in with signs and symptoms that are suggestive of acute cholecystitis, we call the diagnosis and initiate aggressive treatment. However, we have found that the pathology does not always reect what we clinically suspect. We did nd, though, that all 6 of the factors we identied as predictive for conversion were also predictive of a pathologic diagnosis of acute cholecystitis. So it may be that this model, in addition to helping to identify patients who will require conversion, may facilitate and provide more objective data to support our diagnosis of acute cholecystitis. Dr Roland Vega (Madison, Wisconsin): There is a variable that you did not mention, and I do not know if it is actually a variable in the practices that were involved here, and that is that there are really 3 options in cholecystectomy: One is open, one is laparoscopic done from the bottom of the gallbladder up, and the other is dome down using ultrasonic technology. Those of us who have gone to doing dome down routinely over the last 6-8 years have a distinct feeling that the necessity of conversion has dropped to a negligible level. I do think it is an important subset to consider because it is a tool that is going to get these conversion numbers down and avoid some of the vascular and common duct injuries that we see. Dr J. M. Lipman (Cleveland, Ohio): We did not evaluate the incidence of dome down versus the more traditional approach to laparoscopic cholecystectomy. But that is an interesting comment and something we could look at. Dr Henry A. Pitt (Indianapolis, Indiana): You focused on the benign disease patients, and yet many would argue that suspicion of malignancy is another reason to convert. In a series of this size, theoretically you would have 10 or 20 gallbladder cancers. Do you have some data on those patients? Would you please comment on when you should convert a gallbladder cancer patient? Dr J. M. Lipman (Cleveland, Ohio): Conversion for malignancy or suspected malignancy was actually only encountered in a handful of patients in our series. Clearly that is an indication to convert. The majority of patients in whom that was a suspicion preoperatively received a primary open cholecystectomy. Dr Gerald M. Larson (Louisville, Kentucky): I have often found gallbladder wall thickness to be

an indicator of a difcult cholecystectomy and leading to conversion. How close did that gure to your reaching a threshold of signicance? Has your formula worked as you have gone forward and tried to apply it prospectively to selecting cases? Are you nding you are more readily converting certain patients to an open and not even trying the laparoscopic approach? Dr J. M. Lipman (Cleveland, Ohio): Gallbladder wall thickness was signicant on a bivariate analysis, but it fell out on multivariate analysis. It has been shown to be signicant in other studies, however, as predictive of conversion, but did not reach signicance on multivariate analysis in our study. As for the application of this information, I have not had the opportunity to apply it yet. Dr Merril T. Dayton (Buffalo, New York): Mine is a follow-up question to the question just asked. And that is, how are you really going to use this formula? Knowing these factors, is it going to dictate what operation you are going to do? You are going to start out and try all of them laparoscopically, I would think. So I am really curious as to exactly what the real value of this is as you translate it to clinical practice. Dr J. M. Lipman (Cleveland, Ohio): Certainly the decision as to which operation, how to approach a patient, is left to the surgeon. In some instances, however, a patient with an 89% risk for conversion, some surgeons may look at that patient and say that they are not even going to attempt laparoscopy, that the risk for injury and the likelihood of conversion is too high. And this may inuence them to perform a primary or a planned open cholecystectomy. The formula will, I think, facilitate our ability to speak with patients, improve our informed consent and our preoperative relationship with them, talking about scheduling for the operating room, preparing in the operating room, making sure that all the resources that are necessary are available. Clearly the setup for a patient with a 2% likelihood of conversion may not include all the equipment for an open cholecystectomy, or someone with a 50%, 60%, or 70% likelihood it may be benecial to have that equipment available, perhaps having a more senior resident if you are in a teaching hospital. Dr. L. Michael Brunt (St. Louis, Missouri): Dr Lipman, in our own institution there is considerable variation in the rate of conversion from laparoscopic to open according to attending surgeons. Did you look at all at if there was any difference in conversion rate as to whether your surgeons were

Surgery Volume 142, Number 4

Lipman et al 565

primarily basic laparoscopists versus those who do a lot of advanced laparoscopy? Dr J. M. Lipman (Cleveland, Ohio): None of the surgeons at our institution have undergone any laparoscopic training beyond their residency. But at our institution we have an emergency surgery ser-

vice, so the type of cholecystectomy is more heavily weighted in favor of some surgeons than others. We did not feel that we could adequately make a comparison among the surgeons without stratifying for the severity of illness. So we did not look at individual surgeons as a risk factor for conversion.