ORIGINAL ARTICLE

A comparison of cholecystitis grading scales

Tarik D. Madni, MD, MBA, Paul A. Nakonezny, PhD, Jonathan B. Imran, MD, Luis Taveras, MD,
Holly B. Cunningham, MD, Ryan Vela, MD, Audra T. Clark, MD, Christian T. Minshall, MD, PhD,
Alexander L. Eastman, MD, MPH, Stephen Luk, MD, Herb A. Phelan, MD, MSCS,
and Michael W. Cripps, MD, MSCS, Dallas, Texas

BACKGROUND: Previously, our group developed the Parkland grading scale for cholecystitis (PGS) to stratify gallbladder (GB) disease severity that
can be determined immediately when performing laparoscopic cholecystectomy (LC). In prior studies, PGS demonstrated excel-
lent interrater reliability and was internally validated as an accurate measure of LC outcomes. Here, we compare PGS against a
more complex cholecystitis severity score developed by the national trauma society, American Association for the Surgery of
Trauma (AAST), which requires clinical, operative, imaging, and pathologic inputs, as a predictor of LC outcomes.
METHODS: Eleven acute care surgeons prospectively graded 179 GBs using PGS and filled out a postoperative questionnaire regarding the
difficulty of the surgery. Three independent raters retrospectively graded these GBs using PGS from images stored in the electronic
medical record. Three additional surgeons then assigned separate AAST scores to each GB. The intraclass correlation coefficient
statistic assessed rater reliability for both PGS and AAST. The PGS score and the median AAST score became predictors in sep-
arate linear, logistic, and negative binomial regression models to estimate perioperative outcomes.
RESULTS: The average intraclass correlation coefficient of PGS and AAST was 0.8647 and 0.8341, respectively. Parkland grading scale for
cholecystitis was found to be a superior predictor of increasing operative difficulty (R2, 0.566 vs. 0.202), case length (R2, 0.217 vs.
0.037), open conversion rates (area under the curve, 0.904 vs. 0.757), and complication rates (area under the curve, 0.7039 vs.
0.6474) defined as retained stone, small-bowel obstruction, wound infection, or postoperative biliary leak. Parkland grading scale
for cholecystitis performed similar to AAST in predicting partial cholecystectomy, readmission, bile leak rates, and length of stay.
CONCLUSION: Both PGS and AAST are accurate predictors of LC outcomes. Parkland grading scale for cholecystitis was found to be a superior
predictor of subjective operative difficulty, case length, open conversion rates, and complication rates. Parkland grading scale for
cholecystitis has the advantage of being a simpler, operative-based scale which can be scored at a single point in time. (J Trauma
Acute Care Surg. 2018;86: 471–478. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.)
LEVEL OF EVIDENCE: Single institution, retrospective review, level IV.
KEY WORDS: Gallbladder; cholecystitis; score; grade; outcomes.

B ased on the Agency for Healthcare Research and Quality's

Nationwide Inpatient Sample, between 2001 and 2010, emer-
gency general surgery (EGS) accounted for over 27 million hos-
pital admissions and over 7% of all hospitalizations.1 Unlike its
elective equivalents, EGS diseases are often associated with in-
creased rates of medical errors, complications, and deaths.2–4 Given
both the substantial and continuously increasing socioeconomic
burden of such disease, the costs of EGS in the United States is ex-
pected to rise from US $28 billion in 2010 to over US $41 billion
by 2060.5 In an era of increasing costs, declining reimbursements,
and financial penalties associated with quality comparisons, phy-
sicians and health care systems associated with EGS services are
continuously searching for ways to risk-adjust patients for quality
Submitted: July 15, 2018, Revised: September 7, 2018, Accepted: October 8, 2018,
Published online: November 5, 2018.
From the Department of Surgery (T.D.M., J.B.I., L.T., H.B.C., R.V., A.T.C.), Division
of General and Acute Care Surgery (C.T.M., A.L.E., S.L., H.A.P., M.W.C.), and
Division of Biostatistics, Department of Clinical Sciences (P.A.N), University of
Texas Southwestern, Dallas, Texas.
This original work will be presented as an oral at the 2018 American College of Sur-
geons Clinical Congress, October 21–25, 2018 in Boston, Massachusetts and
has not been published elsewhere.
Address for reprints: Michael W. Cripps, MD, Division of General and Acute Care
Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines
Blvd., Dallas, TX 75390-9158; email: michael.cripps@utsouthwestern.edu.
DOI: 10.1097/TA.0000000000002125
J Trauma Acute Care Surg
Volume 86, Number 3
assessment to compare outcomes fairly to their less severe, potentially
elective counterparts.3,6 Of the 31 classified EGS diseases, the nine
most common disorders account for over 80% of EGS disease
burden, with gallbladder (GB) disease accounting for 12% alone.5
Gallbladder disease affects more than 20 million Americans
annually, and roughly 20% of patients who become symptom-
atic will develop acute cholecystitis if left untreated.7 As such,
the laparoscopic cholecystectomy (LC) is one of the most com-
mon operations performed by the general surgeon.8 However, not
all cholecystitis is created equal. Anatomical and inflammatory
changes during LCs can lead to more difficult, time-consuming
operations that are more prone to adverse postoperative events.
As such, it is imperative that an accurate measure for outcome
comparisons is developed for LCs, and other EGS operations, to
avoid penalizing a surgeon or a hospital for complications that may
in fact be associated with disease severity and not clinical care.9
In response to these growing needs, the American Associ-
ation for the Surgery of Trauma (AAST) developed a grading
system for 16 common EGS diseases as a method to qualify dis-
ease severity and risk-adjust patients to allow for accurate out-
come comparison between surgeons and institutions.10,11 While
its acute cholecystitis scale (AAST-C) was recently validated, the
scale's complexity, exclusion criteria, and lack of granularity be-
tween grades suggests it needs to be further refined.12 As such,
we believe our previously created Parkland grading scale for
471

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Madni et al.
cholecystitis (PGS) allows for a similarly accurate grading scale
in a simpler format.13 This five-tiered, operative-based scale was
found to be highly reproducible with an intraclass correlation co-
efficient (ICC) of 0.804. Subsequently, the scale was internally
validated in a single-center, prospective fashion as a predictor of in-
traoperative difficulty and case length, as well as postoperative com-
plications.14 In the study described here, we aimed to compare the
PGS against the more complex cholecystitis severity score of the
AAST-C, which was developed by a national trauma society
and requires clinical, operative, imaging, and pathologic inputs
as a predictor of LC intraoperative and postoperative outcomes.
METHODS
Design and Procedures
This study was approved by the institutional review board
at the University of Texas Southwestern Medical Center. The
Parkland Memorial Hospital acute care surgery (ACS) faculty
perform both urgent, inpatient LCs and elective LCs as part of
the group's practice pattern. All patients at Parkland Memorial
Hospital who underwent LC for acute or chronic cholecystitis
by the ACS service between September 2016 and March 2017
were eligible to be included in the study. All other diagnoses
other than cholecystitis were excluded from comparison as the
first grade the AAST-C scale starts at acute cholecystitis.
Figure 1. Parkland grading scale for cholecystitis.13,14
472
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J Trauma Acute Care Surg
Volume 86, Number 3
Eleven ACS faculty were asked to self-grade the “initial
view” of GBs when performing LC during this 7-month period
using the PGS (Fig. 1). The initial grade was based solely on the
objective criteria of the scale and was assigned immediately after
the “initial view,” which was defined as follows:
After placement of all four laparoscopic ports,
1) If the GB was visualized easily, it was grasped and retracted
cephalad, giving the “initial view.”
2) If severe inflammation was present that limited mobiliza-
tion or the ability to visualize the GB, the “initial view”
was defined as the view of the inflamed area.
If faculty surgeons were scrubbed in at the time of the
initial view, they were instructed to not change or alter the
cholecystitis grade based on further case findings or complexity.
These raters then filled out a subjective, postoperative question-
naire regarding case difficulty and perioperative factors after
each operation. This questionnaire was only allowed to be filled
out in the postoperative period to eliminate any potential time
bias from surveys filled out at later times.
Three separate surgeon raters then retrospectively reviewed
these GB “initial views” from the study period that were stored
on the electronic medical record. These images were randomly
assigned to the three raters. Each of the three independent raters
then rated his or her images using PGS.
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J Trauma Acute Care Surg
Volume 86, Number 3 Cholecystitis grading scale comparison

TABLE 1. AAST Cholecystitis Severity Scale11

AAST
Grade Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
Description Acute cholecystitis GB empyema GB perforation with GB perforation with GB perforation with
or gangrenous local contamination pericholecystic abscess generalized peritonitis
or gastrointestinal fistula
Clinical RUQ or epigastric RUQ or epigastric Localized peritonitis Localized peritonitis at Grade 4, with generalized
pain, Murphy sign, pain, Murphy in RUQ multiple locations, peritonitis
leukocytosis sign, leukocytosis abdominal distention
with symptoms of
bowel obstruction
Imaging Wall thickening, distention, Grade 1 plus air in GB lumen, HIDA with focal transmural Abscess in RUQ outside Free intraperitoneal bile
gallstones or sludge, wall, or in the biliary tree; defect, extraluminal fluid GB, bilioenteric fistula,
pericholecystic fluid, focal mucosal defects collection or radiotracer gallstone ileus
no visualization of GB without frank perforation but limited to RUQ
on HIDA scan
Operative Inflammatory changes Distended GB with pus or Perforated GB wall Pericholecystic abscess, Grade 4, plus generalized
localized to GB, hydrops, necrosis or (noniatrogenic) with bilioenteric fistula, peritonitis
wall thickening, gangrene of wall, bile outside the GB gallstone ileus
distention, gallstones not perforated but limited to RUQ
Pathologic Acute inflammation Grade 1 plus pus in GB Necrosis with perforation Necrosis with perforation Necrosis with perforation
changes in the GB lumen, necrosis of GB of the GB wall of the GB wall (noniatrogenic) of the GB wall
wall without necrosis wall, intramural abscess, (noniatrogenic) (noniatrogenic)
or pus epithelial sloughing,
no perforation
HIDA, hepatobiliary iminodiacetic acid scan; RUQ, right upper quadrant.

Finally, an additional three surgeon raters who were
completely independent of the original study retrospectively
reviewed the electronic medical records of included patients
and assigned separate AAST-C scores to each patient (Table 1).
The AAST scale assigns four separate scores to a patient from
clinical, imaging, operative, and pathologic categories. Once each
score is determined, the highest of these four scores becomes the
overall true AAST grade,11 which was used for comparison
against the PGS grade for each patient.
Measures
Perioperative factors collected using the questionnaire
included: difficulty of surgery measured on a five-point Likert-
type scale that ranged from 1 (least difficult) to 5 (most difficult),
and normality of anatomy (normal/abnormal). Patient demographics
collected from the medical record included: age (years), sex,
preoperative laboratory values (white blood cell count, total bil-
irubin, length of operation (minutes), intraoperative cholangiog-
raphy (yes/no), partial or open cholecystectomy requirements
(yes/no), length of stay (days), postoperative bile duct leak
within 60 days (yes/no), and overall complication (yes/no, with
yes indicating either a retained stone, small bowel obstruction,
wound infection, or postoperative biliary leak).
Statistical Analysis
Demographic characteristics of the patients were described
using a sample mean and standard deviation for continuous variables
and a frequency and percentage for categorical variables.
During comparison of the PGS to the AAST-C scale, the
highest AAST-C score assigned from either clinical, imaging,
pathologic, or operative categories was labeled as the final true
AAST-C score for that patient.11 The PGS score and the median
true AAST-C score of all three raters became the sole predictor
in separate linear, logistic, and negative binomial regression models
to estimate the various perioperative and postoperative outcomes.
The relationship between difficulty of surgery and each scale
was estimated using a linear regression model. Because length
of case was not normally distributed, it was log transformed to
obtain a more normal distribution. Thus, a log-linear regression
with ordinary least-squares estimation was used to estimate the
log of length of case from each scale score. Length of stay (count
variable measured in days) was highly positively skewed, with
~78% of patients having 0 days; thus, a negative binomial re-
gression model was used to estimate length of stay from each
grading scale. Finally, logistic regression, with penalized maxi-
mum likelihood estimation (Firth's bias correction), was imple-
mented to estimate the odds of each binary outcome from each
grading scale.
Model performances were evaluated using misclassifica-
tion error rate, Brier score, and area under the curve (AUC) for
logistic models, R2 for linear models, and Akaike information
criterion (AIC) (smaller is better) for the negative binomial model.
The misclassification (error) rate is the proportion of observations
over the sample for which the predicted outcome and actual out-
come disagree (hence, the correct classification rate or accuracy
rate = 1 − misclassification rate). The Brier score is the weighted
squared difference between the predicted probabilities and their
observed response levels of each outcome over all observations
in the sample. The Brier score measures the accuracy of prob-
abilistic predictions and ranges from 0 (perfect agreement in
prediction) to 1 (perfect disagreement in prediction). In addition
to assess the need for additional non-operative, scoring com-
ponents for PGS, a separate Spearman's ρ test was performed
to determine any correlation between the median AAST-C

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 J Trauma Acute Care Surg
Madni et al. Volume 86, Number 3

TABLE 2. Patient and Surgical Characteristics

RESULTS
n (%) A total of 179 LCs were used to evaluate the PGS along
with the true AAST-C score. Demographic, perioperative, and
Sex
postoperative outcomes, as well as the frequency distribution
Female 132 (26.3)
for the PGS and median true AAST-C are shown in Table 2.
Male 47 (73.7)
Diagnosis Score Reliability (ICC)
Acute cholecystitis 165 (92.2) The ICC between the PGS score assigned by the three sep-
Chronic cholecystitis 14 (7.8) arate raters and the faculty surgeons who performed the opera-
Partial cholecystectomy 14 (7.8) tion demonstrated excellent reliability (ICC, 0.8647; 95%
Open conversion 8 (4.5) confidence interval, 0.8065–0.9054; p = 0.0001). The average
Abnormal anatomy 26 (14.5) ICC for each of the AAST-C scoring components was as fol-
Difficulty of surgery lows: clinical (0.3472), imaging (0.9243), operative (0.9182),
1 18 (10.1) pathologic (0.7023), and true (i.e., highest, 0.8341).
2 59 (33.0)
3 37 (20.7) Comparison of Predictive Performance
4 37 (20.7) Parkland grading scale for cholecystitis was found to be
5 34 (19.0) superior to the AAST-C in predicting increasing operative diffi-
Parkland cholecystitis grade culty (R2 of 0.566 vs. 0.202), case length (R2 0.217 vs. 0.037),
1 22 (12.3) but similar in predicting length of stay (AIC of 314.01 vs.
2 38 (21.2) 318.86; Table 3). Logistic model performance comparisons are
3 63 (35.2) shown in Table 4, where the PGS was found to be a superior pre-
4 22 (12.3) dictor of open conversion (AUC, 0.903 vs. 0.756), partial chole-
5 34 (19.0) cystectomy (AUC, 0.878 vs. 0.833), and overall complication
Median true AAST grade* rates (AUC, 0.703 vs. 0.647). Both the PGS and AAST-C were
1 132 (73.7) similar in discriminating postoperative bile leak (AUC, 0.777 vs.
2 39 (21.8) 0.758). However, neither the PGS nor AAST-C seemed to dis-
3 5 (2.8) criminate abnormal anatomy (AUC, 0.565 vs. 0.578), 60-day
4 3 (1.7) emergency room return visit (AUC, 0.509 vs. 0.491), or 60-day
5 0 (0.0) ACS readmission (AUC, 0.505 vs. 0.552). In a separate post hoc
Performance of IOC 3 (1.7) analysis, PGS was further compared against the median, stand-
60-d ER return visit 31 (17.3) alone AAST-C operative grade. The pattern of predictive perfor-
60-d readmission to ACS services 16 (8.9) mance, not reported, for the median AAST-C operative grade
Postoperative biliary leak 5 (2.8) versus PGS was found similar to that of the median true AAST
Complication 7 (3.9) score versus PGS (i.e., similar to what is reported in Tables 3 and 4).
Mean ± SD Finally, when comparing PGS to the median AAST-C imag-
Age, y 41.7 ± 13.8 ing grade, the Spearman's ρ, the rank-order correlation coefficient,
Preoperative WBC 10.9 ± 3.7 showed a significant, positive relationship (0.19904, p < 0.0076).
Preoperative total bilirubin 0.6 ± 0.6
Length of stay, d 0.6 ± 1.5 DISCUSSION
Length of operation, min 85.0 ± 32.4
Starting with the National Surgical Quality Improvement
*True AAST grade is the highest grade from either clinical, imaging, operative, or path-
ologic AAST scores assigned to a patient.
Program (NSQIP) and at VA systems in the 1990s, health care
ER, emergency room, IOC, intraoperative cholangiogram; WBC, white blood cell count. outcome measurements and comparisons have come under the
national spotlight in both the private and public sectors.15 Now,
both the American College of Surgeons' NSQIP and the Centers
imaging only grade (see Table 1 for imaging component for Medicare and Medicaid Services have begun to publicly re-
score) and PGS. port clinical outcome measures as a way to improve overall care
We assessed the reliability (or consistency) of all five quality through transparency.15,16 While such endeavors have
AAST-C components (clinical, imaging, operative, pathologic, assisted hospitals and providers in achieving safer and better pa-
highest score) from the three independent raters using the ICC tient care,15 the downsides of publicly, available outcomes com-
statistic. In addition, we assessed the reliability of the PGS score parison cannot be ignored. Specifically, centers or providers
of the faculty who performed the operation to the PGS score of who treat higher-risk patients with worse disease severity could
the three independent raters using the ICC statistic. be potentially penalized if their outcomes are not adjusted ac-
The α level for all tests was set at 0.05 (two-tailed), and cordingly. Demographics of an institution (i.e., public vs. pri-
to address multiple testing, p values were adjusted using the vate, geographic location, etc.) could substantially sway certain
false discovery rate procedure. Statistical analyses were per- patient populations toward one hospital versus another (i.e., safety
formed using SAS software, version 9.4 (SAS Institute, Inc, net hospitals). In a regulatory era where the Affordable Care Act
Cary NC). has created programs such as the Hospital Readmission Reduction

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J Trauma Acute Care Surg
Volume 86, Number 3 Cholecystitis grading scale comparison

TABLE 3. Model and Predictive Performance for the Relationship Between the Continuous and Count Outcomes and PGS and
AAST Scales
Outcomes Scales Parameter Estimate Standard Error R2 95% CI Parameter Estimate p
a
Difficulty of surgery PGS 0.7477–0.9172 0.0491 0.5664 0.6507–0.8447 <0.0001
AAST 0.1370 0.2019 0.6468–1.1877 <0.0001
Length of case, minb PGS 0.1335–0.1132 0.0195 0.2174 0.0959–0.1711 <0.0001
AAST 0.0433 0.0370 0.0276–0.1989 <0.0001
AIC p
Length of stay, dc PGS 0.5645–1.1372 0.1491 314.01 0.2702–0.8588 0.0002
AAST 0.2220 318.86 0.6990–1.5754 <0.0001
a
Linear regression model.
b
Log-linear regression model, with mean and variance estimated on the logarithmic scale.
c
Negative binomial regression model, with mean and variance estimated on the logarithmic scale.
False discovery rate for each p value was <0.0002.
CI, confidence interval.

Program, such entities can actually impose financial penalties
and reduce payments to health care institutions and providers
for poor outcomes.17,18 Furthermore, if such penalties are im-
posed without an accurate, risk-adjusted correction, there has
been a demonstrable risk that providers and institutions may be-
gin to avoid high-risk patients and/procedures altogether.18,19
While both the NSQIP and Centers for Medicare and
Medicaid Services may adjust risk based on items, such as pa-
tient demographics and comorbidities,18,20 no current widely
implemented form of outcome comparison uses operative dis-
ease severity as a form of risk stratification. Emergency general
surgery is particularly vulnerable to current forms of outcome
comparison. First, EGS patients have been shown in the literature
to be particularly susceptible to adverse events when compared
with the elective general surgery population.21 Explanations for
such vulnerability have centered on the extreme variability among
both systems (i.e., resources, workforce, etc.) and patients (i.e.,
comorbidities, acute physiology, etc.).2 Such explanations were
highlighted in a review of emergency appendectomies,
cholecystectomies, and colorectal resections at over 95 hospitals
by Ingraham et al. in 2010.22 This study of over 45,000 patients
found that not only did almost 15% of patients experience at least
one morbidity, but that most hospitals did not have consistent risk-
adjusted outcomes across all three procedures.22 Specifically
looking at LCs, a separate analysis of over 65,000 patients from
the NSQIP database by Ingraham et al.23 continued to find
considerable variation among hospital performance when evalu-
ating 30-day outcomes.
These results could suggest one of two things: (1) As
suggested by Ingraham, best practice guidelines should be dis-
seminated among hospital systems to achieve greater unity in
outcome measurements,22 and (2) our argument that to compare
operative outcomes, disease severity and thus intraoperative in-
flammation and findings must be incorporated in risk-adjusted
assessments. An LC performed semielectively at a private insti-
tution for a mild case of acute cholecystitis in a young female
can be very different than one performed urgently, in a safety net
hospital for gangrenous cholecystitis in a 70-year-old man with

TABLE 4. Model and Predictive Performance for the Relationship Between the Binary Outcomes and PGS and AAST Scales
AUC Parameter Standard 95% CI
Outcomes Scales (95% CI) Brier Score Error Rate Estimate Error Parameter Estimate p (FDR)
Abnormal anatomy PGS 0.5653 (0.4525–0.6782) 0.1235 0.1453 0.1624 0.1670 −0.1635 to 0.4938 0.3307 (0.4630)
AAST 0.5789 (0.4738–0.6840) 0.1215 0.1453 0.5474 0.2890 −0.0190 to 1.1138 0.0582 (0.1041)
Partial cholecystectomy PGS 0.8783 (0.8000–0.9567) 0.0553 0.0782 1.6017 0.4012 0.9131 to 2.5767 <0.0001 (0.0007)
AAST 0.8337 (0.7288–0.9387) 0.0616 0.0726 1.5478 0.3735 0.8780 to 2.3476 <0.0001 (0.0007)
Open cholecystectomy PGS 0.9035 (0.8576–0.9495) 0.0364 0.0447 1.8393 0.6251 0.6142 to 3.0645 0.0033 (0.0154)
AAST 0.7565 (0.5891–0.9241) 0.0409 0.0447 1.0663 0.3797 0.3236 to 1.8028 0.0050 (0.0175)
60-d ER return visit PGS 0.5098 (0.3912–0.6284) 0.1432 0.1732 −0.00818 0.1557 −0.3156 to 0.2960 0.9581 (0.9581)
AAST 0.4910 (0.4055–0.5767) 0.1431 0.1732 −0.0633 0.3287 −0.7811 to 0.5212 0.8474 (0.9126)
60-d ACS readmission PGS 0.5051 (0.3372–0.6731) 0.0813 0.0894 0.0559 0.2031 −0.3486 to 0.4584 0.7831 (0.9126)
AAST 0.5525 (0.4305–0.6745) 0.0814 0.0894 0.2086 0.3765 −0.6398 to 0.8689 0.5796 (0.7377)
Postoperative bile leak PGS 0.7775 (0.5092–1.000) 0.0256 0.0279 0.9214 0.4243 0.1584 to 1.9818 0.0299 (0.0837)
AAST 0.7580 (0.5671–0.9490) 0.0274 0.0279 0.8483 0.4501 −0.1397 to 1.6738 0.0595 (0.1041)
Overall complication PGS 0.7039 (0.4955–0.9123) 0.0364 0.0391 0.6196 0.3203 0.0151 to 1.3340 0.0531 (0.1041)
AAST 0.6474 (0.4551–0.8398) 0.0377 0.0391 0.5856 0.4367 −0.4151 to 1.3583 0.1799 (0.2798)
A separate logistic regression model was used to estimate each outcome from PGS and AAST, with penalized maximum likelihood estimation (Firth's bias correction).
FDR, false discovery rate.

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Madni et al.
10 comorbidities. Complications, length of stay, and mortality
should all be judged differently in these two examples. However,
what if we are comparing two LCs with almost identical demo-
graphics and comorbidities? The two operations can still be vastly
different, pending the amount of inflation or anatomic variability.
One operation could take less than 20 minutes, and one could take
multiple hours via a fairly unclear and risky dissection. Given that
the latter operation has a higher risk for future complications, it
is imperative that both patient factors as well as disease severity
be factored into the risk-adjustment of comparable outcomes.
In addition to outcome comparison, we believe that an
intraoperative-based grading scale could also be used to assist
in management decisions. If certain patient-specific factors
(i.e., abnormal anatomy, inflation, etc.) can be realized early
on, then it is feasible to assume that an LC may be managed
or approached differently. For instance, recognition of key intra-
operative factors may allow for a more senior resident or faculty
to take over the dissection in an academic setting. Or, perhaps a
certain degree of intraoperative inflammation may lower a surgeon's
threshold for an open conversion if the data suggest that this surgery
is a likely outcome in the future. Currently, the most widespread
scoring system used for management of GB disease, specifically
acute cholecystitis, has been a three-tiered grading system, the
Tokyo guidelines.24 From its inception, however, the Tokyo guide-
lines have been criticized for not leading to improved outcomes
regardless if its management recommendations were followed
or not.25 A more recent study by Joseph et al. found similar re-
sults in addition to finding no difference in outcomes (i.e., com-
plications, conversion to open, hospital length of stay, mortality)
between grades.26
In our previous work, we have reviewed several additional
scoring systems that have been developed for LC outcome pre-
diction; however, most are complex, based on preoperative data,
and have been in limited use since their inception.13 In response
to the need for more uniform risk stratification, the AAST created
a grading scale for the 16 most common EGS conditions.10,11 This
scale has been found reliable and validated as a method of outcome
prediction in several EGS diseases to date, including small-bowel
obstruction27 skin and soft tissue infections,28 pancreatitis,29 ap-
pendicitis,30 and diverticulitis,31 as well as cholecystitis.12 Spe-
cifically looking at cholecystitis, in addition to its AAST scale
validation, Hernandez et al. compared the AAST-C scale against
the gold standard Tokyo guidelines. In a single-center study of
443 patients, the AAST-C scale was found to outperform the To-
kyo guidelines for key clinical outcomes: mortality, complica-
tions, and cholecystostomy tube placement.32 However, there
are several limitations that this scale has failed to address. First,
the scale is complex, and it requires one through five grades in
four components (clinical, operative, imaging, and pathology)
as shown in Table 1. The true AAST grade is the highest of the
four separate grades. Thus, the scale requires extensive data col-
lection, and the user must wait days to weeks for pathological re-
sults prior to determining a grade.
Second, the AAST scale starts (grade 1) at the diagnosis of
acute cholecystitis, and as such, excludes the comparison of poten-
tial other EGS GB disease (biliary colic, biliary pancreatitis, etc.).
Furthermore, in a validation article by Vera et al.12, the majority
of the patient population had low AAST grade for disease: grade
1 (69.5%), grade 2 (23.8%), grade 3 (5.7%), grade 4 (0.0%), and
476
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J Trauma Acute Care Surg
Volume 86, Number 3
grade 5 (1.0%). As such, and acknowledged by the authors, the
AAST scale does not offer true granularity for less severe dis-
ease, with 90% of the disease appearing in grades 1 and 2.12
We found similar results in our current study, as 96% of our pa-
tients received either an AAST-C grade 1 or 2 score (Table 2)
with an ICC of 0.8341 among three raters.
In contrast to the AAST-C, PGS has a number of
strengths. First, it is an operative-based scale where the grade
can be determined upon the initial view of the GB during LC.
No further data collection is required. This allows the grade to
be notated in the operative report, and thus easily used for future
outcome comparisons. Furthermore, our results demonstrate
that when PGS was compared against the median, stand-alone
AAST-C operative grade (i.e., ignoring the clinical, imaging, and
pathologic components) the pattern of predictive performance for
the median AAST-C operative grade versus PGS is similar to that
of the median true AAST score versus PGS (i.e., similar to what
is reported in Tables 3 and 4). Summarized, our operative-only
grading scale (PGS) was found to be a similar predictor of
length of stay and bile leak rate in addition to superior predictor
of operative difficulty, case length, open and partial cholecystec-
tomy rates, and overall complication rates compared with both
the true AAST-C score as well as the stand-alone operative grad-
ing component of the AAST-C scale. Second, the PGS encom-
passes a wider spectrum of disease and is not specific to just
cholecystitis. Any GB observed during LC, regardless of its pa-
thology, can be included. During our study period, 316 GBs re-
ceived a PGS grade; however, only 179 (57%) could be
compared against the AAST-C grade as the other LCs were per-
formed for reasons other than acute cholecystitis (i.e., symptom-
atic cholelithiasis, choledocholithiasis, biliary pancreatitis, etc.),
which is the first grade of the AAST-C scale. Finally, even within
our acute cholecystitis cohort, the PGS offered better granularity,
demonstrating an almost normal distribution among grades
(Table 2). In summary, PGS is a simpler, superior scale when
compared with either the true AAST-C grade or the AAST-C's
stand-alone operative grade component.
In addition, while the AAST-C scale demonstrated excellent
rater reliability with a κ of 1.00 among two raters in its validation
article12 and within this study (ICC, 0.8341), our study found
discrepancies in the ICC among the individual scoring compo-
nents and question their need. With regards to PGS, we have
demonstrated excellent reliability among 11 raters in our original
work (ICC, 0.804),13 and between three independent, retrospective
surgeon raters of “still” images and the surgeon who performed
the operation and assigned the “live” grade (ICC, 0.8647). On
the other hand, the clinical component of the AAST-C score,
demonstrated an ICC of 0.3472 in this study, suggesting perhaps
this as an unnecessary point of data collection. In addition, while
the AAST-C imaging grade demonstrated excellent rater reli-
ability with an ICC of 0.9243, we find this grading component
largely unnecessary to further define disease severity. It is in our
opinion that true anatomical disease severity for cholecystitis is
best defined and classified in the operating room and is superior
to any imaging findings. To further support such a hypothesis,
we performed a separate Spearman's ρ test to determine any cor-
relation between the median AAST-C imaging grade and PGS.
The results showed a significant relationship between PGS and
the median AAST-C imaging grade, but the magnitude of the
© 2018 Wolters Kluwer Health, Inc. All rights reserved.
J Trauma Acute Care Surg
Volume 86, Number 3
association was quite modest. The statistical significance was
likely secondary to the relatively large N of 179. Since PGS
was found to be either a similar, or superior, predictor of out-
comes to the true AAST-C grade in an operative-only–based
scale, we believe there is little need for an extra imaging com-
ponent to such a scale. Finally, while the ICC of the AAST-C
pathology component was found to be excellent (ICC = 0.7023),
the limited added value of waiting for days to weeks for a pa-
thology report for a final true AAST-C score may limit the
widespread utility of such a scale. As such, we believe the PGS
is a superior predictor of LC outcomes, in a highly reliable,
simple-to-use scale.
We acknowledge a few limitations within our study. First,
while three raters assigned AAST-C grades to GBs to find a true
grade, only one PGS score was assigned per LC. However, such
a limitation is minimal as our previous work demonstrated ex-
cellent interrater reliability among raters.13 Second, it is possible
a rater who assigns a higher PGS score during the “initial view”
may assign a higher difficulty score postoperatively as a self-
fulfilling bias. In the study design itself, we attempted to mini-
mize this potential bias by making the grading scale based on
objective anatomical and inflammatory changes to be assigned
during the initial view of the GB fossa before the dissection begins.
Operative difficulty was graded separately during the postoperative
period with no referral or prior stated relationship to the chole-
cystitis operative grade. A difficulty correlation, however, was
not the only outcome assessed in this study. Even if one were
to assume too much subjectivity in the difficulty ratings, objec-
tive superiority was demonstrated by the PGS in several other
outcomes. Third, one may argue hybrid scores inclusive of mul-
tiple data points (i.e., preoperative, perioperative, and postoper-
ative data) may provide the most information to the level of
disease severity being assessed (i.e., more data may provide
more valid and reliable results); however, our results suggest
the opposite. Parkland grading scale for cholecystitis was found
to perform either similarly or superiorly to the hybrid AAST-C
scale in several perioperative outcomes. In addition, hybrid
scores of multiple findings require cumbersome data collec-
tion at different time points, and thus limit the utility of the
scale for widespread use. Additional components require fur-
ther time for both data mining as well as interpretation, which
may disincentivize the practitioner to incorporate such a tool
into his or her practice. A final limitation is our focus on postop-
erative complications defined as either a retained stone, small
bowel obstruction, wound infection, or postoperative biliary
leak. Other validation studies for the AAST-C scale include out-
comes, such as acute renal failure, urinary tract infection, pneu-
monia, deep venous thrombosis, and so on.12 Given the rarity of
these complications after LC, we did not think our study would
have sufficient power to detect such differences. On post hoc re-
view, however, no patients showed any such complications.
CONCLUSION
In conclusion, while the PGS and AAST-C both demon-
strate excellent reliability among raters, the PGS was found to
be a superior predictor of operative difficulty, case length, open
and partial cholecystectomy rates, and overall complication rates.
The PGS does so in a simpler, easy-to-understand scale with data
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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Cholecystitis grading scale comparison
collection only occurring during the operative portion of the
patient's stay (i.e., a single time point). Future work will focus
on multicenter trial assessment for external validation as well
as comparison against both the AAST-C scale as well as the
Tokyo guidelines.
AUTHORSHIP
T.D.M., P.A.N., J.B.I., A.T.C., H.A.P., M.W.C., C.T.M. participated in the
study conception and design. T.D.M., J.B.I., A.T.C., L.T., H.B.C., R.V., M.
W.C., H.A.P., S.L., A.L.E., C.T.M. participated in the acquisition of data.
T.D.M., P.A.N., H.A.P., M.W.C., C.T.M. participated in the analysis and in-
terpretation of data. T.D.M., P.A.N., A.T.C., J.B.I., H.B.C., R.V., L.T., H.A.P.,
M.W.C., S.L., A.L.E., C.T.M. participated in the drafting of the article. T.D.M.,
P.A.N., A.T.C., J.B.I., H.A.P., M.W.C., A.L.E., C.T.M. participated in the
critical revision.
ACKNOWLEDGMENTS
The authors acknowledge the following: Inna Donovan, NP, for data col-
lection; Karen Garofalo, PA, for data collection; Cynthia Chernyakhovsky,
PA, for data collection; David Primm as the medical editor.
DISCLOSURE
The authors declare no funding or conflicts of interest.
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