Laparoscopic cholecystectomy is the standard treatment for benign gallbladder disease. A bailout procedure is recommended for patients with severe inflammation. This study identified the preoperative factors that predict bailout procedures and developed a predictive nomogram.

A total of 1,898 patients with laparoscopic cholecystectomy from 5 institutions (2015-2020) were divided into training (n = 1,518) and validation (n = 380) sets. Logistic regression was employed to predict bailout procedures and to develop a nomogram on the basis of the training set. The accuracy of the nomogram was evaluated using receiver operating characteristic curve analysis of the validation set. Postoperative outcomes were compared between qualified surgeons certified by the Japanese Society for Endoscopic Surgery and residents who had graduated from a medical university within the past 5 years.

Bailout procedures were performed in 262 (13.8%) patients. Multivariate analysis identified several significant predictors, including sex, age, gallbladder drainage, severity of acute cholecystitis, stone impaction of the gallbladder neck, and serum C-reactive protein. The nomogram achieved an area under the curve of 0.788 in the training set and 0.769 in the validation set. Intraoperative complications were significantly fewer in the qualified surgeon group than in the nonqualified surgeon group.

The nomogram aids surgeons in identifying high-risk patients and making informed decisions about bailout procedures, thereby ensuring patient safety. Involving qualified surgeons in case predicted to be difficult cholecystectomies may help prevent help to avoid intraoperative complications.

Although findings from drip infusion cholangiography with computed tomography (DIC-CT) are useful in preoperative anatomic evaluation for laparoscopic cholecystectomy (LC), their relationship with intraoperative surgical difficulty based on the difficulty score (DS) proposed by Tokyo Guidelines 2018 is unclear. We examined this relationship.

Data were collected from 202 patients who underwent LC for benign gallbladder (GB) disease with preoperative DIC-CT in our department. DIC-CT findings were classified into GB-positive and GB-negative groups based on GB opacification, and clinical characteristics were compared. DS assessed only on findings from around Calot's triangle was considered "cDS", and patients were divided into cDS ≤2 and ≥3 groups. Preoperative data including DIC-CT findings were evaluated using multivariate analysis.

DIC-CT findings showed 151 (74.8%) GB-positive and 51 (25.2%) GB-negative patients. Surgical outcomes were significantly better in the GB-positive versus GB-negative group for operation time (107 vs. 154 min, p < .001), blood loss (8 vs. 25 mL, p < .001), cDS (0.8 vs. 2.2, p < .001), and critical view of safety score (4.0 vs. 3.1, p < .001). cDS was ≤2 in 174 (86.1%) and ≥3 in 28 (13.9%) patients. By multivariate analysis, DIC-CT findings and alkaline phosphatase values were independent factors predicting intraoperative difficulty.

DIC-CT findings are useful for predicting cDS in LC.

Laparoscopic cholecystectomy is a standard procedure for treating cholescytitis, but severe inflammation may cause complications. Our previous study showed that the apparent diffusion coefficient (ADC) values could predict difficult surgery. In the present study, relevance of ADC values in grading the severity of cholecystitis was pathologically investigated.

We retrospectively analyzed a total of 50 patients who underwent laparoscopic cholecystectomy or laparotomic cholecystectomy/choledocholithotomy. The degree of inflammation in the neck of the gall bladder was pathologically graded into three tiers (grade 1, mild; grade 2, moderate; grade 3, severe), and ulceration, lymphoid follicle formation, and wall thickness of the gallbladder neck were recorded. All factors were statistically compared with the measured ADC values.

The ADC value was significantly lower in the severe inflammation group ( grade 3) than in the weak inflammation group (grades 1 and 2) (1.93 ± 0.22 vs 2.38 ± 0.67, respectively; P = .02). Ulceration and wall thickness in the gallbladder neck were significantly correlated with ADC values (P = .04 and .006, respectively), and lymphoid follicle formation was marginally correlated with ADC values (P = .06). The diagnostic utility of the ADC values decreased as the interval between imaging and cholecystectomy increased. [Correction added on 19 October 2022, after first online publication: [On the first sentence of the Results section, (grades 2 and 3) for weak inflammation group has been changed to (grades 1 and 2).] CONCLUSION: ADC values were inversely associated with the pathologic intensity of cholecystitis. We recommend that the ADC value be measured before surgery, so that the procedure can be accordingly planned.