The patients’ characteristics and operative outcomes are shown in Table 1. In total, 160 patients with AC were treated by LC. Standard LC was performed in 125 (78%) patients, and a bailout procedure was performed in 35 (22%) patients. There were no significant differences in age, sex, body mass index (BMI), incidence of preoperative drainage, white blood cell (WBC) count, or Charlson comorbidity index between the two groups. The duration from onset to surgery was significantly longer in the bailout group than in the standard group (39.7 ± 40.5 vs. 28.2 ± 46.8 days, respectively; P = 0.04). The CRP concentration was significantly higher in the bailout group than in the standard group (10.47 ± 9.5 vs. 5.39 ± 7.5 mg/dL, respectively; P = 0.001). There was no significant difference in the incidence rate of complications, defined as Clavien–Dindo grade ≥ II complications. In the bailout group, the operative time was significantly longer (206 ± 61.5 vs. 127 ± 38.7 min, P = 0.04), the blood loss volume was significantly higher (211 ± 226 vs. 37 ± 71.8 mL, P = 0.01), and the postoperative hospital stay was significantly longer (7.5 vs. 6.5 days, P = 0.04).
Table 1
Patients’ characteristics
Variable
|
Standard
(n = 125)
|
Bailout
(n = 35)
|
P value
|
Age, year
|
64.9 ± 15.9
|
66.4 ± 15.5
|
0.66
|
Sex (male : female)
|
11 : 5
|
5 : 1
|
0.56
|
Body mass index, kg/m2
|
25.3 ± 12.2
|
25.6 ± 14.2
|
0.76
|
Duration from onset to operation
|
28.2 ± 46.8
|
39.7 ± 40.5
|
0.04
|
Preoperative drainage, n
|
41 (32)
|
17 (48)
|
0.11
|
WBC /µg
CRP mg/dl
|
11509 ± 4162
5.39 ± 7.5
|
13137 ± 5795
10.47 ± 9.5
|
0.06
0.001
|
CCI > 3, n
|
2
|
3
|
0.35
|
Operative time, min
|
127 ± 38.7
|
206 ± 61.5
|
0.04
|
Blood loss, ml
|
37 ± 71.8
|
211 ± 266
|
0.01
|
Postoperative Hospital stay, day
|
6.5
|
7.5
|
0.02
|
※Complication, n (%)
injure
SSI
|
3
1
2
|
1
0
1
|
0.45
|
Data are presented as mean ± standard deviation, n, or n (%). |
WBC, white blood cells; CRP, C-reactive protein; CCI, Charlson comorbidity index; SSI, surgical site infection |
※Clavien–Dindo grade ≥ II |
Next, we performed univariate and multivariate analyses of risk factors for a bailout procedure (Table 2). The cut-off value of age was the median of all patients, and the cut-off value of the BMI was 22 kg/m2 (the standard value for adults). The cut-off value of the WBC count was 18,000 cells/µg, which is one of the criteria for moderate cholecystitis. A receiver operating characteristic curve analysis showed that the cut-off value of the preoperative duration (onset to surgery) was 35 days (AUC, 0.61; 45% sensitivity, 77% specificity) (Fig. 2A) and that the cut-off of the preoperative CRP concentration was 9.4 mg/dL (AUC, 0.66; 51% sensitivity, 80% specificity) (Fig. 2B). The univariate analysis showed that male sex, preoperative drainage, duration from onset to surgery, WBC count, and CRP concentration were significant risk factors. The multivariate analysis showed that a high CRP concentration was an independent risk factor for bailout (odds ratio, 4.16; 95% confidence interval, 1.56–11.1; P = 0.004).
Table 2
Risk factors for bailout (n = 160)
Variable
|
Univariate analysis
Odd ratio (95% CI) P
|
Multivariate analysis
Odd ratio (95% CI) p
|
Age > 67 years
|
0.85 (0.40–1.81)
|
0.68
|
|
|
Male
|
2.38 (1.02–5.55)
|
0.04
|
2.38 (1.04–4.56)
|
0.06
|
BMI > 22
|
0.86 (0.75–1.34)
|
0.50
|
|
|
Duration from onset > 35day
|
2.90 (1.33–6.41)
|
0.04
|
2.1 (0.83–5.4)
|
0.11
|
Preoperative drainage, n
|
1.93 (1.1–4.1)
|
0.04
|
0.85 (0.33–2.2)
|
0.74
|
WBC > 18000 /µg
|
2.7 (1.17–6.67)
|
0.01
|
1.29 (0.47–3.44)
|
0.619
|
CRP > 9.4 mg/dl
|
5.0 (2.22–12.5)
|
0.001
|
4.16 (1.56–11.1)
|
0.004
|
CI, confidence interval; BMI, body mass index; WBC, white blood cells; CRP, C-reactive protein |
We next performed a subgroup analysis and compared fundus-first and subtotal cholecystectomy versus open conversion (Table 3). There was no significant difference in age, sex, BMI, WBC count, or CRP concentration. The duration from onset to surgery was significantly longer in the open group (63 ± 48.2 vs. 30 ± 33.3, P = 0.04), and a significantly higher proportion of patients underwent preoperative drainage in the open group (90% vs. 47%, P = 0.002). In surgical outcomes of each group, there was no significant difference in the operative time or postoperative complications. However, the open group had significantly greater blood loss (388 ± 308 vs. 141 ± 136 mL, P = 0.02) and significantly longer hospital stays (12.7 vs. 7.0 days, P = 0.002).
Table 3
Variable
|
Fundus or subtotal
(n = 25)
|
Open
(n = 10)
|
P value
|
Age, year
|
64.8 ± 17.3
|
70.4 ± 9.46
|
0.43
|
Sex (male : female)
|
18:7
|
4 : 1
|
1
|
Body mass index, kg/m2
|
24.5
|
23.7
|
0.65
|
Duration from onset to ope
|
30 ± 33.3
|
63 ± 48.2
|
0.04
|
Preoperative drainage, n
|
8 (47%)
|
9 (90%)
|
0.002
|
WBC /µg
CRP mg/dl
|
14032 ± 5314
11.7 ± 9.54
|
10900 ± 6618
7.17 ± 9.16
|
0.06
0.21
|
Operative time, min
|
199 ± 60.5
|
224 ± 63.6
|
0.35
|
Blood loss, ml
|
141 ± 136
|
388 ± 308
|
0.02
|
Postoperative Hospital stay, day
|
7.0
|
12.7
|
0.002
|
※Complication, n (%)
injure
SSI
|
1
0
1
|
2
0
2
|
0.19
|
Data are presented as mean ± standard deviation, n, or n (%). |
WBC, white blood cells; CRP, C-reactive protein; SSI, surgical site infection |
※Clavien–Dindo grade ≥ II |