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Intraoperative Predictors for Converting Laparoscopic Cholecystectomy to Open Cholecystectomy Dr

Intraoperative Predictors for Converting Laparoscopic Cholecystectomy to Open Cholecystectomy Dr

Saeed et al (2020): Predictors of converting LC to OC Dec., 2020 Vol. 23 Issue 24

Intraoperative predictors for Converting Laparoscopic to Open Cholecystectomy Dr. Mohammed Fateh Saeed1, Dr.Ali Mohsin Hasan2, Dr.Souad Khoshaba Aodyshow3

1, 2, 3Azadi Teaching Hospital, Kirkuk, Iraq

*Correspondence author: [email protected] (Saeed)

ABSTRACT

Objective: The normal surgical treatment for benign disease is laparoscopic cholecystectomy (LC), however, sometime there is a need for open cholecystectomy (OC). In this case, measuring the conversion ratio and defining the values involved in raising the conversion risks (LC-OC) are the objectives of this study. Materials and methods: All the cases of LC were conducted at Azadi Teaching Hospital in 2016 to 2019. Each (LC-OC) case was randomly matched to a laparoscopically completed case by the same consultant as LC-OC in a 1:5 ratios in a retrospective study during. Accordingly, 48 parameters were compared between the two research groups. Thus, 8 out of 54 LC cases were translated to OC during the 3- year investigation, so the converting ratio in this research was 1.03%. The input values were adult males with the history of (particularly as previous gunshot wounds) and constrictive or restrictive lung disease and anemia (Hb9 g / dl).Complex anatomy or blurred perspective secondary to extreme adhesions or serious are considered as a highly common intraoperative reasons for conversion. Then, long term hospitalization was reported for the patients in LC-OC arm. Results: Forty-six out of 54 LC were converted to OC over the 3-year study period; the conversion rate in our study was 1.03%. The most predictive of conversion were male gender, advanced age, prior history of laparotomy, especially prior , a history of restrictive or constrictive lung disease and anemia (Hb\9 g/dl) intraoperative reasons difficult anatomy or obscured view secondary to severe adhesions or significant inflammation. Patients who were in the LC–OC arm had a longer length of hospital stay. Conclusion: There is a high conversion ratio for adult males with severe comorbidities and prior background. Patients with these risk factors need to be informed about the relative open surgery. Having the surgery of high risk patients by the surgeons specialized in minimally invasive surgery need to be highly investigated.

Keywords: Laparoscopic cholecystectomy (LC), open cholecystectomy (OC)

How to cite this article: Saeed MF, Hasan AM, Aodyshow SK (2020): Intraoperative predictors for converting laparoscopic cholecystectomy to open cholecystectomy, Ann Trop Med & Public Health; 23(S24): SP232323. DOI: http://doi.org/10.36295/ASRO.2020.232416

INTRODUCTION Laparoscopic cholecystectomy (LC) initially introduced by Mouret(1987) [1] is a significant effective conventional treating for benign gall bladder disease. LC has been replaced to open surgery treating as a Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232416

Saeed et al (2020): Predictors of converting LC to OC Dec., 2020 Vol. 23 Issue 24

highly common surgical method in the world [2, 3]. The benefits of LC could significantly overweigh the open surgery including short hospitalization, less post-operative discomforts, quick convalescence and improved cosmetic outcomes [4-8]. In contrast, there are no major variations relating to the frequency and overall mortality of injuries [5]. Converting to open surgery is essential for that couldn’t be treated laparoscopically. This is relatively because of different reasons including the technical shortcomings related to the vague anatomy[9] or extensive bonding [10, 11].Few parameters raise the risk of conversion, such as being male adult with previous upper abdominal surgery, chronic , morbid obesity, , and emergency admission [10-12]. On the other hand, the expertise of surgeon would be another conversion risk factor [13-16]. According to literature, theOC conversion rate is highly changeable, however, the common ratio is ranged from 2% to 15%[10, 17, 18]. The surgeon should make a proper scheduling process and authorize the patients by a confident estimating of relative conversion. Despite a few conversion prediction methods, none of them has been commonly practiced because of the methodological weaknesses or heterogeneity and impracticality of approaches [8, 19-24]. Therefore, this study has aimed both to recognize the independent risk factors for LC to OC (LC-OC) conversion and to equate the clinical findings with LC-OC arm findings among the patients with LC arm.

MATERIALS AND METHODS Study design All adult patients were treated by laparoscopic cholecystectomy for benign gall bladder disease at Azadi Teaching Hospital from 2016 to 2019. Health Information System (HIS1) has been used to view patient charts. All process was confirmed by the Institutional Review Board (IRB) based on de-identification of patients. According to literature, the experience of the surgeon [16, 19, 20] is highly important in deciding the conversion ratio [13-15]. Therefore, the confinement of complex effects attributed to this experience is essential to verify the morbidity and disease toward the risk parameters for conversion. Obviously, it could be fulfilled over the selected cases performed by the surgeons with at least 3 years of consultant experience and through matching each converted case to the five randomly obtained laparoscopically complete cases in LC-OC case by the same surgeon within the same year. Regarding the 1: 4 matching ratio in most sources, this study preferred 1: 5 matching ratio by increasing the sample size to compensate the lack of power because of the limited conversion numbers. Besides the raising of sample size [25], raising the non-exposed patients rates to exposed patients could improve accuracy. This study removed the patients with hepatobiliary malignancy, cholecystectomy (as part of another treatment) or was unable to endure pneumoperitoneum. With the usual 4-port procedure, LCs were performed, then the cystic arteries and ducts were triply clipped while being separated by endoclips (10 or 5 mm). On the other hand, intraoperative (IOC) was performed on the basis of surgeon’s diagnosis and patient’s specific indications. With a normal right subcostal Kocher incision and the remove of gallbladder in anterograde way, the open procedure was carried out under the supervision of consultant surgeon or senior resident. Study variables

1 An in-house electronic medical record database in 2016 Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232416

Saeed et al (2020): Predictors of converting LC to OC Dec., 2020 Vol. 23 Issue 24

A retrospective review study (48 variables) including intraoperative results, imaging outcomes, clinical outcomes, hospital stay period, demographics, laboratory tests and postoperative admission status was 2 carried out. In this case, age, gender, previous abdominal surgeries’ history, functional status,ASA class, BMI (body mass index), smoking and concomitant systemic diseases (cardiac, renal, respiratory, oncological etc.) were demographic variables. The cutoff values were alanine transaminase (130), aspartate transaminase (100), amylase (200), c-glutamyltransferase (100), (250) and lipase (120) IU/1(twice the normal rate). The cutoff value for complete was 2mg / dl and for direct bilirubin was 0.6 mg / dl. The level of hemoglobin was grouped as 1) greater than 12 g / dl, 2) 9 to 12 mg / dl and 3) less than 9 mg / dl. The standard cutoff ratio is 1.5, while 1.5-fold increase over the average ratio was selected for creatinine based on the International Standardized Ratio (INR). Preoperative variables included diagnosis of admission (, cholelithiasis, and cholangitis of ), septic condition, admission status (inpatient emergency or previous intensive care), ultrasound findings (presence of impacted stone, pericholecystic fluid and thickness of gall bladder wall) and endoscopic findings (endoscopic ultrasound (EUS) or endoscopic ultrasound (EUS)). Align with operative report, operative values including operation time and intraoperative cause of conversion comprising severe bleeding, anatomical difficulty and stone / exploration of (CBD). Postoperative variables included postoperative admission status, 30-day mortality and postoperative complications (regular floor vs. intensive care unit). Statistical analyses The data was analyzed, and managed through SPSS3 (version 24). By summarizing the categorical values, continuous values have been offered as the standard deviations and means of numerical results. Cutoff values validated in literature were applied here to analyze the laboratory variables [26]. The relation between the categorical variables and conversion category were computed through Chi square test align using T-test to relate the continuous variables. Also, the analysis of multivariates to account the potentially conflicting factors was conducted. Stepwise logistic regression analysis was applied to analyze the related between the various predictors and conversion. The outcomes were provided by the odds rates (OR) and 95% trust (CI) interval. P = 0.05 has been applied to shows the significance of results.

RESULTS Considering all 54 LC cases, 9 LC-OC cases were recognized except 1 case excluded because of the inability to access its respective graphs. All the reminded 8 cases were randomly matched in a 1:5 ratios while a LC case was carried out by the same consultant in the same practice year. In this study, the conversion rate was measured as 1.03%. As a result, males with p = 0.0001 were the majority of patients (80%) who experienced intraoperative conversion (Table 1). The mean age group of LC-OC patients was higher than the LC group patients (68.35 ± 13.74 vs. 47.72 ± 16.96, p = 0.0001), respectively. A higher comorbidities incidence was found in LC-OC (Table 1). In addition, a greater ASA class (ASA3 45.7 vs. 11.8% p = 0.0001) was seen in LC-OC category than the control group. There was a prior laparotomy in 4

2American Society of Anesthesiology 3Social Sciences Statistical Kit Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232416

Saeed et al (2020): Predictors of converting LC to OC Dec., 2020 Vol. 23 Issue 24

out of 8 patients in LC-OC group, 48%were against to 19.5% in LC group (p = 0.04). All patients with gunshot wound laparotomy background and nominated to the next stage with benign gallbladder disease needed conversion to OC. It showed the double probability of conversion in these patients compared to those with history for other purposes. 78% of LC-OC population werepatients either in medical ward (intensive care) or in emergency room, while 50% of LC population had identical admission features and the other 50%have been electively admitted (p = 0.0001). In terms of BMI or smoking, there was no differential between the two groups (Table 1). A high conversion risk was seen in patients with difficult chole cystitis during preoperative imaging (US / CT scan) (e.g. perforated gallbladder or early phlegmon formation) (p = 0.0001). In contrast, in terms of uncomplicated cholecystitis ultrasound findings (pericholecystic fluid, impacted stone, wall thickness), there were no related variable to open cholecystectomy conversion (Table 1). The independent values of table 1 (as bivariate analysis) were incorporated into the multivariate analysis of Table 2. Abdominal surgery history especially GSW (OR 4.66, 95% CI 1.78–12.17),age (OR 2.15, 95% CI 1.62–2.85), Pulmonary disease (OR 6.03, 95% CI 1.21–29.97), patients with a hemoglobin level of less than 9 g / dl (OR 36.57, 95% CI 3.16–423.72) and Male gender (OR 0.09, 95%CI 0.03–0.25) were the variables affecting the conversion ratio. Conversion signs included severe inflammation (32.6%), extensive bleeding (6.5%), severe inflammation (32.6%), 36.9%, and intraoperative need for exploration of CBD (15.2%).

Table 1. Pre-operative risk parameters for conversion to OC

LC LC–OC p value OR (95% CI) N 46 N = 8 Demographics Gender < 0.0001 Male (%) 19 (41.3) 7 (80.4) Reference Female (%) 27 (58.7) 2 (19.6) 0.17 (0.08–0.37) Age (years) 47.72 ± 16.96 68.35 ± 13.74 < 0.0001 1.08 (1.05–1.10) BMI (kg/m2) 29.70 ± 6.10 30.29 ± 6.56 0.64 1.01 (0.95–1.08) Smoking 17 (43.9) 5 (58.7) 0.07 1.82 (0.95–3.49)

Functional status Independent 45 (98.7) 3 (89.1) 0.004 Reference Dependenta 1(1.3) 5 (10.9) 9.23 (2.12–40.11) Duration symptoms < 0.0001 NA (days) \30 26 (76.3) 8 (100.0) C30 8 (23.7) 0 (0.0) Clinical ASA class 1 21 (44.5) 0 (0.0) < 0.0001 Reference 2 20(43.7) 5 (52.2) NA 3 5(11.8) 4(45.7) NA 4 0 (0.0) 1 NA (2.2) Admission status Elective 23 (49.6) 2 (21.7) 0.001 Reference Inpatient/emergency 23 (50.4) 7 (78.3) 3.54 (1.68–7.47) Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232416

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History abdominal 8 (19.5) 3 (39.1) 0.004 2.65 (1.34–5.22) surgery Trauma gunshot 0 (0.0) 1 (8.7) 0.001 NA Medical comorbidities Hypertension 14 (30.9) 7 (76.1) < 0.0001 7.12 (3.42–14.83) Renal disease 2 (5.7) 2 (26.1) < 0.0001 5.89 (2.48–13.98) Diabetes mellitus 6 (14.3) 3 (34.8) 0.001 3.18 (1.56–6.48) Drug steroids intake 2 (0.9) 3 (6.5) 0.03 7.95 (1.29–49.02) Radiological finding Cholelithiasis/cholecystitis 39 (86.1) 3 (41.3) < 0.0001 Reference CBD stone 5 (11.3) 2 (26.1) 4.81 (2.10–11.03) Complicatedb 1 (2.6) 3 (32.6) 26.05 (9.05– 75.00) ERCP/EUS 7 (16.1) 2 (26.1) 0.11 1.84 (0.87–3.88) Glomerular filtration rate (ml/min/1.73 m2) MORE 60 2 (6.0) 2 (26.1) < 0.0001 Reference <60 37(94.0) 6 (73.9) 0.18 (0.07–0.44)

Intraoperative blood loss in patients undergoing conversion was found to be slightly higher, as most patients undergoing laparoscopic cholecystectomy had intraoperative blood loss of less than 25 cc. Patients with conversion had a longer operation time (2.98 ± 0.92 vs. 1.15 ± 0.6 h, p = .0001) than those with successfully treated with LC. In addition, 19.8% of LC-OC group is post-operatively admitted to ICU compared to 1.9% in LC group. A drain was also relatively to be put in LC-OC group 38 (82.6%) vs. 25 (10.9%) p = .0001. Compared to LC group, LC-OC group showed improved cumulative perioperative morbidity with long inpatient time (9.85 ± 7.13 days vs. 2 ± 4 days p.0001). Despite similar pre-operative conditions, these patients appeared to be at a greater risk for post-operative pre-renal azotemia. In conversion group, 5 patients showed pre-renal acute kidney injury established (10.9%) vs. 3 patients in LC group (1.3%) (p.004). There are no differential rates among the postoperative bile leakage, urinary tract or pneumonia. In LC-OC group, surgical site infections were formed in 4.3% of patients, but none in LC group. However, on multivariate logistic regression, postoperative inpatient length was the only morbidity that has been indicated to achieve statistical significance in LC-OC on LC community. There was no substantial differential between the surgical site ratio or the occurrence of postoperative acute kidney injury.

Table 2 Multivariate logistic regression, stepwise of independent conversion variables Variables OR (95% CI) p value Gender 0.09 (0.03–0.25) Age 2.15 (1.62–2.85) < 0.0001 History abdominal surgery 4.66 (1.78–12.17) 0.002 Pulmonary disease 6.03 (1.21–29.97) 0.03 Hemoglobin\9 g/dl 36.57 (3.16–423.72) 0.004 Gender (reference: female), age (increase by 10 units), history of abdominal surgery, pulmonary disease, hemoglobin, blood urea nitrogen, creatinine, GFR

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232416

Saeed et al (2020): Predictors of converting LC to OC Dec., 2020 Vol. 23 Issue 24

Table 3. Stepwise multivariate logistic regression model for ‘‘outcomes’’ of LC–OC group Variables OR (95% CI) p value Postoperative length stay (days) 1.17 (1.06–1.29) 0.002 Drain 21.04 (7.80–56.77) < 0.0001

Table 4. Post-operative result of LC compared to LC–OC group LC LC-OC p value OR (95% CI) N = 46 N = 8 Complications Urinary tract 0 (0.0) 1 (2.2) 0.17 infection Pneumoni 1 (1.7) 1 (2.2) 1.00 1.26 (0.14–11.50) Bile leak 1 (0.4) 0 (0.0) 1.00 NA Respiratory failure 0 (0.0) 2 (4.3) 0.03 NA Postoperative 1 (1.3) 0 (0.0) 1.00 NA Outcomes Operative time (h) 1.15 ± 0.60 2.98 ± 0.92 < 0.0001 13.55 (6.62–27.74) Drain insertion 5 (10.9) 7 (82.6) < 0.0001 38.95 (16.35–92.80 Postoperative admission Regular floor 37 (98.3) 4 (80.4) < 0.0001 Reference Intensive care unit 4 (1.7) 2 (19.6) 13.74 (4.02–46.92) Postoperative 2.00 ± 4.06 9.85 ± 7.13 < 0.0001 1.42 (1.27–1.59) length stay (days) Mortality 0 (0.0) 1 (2.2) 0.17 NA Bivariate analysis (numerical values as mean ± standard deviation and categorical values as numbers %)

DISCUSSION LC could play great role in the managing of benign gallbladder disease except few cases requiring to open surgery. Despite the reluctance to conversion, it could be an effort on the favor of patients’ safety and preventing complications. Nowadays, because of the essential experience in invasive surgical training, the conversion rate has been decreased [23] from 3% to 24% based on previous studies [10, 18, 27]. It could be due to the patients’ choice, experience of surgeon and operation values. The conversion ratio is 1.03% in this study. Indeed, it is one of the least conversion ratios in English medical studies by now [9, 10, 18, 27]. It is noted that the conversion ratio of all surgeons at our institution was approximately equivalent, varying between 0% and 4% for more than 15 years. Coffin et al. [24] has stated that for the multiple risk factors analyzed, the conversion ratio of surgeons with minimal invasive surgical training (MIST) was less than the surgeons without formal training in minimally invasive surgery. Likewise, Abelson et al. [28] has stated the conversion ratio of 1.7% for MIST surgeons. The reason of low conversion ratio in our sample might be due to the morbidity or the patients' gallbladder disease than the experience of surgeon. Align with [8, 20, 21], in this study, the main reasons for the low conversion ratio could be because of the uncertain anatomy and extreme inflammation or thick adhesions at Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232416

Saeed et al (2020): Predictors of converting LC to OC Dec., 2020 Vol. 23 Issue 24

Calot's triangle, beside the need for CBD exploration and intraoperative bleeding. Alternatively, few risk factors of conversion could be as emergency procedure, male gender, age, certain comorbidities and stone effect. Another important issue to our research is the clinical outcome and cost utility as the independent variables to predict the conversion from LC to OC [29]. In a bivariate analysis, this study has defined many risk factors for conversion; however, only 5 variables were defined by multivariate stepwise regression analysis with a significant relation to conversion. Also, male and age were considered as independent risk factors based on the literature align with this research.

In a retrospective analysis including 5164 samples with LC attempts, Genc et al.[27] has reported the conversion ratios (2.25%) for female and (5.65%)for males(p.001), showing males as statistically relevant risk factor for conversion that might be associated to the raised severity of male gallstone disease [30, 31]. The current research found that 27 out of 37 male patients (73%) had surgery to LC conversion at the Calot's triangle for either severe inflammation or extreme adhesion compared to 5 out of 9 females (55%). Based on literature, the reported age - risk factor for conversion is 50 to 65 years with twice to four times conversion ratio reported in these patients [7, 8, 15, 24]. In this study, the mean age for LC – OC community was 69 years. Possible factors could be related to the more incidences of complex cholecystitis and comorbid statues in old patients [32]. In multiple processes, health comorbidities were indicated as a risk parameter for conversion from laparoscopic to open surgery. Moghadamyeghaneh et al. [33] has found that in 300.000 patients with laparoscopic colorectal resection, chronic pulmonary disease is an independent risk parameter for conversion. Likewise, Sippey et al.[34] has registered 7242 patients who underwent LC by use of ACS- NSQIP4.The conversion rate was 6% in these groups. Medical comorbidities were considered as risk parameter for conversion, whilst the OR for conversion in patients with pulmonary comorbidity was 2.18 (p = 0.001). There are many risk parameters for comorbidities, however, the transferringrisk from LC to LC-OC was statistically raised only by pulmonary disease, based on the current study. For deciding to keep on open cholecystectomy instead of LC[7], the preoperative comorbidity of patient could essential in decision Despite no contraindication for LC in the prior history of abdominal surgery, prior abdominal surgery was identified to be related to an increased conversion risk in few researches [7, 9, 14, 21]. The conversion ratio increment is associated with the adhesion degree and adhesiolysis need. Ercan et al.[13] registered a conversion ratio of 4.08% in a sequence of 2693 LC. Accordingly, 37%had a prior abdominal surgery history among patients whose operations were converted. In the current study,22 patients out of 46 ones (48%) also had a previous laparotomy. 4 out of 46 patients had a previous abdominal gunshot wound and underwent abdominal exploration with different resection. Thus, it was defined that the maximum conversion ratio was in this sub-category of patients. The amount of hemoglobin below 9 g / dl is another conversion risk factor based on our analysis. Despite showing anemia as a risk parameter, why it raises the chances of conversion is unknown [7]. In chronic diseases, anemia is presented. For other variables with larger sample size analysis, anemia could be a confounding variable. Major fibrosis and inflammation surrounding the Calot triangle

4National Surgical Quality Improvement Programof American College of Surgeons Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232416

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precluding safe dissection were considered as the most common intraoperative conversion causes [9, 35]. There was high conversion risk in patients with the evidence of complex preoperative imaging condition as a gangrenous or perforated gallbladder. Many preoperative ultrasound findings have been reported substantially related to a relative transferring to open surgery, such as dilated common bile duct, air in intrahepatic bile duct, gall bladder wall thickness and stones in common bile duct and absence of fluid or sludge in gall bladder(Tosun et al. [36]). Align this, the current study has shown that complex ultrasound gallbladder pathology as a major risk factor in bivariate, but not multivariate analysis for conversion to open surgery. Tosun et al. [36] has studied the patients who were electively admitted and omitted those morbidities believed to be included in the conversion risk factors reviews, also one surgeon has conducted all the cases in this study while challenging the generalization of study. Many researches tried to build a risk score for LC-OC conversion [8, 21, 22, 31, 37]. Clinically, the mentioned risk ratios have not been utilized because they were obtained either from a lack of evidence in prospective trials, observational tests or tests with a confined sample size. Sutcliffe et al.[ 38] has provided a valid risk score obtained from the UK database of 8820 patients. The scores obtained from the 6 variables estimated a 7.1% high risk conversion instead ofa 1.2 % of high risk conversion versus of low risk patients. In contrast, this risk score has not considered the patient-related variables as prior surgery and comorbidities defined as major risks in the current study. Any decision to conversion differs among the surgeons and majorly connected to the perceived experience and complexity. In any established score, "surgeon" component is difficult to be measured in a sample, so it is taken as a major limitation. Also, it was assumed that, regardless of the surgeon’s expertise, recognizing the independent parameters that could affect the conversion is highly important and relevant to various settings. On the other hand, the post-operative complications ratios between LC and LC-OC differ based on previous researches. Accordingly, a higher incidence of complexes as deep venous thrombosis, wound dehiscence and wound infection has been reported by Kaafarani et al.[7], while according to Ashfaqet al. [35], there was no difference in postoperative hemorrhage, wound infection, bile leakage or subhepatic collection, except a difference in inpatient length. Align with literature, the current research showed higher overall morbidity in patients who underwent the conversion, however, inpatient lengthwas found significant for multivariate analysis. Considering the limitations of study, this is a chart review-based retrospective analysis. For raising the probability of conversion, many disease-related parameters were reported as complex cholecystitis and its severity. By comparing the diagnostic data, the notes of surgeon and histopathology findings, a valid diagnosis tried to be generated. It is noted that, the retrospective nature of our research confines a precise defining of a preoperative diagnosis in analyzing the conversion risk factors. Another disadvantage is to analyze a random sample of active laparoscopic cholecystectomies than the whole population, adding that the major part of these documents were paper- based but not electronic (before 2007). Thus, the review of this high amount of documents could be time- consuming and high cost. However, it was assumed that the rate of 1:5 could be a representative sample of whole population [25] based on the surgeon’s operation notes, which bring another weakness because his/ her decision for conversion could be an intrinsic heterogeneity. This research is the only academic analysis that restricts the generalizability of our findings. In this case, the large number of patients in this study could be one of its strength. Therefore, we analyzed a detailed list of pre-operative values that replicates the Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232416

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clinical image of many cholecystectomy patients while improving the generalizability of our findings, say the least conversion rates recorded by now is(1%) belong to our study (the attempt of 17 surgeons in more than 15 years). This might mean that LC-OC patients have surgery conversion due to the factors beyond the surgeons’ capability [15].

CONCLUSION LC is a surgical treatment option for benign gallbladder, but it should be converted to OC in few cases. The findings of our study align with literature shows that being male and adult, pulmonary disease, significant prior medical history and prior laparotomy could be big risk parameters for conversion. The cost and morbidity of conversion to OC is quite well- known in previous studies. A precise prediction of what is "high risk" helps patients to be properly counseled. There is a need for more researches to see whether surgeons with high experience in minimal invasive surgery could perform operations on high-risk patients.

Authors Contributions

The Author MS contributed to the integral part of paper, editing and writing of data, EM in data collecting and its analyzing, JF in manuscript revision, FW in manuscript revision, BN in manuscript revision and editing, HT in biostatistician lead, analysis and manuscript revise, SY in analysis and critical revision conceptualization, and HA as the lead researcher in the conceptualization of Hey, research, integral aspect of data collection, interpretation of data and critical examination of manuscript. At the end, all the manuscript was approved by the contributors.

REFERENCES

1. Mouret P (1996) How I developed laparoscopic cholecystectomy. AnnAcad Med Singap 25:744–747 2. 2. Wiesen SM, Under SW, Barkin JS et al (1993) Laparoscopic cholecystectomy: the procedure of choice for acute cholecystitis. Am J Gastroenterol 88:334–337 3. Csikesz N, Ricciardi R, Tseng JF et al (2008) Current status of surgical management of acute cholecystitis in the United States. World J Surg 32:2230–2236. https://doi.org/10.1007/s00268-0089679-5 4. Ros A, Gustafsson L, Krook H et al (2001) Laparoscopic cholecystectomy versus mini-laparotomy cholecystectomy. Ann Surg 234(6):741–749 5. Keus F, de Jong J, Gooszen HG et al (2006) Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev, Issue 4. Art. No.:CD006231 6. Diamantis T, Tsigris C, Kiriakopoulos A et al (2005) Bile duct injuries associated with laparoscopic and open cholecystectomy: an 11-year experience in one institute. Surg Today 35(10):841–845 7. Kaafarani HM, Smith TS, Neumayer L et al (2010) Trends, outcomes, and predictors of open and conversion to open cholecystectomy in Veterans Health Administration hospitals. Am J Surg 200:32–40 8. Beksac K, Turhan N, Karaagaoglu E et al (2016) Risk factors for conversion of laparoscopic cholecystectomy to open surgery: a new predictive statistical model. J LaparoendoscAdvSurg Tech A 26(9):693–696 9. Ballal M, David G, Willmott S et al (2009) Conversion after laparoscopic cholecystectomy in England. SurgEndosc 23(10):2338–2344 10. Giger UF, Michel JM, Opitz I et al (2006) Risk factors for perioperative complications in patients undergoing laparoscopic cholecystectomy: analysis of 22,953 consecutive cases from the Swiss Association of Laparoscopic and Thoracoscopic Surgery database. J Am CollSurg 203:723–728

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11. Le VH, Smith DE, Johnson BL et al (2012) Conversion of laparoscopic to open cholecystectomy in the current era of laparoscopic surgery. Am Surg 78(12):1392–1395 12. 12. William LFJR, Chapman WC, Bonan RT et al (1993) Comparison of laparoscopic cholecystectomy with open cholecystectomy in a single center. Am J Surg 165:459–465 13. Pavlidis TE, Marakis GM, Ballas K et al (2006) Risk factors influencing conversion of laparoscopic to open cholecystectomy. J LaparoendoscAdvSurg Tech A 17:414–418 14. Tang B, Cuschieri A (2006) Conversions during laparoscopic cholecystectomy: risk factors and effects on patient outcome.JGastrointestSurg 10:1081–1091 15. Sakpal SV, Bindra SS, Chamderlain RS (2010) Laparoscopic cholecystectomy conversion rates two decades later. JSLS 14:476–483 16. Simopoulos C, Botaitis S, Polychronidis A et al (2005) Risk factors for conversion of laparoscopic cholecystectomy to open cholecystectomy. SurgEndosc 19(7):905–909 17. Rosen M, Brody F, Ponsky J et al (2002) Predictive factors for conversion of laparoscopic cholecystectomy. Am J Surg 184:254–258 18. Zhang W, Li J, Wu G et al (2008) Risk factors affecting conversion in patients undergoing laparoscopic cholecystectomy. ANZ J Surg 78(11):973–976 19. Gholipour C, Fakhree MB, Shalchi RA et al (2009) Prediction of conversion of laparoscopic cholecystectomy to open surgery with artificial neural networks. BMC Surg 9:13 20. Eldar S, Siegelmann HT, Buzaglo D et al (2002) Conversion of laparoscopic cholecystectomy to open cholecystectomy in acute cholecystitis: artificial neural networks improve the prediction of conversion. World J Surg 26:79–85. https://doi.org/10.1007/ s00268-001-0185-2 21. Goonawardena J, Gunnarsson R, de Costa A et al (2015) Predicting conversion from laparoscopic to open cholecystectomy presented as a probability nomogram based on preoperative patient risk factors. Am J Surg 210(3):492–500 22 22. Lipman JM, Claridge JA, Haridas M et al (2007) Preoperative findings predict conversion from laparoscopic to open cholecystectomy.Surgery 142:556–563 23. Bouassida M, Chtourou M, Charrada H et al (2017) The severity grading of acute cholecystitis following the Tokyo Guidelines is the most powerful predictive factor for conversion from laparoscopic cholecystectomy to open cholecystectomy. J ViscSurg 154(4):239–243 24. Coffin SJ, Wrenn SM, Callas PW et al (2017) three decades later: investigating the rate of and risks for conversion from laparoscopic to open cholecystectomy. SurgEndosc 32(2):923–929 25. Brazauskas R, Loga B (2016) Observational studies: matching or regression? Biol Blood Marrow Transplant 22(3):557–563 26. 26. Shaib Y, Hallal A, Karaoui W et al (2017) Predictors of bile tree pathology in patients presenting with gallbladder disease. Gastroenterology 152(5):501–502 27. Genc V, Sulaimanov M, Cipe G et al (2011) what necessitates the conversion to open cholecystectomy? A retrospective analysis of 5164 consecutive laparoscopic operations. Clinics 66(3): 417–420 28. Abelson JS, Afaneh C, Rich BS et al (2015) Advanced laparoscopic fellowship training decreases conversion rates during laparoscopic cholecystectomy for acute biliary diseases: a retrospective cohort study. Int J Surg 13:221–226 29. Coccolini F, Catena F, Pisano M et al (2015) Open versus laparoscopic cholecystectomy in acute cholecystitis. Systematic review and meta-analysis. Int J Surg 18:196–204 30. 30. Lein HH, Huang CS (2002) Male gender: risk factor for severe symptomatic cholelithiasis. World J Surg 26:598–601. https://doi. org/10.1007/s00268-001-0275-1 31. Livingston EH, Rege RV (2004) A nationwide study of conversion from laparoscopic to open cholecystectomy. Am J Surg 188:205–211 32. Brunt LM, Quaseharth MA, Dunnegan DL et al (2001) Outcomes analysis of laparoscopic cholecystectomy in the extremely elderly. SurgEndosc 15:700–705 33. Moghadamyeghaneh Z, Masoomi H, Mills S et al (2014) Outcomes of conversion of laparoscopic colorectal surgery to open surgery. JSLS 18(4):e2014.00230

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Saeed et al (2020): Predictors of converting LC to OC Dec., 2020 Vol. 23 Issue 24

34. Sippey M, Grzybowski M, Manwaring ML et al (2015) Acutecholecystitis: risk factors for conversion to an open procedure. J Surg Res 199(2):357–361 35. Ashfaq A, Ahmadieh K, Shah A et al (2016) The difficult gall bladder: outcomes following laparoscopic cholecystectomy and the need for open conversion. Am J Surg 212(6):1261–1264 36. 36. Tosun A, Hancerliogullari K, Serifoglu I et al (2015) Role of preoperative sonography in predicting conversion from laparoscopic cholecystectomy to open surgery. Eur J Radiol 84(3):346–349 37. Kama NA, Kologlu M, Doganay M et al (2001) A risk score for conversion from laparoscopic to open cholecystectomy. Am J Surg 181:520–525 38. Sutcliffe RP, Hollyman M, Hodson J et al (2016) Preoperative risk factors for conversion from laparoscopic to open cholecystectomy: a validated risk score derived from a prospective UK database of 8820 patients. HPB Oxf 18(11):922–928 2382 World J Surg (2018) 42:2373–2382 39. Predicting Conversion from Laparoscopic to Open Cholecystectomy: A Single Institution Retrospective Study Samer Al Masri1• Yaser Shaib2• Mostapha Edelbi1• Hani Tamim2 Faek Jamali1 • Nicholas Batley3• Walid Faraj1,4

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