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Underlying cholangitis predicts LCBDE failure, conversion to open surgery

Tristan Manalac
08 Nov 2017

In choledocholithiasis patients receiving single-staged laparoscopic common bile duct exploration (LCBDE), prior antibiotic use and abnormal biliary anatomy predict LCBDE failure and conversion to open surgery, according to a recent Singapore study.

“LCBDE is a recognized treatment of choledocholithiasis. It is paramount, however, to select the appropriate patients upfront to minimize the morbidities associated with an open conversion,” the research said.

“The current study demonstrated that the predictors for a failed LCBDE were: prior antibiotic use, previous endoscopic retrograde cholangiopancreatography (ERCP) and an abnormal biliary anatomy,” they added.

The research team performed a retrospective analysis of 109 patients who underwent either a laparoscopic cholecystectomy with concomitant LCBDE (n=62; mean age 59±18 years; 52 percent male) or laparoscopic converted to open cholecystectomy with concomitant CBDE (n=47; mean age 61±16 years; 70 percent male) at the National University Hospital in Singapore.

Significantly predictive variables were included in the final nomogram model which was then validated using a receiver-operating characteristics curve. Goodness of fit of the resulting model was assessed using the Hosmer-Lemeshow test.

In the multivariable logistical regression analysis, three factors were significantly predictive of conversion to open surgery: prior antibiotic use (adjusted odds ratio [OR], 2.98; 95 percent CI, 1.17 to 7.57; p=0.022), abnormal biliary anatomy (adjusted OR, 9.37; 2.18 to 40.20; p=0.003) and prior ERCP (adjusted OR, 4.99; 2.02 to 12.36; p=0.001). [HPB 2017;doi:10.1016/j.hpb.2017.09.005]

The presence of acute cholangitis as the presenting complaint (crude OR, 2.70; 1.12 to 6.56; p=0.017) and undergoing computed tomography (crude OR, 2.50; 1.07 to 5.86; p=0.022) were also significantly tied to conversion to open CBDE in univariate analysis, but these associations were attenuated after adjusting for covariates.

According to the researchers, the significance of the variables in multivariate analysis “suggest[s] that the presence of underlying cholangitis, with its subsequent interventions, is associated with an increased likelihood of open conversion.”

This is supported by the significance of acute cholangitis in univariate analysis. On the other hand, the role of computed tomography may be accounted for by the underlying sepsis that is more likely to occur in patients with biliary cholangitis.

“In such patients, there is a need to exclude other life-threatening intra-abdominal conditions. Thus, they are more likely to receive a [computed tomography] scan compared to an ultrasonography,” researchers explained.

Incorporating the three factors into a predictive nomogram resulted in an area under the curve (AUC) of 0.809 (0.727 to 0.891), which indicates a high discriminative ability of the model. Moreover, the Hosmer-Lemeshow test suggested an acceptable prediction of conversion to open CBDE (p=0.123).

Despite its retrospective design and higher risks of selection and information bias, the current study was able to produce a predictive tool potentially capable of identifying high-risk populations.

“Using the nomogram, a patient with prior antibiotic use, previous ERCP and an abnormal biliary anatomy will have more than a 90 percent likelihood of a failed LCBDE,” researchers said.

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