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USEFULNESS OF RANDHAWA AND PUJAHARI SCORING SYSTEM FOR ASSESSMENT OF DIFFICULTY DURING LAPAROSCOPIC CHOLECYSTECTOMY PROCEDURE.

BACKGROUND

Gallstone disease (GSD) is one of the major causes of morbidity and mortality all over the world. Its prevalence in India has been reported 18.8%. [1] In developed societies too, gallstones constitute a significant health problem, affects 10% to 15% of the adult population. [2] Cholecystectomy is done to remove the gallbladder in case of gallstones with acute or chronic cholecystitis and associated complications. first laparoscopic cholecystectomy (LC) was performed in 1985 by Prof. Dr. Erich Muhe of Germany after a time interval of about 100 years when Carl Langenbuch (1846-1901) of Germany performed the first cholecystectomy in 1882. [3] Laparoscopic cholecystectomy has clearly displaced open cholecystectomy in the management of simple biliary lithiasis and is a safe, efficient technique.

Conversion to open cholecystectomy is occasionally necessary to avoid or repair injury, delineate confusing anatomic relationships, or treat associated conditions. Conversion to open cholecystectomy has been associated with increased overall morbidity, surgical site and pulmonary infections, and longer hospital stays. [4,5] Laparoscopic cholecystectomy is considered to be difficult if adhesions at Calot's triangle are dense, gallbladder is contracted or fibrotic, previous history of upper abdominal surgery, gangrenous gallbladder, acutely inflamed gallbladder, empyema gallbladder including Mirizzi's syndrome, or associated cholecystogastric or cholecystoduodenal fistula. [6] The ability to accurately identify an individual patient's risk for conversion based on preoperative information can result in more meaningful and accurate preoperative counseling, improved operating room scheduling and efficiency, stratification of risks for technical difficulties [7] and appropriate assignment of resident assistance, may improve patient s safety by minimizing time to conversion, and helps to identify patients in whom a planned open cholecystectomy is indicated. On an average, conversion to open cholecystectomy is required in 2% to 15% of patients undergoing laparoscopic cholecystectomy (Alponat et al., 1997; Sanabria et al., 1994). [5,6] It may be helpful to identify difficulties and complications in order to avoid the risk of conversion of a laparoscopic cholecystectomy to open cholecystectomy beforehand (Sanabria et al., 1994). [6] Such prediction may allow a surgeon to take extra precautions to reduce intraoperative complications, and to convert from laparoscopic cholecystectomy to open cholecystectomy at an earlier stage.

Aims and Objectives

The aim of this study is to determine the predictive factors for difficult laparoscopic cholecystectomy and to evaluate the effectiveness of scoring system to predict difficult cholecystectomy.

METHODS

This prospective study was carried out after clearance from the Institutional Ethical Committee and an informed consent was obtained from all the patients. Sample size was calculated at Department of Social & Preventive Medicine, Era's Lucknow Medical College & Hospital on the basis of positive prediction value of scoring method using the formula:

n =[Z.sub.[[alpha].sup.2]] pq/[l.sup.2]

When p=75%, proportion of sensitivity.

q=100-p

Type I error a = 5%

Allocated even L = 7.5% for detecting result with 95% power of study.

Loss to follow-up= 20%

Then sample size comes out to be n=150

150 patients were enrolled for laparoscopic cholecystectomy for cholelithiasis by the following inclusion and exclusion criteria.

Inclusion Criteria

* Age 18-60 years

* Patients found to have Gall Stone Disease on Abdominal Ultrasonography planned for surgery

Exclusion Criteria

1. Common bile duct (CBD) calculus.

2. Dilated CBD.

3. Features of obstructive jaundice.

4. Deranged liver function tests.

5. Not willing for laparoscopic cholecystectomy.

6. Contraindication for Laparoscopic Cholecystectomy.

All the patients were evaluated on the basis of Randhawa & Pujahari, 2009 (8) Scoring system and then predicted the level of difficulty of surgery.

Based upon the above scores for prediction of surgery, patients were divided in three groups: Easy: Score [less than or equal to] 5, Difficult: Score 6-10, Very difficult: Score >10. Intra operative findings such as time taken for the surgery, biliary/stone spillage, injury to duct/artery or conversion to open cholecystectomy were noted and assessment of level of ease experienced by the surgeon was evaluated based on following factors (Randhawa and Pujahari) 2009. [8]

Assessment of level of ease of laparoscopic cholecystectomy procedure was done on the basis of above criteria. Post-operative events such as Drain out, Suture out, biliary leakage, surgical site infection or any other complications, histopathology reports were also recorded. Postoperative cases were followed up for any complications for up to 6 weeks.

Statistical Analysis

The statistical analysis was done using SPSS (Statistical Package for Social Sciences) Version 15.0 statistical Analysis Software. The values were represented in Number (%) and Mean [+ or -] SD. The following statistical formulas were used-

1. Chi Square Test: To test relationship between categorical variables.

2. Student 't' Test: To test the significance of two means, the student 't' test was used.

3. Level of Significance: "p" is level of significance. p > 0.05 Not significant. p <0.05 Significant.

RESULTS

A total of 150 patients of gall stone disease fulfilling the inclusion criteria were enrolled in study. Each patient was assessed for risk factors, age, gender, previous history of hospitalization, BMI, presence of supraumbilical/ infraumbilical scar, palpable gall bladder, gall bladder wall thickness, pericholecystic collection and impacted stone and preoperative scoring method to predict the difficulty/ ease of level for performing laparoscopic cholecystectomy. Out of 150 patients, 99 (66.0%) having pre-operative score 0-5 were classified as Group I defined as Easy laparoscopic cholecystectomy, 51 (34.0%) patients having score 6-10 were classified as Group II defined as Difficult. None of the patient had pre-operative score >10 defined as very difficult.

DISCUSSION

Cholecystectomy can be performed either through open procedure or through laparoscopic procedure. However, laparoscopic cholecystectomy is often criticized as in few patients- conversion to open cholecystectomy, increased risk of bile duct injury or injury to the adjoining viscera and its high cost. Radhawa and Pujahari [8] came up with a systematic scoring system to predict the level of difficulty in laparoscopic cholecystectomy. This scoring system takes into account the demographic factors like age, gender, hospitalization history, clinical factors like BMI, presence of abdominal scar, palpability of gall bladder and sonographic features like wall thickness, pericholecystic collection and impacted stone as the predictors of difficulty. In present study, we also made an attempt to predict the difficulty level in laparoscopic cholecystectomy procedures included in our study and also studied the effectiveness of the scoring system proposed by Randhawa and Pujahari.t8) For this purpose, a total of 150 patients scheduled to undergo laparoscopic cholecystectomy procedure were enrolled in the study. Age of patients ranged from 22 to 60 years with mean age of 39.62 [+ or -] 11.24 years. The sampled population was dominated by females (60%). Yolet al. [9] showed proportion of females to be 50.5% and mean age as 39.2%. Randhawa et al. [8] in their study had 64.9% females and reported the mean age of patients as 44.37 years. The findings in general suggest a predominance of females and middle age group as the representative age domain. In present study, a total of 36 (24%) patients had abdominal scar and except for 16 (12.67%) patients, all the patients had BMI>25 kg/[m.sup.2]. History of previous hospitalization was positive in 35.33% patients, a total of 11.33% patients had palpable gall bladder. Thickened wall was seen in 31 (20.67%) patients and pericholecystic collection in 16 (10.67%) cases. None of the cases had impacted stone. Correspondingly, the difficulty level was assessed as easy in 99 (66%) cases and difficult in 51 (33%) cases. None of the cases were defined as very difficult. Compared to present study, Randhawa and Pujhari [8] in their study found 78.1% of their cases as easy and only 21.2% as difficult. Using a different scoring system based on ultrasonographic features only Lal et al.t10) found 71.23% of their cases as easy and remaining 28.77% as difficult. Chand et al. [11] There was a significant association between predicted difficulty and duration of surgery, presence of adhesions during surgery, bile spillage and conversion to surgery. Thus, validating the usefulness of scoring system for these outcomes. The scoring system did not show any association with postoperative complications and outcomes. Thus, implying that the scoring system was meant exclusively for prediction of intraoperative events and difficulties only. Neither Randhawa and Pujahri [8] nor Gupta et al. [12] who developed and validated the scoring system used in present study reported the usefulness of post-operative outcomes and events as the outcomes to be predicted by the scoring system. In present study, no significant association between histopathological findings and predicted difficulty was observed. No such association has been reported in previous studies too. In this study, during surgery, a total of 97 (64.67%) procedures were found easy, 47 (31.33%) were difficult and 6 (4%) were found very difficult. On validating the observed difficulty, we found that out of 97 cases found easy - a total of 87 (89.7%) were predicted as easy while 10 (10.3%) were predicted as difficult. Out of 47 procedures found difficult, 35 (74.5%) were predicted to be difficult while 12 (25.5%) were predicted to be easy. All the cases found very difficult were predicted as difficult during prediction. Similar to present study, Gupta et al. [12] reported that out of 141 cases found to be easy, a total of 135 (95.7%) were predicted as easy, out of 57 cases found to be difficult, a total of 42 (73.7%) and all the 12 cases found to be very difficult were predicted to be difficult. An evaluation of all these scoring systems showed that very difficult cases are often missed by these scoring systems. The proportion of missed cases (very difficult) was 4.5% in present study as compared to 4.4% in the study of Randhawa and Pujahari [8] and 5.7% in the study of Gupta et al. [12] Incidentally, in all the series none of the cases were predicted to be very difficult, thus raising the question mark over the criteria used for differentiation. In the present study association of presence of abdominal scar had been found to be a significant factor in predicting difficult outcome of surgery and was similar to findings of Agarwal et al (2015) and contrary to that of study by Acharya and Adhikari, 2012 [13] who did not find any association of difficulty level with presence of abdominal scar. In present study, we made an attempt to determine the performance of the scoring system with difficulty (merging difficult and very difficult) as the outcome it was found 77.8% sensitive and 87.9% specific. An overview of predictive efficacy of the scoring system used in present study and previous studies is as follows:
An Overview of Predictive Efficacy of Randhawa and Pujahari [8]
Scoring System for Prediction of Difficulty *

Sl. No.  Author (Year)    Sample Size   Sensitivity  Specificity

1.        Randhawa and        228          68.8%        96.3%
         Pujahari (2009)
              [8]

2.        Gupta et al.        210          78.3%        95.7%
          (2013) [12]

3.        Acharya and         114          71.4%        97.2%
         Adhikari (2012)
             [3] #

4.       Present study        150          77.8%        87.9%
             (2018)

Sl. No.    PPV      NPV     Accuracy

1.         88%     88.8%      88.6%

2.         90%      90%       90.0%

3.        93.8%    85.4%      87.7%

4.        74.5%    89.7%      84.7%

* After merging the final outcome of very difficult and
difficult

# Used a slightly modified scoring system with criteria for age
changed to >60 years and inclusion of TLC>10,000 as an indicator
of difficulty.


This shows that the scoring system lacked equivalent sensitivity and specificity. The role of predictive risk factors on final outcome had been assessed in the present study. We found that only previous history of hospitalization, BMI >27.5 kg/[m.sup.2], abdominal scar and pericholecystic collection were significant contributors in prediction of level of ease of surgery. Role of age, male gender, palpability and thickness GB wall was not found to be significant. BMI >27.5 kg/[m.sup.2] had been found to be associated with difficulty in surgery which had been supported by Hutchinson et al. (1994), [14] Nachnani & Supe (2005) [15] and Bouarfa et al. (2011). [16] Association of pericholecystic collection in prediction of difficulty in laparoscopic cholecystectomy has been found in the present study. Study done by Nidoniet al. 2015 [17] also supported this finding. The question now arises as to why do these predictive scoring systems fail? One of the obvious reasons is that difficulty during a surgical procedure is a multifactorial issue and to identify and assign integer values to different factors is quite difficult. Moreover, most of the times the difficulty is assessed in terms of patient characteristics, however, one must understand that the difficulty during the operative procedure is an interaction of patient, surgeon and the facilities available.

CONCLUSIONS

The overall diagnostic accuracy of preoperative predicting score was found to be 84.7%. In our set up previous history of hospitalization, BMI >27.5 kg/[m.sup.2], abdominal scar and pericholecystic collection were found to be significantly contributing in predicting the outcome of surgery. In prediction of very difficult cases, only hospital stay and abdominal scar were found to be significantly contributing in predicting the outcome of surgery. The present study validated the usefulness of Randhawa and Pujahari scoring system for assessment of difficulty during laparoscopic cholecystectomy procedure and found it to be comparable to other existing scoring systems. Despite this, a compromised efficacy of different scoring systems to miss difficulty remains a question to be answered. Further studies to identify more variables that could be included to improvise the scoring systems are recommended. Moreover, one must also understand that skill acquisition to tackle the difficulties is one of the most important parts of learning in medical field. The difficulties should be identified, solved and the technique should be improvised through new techniques, new instrumentations and acquisition of newer skills. It seems that different scoring systems tend to use relaxed criteria for assessment of difficulty that needs to be modified. Further studies for evolution of newer scoring systems are recommended is future.

REFERENCES

[1] Singh, Trikha B, Nain C, et al. Epidemiology of gallstone disease in Chandigarh: a community-based study. J Gastroenterol Hepatol 2001;16(5):560-3.

[2] Everhart JE, Khare M, Hill M, et al. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 1999;117(3):632-9.

[3] Litynski GS. Highilghts in the history of laparoscopy. Frankfurt, Germany: Barbara Bernert Verlag 1996: p. 165-8.

[4] Livingston EH, Rege RV. A nationwide study of conversion from laparoscopic to open cholecystectomy. Am J Surg 2004;188(3):205-11.

[5] Alponat A, Kum CK, Koh B, et al. Predictive factors for conversion of laparoscopic cholecystectmy. World J Surg 1997;21(6):629-33.

[6] Sanbria JR, Gallinger S, Croxford R, et al. Risk factors in elective laparoscopic cholecystectomy for conversion to open cholecystectomy. J Am Coll Surg 1994;179(6):696-704.

[7] Santambrogio R, Montorsi M, Bianchi P, et al. Technical difficulties and complications during laparoscopic cholecystectomy: predictive use of preoperative ultrasonography. World J Surg 1996;20(8):197-82.

[8] Randhawa JS, Pujahari AK. Preoperative prediction of difficult lap chole: a scoring method. Indian J Surg 2009;71(4):198-201.

[9] Yol S, Kartal A, Vatansev C, et al. Sex as a factor in conversion from laparoscopic cholecystectomy to open surgery. J SLS 2006;10(3):359-63.

[10] Lal P, Agarwal PN, Malik VK, et al. A difficult laparoscopic cholecystectomy that requires conversion to open procedure can be predicted by preoperative ultrasonography. JSLS 2002;6(1):59-63.

[11] Chand P, Singh R, Singh B, et al. Preoperative ultrasonography as a predictor of difficult laparoscopic cholecystectomy that requires conversion to open procedure. Nigerian Journal of Surgery: Official Publication of the Nigerian Surgical Research Society 2015;21(2):102-5.

[12] Gupta N, Ranjan G, Arora MP, et al. Validation of a scoring system to predict difficult laparoscopic cholecystectomy. International Journal of Surgery 2013;11(9):1002-6.

[13] Acharya A, Adhikari SK. Preoperative scoring system to predict difficulty laparoscopic cholecystectomy. Postgraduate Journal of NAMS 2012;12(1):45-50.

[14] Hutchinson CH, Traverso LW, Lee FT. Laparoscopic cholecystectomy. Do preoperative factors predict the need to convert to open? Surg Endosc 1994;8(8):875-80.

[15] Nachnani J, Supe A. Pre-operative prediction of difficult laparoscopic cholecystectomy using clinical and ultrasonography parameters. Indian J Gastroenterol 2005;24(1):16-8.

[16] Bouarfa L, Schneider A, Feussner H, et al. Prediction of intraoperative complexity from preoperative patient data for laparoscopic cholecystectomy. Artif Intell Med 2011;52(3):169-76.

[17] Nidoni R, Udachan TV, Sasnur P, et al. Prediction difficulty laparoscopic cholecystectomy based on clinicoradiological assessment. Journal of Clinical and Diagnostic Research 2015;9(12):PC09-PC12.

Anjani Tripathi (1), Nisar AhmadAnsari (2), Osman Musa (3), Mamta Dwivedi (4)

(1) Resident, Department of General Surgery, Era's Lucknow Medical College, Lucknow, Uttar Pradesh, India.

(2) Associate Professor, Department of General Surgery, Era's Lucknow Medical College, Lucknow, Uttar Pradesh, India.

(3) Professor, Department of General Surgery, Era's Lucknow Medical College, Lucknow, Uttar Pradesh, India.

(4) Senior Resident, Department of General Surgery, KGMU, Lucknow, Uttar Pradesh, India.

'Financial or Other Competing Interest': None.

Submission 15-05-2019, Peer Review 20-06-2019, Acceptance 26-06-2019, Published 08-07-2019.

Corresponding Author:

Dr. Nisar Ahmad Ansari, Era's Lucknow Medical College and Hospital, Sarfarazganj, Lucknow-226003, Uttar Pradesh, India.

E-mail: nisy1972nisy@yahoo.co.in

DOI: 10.14260/jemds/2019/475
Table 1--Randhawa & Pujahari (2009) Scoring Method

Scoring Factors        Score    Maximum Score

History

Age (Years)
<50                      0            1
>50                      1

Sex
Female                   0            1
Male                     1

Previous history
of hospitalization
No                       0            4
Yes                      4

Clinical
BMI

<25                      0
25.1-27.5                1            2
>27.5                    2

Abdominal scar
No                       0
Infraumbilical           1            2
Supraumbilical           2

Palpable gallbladder
No                 0     1
Yes                1

Sonography Findings

Wall thickness
Thin               0     2
Thick >4 mm        2

Pericholecystic collection
No                 0     1
Yes                1

Impacted stone
No                 0     1
Yes                1

Total Score: 15

Table 2- Randhawa and Pujahari (2009), Easy and
Difficult Scoring Factors.

Factors                 Easy    Difficult    Very Difficult

Time taken (min)        <60      60-120         >120
Bile/stone spillage      -         +              +
Injury to duct/artery    -     + duct only        +
Conversion to open       -         -              +
  cholecystectomy

Table 3. Age Distribution of Study Population

Age Group       Group I (n=99)   Group II (n=51)   Total (N=150)
                 No.      %       No.      %       No.      %

[less than or    29     29.29     10     19.61     39     26.00
  equal to]
  30 yrs.
31-40 yrs.       30     30.30     15     29.41     45     30.00
41-50 yrs.       20     20.20     20     39.22     40     26.67
51-60 yrs.       20     20.10      6     11.76     26     17.33

Age of patients ranged between 22-60 years in both the
groups. Difference in age of patients of above two groups
was not found to be statistically significant.

Table 4. Comparison of Gender

Gender         Group I (n=99)    Group II (n=51)   Total (N=150)

                No.       %       No.       %       No.      %

Female           60     60.61      30     58.82     90     60.00
Male             39     39.39      21     41.21     60     40.00
Male:Female       1:0.65             1:0.70           1:0.67
               [chi square]=0.045(df=1); p=0.833

Though proportion of males was higher among Group II
(41.21%) as compared to Group I (39.39%) but this difference
was not found to be statistically significant. All the
patients enrolled in the study presented with complaints of
abdominal pain.

Table 5. Comparison of Clinical Findings

                   Group I      Group II       Total
                   (n=99)          (n=51)      (N=150)

                  No.     %     No.     %     No.    %

Pallor             2     2.02    1     1.96   3     2.00
Abdominal scar     2     2.02    34   66.67   36    24.00
Tenderness         5     5.05    5     9.80   10    6.67
Palpable GB        10            7    13.73   17    11.33

                       Statistical
                       Significance
                  [chi square]       p

Pallor               0.001        0.980
Abdominal scar      77.122       <0.001
Tenderness           1.222        0.269
Palpable GB          0.440        0.507

Of these presenting symptoms, difference was found to be
statistically significant between the above two groups for
incidence of abdominal scar (p<0.001).

Table 6. Comparison of USG Findings

                   Group I      Group II       Total
                   (n=99)        (n=51)       (N=150)

                  No.     %     No.     %     No.     %

Calculi

Single, large     29    29.29   20    39.22   49    32.67
Small, multiple   70    70.71   31    60.78   101   67.33

GB Wall

Normal            85    85.86   34    66.67   119   79.33
Thickened         14    14.14   17    33.33   31    20.67

CBD

Dilated            3    3.03     0    0.00     3    2.00
Mild dilated      11    11.11    5    9.80    16    10.67
Normal            85    85.86   46    90.20   131   87.33

Pericholecystic collection

Present            7    7.07     9    17.65   16    10.67

IHBRD

Absent            93    93.94   48    94.11   141   94.00
Present            6    6.06     3    5.88     9    0.60

                  Statistical
                  Significance
                  [chi square]     p

Calculi

Single, large       1.507       0.220
Small, multiple

GB Wall

Normal               7.562       0.006
Thickened

CBD

Dilated
Mild dilated         1.672       0.433
Normal

Pericholecystic collection

Present              3.951       0.047

IHBRD

Absent               0.570       0.903
Present

There was no statistical difference between two groups on
ultrasonographic finding, lumber of calculi, GB wall
thickness, CBD dilatation, IHBRD and pericholecystic fluid
collection.

Table 7. Comparison of Biochemical/Haematological Variables
among Study Population

Variable      Group I (n=99)   Group II (n=51)   Student 't' test
               Mean      SD     Mean      SD       't'      'P'

Hb            10.75     2.05   10.78     1.98    -0.068   0.946
S. Bilirubin   0.59     0.32    0.66     0.34    -1.194   0.234
SGPT          49.15     5.08   50.08     3.92    -1.139   0.256
SGOT          34.76     4.11   34.04     3.85     1.036   0.302
PT            12.61     1.48   12.25     1.48     1.374   0.171

Above biochemical/haematological variables of Group I and
Group II were found to be comparable.

Table 8. Comparison of BMI and History of Previous
Hospitalization

                      Group I        Group II        Total
                      (n=99)         (n=51)          (N=150)

                     No.      %     No.     %        No.    %

BMI

<25                   14     14.14   2      3.92     16    16.67
25.1-27.5             32     32.32   11     21.57    43    28.67
>27.5                 53     53.53   38     74.51    91    60.67

Previous Hospitalization

No h/o                95     95.95   2      3.92     97    64.67
  hospitalization
H/o hospitalization   4      4.04    49     96.08    53    35.33

                     [chi square]   p

BMI

<25                    7.095       0.029
25.1-27.5
>27.5

Previous Hospitalization

No h/o                124.791      <0.001
  hospitalization
H/o hospitalization

Proportion of patients with BMI >27.5 kg/[m.sup.2] was
significantly higher in Group II (74.51%) as compared to
Group I (53.53%).

Table 9. Comparison of Intraoperative Events

                               Group I          Group II
                               (n=99)           (n=51)

                               No. 1    %       No. 1    %

Duration of surgery

<60 min                        87       87.87     8      15.69
60-120 min                     12       12.12     37     72.55
>120 min                       0        0.00      6      11.76

Adhesions

No adhesions                   82       82.83     11     21.57
Flimsy adhesion                15       15.15     34     66.67
Dense adhesions                2        2.02      6      11.76
Difficult Calot's dissection   9        9.09      8      15.69
Bile spillage                  7        7.07      12     23.53
Cystic artery injury           0        0.00      0      0.00
CBD Injury                     0        0.00      0      0.00

                              Total          [chi square]      p
                              (N=150)
                              No. 1   %

Duration of surgery

<60 min                        95     63.33     76.972      <0.001
60-120 min                     49     32.67
>120 min                       6      4.00

Adhesions

No adhesions                   93     62.00     53.712      <0.001
Flimsy adhesion                49     32.67
Dense adhesions                8      5.33
Difficult Calot's dissection   17     11.33     1.457       0.227
Bile spillage                  19     12.67     8.243       0.004
Cystic artery injury           0      0.00        --          --
CBD Injury                     0      0.00        --          --

In terms of difference in duration of surgery, adhesions,
bile spillage among two groups were found to be highly
significant statistically. Out of 150 cases enrolled in the
study only 6 (4.00%) of cases converted into open surgery.
Proportion of conversion to open surgery was higher among
Group II (11.76%) as compared to Group I (0.00%). Difference
in conversion rate to open surgery among patients of above
two groups was found 1 to be statistically significant.

Table 10. Comparison of Post-operative Events

          Group I       Group II       Total
          (n=99)        (n=51)         (N=150)

          No.     %     No.     %      No.     %

Drain Out

POD1      52    52.53   31    60.78    83    55.33
POD2      36    36.36   16    31.37    52    34.67
POD3       3    3.03     3     5.88     6    4.00
POD4       8    8.08     1     1.96     9    6.00

Suture Out

POD7      68    68.69   36    70.59    104   69.33
POD8      20    20.20   12    23.53    32    21.33
POD9       6    6.06     3     5.88     9    6.00
POD12      5    5.05     0     0.00     5    3.33

SSI

Absent    94    94.95   51    100.00   145   96.67
Present    5    5.05     0     0.00     5    3.33

             Statistical
             Significance

          [chi square]    'P'

Drain Out

POD1
POD2         3.443       0.328
POD3
POD4

Suture Out

POD7
POD8         2.770       0.428
POD9
POD12

SSI

Absent       2.665       0.103
Present

Difference in post-operative events i.e. Drain out, suture
out among cases of Group I and Group II was not found to be
statistically significant. Incidence of SSI was 3.33% (n=5)
among overall study population. SSI was observed in none of
the cases of Group II.

Table 11. Comparison of Histopathological Findings

HPE Finding     Group I (n=99)   Group II (n=51)   Total (N=150)

                 No.      %       No.       %       No.      %

Acute on          4      4.04      3      5.88       7     4.67
chronic
cholecystitis

Chronic          95     95.96     48      94.12     143    95.33
cholecystitis

                [chi square]=0.257(df=1); p=0.612

Histopathological findings of patients of above two groups
were not found statistically significant. Surgical outcome
was assessed on the basis of criteria proposed by Randhawa &
Pujahari (2009), excluding the criteria of injury to duct/
artery as none of the patients enrolled in the study had
experienced duct/artery injury.

Table 12. Comparison of Surgical Outcome

                Group I (n=99)   Group II (n=51)   Total (N=150)

                No.     %        No.     %         No.     %

Easy            87     87.87     10     19.61      97     64.67
Difficult       12     12.12     35     68.63      47     31.33
Very Difficult  0      0.00      6      11.76      6      4.00
                [chi square]=70.208(df=2); p<0.001

Despite low preoperative score of 0-5 (Group I) among 99
patients, the operating surgeon experienced difficulties
that were graded as difficult in 12 (12.12%) patients.
Similarly, for predictive score of 6-10 (Group II), 6
(11.76%) patients were graded as very difficult to operate,
10 (19.61%) were Easy to operate and rest 35 (68.63%)
patients were difficult to operate.

Table 13. Association of Easy and Difficult Outcome with
Risk Factors

Predictive Risk      Total     Easy (n=97)   Difficult
Factors              (n=144)                 (n=47)

                               No.     %     No.     %

Age >50 years          25      19    19.59    6    12.77
Male gender            58      34    35.05   24    51.06
Prev. history of       47      14    14.43   33    70.21
  Hospitalization

BMI (kg/[m.sup.2])

<25                    16      14    14.43    2    4.26
25.1-27.5              41      31    31.96   10    21.28
>27.5                  87      52    53.61   35    74.47
Abdominal scar         30       9    9.28    21    44.68

Palpable GB            17       8    8.25     9    19.15
Thick GB Wall          30      17    17.53   13    27.66
Pericholecystic        16       7    7.22     9    19.15
  collection

Predictive Risk      statistical
Factors              significance

                     [chi square]     p

Age >50 years           1.027       0.311
Male gender             3.375       0.066
Prev. history of        44.804      <0.001
  Hospitalization

BMI (kg/[m.sup.2])

<25                     6.501       0.039
25.1-27.5
>27.5
Abdominal scar          24.059

Palpable GB             3.614       0.057
Thick GB Wall           1.971       0.160
Pericholecystic         4.564       0.033
  collection

The table above shows the comparison between predictive risk
factors with the final outcome. Surgical outcome was Easy in
97 cases and difficult in 47 cases. Very difficult 6 cases
were excluded.

Table 14. Role of Risk Factors in Prediction of Very
Difficult Outcome

Predictive Risk        Total    Easy/Difficult    Very Difficult
Factors               (n=150)      (n=144)           (n=6)

                                  No.       %      No.     %

Age >50 years           26        25      17.36     1    16.67
Male gender             60        58      40.28     2    33.33
H/o Hospitalization     53        47      32.64     6    100.00

BMI (kg/[m.sup.2])

<25                     16        16      11.11     0     0.00
25.1-27.5               43        41      28.47     2    33.33
>27.5                   91        87      60.42     4    66.67
Abdominal scar          36        30      20.83     6    100.00
Palpable GB             17        17      11.81     0     0.00
Thick GB Wall           31        30      20.83     1    16.67
Pericholecystic         16        16      11.11     0     0.00
  collection

Predictive Risk       Statistical Significance
Factors

                      [chi square]      P

Age >50 years             0.002       0.965
Male gender               0.116       0.734
H/o Hospitalization      11.439       0.001

BMI (kg/[m.sup.2])

<25
25.1-27.5                 0.751       0.687
>27.5
Abdominal scar           15.689       <0.001
Palpable GB               0.056       0.813
Thick GB Wall             0.000       1.000
Pericholecystic           0.036       0.850
  collection

Out of 8 factors for prediction of Very difficult surgery,
only 2 i.e. hospital stay and Abdominal scar were found
significant contributing factors in predicting the outcome
of surgery.
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Article Details
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Title Annotation:Original Research Article
Author:Tripathi, Anjani; Ansari, Nisar Ahmad; Musa, Osman; Dwivedi, Mamta
Publication:Journal of Evolution of Medical and Dental Sciences
Geographic Code:9INDI
Date:Jul 8, 2019
Words:4904
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