JOURNAL CLUB PRESENTATION - CRP AS PREDICTOR FOR DIFFICULT CHOLECYSTECTOMY

Journal Club Presentation on CRP as a predictor for difficult cholecystectomy

1. C-reactive protein level as a predictor of difficult emergency laparoscopic cholecystectomy Presenter: KIRENGO MBCHB MBA MSC MRCS YGC GEN SURG JOURNAL CLUB

2. ARTICLE INFORMATION: 11 Citations No conflict of interest Journal Publication: BJS Open Paper accepted 9 May 2019 Published online 2 July 2019

3. JOURNAL INTRO BJS open ISSN-24749842 Year started 2017 Location: United Kingdom Impact factor- 3.1 in 2023 H-index- 24 BJS impact factor- 9.6

4. LEVEL OF EVIDENCE

5. STUDY BACKGROUND The Japanese Society of HPB Surgery developed Tokyo Guidelines (2007) to diagnose & grade acute cholecystitis severity Acute cholecystitis recognized to cause difficult laparoscopic treatment CRP concentration is a good predictor of acute cholecystitis Traditional management of acute cholecystitis was based on conservative treatment with antibiotics Immediate laparoscopic cholecystectomy those assessed as fit for general anaesthesia and surgery Limited research focused on C‐reactive protein (CRP) as a marker of difficult laparoscopic cholecystectomy

6. OBJECTIVES OF STUDY Evaluate the association between preoperative CRP level and Operative difficulty of emergency laparoscopic cholecystectomy in acute biliary admissions

7. STUDY PICO QUESTION Population: Patients undergoing laparoscopic cholecystectomy Intervention: Laparoscopic cholecystectomy Comparison: CRP levels Outcome: Surgical Difficulty

8. STUDY DESIGN Patients with an emergency admission for biliary disease treated between 2012 and 2017 with a documented preoperative CRP level University Hospital Monklands intraoperative difficulty grade based on Nassar scale Exclusion criteria: elective admission and patient with concurrent non‐biliary cause of raised CRP concentration (chest infection)

9. Flow diagram of patient inclusion in the study

10. Statistical Analysis Continuous variables are presented as mean( s.d. ) and median (range) values and compared with Student's t test Categorical variables are presented as frequencies with percentages and compared using the χ2 test Logistic regression analysis was used to assess predictors of high operative difficulty (grade III or above) versus low difficulty (grades I and II) Receiver operating characteristic (ROC) curves were used to determine the accuracy of preoperative peak CRP levels P < 0·050 was considered statistically significant

11. Nassar Scale:

12. RESULTS: Demographics

13. Findings 567 patients were treated by a consultant surgeon 136 (16·9%) by a trainee assisted by the consultant Remaining 101 patients (12·6%), trainees performed a few surgical steps with tutorship Duration of surgical procedure ranged from 22 to 345 min There were no conversions to open surgery complication rate 3·9% and the 30‐day readmission rate 3% 1 mortality

14. Nassar scale grade and timing of surgery No association was found between stratification of Nassar scale grades and the timing of laparoscopic cholecystectomy patients with a previous admission for biliary disease had increased operative difficulty than those with a first admission

15. Nassar scale grade and peak C‐reactive protein levels A statistically significant association was found between the proportion of patients with a CRP level greater than or equal to 6 mg/l and Nassar scale grades (P < 0·001) Logistic regression analysis found preoperative peak CRP concentration to be predictive of Nassar grade I–III versus grade IV–V operative difficulty

16. ROC curve analysis:

17. STUDY DISCUSSION Several studies found an association between increased CRP levels and difficult laparoscopic cholecystectomy An increased CRP level can be a predictor of a high operative difficulty grade, Of use in planning surgical management Selecting patients appropriate for surgical training

18. STUDY LIMITATIONS Logistical difficulties Lack of early access to emergency theatre Lack of a dedicated biliary surgical team Challenging large‐scale adoption of this protocol

19. STUDY CONCLUSION The early identification of potentially complex operations (Nassar grade IV–V) By a simple and reliable serological marker Helpful in planning management and resources.

20. CRITICAL APPRAISAL Did the study address a clearly focused issue? Did the authors use an appropriate method to answer their question? Were the cases selected in an acceptable way? Was the exposure accurately measured to minimise bias? Was the outcome accurately measured to minimise bias? Have the authors identified all important confounding factors? Do you believe the study results? Can the results be applied locally?

21. RECOMMENDATIONS: CRP level useful in predicting difficulty of lap chole Interpret in context with other factors e.g. 1 st episode vs recurrence

22. Reference: Ng HJ, Ahmed Z, Khan KS, Katbeh T, Nassar AHM. C-reactive protein level as a predictor of difficult emergency laparoscopic cholecystectomy. BJS Open. 2019 Jul 2;3(5):641-645. doi : 10.1002/bjs5.50189. PMID: 31592082; PMCID: PMC6773624

23. THANK YOU ANY QUESTIONS