Radiology: Pre-op CT can offer guidance for gallbladder surgery

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Preoperative CT images may help surgeons choose the appropriate approach to dealing with acute calculous cholecystitis. CT imaging showing the absence of gallbladder wall enhancement or the presence of a gallstone in the gallbladder infundibulum has been associated with conversion from laparoscopic to open surgery, according to a study published online Feb. 13 in Radiology.

Acute calculous cholecystitis is a complication of gallstone disease responsible for up to 10 percent of cases of abdominal pain requiring surgery, explained Jean-Marc Regimbeau, MD, PhD, of Amiens University Medical Center in Amiens, France, and colleagues. Removal of the gallbladder with laparoscopic cholecystectomy is the standard of care, as it offers several advantages over open surgery, such as decreased postoperative pain, shorter hospitalization and a quicker return to normal activity.

“However, 2 to 30 percent of patients who undergo laparoscopic cholecystectomy for acute cholecystitis require conversion to open cholecystectomy to clarify anatomic features or to avoid or repair biliary or vascular injuries,” wrote the authors. “Given that conversion to open cholecystectomy is associated with longer procedure times, greater overall morbidity, surgical site morbidity, pulmonary infection, longer hospital stays and higher costs, the ability to accurately identify preoperative risk factors for conversion might improve the care of patients with acute cholecystitis.”

To establish whether CT findings were associated with conversion to open cholecystectomy, the researchers conducted a prospective analysis of 108 patients with acute calculous cholecystitis and for whom a preoperative CT study was available from 2008 to 2010. Cholecystectomy was always initiated laparoscopically and the two radiologists analyzing the CT studies were blinded to the patient’s conversion status.

Conversion occurred in 22 percent of cases and was associated with the absence of gallbladder wall enhancement on preoperative CT images (73 percent sensitivity). Multivariate analysis also revealed an association between acute cholecystitis-related conversion and the presence of a gallstone in the gallbladder infundibulum, which occurred in 78 percent of conversion patients.

Given the results, Regimbeau et al said the use of preoperative imaging to identify rick factors for conversion would provide several benefits for physicians, including:

  • More accurate and meaningful preoperative counseling;
  • Improved scheduling and efficiency of surgeries;
  • Better risk stratification; and
  • More appropriate assignment of support staff.

“Identification of preoperative imaging criteria associated with acute cholecystitis-related conversion may improve patient safety by minimizing time to conversion and helping to identify individuals in whom immediate open cholecystectomy is indicated,” wrote the authors.