Mattia Portinari1,2, Michele Scagliarini3, Giorgia Valpiani4, Simona Bianconcini3, Dario Andreotti5,6, Rocco Stano5,7, Paolo Carcoforo5,6, Savino Occhionorelli5,6,7. 1. Department of Surgery, S. Anna University Hospital of Ferrara, Via Aldo Moro, 8 | Stanza 2 34 39 (1C2) (Cona), 44124, Ferrara, Italy. mattia.portinari@unife.it. 2. Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy. mattia.portinari@unife.it. 3. Department of Statistics, University of Bologna, Bologna, Italy. 4. Research Innovation Office, S. Anna University Hospital of Ferrara, Ferrara, Italy. 5. Department of Surgery, S. Anna University Hospital of Ferrara, Via Aldo Moro, 8 | Stanza 2 34 39 (1C2) (Cona), 44124, Ferrara, Italy. 6. Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy. 7. Acute Care Surgery Service, S. Anna University Hospital of Ferrara, Ferrara, Italy.
Abstract
BACKGROUND: Some authors have proposed different predictive factors of severe acute cholecystitis, but generally, the results of risk analyses are expressed as odds ratios, which makes it difficult to apply in the clinical practice of the acute care surgeon. The severe form of acute cholecystitis should include both gangrenous and phlegmonous cholecystitis, due to their severe clinical course, and cholecystectomy should not be delayed. The aim of this study was to create a nomogram to obtain a graphical tool to compute the probability of having a severe acute cholecystitis. METHODS: This is a retrospective study on 393 patients who underwent emergency cholecystectomy between January 2010 and December 2015 at the Acute Care Surgery Service of the S. Anna University Hospital of Ferrara, Italy. Patients were classified as having a non-severe acute cholecystitis or a severe acute cholecystitis (i.e., gangrenous and phlegmonous) based on the final pathology report. The baseline characteristics, pre-operative signs, and abdominal ultrasound (US) findings were assessed with a stepwise multivariate logistic regression analysis to predict the risk of severe acute cholecystitis, and a nomogram was created. RESULTS: Age as a continuous variable, WBC count ≥ 12.4 × 103/μl, CRP ≥9.9 mg/dl, and presence of US thickening of the gallbladder wall were significantly associated with severe acute cholecystitis at final pathology report. A significant interaction between the effect of age and CRP was found. Four risk classes were identified based on the nomogram total points. CONCLUSIONS: Patients with a nomogram total point ≥ 74 should be considered at high risk of severe acute cholecystitis (at 74 total point, sensitivity = 78.5%; specificity = 78.2%; accuracy = 78.3%) and this finding could be useful for surgical planning once confirmed in a prospective study comparing the risk score stratification and clinical outcomes.
BACKGROUND: Some authors have proposed different predictive factors of severe acute cholecystitis, but generally, the results of risk analyses are expressed as odds ratios, which makes it difficult to apply in the clinical practice of the acute care surgeon. The severe form of acute cholecystitis should include both gangrenous and phlegmonous cholecystitis, due to their severe clinical course, and cholecystectomy should not be delayed. The aim of this study was to create a nomogram to obtain a graphical tool to compute the probability of having a severe acute cholecystitis. METHODS: This is a retrospective study on 393 patients who underwent emergency cholecystectomy between January 2010 and December 2015 at the Acute Care Surgery Service of the S. Anna University Hospital of Ferrara, Italy. Patients were classified as having a non-severe acute cholecystitis or a severe acute cholecystitis (i.e., gangrenous and phlegmonous) based on the final pathology report. The baseline characteristics, pre-operative signs, and abdominal ultrasound (US) findings were assessed with a stepwise multivariate logistic regression analysis to predict the risk of severe acute cholecystitis, and a nomogram was created. RESULTS: Age as a continuous variable, WBC count ≥ 12.4 × 103/μl, CRP ≥9.9 mg/dl, and presence of US thickening of the gallbladder wall were significantly associated with severe acute cholecystitis at final pathology report. A significant interaction between the effect of age and CRP was found. Four risk classes were identified based on the nomogram total points. CONCLUSIONS:Patients with a nomogram total point ≥ 74 should be considered at high risk of severe acute cholecystitis (at 74 total point, sensitivity = 78.5%; specificity = 78.2%; accuracy = 78.3%) and this finding could be useful for surgical planning once confirmed in a prospective study comparing the risk score stratification and clinical outcomes.
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