Maria Vannucci1, Giovanni Guglielmo Laracca2, Paolo Mercantini3, Silvana Perretta4, Nicolas Padoy5, Bernard Dallemagne6, Pietro Mascagni7. 1. University of Tor Vergata, Rome, Italy; Institute for Research against Digestive Cancer (IRCAD), Strasbourg, France. 2. Institute for Research against Digestive Cancer (IRCAD), Strasbourg, France; Department of Medical Surgical Science and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Italy. 3. Department of Medical Surgical Science and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Italy. 4. Institute for Research against Digestive Cancer (IRCAD), Strasbourg, France; Institute of Image-Guided Surgery, Institut Hospitalo-Universitaire (IHU), Strasbourg, France; Department of Digestive and Endocrine Surgery, University of Strasbourg, France. 5. Institute of Image-Guided Surgery, Institut Hospitalo-Universitaire (IHU), Strasbourg, France; ICube, University of Strasbourg, CNRS, Illkirch, France. 6. Institute for Research against Digestive Cancer (IRCAD), Strasbourg, France; Department of Digestive and Endocrine Surgery, University of Strasbourg, France. 7. Institute of Image-Guided Surgery, Institut Hospitalo-Universitaire (IHU), Strasbourg, France; Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. Electronic address: p.mascagni@unistra.fr.
Abstract
BACKGROUND: Laparoscopic cholecystectomy operative difficulty is highly variable and influences outcomes. This systematic review analyzes the performance and clinical value of statistical models to preoperatively predict laparoscopic cholecystectomy operative difficulty. METHODS: PRISMA guidelines were followed. PubMed, Embase, and the Cochrane Library were searched until June 2020. Primary studies developing or validating preoperative models predicting laparoscopic cholecystectomy operative difficulty in cohorts of >100 patients were included. Studies not reporting performance metrics or enough information for clinical implementation were excluded. Data were extracted according to CHARMS, and study quality was assessed using the PROBAST tool. RESULTS: In total, 2,654 articles were identified, and 22 met eligibility criteria. Eighteen were model development, whereas 4 were validation studies. Eighteen studies were at high risk of bias. However, 11 studies showed low concern for applicability. Identified models predict 9 definitions of laparoscopic cholecystectomy operative difficulty, the most common being conversion to open surgery and operating time. The most validated models predict an intraoperative difficulty scale and procedures >90 minutes with an area under the curve of >0.70 and >0.76, respectively. Commonly used predictors include demographic variables such as age and gender (9/18 models) and ultrasound findings such as gallbladder wall thickness (11/18). Clinical implementation was never studied. CONCLUSION: There is a longstanding interest in estimating laparoscopic cholecystectomy operative difficulty. Models to preoperatively predict laparoscopic cholecystectomy operative difficulty have generally good performance and seem applicable. However, an unambiguous definition of operative difficulty, validations, and clinical studies are needed to implement patients' stratification in laparoscopic cholecystectomy.
BACKGROUND: Laparoscopic cholecystectomy operative difficulty is highly variable and influences outcomes. This systematic review analyzes the performance and clinical value of statistical models to preoperatively predict laparoscopic cholecystectomy operative difficulty. METHODS: PRISMA guidelines were followed. PubMed, Embase, and the Cochrane Library were searched until June 2020. Primary studies developing or validating preoperative models predicting laparoscopic cholecystectomy operative difficulty in cohorts of >100 patients were included. Studies not reporting performance metrics or enough information for clinical implementation were excluded. Data were extracted according to CHARMS, and study quality was assessed using the PROBAST tool. RESULTS: In total, 2,654 articles were identified, and 22 met eligibility criteria. Eighteen were model development, whereas 4 were validation studies. Eighteen studies were at high risk of bias. However, 11 studies showed low concern for applicability. Identified models predict 9 definitions of laparoscopic cholecystectomy operative difficulty, the most common being conversion to open surgery and operating time. The most validated models predict an intraoperative difficulty scale and procedures >90 minutes with an area under the curve of >0.70 and >0.76, respectively. Commonly used predictors include demographic variables such as age and gender (9/18 models) and ultrasound findings such as gallbladder wall thickness (11/18). Clinical implementation was never studied. CONCLUSION: There is a longstanding interest in estimating laparoscopic cholecystectomy operative difficulty. Models to preoperatively predict laparoscopic cholecystectomy operative difficulty have generally good performance and seem applicable. However, an unambiguous definition of operative difficulty, validations, and clinical studies are needed to implement patients' stratification in laparoscopic cholecystectomy.