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Evaluation of the CT Scan as the First Examination for the Diagnosis and Therapeutic Strategy for Acute Cholecystitis

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Abstract

Background

The CT scan has supplanted the abdominal ultrasound for emergency examinations. A comparison of CT scan and ultrasound performance for the diagnosis and management of acute cholecystitis in acute care was proposed. The hypothesis is that the CT scan may be sufficient for the diagnosis of acute cholecystitis, which would allow faster progress to surgery.

Methods

The retrospective study of consecutive patients operated for acute cholecystitis or gallbladder distension with pre-operative imaging within 48 h in one centre.

Results

Between 2015 and 2017, a total of 341 cholecystectomies were performed in our centre. The analysis involved 120 patients. Ultrasound had better sensitivity than the CT scan, respectively, 79.4% [70.5–86.6] and 52.3% [42.5–62.1], but less specificity, with 61.5% [31.6–86.1] and 92.3% [64.0–99.8], respectively. However, there was a significant difference in favour of the CT scan for the diagnosis of complicated cholecystitis (p 0.004). The positive likelihood ratio of complicated cholecystitis is better at CT scan (7.8) [2.7–23.1] than in ultrasound (1.0) [0.1–9.7]. CT scan and ultrasound are equivalent for the diagnosis of acute cholecystitis, but CT scan is more efficient for the diagnosis of complicated cases (Youden index J 0.3 vs 0.001).

Conclusion

It is possible to place the surgical indication of cholecystectomy on the only data of the CT scan. We propose a decision-making algorithm that uses the CT scan to make the diagnosis and decide on emergency treatment for complicated cases or that allows us to propose a delayed surgery for simple cholecystitis.

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Correspondence to S. Martellotto or M. Pocard.

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Appendices

Appendix 1

Ckecklist STARD

Section and topic No Item Reported on page #
Title or abstract    
  1 Identification as a study of diagnostic accuracy using at least one measure of accuracy (such as sensitivity, specificity, predictive values, or AUC) 3
Abstract    
  2 Structured summary of study design, methods, results, and conclusions (for specific guidance, see STARD for abstracts) 3
Introduction    
  3 Scientific and clinical background, including the intended use and clinical role of the index test 4
  4 Study objectives and hypotheses  
Methods    
Study design 5 Whether data collection was planned before the index test and reference standard were performed (prospective study) or after (retrospective study) 5
Participants 6 Eligibility criteria 5
  7 On what basis potentially eligible participants were identified (such as symptoms, results from previous tests, inclusion in registry) 5
  8 Where and when potentially eligible participants were identified (setting, location and dates) 5
  9 Whether participants formed a consecutive, random or convenience series 5
Test methods 10a Index test, in sufficient detail to allow replication 5
  10b Reference standard, in sufficient detail to allow replication 5
  11 Rationale for choosing the reference standard (if alternatives exist) 5
  12a Definition of and rationale for test positivity cut-offs or result categories of the index test, distinguishing pre-specified from exploratory 5
  12b Definition of and rationale for test positivity cut-offs or result categories of the reference standard, distinguishing pre-specified from exploratory 5
  13a Whether clinical information and reference standard results were available to the performers/readers of the index test 5
  13b Whether clinical information and index test results were available to the assessors of the reference standard 5
Analysis 14 Methods for estimating or comparing measures of diagnostic accuracy 5
  15 How indeterminate index test or reference standard results were handled 5
  16 How missing data on the index test and reference standard were handled 5
  17 Any analyses of variability in diagnostic accuracy, distinguishing pre-specified from exploratory 5
  18 Intended sample size and how it was determined 5
Results    
Participants 19 Flow of participants, using a diagram 14
  20 Baseline demographic and clinical characteristics of participants 15
  21a Distribution of severity of disease in those with the target condition 14
  21b Distribution of alternative diagnoses in those without the target condition 14
  22 Time interval and any clinical interventions between index test and reference standard 15
Test results 23 Cross tabulation of the index test results (or their distribution) by the results of the reference standard 16
  24 Estimates of diagnostic accuracy and their precision (such as 95% confidence intervals) 16
  25 Any adverse events from performing the index test or the reference standard  
Discussion    
  26 Study limitations, including sources of potential bias, statistical uncertainty, and generalisability 8
  27 Implications for practice, including the intended use and clinical role of the index test 10, 18
Other information    
  28 Registration number and name of registry  
  29 Where the full study protocol can be accessed  
  30 Sources of funding and other support; role of funders 1

Appendix 2: Detailed results of each review strategy

Uncomplicated cholecystitis diagnosis—ultrasound alone

  Illness
+ Total
Examination
+ 40 3 43
3 4 7
Total 43 7 50

Uncomplicated cholecystitis diagnosis—CT scan alone

  Illness
+ Total
Examination
+ 13 1 14
0 1 1
Total 13 2 15

Uncomplicated cholecystitis diagnosis—ultrasound and then CT scan

  Illness
+ Total
Examination
+ 18 0 18
1 1 2
Total 19 1 20

Uncomplicated cholecystitis diagnosis—CT scan and ultrasound

  Illness
+ Total
Examination
+ 30 2 32
2 1 3
Total 32 3 35

Complicated cholecystitis diagnosis—ultrasound alone

  Illness
+ Total
Examination
+ 1 2 3
8 39 47
Total 9 41 50

Complicated cholecystitis diagnosis—CT scan alone

  Illness
+ Total
Examination
+ 2 1 3
6 6 12
Total 8 7 15

Complicated cholecystitis diagnosis—ultrasound then CT scan

  Illness
+ Total
Examination
+ 4 1 5
1 14 15
Total 5 15 20

Complicated cholecystitis diagnosis—CT scan and ultrasound

  Illness
+ Total
Examination
+ 3 2 5
4 26 30
Total 7 28 35

Appendix 3: Correction and diagnosis match, contribution of the second examination

Ultrasound and then scan

Scanner and ultrasound

Blue: good diagnosis, agreement between the 2 examinations

Yellow: bad correction of the second exam

Orange: misdiagnosis, both examinations are wrong

Green: the diagnosis was corrected in a good way with the second examination

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Martellotto, S., Dohan, A. & Pocard, M. Evaluation of the CT Scan as the First Examination for the Diagnosis and Therapeutic Strategy for Acute Cholecystitis. World J Surg (2020). https://doi.org/10.1007/s00268-020-05404-6

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