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C-reactive Protein Is the Best Biomarker to Predict Advanced Acute Cholecystitis and Conversion to Open Surgery. A Prospective Cohort Study of 556 Cases

  • Mahdi BouassidaEmail author
  • Slim Zribi
  • Bassem Krimi
  • Ghazi Laamiri
  • Bassem Mroua
  • Helmi Slama
  • Mohamed Mongi Mighri
  • Mohamed M’saddak Azzouz
  • Lamine Hamzaoui
  • Hassen Touinsi
Original Article
  • 35 Downloads

Abstract

Background

White blood cell levels (WBC) is the only biologic determinant criterion of the severity assessment of acute cholecystitis (AC) in the revised Tokyo Guidelines 2018 (TG18). The aims of this study were to evaluate the discriminative powers of common inflammatory markers (neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP)) compared with WBC for the severity of AC, and the risk for conversion to open surgery and to determine their diagnostic cutoff levels.

Methods

This was a prospective cohort study. Over 3 years, 556 patients underwent laparoscopic cholecystectomy for AC. Patients were classified into two groups: 139 cases of advanced acute cholecystitis (AAC) (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis), and 417 cases of non-advanced acute cholecystitis (NAAC). Multiple logistic regression and receiver-operating characteristic curve analysis were employed to explore which variables (WBC, CRP, and neutrophil-to-lymphocyte ratio (NLR)) were statistically significant in predicting AAC and conversion to open surgery.

Results

On multivariable logistic regression analysis, male gender (OR = 0.4; p = 0.05), diabetes mellitus (OR = 7.8; p = 0.005), 3–4 ASA score (OR = 5.34; p = 0.037), body temperature (OR = 2.65; p = 0.014), and CRP (OR = 1.01; p = 0.0001) were associated independently with AAC. The value of the area under the curve (AUC) of the CRP (0.75) was higher than that of WBC (0.67) and NLR (0.62) for diagnosing AAC. CRP was the only predictive factor of conversion in multivariate analysis (OR = 1.008 [1.003–1.013]. Comparing areas under the receiver operating characteristic curves, it was the CRP that had the highest discriminative power in terms of conversion.

Conclusion

CRP is the best inflammatory marker predictive of AAC and of conversion to open surgery. We think that our results would support a multicenter—international study to confirm the findings, and if supported, CRP should be considered as a severity criterion of acute cholecystitis in the next revised version of the Guidelines of Tokyo.

Keywords

Acute cholecystitis Advanced acute cholecystitis Conversion CRP White blood cell levels Neutrophil-to-lymphocyte ratio 

Notes

Authors’ Contribution

Mahdi Bouassida, Slim Zribi, Bassem Krimi, and Ghazi Laamiri did the conception and the design of the work

Bassem Mroua, Helmi Slama, Mohamed Mongi Mighri, and Lamine Hamzaoui did the acquisition and the analysis of the data

Hassen Touinsi and Mohamed M’saddak Azzouz revised the work critically

Compliance with Ethical Standards

Conflict of Interest

Drs Mahdi Bouassida, Slim Zribi, Bassem Krimi, Ghazi Laamiri, Bassem Mroua, Helmi Slama, Mohamed Mongi Mighri, Mohamed M’saddak Azzouz, Lamine Hamzaoui and Hassen Touinsi have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Yokoe M, Hata J, Takada T, et al (2018) Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobilary Pancreat Sci 25:41-54CrossRefGoogle Scholar
  2. 2.
    Bouassida M, Charrada H, Feidi B, et al (2016) Could the Tokyo guidelines on the management of acute cholecystitis be adopted in developing countries? Experience of one center. Surg Today 46(5) :557-60CrossRefGoogle Scholar
  3. 3.
    Cole DS, Watts A, Scott-Coombes D, et al (2008) Clinical utility of perioperative C-reactive protein testing in general surgery. Ann R Coll Surg Engl 90:317-21CrossRefGoogle Scholar
  4. 4.
    Sato N, Kinoshita A, Imai N, et al (2018) Inflammation based prognostic scores predict disease severity in patients with acute cholecystitis. Eur J Gastroenterol Hepatol 30(4):484-9CrossRefGoogle Scholar
  5. 5.
    Nikfarjam M, Niumsawatt V, Sethu A, et al (2011) Outcomes of contemporary management of gangrenous and nongangrenous acute cholecystitis. HPB (Oxford) 13:551-8CrossRefGoogle Scholar
  6. 6.
    Mok KW, Reddy R, Wood F, et al (2014) Is C-reactive protein a useful adjunct in selecting patients for emergency cholecystectomy by predicting severe/gangrenous cholecystitis? Int J Surg 12:649-53CrossRefGoogle Scholar
  7. 7.
    Juvonen T, Kiviniemi H, Niemela O, et al (1992) Diagnostic accuracy of ultrasonography and C reactive protein concentration in acute cholecystitis: a prospective clinical study. Eur J Surg 158:365-9PubMedGoogle Scholar
  8. 8.
    Gurbulak EK, Gurbulak B, Akgun IE, et al (2015) Prediction of the grade of acute cholecystitis by plasma level of C-reactive protein. Iran Red Crescent Med J 17:e28091PubMedPubMedCentralGoogle Scholar
  9. 9.
    Beliaev AM, Marshall RJ, Booth M (2015) C-reactive protein has a better discriminative power than white cell count in the diagnosis of acute cholecystitis. J Surg Res 198:66-72CrossRefGoogle Scholar
  10. 10.
    Beliaev AM, Angelo N, Booth M, et al (2017) Evaluation of neutrophil-to lymphocyte ratio as a potential biomarker for acute cholecystitis. J Surg Res 209:93-101CrossRefGoogle Scholar
  11. 11.
    Bouassida M, Hamzaoui L, Mroua B, et al (2016) Should acute cholecystitis be operated in the 24 h following symptom onset? A retrospective cohort study. Int J Surg 25 :88-90CrossRefGoogle Scholar
  12. 12.
    Bouassida M, Chtourou MF, Charrada H, et al (2017) The severity grading of acute cholecystitis following the Tokyo Guidelines is the most powerful predictive factor for conversion from laparoscopic cholecystectomy to open cholecystectomy. J Visc Surg 154:239-43CrossRefGoogle Scholar
  13. 13.
    Hussain A (2011) Difficult laparoscopic cholecystectomy: Current evidence and strategies of management. Surg Laparosc Endosc Percutan Tech 21:211-7CrossRefGoogle Scholar
  14. 14.
    Mok KW, Goh YL, Howell LE, et al (2016) Is C-reactive protein the single most useful predictor of difficult laparoscopic cholecystectomy or its conversion? A pilot study. J Minim Access Surg 12:26-32CrossRefGoogle Scholar
  15. 15.
    Wevers KP, van Westreenen HL, Patijn GA (2013) Laparoscopic cholecystectomy in acute cholecystitis: C-reactive protein level combined with age predicts conversion. Surg Laparosc Endosc Percutan Tech 23:163-6CrossRefGoogle Scholar
  16. 16.
    Díaz-Flores A, Cárdenas-Lailson E, Cuendis-Velázquez A et al (2017) C-Reactive Protein as a predictor of difficult laparoscopic cholecystectomy in patients with acute calculous cholecystitis: a multivariate analysis. J Laparoendosc Adv Surg Tech A 27:1263-8CrossRefGoogle Scholar
  17. 17.
    Hayama S, Ohtaka K, Shoji Y, et al (2016) Risk factors for difficult laparoscopic cholecystectomy in acute cholecystitis. JSLS 20:1–8CrossRefGoogle Scholar
  18. 18.
    Patil S, Inamdar PS (2016) Evaluation of preoperative predictive factors that determine difficult laparoscopic cholecystectomy. Int J Surg 3:825-30CrossRefGoogle Scholar
  19. 19.
    Bulbuller N, Ilhan YS, Baktir A, et al (2006) Implementation of a scoring system for assessing difficult cholecystectomies in a single center. Surg Today 36:37-40.CrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  • Mahdi Bouassida
    • 1
    • 2
    Email author
  • Slim Zribi
    • 1
    • 2
  • Bassem Krimi
    • 1
    • 2
  • Ghazi Laamiri
    • 1
    • 2
  • Bassem Mroua
    • 1
    • 2
  • Helmi Slama
    • 1
    • 2
  • Mohamed Mongi Mighri
    • 1
    • 2
  • Mohamed M’saddak Azzouz
    • 2
    • 3
  • Lamine Hamzaoui
    • 2
    • 3
  • Hassen Touinsi
    • 1
    • 2
  1. 1.Depatment of SurgeryMohamed Tahar Maamouri HospitalNabeulTunisia
  2. 2.Faculty of Medicine of TunisTunis El Manar UniversityTunisTunisia
  3. 3.Depatment of GastroenterologyMohamed Tahar Maamouri HospitalNabeulTunisia

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