Incremental value of laboratory and ultrasonographic markers for preoperative risk stratification of difficult laparoscopic cholecystectomy: a cross-validated cohort study.

Authors

Mustafa Kağan Başdoğan, Furkan Saydın, Cem Batuhan Ofluoğlu, Güney Özkaya, Fırat Mülküt

Published in

Frontiers in surgery. Volume 13. Pages 1982578. Epub Oct 13, 2026.

Abstract

Difficult laparoscopic cholecystectomy (LC) is associated with prolonged operative times, bile duct injuries, and increased postoperative morbidity. Reliable preoperative prediction could optimize surgical planning and patient consent, but the incremental value of adding laboratory and ultrasonographic (USG) data to routinely available clinical variables has rarely been quantified.
We conducted a retrospective cohort study of 648 consecutive patients undergoing LC for symptomatic gallstone disease, reported in accordance with the STROCSS 2021 guidelines and relevant TRIPOD recommendations. Difficult LC was defined a priori as a composite outcome (operative time ≥90 min, subtotal cholecystectomy, conversion to open surgery, fundus-first dissection, or additional ports), capturing distinct but overlapping dimensions of operative difficulty ranging from prolonged dissection to surgeon-driven bailout strategies. Independent predictors were identified by multivariable logistic regression, and discriminative performance of clinical, clinical + laboratory, and combined (clinical + laboratory + USG) models was assessed using fivefold cross-validated receiver operating characteristic analysis, with bootstrap-derived 95% confidence intervals (CIs), calibration, and bootstrap optimism correction.
Difficult LC occurred in 125 patients (19.3%). Impacted stone [adjusted odds ratio (OR) 2.86, 95% CI 1.66-4.92], previous cholecystitis attack (OR 1.87, 95% CI 1.15-3.02), gallbladder wall thickness (OR 1.74 per mm, 95% CI 1.36-2.21), body mass index (OR 1.05 per kg/m², 95% CI 1.00-1.11), and C-reactive protein (OR 1.02 per mg/L, 95% CI 1.01-1.04) were independent predictors (all p < 0.05). Cross-validated areas under the receiver operating characteristic curve (AUC) values increased progressively from 0.723 (95% CI 0.687-0.786) (clinical) to 0.734 (95% CI 0.700-0.796) (clinical + laboratory) to 0.768 (95% CI 0.742-0.831) (combined + USG), a pattern preserved after excluding operative time from the outcome definition [0.705 (95% CI 0.635-0.801) → 0.716 (95% CI 0.641-0.808) → 0.739 (95% CI 0.675-0.832)]. The paired-bootstrap increment in AUC was +0.011 (95% CI -0.007 to +0.040) for laboratory variables and +0.034 (95% CI +0.010 to +0.071) for ultrasonographic variables, indicating that the laboratory increment alone was not statistically distinguishable from zero, whereas the ultrasonographic increment was. The combined model showed acceptable calibration (slope 0.76, intercept 0.03, Brier score 0.134) and an optimism-corrected AUC of 0.783. Difficult LC was associated with more postoperative bile leaks, 30-day readmissions, and longer hospital stays (all p < 0.001).
Sequentially adding laboratory and then ultrasonographic data to a clinical-only model produced modest, calibration-confirmed improvements in cross-validated discrimination of difficult LC. This increment was statistically robust for ultrasonographic variables (95% CI excluding zero) but not for laboratory variables alone, indicating a modest incremental improvement in discrimination rather than a clinically transformative gain. External, prospective validation is warranted before routine clinical implementation.

PMID:
42947765
Bibliographic data and abstract were imported from PubMed on 28 Oct 2026.

Read full publication at:
Please sign in to see all details.

Stats

1-terrible, 9-excellent. How would you rate this publication? Sign in in to submit your rating.

Post a comment

You need to be signed in to post comments. You can sign in here.

Comments

There are no comments yet.