title: Identification of risk factors for an unfavorable laparoscopic cholecystectomy course after endoscopic retrograde cholangiography in the treatment of choledocholithiasis.
abstract: BACKGROUND
  Laparoscopic cholecystectomy (LC) after an endoscopic retrograde cholangiography (ERC) has higher rates for complications and conversion caused by unpredictable adhesions. The risk factors for an adverse outcome of LC after an ERC were analyzed.
  
  
  METHODS
  Variables from patients treated by LC after ERC for cholelithiasis in two clinics from 1996 to 2003 were retrospectively stored in a database. Complications and conversions were recorded.
  
  
  RESULTS
  A total of 140 patients underwent LC after ERC (83 from clinic A and 57 from clinic B), 31% (44/140) of whom were men. Peri- or postoperative complications occurred for 28 patients (20%). For 19 patients (14%), a conversion was necessary. Significant variables associated with complications and conversions were an elevated level of C-reactive protein (CRP) at the time of LC (odds ratio [OR], 10.2; 95% confidence interval [CI], 1.1-91, P = 0.037 for both) and severe adhesions during laparoscopy (OR, 3.6; 95% CI, 1.5-8.6; P = 0.003 and OR, 5.2; 95% CI, 1.9-14.4; P = 0.002, respectively). Male gender (OR, 2.8; 95% CI, 1.1-7.6; P = 0.037) and serum bilirubin level at the time of ERC (OR, 3.7; 95% CI, 1.24-11; P = 0.014) were associated with conversion only. Time after ERC (LC within 1 week vs. >1 week or < or = 2 weeks vs. 2-6 weeks vs. >6 weeks or < or = 6 weeks vs. >6 weeks) was not associated with complications or conversion. Multivariate regression analysis showed a pre-LC CRP exceeding 6 to be predictive of complications (OR, 10.5; 95% CI, 1.1-95; P = 0.040) and conversion (OR, 10.6; 95% CI, 1.1-99; P = 0.034).
  
  
  CONCLUSIONS
  Male gender, bilirubin levels during ERC, severe adhesions during LC, and pre-LC CRP levels were associated with an adverse outcome for an LC after endoscopic cholangiography. The time between LC and ERC failed to be a significant risk factor in this larger series.
authors.affiliation: Department of Surgery, Onze Lieve Vrouwe Gasthuis, Postbus 95500, 1090, Amsterdam, HM, The Netherlands. donkpas@wanadoo.nl
authors.forename: S C
authors.initials: SC
authors.lastname: Donkervoort
authors.forename: O
authors.initials: O
authors.lastname: van Ruler
authors.forename: L M
authors.initials: LM
authors.lastname: Dijksman
authors.forename: A A
authors.initials: AA
authors.lastname: van Geloven
authors.forename: E G
authors.initials: EG
authors.lastname: Pierik
mesh_terms: D001663:Bilirubin / Q000097:blood; D002097:C-Reactive Protein / Q000378:metabolism; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods*; D017081:Cholecystectomy, Laparoscopic / Q000379:methods*; D042883:Choledocholithiasis / Q000601:surgery*; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D012307:Risk Factors; D018709:Statistics, Nonparametric; D000267:Tissue Adhesions / Q000453:epidemiology; D016896:Treatment Outcome
chemical_list: D002097:C-Reactive Protein; D001663:Bilirubin
references.citation: Surg Endosc. 2000 Aug;14(8):755-60
references.pmid: 10954824
references.citation: JSLS. 2006 Jul-Sep;10(3):359-63
references.pmid: 17212896
references.citation: Gastroenterology. 1996 Mar;110(3):894-9
references.pmid: 8608900
references.citation: Surg Endosc. 2005 Jul;19(7):996-1001
references.pmid: 15920689
references.citation: Ann Surg. 1998 Feb;227(2):195-200
references.pmid: 9488516
references.citation: World J Surg. 1997 Jul-Aug;21(6):629-33
references.pmid: 9230661
references.citation: World J Surg. 2001 Oct;25(10):1270-2
references.pmid: 11596888
references.citation: Lancet. 2002 Sep 7;360(9335):761-5
references.pmid: 12241833
references.citation: World J Surg. 2003 Feb;27(2):180-6
references.pmid: 12616433
references.citation: J Hepatobiliary Pancreat Surg. 2002;9(1):98-104
references.pmid: 12021903
references.citation: J Laparoendosc Adv Surg Tech A. 2005 Aug;15(4):379-82
references.pmid: 16108740
references.citation: Ann Surg. 1989 Feb;209(2):157-61
references.pmid: 2916860
references.citation: Br J Surg. 2005 Apr;92(4):463-6
references.pmid: 15672361
references.citation: Surg Endosc. 1996 Jul;10(7):742-5
references.pmid: 8662431
references.citation: J Gastrointest Surg. 2006 Feb;10(2):292-6
references.pmid: 16455464
references.citation: J Clin Gastroenterol. 1998 Dec;27(4):296-305
references.pmid: 9855257
references.citation: Am J Surg. 2001 Jun;181(6):520-5
references.pmid: 11513777
references.citation: Surg Endosc. 1995 Jan;9(1):25-8
references.pmid: 7725209
references.citation: Arch Surg. 1996 Jan;131(1):98-101
references.pmid: 8546587
references.citation: Hepatogastroenterology. 1996 Jan-Feb;43(7):203-6
references.pmid: 8682464
references.citation: Surg Endosc. 2001 Jul;15(7):700-5
references.pmid: 11591971
references.citation: Surg Laparosc Endosc. 1998 Jun;8(3):200-7
references.pmid: 9649044