Analysis of bailout procedure in laparoscopic cholecystectomy for acute cholecystitis

Background: The Tokyo Guidelines 2018 recommend a bailout procedure consisting of fundus-first cholecystectomy, subtotal cholecystectomy, or open conversion to prevent serious complications in cases of difficult laparoscopic cholecystectomy (LC). Methods: : The hospital records of patients with acute cholecystitis who underwent LC from October 2014 to April 2019 were retrospectively analyzed. The clinical data were compared between the standard and bailout groups. A subgroup analysis was performed to compare the fundus-first and subtotal cholecystectomy techniques versus open conversion. Results: : In total, 160 of 416 Japanese patients who underwent LC were diagnosed with acute cholecystitis. Standard LC was performed in 125 (78%) patients, and a bailout procedure was performed in 35 (22%). The duration from onset to surgery was significantly longer (P = 0.04) and the C-reactive protein (CRP) concentration was significantly higher (P = 0.001) in the bailout than standard group. The surgical outcomes were worse in the bailout group. In the multivariate analysis, a high CRP concentration at diagnosis was an independent predictor of bailout (P = 0.004). In the subgroup analysis, the open group had a significantly longer duration from onset to surgery (P = 0.04) and a significantly higher incidence of preoperative drainage (P = 0.002). With respect to surgical outcomes, the open group had significantly greater blood loss (P = 0.02) and longer hospital stays (P = 0.002). Conclusion: A high CRP concentration is a risk factor for a bailout procedure. Early LC should be performed for patients with acute cholecystitis and a high CRP concentration.