Factors Associated with Increased Parkland Grading Scale for Cholecystitis in Urgent Cholecystectomies

Author(s):
Cristina Masten; Abagail Raiter; Melissa Harry; Krista Wilhelmson; Kristin Colling

Background:

Gallbladder disease varies in degree of inflammation and can make cholecystectomy significantly more difficult. Preoperative prediction of difficult cases may help surgeons and patients set appropriate expectations.

Hypothesis:

Increased gallbladder inflammation (measured by Parkland Grading Scale for Cholecystitis (PGC)) will be associated with worse outcomes, preoperative patient factors and imaging will predict PGC.

Methods:

A prospective observational study of all urgent cholecystectomies (UC) performed between April 2021 and March 2022 at a level 1 trauma center was performed. Demographics, hospital data, operative data, pathology and PGC scores were evaluated. PGC scores were calculated by the operating surgeon at time of procedure and then scored by 2 independent surgeons, a surgical resident and medical student using intraoperative photos.

Results:

213 patients underwent UC during the study period. 0.5% of cases had a PGC of 1, 17% a PCG of 2, 47% a PGC of 3, 15% PGC of 4 and 21% PGC 5. The interrater reliability of PGC scores were excellent between the operating surgeon, two independent surgeons and different levels of trainees (intraclass correlation coefficient 0.97; 95% Confidence interval 0.96-0.98)). Severe inflammation (PGC score of 4/5) was significantly associated with older age, male sex, increased comorbidity scores and multiple admission laboratory results and vitals. (Table) Cholecystectomies performed with PGC scores of 4/5 had significantly longer operative times, increased rates of bile spillage and were more often converted to open. Postoperative hospital stays were longer in PGC 4/5 and complication rates higher. Wall thickening or 3 or more imaging findings noted in the table more likely in PGC scores of 4/5 but still were not sensitive predictors of intraoperative inflammation identified by elevated PGC scores.

Conclusions:

PGC scores were highly reliable between surgeons and trainees. Most patients undergoing UC in our cohort had PGC scores of 3 and above. PCG scores are a useful tool to describe the severity of inflammation intraoperatively and estimate expected difficulty of the case and increased risk of complications. Preoperative prediction of PGC score remains difficult, some lab values correlated with PGC score, but few imaging findings on preoperative imaging were significantly associated with PGC severity.