TPT 8.15 A Simple End-Of-Operation Risk Score for Clavien–Dindo Grade III–V Complications after Intended Laparoscopic Cholecystectomy: A Multicentre NHS Cohort Study
Aug 2026· British Journal of Surgery· Vol 113· 0 citations
TL;DR
A simple end-of-case score using deprivation and two intra-operative escalation signals identifies patients at higher risk of major (CD III–V) complications after LC.
Abstract
Major complications after laparoscopic cholecystectomy (LC) are uncommon but drive morbidity and resource use. We developed a pragmatic risk score using routinely available variables to support end-of-case escalation and postoperative planning.
Retrospective multicentre cohort of consecutive cholecystectomies across three acute hospitals (NHS Lanarkshire; 4 Jan 2023–3 Nov 2024). Patients with intended LC (including conversions) were included. Outcome was Clavien–Dindo (CD) III–V within 30 days. Prespecified predictors were modelled with parsimonious logistic regression with bootstrap internal validation; coefficients were converted to an integer score. A restricted pre-operative “consent” model was also assessed.
Of 794 cholecystectomies, 780 (98.2%) were intended LC. CD III–V occurred in 44/780 (5.6%), including one death (0.1%). End-of-operation predictors were SIMD deciles 1–2, subtotal/abandoned cholecystectomy, and subhepatic drain placement (AUC 0.70). The integer score (SIMD 1–2=1; subtotal/abandoned=2; drain=3; range 0–6) stratified observed risk from 3.1% (0–1) to 29.6% (6). A restricted pre-operative model (ASA ≥3, acute inflammatory presentation, non-elective surgery, CBD stones, SIMD 1–2) showed lower discrimination (AUC 0.65). Decision-curve analysis demonstrated net benefit for the peri-operative model across thresholds ∼3–25% and for the pre-operative model across ∼4–20%.
A simple end-of-case score using deprivation and two intra-operative escalation signals identifies patients at higher risk of major (CD III–V) complications after LC. It may support targeted surveillance, audit, and quality improvement; external validation with robust 30-day outcome linkage is required.
Male sex is linked to conversion after laparoscopic cholecystectomy (LC); however, conversion is an imprecise surrogate for operative difficulty. We tested whether male sex predicts severe difficulty graded by the Nassar scale in a specialist biliary cohort.
We analysed prospectively maintained database of LC with or without laparoscopic common bile duct exploration (LCBDE), 1992–2023. The cohort only included cases with recorded sex and Nassar grade; severe difficulty was grade IV–V. Multivariable logistic regression adjusted for clinical, imaging, and operative covariates (LCBDE and era); performance was summarised using AUC and Brier score.
Among 6,129 procedures, 1,615 (26.3%) were male; men were older (median 57 vs 49 years) and more often emergency admissions (55.0% vs 44.1%) (both p<0.001). Severe difficulty occurred in 30.1% of men versus 12.8% of women (absolute difference 17.3%; unadjusted OR 2.93; p<0.001); grade IV–V comprised 1,065 cases (17.4%). Men had higher proportions of grade IV (26.1% vs 11.1%) and grade V difficulty (4.0% vs 1.7%). Male sex remained independently associated with severe difficulty (adjusted OR 1.90 (1.59–2.28); p<0.001); AUC was 0.859 and Brier score 0.105. Conversion was rare and did not differ by sex (0.62% vs 0.42%; p=0.299). Severe difficulty stratified outcomes: operative time 105 vs 55 min, stay 8 vs 3 days, conversion 1.9% vs 0.2%, and complications 14.5% vs 5.6% (all p<0.001).
Male sex independently predicted severe intra-operative difficulty (Nassar IV–V). Incorporating sex into preoperative stratification may support list planning, senior support, and anticipatory bail-out strategy selection.
K. Khan, Samantha Ng, Ahmad H. M. Nassar· British Journal of Surgery· 0 citations
As robotic platforms become increasingly adopted across colorectal and general surgical pathways, it is essential to understand their effect on postoperative morbidity. The Clavien–Dindo (CD) classification provides a validated framework for comparing complication severity. This study analysed complication rates and CD profiles following robotic and laparoscopic gastrointestinal procedures at a UK tertiary centre.
A retrospective-review of all robotic and laparoscopic procedures performed between 2024–2025 was undertaken. Procedures included colorectal resections, small-bowel operations, hernia repairs, adhesiolysis, and stoma surgery. Complications and their corresponding CD categories were extracted from postoperative documentation.
Comparisons between approaches used:Chi-square or Fisher’s exact test for overall complication rates, depending on frequency.Ordinal logistic regression to compare CD severity (I–V).Mann–Whitney U tests for length of stay (LOS).Binary logistic regression for predictors of any complication.
Complications occurred across both groups, including ileus, infection, bleeding, electrolyte imbalance, wound issues, and pulmonary events.
CD I–II complications predominated in both cohorts. CD-III events requiring intervention—including returns to theatre or radiological drainage—were observed at similar proportions. CD-IV complications (e.g., sepsis requiring organ support) occurred infrequently in both groups. Readmissions were comparable, typically for ileus or postoperative infection. Statistical-testing demonstrated no-significant difference in overall complication rates, CD category distribution, or LOS between robotic and laparoscopic procedures (all p > 0.05).
Robotic surgery did not demonstrate reduced postoperative-morbidity or CD-severity compared with laparoscopy. Complication severity appeared primarily driven by patient factors and case complexity. Larger, procedure-specific studies are warranted.
Mohammed Arifuzaman· British Journal of Surgery· 0 citations
ERCP after laparoscopic cholecystectomy is uncommon but consequential, exposing patients to procedure-related morbidity and consuming endoscopy capacity. UK ERCP quality standards emphasise governance and audit of avoidable repeat procedures. Contemporary pooled data confirm ERCP adverse events remain clinically important. We quantified 90-day postoperative ERCP incidence and examined drivers relevant to pathway design; bile-leak indications are time-sensitive.
Retrospective cohort across three acute hospitals in one NHS health board (Jan 2023–Nov 2024). The primary outcome was the first ERCP ≤90 days. Secondary outcomes were ERCP ≤30 days, time to ERCP, and 30-day readmission. Logistic regression included age, non-elective surgery, recorded CBD stones, and subtotal cholecystectomy; sensitivity models adjusted for intraoperative cholangiography and CBD exploration.
792/794 operations had ascertainable 90-day ERCP status. ERCP ≤90 days occurred in 55/792 (6.9%, 95% CI 5.4–8.9) and ERCP ≤30 days in 39/792 (4.9%). Median time to ERCP was 10 days (IQR 4–44). Thirty-day readmission was higher among ERCP cases (25.5% vs 6.1%). Independent drivers were recorded CBD stones (aOR 6.14, 95% CI 3.35–11.25), subtotal cholecystectomy (aOR 7.47, 95% CI 3.79–14.70) and non-elective surgery (aOR 1.94, 95% CI 1.06–3.55); intraoperative cholangiography and CBD exploration were not independently associated.
Approximately 1 in 18 patients required ERCP within 90 days. Demand concentrates in stone-phenotype and subtotal cases, supporting risk-stratified follow-up and targeted pathway optimisation; ERCP is a marker of case-mix and pathway design.
Samantha Ng, K. Khan· British Journal of Surgery· 0 citations
Emergency laparotomy (EL) comprises heterogeneous high-risk procedures with substantial postoperative mortality, reaching 8–18% at 30 days. Although overall 30-day mortality (30-dm) is documented, procedure-specific outcomes remain limited. Defining intervention-level mortality may improve risk stratification and resource allocation. This study aimed to quantify actual 30-dm for the five most frequently performed EL procedures in Romania and examine its correlation with Surgical-Outcome-Risk-Tool (SORT) predicted mortality.
This retrospective multicentre cohort study included adults undergoing EL over two years across four acute care hospitals in North-Eastern Romania, including one tertiary centre. The primary outcome was the correlation between actual and SORT predicted 30-dm for the 5 most common EL procedures. The study followed the TRIPOD checklist. Statistical analysis was performed using GraphPad-Prism v10.6.1.
Among 793 EL patients, 448 (56.4%) underwent the five most frequent procedures: incisional hernia repair with adhesiolysis (n=100;12.61%); actual 30-dm 4.0%; SORT 3.8% (1.7,11.2); R²=0.33, AUC=0.9648, p<0.0001; adhesiolysis (n=107;13.495); actual 30-dm 15.9%; SORT 6.86% (3.1,14.0); R²=0.05, AUC=0.7497, p=0.0117; suture of perforated peptic ulcer (n=88;11.09%), actual 30-dm 20.5%; SORT 5.78% (1.4,14.0); R²=0.24, AUC=0.8516, p<0.0001; Hartmann’s procedure (n=88;11.09%), actual 30-dm 21.6%; SORT 23.06% (12.1,40.3); R²=0.16, AUC=0.7645, p=0.0001; and inguinal hernia repair with adhesiolysis (n=65;8.19%) actual 30-dm mortality 1.5%; SORT 3.21% (0.9,8.2); R²=0.13, p=0.0001. Data is presented as median ± IQR.
SORT demonstrated limited reliability, weak correlation, and persistent misprediction of 30-day mortality across the five most common emergency laparotomy procedures in Romania.
G. Iordache, Sergiu Timofeiov, D. Jardan et al.· British Journal of Surgery· 0 citations
To quantify completion and timeliness of definitive cholecystectomy after ERCP for bile duct stones (BDS), and downstream service utilisation, stratified by operative risk.
Retrospective service evaluation of consecutive adults undergoing index ERCP for BDS with gallbladder in situ (January 2023-December 2024) in two hospitals. Non-stone indications and prior cholecystectomy were excluded, and only the first ERCP per patient was analysed. Operative-risk strata were prespecified using ASA and Charlson: low (ASA 1–2 & Charlson 0–2), high (ASA 4–5 or Charlson ≥5), and medium otherwise. Definitive management was completed cholecystectomy after ERCP. Outcomes were completion, time to surgery (≤2 weeks; ≤12 weeks), and downstream readmissions, bed-days, and repeat ERCP.
356 patients (median age 72 years; 56.2% female) were included. Completed cholecystectomy occurred in 81/356 (22.8%; 95% CI 18.7%–27.4%); 4/356 (1.1%) had surgery attempted but not completed, and 21/356 (5.9%) were awaiting surgery at data-lock. Completion rates were 49/78 (62.8%) in low-risk, 30/141 (21.3%) in medium-risk, and 2/137 (1.5%) in high-risk patients. Among 80 patients with dated intervals, the median ERCP-to-cholecystectomy time was 104 days (IQR 49–224); surgery occurred within 2 weeks in 10/356 (2.8%) and within 12 weeks in 33/356 (9.3%). The cohort generated 122 biliary readmissions, 1087 bed-days, and 121 repeat ERCPs; patients without a completed cholecystectomy accounted for 61.5%, 67.2%, and 62.8%.
Definitive cholecystectomy after ERCP was infrequent and delayed, with a steep operative-risk gradient, and most downstream admissions, bed use, and repeat ERCP concentrated in patients without definitive management.
Makthum Muwafikha Ismail, Charlotte Smith, Stewart Campbell et al.· British Journal of Surgery· 0 citations
Robotic Assisted (RAS) colorectal resections have shown positive outcomes when compared to laparoscopic approaches. For laparoscopic resections, BMI is a significant predictor of the development of post-operative complications.
We aimed to report RAS outcomes for colorectal resections, and to assess whether BMI was associated with post-operative complications.
All adult patients undergoing RAS colorectal resections between July 2021-2025 were included from our prospectively updated database. Reversal of stoma operations were excluded. Multivariate regression (MVR) was conducted to assess factors predicting complications. Subgroup chi-squared analysis was used to assess whether each BMI category differed in terms of complications.
Over five years, 270 patients were included. Most were men (54.8), median age was 64. Conversion to open rates, mortality and post-operative complication rates were all low (0.7%, 2.9% and 30% respectively). Severe complications (Clavien-Dindo ≥3) were only present in 3%. The only significant predictor of complications on MVR was CRP on post-operative day 3 (p=0.002). Most patients were overweight (40%) or obese (34.1%). Normal BMIs were present in 21.4% of patients, 1.9% were underweight and 2.4% morbidly obese. BMI was not predictive of post-operative complications in any category: underweight (BMI ≤18.5, p=0.158), normal (BMI 18.6-24.5, p=0.096), overweight (BMI 25-29.9, p=0.999), obese (BMI 30-39.9, p=0.561) and morbidly obese (BMI ≥40, p=0.366).
RAS resections have low conversion to open and mortality rates. Severe complications are rare. BMI is not associated with complications, suggesting that RAS is a more favourable approach than laparoscopic for colorectal resections in patients with a high BMI.
R. Bradley, Erin Prentice, R. Oliphant et al.· British Journal of Surgery· 0 citations
