CholeS Score for Duration of Laparoscopic Cholecystectomy

Why did you develop the CholeS Score? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?

We wanted to use the CholeS dataset, a large multicentre audit of over 8,000 cholecystectomies carried out in the UK collecting intra-operative and postoperative outcomes of these operations in 2014, to look at predictive factors for operative duration in laparoscopic cholecystectomy. As cholecystectomy is a very common operation, we felt that analysis of factors which accurately predicted the duration of surgery would potentially benefit surgeons in several ways: (1) to accurately schedule theatre lists to avoid underutilization and over-runs; (2) reduce costs from cancellations or underbooked lists; and (3) help theatre staff, schedulers, administrators and surgeons in preparing theatre lists.

The score was developed by Reshma Bharamgoudar, Aniket Sonsale, James Hodson, and Ewen Griffiths, and we are very grateful for the surgeons and teams who contributed data to the CholeS study to allow this score to be developed. 

What pearls, pitfalls and/or tips do you have for users of the CholeS Score? Do you know of cases when it has been applied, interpreted, or used inappropriately?

It is only for use in elective surgery, as the data was derived from a cohort of patients undergoing elective surgery, so don't use the score for patients having emergency surgery.

The score is for use in patients who are having laparoscopic surgery and not straight to open cholecystectomy.

The score doesn't take into account the extra time to train junior surgeons, or the anesthesia or theatre turnover time, so these need to be taken into account.

The score uses easily available preoperative data, such as age and gender.

What recommendations do you have for doctors once they have applied the CholeS Score? Are there any adjustments or updates you would make to the score based on new data or practice changes?

Once the CholeS score is calculated, it can be used to predict the likelihood of the operation taking more than 90 minutes. For example, the groups (low, intermediate, and high) have the risks of 5.1%, 5.1 to 41.8%, or >41.8% of the operation taking more than 90 minutes to complete. 

Surgeons who would like a slightly more accurate prediction should look at Figure 1 in the main paper.

We externally validated the score using data from our own hospital's database, and the score was accurate on this dataset too.

How do you use the CholeS Score in your own clinical practice? Can you give an example of a scenario in which you use it?

The score in our hospital is used to help assess how many patients we can fit into a standard half-day cholecystectomy lists. For example, we can usually fit in three low risk cases for surgery (i.e., those predicted to be easy and have a low risk of taking more than 90 mins). But if we have a patient with adverse features and a high risk of taking longer than 90 mins, then we usually only schedule two patients. The score is also used if there is an all day mixed theatre list with around 90 minutes spare operating, to make sure we fit in a likely short duration case rather than one that is likely to be more difficult and thus lead to an overrun on the list.

Any other research in the pipeline that you’re particularly excited about?

We have also assessed and developed scores on the following related topics which may interest your readers:

Griffiths et al, Surg Endosc 2018 Jun 28, “Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy.” This is an intra-operative score which grades the surgical difficulties of performing cholecystectomy and correlates this with postoperative outcome.

Sutcliffe et al, HPB (Oxford). 2016 Nov;18(11):922-928, “Preoperative risk factors for conversion from laparoscopic to open cholecystectomy: a validated risk score derived from a prospective U.K. database of 8820 patients.” This score can be calculated before surgery to predict the risk of conversion to open surgery, and is also good for scheduling lists and consenting patients.

Ewen A. Griffiths, MD, FRCS, is an upper gastrointestinal specialist at Queen Elizabeth Hospital in Birmingham, England. He is also an honorary senior clinical lecturer at the University of Birmingham. Dr. Griffiths' research focuses primarily on hypoxia-associated factors and minimally invasive general surgery procedures.