Prediction of morbidity and mortality after early cholecystectomy for acute calculous cholecystitis: results of the S.P.Ri.M.A.C.C. study
Authors: Fugazzola Paola , Cobianchi Lorenzo , Di Martino Marcello , Tomasoni Matteo , Dal Mas Francesca , Abu-Zidan Fikri M. , Agnoletti Vanni , Ceresoli Marco , Coccolini Federico , Di Saverio Salomone , Dominioni Tommaso , Farè Camilla Nikita , Frassini Simone , Gambini Giulia , Leppäniemi Ari , Maestri Marcello , Martín-Pérez Elena , Moore Ernest E. , Musella Valeria , Peitzman Andrew B. , de la Hoz Rodríguez Ángela , Sargenti Benedetta , Sartelli Massimo , Viganò Jacopo , Anderloni Andrea , Biffl Walter , Catena Fausto , Ansaloni Luca ,   the S.P.Ri.M.A.C.C. Collaborative Group, Augustin Goran , Morić Trpimir , Awad Selmy , Alzahrani Azzah M. , Elbahnasawy Mohamed , Massalou Damien , De Simone Belinda , Demetrashvili Zaza , Kimpizi Athina-Despoina , Schizas Dimitrios , Balalis Dimitrios , Tasis Nikolaos , Papadoliopoulou Maria , Georgios Petrakis , Lasithiotakis Konstantinos , Ioannidis Orestis , Bains Lovenish , Magnoli Matteo , Cianci Pasquale , Conversano Nunzia Ivana , Pasculli Alessandro , Andreuccetti Jacopo , Arici Elisa , Pignata Giusto , Tiberio Guido A. M. , Podda Mauro , Murru Cristina , Veroux Massimiliano , Distefano Costanza , Centonze Danilo , Favi Francesco , Bova Raffaele , Convertini Girolamo , Balla Andrea , Sasia Diego , Giraudo Giorgio , Gabriele Anania , Tartaglia Nicola , Pavone Giovanna , D’Acapito Fabrizio , Fabbri Nicolò , Ferrara Francesco , Cimbanassi Stefania , Ferrario Luca , Cioffi Stefano , Ceresoli Marco , Fumagalli Chiara , Degrate Luca , Degiuli Maurizio , Sofia Silvia , Licari Leo , Improta Mario , Patriti Alberto , Coletta Diego , Conti Luigi , Malerba Michele , Andrea Muratore , Calabrò Marcello , De Zolt Beatrice , Bellio Gabriele , Giordano Alessio , Luppi Davide , Corbellini Carlo , Sampietro Gianluca Matteo , Marafante Chiara , Rossi Stefano , Mingoli Andrea , Lapolla Pierfrancesco , Cicerchia Pierfranco M. , Siragusa Leandro , Grande Michele , Arcudi Claudio , Antonelli Amedeo , Vinci Danilo , De Martino Ciro , Armellino Mariano Fortunato , Bisogno Enrica , Visconti Diego , Santarelli Mauro , Montanari Elena , Biloslavo Alan , Germani Paola , Zaghi Claudia , Oka Naoki , Fathi Mohd Azem , Ríos-Cruz Daniel , Hernandez Edgard Efren Lozada , Garzali Ibrahim Umar , Duarte Liliana , Negoi Ionut , Litvin Andrey , Chowdhury Sharfuddin , Alshahrani Salem M. , Carbonell-Morote Silvia , Rubio-Garcia Juan J. , Moreira Claudia Cristina Lopes , Ponce Iñigo Augusto , Mendoza-Moreno Fernando , Campaña Anna Muñoz , Bayo Heura Llaquet , Serra Andrea Campos , Landaluce-Olavarria Aitor , Serradilla-Martín Mario , Cano-Paredero Antonio , Dobón-Rascón Miguel Ángel , Hamid Hytham , Baraket Oussama , Gonullu Emre , Leventoglu Sezai , Turk Yilmaz , Büyükkasap Çağrı , Aday Ulaş , Kara Yasin , Kabuli Hamit Ahmet , Atici Semra Demirli , Colak Elif , Chooklin Serge , Chuklin Serhii , Ruta Federico , Estraviz-Mateos Begoña , Markinez-Gordobil Izaskun 
Published: March 2023

Abstract
Background
Less invasive alternatives than early cholecystectomy (EC) for acute calculous cholecystitis (ACC) treatment have been spreading in recent years. We still lack a reliable tool to select high-risk patients who could benefit from these alternatives. Our study aimed to prospectively validate the Chole-risk score in predicting postoperative complications in patients undergoing EC for ACC compared with other preoperative risk prediction models.

Method
The S.P.Ri.M.A.C.C. study is a World Society of Emergency Surgery prospective multicenter observational study. From 1st September 2021 to 1st September 2022, 1253 consecutive patients admitted in 79 centers were included. The inclusion criteria were a diagnosis of ACC and to be a candidate for EC. A Cochran-Armitage test of the trend was run to determine whether a linear correlation existed between the Chole-risk score and a complicated postoperative course. To assess the accuracy of the analyzed prediction models—POSSUM Physiological Score (PS), modified Frailty Index, Charlson Comorbidity Index, American Society of Anesthesiologist score (ASA), APACHE II score, and ACC severity grade—receiver operating characteristic (ROC) curves were generated. The area under the ROC curve (AUC) was used to compare the diagnostic abilities.

Results
A 30-day major morbidity of 6.6% and 30-day mortality of 1.1% were found. Chole-risk was validated, but POSSUM PS was the best risk prediction model for a complicated course after EC for ACC (in-hospital mortality: AUC 0.94, p < 0.001; 30-day mortality: AUC 0.94, p < 0.001; in-hospital major morbidity: AUC 0.73, p < 0.001; 30-day major morbidity: AUC 0.70, p < 0.001). POSSUM PS with a cutoff of 25 (defined in our study as a ‘Chole-POSSUM’ score) was then validated in a separate cohort of patients. It showed a 100% sensitivity and a 100% negative predictive value for mortality and a 96–97% negative predictive value for major complications.

Conclusions
The Chole-risk score was externally validated, but the CHOLE-POSSUM stands as a more accurate prediction model. CHOLE-POSSUM is a reliable tool to stratify patients with ACC into a low-risk group that may represent a safe EC candidate, and a high-risk group, where new minimally invasive endoscopic techniques may find the most useful field of action.
Trial Registration: ClinicalTrial.gov NCT04995380.