Multicenter external validation of a nomogram predicting conversion to open cholecystectomy during laparoscopic...

This study aimed to investigate risk factors associated with conversion from early laparoscopic cholecystectomy (ELC) to open cholecystectomy in patients diagnosed with acute calculous cholecystitis (ACC). A retrospective analysis was conducted on 3,191 ACC patients who underwent ELC at eight clinical centers between January 2013 and December 2023. To evaluate risk factors for conversion during ELC, least absolute shrinkage and selection operator (LASSO) regression with ten-fold cross-validation was employed to identify and select the most relevant variables. Subsequently, a binary logistic regression model was built using the variables selected from LASSO regression to develop a nomogram for prediction. The model's performance was evaluated using external validation through receiver operating characteristic (ROC) curves for discrimination, Hosmer-Lemeshow test and calibration curves for calibration, and decision curve analysis (DCA) for clinical practicality. LASSO regression analysis identified five optimal variables from a total of twenty-nine for model development: preoperative C-reactive protein (CRP) level, anesthesia American Society of Anesthesiologists (ASA) classification, calculus location, Tokyo Guidelines 2018 (TG18) classification, and surgeon seniority. External validation of the model using the area under the curve (AUC) from ROC curves yielded moderate discrimination in both the training set (AUC = 0.868) and validation set (AUC = 0.833). Calibration plots indicated good agreement between predicted and observed probabilities, suggesting good calibration of the nomogram. Additionally, DCA analysis supported the model's potential clinical usefulness. This study identified high preoperative CRP level, presence of gallbladder neck calculus, high grades in both anesthesia ASA and TG18 classifications, and junior surgeon as factors that can be used to predict the need for conversion to open surgery during ELC procedures for ACC patients.