Stratification of Surgical Risk in Acute Cholecystitis: Preoperative C-Reactive Protein as an Independent Predictor of Difficulty and Conversion

Abstract Purpose Anticipating the difficulty and clinical course of an emergency cholecystectomy relies heavily on intraoperative judgement. Preoperative C-reactive protein (CRP) has been proposed as a marker of surgical difficulty, but most studies test it against a single outcome in isolation. We assessed whether a single preoperative CRP value could predict three distinct outcomes: surgical difficulty, conversion to open surgery, and postoperative course Methods We analysed 221 prospectively enrolled, consecutive patients undergoing emergency laparoscopic cholecystectomy for acute cholecystitis at a single tertiary centre. Surgical difficulty was graded intraoperatively with the Parkland scale (grades 1–3 vs 4–5). CRP's association with difficulty was assessed with logistic regression; ROC-curve analysis evaluated discrimination for difficulty, conversion, and complications, and Spearman correlation assessed length of stay. Results CRP was higher in patients with a difficult gallbladder (median 166.0 vs 45.1 mg/L, p < 0.001) and remained an independent predictor after adjustment for baseline confounders (adjusted OR 1.006 per mg/L, p < 0.001; AUC 0.73). A higher threshold, approximately 304 mg/L, identified a high risk of conversion (AUC 0.76; specificity 89.4%; negative predictive value 96.9%); CRP was also weakly associated with any complication (AUC 0.64) and correlated with length of stay (rho = 0.37, p < 0.001); the small number of major complications precluded reliable modelling. Conclusion A single preoperative CRP value provides usable information on three distinct outcomes in acute cholecystitis, with different thresholds for anticipating difficulty and for conversion risk. These outcome-specific thresholds warrant prospective, multicentre validation.