Inflammatory Burden Rather Than Symptom Duration Predicts Operative Difficulty in Acute Cholecystitis

Abstract Background Operative difficulty during emergency laparoscopic cholecystectomy (ELC) can vary substantially. This study evaluated whether peak pre-operative C-reactive protein (CRP) is a greater independent predictor of operative difficulty than symptom duration. Methods A retrospective multicentre cohort study was conducted within Wide Bay Hospital and Health Service (November 2021 - May 2024). Adult patients undergoing ELC were included. Operative difficulty was graded 1 to 4 using a validated intra-operative grading system. Multivariable logistic regression adjusted for covariates, and receiver operating characteristic analysis was used to determine optimal CRP threshold for predicting grade 4 difficulty. Results A total of 284 patients were included. CRP was independently associated with increasing operative difficulty (adjusted OR 2.24 per log unit, 95% CI 1.91–2.63; p < 0.001), while longer symptom duration was inversely related (adjusted OR 0.81 per day, 95% CI 0.73–0.90; p < 0.001). A CRP threshold of 92.5 mg/L predicted grade 4 difficulty with 76.2% sensitivity, 82.5% specificity, and 89.2% negative predictive value. Conclusion CRP is a strong independent predictor of operative difficulty in emergency laparoscopic cholecystectomy for cholecystitis and appears to reflect inflammatory burden more accurately than symptom duration. Incorporating CRP into pre-operative assessment may improve risk stratification and facilitate appropriate operative planning.