Tesis

Validasi penilaian kantung empedu intraoperatif 10 poin (G10) pada kolesistektomi laparaskopik di RSUPN Dr.Cipto Mangunkusumo = The validation of 10 points intraoperative gallbladder scoring system (G10) in laparoscopic cholecystectomy at RSUPN Dr. Cipto Mangunkusumo .

Latar Belakang : Penatalaksanaan kolesistektomi laparoskopik telah menjadi baku emas untuk penanganan kolesistolitiasis simptomatik di RS Dr. Cipto Mangunkusumo (RSCM), sedangkan sampai saat ini belum ada sistem penilaian kantung empedu intraoperatif yang diterapkan saat operasi. Penilaian kantong empedu intraoperatif yang sesuai dapat menggambarkan tingkat kesulitan kolesistektomi laparaskopik secara objektif dan akan berpengaruh terhadap pemilihan teknik kolesistektomi laparaskopik yang tepat untuk mencegah terjadinya trauma bilier. Sugrue telah mengembangkan perangkat penilaian kantung empedu intraoperatif 10 poin (G10 ). Nilai G10 terbukti dapat digunakan untuk prediksi konversi kolesistektomi terbuka. Konversi kolesistektomi terbuka hanyalah salah satu prosedur bailout yang dipilih spesialis bedah saat menghadapi difficult gallbladder. Sehingga penilaian G10 ini seharusnya juga dapat dipakai sebagai pedoman untuk melakukan prosedur bailout. Penelitian ini bertujuan mengevaluasi nilai G10 dan mencari hubungan dengan teknik operasi pada pasien yang sudah dilakukan kolesistektomi laparaskopik di RSCM. Metode : Dilakukan penelitian retrospektif pada subjek yang telah dilakukan kolesistektomi laparaskopik pada Januari 2019 sampai Desember 2019 di institusi kami. Kami mengumpulkan karakteristik subjek berdasarkan catatan medis rumah sakit. Kami menentukan nilai G10 dan teknik operasi berdasarkan dokumentasi gambar intraoperatif dan laporan bedah. Data nilai G10 dan klasifikasi teknik operasi dilakukan uji non parametrik Mann-Whitney untuk melihat perbedaannya. Dilakukan uji statistik Kendall’s Tau untuk menilai hubungan antara nilai G10 dengan prosedur bailout. Dilakukan uji ROC untuk melihat sensitifitas dan spesifisitas nilai G10 terhadap prosedur bailout, kemudian ditentukan nilai cut-off nya. Hasil : 99 subjek Indonesia, usia rata-rata 49,80+13,421 tahun, menjalani kolesistektomi laparaskopik di Rumah Sakit Umum Dr.Cipto Mangunkusumo selama satu tahun. Sebagian besar diagnosis adalah kolesistolitiasis tanpa kolesistitis (68 subjek, 68,8% ) dan kolesistitis kronis (23 subjek, 23,2% ). Pembedahan elektif dilakuan pada 91 subjek (91,9% ). Median nilai G10 adalah 2 (rentang 1-8). CVS dilakukan pada 81 subjek (81,8% ), sedangkan 18 subjek dikelola dengan prosedur bailout (18,2% ), terdiri dari 14 subjek dilakukan FF (14,2% ), 2 subjek SC (2,0% ) dan 2 subjek konversi operasi terbuka (2,0% ). Nilai median G10 berbeda pada subjek yang menjalani CVS (1, rentang 1-6), FF (3, rentang 2-6), SC (5, rentang 5-5) dan konversi terbuka (6,5, rentang 5-8). Ada perbedaan median nilai G10 ( < 0,001)antara kelompok yang dilakukan CVS (1, rentang 1-6)dengan kelompok yang dilakukan prosedur bailout (4, rentang 2-8). Terdapat hubungan antara nilai G10 dengan prosedur bailout ( < 0,001, +0,478). Akurasi nilai G10 untuk memprediksi prosedur bailout dinilai dengan menggunakan kurva receiver operating characteristic (ROC ) ( < 0,001, AUC 0,865 ) dan didapatkan cut-off point yang optimal untuk melakukan prosedur bailout adalah 2,5 2 (x , p=0,000019 ). Kesimpulan : Studi ini menunjukkan bahwa G10 adalah sistem penilaian kandung empedu intraoperatif yang objektif dan dapat diterapkan saat melakukan kolesistektomi laparaskopik. Nilai G10 berhubungan dengan prosedur bailout. Nilai 2,5 adalah cut-off point yang optimal untuk melakukan prosedur bailout saat kolesistektomi laparaskopik.
Kata kunci : G10, kolesistektomi laparaskopik, bailout, CVS


Background : Laparoscopic cholecystectomy has become a gold standard for symptomatic cholecystolithiasis management at Dr. Cipto Mangunkusumo Hospital (RSCM ), while there is no intraoperative gallbladder assessment system applied during operation. The use of an appropriate intraoperative gallbladder assessment system will describe objectively the difficulty level during laparoscopic cholecystectomy and will influence the selection of appropriate laparoscopic cholecystectomy techniques to prevent biliary trauma. Sugrue has developed a 10-point intraoperative gallbladder scoring system (G10). The G10 scoring system is proven to be able to predict open cholecystectomy conversion. The open cholecystectomy conversion is just one of the bailout procedures a surgeon chooses when dealing with difficult gallbladder. Thus, the G10 scoring system should also be used as a guideline for performing bailout procedures. This study evaluated the G10 score and looked for the relationship with laparascopic cholecystectomy techniques in patients who have performed operation at RSCM. Method : A retrospective study was established to the patients had performed laparascopic cholecystectomy between Januari 2019 and December 2019 at our institution. We collected characteristic of subjects based on hospital medical records. We assessed the G10 scoring system and operation technique based on the documentation of intraoperatif images and surgical reports. G10 score and classification of operation technique evaluated by a Mann-Whitney statistical test to see the difference. A Kendall’s Tau statistical test was performed to see the relationship between G10 score and bailout procedure. We evaluated sensitivity and specificity of G10 score to performed bailout procedure using ROC Curve. Results : Ninety-nine indonesian patients, mean age 49.80+13.421 yrs, underwent laparascopic cholecystectomy at Dr.Cipto Mangunkusumo General Hospital for a year. Most diagnosis were cholecystolithiasis without cholecystitis (68 subject, 68.8% ) and chronic cholecystitis (23 subject, 23.2% ). Surgery was elective in 91 subject (91.9% ). The median G10 score was 2 (range 1-8). CVS was feasible in 81 subject (81.8% ), whereas 18 subject were managed by bailout procedure (18.2% ). Of those, 14 subject underwent FF (14.2% ), 2 (2.0% ) SC and 2 (2.0% ) open surgery conversion. The median G10 score differs among patients undergoing CVS (1, range 1-6), FF (3, range 2-6), SC (5, range 5-5) and open conversion (6.5, range 5-8). There is a difference of G10 score ( < 0.001)among patients undergoing CVS (1, range 1-6)and bailout procedure (4, range 2-8). There is also a relationship between the G10 score and the bailout procedure ( < 0.001, +0.478 ). The accuracy of the G10 score for predicting bailout procedure was assessed using ROC curve ( < 0.001, AUC 0.865 ) and the optimal cut-off point to perform a bailout procedure was 2,5 2 (x , p=0.000019 ). Conclusion : This study shows that G10 is an objective intraoperative gallbladder scoring system and can be applied when performing laparoscopic cholecystectomy. The G10 score has a relationship with bailout procedure. The score 2.5 is the optimal cut-off point for a bailout procedure when performing laparoscopic cholecystectomy.
Keywords : G10, laparascopic cholecystectomy, bailout, CVS