Tesis

Validasi Skor CLOC dalam Memprediksi Risiko Konversi Kolesistektomi Laparoskopi ke Kolesistektomi Terbuka di RS Dr. Cipto Mangunkusumo = Validation of CLOC Score in Predicting the Risk of Conversion from Laparoscopic to Open Cholecystectomy in Dr. Cipto Mangunkusumo Hospital.

Introduksi: Kolesistektomi laparoskopi menjadi baku emas tatalaksana kolelitiasis simtomatik. Meskipun cukup aman dan efektif, kolesistektomi laparoskopi merupakan prosedur sulit. Angka konversi ke kolesistektomi terbuka mencapai 1-15%. Prediksi praoperatif dapat membantu menilai apakah kolesistektomi terbuka lebih baik dipilih sejak awal sehingga mencegah morbiditas dan mortalitas akibat konversi. Skor CLOC dapat memprediksi risiko konversi berdasarkan parameter praoperatif. Penelitian ini dilakukan untuk melakukan validasi skor CLOC di RS. Dr. Cipto Mangunkusumo sebagai representasi populasi Indonesia. Metode: Penelitian ini merupakan retrospektif terhadap pasien yang menjalani kolesistektomi laparoskopi selama Januari 2018 hingga Desember 2019 di RSCM. Data dan karakteristik subjek diperoleh dari rekam medis. Dilakukan analisis deskriptif, uji chi-square, regresi logistik, dan validasi skor menggunakan kurva receiver operating characteristic (ROC) dengan menghitung area under curve (AUC), sensitivitas, dan spesifisitas. Skor CLOC risiko rendah ( < 6) dan risiko tinggi ( > 6). Hasil: Terdapat 163 dengan rerata umur 51,06 ± 13,3 tahun, Angka kejadian konversi adalah 3,1% (n = 5). Mayoritas (111 subjek, 68,1%) merupakan kelompok umur 40—69 tahun. Sebanyak 103 subjek (63,2%) adalah perempuan dan 60 sisanya laki-laki. Indikasi operasi karena kolik (batu empedu simtomatik) sebanyak 144 subjek (88,3%). Hasil regresi logistik, hanya variabel dilatasi duktus biliaris komunis yang bermakna dengan OR = 10,97 (IK95% : 1,72 - 69,95). AUC = 78,8% (fair) (IK95% : 58,2% - 99,4%; p = 0,029); cut-off = 6,5 (sensitivitas = 80,0%; spesifisitas = 79,1%). Median lama operasi kelompok risiko rendah vs risiko tinggi adalah 120 (30—330) menit vs 180 (45—405) menit (p = 0,001). Kesimpulan: Faktor risiko konversi yang signifikan yaitu dilatasi diameter duktus biliaris komunis. Faktor risiko konversi yang tidak signifikan yaitu umur, jenis kelamin, indikasi operasi, ketebalan dinding kandung empedu, dan skor ASA. Skor risiko CLOC valid dan dapat memprediksi kejadian konversi. Nilai cut-off skor risiko tinggi ( > 6) berhubungan dengan konversi, dan skor risiko rendah ( < 6) berhubungan dengan tidak konversi.
Kata kunci: konversi, kolesistektomi, laparoskopi, skor CLOC


Introduction: Laparoscopic cholecystectomy is the gold standard for treatment of symptomatic cholelithiasis. Although relatively safe and effective, laparoscopic cholecystectomy is a difficult procedure. The rate of conversion to open cholecystectomy is estimated to be 1–15%. A preoperative predictive model may be helpful in determining whether open cholecystectomy is preferred over laparoscopic cholecystectomy to prevent morbidity and mortality associated with conversion. CLOC Score can potentially predict the risk of conversion based on preoperative parameters. The purpose of this study is to validate the application of CLOC Score in Dr. Cipto Mangunkusumo Hospital’s patient population. Methods: This was a retrospective study of patients undergoing laparoscopic cholecystectomy from January 2018 to December 2019 in Dr. Cipto Mangunkusumo Hospital. Patient data were obtained from medical records. Descriptive analysis, chi-square test, logistic regression analysis, and score validation using receiving operating characteristic (ROC) curve by calculating the area under curve (AUC), sensitivity, and specificity were conducted. Based on the CLOC Score, the patients were stratified into two groups: low risk ( < 6) and high-risk ( > 6). Results: There were 163 subjects with a mean age of 51.06 ± 13.3 years, The rate of conversion was 3.1% (n =5). Most of the subjects were 40–69 years of age (111 subjects, 68,1%). Of all 163 subjects, 103 (63,2%) were female. The indications for surgery were colicky pain (symptomatic gallstone disease) in 144 subjects (88,3%). Based on the logistic regression analysis, common bile duct dilation was found to be the only statistically significant variable (odds ratio [OR] =10.97; 95% confidence interval [CI]: 1.72–69.95). The AUC approached 78,8% (fair) (95% CI: 58.2%–99,4%; p =.029) for a cut-off value of 6,5 (sensitivity =80.0%; specificity =79.1%). The median duration of procedure in the low-risk group vs. the high-risk group was 120 minutes (30–330) vs. 180 minutes (45–405) (p =.001), respectively. Conclusions: Common bile duct dilation was the only risk factor found to be significantly associated with conversion of laparoscopic cholecystectomy to open surgery. Other factors, such as age, sex, indication for surgery, gallbladder wall thickness, and ASA Score was not found to be statistically significant risk factors. CLOC Score was considered valid and useful in predicting the risk of conversion. A CLOC Score of 7 or more was associated with a higher risk of conversion to open surgery.
Keywords: conversion, cholecystectomy, laparoscopy, CLOC Score