- Design
- Prospective cohort, non-randomised, single region
- Population
- 221 patients having emergency laparoscopic cholecystectomy for acute cholecystitis
- Primary outcome
- Conversion to open surgery by CRP tertile
- Effect
- Conversion 0/85 with ICG vs 12/136 (8.8%) without; highest CRP tertile ARR 15.4 points (95% CI 8.0 to 27.5)
A prospective Spanish cohort followed 221 patients having emergency laparoscopic cholecystectomy for acute cholecystitis, 85 with indocyanine green (ICG) fluorescence cholangiography and 136 without. The authors asked whether preoperative C-reactive protein (CRP) could identify who gains most.
Conversion to open happened in 12 of 136 without ICG (8.8%) and none of 85 with it. Without ICG, conversion rose from 0 in the lowest CRP third to 15.4% in the highest. The estimated absolute reduction with ICG was about 10 points in the middle third (number needed to treat about 10) and 15 points in the highest (about 6.5). The CRP-by-ICG interaction was significant for operative time but not for conversion, partly because there were no conversions with ICG to model.
This was not randomised, and surgeons chose when to use ICG, so case selection may explain part of the difference. The authors frame it as a strategy to test, not adopt.
Where ICG is limited by cost or availability, as it is in many Indian units, the high-CRP patient is a reasonable place to use it first while the evidence develops.
- Check CRP before emergency cholecystectomy; high values flagged harder operations here.
- Where ICG supply is limited, consider prioritising high-CRP cases.
- ICG supports but does not replace the critical view of safety.
- Plan a bailout strategy in advance for high-CRP cases regardless of ICG.
Why it matters
It offers a way to target a costly tool rather than use it everywhere or nowhere.
Don't overread it
This was a non-randomised cohort; it does not prove ICG prevents conversion.
The statistics, in plain English
A number needed to treat of 6.5 means about one conversion avoided for every six or seven high-CRP patients given ICG, if the association is causal. The interaction test for conversion was not significant, so the claim that benefit varies with CRP is unproven.
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