Published online Jul 27, 2026. doi: 10.4240/wjgs.v18.i7.121443
Revised: May 6, 2026
Accepted: June 2, 2026
Published online: July 27, 2026
Processing time: 124 Days and 23.4 Hours
Laparoscopic cholecystectomy (LC) is the standard treatment for symptomatic cholelithiasis, but a subset of patients still develop clinically relevant biliary complications within 30 days, including retained common bile duct (CBD) stones, bile leak, cholangitis, or biliary pancreatitis that often require therapeutic endo
To develop and internally validate a concise preoperative nomogram based on total bilirubin (TBil) and the CBD/height index for predicting 30-day clinically relevant biliary events after LC.
In this single-center retrospective cohort, consecutive adult patients undergoing LC between 2022 and 2024 (n = 287) were included. Patients were randomly allocated to a training cohort (n = 200) and a validation cohort (n = 87) using stratified randomization by outcome (7:3 ratio). Preoperative candidate variables (demographics, clinical history, laboratory tests, and ultrasound findings) were entered into least absolute shrinkage and selection operator (LASSO) logistic regression for feature selection. Variables retained at the λ1se penalty were further assessed by multivariable logistic regression to identify independent predictors and construct a two-variable prediction model, which was visualized as a nomogram. Model performance was evaluated in both cohorts using the area under the receiver operating characteristic curve (AUC) with 95%CI, Brier score, calibration-in-the-large, calibration slope, calibration plots, and decision curve analysis.
Clinically relevant biliary events within 30 days occurred in 29 of 287 patients (10.1%). At the λ1se penalty, LASSO retained four variables with non-zero coefficients (TBil, gamma-glutamyl transferase, CBD/height index, and ultrasound-suspected CBD stones/obstruction). In multivariable analysis, only preoperative TBil and the CBD/height index remained independent predictors and were used to construct the final model. In the original random-split analysis, the AUC was 0.881 (95%CI: 0.777-0.986) in the training cohort and 0.902 (95%CI: 0.818-0.985) in the validation cohort. Bootstrap-based internal validation of the full-cohort two-variable model showed an apparent AUC of 0.892 and an optimism-corrected AUC of 0.890. In a sensitivity analysis excluding 54 patients who underwent ERCP within 30 days before surgery, the associations of TBil and the CBD/height index with the primary outcome remained materially similar, and model discrimination remained stable (AUC = 0.895).
A simple two-variable preoperative nomogram based on TBil and the CBD/height index can effectively predict 30-day clinically relevant biliary events after LC, with favorable discrimination, calibration, and clinical applicability. This tool may facilitate individualized risk communication and optimization of perioperative strategies, but requires prospective multicenter external validation.
Core Tip: Clinically relevant biliary events within 30 days after laparoscopic cholecystectomy, such as retained common bile duct (CBD) stones, bile leak, cholangitis, and biliary pancreatitis, may necessitate endoscopic retrograde cholangiopancreatography (ERCP), drainage, or un
- Citation: Chen ZP. Preoperative prediction model for 30 days biliary events after laparoscopic cholecystectomy. World J Gastrointest Surg 2026; 18(7): 121443
- URL: https://www.wjgnet.com/1948-9366/full/v18/i7/121443.htm
- DOI: https://dx.doi.org/10.4240/wjgs.v18.i7.121443
Laparoscopic cholecystectomy (LC) has become the standard procedure for symptomatic cholelithiasis, with high overall safety and low mortality. However, even in experienced centers, a subset of patients experience clinically relevant biliary complications within 30 days postoperatively, such as residual or retained common bile duct (CBD) stones, bile leakage, cholangitis, and biliary pancreatitis, some of which require therapeutic endoscopic retrograde cholangiopancreatography (ERCP), percutaneous drainage, reoperation, or unplanned readmission[1-3]. Meta-analyses have reported 30-day readmission rates of approximately 3.3% after LC, highlighting room for improvement in perioperative pathways and risk stratification[2].
Existing guidelines and studies on LC-related biliary risk mainly focus on intraoperative technical strategies (e.g., critical view of safety, bail-out procedures for difficult gallbladders) or broad indications for ERCP, rather than providing a concise, quantitative preoperative model specifically targeting 30-day clinically relevant biliary events[1,4]. Traditional risk assessment relies on individual factors such as markedly elevated bilirubin, dilated CBD, or ultrasound-suspected CBD stones/obstruction, which are used to guide upfront ERCP or further imaging. However, isolated indicators are often insufficient for precise decision-making, and may either underestimate or overestimate risk in borderline patients[4].
The definition of a “normal” CBD diameter is influenced by age, prior cholecystectomy, and other factors, with thresholds of 6-8 mm commonly suggested in the literature[5,6]. A fixed cut-off does not account for individual anatomical variation. Conceptually, indexing CBD diameter to body size is expected to better reflect the relative “structural capacity” of the biliary drainage pathway. Height is an easily obtainable anthropometric measure, and constructing a CBD/height index (mm/m) may partially correct the systematic bias introduced by a uniform millimeter-based threshold, thereby improving comparability across individuals with different body habitus. Although height-adjusted CBD measures are consistent with prior evidence that considers age and surgical status, their role in short-term biliary event risk stratification after LC has not been systematically validated.
Therefore, this study used a single-center retrospective cohort of adult LC patients, randomly split into training and validation sets (7:3 ratio), to develop a preoperative prediction model centered on cholestasis-related markers [particularly total bilirubin (TBil)] and the CBD/height index. The outcome definition of 30-day clinically relevant biliary events was aligned with international consensus documents including the Tokyo Guidelines 2018 (TG18), the revised Atlanta classification for acute pancreatitis, and ASGE criteria for CBD stone risk stratification, to ensure clinical interpretability and comparability[4,7,8]. Using least absolute shrinkage and selection operator (LASSO) for feature selection and multivariable logistic regression for model construction, we aimed to establish and internally validate a parsimonious, interpretable nomogram for predicting 30-day clinically relevant biliary events after LC.
This was a single-center retrospective cohort study conducted in accordance with STROBE and TRIPOD reporting recommendations. Consecutive adult patients who underwent LC at our institution between January 2022 and December 2024 were screened for eligibility. The study protocol was approved by the Ethics Committee of Guangzhou Panyu District Maternal and Child Health Hospital (Approval No. 2025111122). All data were de-identified prior to extraction and used solely for research purposes, in line with the Declaration of Helsinki.
Inclusion criteria: (1) Age ≥ 18 years; (2) Elective or emergency completion of LC; and (3) Availability of complete preoperative laboratory tests [including TBil, alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), alanine aminotransferase (ALT), aspartate aminotransferase (AST)] and abdominal ultrasound records (including CBD diameter).
Exclusion criteria: (1) History of extrahepatic biliary reconstruction or major hepatobiliary-pancreatic surgery; (2) Obstructive jaundice due to malignant tumors; (3) Pregnancy; (4) Perioperative death or loss to follow-up within 30 days postoperatively; and (5) Missing key outcome or exposure variables that precluded analysis.
After applying the criteria, 287 eligible patients were included. Using stratified randomization by the primary outcome with a fixed random seed, patients were allocated to a training cohort (n = 200) and a validation cohort (n = 87) in a 7:3 ratio, ensuring similar event rates and minimizing temporal bias.
General and perioperative variables: Collected variables included age, sex, height, weight [for body mass index (BMI) calculation], emergency vs elective surgery, history of ≥ 2 prior hospitalizations for acute cholecystitis, history of pancreatitis or cholangitis, and ERCP within 30 days before surgery (yes/no).
Preoperative laboratory indices: Preoperative blood tests performed on the day of surgery or within 7 days before surgery were recorded, including: (1) TBil (μmol/L); (2) ALP (U/L); (3) GGT (U/L); (4) ALT (U/L); and (5) AST (U/L). If multiple measurements were available, the value closest to the time of surgery was used.
Ultrasound findings: On standard hepatobiliary ultrasound, CBD diameter (mm) at the porta hepatis was measured “inner wall to inner wall”. The following were also recorded: Ultrasound-suspected CBD stones/obstruction (yes/no), CBD diameter ≥ 8 mm (yes/no), gallbladder wall thickening ≥ 4 mm (yes/no), and impacted neck stone (yes/no). To account for body size, the CBD/height index (mm/m) was calculated as: CBD/height index = CBD diameter (mm)/height (m). All candidate preoperative variables were initially entered into the LASSO procedure. Final model inclusion was determined by a combination of LASSO selection and multivariable logistic regression results.
The primary outcome was a composite of “30-day clinically relevant biliary events” after LC, defined as the occurrence of any of the following within 30 days postoperatively: (1) Therapeutic ERCP (including sphincterotomy, stone extraction, or stent placement) for residual/retained CBD stones, obstructive jaundice, or clinically significant bile leak; (2) Bile leak requiring intervention consistent with ISGLS grade B/C (percutaneous or endoscopic drainage, or reoperation); (3) Cholangitis or biliary pancreatitis requiring hospitalization or intravenous antibiotics (≥ 24 hours), defined according to TG18 and the revised Atlanta classification (moderate or severe disease, or clear need for inpatient management); and (4) Unplanned readmission or prolonged hospitalization (≥ 24 hours) clearly attributed to biliary pathology accompanied by relevant laboratory or imaging abnormalities. The available structured 30-day event-related variables according to primary outcome status are shown in Supplementary Table 1.
Events that did not meet the primary outcome definition included isolated transient biochemical abnormalities without biliary symptoms, outpatient visits without hospitalization (< 24 hours) without meeting the above criteria, purely diagnostic ERCP/magnetic retrograde cholangiopancreatography (MRCP) without therapeutic intervention, and visits lacking evidence of biliary etiology.
All analyses were performed using R version 4.2.0 (packages including glmnet, rms, pROC, and rmda), with two-sided P < 0.05 considered statistically significant. Continuous variables were summarized as mean ± SD or median (interquartile range), as appropriate, and categorical variables as n (%). Baseline characteristics between the training and validation cohorts were compared using the t-test or Wilcoxon rank-sum test for continuous variables and the χ2 test or Fisher’s exact test for categorical variables.
In the training cohort, LASSO logistic regression with 10-fold cross-validation was used for feature selection, with the binomial deviance across log(λ) values examined to identify λmin (the value with minimum mean deviance) and λ1se (the largest λ within one standard error of the minimum deviance, according to the “one-standard-error rule”) to obtain a more parsimonious model. Variables with non-zero coefficients at λ1se were entered into a multivariable logistic regression model to determine independent predictors, from which a final simplified model was developed and visualized as a nomogram.
Model performance in both the training and validation cohorts was assessed comprehensively using the area under the receiver operating characteristic curve (AUC) with 95%CI, Brier score, calibration-in-the-large (CITL; intercept), calibration slope, and calibration plots based on logistic and nonparametric smoothing. Bootstrap internal validation with 1000 resamples was performed to estimate potential optimism. Decision curve analysis (DCA) was further conducted to compare the net clinical benefit of the prediction model with “treat-all” and “treat-none” strategies across a range of threshold probabilities from 0.0 to 0.80, with particular emphasis on clinically relevant thresholds (e.g., 10%, 20%, and 30%).
A total of 287 adult patients undergoing LC were included, with 200 allocated to the training cohort and 87 to the validation cohort. The overall mean age was approximately 54.4 years; the distributions of sex, BMI, emergency surgery proportion, history of cholecystitis, pancreatitis/cholangitis, preoperative ERCP, liver biochemical indices, CBD diameter, and CBD/height index were generally comparable between the two cohorts. The prevalence of impacted neck stones showed a borderline difference (29.0% vs 40.2%, P = 0.083). Detailed baseline characteristics are presented in Table 1.
| Variable | All (n = 287) | Test (n = 87) | Train (n = 200) | P value |
| Age (year) | 54.40 (14.28) | 54.36 (13.67) | 54.42 (14.57) | 0.974 |
| BMI (kg/m2) | 26.90 (23.85, 30.15) | 27.20 (24.50, 30.20) | 26.75 (23.48, 30.13) | 0.417 |
| Sex | 1.000 | |||
| Male | 123 (42.86) | 37 (42.53) | 86 (43.00) | |
| Female | 164 (57.14) | 50 (57.47) | 114 (57.00) | |
| Emergency surgery | 0.903 | |||
| No | 228 (79.44) | 70 (80.46) | 158 (79.00) | |
| Yes | 59 (20.56) | 17 (19.54) | 42 (21.00) | |
| ≥ 2 prior hospitalizations for acute cholecystitis | 1.000 | |||
| No | 225 (78.40) | 68 (78.16) | 157 (78.50) | |
| Yes | 62 (21.60) | 19 (21.84) | 43 (21.50) | |
| Pancreatitis | 0.314 | |||
| No | 245 (85.37) | 71 (81.61) | 174 (87.00) | |
| Yes | 42 (14.63) | 16 (18.39) | 26 (13.00) | |
| Cholangitis | 1.000 | |||
| No | 257 (89.55) | 78 (89.66) | 179 (89.50) | |
| Yes | 30 (10.45) | 9 (10.34) | 21 (10.50) | |
| ERCP within 30 days pre-operative | 0.175 | |||
| No | 233 (81.18) | 66 (75.86) | 167 (83.50) | |
| Yes | 54 (18.82) | 21 (24.14) | 33 (16.50) | |
| Preoperative TBil (μmol/L) | 6.50 (3.30, 13.30) | 7.50 (3.35, 14.50) | 6.25 (3.30, 12.70) | 0.428 |
| Preoperative ALP (U/L) | 40.00 (40.00, 62.00) | 40.00 (40.00, 72.50) | 40.00 (40.00, 56.50) | 0.178 |
| Preoperative GGT (U/L) | 24.00 (15.00, 41.50) | 22.00 (15.00, 36.00) | 24.00 (15.00, 42.50) | 0.562 |
| Preoperative ALT (U/L) | 33.00 (23.00, 44.00) | 34.00 (21.00, 42.00) | 33.00 (23.00, 44.00) | 0.632 |
| Preoperative AST (U/L) | 30.00 (21.00, 40.00) | 28.00 (18.50, 41.00) | 31.00 (22.00, 40.00) | 0.283 |
| CBD diameter (mm) | 6.20 (5.30, 7.50) | 6.20 (5.25, 7.55) | 6.20 (5.40, 7.40) | 0.898 |
| CBD/height index (mm/m) | 3.77 (3.15, 4.45) | 3.67 (3.08, 4.69) | 3.82 (3.20, 4.39) | 0.766 |
| Ultrasound-suspected CBD stone/obstruction | 0.203 | |||
| No | 220 (76.66) | 62 (71.26) | 158 (79.00) | |
| Yes | 67 (23.34) | 25 (28.74) | 42 (21.00) | |
| Gallbladder wall thickening ≥ 4 mm | 0.643 | |||
| No | 164 (57.14) | 52 (59.77) | 112 (56.00) | |
| Yes | 123 (42.86) | 35 (40.23) | 88 (44.00) | |
| Impacted neck stone | 0.083 | |||
| No | 194 (67.60) | 52 (59.77) | 142 (71.00) | |
| Yes | 93 (32.40) | 35 (40.23) | 58 (29.00) |
LASSO logistic regression with 10-fold cross-validation was used for feature selection in the training cohort. In the coefficient path plot (Figure 1), regression coefficients shrank toward zero as log(λ) increased from approximately -9 to -2, with the number of non-zero coefficients progressively decreasing from 16 to 0.
In the cross-validation curve (Figure 2), λmin corresponded to the minimum mean binomial deviance, while λ1se was determined by the one-standard-error criterion, yielding a sparser solution. At λ1se, four variables remained with non-zero coefficients—preoperative TBil, GGT, CBD/height index, and ultrasound-suspected CBD stones/obstruction. These four predictors were carried forward as candidate variables for multivariable modeling.
In multivariable logistic regression including the four LASSO-selected variables, only preoperative TBil and the CBD/height index remained statistically significant independent predictors of 30-day clinically relevant biliary events, whereas GGT and ultrasound-suspected CBD stones/obstruction lost significance after adjustment (Figure 3). Detailed full-cohort model coefficients are provided in Supplementary Table 2.
Based on the final two-variable model (TBil and CBD/height index), a nomogram was constructed to estimate the individual probability of 30-day clinically relevant biliary events after LC (Figure 4). For a given patient, each predictor value is mapped to a corresponding point score, the points are summed, and the total point score is then translated into a predicted 30-day risk using the bottom probability scale.
In the training cohort, the model achieved an AUC of 0.881 (95%CI: 0.777-0.986; Figure 5A). In the validation cohort, the AUC was 0.902 (95%CI: 0.818-0.985), indicating good and stable discriminatory ability in both datasets (Figure 5B).
In the training cohort, calibration was excellent, with CITL (intercept) = approximately 0.000, calibration slope = 1.000, and Brier score = 0.051 (Figure 6A). In the validation cohort, calibration remained good (intercept = -0.051, slope = 1.029, Brier = 0.067; Figure 6B). Calibration plots in both cohorts showed close agreement between predicted and observed risks, with only mild underestimation at low-risk levels and slight overestimation at moderate-to-high risk levels in the validation cohort. Concordance indices (C-statistics) and Dxy statistics were also consistent with good model fit (e.g., training C = approximately 0.882, Dxy = approximately 0.763; validation C = approximately 0.902, Dxy = approximately 0.803). Bootstrap-based internal validation metrics are provided in Supplementary Table 3. Sensitivity analysis excluding patients who underwent preoperative ERCP within 30 days is summarized in Supplementary Table 4.
DCA demonstrated that, within a clinically relevant threshold probability range of approximately 0.05-0.60, the nomogram provided greater net benefit than both “treat-all” and “treat-none” strategies in both the training and validation cohorts. At commonly considered decision thresholds (e.g., 10%, 20%, and 30%), the model yielded positive net benefit, supporting its potential usefulness in guiding selective imaging or intervention strategies. Net benefit declined toward the extremes of very high thresholds but remained close to the zero line, indicating no substantial harm (Figure 7).
In this single-center retrospective cohort, we developed and internally validated a concise two-variable preoperative nomogram incorporating TBil and the CBD/height index to predict 30-day clinically relevant biliary events after LC. The model demonstrated robust discrimination, good calibration, and favorable net clinical benefit in both training and validation cohorts, and can be readily applied using routinely available preoperative laboratory and ultrasound data. These findings align with contemporary methodological standards emphasizing the combined assessment of discrimination, calibration, and clinical utility for prediction models[9-12].
From a pathophysiological and interpretive perspective, TBil reflects cholestasis and biliary obstruction, and has long been incorporated into pretest probability assessments for CBD stones. The 2019 ASGE guideline integrates bilirubin levels, CBD dilatation, and suspected CBD stones on imaging to stratify the probability of choledocholithiasis and to guide ERCP or additional imaging[4]. Our results further confirm that elevated preoperative TBil is independently associated with short-term clinically relevant biliary events after LC, reinforcing its role as a functional marker of biliary burden.
CBD diameter is a key structural parameter; however, the use of a fixed absolute cut-off (e.g., 6-8 mm) does not fully accommodate individual anatomical variability influenced by age, body size, and post-cholecystectomy changes[5,6,13]. By indexing CBD diameter to height, the CBD/height index offers a simple adjustment for body habitus and may mitigate systematic bias associated with uniform thresholds. In our study, the CBD/height index was a stable independent predictor after adjustment, suggesting that height-normalized biliary tract caliber better reflects the relative structural load of bile drainage and improves risk stratification for post-LC biliary events. This concept is consistent with prior work adjusting CBD diameter for demographic or anatomical factors, but here it is applied specifically to 30-day clinically relevant biliary outcomes[13,14].
Compared with earlier studies that focus primarily on intraoperative difficulty, bile duct injury, or general readmission risk, our model targets a clearly defined composite of clinically relevant biliary events within 30 days and restricts predictors to preoperative variables obtainable in routine practice. The resulting nomogram balances simplicity and performance: It relies only on TBil and the CBD/height index, yet achieves AUCs above 0.88 with good calibration and positive net benefit across practical decision thresholds. This suggests that integrating a continuous cholestasis marker with a height-normalized structural index can yield a pragmatic and interpretable tool for preoperative individualized risk assessment.
The slightly higher AUC observed in the validation cohort may reflect sampling variability due to the limited number of events, differences in case-mix (e.g., clearer separation in key predictors), or random variation in measurement error. Bootstrap-based internal validation and comprehensive reporting of calibration metrics according to TRIPOD help mitigate concerns regarding optimism and overfitting, supporting the model’s robustness and potential transportability[9,11,12].
Several variables that showed univariable associations, such as GGT and ultrasound-suspected CBD stones/obstruction, did not remain independent predictors in the multivariable model. This may relate to collinearity with TBil and the CBD/height index, limited event numbers, or misclassification within routine ultrasound assessments. Similarly, preoperative ERCP did not confer a strong protective effect against the composite endpoint, which could be influenced by selection bias (higher-risk patients more often undergo ERCP) and the possibility of residual or recurrent stones and procedure-related complications even after endoscopic clearance[15]. These findings underscore the value of par
Clinically, the proposed nomogram can be applied at admission or in the outpatient setting to rapidly estimate an individual patient’s 30-day biliary event risk after LC. For patients with high predicted risk, clinicians may consider more intensive perioperative management, selective use of MRCP or endoscopic ultrasonography (EUS), early postoperative surveillance, tailored discharge planning, or closer follow-up. For low-risk patients, unnecessary invasive procedures and resource utilization may be reduced. The DCA results indicate that within widely used risk thresholds (approximately 10%-30%), adopting the model-based strategy yields higher net benefit than blanket “treat-all” or “treat-none” approaches, supporting its potential integration into clinical pathways and electronic health record-based decision support systems[10].
This study has limitations. First, it is a single-center retrospective analysis with a relatively small number of events, and risks of overfitting and selection bias cannot be fully excluded. Second, the composite outcome, although defined based on TG18, the revised Atlanta classification, and ASGE criteria, remains heterogeneous and may be influenced by local practice patterns in imaging and intervention. Third, important anatomical details from MRCP/EUS or intraoperative cholangiography were not systematically incorporated, which might further refine risk prediction in selected subsets. Finally, external validation in multicenter, prospective cohorts is needed to confirm generalizability, recalibrate decision thresholds, and evaluate the model’s effectiveness in reducing unnecessary ERCP and 30-day biliary-related readmissions[15-18].
We developed and internally validated a simple, interpretable, and clinically useful preoperative prediction model for 30-day clinically relevant biliary events after LC, based solely on TBil and the CBD/height index. If externally validated and appropriately recalibrated, this two-variable nomogram may serve as a practical quantitative tool for individualized risk assessment, perioperative decision-making, and optimization of resource allocation in patients undergoing LC.
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