Vamsi V Alli, MD, Jie Yang, PhD, Jianjin Xu, Andrew T Bates, MD, Aurora D Pryor, MD, Mark A Talamini, Dana A Telem. Stony Brook Medicine
In the 30 years since the first laparoscopic cholecystectomy, we have seen modifications in technique, evolution of instruments and streamlined postoperative management. Continued experience and comfort with laparoscopic cholecystectomy has led to its entry into the ambulatory arena. We asked whether this migration to an outpatient setting combined with increased penetrance of laparoscopy has had any impact on the indications for cholecystectomy over time.
The New York State Planning and Research Cooperative System (NY SPARCS) longitudinal administrative database was utilized to identify patients who underwent cholecystectomy between 1995 & 2013. ICD-9 and CPT procedure codes were extracted corresponding to laparoscopic and open cholecystectomy and associated primary diagnostic codes. Data was analyzed as relative change in incidence (normalized to 1000 cholecystectomy patients) for respective diagnoses. An increase in state population of 7.85% was used to correct for population growth, according to US Census data.
From 1995 to 2013, 711,406 patients underwent cholecystectomy in NY State, of which 637,308 (89.58%) underwent laparoscopic cholecystectomy. The overall incidence of cholecystectomy has not increased (1.23% increase with a commensurate population increase of 7.85%). The distribution of indications for cholecystectomy during this time was: 65% for acute calculus cholecystitis(n=130,661), 11% for biliary colic (n=22,436), 7% for acalculus cholecystitis (n=13,813), 3% for gallstone pancreatitis (n=5,853), and 1% for biliary dyskinesia (n=2,951). While acute calculus cholecystitis as an indication declined by 20% (p<0.0001) over 19 years, other primary diagnoses increased in incidence as follows: biliary colic (+54.96%, p=0.0013), acalculus cholecystitis (+94.24%, p<0.0001), gallstone pancreatitis (+107.48%, p<0.0001), and biliary dyskinesia (+331.74%, p<0.0001). Ambulatory cholecystectomy has increased dramatically, with only 0.12% of cholecystectomies being performed as outpatient in 1995 but increased by 382 fold to 45.94% in 2013.
An increase in operative volumes in response to the adoption of laparoscopic cholecystectomy was not borne out in our series. A shift in the distribution of diagnoses may reflect that patients with symptomatic cholelithiasis are undergoing operations earlier in their disease course, prior to the development of acute calculus cholecystitis. In addition, we observed a marked increase in the proportion of operations performed for other indications, most notably with biliary dyskinesia demonstrating a 332 fold change over the 19 year span of this study.