Cheguevara Afaneh, MD, Jonathan Abelson, MD, Barrie Rich, MD, Gregory Dakin, MD, Raza Zarnegar, MD, Philip S Barie, MD, MBA, Thomas J Fahey III, MD, Alfons Pomp, MD. Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center.
INTRODUCTION: The purpose of our study was to compare outcomes of surgeons who have completed additional training in a laparoscopic fellowship to those surgeons without additional formal laparoscopic training when performing laparoscopic cholecystectomies (LC) in patients with acute biliary disease.
METHODS: We retrospectively reviewed 1383 consecutive patients who underwent a LC for acute cholecystitis, gallstone pancreatitis, choledocholithiasis, cholangitis, biliary colic/symptomatic cholelithiasis, biliary dyskinesia, gallbladder polyps, chronic cholecystitis, and adenomyosis of the gallbladder from January 2008 to August 2011. A total of 9 surgeons participated in the study (3 with advanced laparoscopic training). We then selected the 592 consecutive patients who underwent a LC for an acute process, including acute cholecystitis, gallstone pancreatitis, choledocholithiasis and acute cholangitis. Preoperative variables included demographics, body mass index (BMI), ASA score, and abdominal surgical history. Surgical variables included number of ports, total operative time, estimated blood loss (EBL), conversion data, performance of an intraoperative cholangiogram (IOC), complication rate, morbidity, and length of stay (LOS). Our primary end-points were conversion rates and surgical morbidity. Our secondary end-point was length of stay.
RESULTS: Demographics, ASA score, and history of previous abdominal surgery did not differ between the two groups (Table 1). The fellowship trained group (Fellowship Group) operated on patients with significantly higher BMI (35.6±14.4 vs. 33.3±13.7 kg/m2, respectively; P=0.005), performed significantly more single-incision LC (SILC) (5.5% vs. 0%, respectively; P<0.0001) and IOCs (57% vs. 20%, respectively; P<0.0001). Total operative time was significantly longer in the Fellowship Group (111±42 vs. 104±39 min, respectively; P=0.04). However, conversion rates were significantly lower in the Fellowship Group (1.7% vs 8.5%, respectively; P=0.0004). There was no difference in EBL, and postoperative surgical morbidity. The intraoperative complication rate was almost twice as high in the non-fellowship trained group; however, this did not reach statistical significance (4.8% vs. 2.5%, respectively; P=0.20). The LOS was significantly lower in the Fellowship Group (median 28 hrs vs. 39 hrs, respectively; P=0.03). On multivariate analysis (MVA), the most significant predictor of avoiding conversion and intraoperative complications were fellowship training (OR 0.211±0.478, 95% CI: 0.089-0.503; P<0.0001) and (OR 0.371±0.082, 95% CI: 0.177-0.779; P=0.009), respectively. The most predictive variable on MVA of a postoperative complication was ASA score (OR 2.656±0.695, 95% CI: 1.590-4.437; P<0.0001).
CONCLUSION: Our data demonstrates that advanced laparoscopic surgical training decreases the need for conversion during LC for an acute process. Moreover, intraoperative complication rates may be decreased with advanced laparoscopic training.