Jesse R Gutnick, MD, Allan E Siperstein, MD. Cleveland Clinic
INTRODUCTION
The National Surgical Quality Improvement (NSQIP) database provides an opportunity to observe practice patterns for cholecystectomy.
METHODS AND PROCEDURES
66103 laparoscopic (LC) and open cholecystectomies (OC) +/- intra-operative cholangiograms (+IOC) and common bile duct explorations (+CBDE) were extracted from the NSQIP database (2007-2009) and analyzed with JMP Version 9.
RESULTS
Overall, LC=88.4%, Converted to OC=1.9%, OC=9.7%.
| Chole only | Chole+IOC only | Chole+IOC+CBDE | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Procedure | % | Time(SE) | % | Time(SE) | % | Time(SE) | |||
| LC | 74.7 | 65.2(0.2) | 24.7 | 73.1(0.3) | 0.5 | 123.1(2.0) | |||
| Converted | 78.3 | 126.1(1.8) | 17.4 | 157.6(3.9) | 4.4 | 195.8(7.7) | |||
| OC | 75.9 | 118.9(1.0) | 17.6 | 144.4(2.0) | 6.5 | 169.0(3.3) |
(Table 1: all p<0.0001 (SE=standard error))
Elevated bilirubin, aspartate transaminase, alkaline phosphatase are pre-operative risk factors for choledocholithiasis. In patients with 0, 1, 2, 3 risk factors elevated, IOC was performed in 24.2%, 30.0%, 37.8%, 41.5%, and IOC+CBDE was performed in 0.7%, 1.5%, 3.5%, 7.8% of patients (p<0.0001).
Cholecystectomy cases were performed by: attending alone in 37.6%, attending in the operating room with resident in 61.2%, attending in the operating suite in 0.9%, with attending not present or not entered in 0.3%.
| Attending Alone | Attending with Resident | Attending in Suite | ||||||||||
| Procedure | % | Time(SE) | Complication% | % | Time(SE) | Complication% | % | Time(SE) | Complication% | |||
| LC | 91.8 | 54.2(0.2) | 3.9 | 86.4 | 75.8(0.2) | 3.8 | 81.4 | 82.0(2.0) | 5.3 | |||
| Converted | 1.4 | 116.0(1.7) | 16.2 | 2.3 | 114.3(1.4) | 17.8 | 1.5 | 155.1(15.0) | 22.2 | |||
| OC | 6.8 | 105.5(0.8) | 19.2 | 11.3 | 134.0(0.6) | 20.3 | 17.1 | 136.6(4.4) | 21.1 |
(Table 2: all p<0.0001, except p>0.1 for complications rate by attending involvement)
| Attending Alone | Attending with Resident | Attending in Suite | ||||||||||
| Procedure | % | Time(SE) | Complication% | % | Time(SE) | Complication% | % | Time(SE) | Complication% | |||
| Chole-only | 67.3 | 55.7(2.1) | 5.0 | 7.5 | 79.8(0.3) | 5.8 | 82.7 | 88.2(2.2) | 7.9 | |||
| Chole+IOC | 31.7 | 63.1(0.4) | 5.1 | 21.2 | 94.3(0.5) | 5.9 | 16.3 | 112.8(5.1) | 5.8 | |||
| Chole+IOC+CBDE | 1.0 | 117.9(2.1) | 15.1 | 1.3 | 169.5(2.0) | 18.3 | 1.0 | 136.2(20.1) | 33.3 |
(Table 3: chole-only complication rate p=0.0009, other complication rates p>0.05, other p<0.0001)
Morbidity for all cholecystectomies, LC, Converted to OC, OC: 5.7%, 3.9%, 17.4%, 20.1% (p<0.0001). Return to operating room rate: 1.4% overall, LC 1.1%, Converted to OC 2.8%, OC 3.8% (p<0.0001).
CONCLUSIONS
This large dataset reveals several patterns. Operative times are longer, conversion rates are higher, and OC are more common with resident involvement, but complication rates are negligibly higher, and may reflect case mix. OC and Converted cases have comparable operating times and rates for morbidity, return to operating room, IOC, and CBDE, suggesting that conversion is most likely for elective indications other than choledocholithiasis, rather than intra-operative mishaps. IOC is performed less frequently than one would expect based on this dataset, i.e. pre-operative risk of choledocholithiasis and the minimal additional time for LC+IOC, or based on SAGES guidelines and teaching priorities. Similarly, LC+CBDE is rare in this dataset, despite its demonstrated utility. These data suggest that resident training in cholecystectomy is safe, but indicates missed opportunities to perform IOC and laparoscopic CBDE.
Session Number: SS04 – Quality Outcomes
Program Number: S019