Gallbladder Damage Control: Compromised Procedure for Compromised Patients

Justin Lee, MD, Reza Kermani, MD, Haisar Dao, MD, Kevin F O’donnell, MD. St. Elizabeth Medical Center, Tufts University School of Medicine

 

Introduction
As experience of open cholecystectomy has decreased significantly in the past two decades both in surgical practice and training, open cholecystectomy is generally performed for severe inflammation necessitating conversion to an open procedure or suspected malignancy. Literature describes partial cholecystectomy (PC), laparoscopic partial cholecystectomy (LPC), and trocar cholecystostomy (TC) in an effort to avoid common bile duct injury. PC however is not without complications with recent case reports of recurrent biliary stone and “stump” cholecystitis. The objectives of this study were to 1) analyze recent nine year trends in utilization of PC, LPC, and TC, 2) characterize patient and hospital variables, and 3) identify associated variables for common bile duct injury. 

Methods
Retrospective cohort analysis of the Nationwide Inpatient Sample (NIS) files from 2000 to 2008 was performed. For the purpose of the study, gallbladder damage control was defined as PC, LPC, and TC. Data analysis included patient demographics, diagnoses, procedures, complications, hospital characteristics, length of stay, total hospital charges, and inpatient mortality.

Results
A national estimate of 10,872 gallbladder damage control cases were identified, characterized by mean age 61.12 (0.18, SEM) years old, 50.6% female, 67.9% white, and 14.5% Hispanic. Most common diagnoses were, calculus gallbladder cholecystitis (49.4%), acalculus cholecystitis (20.9%), and pancreatitis (10.7%). Procedures performed included PC (47.8%), LPC (27.2%), TC (25.3%), and intraoperative cholangiogram (IOC) (19.7%). 13.6% postoperative complications were identified, including pulmonary complications (4.3%), hemorrhage/hematoma/seroma (3.4%), and accidental puncture or laceration during procedure (3.3%). Common bile duct injury occurred in 3.3% overall. Hospital characteristics included non-teaching (82.1%), urban hospitals (67.8%), and regional variations of 42.1% from the South and 45.2% from the West. Inpatient outcomes included: mean length of stay of 11.4 days (0.16, SEM), mean total hospital charge of $71,296.69 (1106.03, SEM), 7.4% mortality, and 16.8% discharges to skilled nursing facility. Multivariate logistic regression analysis identified assoicated variables for common bile duct injury: pancreatitis (1.38 OR, 1.03-1.86 CI, P=0.031), open PC (2.98 OR, 2.18-4.07 CI, P<0.001), and teaching hospitals (1.48 OR, 1.13-1.94 CI, P=0.004). IOC was a commonly associated procedure in the setting of common bile duct injury (2.03 OR, 1.59-2.59 CI, P<0.001).

Conclusion
Various circumstances may require gallbladder damage control with PC, LPC, and TC. Postoperative complications and common bile duct injury remain significantly high despite limited resection. We found pancreatitis, open PC, use of IOC, and teaching status of hospitals to be associated with common bile duct injury. High morbidity and mortality of gallbladder damage control may reflect both compromised nature of the procedures and multiple comorbidities.
 

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Session Number: ResFel – Residents/Fellows Scientific Session
Program Number: S135