The American Journal of Surgery
Volume 200, Issue 1 , Pages 32-40, July 2010

Trends, outcomes, and predictors of open and conversion to open cholecystectomy in Veterans Health Administration hospitals

  • Haytham M.A. Kaafarani, M.D., M.P.H.

      Affiliations

    • Department of Surgery, VA Boston Healthcare System, West Roxbury, MA, USA
    • ,
  • Tracy Schifftner Smith, M.S.

      Affiliations

    • Department of Veterans Affairs, Eastern Colorado Healthcare System, Denver, CO, USA
    • ,
  • Leigh Neumayer, M.D., M.S.

      Affiliations

    • Department of Surgery, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
    • ,
  • David H. Berger, M.D., M.H.C.M.

      Affiliations

    • Department of Surgery, Michael E. DeBakey VA Medical Center, Houston, TX, USA
    • ,
  • Ralph G. DePalma, M.D.

      Affiliations

    • Patient Care Services, Department of Veterans Affairs Central Office, Washington, DC, USA
    • ,
  • Kamal M.F. Itani, M.D.

      Affiliations

    • Department of Surgery, VA Boston Healthcare System, West Roxbury, MA, USA
    • Corresponding Author InformationCorresponding author. Tel.: +1 857 203 6205; fax: +1 857 203 5549

Received 8 July 2009; received in revised form 31 July 2009

Abstract 

Background

Laparoscopic cholecystectomy (LC) accounts for more than 85% of cholecystectomies. Factors prompting open cholecystectomy (OC) or conversion from LC to OC (CONV) are not completely understood.

Methods

Prospectively collected data from the National Surgical Quality Improvement Program (NSQIP) were combined with administrative data to identify patients undergoing cholecystectomy from October 2005 to October 2008. Three cohorts were defined: LC, OC, and CONV. Using logistic hierarchical modeling, we identified predictors of the choice of OC and the decision to CONV.

Results

A total of 11,669 patients underwent cholecystectomy at 117 VA hospitals, including 9,530 LC (81.7%). While the rate of conversion from LC to OC remained stable over the study period (9.0% overall), the percentage of OC decreased from 11.5% in 2006 to 10.1% in 2007 and 8.9% in 2008 (P = .0002). Compared with LC, the OC cohort had more comorbidities (35 of 41 preoperative characteristics, all P <.05), a higher 30-day morbidity rate (18.7% vs 4.8%. P <.0001), and a higher 30-day mortality rate (2.4% vs .4%, P <.0001). American Society of Anesthesiologist (ASA) class, patient comorbidities (eg, ascites, bleeding disorders, pneumonia) and functional status predicted a choice of OC. Age, preoperative albumin, previous abdominal surgery and emergency status predicted OC and CONV (all P <.05). A higher hospital conversion rate was independently predictive of OC (odds ratio [1% rate increase]: 1.05 [1.02–1.07]; P = .0004).

Conclusion

In the last 3 years, there has been a trend towards performing fewer OCs in VA hospitals. More patient comorbidities and higher hospital-level conversion rates are predictive of the choice to perform or convert to OC.

Keywords: Laparoscopic cholecystectomy, Open cholecystectomy, Conversion rate, Surgical outcomes, Mortality, Morbidity, Predictors, Secular trends, Quality of care

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PII: S0002-9610(09)00651-5

doi:10.1016/j.amjsurg.2009.08.020

The American Journal of Surgery
Volume 200, Issue 1 , Pages 32-40, July 2010

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