title: Growing use of laparoscopic cholecystectomy in the national Veterans Affairs Surgical Risk Study: effects on volume, patient selection, and selected outcomes.
abstract: OBJECTIVE
  To study the introduction of laparoscopic cholecystectomy to the 43 tertiary-care university-affiliated Veterans Administration medical centers (VAMCs) participating in the National Veterans Affairs Surgical Risk Study from October 1991 through December 1993.
  
  
  BACKGROUND
  Previous studies in the private sector have documented growth in the number of cholecystectomies and falling clinical thresholds for cholecystectomy with the introduction of laparoscopic cholecystectomy.
  
  
  METHODS
  The following were analyzed for changes over time: measures of patient preoperative risk, complexity of surgery, severity of biliary disease, numbers of procedures, postoperative length of stay, and 30-day postoperative mortality and general complication rates.
  
  
  RESULTS
  The number of cholecystectomies performed laparoscopically increased, but the total number of cholecystectomies performed remained stable over time. The proportion of patients with acute cholecystitis, emergent cholecystectomies, and technically complex cholecystectomies did not change or increased slightly over time. Adjusted odds for postoperative general complications were lower for laparoscopic than for open cholecystectomy, but 30-day postoperative mortality and general complication rates for all cholecystectomies remained constant over time. Postoperative length of stay for all cholecystectomies fell significantly. Implementation rates of laparoscopic cholecystectomy varied widely between hospitals. Laparoscopic cholecystectomy was adopted more slowly and used in a lower percentage of cholecystectomies than in non-VA settings.
  
  
  CONCLUSIONS
  In contrast to non-VA studies showing increases in overall cholecystectomy volume since the introduction of laparoscopic cholecystectomy, these VAMCs implemented laparoscopic cholecystectomy without growth in cholecystectomies or a change in the clinical threshold for cholecystectomy. Laparoscopic cholecystectomy was associated with better outcomes, but its introduction in the setting of stable cholecystectomy volume and biliary disease case mix did not change postoperative mortality and complication rates. The stable cholecystectomy volume and biliary disease case mix, slower adoption, and lower use of laparoscopic cholecystectomy contrast with previous reports and may result from differences in patients and organization and financing of VA versus non-VA settings.
authors.affiliation: Department of Medicine, Brockton/West Roxbury VAMC.
authors.forename: A Y
authors.initials: AY
authors.lastname: Chen
authors.forename: J
authors.initials: J
authors.lastname: Daley
authors.forename: T N
authors.initials: TN
authors.lastname: Pappas
authors.forename: W G
authors.initials: WG
authors.lastname: Henderson
authors.forename: S F
authors.initials: SF
authors.lastname: Khuri
mesh_terms: D000368:Aged; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000401:mortality / Q000706:statistics & numerical data*; D005260:Female; D019538:Health Care Surveys; D006787:Hospitals, Veterans / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D018579:Patient Selection; D011446:Prospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs