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


CONCLUSIONS
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.
Kaafarani
Haytham M A
HM
Department of Surgery, VA Boston Healthcare System, West Roxbury, MA, USA.
Smith
Tracy Schifftner
TS
Neumayer
Leigh
L
Berger
David H
DH
Depalma
Ralph G
RG
Itani
Kamal M F
KM
D000328:Adult; D000368:Aged; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000706:statistics & numerical data* / Q000639:trends*; D015331:Cohort Studies; D016208:Databases, Factual; D005260:Female; D005705:Gallbladder Diseases / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D006787:Hospitals, Veterans; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States