title: Predictors of major complications after laparoscopic cholecystectomy: surgeon, hospital, or patient?
abstract: BACKGROUND
  Regionalization of care has been proposed for complex operations based on hospital/surgeon volume-mortality relationships. Controversy exists about whether more common procedures should be performed at high-volume centers. Using mortality alone to assess routine operations is hampered by relatively low perioperative mortality. We used a large national database to analyze the risk of major in-hospital complications after laparoscopic cholecystectomy (LC).
  
  
  METHODS
  Patients undergoing LC were identified in the Nationwide Inpatient Sample 1998-2006 from states with surgeon/hospital identifiers. Previously validated major complications including acute myocardial infarction, pulmonary compromise, postoperative infection, deep vein thrombosis, pulmonary embolism, hemorrhage, and reoperation were assessed. Univariate and multivariable analyses were performed and independent risk factors of complications were identified.
  
  
  RESULTS
  A total of 1,102,071 weighted patient discharges were identified, with a complication rate of 6.8%. Univariate analyses showed that advanced age, male gender, and higher Charlson Comorbidity Score were associated with higher complication rates (p < 0.0001). Higher surgeon volume (>or=36/year versus <12/year) and higher hospital volume (>or=225/year versus <or=120/year) were associated with fewer complications (6.7% versus 7.0%, 6.4% versus 7.0%, respectively; p < 0.0001). Multivariable analysis showed that advanced age (65 years or older versus younger than 65 years; adjusted odds ratio [AOR] = 2.16; 95% CI, 2.01-2.32), male gender (AOR = 1.14; 95% CI, 1.10-1.19), and comorbidities (Charlson Comorbidity Score 2 versus 0; AOR = 2.49; 95% CI, 2.34-2.65) were associated with complications. Neither surgeon nor hospital volume was independently associated with increased risk of complications.
  
  
  CONCLUSIONS
  Major in-hospital complications after LC are associated with individual patient characteristics rather than surgeon or hospital operative volumes. These results suggest regionalization of general surgical procedures might be unnecessary. Rather, careful patient selection and preoperative preparation can diminish overall complication rates.
authors.affiliation: Department of Surgery, Surgical Outcomes Analysis and Research, University of Massachusetts Medical School, Worcester, MA 01655, USA.
authors.forename: Melissa M
authors.initials: MM
authors.lastname: Murphy
authors.forename: Sing-Chau
authors.initials: SC
authors.lastname: Ng
authors.forename: Jessica P
authors.initials: JP
authors.lastname: Simons
authors.forename: Nicholas G
authors.initials: NG
authors.lastname: Csikesz
authors.forename: Shimul A
authors.initials: SA
authors.lastname: Shah
authors.forename: Jennifer F
authors.initials: JF
authors.lastname: Tseng
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D016009:Chi-Square Distribution; D017081:Cholecystectomy, Laparoscopic; D015897:Comorbidity; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D012307:Risk Factors; D014481:United States / Q000453:epidemiology