Predictors of Major Complication Following Laparoscopic Cholecystectomy: Surgeon, Hospital or Patient?
Melissa M. Murphy, MD, MPH, Shimul A. Shah, MD, Jessica P. Simmons, MD, Nicholas G. Csikesz, BS, Sing-Chau Ng, MS, Jennifer F. Tsend, MD, MPH
University of Massachusetts Medical School, Worcester, MA
PURPOSE OF STUDY
Regionalization of care has been proposed for complex operations based on hospital/surgeon volume-mortality relationships. Controversy exists whether common surgeries should be performed at high-volume centers. Using mortality to assess routine operations is hampered by low perioperative mortality. We used a large national database to analyze the risk of major in-hospital complications following laparoscopic cholecystectomy (LC).
Patients undergoing LC were identified in the Nationwide Inpatient Sample 1998-2006 from states with surgeon/hospital identifiers. Previously validated major complications including acute MI, pulmonary compromise, postoperative infection,
SUMMARY OF RESULTS
1,102,071 weighted patient-discharges were identified with a complication rate of 6.7%. Univariate analyses: Advanced age, male sex, higher Charlson score were associated with higher complications (p<.0001). Higher surgeon-volume (≥39/year vs. <12/year) and higher hospital-volume (≥225/year vs. <120/year) were associated with fewer complications (6.5% vs. 6.9%, 6.8% vs. 6.3%, respectively; p<.0001). Multivariable analysis: Advanced age (≥65 years vs. <65, adjusted odds ratio (AOR) 1.77; 95% confidence interval (CI) 1.61-1.94), male sex (AOR 1.15; 95% CI 1.11-1.19), and comorbidities (Charlson score 2 vs. 1, AOR 2.4; 95% CI 2.27-2.58) were associated with complications. Neither surgeon nor hospital volume was independently associated with increased risk of complications.
Major in-hospital complications following LC are associated with individual patient characteristics, rather than surgeon or hospital operative volumes. These results suggest regionalization of general surgical procedures may be unnecessary. Rather, careful patient selection and preoperative preparation may diminish overall complication rates.