Skip to main content
NCBI home page
Annals of Surgery logoLink to Annals of Surgery
. 1998 Jan;227(1):12–24. doi: 10.1097/00000658-199801000-00003

Growing use of laparoscopic cholecystectomy in the national Veterans Affairs Surgical Risk Study: effects on volume, patient selection, and selected outcomes.

A Y Chen 1, J Daley 1, T N Pappas 1, W G Henderson 1, S F Khuri 1
PMCID: PMC1191167  PMID: 9445105

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. SUMMARY BACKGROUND DATA: 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.

Full text

PDF
12

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Charlson M. E., Pompei P., Ales K. L., MacKenzie C. R. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–383. doi: 10.1016/0021-9681(87)90171-8. [DOI] [PubMed] [Google Scholar]
  2. Diehl A. K. Laparoscopic cholecystectomy. Too much of a good thing? JAMA. 1993 Sep 22;270(12):1469–1470. doi: 10.1001/jama.270.12.1469. [DOI] [PubMed] [Google Scholar]
  3. Escarce J. J., Bloom B. S., Hillman A. L., Shea J. A., Schwartz J. S. Diffusion of laparoscopic cholecystectomy among general surgeons in the United States. Med Care. 1995 Mar;33(3):256–271. doi: 10.1097/00005650-199503000-00005. [DOI] [PubMed] [Google Scholar]
  4. Escarce J. J., Chen W., Schwartz J. S. Falling cholecystectomy thresholds since the introduction of laparoscopic cholecystectomy. JAMA. 1995 May 24;273(20):1581–1585. [PubMed] [Google Scholar]
  5. Fendrick A. M., Escarce J. J., McLane C., Shea J. A., Schwartz J. S. Hospital adoption of laparoscopic cholecystectomy. Med Care. 1994 Oct;32(10):1058–1063. doi: 10.1097/00005650-199410000-00007. [DOI] [PubMed] [Google Scholar]
  6. Fisher E. S., Welch H. G. The future of the Department of Veterans Affairs health care system. JAMA. 1995 Feb 22;273(8):651–655. [PubMed] [Google Scholar]
  7. Fleming C., Fisher E. S., Chang C. H., Bubolz T. A., Malenka D. J. Studying outcomes and hospital utilization in the elderly. The advantages of a merged data base for Medicare and Veterans Affairs hospitals. Med Care. 1992 May;30(5):377–391. doi: 10.1097/00005650-199205000-00001. [DOI] [PubMed] [Google Scholar]
  8. Goldschmid S., Brady P. G. Approaches to the management of cholelithiasis for the medical consultant. Med Clin North Am. 1993 Mar;77(2):413–426. doi: 10.1016/s0025-7125(16)30260-7. [DOI] [PubMed] [Google Scholar]
  9. Goldsmith M. F. Future surgery: minimal invasion. JAMA. 1990 Dec 5;264(21):2723–2723. [PubMed] [Google Scholar]
  10. Greer A. L. Medical technology and professional dominance theory. Soc Sci Med. 1984;18(10):809–817. doi: 10.1016/0277-9536(84)90148-5. [DOI] [PubMed] [Google Scholar]
  11. Harness J. K., Strodel W. E., Talsma S. E. Symptomatic biliary tract disease in the elderly patient. Am Surg. 1986 Aug;52(8):442–445. [PubMed] [Google Scholar]
  12. Kane R. L., Lurie N., Borbas C., Morris N., Flood S., McLaughlin B., Nemanich G., Schultz A. The outcomes of elective laparoscopic and open cholecystectomies. J Am Coll Surg. 1995 Feb;180(2):136–145. [PubMed] [Google Scholar]
  13. Khuri S. F., Daley J., Henderson W., Barbour G., Lowry P., Irvin G., Gibbs J., Grover F., Hammermeister K., Stremple J. F. The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg. 1995 May;180(5):519–531. [PubMed] [Google Scholar]
  14. Larson G. M., Vitale G. C., Casey J., Evans J. S., Gilliam G., Heuser L., McGee G., Rao M., Scherm M. J., Voyles C. R. Multipractice analysis of laparoscopic cholecystectomy in 1,983 patients. Am J Surg. 1992 Feb;163(2):221–226. doi: 10.1016/0002-9610(92)90105-z. [DOI] [PubMed] [Google Scholar]
  15. Legorreta A. P., Silber J. H., Costantino G. N., Kobylinski R. W., Zatz S. L. Increased cholecystectomy rate after the introduction of laparoscopic cholecystectomy. JAMA. 1993 Sep 22;270(12):1429–1432. [PubMed] [Google Scholar]
  16. Lygidakis N. J. Operative risk factors of cholecystectomy-choledochotomy in the elderly. Surg Gynecol Obstet. 1983 Jul;157(1):15–19. [PubMed] [Google Scholar]
  17. Menon D., Marshall D. Diffusion of laparoscopic cholecystectomy in Canada. Int J Technol Assess Health Care. 1994 Spring;10(2):287–292. doi: 10.1017/s0266462300006243. [DOI] [PubMed] [Google Scholar]
  18. Orlando R., 3rd, Russell J. C., Lynch J., Mattie A. Laparoscopic cholecystectomy. A statewide experience. The Connecticut Laparoscopic Cholecystectomy Registry. Arch Surg. 1993 May;128(5):494–499. doi: 10.1001/archsurg.1993.01420170024002. [DOI] [PubMed] [Google Scholar]
  19. Perissat J., Vitale G. C. Laparoscopic cholecystectomy: gateway to the future. Am J Surg. 1991 Mar;161(3):408–408. doi: 10.1016/0002-9610(91)90609-h. [DOI] [PubMed] [Google Scholar]
  20. Ransohoff D. F., McSherry C. K. Why are cholecystectomy rates increasing? JAMA. 1995 May 24;273(20):1621–1622. [PubMed] [Google Scholar]
  21. Rosen A. K., Ash A. S., Geraci J. M., McCarthy E. P., Moskowitz M. A. Postoperative adverse events of cholecystectomy in the Medicare population. Am J Med Qual. 1995 Spring;10(1):29–37. doi: 10.1177/0885713X9501000106. [DOI] [PubMed] [Google Scholar]
  22. Scott W. R. Managing professional work: three models of control for health organizations. Health Serv Res. 1982 Fall;17(3):213–240. [PMC free article] [PubMed] [Google Scholar]
  23. Soper N. J., Brunt L. M., Kerbl K. Laparoscopic general surgery. N Engl J Med. 1994 Feb 10;330(6):409–419. doi: 10.1056/NEJM199402103300608. [DOI] [PubMed] [Google Scholar]
  24. Steiner C. A., Bass E. B., Talamini M. A., Pitt H. A., Steinberg E. P. Surgical rates and operative mortality for open and laparoscopic cholecystectomy in Maryland. N Engl J Med. 1994 Feb 10;330(6):403–408. doi: 10.1056/NEJM199402103300607. [DOI] [PubMed] [Google Scholar]
  25. Twomey P. General surgery. JAMA. 1993 Jul 14;270(2):211–213. [PubMed] [Google Scholar]
  26. Vitale G. C., Collet D., Larson G. M., Cheadle W. G., Miller F. B., Perissat J. Interruption of professional and home activity after laparoscopic cholecystectomy among French and American patients. Am J Surg. 1991 Mar;161(3):396–398. doi: 10.1016/0002-9610(91)90606-e. [DOI] [PubMed] [Google Scholar]
  27. White J. V. Laparoscopic cholecystectomy: the evolution of general surgery. Ann Intern Med. 1991 Oct 15;115(8):651–653. doi: 10.7326/0003-4819-115-8-651. [DOI] [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES