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The American Journal of Surgery (2009) 197, 781-784

Clinical Surgery-American

of Surgery (2009) 197, 781-784 Clinical Surgery-American Surgical outcomes of open cholecystectomy in the

Surgical outcomes of open cholecystectomy in the laparoscopic era

Andrea S. Wolf, M.D., Bram A. Nijsse, B.S., Suzanne M. Sokal, M.S.P.H., Yuchiao Chang, Ph.D., David L. Berger, M.D.*

Department of Surgery, Massachusetts General Hospital, Boston, MA, USA

KEYWORDS:

Cholecystitis; Cholelithiasis; Laparoscopic conversion to open procedure; Laparoscopy; Open cholecystectomy

Abstract BACKGROUND: Although laparoscopic cholecystectomy has become the standard of care for symptomatic cholelithiasis and cholecystitis, 10% to 30% of cholecystectomies are still performed in open fashion. Because the total number of cholecystectomies is increasing with time, the average patient undergoing open cholecystectomy in the laparoscopic era is older and has more comorbidities. METHODS: The records of 1629 consecutive patients who underwent cholecystectomy from July 1997 to September 2006 were evaluated. Analysis of variance, chi-square test, logistic regression, and linear regression were used to compare the following outcomes: length of procedure, length of stay, readmission (within 15 days and within 31 days), reoperation, and complication. RESULTS: Major complications (death, bile duct injury, bile leak, or bleeding requiring reoperation or transfusion) occurred more frequently in laparoscopic cholecystectomy patients who were coverted to open procedure (5.9%) than in those who underwent open cholecystectomy (4.4%). Mortality rates were 2.9%, 1.5%, and 0% for open, converted, and laparoscopic cholecystectomy, respectively. CONCLUSIONS: Older patients, male patients, and patients with previous upper abdominal surgery are at higher risk for mortality. They should be considered for open cholecystectomy given their increased likelihood of major complications when laparoscopic cholecystectomy is converted to open surgery. © 2009 Elsevier Inc. All rights reserved.

The introduction of laparoscopic cholecystectomy revolu- tionized the management of symptomatic cholelithiasis and cholecystitis. 13 Although both laparoscopic and open chole- cystectomy are safe and effective procedures, laparoscopic cholecystectomy has become the standard of care. 1,46 Never- theless, because of a host of preoperative factors and unantic- ipated conversions, 10% to 30% of cholecystectomies are still performed in an open fashion. 711 The laparoscopic technique has been of great interest to general surgeons around the world since its introduction in the late 1980s. The learning curve

* Corresponding author: Tel.: 617-724-6980; fax: 617-724-0067. E-mail address: dberger@partners.org

Manuscript received January 14, 2008; revised manuscript May 22,

2008

0002-9610/$ - see front matter © 2009 Elsevier Inc. All rights reserved.

doi:10.1016/j.amjsurg.2008.05.010

associated with the new technique and the long-term advan- tages of laparoscopic cholecystectomy have been studied and reported in many series during the past 2 decades. 1214 The advent of laparoscopy led to an increase in the total number of cholecystectomies being performed, making the average patient undergoing cholecystectomy (mostly lapa- roscopic) younger and healthier. However, the average pa- tient undergoing open cholecystectomy now has become relatively older and sicker. 15,16 As the subpopulations un- dergoing laparoscopic and open cholecystectomy have changed with time, it is no longer appropriate to compare current patients with those from the past. 13,13,17 This study sought to define the characteristics and outcomes of patients undergoing laparoscopic, open, and converted cholecystec- tomy in the laparoscopic era.

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The American Journal of Surgery, Vol 197, No 6, June 2009

Table 1

Patient characteristics

Characteristics

Group 1 (open)

Group 2 (conversion)

Group 3 (laparoscopic)

All groups

Age ( SD) Male sex (%) BMI† ASA (%)

68.1 14.4*

62.7 12.9

49.3 15.4

51.7 16.4

51*

37

25

28

26.8 6.5

29.3 6.6

29.5 6.7

29.2 6.7

I

2.2

2.9

22.1

19.3

II

41.2

67.6

66.4

64.0

III

51.5*

25.0

9.5

14.3

IV

4.4%*

2.9

.5

1.0

History of abdominal surgery (%)

None

44.1

48.5

60.8

58.6

Lower

31.6

41.2

37.1

36.8

Upper

9.6*

5.9

1.2

2.2

Both

14

4.4

.8

2.3

BMI body mass index.

* P .001 when compared with group 2.

†There was no statistically significant difference in BMI among the 3 groups.

Materials and Methods

After obtaining Institutional Review Board approval, the records of 1629 consecutive patients who underwent cholecys- tectomy from July 1997 to September 2006 were evaluated. All operations were performed by a single surgeon. Whether to initiate the operation laparoscopically was entirely at the sur- geon’s discretion. In general, open cholecystectomy was pre- ferred in selected patients based on generalized assessment involving such features as male sex, obesity, history of previ- ous upper abdominal surgery, and signs of sepsis from chole- cystitis. After excluding cholecystectomies performed during other abdominal procedures, patients were divided into 3 groups: group 1 consisted of 136 open cholecystectomy pa- tients; group 2 consisted of 68 patients who were converted from laparoscopic to open cholecystectomy; and group 3 con- sisted of 1210 laparoscopic cholecystectomy patients. Medical records were reviewed retrospectively for the fol- lowing variables: length of procedure, length of stay, readmis- sion (within 15 days and within 31 days), reoperation, and complications. Length of procedure was measured in minutes from the time of incision until the time of skin closure. Length of stay was measured from admission until discharge. As in the

National Surgical Quality Improvement Program, complica- tions that occurred after 31 days postoperatively were exclud- ed. 18 Similarly, readmissions, reoperations, and complications that occurred outside this institution and readmissions and reoperations that occurred after 31 days were excluded. Death, bile duct injury, bile leak, and bleeding requiring reoperation or transfusion were classified as major complications. All other complications were classified as minor. Analysis of variance and chi-square tests were used to compare patient characteristics. Logistic regression models were used to compare dichotomized outcomes (complications, death, readmission, and reoperation), and linear regression models were used to compare continuous outcomes (length of stay and length of procedure in the log scale) controlling for sex and American Society of Anesthesiologists (ASA) class.

Results

Patients

Patient characteristics are displayed in Table 1. Patients in group 1 were older and more commonly had undergone pre-

Table 2

Main outcome measures

Outcomes

Group 1 (open)

Group 2 (conversion)

Group 3 (laparoscopic)

All groups

No. of complications (%) No. of major complications Mortality Length of procedure (min) Length of stay (d) 15-day readmission (%) 31-day readmission (%) Reoperation (%)

46 (34)* 6 (4.4) 4 (2.9)* 41.3 19.2 6.9 7.6*

20 (29)* 4 (5.9)* 1 (1.5)* 57.3 22.8* 6.0 9.3*

77 (6.4) 14 (1.2) 0 (0) 33.1 15.2 1.3 2.7

143 (10) 24 (1.7) 5 (.4) 35.0 17.0 2.0 4.4

6.6

10*

2.2

3.0

8.1

8.8

3.0

3.7

0

4.4*

.6

.7

* P .05 compared with group 3.

A.S. Wolf et al.

Surgical outcomes of open cholecystectomy

783

Table 3

Major complications

Major

Group 1 (open) n 136

Group 2 (conversion) n 68

Group 3 (laparoscopic) n 1210

Total n 1414

complications

No. bile leak (%) No. bleeding (%) No. CBD injury (%) No. dead (%) Total (%)

2 (1.5)

1 (1.5)

11 (.9)

14 (1)

0 (0)

1 (1.5)

3 (.2)

4 (.3)

0 (0)

1 (1.5)

0 (0)

1 (.07)

4 (0)

1 (1.5)

0 (0)

5 (.4)

6 (4.4)

4 (5.9)

14 (1.2)

24 (1.7)

CBD common bile duct.

vious upper abdominal surgery, and more than half of these patients had an ASA score of III or IV (severe systemic disease). Patients in group 3 were younger and rarely had undergone previous upper abdominal surgery, and only 10% of these patients were ASA score III or IV. The average age, percentage of patients with previous upper abdominal surgery, and percentage of patients with ASA classification of III or IV in group 2 were in between those in groups 1 and 3. Interest- ingly, average body mass index was not significantly different among the 3 groups. The overall conversion rate was 4.8%, decreasing from 6.3% in the first 350 cases to 3.3% in the last 364 cases.

Main outcome measures

Outcomes for the 3 groups are displayed in Table 2. Overall complication rates were 34%, 29%, and 6.4% for groups 1, 2, and 3, respectively. Major complications, however, occurred more frequently in group 2 (5.9%) than in group 1 (4.4%). Fifteen-day readmission rates and reoperative rates were also higher in group 2 than in group 1. Open procedures took less time than converted procedures. Mean hospital length of stay for open and converted procedures was not significantly dif- ferent. As expected, complication rate, mortality, length of procedure and length of stay were all significantly less in group 3 compared with groups 1 and 2. Table 3 shows the distribution of specific major compli- cations among the 3 groups. The only common bile duct injury occurred during a laparoscopic case that was con- verted to open in order to repair the injury successfully. There was a total of 14 bile leaks: 2 in the group 1, 1 in

group 2, and 11 in group 3. Four patients with postoperative bleeds required reoperation for evacuation. With only 5 deaths in a 10-year study period, overall mortality was low (.4%). Mortality rates were 2.9%, 1.5%, and 0% for groups 1, 2 and 3, respectively. Four deaths occurred after open cholecystectomy; 4 of these patients were 70 years and had ASA scores of III or IV. The only death occurring after a laparoscopic procedure converted to open procedure was in a 64-year-old man who was ASA class IV and who developed postoperative pneumonia.

Comments

Reports on patients undergoing open cholecystectomy

during the laparoscopic era are scarce. Studies comparing laparoscopic and open cholecystectomy were performed almost 2 decades ago. 1,3,7,8,13,16,17 Table 4 compares the characteristics and outcomes of open cholecystectomy from 1971 to 1990 with those from

1997 to 2006. Patients undergoing open cholecystectomy in

this study were older than those in previous studies. Previ- ous studies of open cholecystectomy demonstrated that older patients are at higher risk of complications and mor-

tality than their younger counterparts. In a large series from

1971 to 1990, Girard and Morin 1 found that patients 70

years had a 13.8% complication rate and a 2.5% mortality rate compared with 6.5 and .3%, respectively, for patients age 50 to 70 years. In their review of 42,474 patients who underwent open cholecystectomy, Roslyn et al 3 found a complication rate of 26% in patients 65 years and 10% in those 65 years. 3 The increased age and comorbidities of

Table 4

Outcomes of open cholecystectomy

 
 

Study

No. of

Patient

Morbidity

Major

Mortality

Study

period

cases

age (y)

M:F Ratio

LOP (min)

LOS (d)

(%)

complications

(%)

This study Roslyn et al 3 Girard and Morin 1 Cox et al 17 Sanabria et al 13

1997–2006

135

68.1

1:1

41.3

6.9

34

4.4

2.9

1988–1989

42,474

60

1:3

14.7

.2

.17

1971–1990

10,471

48

3:7

5.1

.3

.4

1985–1889

457

52.5

1:3

73

6

9

3.5

0

1989

121

45.3

1:3

94

6.4

9.1

0

LOP length of procedure; LOS length of stay.

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The American Journal of Surgery, Vol 197, No 6, June 2009

patients selected for open cholecystectomy in the present series may have contributed to the higher rates of compli- cation and mortality in this study relative to these earlier studies. In contrast, length of stay has not increased, likely because of discharge pathways and current strict efforts to limit hospital length of stay. As described previously, the patients in group 1 were older, comprised a higher percentage of ASA class III or IV and were more likely to have undergone previous upper abdominal sur- gery. Therefore, it is not surprising that patients in group 1 had a higher total complication rate, mortality rate, and length of stay. Patients in group 2, however, had higher rates of major complications, reoperation, and readmission, implying that pa- tients who undergo laparoscopic cholecystectomy and who are converted to open procedure are more likely to have a com- plicated postoperative course. Several studies have described risk factors for converting laparoscopic to open cholecystectomy: age, male sex, ad- hesions in the region of the gallbladder, acute cholecystitis, and obesity. 1921 The distribution of age, sex, and previous upper abdominal surgery among patients in groups 1 and 3 likely reflects the surgeon’s decision to pursue open versus laparoscopic cholecystectomy in these patients based on their preoperative risk for conversion. By these criteria, one would expect the patients in group 2 (who began as group 3 patients before conversion) to have characteristics similar to patients in group 3. Patients in group 2, however, were older, more often male, and more likely to have undergone previous upper abdominal surgery than patients in group 3. This implies that some of the higher risk patients ap- proached laparoscopically might have been better served with a straight open approach. This study has several weaknesses. It is limited by sam- ple size, especially for open cholecystectomy and converted cases, thereby limiting the clinical significance of the com- plication and mortality rates in these groups. In addition, there is a major confounding variable in the converted group in the tendency to convert a laparoscopic cholecystectomy to open procedure in order to treat a complication; this is exemplified by the single common bile duct injury that was repaired in open fashion after the surgery was initiated laparoscopically. Finally, this study is based on the experi- ence of a single surgeon at a single institution. Although there is uniformity in case selection in such a study, it is also prone to the influence of bias and the learning curve of one person. Nevertheless, this is a large series during a 10-year period, and the results are still useful for comparison with other surgeons’ results. Cholecystectomy is a safe procedure with few postoper- ative complications. In this series, major complications, length of procedure, and rates of readmission and reopera- tion were highest after conversion from laparoscopic to open cholecystectomy compared with straight laparoscopic or straight open cholecystectomy. The key to successful patient outcomes is in careful patient selection for laparo- scopic and open cholecystectomy. Older patients, male pa-

tients, and patients likely to have adhesions in the region of the gallbladder (either from previous surgery in that area or from acute cholecystitis) should be approached with cau- tion. They may be better served with open cholecystectomy rather than laparoscopic cholecystectomy when conversion to open procedure is likely because the occurrence of major complications is greatest in this setting.

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