Kaafarani Haytham M A, Smith Tracy Schifftner, Neumayer Leigh, Berger David H, Depalma Ralph G, Itani Kamal M F
Department of Surgery, VA Boston Healthcare System, West Roxbury, MA, USA.
Am J Surg. 2010 Jul;200(1):32-40. doi: 10.1016/j.amjsurg.2009.08.020.
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.
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.
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).
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.
腹腔镜胆囊切除术（LC）占胆囊切除术的比例超过85%。促使进行开腹胆囊切除术（OC）或由LC转为OC（CONV）的因素尚未完全明确。
将前瞻性收集的来自国家外科质量改进计划（NSQIP）的数据与管理数据相结合，以识别2005年10月至2008年10月期间接受胆囊切除术的患者。定义了三个队列：LC、OC和CONV。使用逻辑分层模型，我们确定了选择OC和决定CONV的预测因素。
共有11669例患者在117家退伍军人事务部（VA）医院接受了胆囊切除术，其中9530例为LC（81.7%）。虽然在研究期间从LC转为OC的比例保持稳定（总体为9.0%），但OC的比例从2006年的11.5%降至2007年的10.1%和2008年的8.9%（P = 0.0002）。与LC相比，OC队列有更多的合并症（41项术前特征中的35项，所有P < 0.05），30天发病率更高（18.7%对4.8%，P < 0.0001），30天死亡率更高（2.4%对0.4%，P < 0.0001）。美国麻醉医师协会（ASA）分级、患者合并症（如腹水、出血性疾病、肺炎）和功能状态可预测选择OC。年龄、术前白蛋白水平、既往腹部手术史和急诊状态可预测OC和CONV（所有P < 0.05）。较高的医院转换率可独立预测OC（比值比[率增加1%]：1.05[1.02 - 1.07]；P = 0.0004）。
在过去3年中，VA医院进行OC的趋势有所减少。更多的患者合并症和更高的医院层面转换率可预测选择进行或转为OC。
