Outcomes of cholecystectomy in US veterans with cirrhosis: Predicting outcomes using nomogram

BACKGROUND

This study examines the outcomes of open and laparoscopic cholecystectomy (OC/LC) in veterans with cirrhosis and develops a nomogram to predict outcomes.

METHODS

We analyzed the Veterans Affairs Surgical Quality Improvement Program to identify all patients with cirrhosis and ascites who underwent cholecystectomy from 2008 to 2015. Univariate and multivariate regression were used to identify predictors of morbidity and mortality. A predictive nomogram was constructed and internally validated.

RESULTS

A total of 349 patients were identified. Overall, complications occurred in 18.7% of patients, and mortality was 3.8%. LC was performed in 58.9%, and 19.2% were preformed emergently. Overall, Model for End-Stage Liver Disease score was an independent factor of morbidity and mortality, while laparoscopic approach had a protective effect on morbidity.

CONCLUSIONS

Although cholecystectomy is a high-risk operation in cirrhotic veterans, LC may have favorable outcomes than OC in selected patients. An easy-to-use nomogram to predict morbidity and mortality for cirrhotic patients undergoing cholecystectomy is proposed.

Postoperative outcomes of ventral hernia repair in veterans

BACKGROUND

Ventral hernia repair is a common procedure with reported 15% to 37% morbidity and 0.3% to 1.4% mortality rates. This study examines the 30-day morbidity and mortality of open and laparoscopic ventral hernia repair in veterans, along with the impact of body mass index on these outcomes.

METHODS

The Veterans Affairs Surgical Quality Improvement Program was queried for all ventral hernia repairs during the period 2008 to 2015. In this retrospective analysis, we compared outcomes of open ventral hernia repair versus laparoscopic ventral hernia repair and among different body mass index classes.

RESULTS

A total of 19,883 patients were identified (92.6% male, mean age 59.7, 53.1% obese, and 71.6% with American Society of Anesthesiologists class ≥III). There were 95 (0.5%) mortalities, and complications occurred in 1,289 (6.5%) patients. Open ventral hernia repair was performed in 60.2%; 14.5% were recurrent, and 3.3% were performed as an emergency operation. When compared with open ventral hernia repair, the laparoscopic ventral hernia repair group had higher mean body mass index, less patients with American Society of Anesthesiologists class ≥III, fewer emergency operations, longer operative time, less complications, decreased mortality, and shorter duration of stay. Body mass index 35.00 to 49.99 was predictive of overall complications in the open ventral hernia repair group.

CONCLUSION

Ventral hernia repair can be performed in the veteran population with outcomes comparable to those in the private sector. Morbid obesity has a negative impact on ventral hernia repair outcomes that is most prominent following open surgery. Laparoscopic ventral hernia repair may offer superior outcomes when compared to open ventral hernia repair and may be considered.

Recent trends in cholecystectomy in US veterans

INTRODUCTION

We hypothesize that the recent trend in performing cholecystectomy in US Veterans shows wide adoption of the laparoscopic technique and improvement in the outcome following both laparoscopic (LC) and open cholecystectomy (OC). This study utilizes the Veterans Affairs Surgical Quality Improvement Program database to examine the status and outcome of cholecystectomy.

METHODS

A retrospective review of veterans who underwent cholecystectomy between 2008 and 2015 was performed. Data analysis included patient demographics, operations, and postoperative outcomes. Cochran-Armitage trend analysis was used to assess significant changes in outcome over the study period. p ≤ 0.05 was considered significant.

RESULTS

A total of 40,722 patients (average age of 61 years) were included in the study (males 85.6%). LC was performed in the majority of patients (86.4%). Patients in the OC group (13.6%) were more likely to have advanced age (≥ 65 years) (47.6% vs 32.0%, p < 0.001) and higher ASA class (III-V) (81.9% vs 65.4%, p < 0.001) than those in the LC group. Compared with LC, OC had higher mortality rates at 30 days (1.3% vs 0.3%; OR = 1.6, p = 0.03), 3 months (2.6% vs 0.7%; OR = 1.7, p < 0.001), 6 months (3.9% vs 1.1%; OR = 1.5, p < 0.001) and 1 year (5.7% vs 2.0%; OR = 1.5, p < 0.001); higher rates of morbidity, including pneumonia (OR = 1.9, p < 0.001), deep venous thrombosis (OR = 2.4, p = 0.02), reoperation (OR = 1.8, p < 0.001), and superficial (OR = 4.9, p < 0.001) and deep (OR = 1.5, p = 0.01) surgical site infections; and a longer length of stay (6.5 days vs 2.6 days, p < 0.001). Trend analysis showed a significant decrease in both mortality (p = 0.02) and morbidity (p < 0.001) for LC over the study period, but no improvement in mortality (p = 0.35) and a only a minimal improvement in morbidity (p = 0.04) for OC.

CONCLUSION

In the recent era, LC has been widely performed in the VA with significant improvement in outcome. Efforts are needed to adopt alternative approaches to planned OC and to improve postoperative outcomes.