B. M. Tracy1, C. Paterson1, D. Torres2, K. Young2, B. Hochman3, M. B. Mulder4, M. Zielinski5, X. Luo-Owen6, D. D. Yeh4, R. Gelbard1 1Emory University School Of Medicine,Surgery,Atlanta, GA, USA 2Geisinger Medical Center,Danville, PA, USA 3Columbia University College Of Physicians And Surgeons,New York, NY, USA 4Jackson Memorial Hospital/Ryder Trauma Center,Miami, FL, USA 5Mayo Clinic,Rochester, MN, USA 6Loma Linda University School Of Medicine,Loma LInda, CA, USA
Introduction: The current understanding of complications following cholecystectomy (CCY) for common bile duct stones is largely based on single center retrospective studies. We sought to prospectively identify risk factors for biliary complications and 30-day readmission after CCY for choledocholithiasis (CDL) and gallstone pancreatitis (GP) across multiple U.S. hospitals.
Methods: We performed a prospective observational study of patients who underwent same admission CCY for CDL and GP between 2016 and 2019 at 12 U.S. centers. Patients with prior history of endoscopic retrograde cholangiopancreatography (ERCP) or diagnosis of cholangitis were excluded. We used univariable logistic regression to determine the association between preoperative demographics, labs, and imaging on primary outcomes: postoperative biliary complications (POBC) and 30-day readmission. Multivariable logistic regression was then used to determine overall risk factors for these outcomes.
Results: There were 989 patients included (median age 51.3 years (IQR 33.6-66.7); 662/989 (66.9%) were female). Presenting mean laboratory values included total bilirubin 2.6 mg/dL (±2.4) and WBC 10.2 x 103/uL (±4.5). Median sonographic CBD diameter was 7 mm (IQR 5-9). Intraoperative details included median OR duration of 96.5 minutes (IQR 69.0-133.3) with 92.2% (n=912) cases being laparoscopic, 6.7% (n=66) open, and 1.1% (n=11) robotic. There were 18 (1.8%) POBC including but not limited to 8 bile leaks requiring stenting and 4 organ space abscesses requiring drainage. On multivariable logistic regression increasing operative time (aOR 1.01, 95% CI 1.01-1.01, p=0.049), worsening preoperative leukocytosis (aOR 1.13, 95% CI 1.06-1.2, p=0.0001) and preoperative jaundice (aOR 4.4, 95% CI 1.5-13.2, p=0.009) were significantly associated with POBC (AUC 0.843). There were 55 readmissions within 30-days; 65.5% (n=36) were from surgical complications including 9 retained stones, 9 organ-space infections (OSI), and 5 bile leaks. Multivariable logistic regression revealed that a prior postoperative biliary complication (aOR 10.7, 95% CI 2.3-50.5, p=0.003), male gender (aOR 2.5, 95% CI 1.2-5.1, p=0.01), and index operative duration (aOR 1.01, 95% CI 1.00-1.01, p=0.048) were significantly associated with 30-day readmission.
Conclusion: Among patients undergoing CCY for common bile duct stones, jaundice, leukocytosis, and longer operations appear to be associated with POBCs. A prior biliary complication is also significantly and independently predictive of a 30-day readmission. Recognizing modifiable risk factors and implementing targeted interventions may help minimize the incidence of POBC and early readmission.