Race Is a Predictor of In-Hospital Mortality After Cholecystectomy, Especially in Those With Portal Hypertension
ABSTRACT Cholecystectomy is the most frequently performed gastrointestinal surgery in the United States. In this study, we characterized racial disparities in in-hospital mortality after cholecystectomy among patients with and without decompensated cirrhosis.
All patients who underwent cholecystectomy between 1998 and 2003 were queried from the Nationwide Inpatient Sample, the largest population-based and geographically representative all-payer database of hospital discharges in the United States. Crude mortality among races was determined for those with and without cirrhosis with portal hypertension and subsequently adjusted for demographic and clinical factors.
In-hospital mortality associated with cholecystectomy was higher in the portal hypertensive group compared with those without portal hypertension (10.8% vs 1.4%; P < .0001). African Americans had greater adjusted mortality risk than whites in both the nonportal hypertensive (odds ratio [OR], 1.48; 95% CI, 1.35-1.63) and portal hypertensive (odds ratio [OR], 2.37; 95% CI, 1.47-3.84) groups, although the mortality gap was more pronounced in the latter. For portal hypertensive patients, undergoing cholecystectomy at a liver transplant center was associated with dramatically lower mortality (OR, 0.41; 95% CI, 0.25-0.69).
In-patient mortality after cholecystectomy is 7.8-fold higher in patients with portal hypertension compared with those without portal hypertension. African Americans experienced higher mortality than whites after cholecystectomy, especially in the presence of portal hypertension. Cholecystectomy at a liver transplant center may offer survival benefit for patients with portal hypertension.
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ABSTRACT: To assess the impact of open versus laparoscopic surgery in cirrhotic patients undergoing a cholecystectomy using the Nationwide Inpatient Sample (NIS). All patients with cirrhosis who underwent a cholecystectomy (open or laparoscopic) between 2003 and 2006 were queried from the NIS. Associated complications including infection, transfusion, reoperation, liver failure and mortality were determined. A total of 3240 patients with cirrhosis underwent a cholecystectomy: 383 patients underwent an open cholecystectomy (OC) whereas 2857 patients underwent a laparoscopic cholecystectomy (LC), which included 412 patients converted (LCC) from a LC to an OC. Post-operative infection was higher in OC as opposed to a laparoscopic cholecystectomy (TLC) or LCC (3.5% versus 0.7% versus 0.2%, P < 0.0001). The need for a blood transfusion was significantly higher in the OC and LCC groups as compared with the TLC group (19.2% versus 14.4% versus 6.2%, P < 0.0001). Reoperation was more frequent after OC or LCC versus TLC (1.5% versus 2.5% versus 0.8%, P = 0.007). In-hospital mortality was higher after OC as compared with TLC and LCC (8.3% versus 1.3% versus 1.4%, P < 0.0001). Patients with cirrhosis have increased in-hospital morbidity and mortality after an open as opposed to a laparoscopic or conversion to an open cholecystectomy. LC should be the preferred initial approach in cirrhotic patients.HPB 12/2012; 14(12):848-53. DOI:10.1111/j.1477-2574.2012.00562.x · 2.05 Impact Factor
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ABSTRACT: BACKGROUND AND AIM: Our previous single-center study showed that patients with underlying inflammatory bowel disease (IBD) had a higher risk for post-cholecystectomy complications. The aim of the current population-based study was to verify whether concomitant IBD was indeed associated with an increased risk of post-cholecystectomy complications. METHODS: In this cross-sectional study, all 1,155,432 patients from the Nationwide Inpatient Sample (NIS) with a primary procedure of cholecystectomy were examined, and 5891 patients with IBD were compared with 1,149,541 patients without IBD from 2006 to 2008. RESULTS: There were no significant differences in age, gender, frequency of obesity, and post-operative mortality between the two groups. More patients in the IBD group had post-operative complications than the non-IBD group [398/5891 (6.8%) vs. 55,202/1,149,541 (4.8%), p=0.002)]. On multivariate analysis, the presence of Crohn's disease (CD) was associated with an increased risk for post-operative complications (odds ratio [OR]=1.6; 95% confidence interval [CI], 1.2-2.1, p=0.003). The other risk factors for post-cholecystectomy complications were older age, male gender, African-American race, malnutrition and patients with higher co-morbidity index. The presence of ulcerative colitis (UC) was associated with a trend for increased complications (OR=1.3, 95% CI 0.8-2.1, p=0.08). Patients with IBD who underwent cholecystectomy incurred higher mean hospital costs ($39,651 vs. $35,196, p=0.006) and also stayed in the hospital 1.2days longer than those without underlying IBD. CONCLUSIONS: CD patients undergoing cholecystectomy were shown to have a significantly increased risk for postoperative complications, have a longer stay in the hospital, and incur higher hospitalization costs.Journal of Crohn s and Colitis 09/2012; DOI:10.1016/j.crohns.2012.07.032 · 3.56 Impact Factor
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ABSTRACT: Few have examined determinants of adverse outcomes in patients presenting with ascending cholangitis. The objective of this study was to examine factors associated with in-hospital mortality, prolonged length of stay (LOS) and increased hospital charges (HC) in patients presenting with acute cholangitis. Within the Health Care Utilization Project Nationwide Inpatient Sample (NIS), we focused on patients, 18 years and older, admitted to the emergency department with cholangitis as primary diagnosis (1998-2009). Models were fitted to predict likelihood of in-hospital mortality, prolonged LOS and increased HC. Covariates included race, day of admission, insurance status, socio-economical status and other patient and hospital characteristics. Overall, weighted estimates of 248,942 patients were admitted with acute cholangitis between 1998 and 2009, of which 13,534 (5.4%) died during the admission. Multivariable analyses revealed that relative to Caucasian patients, African American, Hispanic and Asian and Pacific Islander patients were more likely to die (OR = 1.61, p<0.001, OR = 1.20, p = 0.01 and OR = 1.26, p = 0.008), to experience a prolonged LOS (OR = 1.77, p<0.001, OR = 1.30, p<0.001, 1.34, p<0.001), and to incur high HC (OR = 1.83, p<0.001, OR = 1.51, p<0.001, OR = 1.56, p<0.001). Moreover, Medicaid and Medicare patients were more likely to die (OR = 1.64, p<0.001, OR = 1.24, p<0.001), to experience a prolonged LOS (1.74, p<0.001, OR = 1.25, p<0.001) and to incur high HC (OR = 1.23, p = 0.002, OR = 1.12, p = 0.002) compared to privately insured patients. In subgroup analysis, there were no differences for Medicare patients age 65 years and over. However, those under 65, most of whom have disability or end stage renal disease, were more likely to experience the negative outcomes. Race and insurance status represent independent predictors of in-hospital mortality and adverse outcomes in patients presenting with cholangitis. Whether these disparities are due to biological predisposition or unequal quality of care requires further investigation. Regardless, efforts should be made to reduce these outcome disparities.PLoS ONE 03/2013; 8(3):e59487. DOI:10.1371/journal.pone.0059487 · 3.53 Impact Factor