Relationship between surgical volume and outcomes in elective and acute cholecystectomy: nationwide, observational study.

BACKGROUND: High surgical volumes are attributed to improved quality of care, especially for extensive procedures. However, it remains unknown whether high-volume surgeons and hospitals have better results in gallstone surgery. The aim of this study was to investigate whether operative volume affects outcomes in cholecystectomies. METHODS: A registry-based cohort study was performed, based on the Swedish Registry of Gallstone Surgery. Cholecystectomies from 2006 to 2019 were included. Annual volumes for the surgeon and hospital were retrieved. All procedures were categorized into volume-based quartiles, with the highest group as reference. Low volume was defined as fewer than 20 operations per surgeon per year and fewer than 211 cholecystectomies per hospital per year. Differences in outcomes were analysed separately for elective and acute procedures. RESULTS: The analysis included 154 934 cholecystectomies. Of these, 101 221 (65.3 per cent) were elective and 53 713 (34.7 per cent) were acute procedures. Surgeons with low volumes had longer operating times (P < 0.001) and higher conversion rates in elective (OR 1.35; P = 0.023) and acute (OR 2.41; P < 0.001) operations. Low-volume surgeons also caused more bile duct injuries (OR 1.41; P = 0.033) and surgical complications (OR 1.15; P = 0.033) in elective surgery, but the results were not statistically significant for acute procedures. Low-volume hospitals had more bile duct injuries in both elective (OR 1.75; P = 0.002) and acute (OR 1.96; P = 0.003) operations, and a higher mortality rate after acute surgery (OR 2.53; P = 0.007). CONCLUSION: This study has demonstrated that operative volumes influence outcomes in cholecystectomy. The results indicate that gallstone surgery should be performed by procedure-dedicated surgeons at hospitals with high volumes of this type of benign surgery.

Surgeons who perform an operation are often thought to have better results. It remains unknown whether this is true for gallstone surgery. This research study investigated whether the surgeon's and hospital's volume of operations affects results after gallstone operations. The study was based on the Swedish Registry of Gallstone Surgery, in which all gallstone operations in Sweden are registered. Some 14 000 operations are performed every year. Operations from 2006 to 2019 were included. The annual volume for each surgeon was counted and all operations were divided into four groups. The operating time and number of unwanted events were compared between the groups, for both planned and acute operations. : The study included 154 934 operations. Of these, 101 221 (65.3 per cent) were planned and 53 713 (34.7 per cent) were acute. Surgeons with low volumes had longer operating times and higher risk of a change in technique from keyhole to open surgery, in both planned and acute operations. Surgeons and hospitals with low volumes also had more unwanted events after planned operations. The risk of death at a hospital with low volumes was slightly higher in acute surgery. This study has shown that the surgeon's and hospital's volumes affect results after gallstone surgery, suggesting that this type of surgery should be performed by surgeons and at hospitals that perform these operations frequently.

Learning by doing: an observational study of the learning curve for ultrasonic fundus-first dissection in elective cholecystectomy.

BACKGROUND: Surgical safety and patient-related outcomes are important considerations when introducing new surgical techniques. Studies about the learning curves for different surgical procedures are sparse. The aim of this observational study was to evaluate the learning curve for ultrasonic fundus-first (FF) dissection in elective laparoscopic cholecystectomy (LC). METHODS: The study was conducted at eight hospitals in Sweden between 2017 and 2019. The primary endpoint was dissection time, with secondary endpoints being intra- and postoperative complication rates and the surgeon's self-assessed performance level. Participating surgeons (n = 16) were residents or specialists who performed LC individually but who had no previous experience in ultrasonic FF dissection. Each surgeon performed fifteen procedures. Video recordings from five of the procedures were analysed by two external surgeons. Patient characteristics and data on complications were retrieved from the Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks). RESULTS: Dissection time decreased as experience increased (p = 0.001). Surgeons with limited experience showed more rapid progress. The overall complication rate was 14 (5.8%), including 3 (1.3%) potentially technique-related complications. Video assessment scores showed no correlation with the number of procedures performed. The self-assessed performance level was rated lower when the operation was more complicated (p < 0.001). CONCLUSIONS: Our results show that dissection time decreased with increasing experience. Most surgeons identified both favourable and unfavourable aspects of the ultrasonic FF technique. The ultrasonic device is considered well suited for gallbladder surgery, but most participating surgeons preferred to dissect the gallbladder the traditional way, beginning in the triangle of Calot. Nevertheless, LC with ultrasonic FF dissection can be considered easy to learn with a low complication rate during the initial learning curve, for both residents and specialists.

The Sooner, the Better? The Importance of Optimal Timing of Cholecystectomy in Acute Cholecystitis: Data from the National Swedish Registry for Gallstone Surgery, GallRiks.

Up-front cholecystectomy is the recommended therapy for acute cholecystitis (AC). However, the scientific basis for the definition of the optimal timing for surgery is scarce. The aim of this study was to analyze how the timing of surgery, after the admission to hospital for AC, affects the intra- and postoperative outcomes. Within the national Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks), all patients undergoing cholecystectomy for acute cholecystitis between January 2006 and December 2014 were identified. Data regarding patient characteristics, intra- and postoperative adverse events (AEs), bile duct injuries, and 30- and 90-day mortality risk were captured, and the correlation between the surgical timing and these parameters was analyzed. In total, data on 87,108 cholecystectomies were analyzed of which 15,760 (18.1 %) were performed due to AC. Bile duct injury, 30- and 90-day mortality risk, and intra- and postoperative AEs were significantly higher if the time from admission to surgery exceeded 4 days. The time course between surgery and complication risks seemed to be optimal if surgery was done within 2 days after hospital admission. Although AC patients operated on the day of hospital admission had a slightly increased AE rate as well as 30- and 90-day mortality rates than those operated during the interval of 1-2 days after admission, the bile duct injury and conversion rates were, in fact, significantly lower. The optimal timing of cholecystectomy for patients with AC seems to be within 2 days after admission. However, the somewhat higher frequency of AE on admission day may emphasize the importance of optimizing the patient before surgery as well as ensuring that adequate surgical resources are available.

Sensory disturbances and neuropathic pain after inguinal hernia surgery.

Objectives The aim of this study was to explore how the handling of nerves affects the risk for developing sensory disturbances (SDs) following groin hernia surgery. Patients and methods All patients 18 years or older undergoing surgery for inguinal hernia at Mora Hospital, Sweden, during an eight-month period in 2006, were eligible for inclusion. The surgical procedure was recorded prospectively according to a standardised protocol. One year postoperatively all patients were requested to answer the Inguinal Pain Questionnaire as well as a set of 18 sensory and affective pain descriptors. They were also invited to clinical examination including sensory testing. Results Of the 157 hernia repairs in Mora during the period of study, 128 repairs in 116 patients, were registered prospectively according to the study protocol. Laparoscopic total extraperitoneal (TEP) repair was performed in 36 (28%) of the patients. Ninety-two (79%) patients, including five patients operated bilaterally, underwent postoperative examination. SDs were found in 33 (34%) of the groins examined. No descriptor was found that significantly predicted the presence of altered examination findings. No significant association between the intraoperative handling of nerves and SD was seen. In the TEP-group, no SDs were seen. Infiltration of local anaesthetic agents and blockade of the ilioinguinal nerve prior to surgery were found to be significantly associated with SD more than 2 cm away from the scar (both p < 0.05). The presence of SD was not associated with significant pain. Conclusions SDs are common after open hernia surgery, but are not associated with persistent postoperative pain.