Surgical removal of the largest transgastric migrated gossypiboma: A case report.

RATIONALE: Gossypiboma is a term that refers to the condition of accidentally retained surgical gauze after surgeries. While many manifestations and complications are possible in this case, the migration of the retained gauze into the gastric cavity is one of the rarest. In this paper, we report the largest migrated surgical towel to the gastric cavity in the literature, measuring 90 cm × 90 cm. PATIENT CONCERNS: A 33-year-old woman with recurrent epigastric pain unresponsive to treatment was referred to our hospital. She had undergone an open surgery cholecystectomy 11 years before admission during wartime in Syria. DIAGNOSES: Abdominal computed tomography with contrast showed a large mass in the stomach, indicating malignancy. However, upper gastrointestinal endoscopy revealed a gray-black foreign body occupying the entire gastric lumen, which indicated the presence of bezoar. Upon surgery, the final diagnosis of gastric gossypiboma was made; which was a retained surgical towel from the previous cholecystectomy that had fully migrated to the stomach and resembled both malignancy and bezoar upon investigation. INTERVENTIONS: The patient underwent open surgery to excise the foreign body. OUTCOMES: The gossypiboma was successfully removed, and the patient was discharged 5 days after the operation without complications. LESSONS: Retained surgical items, such as gossypiboma, can lead to significant medical complications. The migration of gossypiboma to the stomach, though rare, poses challenges in diagnosis and management, often requiring open surgical removal to prevent adverse outcomes. Early detection and intervention are crucial to avoiding associated morbidity and mortality. It is important to consider gossypiboma in patients with unexplained abdominal pain following surgery and to emphasize meticulous sponge counting to prevent this complication.

[Traumatic gallbladder rupture in a 9-year-old child]. / Travmaticheskii razryv zhelchnogo puzyrya pri sochetannoi travme u rebenka 9 let.

We present gallbladder rupture following trauma. A 9-year-old boy admitted in 1.5 hours after injury. Considering clinical and ultrasound data, we diagnosed traumatic damage to the spleen and hemoperitoneum, biliary dyskinesia, cholestasis, sludge. Hemostatic therapy was carried out. After 3 days, signs of peritonitis appeared. Follow-up ultrasound revealed gallbladder enlargement with heterogeneous content, fluid in all parts of abdominal cavity. Intraoperatively, the gallbladder was enveloped in omentum soaked in bile. After mobilization of the gallbladder, we found longitudinal linear tear up to 3 cm clogged with omentum. Cholecystectomy was performed. Thus, we present a patient with combined injury and damage to the spleen. However, gallbladder wall thickening and heterogeneous content were interpreted as concomitant pathology. Delayed manifestation of peritonitis was due to gallbladder enveloped in omentum. The last one soaked in bile partially entered the gallbladder through perforation and prevented bile leakage into abdominal cavity. Timely diagnosis of gallbladder damage presents certain difficulties, especially in case of combined injury. Ultrasound signs of traumatic gallbladder rupture in this case were wall thickening, heterogeneous content and gradual gallbladder enlargement. It is necessary to analyze all organs at the damage site including computed tomography in patients with combined trauma.

Neuroendocrine carcinoma of the gallbladder: A case report and literature review.

RATIONALE: Neuroendocrine neoplasms (NENs) originating from neuroendocrine cells occur in the thyroid, respiratory, and digestive systems, with Gallbladder Neuroendocrine Carcinoma (GB-NEC) accounting for only 0.5% of all NENs and 2.1% of gallbladder cancers. Due to its rarity, little is known about GB-NEC's clinical presentation and treatment. PATIENT CONCERNS: We report a case of a 52-year-old male presenting with acute upper right abdominal pain, leading to further investigation. DIAGNOSES: Initial diagnostic workup, including abdominal ultrasound and contrast-enhanced CT, suggested gallbladder malignancy. Post-surgical pathology confirmed GB-NEC, with immunohistochemistry supporting the diagnosis. INTERVENTIONS: The patient underwent radical cholecystectomy, followed by etoposide plus cisplatin chemotherapy. After disease progression indicated by CT, the patient received additional cycles of chemotherapy with cisplatin and irinotecan, plus targeted therapy with anlotinib and immunotherapy with paimiplimab. OUTCOMES: The patient showed a partial response to initial treatment. Subsequent liver biopsy confirmed NEC, consistent with small cell carcinoma. With continued treatment, the patient maintains a good survival status. LESSONS: GB-NEC is associated with poor prognosis, emphasizing the importance of early detection and multimodal treatment strategies. Our case underlines the potential benefit of a comprehensive treatment plan, including aggressive surgery and chemotherapy, with further research needed to standardize treatment for this rare condition.

Bile acid diarrhoea and metabolic changes after cholecystectomy: a prospective case-control study.

INTRODUCTION: Bile acid diarrhoea (BAD) can occur due to disruption to the enterohepatic circulation such as following cholecystectomy. However, the mechanism behind this is as yet unknown. The aim of this study was to determine the rate of post-cholecystectomy diarrhoea and to assess whether FGF19 within the gallbladder was associated with the development of BAD. METHODS: This was a prospective case-control study in which patients were assessed pre- and post- cholecystectomy (study group) and compared with patients also having laparoscopic surgery but not cholecystectomy (control group). Their bowel habits and a GIQLI questionnaire was performed to compare the pre- and post-operative condition of the two groups. Gallbladder tissue sample was tested for FGF19 and PPARα in the study group patients. A subset had serum lipid levels, FGF19 and C4 measurements. RESULTS: Gallbladder PPAR α was found to have a significant correlation with stool consistency, with the lower the PPARα concentration the higher the Bristol stool chart number (i.e. looser stool). There were no significant correlation when assessing the effect of gallbladder FGF19 concentration on bowel habit, stool consistency, lipid levels, BMI or smoking. The study group showed a significant increase in triglycerides post-operatively, however there were no changes in cholesterol, HDL and LDL levels. Correlation of the increased triglyceride levels with stool consistency and frequency showed no significant results DISCUSSION AND CONCLUSION: We did not find any direct evidence that FGF19 levels within the gallbladder impact the development of post-cholecystectomy diarrhoea. There was however a significant increase in triglycerides postoperatively. There was also no correlation of bowel habits with PPARα suggesting the observed rise is independent of this pathway. Further work is required particularly relating to the gut microbiome to further investigate this condition.

CHOLECYSTECTOMY WITH INTRAOPERATIVE ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: DOES THE ORDER MATTER?

BACKGROUND: The recommended treatment for cholecystocholedocholithiasis is cholecystectomy (CCT) associated with endoscopic retrograde cholangiopancreatography (ERCP). CCT with intraoperative ERCP is associated with higher success rates and lower hospital stays and hospital costs. However, some case series do not describe the exact methodology used: whether ERCP or CCT was performed first. AIMS: Verify if there is a difference, in terms of outcomes and complications, when intraoperative ERCP is performed immediately before or after CCT. METHODS: This is a retrospective case-control study analyzing all patients who underwent CCT with intraoperative ERCP between January 2021 and June 2022, in a tertiary hospital in southern Brazil, for the treatment of cholecystocholedocholithiasis. RESULTS: Out of 37 patients analyzed, 16 (43.2%) underwent ERCP first, immediately followed by CCT. The overall success rate for the cannulation of the bile duct was 91.9%, and bile duct clearance was achieved in 75.7% of cases. The post-ERCP pancreatitis rate was 10.8%. When comparing the "ERCP First" and "CCT First" groups, there was no difference in technical difficulty for performing CCT. The "CCT First" group had a higher rate of success in bile duct cannulation (p=0.020, p<0.05). Younger ages, presence of stones in the distal common bile duct and shorter duration of the procedure were factors statistically associated with the success of the bile duct clearance. Lymphopenia and cholecystitis as an initial presentation, in turn, were associated with failure to clear the bile duct. CONCLUSIONS: There was no significant difference in terms of complications and success in clearing the bile ducts among patients undergoing CCT and ERCP in the same surgical/anesthetic procedure, regardless of which procedure was performed first. Lymphopenia and cholecystitis have been associated with failure to clear the bile duct.

[Current situation of surgical treatment of gallbladder polyps and some problems that should be paid attention to].

Gallbladder polyp is a common disease of gallbladder, the incidence of gallbladder polyp in China is about 5%~10%, and the trend is increasing year by year. The patients with gallbladder polyps had no obvious clinical symptoms, which was more than that found by ultrasonography during physical examination. At present, the diameter of gallbladder polyps>10 mm is still used by clinicians as the main surgical indication for cholecystectomy. According to the data, about 80% to 90% of gallbladder polyps are cholesterol type polyps and benign gallbladder polyps. For these patients whose gallbladder is removed due to benign gallbladder polyps, we consider that we can continue to observe or retain the gallbladder, without having to bear the adverse consequences that may be caused by gallbladder removal. Based on the literature analysis at home and abroad, this paper discusses the surgical treatment of gallbladder polyps and the results of postoperative pathological diagnosis, and reminds the majority of clinicians to be careful when removing gallbladder polyps.

Molecular Detection of Salmonella typhi Isolated from Patients Undergoing Gallbladder Cholecystectomy in Baghdad.

BACKGROUND: Salmonella typhi is a specific strain of the Salmonella bacterium, responsible for triggering typhoid fever; a significant public health concern in developing nations. OBJECTIVE: The current study aimed to identify the bacteria from the gallbladder, taken during cholecystectomies of patients, by isolating Salmonella typhi and by using microscopic characteristics, biochemical and polymerase chain reaction (PCR) tests. METHODS: A total of 120 specimens were collected from the Baghdad Teaching Hospital, Iraq. A cross-sectional descriptive study was carried out from October, 2021, to July, 2022. During that study, 26 (54.2%) male patient tested positive for Salmonella typhias well as 22 (45.8%) female patients. The age of the patients varied from < 30 to > 60 years. p-value > 0.05 was considered significant to confirm a relationship between age and Salmonella typhi effect for patients. RESULTS: Out of the 120 blood samples taken for this study, 48 (40%) tested positive by use of PCR test, 40 (33.3%) tested positive by use of the Widal test, 35 (29.1%) were positive for biopsy culture, and 35 (29.1%) were positive for blood culture. All Salmonella typhi isolates were found to be sensitive to the imipenem, cefepime, and ceftriaxone, but were resistant to gentamycin, ciprofloxacin, amikacin, erythromycin, and tetracycline (72%, 29%, 43%, 100%, 100%, respectively). CONCLUSIONS: The real time polymerase chain reaction (RT-PCR) tests and the Vitek 2 compact system showed a high level of accuracy in the detection of Salmonella typhi. Multidrug resistance was observed, which should be a signal to reduce antibiotic consumption.

Enhanced Recovery After Surgery versus Conventional Care in Cholecystectomy: A Systematic Review and Meta-Analysis.

Objectives: The primary objective of this study was to evaluate the safety and efficacy of the enhanced recovery after surgery (ERAS) protocol in cholecystectomy, comparing it with standard care. Methods: A comprehensive literature search was conducted in December 2023, using globally recognized databases such as PubMed, Embase, and the Cochrane Library. Various parameters were compared using Review Manager software. This study was duly registered with PROSPERO (CRD420223). Results: The meta-analysis included nine studies, encompassing a total of 1920 patients. The findings revealed that the ERAS group, in comparison to traditional care, experienced shorter hospitalization periods (weighted mean difference [WMD]: -1.23, 95% confidence interval [CI]: -1.98 to -0.47; P = .001), lower visual analog scale at 24 hours (WMD: -1.10, 95% CI: -1.30 to -0.90; P < .00001), faster time to first flatus (WMD: -4.48, 95% CI: -4.50 to -4.46; P < .00001), and reduced operative times (WMD: -9.94, 95% CI: -17.88 to -0.96; P = .03). In addition, there was a notable decrease in instances of postoperative nausea and vomiting (odds ratio [OR]: 0.46, 95% CI: 0.28 to 0.74; P = .002). No significant differences were observed in readmission rates, blood loss, postoperative complications, or bile leakage between the two care methods. Conclusions: This study substantiates that the ERAS protocol is an advantageous perioperative care strategy for patients undergoing cholecystectomy. It significantly outperforms traditional care in reducing the length of stay, decreasing the likelihood of postoperative nausea/vomiting, alleviating postoperative pain, and accelerating the time to the first flatus. These findings highlight the effectiveness of ERAS in enhancing patient outcomes in cholecystectomy.

Symptomatic uncomplicated gallstone disease is associated with a high short-term risk of gallstone-related complications: a contemporary cohort study.

BACKGROUND: The natural history of symptomatic uncomplicated gallstone disease is largely unknown. We examined the risk of progressing from symptomatic uncomplicated to complicated gallstone disease in a large regional cohort of patients, where disruptions in elective surgical capacities have led to the indefinite postponement of surgery for benign conditions, including cholecystectomies. METHODS: Patients with radiologically diagnosed incident symptomatic and uncomplicated gallstone disease were identified from outpatient clinics and emergency departments on the Island of Funen, Denmark. The absolute risk of complications (cholecystitis, cholangitis, pancreatitis, acute cholecystectomy for unremitting pain) was calculated using death and elective cholecystectomies as competing risks using the Aalen-Johansen method. Cox proportional hazards regression analysis was used to estimate hazard ratios (HRs) of gallstone complications associated with patient and gallstone characteristics. RESULTS: Two hundred eighty-six patients diagnosed with incident symptomatic, uncomplicated gallstone disease from 1 January 2020 to 1 July 2023 were identified. During 79,170 person-years of observation, 176 (61.5%) patients developed a gallstone-related complication. The 6-, 12- and 24-month risk of developing gallstone-related complications were 36%, 55% and 81%. The risk of developing complications related to common bile duct stones was lowest with larger stones (aHR per millimeter increase = 0.89 (0.82-0.97), p < 0.01), while no covariates were statistically significantly associated with the risk of cholecystitis. Eighty-five (30%) patients underwent elective laparoscopic cholecystectomy, with one patient (1.2%) developing a gallstone-related complication afterward. CONCLUSIONS: The risk of developing complications to symptomatic gallstones in a general Scandinavian population is high, and prophylactic cholecystectomy should be considered.

Minimally invasive approach in a rare emergency surgery, gallbladder perforation.

BACKGROUND: Gallbladder perforations are challenging to manage for surgeons due to their high morbidity and mortality, rarity, and surgical approach. Laparoscopic cholecystectomy (LC) is now included with open cholecystectomy in surgical managing gallbladder perforations. This study aimed to evaluate the factors affecting conversion from laparoscopic to open cholecystectomy in cases of type I gallbladder perforation according to the Modified Niemeier classification. METHODS: Patients who met the inclusion criteria were divided into two groups: LC and conversion to open cholecystectomy (COC). Demographic, clinical, radiologic, intraoperative, and postoperative factors were compared between groups. RESULTS: This study included 42 patients who met the inclusion criteria, of which 28 were in the LC group and 14 were in the COC group. Their median age was 68 (55-85) years. Age did not differ significantly between groups (p = 0.218). However, the sex distribution did differ significantly between groups (p = 0.025). The location of the perforation differed significantly between groups (p < 0.001). In the LC group, 22 patients were perforated from the fundus, four from the trunk, and two from the neck. In the COC group, two patients were perforated from the fundus, four from the trunk, and eight from the neck. Surgical procedure times differed significantly between the LC (105.0 min [60-225]) and COC (125.0 min [110-180]) groups (p = 0.035). The age of the primary surgeons also differed significantly between the LC (42 years [34-63]) and COC (55 years [36-59]) groups (p = 0.001). CONCLUSIONS: LC can be safely performed for modified Niemeier type I gallbladder perforations. The proximity of the perforation site to Calot's triangle, Charlson comorbidity index (CCI), and Tokyo classification are factors affecting conversion from laparoscopic to open surgery of gallbladder perforations.

Initial Experience of Robot-Assisted Surgeries.

OBJECTIVE: To present initial experience with the first 100 cases of robotic-assisted surgery by the Department of General Surgery. STUDY DESIGN: Descriptive study. Place and Duration of the Study: Department of Surgery, National Hospital and Medical Centre, Lahore, Pakistan, from May 2022 to August 2023. METHODOLOGY: Demographic and postoperative details of the first 100 patients to undergo robotic-assisted surgery by the Department of General Surgery were reviewed. Prospective data were collected from the hospital information database as well as the CMR database. The data collected in the hospital database included the patients' age, diagnoses, genders, complications during hospital stay as well as 90-day readmission, morbidity, and mortality. Data collected by CMR via Versius robotic surgery console or internal databases included operative minutes using the console. RESULTS: The average age of patients undergoing robotic surgery was 44.26 ± 14.08 years. Cholecystectomy (78%) was the most commonly performed robotic-assisted procedure. Only one patient had blood loss of more than 100ml. There was no postoperative complication, readmission or mortality during the study period. CONCLUSION: With proper patient selection, robotic-assisted surgery is safe and feasible even in low- middle-income countries (LMICs). KEY WORDS: Robotic-assisted surgery, Pakistan, Initial experience, Outcomes, Versius.

Short- and long-term predictive power of the preoperative Geriatric Assessment components in older patients undergoing cholecystectomy.

<b><br>Introduction:</b> Increasing numbers of older patients will require laparoscopic cholecystectomies. Physicians may have doubts when qualifying these patients for elective surgeries since older age is considered a risk factor for complications. Determining biological age, using a Geriatric Assessment (GA), should be the key factor in the preoperative assessment.</br> <b><br>Aim:</b> The aim of this study was to determine which GA components and frailty alone are most useful for predicting postoperative outcomes in both short- and long-term follow-up.</br> <b><br>Materials and methods:</b> 219 consecutive patients aged ≥70 years underwent surgery and were followed up prospectively for 12 months. The preoperative GA consisted of functionality, physical activity, comorbidity, polypharmacotherapy, nutrition, cognition, mood, and social support domains. Logistic regression analyses were used to analyze the predictive ability of GA.</br> <b><br>Results:</b> GA, frailty, and chronological age were not predictive of major 30-day morbidity. There were significantly more overall postoperative complications in the frail group than in the fit group (21% vs 4%), with mainly minor (Clavien-Dindo I, II) and medical (16 patients; 72.7%) complications. There were no significant differences in the rate of major and surgical complications (8 patients; 36.4%) between frail and fit patients. Only frailty was a predictor of 1-year mortality odd ratio 12.17 (2.47-59.94) P = 0.002.</br> <b><br>Conclusions:</b> Performing GA before elective laparoscopic cholecystectomies seems unnecessary for the evaluation of short-term outcomes but helpful for the assessment of long-term outcomes. Laparoscopic cholecystectomy can be safely performed also in older frail patients.</br>.

Timely cholecystectomy: important factors to improve guideline adherence and patient treatment.

OBJECTIVE: Cholecystectomy is one of the most frequently performed surgeries in Germany and is performed as a treatment of acute cholecystitis (guideline S3 IIIB.8) and after endoscopic retrograde cholangiopancreatography for choledocholithiasis with simultaneous cholecystolithiasis (guideline S3 IIIC.6). This article examines the effects of a guideline update from 2017, which recommends prompt cholecystectomy within 24 hours of admission due to cholecystitis or within 72 hours after bile duct repair. In addition, it aims to identify reasons (eg, financial disincentives) and potential for improvement for non-adherence to the guidelines. DESIGN: Methodologically, a retrospective analysis based on routine billing data from 84 Helios Group hospitals from 2016 and 2022, with a total of 45 393 included cases, was applied. The guideline adherence rate is used as the main outcome measure. RESULTS: Results show the guideline updates led to a statistically significant increase in the proportion of cholecystectomy performed in a timely manner (guideline S3 IIIB.8: increase from 43% to 49%, p<0.001; guideline S3 IIIC.6: increase from 7% to 20%, p<0.001). Medical, structural and financial reasons for non-adherence could be identified. CONCLUSION: As possible reasons for non-adherence, medical factors such as advanced age, multimorbidity and frailty could be identified. Analyses of structural factors revealed that hospitals in very rural regions are less likely to perform timely cholecystectomies, presumably due to infrastructural and personnel-capacity bottlenecks. A similar picture emerges for maximum-care hospitals, which might be explained by more severe and complex cases on average. Further evaluation indicates that an increase in and better hospital-internal participation of gastroenterologists in remuneration could lead to even greater adherence to the S3 IIIC.6 guideline.

Global evaluation and outcomes of cholecystectomy: protocol for a multicentre, international, prospective cohort study (GlobalSurg 4).

INTRODUCTION: Cholecystectomy is one of the most common operations performed worldwide. Although laparoscopic surgery has been the 'gold-standard' approach for this operation, there is a paucity of global evidence around the variations of safe provision of cholecystectomy, including low-income and middle-income countries. This international collaborative study will allow contemporaneous data collection on the quality of cholecystectomies using measures covering infrastructure, care processes and outcomes, with the primary aim define the global variation in compliance with preoperative, intraoperative and postoperative audit standards. METHODS AND ANALYSIS: Global Evaluation of Cholecystectomy Knowledge and Outcomes is a prospective, international, multicentre, observational cohort study delivered by the GlobalSurg Collaborative. Consecutive patients undergoing cholecystectomy between 31 July 2023 and 19 November 2023 will be recruited, with follow-up at 30 days and 1-year postoperatively. The study will be undertaken at any hospital providing emergency or elective surgical services for biliary disease. The primary endpoint of this study is compliance with preoperative, intraoperative and postoperative audit standards. Secondary outcomes include rates of 30-day complications, achievement of critical view of safety and rates of gallbladder cancer. ETHICS AND DISSEMINATION: This project will not affect clinical practice and has been classified as clinical audit following research ethics review at University Hospital Birmingham NHS Trust. The protocol will be disseminated through the international GlobalSurg and CovidSurg network. TRIAL REGISTRATION NUMBER: NCT06223061.

[Association between previous appendectomy and cognitive impairment in adults: a case-control study]. / Vliyanie predshestvuyushchei appendektomii na kognitivnye narusheniya u vzroslykh: issledovanie «sluchai-kontrol'¼.

OBJECTIVE: To determine the relationship between appendectomy and cognitive impairment in adults aged 50-70 years. MATERIAL AND METHODS: A case-control study was carried out with 270 patients between May and July 2023. Ninety cases (with cognitive impairment) and 180 controls (without impairment), diagnosed by the Montreal Cognitive Assessment (MoCA), were assessed. RESULTS: 31.11% of the total cases with cognitive impairment were submitted to an appendectomy, with an average of 25 years since surgery. Regarding other surgeries: 40% with impairment underwent cholecystectomy and 23.33% reported other operations. The analysis revealed significant differences in age, body mass index, hypertension, diabetes and smoking between the groups. However, there was no significant difference by gender. Logistic regression analysis highlighted that age and past appendectomy were strongly associated with cognitive impairment, with an Odds Ratio (OR) of 1.20 and 12.91, respectively. Associations were also found with cholecystectomy (OR 7.33), other surgeries (OR 13.39) and smoking (OR 6.91). CONCLUSION: Appendectomy might be a significant risk factor for cognitive impairment in adults aged 50-70 years.

Prevalence of gallbladder cancer in cholecystectomized patients in Sulaymaniyah city.

Gallbladder cancers (GBC) are rare, and they are one of lethal neoplasms of biliary system. The diagnosis is either incidentally during histopathological examinations after cholecystectomy or due to complications of local or systemic spread of the malignancy. The incidence differs ethnically and geographically. The aim was to identify increase risk of cancer in the Kurdistan region by searching for the number of GBC cases among cholecystectomy patients in Sulaymaniyah governorate. This study is laboratory-based retrospective study, including data obtained from 8315 cholecystectomized patients in Sulaymaniyah governorate from 2017- 2021. The information within the questionnaire included: age, sex, clinical notes and histopathological findings; including GBC. The total of 8315 cases; were 2149 males (25.8%) and 6166 females (74.2%). The mean age was (44.67+/-15.18) years. Forty-five cases have been reported as adenocarcinoma of GB and one case of Carcinosarcoma. Among the patients, 875 cases (10.50%) had acute cholecystitis. A significant relationship was found between the findings and the age and gender of the patients. GBC is not common and is mainly diagnosed incidentally after routine post-operative histopathological examination, and mainly affects old ages.

[Contribution of A.F. Kablukov (1857-1915) to biliary surgery]. / Vklad A.F. Kablukova (1857­1915) v biliarnuyu khirurgiyu.

In 2023, it was 130 years since the opening of the Alexander Surgical Hospital at the Tauride Provincial Zemstvo Hospital, where many talented doctors worked. This authors present new facts about outstanding surgeon who worked in Simferopol at the turn of the 19th and 20th centuries, Alexander Fedorovich Kablukov (1857-1915). He was a founder of surgical school in the Tauride province, who first described cholecystectomy In Russian-language literature. The report covers in detail famous surgery restored thanks to pre-revolutionary sources. Excerpts from other little-known reports of surgeon related to the treatment of gallbladder and biliary diseases are also presented.

Variation in Postoperative Outcomes Across Federally Designated Hospital Star Ratings.

Importance: Despite widespread use to guide patients to hospitals providing the best care, it remains unknown whether Centers for Medicare & Medicaid Services (CMS) hospital star ratings are a reliable measure of hospital surgical quality. Objective: To examine the CMS hospital star ratings and hospital surgical quality measured by 30-day postoperative mortality, serious complications, and readmission rates for Medicare beneficiaries undergoing colectomy, coronary artery bypass graft, cholecystectomy, appendectomy, and incisional hernia repair. Design, Setting, and Participants: This cohort study evaluated 100% Medicare administrative claims for nonfederal acute care hospitals with a CMS hospital star rating for calendar years 2014-2018. Data analysis was performed from January 15, 2022, to April 30, 2023. Participants included fee-for-service Medicare beneficiaries aged 66 to 99 years who underwent colectomy, coronary artery bypass graft, cholecystectomy, appendectomy, or incisional hernia repair with continuous Medicare coverage for 3 months before and 6 months after surgery. Exposure: Centers for Medicare & Medicaid Services hospital star rating. Main Outcomes and Measures: Risk- and reliability-adjusted hospital rates of 30-day postoperative mortality, serious complications, and 30-day readmissions were measured and compared across hospitals and star ratings. Results: A total of 1 898 829 patients underwent colectomy, coronary artery bypass graft, cholecystectomy, appendectomy, or incisional hernia repair at 3240 hospitals with a CMS hospital star rating. Mean (SD) age was 74.8 (7.0) years, 50.6% of the patients were male, and 86.5% identified as White. Risk- and reliability-adjusted 30-day mortality rate decreased in a stepwise fashion from 6.80% (95% CI, 6.79%-6.81%) in 1-star hospitals to 4.93% (95% CI, 4.93%-4.94%) in 5-star hospitals (adjusted odds ratio, 1.86; 95% CI, 1.73-2.00). There was wide variation in the rates of hospital mortality (variation, 1.89%; range, 2.4%-16.2%), serious complications (variation, 1.97%; range, 5.5%-45.1%), and readmission (variation, 1.27%; range, 9.1%-22.5%) across all hospitals. After stratifying hospitals by their star rating, similar patterns of variation were observed within star rating groups for 30-day mortality: 1 star (variation, 1.91%; range, 3.6%-12.0%), 2 star (variation, 1.86%; range, 2.8%-16.2%), 3 star (variation, 1.84%; range, 2.9%-12.3%), 4 star (variation, 1.76%; range, 2.9%-11.5%), and 5 star (variation, 1.79%; range, 2.4%-9.1%). Similar patterns were observed for serious complications and readmissions. Conclusion and Relevance: Although CMS hospital star rating was associated with postoperative mortality, serious complications, and readmissions, there was wide variation in surgical outcomes within each star rating group. These findings highlight the limitations of the CMS hospital star rating system as a measure of surgical quality and should be a call for continued improvement of publicly reported hospital grade measures.