HAS LAPAROSCOPIC CHOLECYSTECTOMY CHANGED PATTERNS OF PRACTICE AND PATIENT OUTCOME IN ONTARIO

Objective: To examine the effect of the introduction of laparoscopic c holecystectomy (LC) on patterns of practice (number of cholecystectomy procedures, case-mix and length of hospital stay) and patient outcome s in Ontario. Design: Cross-sectional population-based time trends usi ng hospital discharge data. Setting: All acute care hospitals in Ontar io where cholecystectomy was provided. Patients: All 119 821 Ontario r esidents who underwent cholecystectomy between 1989-90 and 1993-94. Af ter exclusions (initial bile duct exploration, cancer, incidental chol ecystectomy, or missing codes for age, sex or residence) 108 442 patie nts remained. Outcome measures: Number of cholecystectomy procedures, proportion of patients with acute or chronic gallstone disease, length of hospital stay, and rates of death, readmission, and bile duct inju ry and other in-hospital complications after cholecystectomy by year. Results: The number of cholecystectomy procedures increased by 30.4% b etween 1989-90 and 1993-94. The number of patients with chronic gallst one disease increased by 33.6%, and the number who underwent elective surgery increased by 48.3%. The proportion of procedures performed as LC increased from 1.0% in 1990-91 to 85.6% in 1993-94. Patients who re ceived LC tended to be younger female patients with chronic gallstone disease with no coexisting conditions undergoing elective. operations. The mean length of stay, adjusted for case-mix differences, was signi ficantly lower in 1993-9$ than in 1989-90 (2.6 days v. 7.5 days) (P < 0.05); the values for LC and open cholecystectomy in 1993-94 were 1.8 days and 7.3 days respectively. The decrease in the crude death rate o ver the study period (0.3% to 0.2%) was not significant (relative odds 1.10, 95% confidence interval [CI] 0.72 to 1.69). In 1993-94 the adju sted risk of readmission to hospital within 30 days was 1.38 (95% CI 1 .19 to 1.58) as compared with 1989-90. Over the 5 years the rate of bi le duct injuries tripled (0.3% in 1989-90 v. 0.9% in 1993-94). The adj usted risk of having at least one complication after,cholecystectomy i n 1993-94 was 1.90 (95% CI 1.75 to 2.07) as compared with 1989-90. Con clusions: LC has had a substantial effect on the number of cholecystec tomy procedures performed, the type of patient having the gallbladder removed and the length of hospital stay. Death rates are unchanged, bu t the odds of readmission and in-hospital complications are both incre ased. Future research should be directed toward determining the reason s for the overall increase in rates, developing methods to reduce bile duct injuries and identifying other relevant outcomes, such as patien t satisfaction with the procedure.