Overuse of subtotal cholecystectomy: surgeon practice patterns and outcomes in a large healthcare system.

BACKGROUND

Subtotal cholecystectomy (SC) is a possible bailout procedure to prevent bile duct injuries (BDIs) when a critical view of safety cannot be obtained during cholecystectomy (CC).

METHODS

This retrospective study analyzed 17,299 CCs performed by 111 surgeons across 12 hospitals within 1 large healthcare system using multilevel propensity-weighted logistic regression to model the risk of SC and reinterventions, accounting for patient-, surgeon-, and hospital-level factors.

RESULTS

Among 157 SC cases, 94 (60%) were performed by just 8 surgeons, who collectively accounted for only 13% of all CCs. In addition, 136 cases (87%) of SC were concentrated in 3 hospitals, accounting for 31% of all CCs. Surgeons with increasing experience performing SC were significantly more likely to perform the procedure (odds ratio [OR], 1.13; P =.004). Conversely, the more CCs a surgeon performed, the lower the likelihood of performing an SC (OR, 0.998; P <.001). Fellowship training and years of experience were not significant independent predictors. The 30-day disease-specific reintervention rate after SC was 22.3%. There was no detectable increase in reinterventions among surgeons or hospitals who had never or rarely performed SC. In addition, 6 major BDIs requiring reconstruction were identified after CC (BDI rate of 0.03%). Surgeon-level variability, not hospital-level variability, explained the residual clustering of SC use, accounting for 16% of the adjusted residual.

CONCLUSION

SC use was primarily surgeon driven, even after accounting for patient factors that were independently associated with SC. These findings challenge SC's role as a universal bailout and call for curbing its discretionary overuse.