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

This registry-based cohort study demonstrated that operative volumes, both for the surgeon and the hospital, influence outcomes of cholecystectomies. The results indicated that gallstone surgery should be performed by procedure-dedicated surgeons at hospitals with high volumes of this type of benign surgery Lay Summary 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. 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.