Cancer of the Gallbladder: National Patterns of Surgical Intervention
James T. McPhee, Maksim Zayaruzny, Giles F. Whalen, Demetrius E. Litwin, Mary E. Sullivan, Frederick A. Anderson, Jennifer F. Tseng; Surgery, University of Massachusetts Memorial Medical Center , Worcester , MA
Purpose: Gallbladder cancer (GBC) is the 5th most common gastrointestinal malignancy. GBC carries a poor prognosis due to its often advanced stage at presentation. We sought to evaluate disease demographics as well as national patterns of surgical intervention. Methods: Using the National Inpatient Sample (NIS) 1998-2003 we identified 3345 patients (16,460 nationally by weighted average) discharged from U.S. hospitals with a primary diagnosis of GBC (ICD-9 diagnostic code [156.0]). Patients were categorized based on primary as well as secondary (up to 15) surgical interventions during the same hospitalization based on ICD-9 procedure codes for cholecystectomy (CCY), bile duct resection, hepatectomy or pancreaticoduodenectomy. Primary outcomes measured were procedure type and in-hospital mortality. Results: Of 3345 patients with GBC, 71% were female. 70% were white, 12% were Hispanic, and 10% were Black. Mean age was 70. Overall in-hospital mortality for the entire cohort was 11.6 %. Of the initial cohort, 44.3% underwent CCY as the primary surgical intervention (28.9% open, 15.6% laparoscopic). Other primary procedures included pancreaticoduodenectomy (0.2%), hepatic resection (5.3%), or bile duct resection (1.1%) in conjunction with CCY. For the simple CCY group, 2.5% of patients underwent further resection (hepatic resection or bile duct resection) during the same hospitalization. Patients admitted to non-teaching hospitals had higher mortality than patients admitted to teaching hospitals on univariate analysis; after adjustment for comorbidities using multivariate logistic regression, this difference remained significant [adjusted OR 2.03, 95% CI 1.36-3.03]. Females had a decreased risk of in-hospital mortality compared to males after multivariate analysis [adjusted OR 0.79, 95% CI 0.63-0.99]. Of note, on univariate analysis, open CCY had a significantly higher mortality rate than laparoscopy (5.3% vs. 4.1%, p<.05, chi square), however after multivariate analysis, this difference became insignificant [adjusted OR 0.69, 95% CI 0.41-1.18]. Conclusions: The surgical management of GBC is critical, as 1) GBC is generally only diagnosed in early stages as an incidental finding at routine cholecystectomy, and 2) at present, treatment of GBC with curative intent must include complete surgical resection. Based on this large population study, >50% of patients discharged with a diagnosis of GBC underwent resection, with the vast majority of patients undergoing cholecystectomy alone. More detailed studies that include follow-up care are warranted to ascertain that patients with GBC receive adequate surgical treatment for this aggressive malignancy.
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