Cholecystectomy also on rise in Alberta
Online posting: May 3, 1996
Published in print: July 15, 1996 (CMAJ 1996;155:161-162)
Re: Has laparoscopic cholecystectomy changed patterns of practice and patient outcome in Ontario?, by Marsha M. Cohen and associates,
CMAJ 1996; 154: 491-500
In their article, Dr. Marsha M. Cohen and associates show that
the introduction of the laparoscopic technique significantly
affected rates of cholecystectomy and the type of patient who
underwent the procedure in Ontario. We have found similar trends
in Alberta, where the cholecystectomy rate increased from 23.1
per 10 000 in the 1988û89 fiscal year to 25.1 per 10 000 in
1992û93, with a small drop in 1993û94.[1]
The authors suggest that the observed increase in the proportion
of cholecystectomies among patients with uncomplicated gallstone
disease and in the proportion performed as elective surgery
support the hypothesis that the threshold for surgery had been
lowered. However, symptomatic uncomplicated gallstone disease
(also called biliary colic) is the primary indication for
cholecystectomy. Furthermore, gallstone disease is best treated
at this stage, since these patients are at an increased risk of
complications such as acute cholecystitis and pancreatitis. The
emergency procedures performed for these complications are
associated with high rates of illness and death. In this respect,
the recent trends could be viewed as potentially beneficial.
Thanks to the laparoscopic technique, patients may accept surgery
more often for gallstone disease with mild to moderate symptoms.
The data support this view. The greatest increase in laparoscopic
surgery has occurred among young women, who, because of family or
occupational responsibilities, may have been unwilling to stay in
hospital for several days and spend a few weeks recovering from
an open cholecystectomy. Indeed, a pool of such patients may have
accumulated, and this pool may have resulted in the observed
increased in the rate of the procedure after laparoscopic
cholescystectomy was introduced. After this pool of patients has
been treateed, the rate may stabilize, albeit at a level somewhat
higher than before the advent of laparoscopic cholecystectomy.
Laparoscopic cholecystectomy has also affected hospitals. After
its introduction in Alberta, there was a sharp decline in the
number of hospitals performing cholecystectomies, which was
attributable to a marked decline in the number of small hospitals
(those with less than 100 beds) performing the procedure.
However, in the past 2 years, the number of small hospitals
performing laparoscopic cholecystectomies has increased markedly.
This may be of some concern, given that some of these hospitals
may perform only a few procedures each year.
Cohen and associates have shown that hospitals and providers can
change their practice patterns in very short order, even in times
of fiscal constraint. Unfortunately, they can do so before the
effectiveness, safety and potential economic impact of the new
service have been fully evaluated.
A greater concern than the possible change in the threshold for
surgery is a change in the indication for surgery. Should this
procedure be used as a diagnostic test among patients with
unexplained abdominal symptoms and gallstones? Prospective
studies are required to evaluate more fully the changes in the
population of patients undergoing cholecystectomy.
Robert J. Hilsden, MD, FRCPC
Department of Community Health Sciences
University of Calgary
Calgary, Alta.
rhilsden@acs.ucalgary.ca
Eldon A. Shaffer, MD, FACP, FRCPC
Head
Department of Medicine
University of Calgary
Calgary, Alta.
Reference
- Hilsden RJ, Kuehn NP, Shaffer EA: Has the advent of
laparoscopic cholecystectomies led to overuse of this new
procedure? The Alberta record. Clin Invest Med 1995; 18:
B55
CMAJ email
CMAJ Readers' Forum