The American Journal of Surgery (2015) 210, 864-870

Clinical Science

How sick are dialysis patients undergoing cholecystectomy? Analysis of 92,672 patients from the American College of Surgeons National Surgical Quality Improvement Program database Sophia F. Tam, M.D.a, Joyce T. Au, M.D.b, Wataru Sako, M.D., Ph.D.c, Antonio E. Alfonso, M.D., F.A.C.S.b, Gainosuke Sugiyama, M.D., F.A.C.S.b,* a

Department of Surgery, SUNY Downstate College of Medicine, Brooklyn, NY, USA; bDepartment of Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA; cDepartment of Neurosciences, The Feinstein Institute for Medical Research, Manhasset, NY, USA

KEYWORDS: Dialysis; Hemodialysis; End-stage renal disease; Cholecystectomy; Abdominal surgery; ACS NSQIP

Abstract BACKGROUND: Although cholecystectomy is one of the most common surgical procedures performed in the United States, there is an absence of data on the risks of cholecystectomy in dialysis patients. Our objective was to analyze the outcomes of cholecystectomy in dialysis patients. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, we selected all patients who underwent cholecystectomy from 2005 to 2010. Univariate analysis was performed and logistic and linear regression models were used to obtain risk-adjusted outcomes. The main outcomes were morbidity, mortality, and length of stay. RESULTS: Dialysis was associated with a higher risk of 30-day postoperative morbidity (16.1% vs 3.8%, adjusted odds ratio 1.91, 95% confidence interval 1.18 to 3.10), but not mortality. The average length of stay following any cholecystectomy was 4.1 days longer for dialysis patients (5.5 vs 1.4 days, P , .0001). CONCLUSION: Patients on dialysis who undergo cholecystectomy are at a higher risk for postoperative morbidity, but not mortality. Ó 2015 Elsevier Inc. All rights reserved.

The authors declare no conflicts of interest. Presented at the Eighth Annual Academic Surgical Congress, February 2013, New Orleans, Louisiana, and the Fifth Annual ACS NSQIP National Conference, July 2013, San Diego, California. * Corresponding author. Tel.: 11-718-270-6718; fax: 11-718-2702826. E-mail address: [email protected] Manuscript received January 21, 2014; revised manuscript June 2, 2014 0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2015.01.020

From 2007 to 2009, the number of patients treated with dialysis for end-stage renal disease increased by 7.8% in the United States. In 2009, 398,861 patients were treated with dialysis.1 The rapid growth and significant size of this patient population is of great concern as the number of surgical procedures performed on these patients is likely to increase as well. Chronic renal failure has been associated with a higher risk of postoperative complications such as hyperkalemia, hypotension, hemorrhage, sepsis, and poor wound healing.2,3

S.F. Tam et al.

Dialysis patients undergoing cholecystectomy

Studies have explored the outcomes of abdominal surgery in dialysis patients with morbidity and mortality rates being substantially greater in emergency abdominal surgery.4–7 However, most studies use data from single institutions and include a large variety of surgical procedures, obscuring the conclusions regarding the safety of one specific procedure. Cholecystectomy is one of the most common surgical procedures performed in the United States. In the general population, the introduction of a laparoscopic approach to cholecystectomy has yielded low postoperative morbidity and mortality rates.8 Although multiple studies have determined age, cirrhosis, and obesity as risk factors for poor postoperative complications, there has not been a study on the effect of chronic renal failure on the postoperative outcomes following cholecystectomy.9–11 We explored the outcomes of cholecystectomy in dialysis patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. The objective of this study was to determine the impact of chronic renal failure on morbidity and mortality following cholecystectomy.

Methods Data were acquired from the ACS NSQIP Participant Use Data File. The ACS NSQIP is the first nationally validated program that measures risk-adjusted surgical outcomes to improve the quality of surgical care. The ACS NSQIP uses a systematic sampling process that ensures a randomized selection of multiple surgical specialties. The sampling process adjusts for hospital surgical volume and oversampling by applying restrictions such as including no more than 3 laparoscopic cholecystectomies in an 8-day period.12 We identified adult patients aged 16 and older who underwent cholecystectomy from 2005 to 2010 using Current Procedural Terminology codes: 47562, 47563, 47564, 47600, 47605, and 47610. This included a laparoscopic or open approach with or without cholangiogram or common bile duct exploration. We then selected patients based on International Classification of Diseases 9th revision codes that had a postoperative diagnosis of cholecystitis or cholelithiasis: 574.00, 574.01, 574.30, 574.31, 574.60, 574.61, 574.80, 574.81, 575.0, 575.12, 575.11, 574.10, 574.11, 574.40, 574.41, 574.70, 575.71, 575.1, 575.10, 574.20, 574.21, 574.50, 574.51, 574.90, and 574.91. This excluded patients who underwent surgery because of other etiologies such as trauma, chronic hemolysis, or bariatric surgery. Patients on dialysis were identified based on the ACS NSQIP definition: chronic renal failure requiring treatment with peritoneal dialysis, hemodialysis, hemofiltration, hemodiafiltration, or ultrafiltration within 2 weeks before surgery. The database does not distinguish which dialysis modality each patient was receiving. Patients were excluded if they suffered from acute renal failure. To minimize the

865 heterogeneity found between the dialysis and nondialysis groups in the aggregate cholecystectomy population, cohorts were created and randomly matched 1:1 based on age, sex, surgical approach, and emergency status. The primary outcomes of interest were 30-day morbidity and mortality. Morbidity was defined as having documentation of at least one of the following complications as defined by ACS NSQIP: superficial surgical site infection (SSI), deep incisional SSI, organ/space SSI, wound disruption, pneumonia, unplanned intubation, pulmonary embolism, ventilator dependence greater than 48 hours, cardiac arrest, myocardial infarction, bleeding transfusion, deep vein thrombosis, sepsis, septic shock, or an unplanned return to the operating room. Patients could have more than one of the listed complications. Patients were excluded from having the following outcomes if the condition was documented preoperatively: wound occurrence, pneumonia, ventilator dependence, urinary tract infection, sepsis, or septic shock. Risk factors, morbidity, and mortality rates were compared using chi-square test for categorical variables and Wilcoxon rank-sum or 2-sided t tests for continuous variables, with significance set at P less than .05. Forward stepwise logistic and linear regression models were used to study the association among 30-day postoperative mortality, morbidity, and length of hospital stay with dialysis. The multivariate model adjusted for the following variables: diabetes, dyspnea, ascites, chronic obstructive pulmonary disease (COPD), pneumonia, ventilator dependence, steroid use, bleeding disorder, congestive heart failure, hypertension requiring medication, preoperative sepsis, and emergency status. The length of stay (LOS) was also measured and compared. All statistical analysis was performed using SPSS software (SPSS 20; IBM Corporation, Armonk, NY).

Results From 2005 to 2010, a total of 92,672 patients underwent cholecystectomy at participating ACS NSQIP hospitals. Of these patients, 623 (.8%) were on dialysis. In general, dialysis patients tended to be older, male, and black with the following comorbidities: diabetes, dyspnea, ascites, on steroids for a chronic condition, COPD, bleeding disorder, congestive heart failure, hypertension requiring medication, coronary artery disease, peripheral vascular disease, neurological disorder, and preoperative sepsis. Because of the significant heterogeneity among the demographics of the 2 groups, cohorts were created and matched based on age, sex, surgical approach, and emergency status (Table 1). Out of all 92,672 patients, 357 (.3%) patients died postoperatively within 30 days. Dialysis patients had a higher rate of mortality (5.1% vs .4%, P ,.0001), which was similar to the matched cohort (4.3% vs .0%, P , .0001) as seen in Table 2. However, there was no increased risk of mortality in dialysis patients following the multivariate analysis. Overall, 3,390 (3.9%) patients experienced at least one postoperative complication. Dialysis patients had a higher

866 Table 1

The American Journal of Surgery, Vol 210, No 5, November 2015 Risk factors of patients by dialysis status undergoing cholecystectomy at participating ACS NSQIP hospitals (2005–2010)

Age (years) Sex Female Male Race White Black Other Body mass index Alcohol use Current smoker within 1 year Diabetes Dyspnea Ascites COPD Pneumonia Ventilator dependent Steroid use Bleeding disorder Congestive heart failure Hypertension requiring medication Coronary artery disease* Peripheral vascular disease† Neurologic disorder‡ Preoperative transfusionx Preoperative sepsisk ASA class 1 (no disturbance) 2 (mild disturbance) 3 (severe disturbance) 4 (life-threatening) 5 (moribund) Functional status Independent Partially dependent Totally dependent Emergency case Laparoscopic

Aggregate cohort (n 5 92,672)

Matched cohort (n 5 1,243)

Dialysis (n 5 623)

Nondialysis (n 5 92,049)

Dialysis (n 5 623)

Nondialysis (n 5 620)

59.4 6 14.6

49.5 6 17.4

59.4 6 14.6

59.4 6 14.6

285 (45.7%) 338 (54.3%)

65,325 (71.0%) 26,528 (28.8%)

285 (45.7%) 338 (54.3%)

284 (45.8%) 336 (54.2%)

344 (55.2%) 185 (29.7%) 55 (8.8%) 28.6 6 7.3 4 (.6%) 75 (12.0%) 280 (44.9%) 131 (21.0%) 32 (5.1%) 40 (6.4%) 13 (2.1%) 12 (1.9%) 59 (9.5%) 93 (14.9%) 34 (5.5%) 541 (86.8%) 206 (33.1%) 73 (11.7%) 121 (19.4%) 4 (.6%) 113 (18.1%)

65,359 (71.0%) 8,905 (9.7%) 8,617 (9.4%) 30.8 6 18.2 1,391 (1.5%) 18,115 (19.7%) 10,292 (11.2%) 6,325 (6.9%) 420 (.5%) 2,548 (2.8%) 212 (.2%) 97 (.1%) 1,595 (1.7%) 2,999 (3.3%) 485 (.5%) 32,868 (35.7%) 6,598 (7.2%) 687 (.7%) 3,951 (4.3%) 66 (.1%) 7,292 (7.9%)

344 (55.2%) 185 (29.7%) 55 (8.8%) 28.6 6 7.3 4 (.6%) 75 (12.0%) 280 (44.9%) 131 (21.0%) 32 (5.1%) 8 (6.2%) 13 (2.1%) 12 (1.9%) 59 (9.5%) 93 (14.9%) 34 (5.5%) 541 (86.8%) 206 (33.1%) 73 (11.7%) 121 (19.4%) 4 (.6%) 113 (18.1%)

465 (75.0%) 47 (7.6%) 44 (7.1%) 30.1 6 7.3 22 (3.5%) 120 (19.4%) 87 (14.0%) 58 (9.4%) 2 (.3%) 9 (1.3%) 4 (.6%) 0 (.0%) 11 (1.8%) 35 (5.6%) 5 (.8%) 325 (52.4%) 83 (13.4%) 16 (2.6%) 36 (5.8%) 0 (.0%) 57 (9.2%)

0 17 365 237 4

(.0%) (2.7%) (58.6%) (38.0%) (.6%)

11,933 54,533 23,593 1,884 17

(13.0%) (59.2%) (25.6%) (2.0%) (.0%)

0 17 365 237 4

(.0%) (2.7%) (58.6%) (38.0%) (.6%)

38 320 236 22 1

(6.1%) (51.6%) (38.1%) (3.5%) (.2%)

502 89 32 82 478

(80.6%) (14.3%) (5.1%) (13.2%) (76.7%)

89,180 2,339 525 8,608 83,494

(96.9%) (2.5%) (.6%) (9.4%) (90.7%)

502 89 32 82 478

(80.6%) (14.3%) (5.1%) (13.2%) (76.7%)

594 20 6 82 476

(95.8%) (3.2%) (1.0%) (13.2%) (76.8%)

P value ,.0001 ,.0001 ,.0001

,.0001 .205 ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 .001 ,.0001 ,.0001

1.0000 .983

,.0001

,.0001

.001 ,.0001

P value

,.0001 ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 .837 .029 .001 ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 .124 ,.0001 ,.0001

.974

1.000 .984

ACS NSQIP 5 American College of Surgeons National Surgical Quality Improvement Program; ASA 5 American Society of Anesthesiologists; COPD 5 chronic obstructive pulmonary disease; CVA 5 Cerebrovascular attack. *History of angina 1 month before surgery, history of myocardial infarction 6 months before surgery, previous percutaneous cardiac intervention, or previous cardiac surgery. † History of revascularization or amputation for peripheral vascular disease and rest pain or gangrene. ‡ CVA or stroke with or without neurological deficit, history of transient ischemic attacks, hemiplegia, paraplegia, impaired sensorium, or quadriplegia. x Transfusion greater than 4 U of packed red blood cells within 72 hours before surgery. k Preoperative systemic inflammatory response syndrome, sepsis, or septic shock.

rate of morbidity compared with nondialysis patients (16.1% vs 3.8%, P , .0001). The postoperative complications of all patients who underwent cholecystectomy are shown in Table 2. After univariate analysis of the matched cohorts, dialysis patients still had a higher rate of morbidity (16.1% vs 6.0%, P , .0001) (Table 2). Outcomes for wound disruption, pneumonia, unplanned intubation, requiring a ventilator for more than 48 hours, cardiac arrest,

myocardial infarction, bleeding transfusions, sepsis or septic shock, and unplanned return to the operating room were significantly higher in the dialysis group compared with the nondialysis group (Fig. 1). After adjusting for confounders, the probability of postoperative morbidity was 2-fold greater in dialysis patients (adjusted odds ratio [OR] 1.91, 95% confidence interval [CI] 1.18 to 3.10, P 5 .009) (Table 3).

S.F. Tam et al.

Dialysis patients undergoing cholecystectomy

867

Table 2 Univariate analysis of 30-day outcomes after cholecystectomy in dialysis versus nondialysis patients at ACS NSQIP hospitals (2005 – 2010) Aggregate cohort (n 5 92,672) Dialysis (n 5 623) Mortality 32 (5.1%) Overall morbidity 100 (16.1%) Surgical site infection Superficial 14 (2.2%) Deep incisional 8 (1.3%) Organ/Space 7 (1.1%) Wound disruption 10 (1.6%) Pneumonia 13 (2.1%) Unplanned intubation 29 (4.7%) Pulmonary embolism 3 (.5%) On ventilator for .48 hours 29 (4.7%) Cardiac arrest 15 (2.4%) Myocardial infarction 7 (1.1%) Bleeding transfusions* 15 (2.4%) Deep vein thrombosis 2 (.3%) Sepsis 34 (5.5%) Septic shock 24 (3.9%) Return to OR 33 (5.3%) Length of postoperative stay (days), mean All 5.5 6 10.5 Laparoscopic 3.6 6 6.4 Open 11.8 6 17.0

Matched cohort (n 5 1,060)

Nondialysis (n 5 92,049)

P value

Dialysis (n 5 623)

Nondialysis (n 5 620)

P value

325 (.4%) 3,480 (3.8%)

,.0001 ,.0001

32 (5.1) 100 (16.1)

0 (.0) 37 (6.0)

,.0001 ,.0001

1,071 138 476 113 489 429 114 336 105 84 267 183 622 278 1,098

.155 .103 .054 ,.0001 ,.0001 ,.0001 .455 ,.0001 ,.0001 ,.0001 ,.0001 .703 ,.0001 ,.0001 ,.0001

14 2 9 2 6 6 1 4 1 0 3 2 9 3 9

.990 .058 .608 .021 .108 ,.0001 .624 ,.0001 ,.0001 .015 .005 .996 ,.0001 ,.0001 ,.0001

(1.2%) (.1%) (.5%) (.1%) (.5%) (.5%) (.1%) (.4%) (.1%) (.1%) (.3%) (.2%) (.7%) (.3%) (1.2%)

1.4 6 3.0 1.0 6 2.2 5.5 6 5.9

,.0001 ,.0001 ,.0001

14 8 7 10 13 29 3 29 15 7 15 2 34 24 33

(2.2) (1.3) (1.1) (1.6) (2.1) (4.7) (.5) (4.7) (2.4) (1.1) (2.4) (.3) (5.5) (3.9) (5.3)

5.5 6 10.5 3.6 6 6.4 11.8 6 17.0

(2.3) (.3) (1.5) (.3) (1.0) (1.0) (.2) (.6) (.2) (.0) (.5) (.3) (1.5) (.5) (1.5)

2.0 6 3.6 1.1 6 1.8 5.0 6 5.8

,.0001 ,.0001 ,.0001

ACS NSQIP 5 American College of Surgeons National Surgical Quality Improvement Program; OR 5 operating room. *Any transfusion (including autologous) of packed red blood cells or whole blood given from the time the patient leaves the operating room up to and including 72 hours postoperatively.

Dialysis patients had a higher rate of return to the operating room (5.3% vs 1.2%, P , .0001) compared with nondialysis patients. This rate was similar among the matched cohort (Table 2). After multivariate analysis, dialysis patients were almost 4 times as likely to return to the operating room (OR 3.78, 95% CI 1.61 to 8.9, P , .002) (Table 3). Overall hospital LOS was longer for dialysis patients after cholecystectomy (5.5 vs 1.4 days, P , .0001) (Table 2).

Figure 1 Univariate comparison of 30-day postoperative morbidity after cholecystectomy at ACS NSQIP hospitals (2005–2010).

Of the matched cohorts, dialysis patients had a statistically significant longer LOS than nondialysis patients (5.5 vs 2.0 days, P , .0001). After adjustment for confounding risk factors, the LOS for dialysis patients was doubled as compared with nondialysis patients (adjusted OR 2.70, 95% CI 1.61 to 3.68, P , .0001) (Table 3).

Comments In this study, we examined the 30-day outcomes of 92,672 patients who underwent cholecystectomy from 2005 to 2010 at participating ACS NSQIP hospitals. We demonstrated that dialysis was associated with an increased risk of morbidity but not mortality. Notably, a greater proportion of dialysis patients experienced infectious, pulmonary, cardiac, and hematologic complications, as well as an unplanned return to the OR. We report a morbidity rate of 16.1% and a mortality rate of 5.1% in dialysis patients, which are comparable with previous studies that report morbidity rates ranging from 5% to 25% following elective abdominal procedures in dialysis patients.4–7 The major causes of postoperative complications reported have been hyperkalemia, sepsis, hemorrhage, cardiac dysfunction, and hemodynamic instability.2,3,7 Although these studies included a small number of dialysis patients

868 Table 3

The American Journal of Surgery, Vol 210, No 5, November 2015 Multivariate analysis of 30-day outcomes following cholecystectomy at ACS NSQIP hospitals (2005 – 2010) Aggregate

Mortality Morbidity Return to operating room LOS

Matched

OR (95% CI)*

P value

OR (95% CI)*

P value

4.19 2.06 2.63 2.58

,.0001 ,.0001 ,.0001 ,.0001

– 1.91 (1.18–3.10) 3.78 (1.61–8.90) 2.70 (1.61–3.68)



(2.62–6.71) (1.60–2.65) (1.80–3.85) (2.34–2.82)

.009 .002 ,.0001

ACS NSQIP 5 American College of Surgeons National Surgical Quality Improvement Program; CI 5 confidence interest; LOS 5 length of stay; OR 5 odds ratio. *All odds ratios are dialysis versus nondialysis.

and only a small proportion underwent cholecystectomy, our results with a much larger number of patients remained consistent with these previous findings. Of the dialysis patients in our report, 14% experienced infectious outcomes, which represented the most frequent complication that occurred. Sepsis and septic shock accounted for more than half of these occurrences. Pinson et al2 reported a rate of 9% with sepsis accounting for 3% of these complications and 5% of postoperative mortality. Uremia is associated with alterations in primary host immune response, which increases the risk of bacterial infection.13 This underlines the importance that uremia may place dialysis patients at a greater risk of postoperative infectious complications. These infections usually respond to appropriate treatment at the site of infection.14 As a prevention technique, many patients on chronic hemodialysis are given prophylactic antibiotics.15 It remains to be seen whether this affects infectious outcomes or contributes to antibiotic resistance. Pulmonary incidents were the next most common complication, with the majority being that patients required unplanned intubation or maintenance with ventilator. Hemodialysis has been shown to induce hypoxemia by diffusion of carbon dioxide into the dialysate leading to hypocapnia and concomitant hypoventilation.16 Lissoos et al14 report dialysis patients suffering from significant episodes of hypoventilation postoperatively. Because of the possible association between preoperative dialysis and hypoventilation, they suggest to avoid elective surgery within 24 hours of the last dialysis if possible.14 A significant proportion of dialysis patients also experienced vascular complications compared with nondialysis patients. Chronic renal failure is associated with an increased risk of death related to cardiovascular compromise because of accelerated atherogenesis, which may lead to an increased risk of vascular complications including myocardial infarction and cardiac arrest.17 In this study, 2.4% of dialysis patients suffered from cardiac arrest. Hyperkalemia has been reported as a common complication in multiple studies of dialysis patients undergoing abdominal surgery.14,18,19 Factors that may contribute to hyperkalemia are transfusions, hypercatabolic state following surgery, and an elevated preoperative potassium level.18 It has been postulated that respiratory compensation may be altered in renal failure patients leading to a fall in arterial pH and an increase in plasma potassium concentration.20 Because of the possibility of

arrhythmias in the dialysis patient, estimated serum potassium levels and electrocardiographic monitoring should be carried out frequently.14 Some studies advocate dialysis 1 day preoperatively18,21 and resumption of dialysis 24 to 36 hours postoperatively or if hyperkalemia is detected before this time frame.19 Patients with chronic kidney disease have been known to have bleeding tendencies leading to an increased rate of blood transfusions postoperatively.21 About 2% of dialysis patients in this study required transfusions postoperatively compared with .3% of nondialysis patients. Studies suggest that urea or one of its metabolites have a direct effect on platelet function.22 Furthermore, anemia of patients on chronic hemodialysis is related to multiple factors such as decreased erythropoietin production and uremic toxic depression of the bone marrow.23,24 It is not necessary to raise the hematocrit to normal preoperatively because these patients are adjusted to low levels over years.19 When necessary, transfusions with desmopressin or cryoprecipitate have been shown to decrease bleeding time and aid in avoiding hemorrhage.25,26 It is also important to be aware of late bleeding because of a ‘‘heparin rebound’’ in patients receiving regional heparin during dialysis.27 Dialysis patients were more likely to return to the operating room compared with their nondialysis counterparts. The ACS NSQIP does not provide information regarding the indication for returning to the operating room, but this noticeable discrepancy is of concern. Nandipati et al28 found that chronic dialysis was an independent risk factor for return to the operating room in patients who underwent bariatric surgery. It is unclear whether this is because of infection or vascular accessrelated complications but is important to be aware of perioperatively in these patients. Subsequently following complications, dialysis patients experienced a significantly longer length of postoperative hospital stay. Previous reports found similar findings.3,5,7 Being aware of an increased LOS in these patients is important preoperatively to prepare the patient for possible complications associated with longer hospital stays as well as potential financial concerns. Our study has several limitations. First, there was significant heterogeneity between the dialysis and nondialysis cohorts. Patients were matched based on age, sex, surgical approach, and emergent status, but there were still

S.F. Tam et al.

Dialysis patients undergoing cholecystectomy

statistically significant differences in risk factors. To minimize confounders, the multivariate analysis took into account diabetes, dyspnea, ascites, COPD, pneumonia, ventilator dependence, steroid use, bleeding disorder, congestive heart failure, hypertension requiring medication, preoperative sepsis, and emergent status. However, there are other factors that may have contributed to postoperative occurrences in dialysis patients. Functional status and American Society of Anesthesiologists class showed statistically significant differences between the groups but were not included in the logistic regression model because these categorizations are subjective and classification may not be uniform among hospitals. Previous studies have shown that there is only a moderate agreement between measures of American Society of Anesthesiologists score among anesthesiologists with a lack of inter-rater reliability.29,30 Second, the ACS NSQIP database does not provide the causes of mortality, which makes it difficult to determine if chronic hemodialysis was truly a risk factor for the mortality observed. Although it is apparent that cholecystectomy performed as an ambulatory procedure for biliary colic is very different than cholecystectomy performed in association with cholangitis or biliary pancreatitis, there were only 82 dialysis patients who underwent emergent cholecystectomy which would have yielded a lower power in a statistical analysis. Because emergent surgery in dialysis patients has been associated with high mortality rates,6,7 we took this into account by creating a matched cohort based on this variable as well as including it in the logistic regression model. Finally, the ACS NSQIP definition of dialysis includes peritoneal dialysis, hemodialysis, hemofiltration, hemodiafiltration, or ultrafiltration, and the database does not allow the ability to distinguish which modality each dialysis patient had been receiving. Different forms of dialysis could have impacted the outcomes of an abdominal surgery differently. Despite these limitations, the major strength of our study is the large sample size selected from a national database rather than single institutions, providing an adequate representation of the impact of dialysis on the morbidity and mortality following cholecystectomy. Considering the rapidly increasing number of patients on dialysis for end-stage renal disease, it is important to understand the risks associated with performing common general surgery procedures in these patients. Complications to be aware of include infections, respiratory compromise, cardiac arrest, and bleeding requiring transfusion. Further examination is warranted considering whether a laparoscopic or open cholecystectomy is a predictor of adverse outcomes in dialysis patients. Using the results obtained in this study, when faced with the decision to perform cholecystectomy in patients on chronic hemodialysis, healthcare professionals can quantify the risks of postoperative morbidity and mortality and communicate this information to patients. Furthermore, surgeons may be more vigilant of the particular potential complications that dialysis patients are more susceptible to, for earlier diagnosis, recognition, and management.

869

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How sick are dialysis patients undergoing cholecystectomy? Analysis of 92,672 patients from the American College of Surgeons National Surgical Quality Improvement Program database.

Although cholecystectomy is one of the most common surgical procedures performed in the United States, there is an absence of data on the risks of cho...
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