過剰な亜全的胆嚢摘出術：大規模医療システムにおける外科医の診療パターンと転帰

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

We retrospectively analyzed 17,299 (CCs) performed by 111 surgeons across 12 hospitals within one 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.

Among 157 SC cases, 60% were performed by just eight surgeons, who collectively accounted for only 13% of all cholecystectomies. 136 cases (87%) of SC were concentrated in 3 hospitals, which accounted for 31% of all CC. Surgeons with increasing experience performing SC were significantly more likely to perform the procedure (OR 1.13, p = 0.004). Conversely, the more CC a surgeon performed, the lower the likelihood of performing an SC (OR 0.998, p < 0.001). 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. Six major bile duct injuries requiring reconstruction were identified after CC (0.03% BDI rate). Surgeon-level variability, not hospital-level variability, explained the residual clustering of SC use, accounting for 16% of the adjusted residual.

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.