World J Surg (2016) 40:849–855

DOI 10.1007/s00268-015-3337-5

ORIGINAL SCIENTIFIC REPORT

Cholecystectomy During the Weekend Increases Patients’ Length

of Hospital Stay
Josephine Philip Rothman1 • Jakob Burcharth1 • Hans-Christian Pommergaard1 •

Jacob Rosenberg1

Published online: 12 November 2015

Ó Société Internationale de Chirurgie 2015

Abstract
Background A higher risk of complications and mortality has previously been proven in selected settings. The
purpose of this study was to investigate whether length of stay differentiates throughout the week and register if intra-
and postoperative complications vary on weekends compared to weekdays.
Methods The population originated from the Danish Cholecystectomy Database. It consists of adult patients, who
had a cholecystectomy performed by standard four-port laparoscopic or open surgery. Adjusted analyses were used to
study if day of the week had an influence on conversion, readmission within 30 days, post-operative supplemental
procedures within 30 days, and variance in postoperative length of stay across the week.
Results A total of 28,759 patients were included in the study. We found no difference in conversion rate, read-
mission within 30 days, or post-operative procedures within 30 days between week time and weekend time. A longer
postoperative length of stay was observed for patients operated on Fridays and Saturdays even though surgical
complication rates were alike between weekdays. Patients with acute cholecystitis had a longer length of stay on
Saturdays.
Conclusion We found no evidence of a higher risk of conversions, post-operative procedures, or readmission during
weekends compared with weekdays. Despite this, a prolonged length of stay was observed in patients operated with
cholecystectomy on Fridays and Saturdays. The observed difference could be due to ward rounds on weekends
mainly focus on the sickest patients leaving less time for discharge.

Introduction
A phenomenon ‘‘weekend effect’’ has previously been used
to describe the higher risk of death and complications after
surgery during the weekend compared to weekdays [1, 2].
The weekend effect is mostly seen in acute settings [3], but
& Josephine Philip Rothman
josephineprothman@gmail.com
Jacob Rosenberg
josephineprothman@gmail.com
1
Department of Surgery, Center for Perioperative
Optimization, Herlev Hospital, University of Copenhagen,
Herlev Ringvej 75, 2730 Copenhagen, Denmark
has also been proven for elective procedures [4, 5]. It is
commonly described with diseases such as childbirth [6],
diverticulitis [7], gastrointestinal bleeding [8], and in car-
diology [9]. In addition, weekend time has also been
described to lead to a longer length of stay (LOS) after
operation for diverticulitis and hip fracture [10, 11].
Despite that elective laparoscopic cholecystectomy is
often considered a safe outpatient procedure with a short
convalescence and low risk of complications [12, 13],
some patients are operated acute with a higher risk of
complications. An increased risk of complications with
nighttime cholecystectomy compared with daytime sur-
gery, has previously been suggested [14]. The purpose of
this study was to investigate if LOS differed throughout the

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week and register if intra- and postoperative complications
varied on weekend days compared to weekdays.
Methods
This prospective database study was performed using a
cohort from the Danish Cholecystectomy Database (DCD).
The DCD was a nationwide mandatory registry existing
from early 2006 to end 2011. It included patients from all
surgical departments in Denmark, at both public and pri-
vate hospitals, who for any reason had a cholecystectomy
performed [15]. The DCD had a registration rate around
90 % from the start until mid 2011 [16].
Registrations in the DCD consisted of patient-related
variables and operative findings entered into a secure
website by the operating surgeon immediately following
surgery. This was matched with register-based adminis-
trative data from the National Patient Registry including
LOS, type of admission (emergency or elective), read-
missions, and post-operative surgical procedures within
30 days. The DCD defined acute cholecystitis as clinical
and ultrasonic pre-operative findings of acute cholecystitis
combined with perioperative finding of edema in the gall-
bladder wall. Chronic cholecystitis required a thickened
wall with fibrosis and dense adhesions judged by the
operating surgeon. Previous pancreatitis was defined as an
admission with the diagnosis 3 months prior to surgery.
Previous upper abdominal surgery was defined as a scar in
the area between the umbilicus and the xiphoid process.
The cohort in this study included adults (C18 years)
who had a cholecystectomy performed by either open
surgery or standard four-port laparoscopy [17] in the reg-
istration period of the DCD. Patients treated with open
surgery in accordance with Danish cholecystectomy
guidelines [18] were excluded. Likewise, patients treated
with single-incision cholecystectomy (SILS) or natural
orifice transluminal endoscopic surgery (NOTES) tech-
nique were excluded. If data on operation type (open,
laparoscopic, SILS, NOTES) or type of admission (emer-
gency or elective) or other risk factors used for adjusting
the outcome were missing, the patients were excluded.
The outcomes chosen for this study were conversion
rate, readmission rate within 30 days, post-operative sur-
gical procedures within 30 days, and LOS. Two previously
validated quality parameters, high-quality hospitalization
process (defined as length of stay (LOS) B1 day and no
readmission), low-quality hospitalization process (defined
as LOS [3 days and/or readmission within 30 days), were
used [19]. All outcomes were compared by weekdays
(Monday through Friday) versus weekend days (Saturday
and Sunday including public holidays on weekdays). The
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World J Surg (2016) 40:849–855
Fig. 1 The association between day of surgery and length of stay
(LOS) in days, illustrated with median, and error bar from 25th to
75th percentiles
LOS (median and quartiles) was stratified by the day of the
week (Fig. 1).
Statistics
Outcomes were adjusted in a multivariate logistic regres-
sion analysis (using the enter method) for risk factors that
were found significant in the so far largest published risk
factor study on this subject (Table 1) [20]. Public holidays
were grouped in the same category as Sundays, as the
health care resources available in the Danish health care
sector are comparable on these days. Results from the
analysis were presented as odds ratios (OR) with 95 %
confidence interval (CI).
The multivariate logistic regression analysis was per-
formed to determine if there was a higher risk of conver-
sion, readmissions within 30 days, post-operative surgical
procedures within 30 days, high-quality hospitalization
process, or low-quality hospitalization process when being
operated on the weekend days compared with ordinary
weekdays. Median LOS and quartiles were used to describe
LOS graphically stratified to each day of the week. Patients
with a LOS of more than 1 day were grouped together. To
determine if the day of the week was an independent risk
factor for a prolonged LOS, a multivariate logistic
regression was performed. All risk factors for a prolonged
LOS (Table 1) as well as the specified weekday of opera-
tion were included in the multivariate model. This multi-
variate analysis was made for each of the days in the week
(Table 2). A subgroup analysis for patients operated for
acute cholecystitis was performed. p \ .05 was defined as
significant.
World J Surg (2016) 40:849–855 851

Table 1 Known risk factors for each outcome

Conversion Length of stay Post-operative procedures Readmission

Sex Yes No No No
Age \60 years Yes Yes Yes No
ASA score \2 Yes Yes Yes Yes
Acute cholecystitis Yes Yes Yes No
Chronic cholecystitis Yes Yes Yes No
Previous upper abdominal surgery Yes Yes No No
Previous pancreatitis No Yes Yes No
Open cholecystectomy No Yes Yes Yes
Surgical experience Yes No No No
Conversion rate was adjusted for acute cholecystitis, age, American Society of Anesthesiologists (ASA) risk score, chronic cholecystitis,
previous upper abdominal surgery, sex, and surgical experience. Length of stay was adjusted for acute cholecystitis, age, ASA score, chronic
cholecystitis, open cholecystectomy, previous upper abdominal surgery, and previous pancreatitis. Post-operative procedures within 30 days
were adjusted for acute cholecystitis, age, ASA score, chronic cholecystitis, open cholecystectomy, and previous pancreatitis. Readmission
within 30 days was adjusted for ASA score and open cholecystectomy

Table 2 Risk of intra- and postoperative complications adjusted for known risk factors
Monday to Friday adjusted OR Saturday adjusted OR Sunday/holiday adjusted OR
thursday (95 % CI) (95 % CI) (95 % CI)

Conversion 1 .91 (.8–1.04) 1.21 (.97–1.51) 1.09 (.86–1.38)

Readmission (30 days) 1 1.03 (.93–1.15) 1.07 (.85–1.35) 1.22 (.97–1.55)
Post-operative procedures 1 1.02 (.88–1.18) 1.03 (.77–1.38) 1.12 (.83–1.50)
(30 days)
High-quality hospitalization 1 .85 (.79–.92) .72 (.60–.87) .88 (.72–1.07)
process
Low-quality hospitalization 1 1.11 (.99–1.26) .91 (.73–1.13) 1.03 (.82–1.29)
process
OR odds ratio, CI confidence interval
Results in italics indicate statistical significance at (P \ 0.05)

Statistical analyses were performed using SPSS version
22 (IBM Corp., Armonk, NY, US). The study was
approved by the Danish Data Protection Agency (Journal
Number HEH-2013-078) and the DCD. No permission
from the local ethics committee was needed according to
Danish law.
Results
A total of 28,759 patients were treated with cholecystec-
tomy between January 2006 and December 2011 and met
our inclusion criteria. A total of 8211 patients were
excluded due to missing risk factors used for adjusted
analyses. The majority of the included patients were
completed laparoscopically, while some were converted to
open surgery or primarily started as open surgery (against
recommendations from the guidelines) (Fig. 2). The
patients’ demographics and surgical findings are presented
in Table 3. The greater part of cholecystectomies was
performed during the week, while only 4.7 % were per-
formed during the weekend and public holidays. Patients
operated on weekends and public holidays tended to be
slightly older (54 years (40–68) vs. 50 years (37–62),
p \ .05), had a higher ASA score (2 (2-2) vs. 1 (1-2),
p \ .05), and a larger proportion of male patients were
operated during the weekend compared to during the week
(38.3 vs. 28.3 %, p \ .05). The underlying diagnoses that
lead to surgery were more often acute cholecystitis during
the weekend (70.8 vs. 16.7 %) while chronic cholecystitis
and previous pancreatitis more often were operated during
the week, respectively, 28 vs. 12.1 % and 6.6 vs. 2.8 %
(Table 3).
During the weekends, 17 % of the patients operated by
laparoscopy were converted to open surgery compared to
7 % during the weekdays (OR 2.54 (2.18–2.95)) in the
univariate analysis. However, in the adjusted analysis, the
OR for conversion on weekdays versus weekend days was
1.17 (.76–1.08). No difference was observed in conversion
when comparing Monday to Thursday with Friday or

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Fig. 2 Study flow diagram for
the trial
Saturday or Sunday (Table 2). Table 2 shows that the
results were non-significant for readmission within
30 days, post-operative procedures within 30 days, and a
low-quality hospitalization process as well. In general,
there were higher rates of readmission and post-operative
procedures in patients operated during the weekends, but
when all known risk factors were included in the multi-
variate analysis, the differences disappeared. Although the
patients did not have more complications during the
weekends, they less often received a high quality hospi-
talization process on Fridays and Saturdays, but not on
Sundays (Table 2). Patients with acute cholecystitis did not
vary from the general tendency.
Monday through Friday the median LOS was 1 day, but
increased on Saturdays and Sundays to 2 days (Fig. 1). The
multivariate logistic regression revealed that the risk of
having a LOS of more than 1 day was higher on Fridays
and Saturdays, but significantly shorter on Wednesdays and
Thursdays compared to the rest of the week (Table 4). An
interesting finding was that the risk of a longer LOS did not
increase when operated on Sundays and public holidays.
As the majority of patients operated on weekends were
patients with acute cholecystitis, a subgroup analysis was
performed on these patients. For this subgroup, the analysis
revealed that the risk of having a LOS of more than 1 day
was higher on Saturdays than any other day of the week
(OR 1.47 95 % CI 1.15–1.86) (Table 4).
Discussion
This study was a prospective database study on 28,759
patients who had a cholecystectomy performed in the
period from 2006 to 2011. No differences in complications
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World J Surg (2016) 40:849–855
were observed between whether the operation was per-
formed on weekdays or weekends. Despite this, a longer
length of stay was observed on Fridays and Saturdays
compared to the rest of the week. Operation on Wednes-
days and Thursdays resulted in a reduced length of stay.
Patients with acute cholecystitis had a longer length of stay
on Saturdays.
Similar to the results of the present study, an analysis of
multiple Danish database registers on elective surgeries
(bariatric surgery, knee and shoulder and hip replacement
surgery) did not find a weekend effect when comparing
readmissions in hospitals performing elective surgery both
during work days and weekend days [21]. It might there-
fore not be a question of qualifications, but more structural
or organizational issues that determine length of stay after
operation. An English study has on the contrary found a
higher mortality risk during weekends compared with
Mondays for elective surgery [4].
To explain the phenomenon ‘‘weekend effect’’, it has
been suggested that the likelihood of undergoing a surgical
procedure is lower at the end of the week and during the
weekends while, delay to surgery would typically be longer
[22]. In the current study LOS was defined as the post-
operative LOS and a longer LOS prior to the surgery, can
therefore not explain our findings.
It has also been suggested that staff on duty during the
weekends, including doctors and nurses, are less special-
ized. The hypothesis is that the discharge therefore will be
postponed to during the week when more specialized staff
are on duty. Another explanation for a longer LOS during
weekends could be due to the fact that ward rounds in
weekends in Denmark mostly are conducted on a need-to-
do basis. The result may be that the most sick patients are
prioritized, which potentially could limit the opportunity
 Table 3 Patients’ demographics and outcome results split on day of the week with quantity of patients and percentage in parenthesis
Monday Tuesday Wednesday Thurday Friday Saturday Sunday Public Total n (%)
n (%) n (%) n (%) n (%) n (%) n (%) n (%) holiday
n (%)

Sex
Female 4175 (72.2) 3664 (70.4) 4265 (72.1) 4469 (71.7) 3090 (72.2) 448 (62.8) 281 (60.3) 100 (61.) 20492 (71.3)
World J Surg (2016) 40:849–855

Age
\20 58 (1.) 37 (.7) 49 (.8) 44 (.7) 45 (1.1) 5 (.7) 4 (.9) 0 (.) 242 (.8)
20–39 1660 (28.7) 1459 (28.1) 1661 (28.1) 1724 (27.7) 1247 (29.1) 165 (23.1) 114 (24.5) 30 (18.3) 8060 (28.)
40–59 2322 (40.1) 2029 (39.) 2353 (39.8) 2500 (40.1) 1643 (38.4) 251 (35.2) 152 (32.6) 63 (38.4) 11313 (39.3)
60–79 1599 (27.6) 1512 (29.1) 1683 (28.4) 1785 (28.6) 1238 (28.9) 243 (34.1) 154 (33.) 54 (32.9) 8268 (28.7)
[80 146 (2.5) 164 (3.2) 173 (2.9) 178 (2.9) 107 (2.5) 49 (6.9) 42 (9.) 17 (10.4) 876 (3.)
ASA score
1 3262 (56.4) 2765 (53.2) 3428 (57.9) 3497 (56.1) 2326 (54.3) 351 (49.2) 237 (50.9) 83 (50.6) 15949 (55.5)
2 2195 (37.9) 2092 (40.2) 2153 (36.4) 2388 (38.3) 1676 (39.2) 300 (42.1) 165 (35.4) 61 (37.2) 11030 (38.4)
3 314 (5.4) 325 (6.2) 316 (5.3) 330 (5.3) 254 (5.9) 56 (7.9) 50 (10.7) 17 (10.4) 1662 (5.8)
4 11 (.2) 13 (.2) 19 (.3) 11 (.2) 21 (.5) 4 (.6) 12 (2.6) 3 (1.8) 94 (.3)
5 3 (.1) 6 (.1) 3 (.1) 5 (.1) 3 (.1) 2 (.3) 2 (.4) 0 (.) 24 (.1)
Acute cholecystitis 769 (13.3) 958 (18.4) 1021 (17.2) 959 (15.4) 881 (20.6) 492 (69.) 351 (75.3) 108 (65.9) 5539 (19.3)
Chronic cholecystitis 1705 (29.5) 1472 (28.3) 1735 (29.3) 1719 (27.6) 1039 (24.3) 85 (11.9) 55 (11.8) 23 (14.) 7833 (27.2)
Previous upper abdominal surgery 237 (4.1) 194 (3.7) 269 (4.5) 284 (4.6) 169 (3.9) 20 (2.8) 20 (4.3) 4 (2.4) 1197 (4.2)
Previous pancreatitis 381 (6.6) 325 (6.2) 403 (6.8) 404 (6.5) 309 (7.2) 19 (2.7) 15 (3.2) 4 (2.4) 1860 (6.5)
Conversion 403 (7.) 398 (7.7) 468 (7.9) 451 (7.2) 315 (7.4) 121 (17.) 84 (18.) 22 (13.4) 2262 (7.9)
Readmission (30 days) 571 (9.9) 596 (11.5) 599 (10.1) 667 (10.7) 464 (10.8) 86 (12.1) 68 (14.6) 20 (12.2) 3071 (10.7)
Frequent additional procedures
ERS 109 (1.9) 107 (2.1) 110 (1.9) 113 (1.8) 96 (2.2) 21 (2.9) 16 (3.4) 1 (.6) 573 (2.)
Endoscopic stent placement 47 (.8) 44 (.8) 43 (.7) 31 (.5) 28 (.7) 12 (1.7) 11 (2.4) 1 (.6) 217 (.8)
Percutaneous drainage of intraperitoneal abscess 23 (.4) 37 (.7) 32 (.5) 27 (.4) 11 (.3) 6 (.8) 6 (1.3) 2 (1.2) 144 (.5)
Laparoscopy 30 (.5) 18 (.3) 15 (.3) 32 (.5) 17 (.4) 1 (.1) 2 (.4) 2 (1.2) 117 (.4)
Reoperation (deep bleeding) 14 (.2) 19 (.4) 21 (.4) 19 (.3) 11 (.3) 1 (.1) 1 (.2) 0 (.) 86 (.3)
High-quality cholecystectomy 3917 (67.7) 3296 (63.4) 3904 (66.) 4207 (67.5) 2624 (61.3) 216 (30.3) 142 (30.5) 52 (31.7) 18358 (63.8)
Low-quality cholecystectomy 633 (10.9) 607 (11.7) 683 (11.5) 776 (12.5) 586 (13.7) 202 (28.3) 154 (33.) 52 (31.7) 3693 (12.8)
853

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