Day-case laparoscopic cholecystectomy: treatment of choice for selected patients?

Development of a prospective biliary dashboard to compare performance and surgical cost

BACKGROUND

Transparency around surgeon level data may align healthcare delivery with quality care for patients. Biliary surgery includes numerous procedures performed by both general surgeons and subspecialists alike. Cholecystectomy is a common surgical procedure and an optimal cohort to measure quality outcomes within a healthcare system.

METHODS

Data were collected for 5084 biliary operations performed by 68 surgeons in 11 surgical divisions in a health system including a tertiary academic hospital, two regional community hospitals, and two ambulatory surgery centers. A privacy protected dashboard was developed to compare surgeon performance and cost between July 2018 and June 2022. A sample cohort of patients ≥ 18 years who underwent cholecystectomy were compared by operative time, cost, and 30-day outcomes.

RESULTS

Over 4 years, 4568 cholecystectomy procedures were performed by 57 surgeons. Operations were done by 57 surgeons in four divisions and included 3846 (84.2%) laparoscopic cholecystectomies, 601 (13.2%) laparoscopic cholecystectomies with cholangiogram, and 121 (2.6%) open cholecystectomies. Patients were admitted from the emergency room in 2179 (47.7%) cases while 2389 (52.3%) cases were performed in the ambulatory setting. Individual surgeons were compared to peers for volume, intraoperative data, cost, and outcomes. Cost was lowest at ambulatory surgery centers, yet only 4.2% of elective procedures were performed at these facilities. Prepackaged kits with indocyanine green were more expensive than cholangiograms that used iodinated contrast. The rate of emergency department visits was lowest when cases were performed at ambulatory surgery centers.

CONCLUSION

Data generated from clinical dashboards can inform surgeons as to how they compare to peers regarding quality metrics such as cost, time, and complications. In turn, this may guide strategies to standardize care, optimize efficiency, provide cost savings, and improve outcomes for cholecystectomy procedures. Future application of clinical dashboards can assist surgeons and administrators to define value-based care.

A Prospective Cohort Analysis of the Prevalence and Predictive Factors of Delayed Discharge After Laparoscopic Cholecystectomy in Italy: The DeDiLaCo Study

BACKGROUND

The concept of early discharge ≤24 hours after Laparoscopic Cholecystectomy (LC) is still doubted in Italy. This prospective multicentre study aims to analyze the prevalence of patients undergoing elective LC who experienced a delayed discharge >24 hours in an extensive Italian national database and identify potential limiting factors of early discharge after LC.

METHODS

This is a prospective observational multicentre study performed from January 1, 2021 to December 31, 2021 by 90 Italian surgical units.

RESULTS

A total of 4664 patients were included in the study. Clinical reasons were found only for 850 patients (37.7%) discharged >24 hours after LC. After excluding patients with nonclinical reasons for delayed discharge >24 hours, 2 groups based on the length of hospitalization were created: the Early group (≤24 h; 2414 patients, 73.9%) and the Delayed group (>24 h; 850 patients, 26.1%). At the multivariate analysis, ASA III class ( P <0.0001), Charlson's Comorbidity Index (P=0.001), history of choledocholithiasis (P=0.03), presence of peritoneal adhesions (P<0.0001), operative time >60 min (P<0.0001), drain placement (P<0.0001), pain ( P =0.001), postoperative vomiting (P=0.001) and complications (P<0.0001) were independent predictors of delayed discharge >24 hours.

CONCLUSIONS

The majority of delayed discharges >24 hours after LC in our study were unrelated to the surgery itself. ASA class >II, advanced comorbidity, the presence of peritoneal adhesions, prolonged operative time, and placement of abdominal drainage were intraoperative variables independently associated with failure of early discharge.

Safety of ambulatory laparoscopic cholecystectomy in the elderly

BACKGROUND

This study aims to retrospectively analyse the safety of ambulatory laparoscopic cholecystectomy (ALC) and identify risk factors for delayed discharge after ALC in the elderly.

METHODS

Consecutive patients who were scheduled to undergo ALC were assigned to the elderly group (age ≥ 65 years) or the non-elderly group. The primary outcome was postoperative discharge within 24 h (D24). Secondary outcomes were perioperative mortality, reasons for delayed discharge (psychosocial reasons (DP), complications (DC), drainage (DD) and conversion to open surgery (DCO)), intraoperative data and readmission within 30 days after discharge (readmission). Differences were statistically significant when P < 0.05.

RESULTS

There were 7657 patients assigned to the elderly group (n = 1143) or the non-elderly group (n = 6514). The differences between elderly patients and non-elderly patients in the operation time (51.0 (37.0-70.0) versus 50.0 (35.0-65.0) min), blood loss (10.0 (5.0-10.0) versus 5.0 (5.0-10.0) mL), D24 (75.5% versus 81.7%) and DD (7.8% versus 3.2%) were statistically significant (P < 0.05, respectively). The differences between elderly patients and non-elderly patients in DP (8.2% versus 6.7%), DC (7.8% versus 7.9%), DCO (0.7% versus 0.5%) and readmission (0.5% versus 0.4%) were not statistically significant (P > 0.05, respectively). Independent risk factors for delayed discharge after ALC in the elderly were male sex, octogenarian status, prolonged operation time, arrhythmia, type 2 diabetes mellitus, a previous operation in the upper abdomen, acute inflammation of gallbladder and a gallbladder wall thicker than 3 mm (P < 0.05, respectively).

CONCLUSION

ALC in the elderly is feasible and safe.

Ambulatory laparoscopic cholecystectomy: Systematic review and meta-analysis of predictors of failure

BACKGROUND

Outpatient laparoscopic cholecystectomy has proven to be a safe and cost-effective technique; however, it is not yet a universally widespread procedure. The aim of the study was to determine the predictive factors of outpatient laparoscopic cholecystectomy failure.

METHOD

A systematic review and meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis methodology. MEDLINE, Cochrane Library, Ovid, and ISRCTN Registry were searched. The main variables were demographic (age, sex), clinical (weight, American Society of Anesthesiologists classification, previous complicated biliary pathology, history of abdominal surgery in supramesocolic compartment, gallbladder wall thickness), and surgical factors (operative time, afternoon surgery). The secondary variables were the prevalence rates of outpatient laparoscopic cholecystectomy failure due to pain or postoperative nausea and vomiting.

RESULTS

Fourteen studies (4,194 patients) were included, with a mean outpatient laparoscopic cholecystectomy failure rate of 23.4%. The predictors of outpatient laparoscopic cholecystectomy failure were: age ≥65 years (odds ratio: 2.34; 95% confidence interval, 1.42-3.86; P = .0009), body mass index ≥30 (odds ratio: 1.6; 95% confidence interval, 1.05-2.45; P = .03), American Society of Anesthesiologists score ≥III (odds ratio: 2.89; 95% confidence interval, 1.72-4.87; P < .0001), previous complicated biliary pathology (odds ratio: 2.39; 95% confidence interval, 1.40-4.06; P = .001), gallbladder wall thickening (odds ratio: 2.33; 95% confidence interval, 1.34-4.04; P = .003), surgical time exceeding 60 minutes (mean difference: -16.03; 95% confidence interval,-21.25 to -10.81; P < .00001), and the beginning of surgery after 1:00 pm (odds ratio: 4.20; 95% confidence interval, 1.97-11.96; P = .007). Sex (odds ratio: 1.07; 95% confidence interval, 0.73-1.57, P = .73) and history of abdominal surgery in the supramesocolic compartment (odds ratio: 2.32; 95 confidence interval, 0.92-5.82, P = .07) were not associated with outpatient laparoscopic cholecystectomy failure.

CONCLUSION

Our meta-analysis allowed us to identify the predictors of outpatient laparoscopic cholecystectomy failure. The knowledge of these factors could help surgeons in their decision-making process for the selection of patients who are suitable for outpatient laparoscopic cholecystectomy.

Day-only elective cholecystectomy: early experience and barriers to implementation in Australia

BACKGROUND

Day-only laparoscopic cholecystectomy (DOLC) has been shown to be safe and feasible yet has not been widely implemented in Australia. This study explores the introduction of routine DOLC to Westmead Hospital, and highlights the barriers to its implementation.

METHODS

Routine day-only cholecystectomy protocol was introduced at Westmead Hospital in 2014. A retrospective review of patients who underwent elective laparoscopic cholecystectomy during a 12-month period in 2014 was compared to a 12-month period in 2018, to examine the changes in practice after implementation of a unit protocol. Data were collected on patient demographics, admission category, outcomes and re-presentations.

RESULTS

A total of 282 patients were included in the study, of these 169 were booked as day procedures, with 124 (73%) successfully discharged on the same day. There was a significant increase in the proportion of patients booked as day-only from 2014 to 2018 (48% versus 73%, P < 0.001). Day-only failure rates (unplanned overnight admissions), readmissions and complication rates were comparable between the two periods. The most common reason for unplanned overnight admissions were due to intraoperative findings (n = 28/45).

CONCLUSION

Routine DOLC can be adopted in Australian hospitals without compromise to patient safety. Unplanned overnight admission is predominantly due to unexpected surgical pathology and can be reduced by protocols for the use of drains and planned outpatient endoscopic retrograde cholangiopancreatography. Unplanned outpatient review can be minimized by optimizing both intra- and post-operative pain management. Individual surgeon and anaesthetist preferences remain an obstacle to a standardized protocol in the Australian setting.

The Safety of Laparoscopic Cholecystectomy in the Day Surgery Unit Comparing with That in the Inpatient Unit: A Systematic Review and Meta-Analysis

We aimed to perform a systematic review and meta-analysis on the safety of laparoscopic cholecystectomy performed in the day surgery unit versus those performed in the inpatient unit. Several databases including Ovid Embase, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar were searched from inception through February 2019. Our results revealed that laparoscopic cholecystectomy can be conducted safely and effectively in day surgery units, helping bed shortage.

Improving the day case rate for laparoscopic cholecystectomy via introduction of a dedicated clinical pathway

Day case laparoscopic cholecystectomy is a safe and economical procedure. However, successful discharge on the same day of the procedure has been difficult to achieve at our institution. This study introduced a standardised anaesthetic pathway aiming to increase same day discharges. This led to an overall increase in same day discharges from 42.0% to 54.1%. When the pathway was fully followed, 71% of patients were discharged on the same day. When the pathway was not followed at all, the same day discharge rate was 0%. Our study successfully demonstrates that small enhancements to perioperative care can accelerate patient recovery and improve same day discharges.

Laparoscopic cholecystectomy: do risk factors for a prolonged length of stay exist?

Gallstones are one of the most common morbidities in the world. Laparoscopic cholecystectomy is the gold standard for gallbladder stones' removal. Few studies focus on the existence of predictive factors aimed at facilitating cholecystectomy in a day surgery setting. The aim of this retrospective study was to identify clinical factors that could guide day-surgery laparoscopic cholecystectomy safety. The study included 985 consecutive patients who underwent elective laparoscopic cholecystectomy for gallstone disease between May 2006 and February 2015. Patients were divided into two groups: group A with a length of stay ≤ 2 days (922 patients); group B with a length of stay > 2 days (63 patients). Univariate analysis showed that age, sex and the presence of obesity, cardiological, and nephrological comorbidities had a higher likelihood of a longer hospital stay. The logistic regression model showed that only age was a significant predictor of a longer stay. No complication has reached the statistical significance of extending the length of stay in group B. Conversely, the presence of such comorbidities has influenced the hospitalization. Our results allow the identification of a category of patients at high risk of hospitalization within 1 or 2 days from treatment. Moreover, we reported that there is no complication specifically affecting the length of stay. Our findings support the idea that a prolonged length of stay is not linked to the surgical procedure but to the patient's comorbidities.

Evaluation of patient safety and satisfaction in a program of ambulatory laparoscopic cholecystectomy program with expanded criteria

INTRODUCTION

The good results obtained with the implementation of ambulatory laparoscopic cholecystectomy programs have led to the expansion of the initial inclusion criteria. The main objective was to evaluate the results and the degree of satisfaction of the patients included in a program of laparoscopic cholecystectomy without admission, with expanded criteria.

METHODS

Observational study of a cohort of 260 patients undergoing ambulatory laparoscopic cholecystectomy between April 2013 and March 2016 in a third level hospital. We classified the patients into 2groups based on compliance with the initial inclusion criteria of the outpatient program. Group I (restrictive criteria) includes 164 patients, while in group ii (expanded criteria) we counted 96 patients. We compared the surgical time, the rate of failures in ambulatory surgery, rate of conversion, reinterventions and mortality and the satisfaction index.

RESULTS

The overall success rate of ambulatory laparoscopic cholecystectomy was 92.8%. The most frequent cause of unexpected income was for medical reasons. There was no statistically significant difference between the 2groups for total surgery time, the rate of conversion to open surgery and the number of major postoperative complications Do not demostrate differences in surgical time, nor in the number of perioperative complications (major complications 1,2%), or the number of failures in ambulatory surgery, nor the number of readmissions between both groups. There was no death. 88.5% of patients completed the survey, finding no differences between both groups in the patient satisfaction index. The overall score of the process was significantly better in group ii(P=.023).

CONCLUSIONS

Ambulatory laparoscopic cholecystectomy is a safe procedure with a good acceptance by patients with expanded criteria who were included in the surgery without admission program.

The clinical utility of pre-operative neutrophil-to-lymphocyte ratio as a predictor of outcomes in patients undergoing elective laparoscopic cholecystectomy

BACKGROUND

In recent years, there has been an increasing trend towards day-case surgery for patients undergoing laparoscopic cholecystectomy (LC). We investigated the predictive value that pre-operative neutrophil-to-lymphocyte ratio (PNLR) had on surgical outcomes.

METHODS

A review of all patients who underwent LC during a 6-year period in a single institution was performed and PNLR recorded. A PNLR cutoff value of 3 was utilised. We compared operation time, length of stay (LOS), and conversion to open between those with PNLR less and greater than 3.

RESULTS

A total of 567 patients underwent elective LC. Those with PNLR>3 had associated prolonged operation time (p < 0.005), prolonged LOS (p < 0.005), and higher rates of conversion to open surgery (p < 0.005).

CONCLUSIONS

PNLR correlates with outcomes following LC. It is useful in delineating patients that have higher risk of conversion or prolonged length of hospital stay and is helpful in assessing suitability of day-case surgery.

Evaluation of the impact of preoperative education in ambulatory laparoscopic cholecystectomy. A prospective, double-blind randomized trial

INTRODUCTION

Outpatient laparoscopic cholecystectomy is a safe procedure and provides a better use of health resources and perceived satisfaction without affecting quality of care. Preoperative education has shown less postoperative stress, pain and nausea in some interventions. The principal objective of this study is to assess the impact of preoperative education on postoperative pain in patients undergoing ambulatory laparoscopic cholecystectomy. Secondary objectives were: to evaluate presence of nausea, morbidity, hospital admissions, readmissions rate, quality of life and satisfaction.

METHODS

Prospective, randomized, and double blind study. Between April 2014 and May 2016, 62 patients underwent outpatient laparoscopic cholecystectomy.

INCLUSION CRITERIA

ASA I-II, age 18-75, outpatient surgery criteria, abdominal ultrasonography with cholelithiasis. Patient randomization in two groups, group A: intensified preoperative education and group B: control.

RESULTS

Sixty-two patients included, 44 women (71%), 18 men (29%), mean age 46,8 years (20-69). Mean BMI 27,5. Outpatient rate 92%. Five cases required admission, two due to nausea. Pain scores obtained using a VAS was at 24-hour, 2,9 in group A and 2,7 in group B. There were no severe complications or readmissions. Results of satisfaction and quality of life scores were similar for both groups.

CONCLUSIONS

We did not find differences due to intensive preoperative education. However, we think that a correct information protocol should be integrated into the patient's preoperative preparation. Registered in ISRCTN number ISRCTN83787412.

Day Care vs Overnight Stay after Laparoscopic Cholecystectomy even with Co-morbidity and a Possible Second Surgery: A Patient's Choice

INTRODUCTION

Laparoscopic Cholecystectomy (LC) has become the gold standard for symptomatic gall stone disease. It is being practiced as a day care procedure in healthy individuals in American Society of Anaesthesialogists (ASA) grade I and II. It is not yet established in presence of co-morbidity and when a second surgery is added. In most of the study, patient's choice and the psycho-social factors were not considered in deciding the day care procedure.

AIM

To find the safety of LC and a second surgery as day care in presence of compensated co-morbidity. To study the choice of the patient whether to stay in hospital or go home after declaring them fit for day care.

MATERIALS AND METHODS

All the patients of symptomatic cholelithiasis with co-morbidity and associations were evaluated and made uncompromising for elective surgery. All the LC were done at 8mmHg CO₂ peumo-peritoneal pressure using harmonic scalpel as the energy source for dissection of gall bladder from the liver bed. Cases with conversion and placement of drain were excluded.

RESULTS

A total of 1029 out of 1042 patients was included from Jan 2005 to Jan 2015. The age range was 38 to 91years (mean 44.65, SD 14.15). There were 634 females and 395 males. A total of 121(11.7%) of them had co-morbidity and associations. A total of 72(7%) had undergone a second surgery. Only 0.8% had real day care. A total of 95.7% had overnight stay even after fulfilling all the criteria. Only 0.2% needed re-admission in 30 days and one required intervention.

CONCLUSION

Patients like to stay over night in the hospital even if found fit for day care after LC. Overnight stay makes them happy, psycho-socially confident in developing nation and best suited for all patients including co-morbidity.

Day case laparoscopic cholecystectomy in patients with high BMI: Experience from a UK centre

INTRODUCTION

Symptomatic gall stones may require laparoscopic cholecystectomy (LC), which is one of the most commonly performed general surgical operations in the western world. Patients with a high body mass index (BMI) are at increased risk of having gall stones, and are often considered at high risk of surgical complications due to their increased BMI. We believe that day case surgery could nevertheless have significant benefits in terms of potential cost savings and patient satisfaction in this population. We therefore compared the outcomes of day case patients undergoing LC stratified by BMI, with a specific focus on the safety and success of the procedure in obese and morbidly obese groups.

METHODS

We reviewed a database of day case procedures performed between January 2004 and December 2012, including all patients with symptomatic gall stone disease who underwent LC. The patients were divided in four BMI groups: less than 25 kg/m(2), 25-29 kg/m(2), 30-39 kg/m(2) and 40 kg/m(2) or above.

RESULTS

The overall success rate for day case surgery was 78%. There were no significant differences in rates of intra-abdominal collection or readmission with increasing BMI. However, increasing BMI was associated with a significant increase in the rate of wound infection.

CONCLUSIONS

LC in patients with a high BMI is safe and can be performed effectively as a day case procedure.

A randomised, single blinded trial, assessing the effect of a two week preoperative very low calorie diet on laparoscopic cholecystectomy in obese patients

BACKGROUND

Laparoscopic cholecystectomy (LC) can be technically challenging in the obese. The primary aim of the trial was to establish whether following a Very Low Calorie Diet (VLCD) for two weeks pre-operatively reduces operation time. Secondary outcomes included perceived operative difficulty and length of hospital stay.

METHODS

A single-blinded, randomized controlled trial of consecutive patients with symptomatic gallstones and BMI >30 kg/m(2) 46 patients were randomized to a VLCD or normal diet for two weeks prior to LC. Food diaries were used to document dietary intake. The primary outcome measure was operation time. Secondary outcomes were length of stay, weight change operative complications, day case rates and perceived difficulty of operation.

RESULTS

The VLCD was well tolerated and had significantly greater preoperative weight loss (3.48 kg vs. 0.98 kg; p < 0.0001). Median operative time was significantly reduced by 6 min in the VLCD group (25 vs. 31 min; p = 0.0096). There were no differences in post-operative complications, length of stay, or day case rates between the groups. Dissection of Calot's triangle was deemed significantly easier in the VLCD group.

CONCLUSION

A two week VLCD prior to elective laparoscopic cholecystectomy in obese patients is safe, well tolerated and was shown to significantly reduce pre-operative weight and operative time.

ISRCTN

61630192. http://www.isrctn.com/ISRCTN61630192 Trial registration.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

The possibilities of day surgery system development within the health policy in Slovakia

BACKGROUND

In the day surgery system are intertwined elements of state health policy, health care payers' interests, employers of health care system, as well as the interests and wishes of patients. A problem in the health policy is to find a way to regulate ambulatory and short-term surgical procedures, which are hardly distinguishable, and still fulfil the requirements of transparent financing, quality and security. The objective of this paper is to highlight the reasons for the long-term stagnation in Slovakia day surgery and the possibilities of eliminating the structural drivers causing this negative phenomenon.

METHODS

Due to the nature of the analyzed data and desired outcomes, we selected application of correspondence analysis. Results of correspondence analysis provide valuable information necessary for the projection of specialization of one day surgery clinics for that type of procedure, as well as for the support of the new clinics creation (also with the potential state support), the pricing policy, systemic reduction of beds what is connected with reduction of underutilized departments in hospitals, in order to optimize management processes in the healthcare system.

RESULTS

Contribution reveals negative aspects which causing a low level of day surgery in Slovakia. Moreover, it reveals the approaches of the different subjects of day surgery. Presented options for setting optimal strategy supporting its development are based on the results of the analysis. Correspondence analysis provided valuable information of present structure of the day surgery system. The determined similarity of the regions and association of specialized fields indicate specific settings of the day surgery system and its components that are inevitable to analyze in the subsequent analytical process.

CONCLUSIONS

Results of the analysis are very important in order to set up the system measures in the process of its further development, which should be part of the strategic plan of each health system. On conceptual and methodological issues related with reporting of day surgery performances are highlighting international organizations such as the OECD,WHO.

JEL CLASSIFICATION

I13, I18, H51.

Day case laparoscopic cholecystectomy in children: A review of 11 cases

AIM

The aim of this paper is to study the outcome of day case laparoscopic cholecystectomy (DCLC) in children.

MATERIALS AND METHODS

A clinical pathway for day care laparoscopic cholecystectomy was followed with emphasis on the analgesia, post-operative nausea and vomiting (PONV), feeding, mobilization, pain scoring and patient satisfaction. Demographic and clinical data were recorded prospectively from March 2013 to November 2013. The setup allowed easy access to an overnight stay if needed. Hospital stay, complications, the need for medical advice after discharge, convalescence and patients satisfaction were analyzed.

RESULTS

We admitted 11 children with symptomatic cholelithiasis for day case laparoscopic surgery. There were no intra- or post-operative complications. The incidence of PONV was 0/11. There was no readmission. 4/11 patients complained of shoulder tip pain on follow-up next day. There was no overnight stay.

CONCLUSIONS

Adoption of a DCLC pathway is feasible and safe for children. Emphasis on adequate pain management and avoidance of PONV results in a high rate of day case surgery equivalent to that achieved in adult practice.

Ambulatory laparoscopic cholecystectomy: An audit of day case vs overnight surgery at a community hospital in Japan

AIM: To evaluate the applicability and safety of ambulatory laparoscopic cholecystectomy (LC) and to compare day case and overnight stay LC.

METHODS: Data were collected retrospectively and consecutively for day case and overnight stay LC patients from July 1, 2009 to April 30, 2011. Outcomes were analyzed for patient demographics, operation time, blood loss during operation and frequency and reasons for unexpected or prolonged hospitalization in each group.

RESULTS: There was no hospital mortality and no patient was readmitted with serious morbidity after discharge. 50 patients received a day case LC and 19 had an overnight stay LC. There was a significant difference in age between both groups (P < 0.02). There were no significant differences between the day case LC performed (n = 41) and failed (n = 9) groups and between the day case LC performed and the one night stay LC (n = 12) groups. There was a significant difference in age between the one night stay and more nights stay LC groups (P < 0.05). Thus, elderly patients showed a tendency to like to stay in hospital rather than being a day case. The proportion of unexpected or prolonged hospitalization was not significantly different between the day case and overnight stay LC groups, when the patient’s request was excluded.

CONCLUSION: Day case LC can be performed with a low rate of complications. In overnight stay patients, there are many who could be performed safely as a day case. Moreover, we need to take special care to treat elderly patients.

The Effects of Repeat Laparoscopic Surgery on the Treatment of Complications Resulting from Laparoscopic Surgery

Laparoscopic surgery is frequently applied in the operative management of appendicitis and symptomatic cholelithiasis because it is a minimally invasive procedure. There are, however, some complications of laparoscopic cholecystectomy (LC) and laparoscopic appendectomy (LA) that result in the need for reoperation. In the current study, we examine the effects of repeat laparoscopic surgery on the treatment of complications arising from LC/LA. From April 2005 to March 2011, we examined a cohort of patients who had received LC or LA and experienced complications that required reoperations. We focused on patients with postoperative hemorrhages, postoperative peritonitis, early postoperative small bowel obstructions (EPSBO), and biliary complications (after LC) who were treated through a repeat laparoscopic approach. The general demographics of the patients, their postoperative complications, procedures for selecting the appropriate reoperation method, and repeat laparoscopic findings are described in detail. During the 6-year period examined, 1608 patients received LC and 1486 patients received LA at the hospitals participating in this study. In patients with complications requiring reoperation, the repeat laparoscopic approach was performed successfully (without the need for further laparotomy) in 50 per cent of the patients with postoperative hemorrhage (2 of 4), 50 per cent of the patients with postoperative peritonitis (2 of 4), 75 per cent of the EPSBO patients (3 of 5), and 50 per cent the of patients with biliary complications (1 of 2). The repeat laparoscopic approach is an appropriate method for the management of complications arising from laparoscopic surgery. In patients with postoperative hemorrhage, laparoscopic hemostasis and hematoma evacuations can be performed while maintaining stable hemodynamics. In addition, laparoscopic approaches are also feasible for selective post-LC ductal injuries, EPSBO, and unconfirmed diagnoses of peritonitis after laparoscopic surgery.

Single-Incision Laparoscopic Cholecystectomy for Day Surgery Procedure: Are We Prepared?

Single-incision laparoscopic surgery (SILS) for cholecystectomy is a well-established procedure and represents the next step in developing the concept of fast track surgery. This report describes our experience with SILS cholecystectomy in patients that stay overnight. Between February 2009 and July 2010, patients referred for cholecystectomy to the day surgery unit who agreed to undergo SILS were included in a prospective study. All operations were performed by the same surgical team specially trained in this type of surgery and the same operative technique was used in all cases. Postoperative pain and nausea were assessed using a 10-cm visual analogue scale on a self-completion questionnaire on the night of operation and the morning of discharge. A total of 107 patients (58% women, mean age 56 years) with symptomatic gallstones were included in the study. SILS was successfully performed in all patients and no patient required conversion to an open procedure. There were no significant differences in the median visual analogue scale for postoperative pain and nausea between the night of surgery and the next morning. The mean length of hospital stay was 23 hours, and 98 per cent of patients were satisfied with the results of surgery and would be willing to undergo the same procedure again. SILS cholecystectomy is a valid alternative to standard laparoscopic cholecystectomy as an outpatient surgery or overnight stay procedure. According to these promising results, SILS cholecystectomy could be included in a major ambulatory surgery program.

Day case laparoscopic cholecystectomy carried out using the harmonic scalpel: analysis of a standard procedure

INTRODUCTION

Our aim was to determine the efficiency and safety of laparoscopic cholecystectomy carried out using the harmonic scalpel as a day case procedure.

METHODS

A prospective study was done on patients presenting for Laparoscopic cholecystectomy. The harmonic scalpel was used with retrograde dissection. All patients were considered for discharge the same day unless considered medically unfit.

RESULTS

Laparoscopic cholecystectomy using the harmonic scalpel was carried out on 100 patients. Major complications were as follows: conversion to open procedure -1%, common bile duct injury -1%, and bile leak from the cystic duct stump -1%. Our same day discharge rate was 65%, and age more than 65 was the only independent predictor of overnight admission (P=0.009).

CONCLUSIONS

Laparoscopic cholecystectomy using the harmonic scalpel is associated with a low complication rate and a high-same-day discharge rate when carried out as a day case procedure.

[The development of laparoscopic technology in light of cholecystectomies performed between 1994 and 2007]

The spread of laparoscopy has required surgeons to familiarize with a completely new surgical method and by today this method has clearly become of major importance in gastrointestinal surgery. The evolution of laparoscopic cholecystectomy offers many good lessons to learn for the purposes of advanced laparoscopic surgeries and surgeons may benefit from this experience in any process of introducing new minimal invasive techniques.

METHODS AND MATERIAL

We have made a retrospective analysis of the data of the cholecystectomies made in the 1st. Department of Surgery, Semmelweis University, right after laparoscopy had become a widely spread, routine surgical method (1994) as well as 13 years later (2007). The data have been processed using the SPSS 16.0 application package. Significance levels have been established with the chi-square probe.

RESULTS

Within the analyzed timeframe we could clearly see a growing use of laparoscopic techniques (52.09% vs. 90.13%) with a growing number of cases (263/304), unchanged average age (approximately 53.5 years) and constant male/female ratio (75/25%). The BMI increased moderately (26.5 vs. 27.6), but the frequency of laparoscopic interventions on extremely obese patients grew (BMI: 25-30 37.93% vs. 44.39%, 30-35 13.79% vs. 20.6% 35-40 6.89% vs. 5.82% and 40 \lt; 0% vs. 1.34%) while the postoperative hospitalization decreased dramatically from 5.9 days to 2.3. In year 1994, patients spent on the average 2.9 days in hospital after a laparoscopic surgery, while in year 2007 nearly 25% of the patients left the hospital 1 day after surgery. The duration of a laparoscopic surgery decreased from 78 minutes to 53, and the occurrence of intraoperative bleeding, gall bladder perforation and gallstone spillage also decreased. The conversion ratio increased from 2.7% to 4.9%. In 3% of the laparoscopic cholecystectomies (10 patients) only 3 ports were used during surgery.

DISCUSSION

As surgeons have come to master the new technique, the previous relative and absolute pros and cons have been revised and at present 90% of cholecystectomies are made using laparoscopy. The data collected in the analysis of laparoscopic techniques can be used to research, learn and eventually introduce Natural Orifice Transluminal Endoscopic Surgery.

Elective surgical patients as living organ donors: a clinical and ethical innovation

We propose a new model for living organ donation that would invite elective laparoscopic cholecystectomy patients to become volunteer, unrelated living kidney donors. Such donors would be surgical patients first and living donors second, in contrast to the current system, which 'creates' a surgical patient by operating on a healthy individual. Elective surgery patients have accepted the risks of anesthesia and surgery for their own surgical needs but would face additional surgical risks when a donor nephrectomy is combined with their cholecystectomy procedure. Because these two procedures have never been performed together, the precise level of additional risk entailed in such a combined approach is unknown and will require further study. However, considering the large number of elective cholecystectomies performed each year in the United States, if as few as 5% of elective cholecystectomy patients agreed to also serve as living kidney donors, the number of living kidney donors would increase substantially. If this proposal is accepted by a minority of patients and surgeons, and proves safe and effective in a protocol study, it could be applied to other elective abdominal surgery procedures and used to obtain other abdominal donor organs (e.g. liver and intestinal segments) for transplantation.

Implementation of a direct-from-recovery-room discharge pathway: a process improvement effort

BACKGROUND

The authors describe a process improvement effort to achieve direct-from-recovery-room discharge for elective laparoscopic cholecystectomy patients--without prior patient selection.

METHODS

The authors developed and implemented a new pathway, and then measured the learning curve (ie, success rate over time for direct discharge) and compared patients achieving direct discharge with patients admitted after surgery.

RESULTS

The learning curve between the first patient and steady-state performance was 56 patients. A total of 80% of patients achieved direct discharge. Directly discharged patients were younger (P<.001), had lower ASA physical status classifications (P<.005), and left the recovery room earlier in the day (P<.0001). However, elderly patients and those with high ASA scores frequently could be directly discharged from the recovery room.

CONCLUSIONS

Through small team based rapid cycle process improvement, direct-from-recovery-room discharge of laparoscopic cholecystectomy patients can be achieved in an unselected patient population with a short learning curve.

Laparoscopic cholecystectomy as day-surgery procedure: current indications and patients' selection

AIM OF THE STUDY

To review the current indications, to establish predictive factors of success and the safety of LC as a day-surgery procedure.

METHODS

Randomized clinical trials were searched on PubMed between January 2000 and June 2008 using "laparoscopic cholecystectomy", "day-surgery" as keywords.

RESULTS

A total of 20 trials was identified and analyzed. The indications for LC in day-surgery unit were symptomatic and chronic cholelitiasis without evidence of common bile duct stones; acute cholecystitis and pancreatitis cases were excluded. The trials considered as inclusion criteria: ASA score, BMI, social aspect and the preoperative workout included: abdominal US, liver function tests and routine preoperative tests, while the results considered the reasons for hospital stays and for readmission and measured patient satisfaction; some trials included analyze of costs of LC as day-surgery procedure the role of the surgeon's experience.

DISCUSSION

The present study confirms that day-surgery LC is safe and feasibility in selected patients; serious complications are rare and most frequently prolonged hospital stay and the readmission are connected with minor and more easily controlled complications or social reasons. Outpatient surgery requires careful planning and preparation in order to reach acceptable patients' satisfaction: preoperative workout is extremely imports allowing to reduce errors selection. Considering surgical training, it has been demonstrated that in the centres in which the trainees are involved in day-surgery LC there not significant difference in terms of number of complications, patient outcomes, prolonged stay and readmission. The adequate control of pain, nausea or vomiting is essential component in day-case LC service and it is possible at home after LC.

CONCLUSION

Day-case laparoscopic cholecystectomy is feasible with an acceptable discharge rate and level of patient satisfaction. The success depends on appropriate patient selection and on well-trained staff and skilful operative technique together with safe anaesthesia.

Current indications for laparoscopy in day-case surgery

Day-surgery setting allows to combine patients' satisfaction to cost-saving policies that seems to be more and more important for a modern hospital management. Minimally invasive surgery seems to be the ideal surgical approach for day-case procedures since, reducing trauma to a minimal level, allows patients to return quick to a normal life with minimal nursing assistance. Extensive review of the most recent article has been performed in this article in order to define the current evidences that support the use of laparoscopic surgery in a day-case setting. Laparoscopic cholecystectomy, anti-reflux procedure and hernia repair seems to be justified according to the results of the published data. Patients' selection and hospital organization seem to be mandatory in order to obtain successful results.

An audit of ambulatory laparoscopic cholecystectomy in a Singapore institution: are we ready for day-case laparoscopic cholecystectomy?

BACKGROUND

Day-Case laparoscopic cholecystectomy (LC) is practiced in many countries. However, this has yet to be widely accepted in Singapore. This study aims to determine the potential success rate of day-case LC in our institution.

PATIENT AND METHODS

We retrospectively assessed the proportion of our Ambulatory Surgery 23 hour (AS23) LC patients that met discharge criteria. Our proposed same-day discharge criteria include minimal pain, ability to tolerate feeds, ambulate independently and void spontaneously after 6-8 hours of monitoring.

RESULTS

From January 2005 to December 2006, of 405 patients listed for elective LC, 84% of patients were admitted to our AS23 ward. Patients with previous biliary sepsis or pancreatitis or who need laparoscopic common bile duct exploration (LCBDE) were included. The other 66 were admitted as inpatient. Forty-one of them were admitted due to conversion. A history of cholecystitis or cholangitis was a significant predictor of conversion to open surgery (OR=5.73 and 5.74 respectively, p<0.001). Of the 339 patients, 66% of them fulfilled all four criteria within eight hours of monitoring. Therefore, based on an intention-to-treat analysis, 51.2% fulfilled all four criteria and could potentially be discharged the same day. No predictor for failure was identified, including presence of co-morbidities, duration of operation, surgeon's grade and additional procedures like LCBDE.

CONCLUSION

Using our current inclusion criteria, we projected a success rate of at least 50% with the implementation of day-case LC. With the attendant advantages of cost savings and reduced resource utilization, it is therefore worthwhile to start it in Singapore.

Assessing patient-reported outcomes of cholecystectomy in short-stay surgery

BACKGROUND

The project aimed at testing the feasibility of a quality improvement system based on patient-reported outcomes in short-stay surgery for cholecystectomy.

METHODS

In two centers for short-stay surgery, patients referred for laparoscopic cholecystectomy were surveyed between Aug 1999 and Jan 2002. Patients reported on health-related quality of life (SF-36), symptoms (gallstone symptom checklist, GSCL) and other indicators preoperatively (T0), 14 days (T1) and 6 months postoperatively (T2). The SF-36 subscales physical functioning, bodily pain, and role physical as well as the GSCL and treatment satisfaction at T2 were considered as main outcomes. The main outcomes were analyzed by generalized linear models with regard to predictors.

RESULTS

At T0 a total of 205 patients were included. The response rate at T2 was 63.4% (74.6% females, 53.6 years of age). The GSCL score at T0 (29.4% preoperatively) fell slightly to 27.9% at T1 and decreased to 14.8% at T2 (T0-T2: p < 0.001). The SF-36 subscales showed a different course over time (decrease of health-related quality of life at T1 and large increase at T2). The level of satisfaction with the outcome of cholecystectomy was 82.3%. The patient-reported outcomes were mainly influenced by the preoperative level, age and self-reported postoperative complaints.

CONCLUSION

The low response rate was mainly due to nondelivery of questionnaires at T1 during the regular postoperative visit by the operating physician. Though nonresponse occurs under conditions of routine care, meaningful information was gained, which should be used for quality improvement activities. Because the preoperative level is a major determinant of the postoperative health outcomes, the prospective pre-post measurement should be preferred if institutional comparisons are intended.

Male gender is not a risk factor for the outcome of laparoscopic cholecystectomy: a single surgeon experience

BACKGROUND/AIM

Previous studies regarding the outcome of laparoscopic cholecystectomy (LC) in men have reported inconsistent findings. We conducted this prospective study to test the hypothesis that the outcome of LC is worse in men than women.

MATERIALS AND METHODS

Between 1997 and 2002, a total of 391 consecutive LCs were performed by a single surgeon at King Fahd Hospital of the University. We collected and analyzed data including age, gender, body mass index (kg/m(2)), the American Society of Anesthesiologists (ASA) class, mode of admission (elective or emergency), indication for LC (chronic or acute cholecystitis [AC]), comorbid disease, previous abdominal surgery, conversion to open cholecystectomy, complications, operation time, and length of postoperative hospital stay.

RESULTS

Bivariate analysis showed that both genders were matched for age, ASA class and mode of admission. The incidences of AC (P = 0.003) and comorbid disease (P = 0.031) were significantly higher in men. Women were significantly more obese than men (P < 0.001) and had a higher incidence of previous abdominal surgery (P = 0.017). There were no statistical differences between genders with regard to rates of conversion (P = 0.372) and complications (P = 0.647) and operation time (P = 0.063). The postoperative stay was significantly longer in men than women (P = 0.001). Logistic regression analysis showed that male gender was not an independent predictor of conversion (Odds ratio [OR] = 0.37 and P = 0.43) or complications (OR = 0.42, P = 0.42). Linear regression analysis showed that male gender was not an independent predictor of the operation time, but was associated with a longer postoperative stay (P = 0.02).

CONCLUSION

Male gender is not an independent risk factor for satisfactory outcome of LC in the experience of a single surgeon.