Outpatient laparoscopic cholecystectomy: clinical pathway implementation is efficient and cost effective and increases hospital bed capacity

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.

Propensity score-matched comparison of safety outcomes between high-risk and low-risk patients towards early hospital discharge after laparoscopic cholecystectomy

Background

Laparoscopic cholecystectomy (LC), a common treatment for symptomatic gallstones, has demonstrated safety in low-risk patients. However, existing data are scarce regarding the safety of LC in high-risk patients and the feasibility of early hospital discharge.

Materials and methods

This retrospective study included 2296 patients diagnosed with symptomatic gallstones who underwent LC at a tertiary care centre from January 2009 through December 2019. The authors employed propensity score matching to mitigate bias between groups. Statistical significance was set at P less than 0.05.

Results

The median age of the patients was 56 years (range 46-67), with a mean BMI of 25.2±4.3 kg/m2. Patients were classified as: American Society of Anesthesiologists (ASA) I (19.7%), II (68.3%), III (12.0%), and IV (0%). ASA I-II included low surgical risk patients (88%) and ASA III-IV comprised high-risk patients (12%). The LC-related 30-day reoperative rate was 0.2% and the readmission rate was 0.87%. Nine patients (0.4%) sustained major bile duct injuries, resulting in a conversion rate of 2.4%. The postoperative mortality rate was 0.04%, and the mean hospitalization time was 3.5 days. Patients in the high-risk group with a history of acute cholecystitis exhibited greater estimated blood loss, longer operative times, and were significantly more likely to be in the longer-stay group.

Conclusion

These findings suggest that LC can be conducted safely on high-risk patients, and early hospital discharge is achievable. However, specific factors, such as a history of acute cholecystitis, may result in prolonged hospitalization owing to increased blood loss and longer operative times.

Classification and regression model to manage the hospitalization for laparoscopic cholecystectomy

Gallstone disease (GD) is one of the most common morbidities in the world. Laparoscopic Cholecystectomy (LC) is currently the gold standard, performed in about 96% of cases. The most affected groups are the elderly, who generally have higher pre- and post-operative morbidity and mortality rates and longer Length of Stay (LOS). For this reason, several indicators have been defined to improve quality and efficiency and contain costs. In this study, data from patients who underwent LC at the "San Giovanni di Dio e Ruggi d'Aragona" University Hospital of Salerno in the years 2010-2020 were processed using a Multiple Linear Regression (MLR) model and Classification algorithms in order to identify the variables that most influence LOS. The results of the 2352 patients analyzed showed that pre-operative LOS and Age were the independent variables that most affected LOS. In particular, MLR model had a R2 value equal to 0.537 and the best classification algorithm, Decision Tree, had an accuracy greater than 83%. In conclusion, both the MLR model and the classification algorithms produced significant results that could provide important support in the management of this healthcare process.

Patient selection for ambulatory laparoscopic cholecystectomy: A systematic review

Background

Currently, there is no consensus on patient selection for ambulatory laparoscopic cholecystectomy (LC). This study is a systematic review of previously published patient selection for ambulatory LC.

Methods

A comprehensive search was done in PubMed, Web of Science, Embase and Google Scholar Database up to March 2020 to summarise previously reported medical or surgical selection criteria used for inclusion and exclusion of patients, as well as successful same-day discharge rates and readmission rate after discharge.

Results

Fifty-nine studies with a total of 13,219 patients were included in this systematic review. In total, the median same-day discharge rate was 90% (range: 63%-99.4%), and median readmission rate was 2.22% (range: 0%-16.9%). The most considered medical criteria were American Society of Anesthesiologists classification I and II, age <70, and body mass index <35. Surgical criteria varied greatly. The top three accessible exclusion variables were (1) common bile duct stones, cholangitis, or jaundice (27 publications, 45.8%); (2) history of abdominal surgery (12 publications, 20.3%) and (3) history of pancreatitis (9 publications, 15.3%).

Conclusion

The results of the current study showed the variable patient selection in different centres, the medical aspect criteria may be expanded under adequate pre-anaesthetic assessment and preparation and the surgical aspect criteria should include more laboratory or imaging parameters to ensure the surgical safety.

Systematic review and meta-analysis of factors which reduce the length of stay associated with elective laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is a safe ambulatory procedure in appropriately selected patients; however, day case rates remain low. The objective of this systematic review and meta-analysis was to identify interventions which are effective in reducing the length of stay (LOS) or improving the day case rate for elective laparoscopic cholecystectomy.

METHODS

Comparative English-language studies describing perioperative interventions applicable to elective laparoscopic cholecystectomy in adult patients and their impact on LOS or day case rate were included.

RESULTS

Quantitative data were available for meta-analysis from 80 studies of 10,615 patients. There were an additional 17 studies included for systematic review. The included studies evaluated 14 peri-operative interventions. Implementation of a formal day case care pathway was associated with a significantly shorter LOS (MD = 24.9 h, 95% CI, 18.7-31.2, p < 0.001) and an improved day case rate (OR = 3.5; 95% CI, 1.5-8.1, p = 0.005). Use of non-steroidal anti-inflammatories, dexamethasone and prophylactic antibiotics were associated with smaller reductions in LOS.

CONCLUSION

Care pathway implementation demonstrated a significant impact on LOS and day case rates. A limited effect was noted for smaller independent interventions. In order to achieve optimal day case targets, a greater understanding of the effective elements of a care pathway and local barriers to implementation is required.

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.

Review of methods and study designs of evaluations related to clinical pathways

Objective The HealthPathways program is an online information portal that helps clinicians provide consistent and integrated patient care within a local health system through localised pathways for diagnosis, treatment and management of various health conditions. These pathways are consistent with the definition of clinical pathways. Evaluations of HealthPathways programs have thus far focused primarily on website utilisation and clinical users' experience and satisfaction, with limited evidence on changes to patient outcomes. This lack motivated a literature review of the effects of clinical pathways on patient and economic outcomes to inform a subsequent HealthPathways evaluation. Methods A systematic review was performed to summarise the analytical methods, study designs and results of studies evaluating clinical pathways with an economic outcome component published between 1 January 2000 and 31 August 2017 in four academic literature databases. Results Fifty-five relevant articles were identified for inclusion in this review. The practical pre-post study design with retrospective baseline data extraction and prospective intervention data collection was most commonly used in the evaluations identified. Straightforward statistical methods for comparing outcomes, such as the t-test or χ2 test, were frequently used. Only four of the 55 articles performed a cost-effectiveness analysis. Clinical pathways were generally associated with improved patient outcomes and positive economic outcomes in hospital settings. Conclusions Clinical pathways evaluations commonly use pragmatic study designs, straightforward statistical tests and cost-consequence analyses. More HealthPathways program evaluations focused on patient and economic outcomes, clinical pathway evaluations in a primary care setting and cost-effectiveness analyses of clinical pathways are needed. What is known about the topic? HealthPathways is a web-based program that originated from Canterbury, New Zealand, and has seen uptake elsewhere in New Zealand, Australia and the UK. The HealthPathways program aims to assist the provision of consistent and integrated health services through dedicated, localised pathways for various health conditions specific to the health region. Evaluations of HealthPathways program focused on patient and economic outcomes have been limited. What does this paper add? This review synthesises the academic literature of clinical pathways evaluations in order to inform a subsequent HealthPathways evaluation. The focus of the synthesis was on the analytical methods and study designs used in the previous evaluations. The previous clinical pathway evaluations have been pragmatic in nature with relatively straightforward study designs and analysis. What are the implications for practitioners? There is a need for more economic and patient outcome evaluations for HealthPathways programs. More sophisticated statistical analyses and economic evaluations could add value to these evaluations, where appropriate and taking into consideration the data limitations.

Feasibility and cost effectiveness of ambulatory laparoscopic cholecystectomy. A retrospective cohort study

Ambulatory surgery is an efficient, safe and widely performed procedure; this study would shows the advantages of the ambulatory laparoscopic cholecystectomy procedure from the point of view of patients and the Hospital/National Health System. Materials and Methods: Single-center retrospective cohort study including 288 patients who underwent laparoscopic-cholecystectomy at **** from January 2016 to July 2018. Ambulatory LC were compared to well-matched inpatient procedures performed in the same study period. The primary endpoints was the 30-day readmission rate. Secondary endpoints were the discharge rate in the ambulatory group, the post-operative complications rate and cost effectiveness. Results: 120/288 (41.7%) patients underwent ambulatory laparoscopic cholecystectomy. Thirty-two (26.7%) patients who underwent ambulatory laparoscopic cholecystectomy had major preoperative comorbidities and 35 (29.2%) had undergone prior abdominal surgery. The readmission rates for ambulatory patients and inpatients were 0.8% and 1.7% (p = 0.56), respectively; 104 (86.7%) ambulatory patients were discharged successfully on the same day. The two groups showed the same post-operative complication rate (p = 0.40). Ambulatory procedures resulted in related cost savings of more than 300% for the hospital and a remarkable financial benefit for the National Italian Healthcare System, accounting for savings exceeding € 27 000 per year. Conclusions: Ambulatory laparoscopic cholecystectomy is safe and cost effective. Since a third of ambulatory patients showed comorbidity or previous abdominal surgery, we believe that this procedure may be performed safely in a tertiary HPB centre, even in complex patients.

Evaluating a Clinical Pathway in Laparoscopic Cholecystectomy: Effective in Reducing Complications? A Propensity Score Matching Analysis

Background

Care pathways are primarily aimed at decreasing length of hospital stay (LOS) and preventing unnecessary costs while maintaining or improving the quality of care. In laparoscopic cholecystectomy, there is insufficient evidence for proving an impact upon postoperative complications.

Methods

In this retrospective study, logistic regression was used to calculate a propensity score, and, after carrying out 1:1 nearest-neighbor matching, 296 patients were analyzed in both groups with regard to postoperative complications using the Clavien-Dindo classification system as a primary aim. In addition, secondary aims were LOS, compliance to care, and deviation from the care pathway with respect to patient discharge. Relative risk of the primary outcome was calculated and compared with the e-value as sensitivity testing approach.

Results

Due to the mandatory part of the care pathway, patient record compliance was 100%. Deviation from the care pathway with respect to the planned patient discharge on postoperative day 2 was noted in 16% of the cases. After adjustment for potential factors, the relative risk when comparing Clavien-Dindo complication grades 0 versus 1-4 is 1.64 (95% CI 0.87-3.11), which did not reach significance (p = 0.127). After matching, LOS lasted 3.69 days without and 3.26 days with the care pathway, respectively.

Conclusions

Against the background of already implemented structured standard operation procedures, a care pathway is not able to reduce postoperative complications. Nevertheless, we consider our clinical pathway a highly valuable tool for the interdisciplinary management of patient hospitalization under the supervision of experienced specialized surgeons.

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.

Feasibility of Routine Ambulatory Laparoscopic Cholecystectomy in Brazil

Background and Objectives

In several developed countries, most laparoscopic cholecystectomies (LCs) are performed as an ambulatory operation (ALC) with a high rate of success. In Latin America, the experience with this procedure is still limited. Our objective is to evaluate the feasibility to implement ALC in a Brazilian teaching hospital.

Methods

Data obtained from electronic medical records and study protocols of all patients who underwent an LC between January 2011 and March 2018 were evaluated. All patients with chronic or acute cholecystitis were initially considered for an ALC.

Results

Of a total of 1645 patients who underwent LC, 1577 (95.9%) were discharged on the same day of the operation. The main reasons for hospital admission after ALC were patient refusal to be discharged (n = 23; 1.4%), nausea and vomiting (n = 15; 0.9%), and complicated acute cholecystitis. No patient was excluded from consideration for ALC based only on age, history of previous upper abdominal operation, and presence of comorbidity. Patient age ranged from 12 to 100 years, with a mean of 50.23 ± 15.35 years. Intraoperative and postoperative complication rates were 0.4% and 5.5%, respectively. Most perioperative complications were because of technical surgical difficulties and complications common to most abdominal operations (surgical site, pulmonary, urinary, and venous complications). Thirteen (0.8%) patients were readmitted to the hospital because of abdominal pain and fever (n = 4), pneumonia (n = 3), deep venous thrombosis (n = 3), or urinary retention (n = 3).

Conclusions

ALC may be performed in Brazil with low rates of morbidity, mortality, and hospital readmission. Its implementation should be stimulated in Latin America.

Appropriate Hospital Discharge Timing after Laparoscopic Cholecystectomy: Comparison of Postoperative Day 1 vs. Day 2 Discharge Protocol

Purpose

The critical pathway (CP) was introduced as a means to provide quality healthcare service in many fields of surgery. CP may increase the patient's satisfaction rate and lowering hospital stay and medical cost also. We aimed to compare the two kinds of CP applied in laparoscopic cholecystectomy patients by different hospital stay length.

Methods

From March 2016 to October 2016, 71 patients were enrolled in this analysis among 241 patients who underwent elective laparoscopic cholecystectomy. Patients were divided into two groups, 38 patients in the 1-day CP group and 33 patients in the 2-day CP group. In a retrospective review, surgical outcomes and related hospital costs were analyzed.

Results

Preoperative characteristics were not different between two CP groups. In analysis of operative outcome, 2-day CP group showed longer operative time than 1-day CP (73.4 vs 54.1 min, p<0.001); otherwise, there was no significant difference in frequency of postop complications (6.1% vs 2.6%, p=0.474), numerical rating scale (NRS) pain score (1.82 vs 2.16, p=0.052), and count of analgesics injection (0.12 vs 0.16, p=0.754). Total admission cost and actual patient's expenditures were higher in 2-day CP group, but there was no statistically significant difference (347.04 vs 306.69×104 won, p=0.106; 147.85 vs 125.58×104 won, p=0.276).

Conclusion

The length of hospital stay was shortened in 1-day CP group than in 2-day CP group, while there was no difference in other parameters. Therefore, it is feasible and safe practical policy the use 1-day CP in selected patients who undergo cholecystectomy according to our results.

Increasing success in outpatient laparoscopic cholecystectomy by an optimal clinical pathway

BACKGROUND

The objective of this study was to evaluate the impact of more convincing and reassuring remarks from the surgeon in the preoperative consult associated with a dedicated outpatient facility to increase our rate of success in outpatient laparoscopic cholecystectomy.

METHODS

A one-centre prospective clinical study was conducted between February 2013 and May 2015. During the first time period (February 2013-March 2014), patients were hospitalized in conventional care unit and given the possibility to choose an outpatient procedure. In the second phase (April 2014-May 2015), the patients were held in a dedicated outpatient facility. Outpatient success rate was evaluated using Chung's discharge score 6 h after surgery.

RESULTS

Eighty patients were included (30 in a traditional setting, 50 in an optimal clinical pathway). Both groups were comparable for mean age, American Society of Anesthesiologists score and mean operative time (P = 0.36, P = 1 and P = 0.09, respectively). Success in outpatient surgery was significantly higher in the optimal clinical pathway group (73.3% versus 96%, P = 0.005). The only criteria which was significantly improved in Chung score was perambulation (P = 0.001). There was no significant difference between the two groups for post-operative complications (P = 0.28) or readmission (P = 1).

CONCLUSION

Optimal clinical pathway (more convincing and reassuring remarks in the preoperative consult and a dedicated outpatient facility) is the key to increase success in outpatient laparoscopic cholecystectomy.

Value analysis of postoperative staging imaging for asymptomatic, early-stage breast cancer: implications of clinical variation on utility and cost

BACKGROUND

Routine staging imaging for early-stage breast cancer is not recommended. Despite this, there is clinical practice variation with imaging studies obtained for asymptomatic patients with a positive sentinel node (SN+). We characterize the utility, cost, and clinical implications of imaging studies obtained in asymptomatic SN+ patients.

METHODS

A retrospective review was performed of asymptomatic, clinically node-negative patients who were found to have a positive sentinel node after surgery. The type of imaging, subsequent tests/interventions, frequency of additional malignancy detected, and costs were recorded.

RESULTS

From April 2009 to April 2013, a total of 50 of 113 (44%) asymptomatic patients underwent staging imaging for a positive sentinel node; 11 (22%) patients had at least 1 subsequent imaging study or diagnostic intervention. No instance of metastatic breast cancer was identified, with a total cost of imaging calculated at $116,905.

CONCLUSIONS

Staging imaging for asymptomatic SN+ breast cancer demonstrates clinical variation. These tests were associated with low utility, increased costs, and frequent false positives leading to subsequent testing/intervention. Evidence-based standardization may help increase quality by decreasing unnecessary variation and cost.

The application of clinical pathways in laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) is one of the most frequent abdominal surgical procedures. The present meta-analysis aimed to estimate the clinical effects of implementing a clinical pathway for LC compared with standard medical care by evaluating the length of hospital stay, costs, and the outcomes of patients undergoing LC.

DATA SOURCES

Data were extracted from the following databases: PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, Chinese Medical Citation Index (CMCI), Chinese Medical Current Contents (CMCC), and China BioMedical Literature Database (CBM). We also searched the reference lists of the relevant articles and conference articles. Only randomized controlled trials and controlled clinical trials published from 1980 to 2013 were included. We did not set restrictions on language and country of publications. All of the data were evaluated and analyzed by two reviewers independently with RevMan software (version 5.0).

RESULTS

A total of 7 trials with 1187 patients were included. The patients who underwent LC with clinical pathway had shorter hospital stay [weighted mean difference=-1.90, 95% CI: -2.65 to -1.16, P<0.00001], lower cost [standard mean difference=-0.69, 95% CI: -0.82 to -0.56, P<0.00001], and better questionnaires based satisfaction with the medical services.

CONCLUSIONS

The applications of the clinical pathway for LC effectively reduced hospital stay and total costs. However, there was insufficient evidence for proving the differences in postoperative complications. Future research should focus on patient outcomes and identify the mechanisms underlying the effect of the clinical pathway.

Robotic-assisted laparoscopic day-case nephroureterectomy

Objective:

The objective of this article is to describe our initial experience of performing day-case robotic-assisted laparoscopic nephroureterectomy.

Subjects/patients and methods:

Based on our previous experience of performing day-case laparoscopic nephrectomies, a standardised surgical and anaesthetic procedure, and patient selection criteria were applied to two patients undergoing nephroureterectomy.

Results:

Both patients underwent successful robotic-assisted laparoscopic nephroureterectomy for upper tract transitional cell carcinoma and were discharged home on the day of surgery. Neither experienced a post-operative complication or required hospital admission.

Conclusion:

Day-case nephroureterectomy is a viable option in appropriately selected patients. We present the first report of nephroureterectomies performed as day-case surgery.

[Development of an internet-based clinical pathway exemplified by the fibromyalgia syndrome]

Clinical pathways (CP) are considered to be a tool of clinical process management describing the optimal route for diagnostic and therapeutic medical treatment of a specified patient. Apart from economic aspects CPs can make a contribution to optimization of health quality management as well as to improvement of medical staff and both patient satisfaction and patient safety whereas the feasibility and acceptance of evidence-based medicine guidelines are often found to be low. In order to stimulate critical discussion by offering the opportunity to easily gain first practical experience, a free web-based clinical pathway system for diagnosis and treatment for patients with fibromyalgia syndrome (FMS) will be presented.

Day Care Laparoscopic Cholecystectomy: Next Standard of Care for Gall Stone Disease

Background

To access the feasibility, safety and success of day care laparoscopic cholecystectomy in a tertiary center in India.

Methods

This is a retrospective analysis of prospectively collected data between 2004 and 2009 from a tertiary center in north India. All patients of symptomatic gallstone diseases having age less than 70 years, American Society of Anesthesiologists (ASA) grade I and grade II, living within 20 Kilometers of the hospital, availability of a responsible adult care taker at home, access to a telephone and a means of transportation to hospital if needed, underwent laparoscopic cholecystectomy under the care of the two participating surgeons, were considered for day care laparoscopic cholecystectomy. Clinical and operative data were recorded prospectively. All patients were discharged 6 to 8 hours after surgery with the advice to contact the surgical team over phone whenever necessary or on the day after discharge.

Results

A total of 602 laparoscopic cholecystectomies were performed over a period of 6years, among them 309 (51.32%) were operated on day care basis. Nine patients in day care procedure group had conversion to open procedure (5 due to distorted anatomy of calot’s triangle, 2 due to common bile duct stones, 1 due to bile duct injury and 1 due to bleeding from cystic artery stump). One patient had myocardial infarction and 3 had nausea and vomiting which failed to resolve by intravenous ondensteron and all these (13) patients (4.20%) needed unplanned admission to the hospital. Two hundred and ninety-six patients (95.79%) were discharged on same day.

Conclusions

In conclusion day care laparoscopic cholecystectomy is feasible, safe and equally effective in selected patients in Indian setup.

Efficacy of turmeric (curcumin) in pain and postoperative fatigue after laparoscopic cholecystectomy: a double-blind, randomized placebo-controlled study

OBJECTIVE

Better patient-reported outcomes (PROs) of laparoscopic cholecystectomy (LC) are premised upon PROs such as postoperative pain and fatigue. These PROs are indices of convalescence and return to normal activity. Curcumin (turmeric) is used in India for traumatic pain and fatigue for its anti-inflammatory/antioxidant and tissue modulation/healing properties. We studied the effect of curcumin on pain and postoperative fatigue in patients of LC.

METHODS AND PROCEDURES

From July to September 2009, 50 consecutive day-care LC candidates were enrolled for a prospective, double-blind randomized placebo-controlled study. A uniform general anesthesia and analgesia protocol was followed. Curcumin/placebo and rescue analgesic were prescribed at discharge. Patients were told to maintain pain/fatigue/adverse event diaries based upon 100-point visual analog pain scale (VAS) and 10-point interval rating fatigue scale (IRS). Patients were followed up at third day (D3), first week (W1), second week (W2), and third week (W3). The blind labels were opened at the end of study.

RESULTS

Demographic characteristics, comorbidity, and gallbladder pathology profiles were comparable in the study (n = 25) and control groups (n = 25). There was no adverse surgical outcome, adverse PRO or withdrawal. Pain and fatigue scores at D3 were similar in the two groups. At W1 and W2, the study group showed significantly lower (p value 0.000) mean pain scores, i.e., 15 ± 5.204 versus 30 ± 13 in controls. Fatigue scores at W1, W2, and W3 were significantly lower (p value 0.000) in the study group, i.e., 2.16 ± 1.748, 1, and 0, respectively, versus 5.16 ± 1.375, 4.20 ± 1.633, and 1 in controls. All patients were pain free at W3. Analgesic tablet usage was significantly lower (p value 0.000) in the study group, i.e., 6.96 ± 1.837 versus 39.32 ± 16.509 in controls.

CONCLUSIONS

Turmeric (curcumin) improves postoperative pain- and fatigue-related PROs following LC.

Implementation of a critical pathway for complicated gallstone disease: translation of population-based data into clinical practice

BACKGROUND

Evidence-based guidelines recommend cholecystectomy during initial hospitalization for complicated gallstone disease. Previous studies and quality initiative data from our institution demonstrated that only 40% to 75% of patients underwent cholecystectomy on index admission.

STUDY DESIGN

In January 2009, we implemented a critical pathway to improve cholecystectomy rates for all patients emergently admitted for acute cholecystitis, mild gallstone pancreatitis, or common bile duct stones. We compared cholecystectomy rates during initial hospitalization, time to cholecystectomy, length of initial stay, and readmission rates in prepathway (January 2005 to February 2008) and postpathway patients (January 2009 to May 2010).

RESULTS

Demographic and clinical characteristics were similar between prepathway (n = 455) and postpathway patients (n = 112). Cholecystectomy rates during initial hospitalization increased from 48% to 78% after pathway implementation (p < 0.0001). There were no differences in operative mortality or operative complications between the 2 groups. For patients undergoing cholecystectomy on initial hospitalization, the mean length of stay decreased after pathway implementation (7.1 days to 4.5 days; p < 0.0001), primarily due to a decrease in the time from admission to cholecystectomy (4.1 days to 2.1 days; p < 0.0001). Thirty-three percent of prepathway and 10% of postpathway patients required readmission for gallstone-related problems or operative complications (p < 0.0001), and each readmission generated an average of $19,000 in additional charges.

CONCLUSIONS

Implementation of a multidisciplinary critical pathway improved cholecystectomy rates on initial hospitalization and lowered costs by shortening length of stay and markedly decreasing readmission rates for gallstone-related problems. Broader implementation of similar pathways offers the potential to translate evidence-based guidelines into clinical practice and minimize the cost of medical care.

Treatment of gallbladder disease during operations Iraqi Freedom and Enduring Freedom

BACKGROUND

We examined the outcome after treatment for gallbladder disease in deployed military service members and the impact of instituting a clinical pathway to expedite return to duty (RTD).

METHODS

A retrospective chart review of 97 medically evacuated patients with gallbladder disease was carried out. These patients were evacuated from the field to Landstuhl Regional Medical Center (LRMC), Germany, between March 2003 and November 2004. In October 2003, a clinical pathway was established to facilitate returning these deployed patients back to their combat units. These service members were compared with 90 local patients who underwent the same surgery during the study period.

RESULTS

Twenty-nine patients were treated before the implementation of the clinical pathway. Of those, five had complications, five were converted to open, and 52% returned to their deployed units. After the clinical pathway was established, there were no complications (p = 0.023), two were converted to open (p = 0.002), and 84% returned to duty (p = 0.002). The Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) service members had delayed presentations for definitive treatment. When compared with the local patient group, OIF/OEF surgical cases were more often male (78 vs. 32%, p < 0.001), younger (average 31 vs. 35 years, p < 0.001), and associated with longer operative times (89 vs. 52 min, p < 0.001), and had higher conversion rate to open (7.2 vs. 2.2%, p = 0.17) and higher major complication rate (5.1 vs. 0%, p = 0.06). Time to operation and final pathologic diagnosis were significantly different between the two groups.

CONCLUSIONS

Gallbladder surgery can be performed in a delayed manner in the deployed service member, although with a significantly higher morbidity as compared with the local population. We suggest that changes in the immediate treatment and transportation of these service members should occur at the theater level. The use of a clinical pathway facilitates the rapid RTD of soldiers diagnosed with gallbladder disease.

Hospital cost categories of one-stage versus two-stage management of common bile duct stones

BACKGROUND

In the era of cost-conscious healthcare, hospitals are focusing on costs. Analysis of hospital costs per cost category may provide indications for potential cost-saving measures in the management of common bile duct stones (CBDS) with gallbladder in situ.

METHODS

Between October 2005 and September 2006, 53 consecutive patients suffering from CBDS underwent either a one-stage procedure [laparoscopic common bile duct exploration (LCBDE) with stone clearance and cholecystectomy (LCCE)] or a two-stage procedure [endoscopic retrograde cholangiopancreatography with sphincterotomy and stone clearance (ERCP/ERS) followed by LCCE]. Costs were defined in different cost categories for each activity centre and were linked to the individual patient via the "bill of activities". Only patients (n = 38) with an uneventful post-procedural course and with available cost data were considered for cost analysis. Total length of hospital stay (LOS) was 2 (0-6) days after one-stage and 8 (3-18) days after two-stage procedure (p < 0.0001).

RESULTS

Costs per patient were significantly (p < 0.0001) less after one-stage versus two-stage management, i.e. total hospital costs (euro2,636 versus euro4,608), hospitalisation costs (euro701 versus euro2,190), consumables/pharmacy (euro645 versus euro1,476) and para-medical personnel (euro1,035 versus euro1,860; p = 0.0002). Operation room (OR) costs were comparable for one-stage and two-stage management (euro1,278 versus euro1,232; p = 0.280). Total hospital costs during ERCP were euro2,648 (euro729-4,544), during LCCE without LCBDE were euro2,101 (euro1,033-4,269), and during LCCE with LCBDE were euro2,636 (euro1,176-4,235).

CONCLUSION

In the management of patients with CBDS and gallbladder in situ a one-stage procedure is associated with significantly less costs as compared with a two-stage procedure. From the economical point of view these patients should preferably be treated via a one-stage procedure as long as safety and efficacy of this approach are provided.

Evidence-based surgical care and the evolution of fast-track surgery

BACKGROUND

Optimization of postoperative outcome requires the application of evidence-based principles of care carefully integrated into a multimodal rehabilitation program.

OBJECTIVE

To assess, synthesize, and discuss implementation of "fast-track" recovery programs.

DATA SOURCES

Medline MBASE (January 1966-May 2007) and the Cochrane library (January 1966-May 2007) were searched using the following keywords: fast-track, enhanced recovery, accelerated rehabilitation, and multimodal and perioperative care. In addition, the synthesis on the many specific interventions and organizational and implementation issues were based on data published within the past 5 years from major anesthesiological and surgical journals, using systematic reviews where appropriate instead of multiple references of original work.

DATA SYNTHESIS

Based on an increasing amount of multinational, multicenter cohort studies, randomized studies, and meta-analyses, the concept of the "fast-track methodology" has uniformly provided a major enhancement in recovery leading to decreased hospital stay and with an apparent reduction in medical morbidity but unaltered "surgery-specific" morbidity in a variety of procedures. However, despite being based on a combination of evidence-based unimodal principles of care, recent surveys have demonstrated slow adaptation and implementation of the fast-track methodology.

CONCLUSION

Multimodal evidence-based care within the fast-track methodology significantly enhances postoperative recovery and reduces morbidity, and should therefore be more widely adopted. Further improvement is expected by future integration of minimal invasive surgery, pharmacological stress-reduction, and effective multimodal, nonopioid analgesia.