Veinticinco años de colecistectomía laparoscópica en régimen ambulatorio

The Analgesic Efficacy of Intraperitoneal Ropivacaine Versus Bupivacaine for Laparoscopic Cholecystectomy: a Meta-Analysis

Introduction This meta-analysis aimed to compare the analgesic efficacy of intraperitoneal ropivacaine versus bupivacaine for laparoscopic cholecystectomy.

Methods We searched PubMed, EMbase, Web of Science, EBSCO, and Cochrane Library databases from inception through January 2020 and included randomized controlled trials (RCTs) evaluating the analgesic efficacy of ropivacaine versus bupivacaine for laparoscopic cholecystectomy.

Results Five RCTs are included in the meta-analysis. In patients with laparoscopic cholecystectomy, ropivacaine and bupivacaine demonstrated comparable pain scores at 2 h (SMD = –0.22; 95% CI = –0.54 to 0.10; p = 0.18), 4 h (SMD = –0.16; 95% CI = –0.42 to 0.10; p = 0.22), 8 h (SMD = –0.60; 95% CI = –1.19 to –0.01; p = 0.05), and 24 h (SMD = 0.33; 95% CI = –1.19 to 1.84; p = 0.67), as well as time to first analgesic requirement (SMD = 0.10; 95% CI = –0.23 to 0.42; p = 0.56).

Conclusions Intraperitoneal ropivacaine and bupivacaine have a similar analgesic efficacy for laparoscopic cholecystectomy.

Erector spinae plane block reduces pain after laparoscopic cholecystectomy

PURPOSE

After laparoscopic cholecystectomy patients have moderate pain in the early postoperative period. According to several studies an erector spinae plane (ESP) block can be a valuable part of multimodal analgesia. Our intention was to evaluate how ESP block influences postoperative pain scores and opioid consumption after laparoscopic cholecystectomy.

METHODS

This single-blinded, prospective, randomized study included 60 patients undergoing laparoscopic cholecystectomy to receive either bilateral ESP block at the Th 7 level (n = 30) with 20 ml of 0.25% levobupivacaine plus dexamethasone 2 mg per side, or standard multimodal analgesia (n = 30). Patients from the standard multimodal analgesia group received tramadol 100 mg at the end of the procedure. Postoperative analgesia for both groups was acetaminophen 1 g/8 h i.v. and ketorolac 30 mg/8 h. Tramadol 1 mg/kg was a rescue treatment for pain breakthrough (numeric rating scale/NRS ≥ 6) in both groups. Pain at rest was recorded at 10 min, 30 min, 2 h, 4 h, 8 h, 12 h and 24 h after surgery using NRS (0-10).

RESULTS

An ESP block significantly reduced postoperative pain scores compared to standard multimodal analgesia after 10 min (p = 0.011), 30 min (p = 0.004), 2 h (p = 0.011), 4 h (p = 0.003), 8 h (p = 0.013), 12 h (p = 0.004) and 24 h (p = 0.005). Tramadol consumption was significantly lower in the ESP group 25.02 ± 56.8g than in the standard analgesia group 208.3 ± 88.1g (p < 0.001).

CONCLUSION

An ESP block can provide superior postoperative analgesia and reduction in opioid requirement after laparoscopic cholecystectomy.

Corrosion and biocompatibility behaviours of microarc oxidation/phytic acid coated magnesium alloy clips for use in cholecystectomy in a rabbit model

With the popularisation of laparoscopic cholecystectomy, ligation clips have been commonly used for ligating the cystic duct and cystic artery. However, non-degradable clips remain in the body long-term, which significantly increases the risk of the clip becoming detached. Thus, magnesium alloys have attracted tremendous attention owing to their biodegradability and good biocompatibility. However, the poor corrosion resistance hinders the clinical application of magnesium alloys with microarc oxidation/phytic acid (MAO/PA) composite coatings as protective coatings. Here, these alloys were used to hinder the rapid material degradation in aqueous solution. Electrochemical tests were conducted to evaluate the in vivo degradation behaviour in simulated body fluid (SBF) for Mg-Zn-Y-Nd alloys, and scanning electron microscopy (SEM) was used to observe the micromorphology of in vivo clip degradation. Cell toxicity, cell adhesion, and flow cytometry were performed in vitro to detect cytocompatibility. Biochemical detection of serum magnesium, serum creatinine (CREA), blood urea nitrogen (BUN), alanine transaminase (ALT), and alanine aminotransferase (AST), and haematoxylin-eosin (HE) staining of the heart, liver, and kidney tissues in vivo was conducted to determine the biocompatibility properties after surgery. Electrochemical measurements and SEM images revealed that the MAO/PA-coated magnesium alloy delayed corrosion in SBF. The apoptosis rate increased slightly with increased extract concentration. Nevertheless, MAO/PA-coated magnesium alloys still exhibited good cytocompatibility. No obvious abnormality was observed in the blood biochemical test or HE staining. Thus, MAO/PA-coated magnesium alloys exhibit better corrosion than bare magnesium. In addition, Mg-Zn-Y-Nd and MAO/PA-coated magnesium alloys exhibited no cytotoxicity, good adhesion, and biosafety.

Heart Failure Is a Poor Prognosis Risk Factor in Patients Undergoing Cholecystectomy: Results from a Spanish Data-Based Analysis

Background: The incidence of cholecystectomy is increasing as the result of the aging worldwide. Our aim was to determine the influence of heart failure on in-hospital outcomes in patients undergoing cholecystectomy in the Spanish National Health System (SNHS). Methods: We conducted a retrospective study using the Spanish National Hospital Discharge Database. Patients older than 17 years undergoing cholecystectomy in the period 2007–2015 were included. Demographic and administrative variables related to patients’ diseases as well as procedures were collected. Results: 478,111 episodes of cholecystectomy were identified according to the data from SNHS hospitals in the period evaluated. From all the episodes, 3357 (0.7%) were excluded, as the result the sample was represented by 474,754 episodes. Mean age was 58.3 (+16.5) years, and 287,734 (60.5%) were women (p < 0.001). A primary or secondary diagnosis of HF was identified in 4244 (0.89%) (p < 0.001) and mean age was 76.5 (+9.6) years. A higher incidence of all main complications studied was observed in the HF group (p < 0.001), except stroke (p = 0.753). Unadjusted in-hospital mortality was 1.1%, 12.9% in the group with HF versus 1% in the non HF group (p < 0.001). Average length of hospital stay was 5.4 (+8.9) days, and was higher in patients with HF (16.2 + 17.7 vs. 5.3 + 8.8; p < 0.001). Risk-adjusted in-hospital mortality models’ discrimination was high in both cases, with AUROC values = 0.963 (0.960–0.965) in the APRG-DRG model and AUROC = 0.965 (0.962–0.968) in the CMS adapted model. Median odds ratio (MOR) was high (1.538 and 1.533, respectively), stating an important variability of risk-adjusted outcomes among hospitals. Conclusions: The presence of HF during admission increases in hospital mortality and lengthens the hospital stay in patients undergoing cholecystectomy. However, mortality and hospital stay have significantly decreased during the study period in both groups (HF and non HF patients).

Thirty-Day Unplanned Readmission After Ambulatory Laparoscopic Cholecystectomy in Western China: A Retrospective Study

Background Day surgery has been gradually accepted by health professions globally, which can shorten the hospital stay and reduce medical costs. The ambulatory laparoscopic cholecystectomy (LC) has been performed in China since over 10 years. However, few studies focus on its 30-day unplanned readmission rate of ambulatory LC and no standard of unplanned readmission rate for that now. Purpose This study aimed to evaluate the unplanned readmission rate and the reasons readmission after ambulatory LC in a tertiary hospital, which is the earliest ambulatory surgery implementation place in western China. Methods A retrospective analysis was conducted. The patients who underwent ambulatory LC from September 2015 to September 2019 in West China Hospital were screened. The 30-day unplanned readmission rate was calculated as the first outcome. The reasons for unplanned readmission were analyzed and classified as the second outcome. Results The study included 3,014 patients, and the unplanned readmission rate was 1.53%. The rate of patients diagnosed with cholecystolithiasis with cholecystitis was significantly higher in the unplanned readmission group (73.9% vs. 48.9%, p=0.003), and medical cost of unplanned readmission patients was significantly more than that of non-readmission patients (8,102.4±1,375.7 Yuan vs. 7,574.61±10,14.0 Yuan; p=0.008). It was observed that 71.7% readmission happened in the first seven days. Wound problems (60.9%) and abdominal pain (26.1%) went the two main reasons for unplanned readmission. Conclusions The analysis revealed that the unplanned readmission rate of 1.53% was low for ambulatory LC. Some causes of unplanned readmission, such as abdominal pain and wound site pain, wound exudate could be reduced by some simple interventions of the clinical professions.

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.

Predictive Factors of Admission in Outpatient Laparoscopic Surgery

INTRODUCTION

The aim of the study is to analyze the rate of no planificated hospitalization after ambulatory surgical procedures by laparoscopy, and identify associated risk factors to failure in the ambulatory manage of this patients.

METHODS

A prospective observational study was performed during 18 months and included 297 patients treated with ambulatory laparoscopies performed at University Hospital La Fe of Valencia. The need for hospital admission, same day after surgery, was considered the main variable. Variables were recorded for preoperatives, intraoperatives o postoperatives factors. To identify risk factors and variables associated with complications, statistical analyses were calculated with logistic regression models.

RESULTS

After laparoscopic surgery, the 8.1% of patients required hospitalization. This rate was significantly superior in gynecologic surgery, patients with previous surgery complications, superior ASA classified (II and III) and smokers. Likewise, patients with pneumoperitoneum time over 45minutes presented a higher hospitalization rate; also founded in patients with anesthetic or surgery complications (including conversion to laparotomy). At least, the rate of hospitalization was significantly superior in relation with postoperative nausea and vomiting (PONV).

CONCLUSION

The rate of patients who need hospitalization after ambulatory laparoscopic surgery was 8.1%, of which 5.5% were general surgeries and 12.1% were gynecologic surgeries. The mots relationated factors with ambulatory manage failure, analyzed with multiple regression, were the appearance of surgery complications, the pneumoperitoneum time over 100minutes and the PONV.

Evidence-Based Management of Calculous Biliary Disease for the Acute Care Surgeon

Background: Gallstones and cholecystitis are common clinical problems. There is a wide spectrum of disease severity, from rare symptoms of biliary colic to severe cholecystitis with marked gallbladder infection and inflammation that can cause life-threatening sepsis. The care of such patients is similarly varied and multi-disciplinary. Despite the prevalence of cholecystitis, there remain questions about how to manage patients appropriately. Methods: A multi-disciplinary team created institutional cholecystitis guidelines, and supporting evidence was compiled for review. Results: Even in "routine" cholecystitis, patient triage and work-up can be variable, resulting in unnecessary tests and delay to cholecystectomy. Beyond this, there are new treatment options available that may serve special populations particularly well, although the appropriate pattern of emerging endoscopic and percutaneous treatment modalities is not well defined. Conclusions: This review outlines evidence-based management of cholecystitis from diagnosis to treatment with a focused discussion of special populations and emerging therapies.

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.

Effects of Gabapentinoids Premedication on Shoulder Pain and Rehabilitation Quality after Laparoscopic Cholecystectomy: Pregabalin versus Gabapentin

Introduction

Gabapentinoids are increasingly used in preoperative premedication despite controversial results. The aim of our study was to evaluate the effects of preemptive use of gabapentin or pregabalin on postoperative shoulder pain and rehabilitation quality after laparoscopic cholecystectomy.

Methods

This is a clinical trial comparing the effects of a preoperative premedication with 600 mg of gabapentin or 150 mg of pregabalin versus placebo on postoperative pain and recovery quality after laparoscopic cholecystectomy. Premedication was taken 2 hours before the surgery beginning. Ninety patients were included and randomized into 3 groups (gabapentin, pregabalin, and placebo). The anesthetic protocol was the same for all patients. Primary endpoint was the shoulder pain intensity at the 48th postoperative hour. Secondary endpoints were postoperative nausea and vomiting (PONV), sleep quality during the first night, and the onset time for the first standing position.

Results

During the first 48 postoperative hours, the gabapentin and pregabalin groups had significantly lower shoulder pain than the placebo group (p < 0.05). In gabapentinoids groups, the incidence of PONV was lower and the sleep quality during the first postoperative night was better with significant results. Mean Spiegel scores were 22.43 ± 1.45, 22.30 ± 1.44, and 17.17 ± 1.66, respectively, in pregabalin, gabapentin, and placebo groups (p < 0.05). The delay for the first standing position was 14.9 ± 4.9 hours in the pregabalin group, 9.7 ± 3.6 hours in the gabapentin group, and 21.6 ± 2.1 hours in the placebo group. No superiority was found between gabapentin and pregabalin.

Conclusion

Preemptive premedication with gabapentinoids can enhance postoperative rehabilitation quality after laparoscopic cholecystectomy by reducing postoperative shoulder pain, decreasing PONV incidence, and improving sleep quality during the first postoperative night. This trial is registered with ClinicalTrial.gov (NCT03241875).

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.