Day case laparoscopic cholecystectomy is safe and feasible: a case controlled study

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.

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.

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.

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 Surgery Program at West China Hospital: Exploring the Initial Experience

Healthcare facilities in China are facing increasing demands as the country has the fastest aging populations in the world. Day surgery can be utilized to address some of these demands. Benefits of day surgery include shortened hospital stay, decreased risk of hospital-associated infections, and increased cost efficiency. We present a retrospective study of eight years of day surgery data from West China Hospital, one of the largest hospitals in China, with an emphasis on an examination of the growth in day surgeries. We examined patterns of utilization of day surgery versus inpatient surgery (including types of surgeries performed in the Day Surgery Center and the ratio of day surgery versus elective surgery), as well as unplanned readmission and return to inpatient department rates, and a comparison of average costs and length of stay for day surgery versus hospital surgery.

Day surgery has a safe and cost-effective way to alleviate the soaring healthcare demands in West China. There is potential opportunity to further address the ever-increasing demands on the healthcare system in this area by performing more complex surgeries as day surgeries. This article presents an effective organizational protocol and proposes a reliable medical quality assurance system, which prioritizes safety of the growing day surgery program; furthermore, it describes the factors and lessons learned from the successful implementation of a day surgery system.

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.

'True Day Case' Laparoscopic Cholecystectomy in a High-Volume Specialist Unit and Review of Factors Contributing to Unexpected Overnight Stay

Introduction

Laparoscopic cholecystectomy (LC) is the gold standard treatment for gallstones. British Association of Day Case Surgery recommends at least 60% of LCs be performed as day cases. The aim of this study was to assess our rate of true day case LCs and review factors preventing same-day discharge.

Methods

We prospectively collected data of all elective LCs performed in a district general hospital over 32 months.

Results

500 patients underwent LC during this period; 438 (88.2%) patients were planned day cases and 59 patients (11.8%) planned overnight stays. Of the planned day cases, 75.8% (n=332) were discharged on the same day and 106 (24.2%) had unexpected overnight stay (UOS). Most patients with BMI >35 and ASA3 planned day case patients were successfully discharged. Drain insertion, longer operations, and late recovery departure were the main reasons for UOS. There were more complications in this group compared to day cases.

Conclusions

This unit has a high ‘true day case' rate of 75.8%. High BMI and ASA3 should not be absolute contraindications to day case surgery. The majority of unexpected overnight stays are unavoidable but may be reduced by patient selection, stringent preoperative assessment, operation scheduling, and reduction in unnecessary drain insertion.

Safety of outpatient anterior cervical discectomy and fusion: a systematic review and meta-analysis

Background

Anterior cervical discectomy and fusion (ACDF) is one of the most prevalent spine surgeries and neurosurgical procedures performed to treat a variety of disorders in the cervical spine. Over the last several years, ACDF has been done in the outpatient setting for less invasive approaches and exposures, as well as modified anesthetic and pain management techniques. Despite the fact that it may be innocuous in other parts of the body, complications in the spine can literally be fatal. The objective of this article is to evaluate the safety of outpatient surgery compared with inpatient surgery in the cervical spine for adult patients.

Methods

The multiple databases including Pubmed, Springer, EMBASE, EBSCO and China Journal Full-text Database were adopted to search for the relevant studies in English or Chinese. Full-text articles involving to the safety of outpatient cervical spine surgery were selected. Review Manager 5.0 was adopted to estimate the effects of the results among selected articles. Forest plots, sensitivity analysis and bias analysis for the articles included were also conducted. Chi-square tests were conducted with SPSS 20.0 software.

Results

Finally, 12 articles were included. The results of meta-analysis suggested that in the articles included, no death occurred, and compared with inpatient surgery, outpatient surgery has a similar risk (RR = 0.99, 95 % CI [0.98, 1.00], P = 0.02; P for heterogeneity = 0.47, I² = 0 %). An I² value of 0 % indicates no heterogeneity observed. All complications were occurred in both outpatients and inpatients. Among the studies selected, after the outpatient spine surgery, the highest incidences of complication were dysphagia (18/29) and hematoma (4/29). Compared with the overall complication rate in inpatient group, no significant difference was observed (x² = 1.820, P = 0.177).

Conclusion

In this study, outpatient surgery has a similar risk with inpatient surgery, and no difference of morbidity between outpatient and inpatient was found. Because of short operative time and moderate postoperative pain, we believe that outpatient cervical spine surgery is a safe and convenient alternative procedure, which also decrease the cost of care. Besides, postoperative complications including dysphagia and hematoma should be noticed.

AMBULATORY LAPAROSCOPIC CHOLECYSTECTOMY IS SAFE AND COST-EFFECTIVE: a Brazilian single center experience

ABSTRACT Background - Laparoscopic cholecystectomy is the treatment of choice for gallstone disease, and has been perfomed as an outpatient surgery in many Institutions over the last few years. Objective - This is a retrospective study of a single center in Brazil, that aims to analyze the outcomes of 200 cases of ambulatory laparoscopic cholecystectomy performed by the same Hepato-Pancreato-Biliary team, evaluating the safety and cost-effectiveness of the method. Methods - Two hundred consecutive patients who underwent elective laparoscopic cholecystectomy were retrospectively analyzed; some of them underwent additional procedures, as liver biopsies and abdominal hernias repair. Results - From a total of 200 cases, the outpatient surgery protocol could not be carried out in 22 (11%). Twenty one (95.5%) patients remained hospitalized for 1 day and 1 (4.5%) patient remained hospitalized for 2 days. From the 178 patients who underwent ambulatory laparoscopic cholecystectomy, 3 (1.7 %) patients returned to the emergency room before the review appointment. Hospital cost was on average 35% lower for the ambulatory group. Conclusion - With appropriate selection criteria, ambulatory laparoscopic cholecystectomy is feasible, safe and effective; readmission rate is low, as well as complications related to the method. Cost savings and patient satisfaction support its adoption. Other studies are necessary to recommend this procedure as standard practice in Brazil.

Ambulatory spine surgery: a survey study

Study Design Cross-sectional study. Objective To assess the current practices of spine surgeons performing ambulatory surgery in the United States. Methods An electronic survey was distributed to members of the International Society for the Advancement of Spine Surgery. Data were initially examined in a univariate manner; variables with a p value < 0.25 were entered into a multiple logistic regression model. All statistical analyses were performed using the SAS System software Version 9.2 (SAS Institute, Inc., Cary, North Carolina, United States). Results Overall, 84.2% of respondents performed some manner of ambulatory spine surgery, and 49.1% were investors in an ambulatory surgery center. Surgeon investors in ambulatory surgery centers were more likely to perform procedures of increased complexity than noninvestors, though limited data precluded a statistical correlation. Surgeons in private practice were more likely to perform ambulatory surgery (94.3%; p = 0.0176), and nonacademic surgeons were both more likely to invest in ambulatory surgery centers (p = 0.0024) and perform surgery at least part of the time in a surgery center (p = 0.0039). Conclusions Though the numbers were too few to calculate statistical significance, there was a trend toward the performance of high-risk procedures on an ambulatory basis being undertaken by those with investment status in an ambulatory center. It is possible that this plays a role in the decision to perform these procedures in this setting versus that of a hospital, where a patient may have better access to care should a complication arise requiring emergent assessment and treatment by a physician. This decision should divest itself of financial incentives and focus entirely on patient safety.

National trends in outpatient surgical treatment of degenerative cervical spine disease

Study Design Retrospective population-based observational study. Objective To assess the growth of cervical spine surgery performed in an outpatient setting. Methods A retrospective study was conducted using the United States Healthcare Cost and Utilization Project's State Inpatient and Ambulatory Surgery Databases for California, New York, Florida, and Maryland from 2005 to 2009. Current Procedural Terminology, fourth revision (CPT-4) and International Classification of Diseases, ninth revision Clinical Modification (ICD-9-CM) codes were used to identify operations for degenerative cervical spine diseases in adults (age > 20 years). Disposition and complication rates were examined. Results There was an increase in cervical spine surgeries performed in an ambulatory setting during the study period. Anterior cervical diskectomy and fusion accounted for 68% of outpatient procedures; posterior decompression made up 21%. Younger patients predominantly underwent anterior fusion procedures, and patients in the eighth and ninth decades of life had more posterior decompressions. Charlson comorbidity index and complication rates were substantially lower for ambulatory cases when compared with inpatients. The majority (>99%) of patients were discharged home following ambulatory surgery. Conclusions Recently, the number of cervical spine surgeries has increased in general, and more of these procedures are being performed in an ambulatory setting. The majority (>99%) of patients are discharged home but the nature of analyzing administrative data limits accurate assessment of postoperative complications and thus patient safety. This increase in outpatient cervical spine surgery necessitates further discussion of its safety.

Introduction of a day-case laparoscopic cholecystectomy service in the UK: a critical analysis of factors influencing same-day discharge and contact with primary care providers

INTRODUCTION

The objective of this study was to determine the safety and acceptability of the implementation of a day-case laparoscopic cholecystectomy (LC) service in a large UK teaching hospital, and analyse factors influencing contact with primary care providers. Wide-spread introduction of day-case LC in the UK is a major target of healthcare providers. However, few centres have reported their experience. In the US, out-patient surgery for LC has been reported, though many groups have utilised 24-h observation units to facilitate discharge. Concerns remain amongst surgeons regarding the feasibility and acceptability of the introduction of day-case LC in the UK.

PATIENTS AND METHODS

Comprehensive care and operative data were prospectively collected on the first 106 consecutive day-case procedures in our hospital. Postoperative recovery was monitored by telephone questionnaire on days 2, 5 and 14, including complications, satisfaction and general practitioner consultation.

RESULTS

A total of 106 patients were admitted for day-case LC, of whom 84% were discharged on the day of surgery. Patient satisfaction rate was 94% in both the successful day-case and the admitted patients. Mean operation time was 62 min, with an average total stay on the day-care unit of 426 min. Training-grade surgeons performed 31% of operations. Both the readmission rate after surgery and rate of conversion to open surgery were 2%. Advice from primary healthcare providers was sought by 33% of patients within the first 14 postoperative days.

CONCLUSIONS

Introduction of day-case LC in the UK is feasible and acceptable to patients. The potential burden to primary care providers needs further study.

Comparison of inpatient vs. outpatient anterior cervical discectomy and fusion: a retrospective case series

Background

Spinal surgery is increasingly being done in the outpatient setting. We reviewed our experience with inpatient and outpatient single-level anterior cervical discectomy and fusion with plating (ACDF+P).

Methods

All patients undergoing single-level anterior cervical discectomy and fusion with plating between August 2005 and May 2007 by two surgeons (RPB or JAF) were retrospectively reviewed. All patients underwent anterior cervical microdiscectomy, arthrodesis using structural allograft, and titanium plating. A planned change from doing ACDF+P on an inpatient basis to doing ACDF+P on an outpatient basis was instituted at the midpoint of the study. There were no other changes in technique, patient selection, instrumentation, facility, or other factors. All procedures were done in full-service hospitals accommodating outpatient and inpatient care.

Results

64 patients underwent ACDF+P as inpatients, while 45 underwent ACDF+P as outpatients. When outpatient surgery was planned, 17 patients were treated as inpatients due to medical comorbidities (14), older age (1), and patient preference (2). At a mean follow-up of 62.4 days, 90 patients had an excellent outcome, 19 patients had a good outcome, and no patients had a fair or poor outcome. There was no significant difference in outcome between inpatients and outpatients. There were 4 complications, all occurring in inpatients: a hematoma one week post-operatively requiring drainage, a cerebrospinal fluid leak treated with lumbar drainage, syncope of unknown etiology, and moderate dysphagia.

Conclusion

In this series, outpatient ACDF+P was safe and was not associated with a significant difference in outcome compared with inpatient ACDF+P.

Pre-incision local infiltration with levobupivacaine reduces pain and analgesic consumption after laparoscopic cholecystectomy: a new device for day-case procedure

All over the World laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis; use of local long lasting anesthetics reduces post-operative pain. Levobupivacaine is one of the most effective local anesthetics. The aim of our study is to test the effectiveness of local anesthetics comparing pre- versus post-operative trocar site's infiltration. 50 patients were enrolled in our study and 25 five patients were randomized into pre-I group (pre-incisional infiltration) and 25 into post-I group (post-operative infiltration); all the operations were performed with the same technique (Anglo-Saxon with 4 accesses) by 4 expert laparoscopic surgeons; our results showed different analgesic consumption between the 2 groups of patients; in the pre-I group the mean intravenous dose of Ketorolac post-operative used was 124 mg while in the post-I group was 339 mg: this difference was statistically significant.; the mean VAS was 10.7 in the post-I group while in the pre-I group was 5.1, also the i-VAS score's difference was statistically significant: in fact in the post-I group i-VAS was 8.8 while in the post-I group 14.8. Our study demonstrated that infiltration of the trocar site with long lasting local anesthetic is extremely effective for the treatment of post-operative pain after laparoscopic cholecystectomy; pre-incisional local infiltration seems to be better in term of pain perception and intravenous post-operative analgesic consumption.

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.