Can we consider day-case laparoscopic cholecystectomy for acute calculous cholecystitis? Identification of potentially eligible patients

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.

Management of Uncomplicated Acute Appendicitis as Day Case Surgery: Can Outcomes of a Prospective Study Be Reproduced in Real Life?

BACKGROUND

The feasibility of day case surgery (DCS) appendectomy for uncomplicated acute appendicitis (UCAA) was evaluated by the prospective AppendAmbu (Feasibility of Outpatient Appendectomy for Acute Appendicitis) study (ClinicalTrials.gov ID NCT01839435). The aim of this study was to evaluate the real-life feasibility of DCS for UCAA.

STUDY DESIGN

This single-center, retrospective, non-interventional study was conducted after the AppendAmbu study and included UCAA only. The primary end point was DCS success rate (ie length of stay <12 hours) in the intention-to-treat population (all patients with UCAA) and in the per-protocol population (population with UCAA and no preoperative and intraoperative exclusion criteria). The secondary end points were to determine the DCS quality criteria to evaluate and compare the morbidity and mortality of DCS and conventional hospitalization for UCAA (Clavien, Comprehensive Complication Index) and to externally validate the St Antoine criteria for the selection of patients for DCS.

RESULTS

From January 2016 to September 2017, two hundred and ninety-six patients underwent operations for acute appendicitis. The proportion of patients with successful DCS management was 27% in the intention-to-treat population and 95% in the per-protocol population. The unplanned consultation rate was 15%, the unplanned hospitalization rate was 4%, and the unplanned reoperation rate was 0%. The postoperative morbidity of patients managed by DCS was not different from that of patients managed in conventional hospitalization. The DCS success rate was 0%, with a St Antoine score of 0, and 80% of patients had a St Antoine score of 5 (p < 0.0001).

CONCLUSIONS

Day case surgery constitutes progress in surgery as a result of enhanced recovery programs. It avoids unnecessary prolonged hospitalization.

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.

[Surgical treatment of acute calculous cholecystitis followed by one-day discharge of patients]

AIM

To develop rational tactics of surgical treatment of patients with acute calculous cholecystitis with their subsequent discharge within 1 day since admission.

MATERIAL AND METHODS

There were 283 patients with acute cholecystitis and 58 patients with chronic cholecystitis. All patients underwent laparoscopic cholecystectomy. Patients with acute cholecystitis were divided into 2 groups: main group - 136 patients were discharged within 1 day since admission, control group - 147 patients who were discharged later. Age, gender, duration of attack and ASA score were similar in both groups.

RESULTS

Incidence of intraoperative complications was significantly higher in the control group compared with the main group (6.1% vs. 0.7%). There were no postoperative complications in the main group; postoperative morbidity in the control group was 6.1%. Criteria preventing discharge within 1 day since admission were developed. Uneventful early postoperative period after laparoscopic cholecystectomy allows us to discharge 48% of patients with uncomplicated acute calculous cholecystitis within 1 day since hospitalization. The developed algorithm of treatment is followed by reduced hospital-stay by 4 days.

CONCLUSION

The developed algorithm of treatment of patients with acute calculous cholecystitis can reduce hospital-stay up to 1 day. Favorable early postoperative period and follow-up of patients after discharge are essential for safe treatment.

Laparoscopic cholecystectomy combined with Xiaoyanlidan tablets for treatment of acute cholecystitis patients: Curative effect and impact on prognosis and serological indicators

AIM

To observe the curative effect of laparoscopic cholecystectomy combined with Xiaoyanlidan tablets in the treatment of acute cholecystitis as well as its impact on prognosis and serological indicators.

METHODS

One hundred cases of acute cholecystitis treated at Jiaxing Hospital of Traditional Chinese Medicine from January 2017 to December 2017 were randomly divided into an observation group and a control group, with 50 cases in each group. Both groups underwent laparoscopic cholecystectomy, and the observation group was additionally treated with Xiaoyanlidan tablets. The clinical efficacy, incidence of complications, serological indicators [C reactive protein (CRP), procalcitonin (PCT), cancer antigen (CA) 19-9, thyroid-stimulating hormone (TSH), and insulin (Ins)], recurrence rate of choledocholithiasis, and indexes of liver function were observed and compared in the two groups.

RESULTS

The total effective rate of the observation group was 90%,which was significantly higher than that of the control group (76%, P < 0.05).The incidence of postoperative complications in the observation group was 2%, which was significantly lower than that in the control group (16%, P < 0.05). CRP, PCT, CA19-9, TSH, and Ins in the observation group were significantly lower than those in the control group 1 wk after operation (P < 0.05). The incidence of postoperative choledocholithiasis in the observation group was 10%, which was significantly lower than that in the control group (26%, P < 0.05). Glutamic-pyruvic transaminase and aspartate aminotransferase levels in the observation group were significantly lower than those in the control group (P < 0.05).

CONCLUSION

Laparoscopic cholecystectomy combined with Xiaoyan-lidan tablets can effectively improve the inflammatory response, reduce the incidence of postoperative complications, and improve the total effective rate in the treatment of acute cholecystitis.

The Value of Abdominal Drainage After Laparoscopic Cholecystectomy for Mild or Moderate Acute Calculous Cholecystitis: A Post Hoc Analysis of a Randomized Clinical Trial

BACKGROUND

Although the preoperative management of mild and moderate (Grade I-II) acute calculous cholecystitis (ACC) has been standardized, there is no consensus on the value of abdominal drainage after early cholecystectomy.

METHODS

In a post hoc analysis of a randomized controlled trial (NCT01015417) focused on the value of postoperative antibiotic therapy in patients with ACC, we determined the value of abdominal drainage in patients having undergone laparoscopic cholecystectomy for Grades I-II ACC. All postoperative complications were analyzed after using a propensity score. A post hoc test was used to assess the statistical robustness of our results.

RESULTS

Of the 414 enrolled patients, 178 did not have abdominal drainage (forming the no-drainage group) and 236 had drainage (the drainage group). After matching on PS, the deep incisional site infection was 1.1 versus 0.8 %, p = 0.78. This result is similar for the superficial incisional site infections; the distant infections; the overall morbidity, and the readmission rate. Only the hospital length of stay was significantly longer in the drainage group (3.3 vs. 5.1 days, p = 0.003). Neither abdominal drainage nor the absence of postoperative antibiotic therapy was found to be a risk factor for deep incisional site infections.

CONCLUSIONS

The use of abdominal drainage depends on the surgeon's personal preferences but is often used in high-risk populations. However, abdominal drainage does not appear to be of any benefit (in terms of postoperative outcomes) and may even compromise recovery in patients having undergone early laparoscopic cholecystectomy for mild or moderate ACC.

Identifying Patients Eligible for a Short Hospital Stay After Stoma Closure

INTRODUCTION

The implementation of enhanced recovery programmes after elective colorectal surgery has dramatically reduced the length of stay. The objective of this study was to assess the selection of good candidates for short post-operative stay (GCSS) in the context of stoma closure.

METHODS

Between January 2011 and December 2014, 222 patients were included in the present retrospective, single-center study. The primary endpoint was the proportion of GCSS. We also identified factors associated with GCSS status and built a predictive score.

RESULTS

The study population was predominantly male (n = 122, 55%). 60% of the patients had undergone ileostomy and 85% had undergone hand-sewn anastomosis. The postoperative ileus rate was 5% and the readmission rate was 3.5%. 41% (n = 92) of the study population were considered to be GCSS. In a multivariate analysis, age under 50 (odds ratio (OR) [95% confidence interval (CI)] = 2.8 [1.2-5.6], p = 0.008), the absence of vascular comorbidities (OR [95%CI] = 3.2 [1.3-12.3]; p = 0.006) and stapled anastomosis (OR: 4.2, 95%CI: 1.1-17.3, p = 0.03) were associated with GCSS status. Predictive scores of 0, 1, 2, and 3 were associated with GCSS rates of 20%, 18%, 44%, and 62%, respectively (p < 0.001).

CONCLUSION

In the context of stoma closure, 41% of patients were GCSS.

Re-admission after gastro-intestinal surgery

Re-admission is a new concept in France, born with the advent of day-case surgery, and defined as any re-admission occurring within 30 days after surgery. The re-admission rate has increasingly come to be considered a criterion of the quality of medical care, by both the medical profession and by insurance companies. This report outlines the generalities and definitions related to re-admission after gastro-intestinal surgery, describes the current situation, rationalizes the value of re-admission rates as a measure of quality of care, details the risk factors for re-admission according to the type of intervention, exposes the possible means of prevention and what to do when a patient comes to the emergency room within 30 days after an operation.

Short-term outcomes of laparoscopic transcystic common bile duct exploration with discharge less than 24 hours

BACKGROUND

Reducing the length of stay and discharge time for patients could benefit multiple hospital units by saving money, reducing waiting time, and providing the opportunity for more patients to be treated. However, no experience of laparoscopic transcystic common bile duct exploration (LTCBDE) with discharge less than 24 hours has been reported until now. The objective of this study was to assess the feasibility and safety of LTCBDE with discharge less than 24 hours.

PATIENTS AND METHODS

A retrospective review showed that 34 of 111 patients scheduled in our institution were discharged less than 24 hours after LTCBDE between June 1 and December 31, 2011. A multimodal approach including appropriate preoperative assessment, education and counseling, early postoperative oral intake, and early mobilization was carried out. Outcomes were analyzed for patient demographics, postoperative stay, operation time, intraoperative bleeding, and reasons for failed LTCBDE.

RESULTS

Of 111 patients admitted for LTCBDE, 34 patients were discharged within 24 hours postoperatively. This study population comprised 11 males and 23 females with a mean age of 54.6±14.7 years (range, 28-79 years). The mean postoperative stay was 20.21±0.39 hours. There were no postoperative complications or deaths during the hospital stay or at the follow-up 12 months postoperatively in these 34 patients.

CONCLUSIONS

LTCBDE with discharge less than 24 hours is feasible and safe in selected patients with common bile duct stones of no more than three in number and no more than 6 mm in size. The benefit of the multimodal approach and LTCBDE may be synergistic, allowing a quick recovery of gastrointestinal function.