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

Utility of a Novel Scale to Assess Readiness for Discharge After Bariatric Surgery

BACKGROUND

The safe release of a patient from hospital care after bariatric surgery depends upon the achievement of satisfactory health status. Here, we describe a new objective scale (the Readiness for Discharge, RFD Scale) to measure the patient's suitability for hospital discharge after bariatric surgery.

METHODS

We conducted a retrospective, observational analysis of data collected in a randomized clinical trial of an enhanced recovery after surgery protocol for laparoscopic sleeve gastrectomy from 3/15/2018 to 1/12/2019. Nursing staff assessed 122 patients every 4-8 h after surgery using a checklist to document 5 components: ambulation, vital signs, pain, nausea, and oral intake of clear fluid. Satisfaction of each component was scored as "1" (satisfactory) or "0" (not satisfactory). Scores were summed and analyzed for patterns. RFD = 5 marked the patient as ready for discharge.

RESULTS

Sufficient intake of clear liquid was the last RFD component satisfied in 87% of patients. Two overall response patterns emerged: "Steady Progressors" (n = 51) whose RFD score rose steadily from 0 to 5 without reversion to a lower score; and "Oscillators" (n = 71) who had at least one temporary decrease in RFD score on the way to attaining 5, or showed a simultaneous oscillation of components without change in RFD.

CONCLUSIONS

The RFD checklist allows objective scoring of medical readiness for discharge after LSG and has the potential to improve clinical communication.

Early identification of the critical view of safety in laparoscopic cholecystectomy using indocyanine green fluorescence cholangiography: A randomised controlled study

BACKGROUND

Achieving critical view of safety (CVS) is vital during laparoscopic cholecystectomy (LC). There is no known study determining use of indocyanine green fluorescence cholangiography (ICGFC) in early identification of CVS during LC. This study aims to compare use of ICGFC in LC against conventional LC in early identification of CVS.

METHODOLOGY

Patients undergoing LC in a single centre were randomized into ICGFC-LC and conventional LC. Surgery was performed by a single surgeon and the time taken to achieve CVS from the time of gallbladder fundus retraction was measured. Difficulty level for each surgery was rated and analysed using a modified scoring system (Level 1- Easy to Level 4-Very difficult).

RESULTS

63 patients were recruited where mean time (min) to achieve CVS was 22.3 ± 12.9 in ICGFC-LC (n = 30) and 22.8 ± 14.3 in conventional LC (p = 0.867). The time taken to achieve CVS was shorter in ICGFC-LC group across all difficulty levels, although not significant (p > 0.05). No major complication was observed in the study.

CONCLUSIONS

This study had shown ICGFC-LC reduces time to CVS across all difficulty levels but not statistically significant. ICGFC-LC maybe useful in difficult LC and in surgical training.

TRIAL REGISTRATION

Clinical Trials NCT04228835.

STUDY GRANT

UMMI Surgical - Karl Storz Distributor (Malaysia).

Patient reported outcomes in elective laparoscopic cholecystectomy

Backgrounds/Aims

Traditional outcome measures (e.g., length of hospital stay, morbidity, and mortality) are used to determine the quality of care, but these may not be most important to patients. It is unclear which outcomes matter to patients undergoing elective laparoscopic cholecystectomy (ELC). We aim to identify patient-reported outcome measures (PROM) which patients undergoing ELC valued most.

Methods

A 45-item questionnaire with Four-point Likert-type questions developed from prior literature review, prospectively administered to patients treated with ELC at a tertiary institution in Singapore.

Results

Seventy-five patients participated. Most essential factors were technical skill and experience level of a surgeon, long-term quality of life (QoL), patient involvement in decision-making, communication skill of a surgeon, cleanliness of the ward environment, and standards of nursing care. Least important factors were hospitalization leave duration, length of hospital stay, a family's opinion of the hospital, and scar cosmesis. Employed patients were more likely to find hospitalization leave duration (p<0.001) and procedure duration (p=0.042) important. Younger patients (p=0.048) and female gender (p=0.003) were more likely to perceive scar cosmesis as important.

Conclusions

Patients undergoing ELC value long-term QoL, surgeon technical skill and experience level, patient involvement in decision-making, surgeon communication skill, cleanliness of the ward environment, and nursing care standards. Day-case surgery, medical leave, family opinion of hospital, and scar cosmesis were least important. Understanding what patients value will help guide patient-centric healthcare delivery.

'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.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

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