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Scala A, Improta G. Lean Six Sigma Approach to Improve the Management of Patients Undergoing Laparoscopic Cholecystectomy. Healthcare (Basel) 2024; 12:292. [PMID: 38338177 PMCID: PMC10855321 DOI: 10.3390/healthcare12030292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/08/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both emergency and elective surgery. The incidence of the disease related to an increasingly elderly population coupled with the efficacy and safety of LC treatment resulted in an increase in the frequency of interventions without an increase in surgical mortality. For these reasons, managers implement strategies by which to standardize the process of patients undergoing LC. Specifically, the goal is to ensure, in accordance with the guidelines of the Italian Ministry of Health, a reduction in post-operative length of stay (LOS). In this study, a Lean Six Sigma (LSS) methodological approach was implemented to identify and subsequently investigate, through statistical analysis, the effect that corrective actions have had on the post-operative hospitalization for LC interventions performed in a University Hospital. The analysis of the process, which involved a sample of 478 patients, with an approach guided by the Define, Measure, Analyze, Improve, and Control (DMAIC) cycle, made it possible to reduce the post-operative LOS from an average of 6.67 to 4.44 days. The most significant reduction was obtained for the 60-69 age group, for whom the probability of using LC is higher than for younger people. The LSS offers a methodological rigor that has allowed us, as already known, to make significant improvements to the process, standardizing the result by limiting the variability and obtaining a total reduction of post-operative LOS of 67%.
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Affiliation(s)
- Arianna Scala
- Department of Public Health, University of Naples “Federico II”, 80138 Naples, Italy;
| | - Giovanni Improta
- Department of Public Health, University of Naples “Federico II”, 80138 Naples, Italy;
- Interdepartmental Center for Research in Healthcare Management and Innovation in Healthcare (CIRMIS), University of Naples “Federico II”, 80138 Naples, Italy
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Wu H, Liao B, Cao T, Ji T, Huang J, Luo Y, Ma K. Comparison of the safety profile, conversion rate and hospitalization duration between early and delayed laparoscopic cholecystectomy for acute cholecystitis: a systematic review and meta-analysis. Front Med (Lausanne) 2023; 10:1185482. [PMID: 38148916 PMCID: PMC10750350 DOI: 10.3389/fmed.2023.1185482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 11/13/2023] [Indexed: 12/28/2023] Open
Abstract
Background Although the past decade has witnessed unprecedented medical progress, no consensus has been reached on the optimal approach for patients with acute cholecystitis. Herein, we conducted a systematic review and meta-analysis to assess the differences in patient outcomes between Early Laparoscopic Cholecystectomy (ELC) and Delayed Laparoscopic Cholecystectomy (DLC) in the treatment of acute cholecystitis. Our protocol was registered in the PROSPERO database (registration number: CRD42023389238). Objectives We sought to investigate the differences in efficacy, safety, and potential benefits between ELC and DLC in acute cholecystitis patients by conducting a systematic review and meta-analysis. Methods The online databases PubMed, Springer, and the Cochrane Library were searched for randomized controlled trials (RCTs) and retrospective studies published between Jan 1, 1999 and Jan 1, 2022. Results 21 RCTs and 13 retrospective studies with a total of 7,601 cases were included in this research. After a fixed-effects model was applied, the pooled analysis showed that DLC was associated with a significantly high conversion rate (OR: 0.6247; 95%CI: 0.5115-0.7630; z = -4.61, p < 0.0001) and incidence of postoperative complications (OR: 0.7548; 95%CI: 0.6197-0.9192; z = -2.80, p = 0.0051). However, after applying a random-effects model, ELC was associated with significantly shorter total hospitalization duration than DLC (MD: -4.0657; 95%CI: -5.0747 to -3.0566; z = -7.90, p < 0.0001). Conclusion ELC represents a safe and feasible approach for acute cholecystitis patients since it shortens hospitalization duration and decreases the incidence of postoperative complications of laparoscopic cholecystectomy. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=389238, identifier (CRD42023389238).
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Affiliation(s)
- Hongsheng Wu
- Department of Hepatobiliary Pancreatic Surgery, Affiliated Huadu Hospital, Southern Medical University, Guangzhou, China
| | | | | | | | | | | | - Keqiang Ma
- Department of Hepatobiliary Pancreatic Surgery, Affiliated Huadu Hospital, Southern Medical University, Guangzhou, China
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Bergeron E, Doyon T, Manière T, Désilets É. Cholecystectomy following endoscopic clearance of common bile duct during the same admission. Can J Surg 2023; 66:E477-E484. [PMID: 37734850 PMCID: PMC10521812 DOI: 10.1503/cjs.008322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND The recurrence of common bile duct stones and other biliary events after endoscopic retrograde cholangiopancreatography (ERCP) is frequent. Despite recommendations for early cholecystectomy, intervention during the same admission is carried out inconsistently. METHODS We reviewed the records of patients who underwent ERCP for gallstone disease and common bile duct clearance followed by cholecystectomy between July 2012 and June 2022. Patients were divided into 2 groups: the index group underwent cholecystectomy during the same admission and the delayed group was discharged and had their cholecystectomy postponed. Data on demographics and prognosis factors were collected and analyzed. RESULTS The study population was composed of 268 patients, with 71 (26.6%) having undergone cholecystectomy during the same admission after common bile duct clearance with ERCP. A greater proportion of patients aged 80 years and older were in the index group than in the delayed group. The American Society of Anesthesiologists score was significantly higher in the index group. There was no significant difference between groups regarding surgical complications, open cholecystectomy and death. The operative time was significantly longer in the delayed group. Among patients with delayed cholecystectomy, 18.3% had at least 1 recurrence of common bile duct stones (CBDS) and 38.6% had recurrence of any gallstone-related events before cholecystectomy. None of these events occurred in the the index group. There was no difference in the recurrence of CBDS and other biliary events after initial diagnosis associated with stone disease. CONCLUSION Cholecystectomy during the same admission after common bile duct clearance is safe, even in older adults with comorbidities. Compared with delayed cholecystectomy, it was not associated with adverse outcomes and may have prevented recurrence of biliary events.
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Affiliation(s)
- Eric Bergeron
- Department of Surgery, Hôpital Charles LeMoyne, Greenfield Park, Que. (Bergeron); Department of Gastroenterology, Hôpital Charles LeMoyne, Greenfield Park, Que. (Doyon, Maniere, Desilets)
| | - Théo Doyon
- Department of Surgery, Hôpital Charles LeMoyne, Greenfield Park, Que. (Bergeron); Department of Gastroenterology, Hôpital Charles LeMoyne, Greenfield Park, Que. (Doyon, Maniere, Desilets)
| | - Thibaut Manière
- Department of Surgery, Hôpital Charles LeMoyne, Greenfield Park, Que. (Bergeron); Department of Gastroenterology, Hôpital Charles LeMoyne, Greenfield Park, Que. (Doyon, Maniere, Desilets)
| | - Étienne Désilets
- Department of Surgery, Hôpital Charles LeMoyne, Greenfield Park, Que. (Bergeron); Department of Gastroenterology, Hôpital Charles LeMoyne, Greenfield Park, Que. (Doyon, Maniere, Desilets)
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Kelly-Schuette KA, Chapman AJ, Messer LE, Kuk CC, Lypka MM, Krech LA, Pounders SJ, Iskander GA, Gibson CJ. Hotter Than It Looks: A Retrospective Review of Patients With Cholecystitis and With Negative Imaging. J Surg Res 2022; 273:93-99. [PMID: 35033822 DOI: 10.1016/j.jss.2021.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 10/27/2021] [Accepted: 12/04/2021] [Indexed: 12/07/2022]
Abstract
INTRODUCTION Ultrasound is the gold standard for workup of cholecystitis in the emergency department, and findings heavily influence clinical decision-making. Patients with negative imaging for acute cholecystitis may be inappropriately sent home. The purpose of our study was to review the pathology and outcomes of patients presenting with biliary pain and negative ultrasound findings of acute cholecystitis. MATERIALS AND METHODS Emergency department patients who underwent laparoscopic cholecystectomy between January 2015 and February 2019 were reviewed retrospectively. Only patients with negative or equivocal imaging were included. The primary outcome was the incidence of cholecystitis on final pathology. RESULTS Two hundred fifty-seven patients underwent laparoscopic cholecystectomy. Pathology demonstrated cholecystitis in 84% of patients. Only 15% of patients had cholelithiasis without cholecystitis on pathology. The incidence of cholecystitis was similar in negative and equivocal imaging groups (84% versus 83%; P = 0.960). The median time from admission to the operating room was 12.1 h (interquartile range 7.1-18.3 h), and hospital length of stay was 1.2 d (interquartile range 0.8-1.7 d). CONCLUSIONS This study found that patients with negative or equivocal imaging had cholecystitis on pathology. On review of patient outcomes, those patients who underwent surgical intervention had a low rate of complications and short hospital stay.
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Affiliation(s)
- Kathrine A Kelly-Schuette
- Spectrum Health, Michigan State University College of Human Medicine, General Surgery Residency, Grand Rapids, Michigan.
| | - Alistair J Chapman
- Spectrum Health Acute Care Surgery, Grand Rapids, Michigan; Spectrum Health Office of Research, Grand Rapids, Michigan
| | - Lauren E Messer
- Spectrum Health Trauma Research Institute, Grand Rapids, Michigan
| | - ChiuYing C Kuk
- Spectrum Health Trauma Research Institute, Grand Rapids, Michigan
| | - Matthew M Lypka
- Michigan State University College of Human Medicine, Grand Rapids, Michigan
| | - Laura A Krech
- Spectrum Health Acute Care Surgery, Grand Rapids, Michigan; Spectrum Health Office of Research, Grand Rapids, Michigan
| | - Steffen J Pounders
- Spectrum Health Office of Research, Grand Rapids, Michigan; Michigan State University College of Human Medicine, Grand Rapids, Michigan
| | - Gaby A Iskander
- Spectrum Health Acute Care Surgery, Grand Rapids, Michigan; Spectrum Health Office of Research, Grand Rapids, Michigan
| | - Charles J Gibson
- Spectrum Health Acute Care Surgery, Grand Rapids, Michigan; Spectrum Health Office of Research, Grand Rapids, Michigan; Spectrum Health Trauma Research Institute, Grand Rapids, Michigan
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Abstract
Cholecystectomy is one of the most common general surgery procedures performed worldwide. Complications include bile duct injury, strictures, bleeding, infection/abscess, retained gallstones, hernias, and postcholecystectomy syndrome. Obtaining a critical view of safety and following the other tenets of the Safe Cholecystectomy Task Force will aid in the prevention of bile duct injury and other morbidity associated with cholecystectomy.
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Affiliation(s)
- Xiaoxi Chelsea Feng
- Department of Surgery, Cedars Sinai Medical Center, 8635 W Third Street, West Medical Office Tower, Suite 795, Los Angeles, CA 90048, USA
| | - Edward Phillips
- Department of Surgery, Cedars Sinai Medical Center, 8635 W Third Street, West Medical Office Tower, Suite 795, Los Angeles, CA 90048, USA
| | - Daniel Shouhed
- Department of Surgery, Cedars Sinai Medical Center, 459 North Croft Avenue, Los Angeles, CA 90048, USA.
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Calkins B, Chininis J, Williams GA, Sanford DE, Hammill CW. Development of a novel intraoperative difficulty score for minimally invasive cholecystectomy. HPB (Oxford) 2021; 23:1025-1029. [PMID: 33218950 DOI: 10.1016/j.hpb.2020.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 08/23/2020] [Accepted: 10/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The rate of biliary injuries from minimally invasive cholecystectomy has remained high for over two decades. To improve outcomes there are multiple bail-out methods described, including aborting the procedure, converting to open, or performing a sub-total cholecystectomy. However, the intraoperative difficulty threshold for when a bail-out method should be implemented is poorly understood. METHODS From 1/2014 to 2/2019 cholecystectomy videos were collected, de-identified, edited to include the 2-3 minutes when the gallbladder was first visualized, and accelerated. They were then rated on a 5-point difficulty scale. Inter-coder reliability was evaluated using Krippendorff's alpha and regression models were used to evaluate the scores ability to predict the need for a bail-out technique. RESULTS 62 videos were analyzed with a median length after editing of 37.5 (29.0-43.3) seconds. A median time of 46.2 (38.3-53.4) seconds was required for grading. The bail-out rate was 42.9%. The inter-coder reliability between 2 surgeons and 8 non-clinical reviewers was 0.675 with an average difficulty score of 3.0 (SD = 1.01). Regression models showed that the scale was able to significantly predict conversion (β=0.56,p<.01). CONCLUSION This novel difficulty score was able to predict conversion to a bail-out technique early in the course of minimally invasive cholecystectomy.
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Affiliation(s)
- Brittany Calkins
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Jeff Chininis
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Gregory A Williams
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Dominic E Sanford
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Chet W Hammill
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA.
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Jamdar S, Chandrabalan VV, Obeidallah R, Stathakis P, Siriwardena AK, Sheen AJ. The Impact of a Dedicated "Hot List" on the In-Patient Management of Patients With Acute Gallstone-Related Disease. Front Surg 2021; 8:643077. [PMID: 34055866 PMCID: PMC8158421 DOI: 10.3389/fsurg.2021.643077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/14/2021] [Indexed: 01/25/2023] Open
Abstract
Background: Index admission laparoscopic cholecystectomy is the standard of care for patients admitted to hospital with symptomatic acute cholecystitis. The same standard applies to patients suffering with mild acute biliary pancreatitis. Operating theatre capacity can be a significant constraint to same admission surgery. This study assesses the impact of dedicated theatre capacity provided by a specialist surgical team on rates of index admission cholecystectomy. Methods: This clinical cohort study compares the management of patients with symptomatic gallstone disease admitted to a tertiary care university teaching hospital over two equal but chronologically separate time periods. The periods were before and after service reconfiguration including a specialist HPB service with dedicated operating theatre time allocation. Results: There was a significant difference in the number of admissions over the two time periods with a greater proportion of patients having index admission surgery in the second time period with correspondingly fewer having more than one admission during this latter time period. In the second time period 43% of patients underwent index admission cholecystectomy compared to 23% in the first (P < 0.001). The duration of surgery was shorter for patients undergoing surgery during the second time period [135 (102–178) min in the first period and in the second period 106 (89–145) min] (P = 0.02). Discussion: This paper shows that the concentration of theatre resources and surgical expertise into regular theatre access for patients undergoing urgent laparoscopic cholecystectomy is an effective and safe model for dealing with acute biliary disease.
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Affiliation(s)
- Saurabh Jamdar
- Regional Hepato-Pancreato-Biliary Service, Manchester Royal Infirmary, Manchester, United Kingdom.,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Vishnu V Chandrabalan
- Regional Hepato-Pancreato-Biliary Service, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Rami Obeidallah
- Regional Hepato-Pancreato-Biliary Service, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Panagiotis Stathakis
- Regional Hepato-Pancreato-Biliary Service, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Ajith K Siriwardena
- Regional Hepato-Pancreato-Biliary Service, Manchester Royal Infirmary, Manchester, United Kingdom.,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Aali J Sheen
- Regional Hepato-Pancreato-Biliary Service, Manchester Royal Infirmary, Manchester, United Kingdom.,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.,Centre of Biosciences, Manchester Metropolitan University, Manchester, United Kingdom
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Warchałowski Ł, Łuszczki E, Bartosiewicz A, Dereń K, Warchałowska M, Oleksy Ł, Stolarczyk A, Podlasek R. The Analysis of Risk Factors in the Conversion from Laparoscopic to Open Cholecystectomy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17207571. [PMID: 33080991 PMCID: PMC7588875 DOI: 10.3390/ijerph17207571] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/01/2020] [Accepted: 10/15/2020] [Indexed: 12/24/2022]
Abstract
Laparoscopic cholecystectomy is a standard treatment for cholelithiasis. In situations where laparoscopic cholecystectomy is dangerous, a surgeon may be forced to change from laparoscopy to an open procedure. Data from the literature shows that 2 to 15% of laparoscopic cholecystectomies are converted to open surgery during surgery for various reasons. The aim of this study was to identify the risk factors for the conversion of laparoscopic cholecystectomy to open surgery. A retrospective analysis of medical records and operation protocols was performed. The study group consisted of 263 patients who were converted into open surgery during laparoscopic surgery, and 264 randomly selected patients in the control group. Conversion risk factors were assessed using logistic regression analysis that modeled the probability of a certain event as a function of independent factors. Statistically significant factors in the regression model with all explanatory variables were age, emergency treatment, acute cholecystitis, peritoneal adhesions, chronic cholecystitis, and inflammatory infiltration. The use of predictive risk assessments or nomograms can be the most helpful tool for risk stratification in a clinical scenario. With such predictive tools, clinicians can optimize care based on the known risk factors for the conversion, and patients can be better informed about the risks of their surgery.
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Affiliation(s)
- Łukasz Warchałowski
- Department of General Surgery, Clinical Regional Hospital No. 2 in Rzeszów, 35-301 Rzeszów, Poland;
- Correspondence: ; Tel.: +48-17-866-47-01
| | - Edyta Łuszczki
- Institute of Health Sciences, Medical College of Rzeszów University, 35-959 Rzeszów, Poland; (E.Ł.); (A.B.); (K.D.)
| | - Anna Bartosiewicz
- Institute of Health Sciences, Medical College of Rzeszów University, 35-959 Rzeszów, Poland; (E.Ł.); (A.B.); (K.D.)
| | - Katarzyna Dereń
- Institute of Health Sciences, Medical College of Rzeszów University, 35-959 Rzeszów, Poland; (E.Ł.); (A.B.); (K.D.)
| | | | - Łukasz Oleksy
- Orthopaedic and Rehabilitation Department, Medical University of Warsaw, 02-091 Warszawa, Poland; (Ł.O.); (A.S.)
- Oleksy Medical & Sports Sciences, 37-100 Łańcut, Poland
| | - Artur Stolarczyk
- Orthopaedic and Rehabilitation Department, Medical University of Warsaw, 02-091 Warszawa, Poland; (Ł.O.); (A.S.)
| | - Robert Podlasek
- Department of General Surgery, Clinical Regional Hospital No. 2 in Rzeszów, 35-301 Rzeszów, Poland;
- Department of Surgery with the Trauma and Orthopedic Division, District Hospital in Strzyżów, 38-100 Strzyżów, Poland
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