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.

Digital Follow-Up After Elective Laparoscopic Cholecystectomy: A Feasibility Study

BACKGROUND

Although recommendations exist for patients to be offered a post-operative helpline or telephone follow-up appointment at discharge after cholecystectomy, implementation of these is resource-intensive. Whilst the benefits of telephone follow-up are well documented, the use of digital modalities is less so. We aimed to identify if digital follow-up (DFU) was equivalent to routine care with telephone follow-up (TFU), for patients undergoing elective laparoscopic cholecystectomy.

METHODS

All patients listed for elective laparoscopic cholecystectomy between August 2016 and March 2018 were offered routine post-operative care (TFU or no follow-up) or DFU at a tertiary referral centre in Nottingham.

RESULTS

Of 597 patients undergoing laparoscopic cholecystectomy, 199 (33.3%) opted for TFU, and 98 (16.4%) for DFU. DFU was completed for 85 (86.7%) participants and TFU for 125 (62.8%), p &lt; 0.0001. Over 5 times as many patients who chose TFU missed their appointment compared to DFU (5.6% vs. 30.9%, p &lt; 0.001). At 30-days post-operatively, patients undergoing TFU had significantly more post-operative wound infections identified then those undergoing DFU (17.6% vs 5.9%, p = 0.01). However, this did not impact the incidence of 30-day readmissions between groups (7.2% TFU vs. 7.1% DFU). No complications were missed by either the DFU or TFU modalities. DFU was completed significantly earlier than TFU (median 6 days vs. 13.5 days, p = 0.001) with high patient acceptability, identifying complications and alerting clinicians to those patients requiring an early review.

CONCLUSION

This feasibility study has demonstrated that digital follow-up is an acceptable alternative to telephone follow-up after elective laparoscopic cholecystectomy.

Evaluation of Textbook Outcome as a Composite Quality Measure of Elective Laparoscopic Cholecystectomy

IMPORTANCE

A textbook outcome (TO) is a composite quality measure that incorporates multiple perioperative events to reflect the most desirable outcome. The use of TO increases the event rate, captures more outcomes to reflect patient experience, and can be used as a benchmark for quality improvement.

OBJECTIVES

To introduce the concept of TO to elective laparoscopic cholecystectomy (LC), propose the TO criteria, and identify characteristics associated with TO failure.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was performed at 3 surgical units in a single health board in the United Kingdom. Participants included all patients undergoing elective LC between January 1, 2015, and January 1, 2020. Data were analyzed from January 1, 2015, to January 1, 2020.

MAIN OUTCOMES AND MEASURES

The TO criteria were defined based on review of existing TO metrics in the literature for other surgical procedures. A TO was defined as an unremarkable elective LC without conversion to open cholecystectomy, subtotal cholecystectomy, intraoperative complication, postoperative complications (Clavien-Dindo classification ≥2), postoperative imaging, postoperative intervention, prolonged length of stay (>2 days), readmission within 100 days, or mortality. The rate of TOs was reported. Reasons for TO failure were reported, and preoperative characteristics were compared between TO and TO failure groups using both univariate analysis and multivariable logistic regressions.

RESULTS

A total of 2166 patients underwent elective LC (median age, 54 [range, 13-92] years; 1579 [72.9%] female). One thousand eight hundred fifty-one patients (85.5%) achieved a TO with an unremarkable perioperative course. Reasons for TO failure (315 patients [14.5%]) included conversion to open procedure (25 [7.9%]), subtotal cholecystectomy (59 [18.7%]), intraoperative complications (40 [12.7%]), postoperative complications (Clavien-Dindo classification ≥2; 92 [29.2%]), postoperative imaging (182 [57.8%]), postoperative intervention (57 [18.1%]), prolonged length of stay (>2 days; 142 [45.1%]), readmission (130 [41.3%]), and mortality (1 [0.3%]). Variables associated with TO failure included increasing American Society of Anesthesiologists score (odds ratio [OR], 2.55 [95 CI, 1.69-3.85]; P < .001), increasing number of prior biliary-related admissions (OR, 2.68 [95% CI, 1.36-5.27]; P = .004), acute cholecystitis (OR, 1.42 [95% CI, 1.08-1.85]; P = .01), preoperative endoscopic retrograde cholangiopancreatography (OR, 2.07 [95% CI, 1.46-2.92]; P < .001), and preoperative cholecystostomy (OR, 3.22 [95% CI, 1.54-6.76]; P = .002).

CONCLUSIONS AND RELEVANCE

These findings suggest that applying the concept of TO to elective LC provides a benchmark to identify suboptimal patterns of care and enables institutions to identify strategies for quality improvement.

Worldwide incidence of surgical site infections in general surgical patients: A systematic review and meta-analysis of 488,594 patients

BACKGROUND

Establishing worldwide incidence of general surgical site infections (SSI) is imperative to understand the extent of the condition to assist decision-makers to improve the planning and delivery of surgical care. This systematic review and meta-analysis aimed to estimate the worldwide incidence of SSI and identify associated factors in adult general surgical patients.

MATERIALS AND METHODS

A systematic review was undertaken using MEDLINE (Ovid), CINAHL (EBSCO), EMBASE (Elsevier) and the Cochrane Library to identify cross-sectional, cohort and observational studies reporting SSI incidence or prevalence. Studies of less than 50 participants were excluded. Data extraction and quality appraisal were undertaken independently by two review authors. The primary outcome was cumulative incidence of SSI occurring up to 30 days postoperative. The secondary outcome was the severity/depth of SSI. The I² statistic was used to explore heterogeneity. Random effects models were used in the presence of substantial heterogeneity. Subgroup, meta-regression sensitivity analyses were used to explore the sources of heterogeneity. Publication bias was assessed using Hunter's plots and Egger's regression test.

RESULTS

Of 2091 publications retrieved, 62 studies were included. Of these, 57 were included in the meta-analysis across six anatomical locations with 488,594 patients. The pooled 30-day cumulative incidence of SSI was 11% (95% CI 10%-13%). No prevalence data were identified. SSI rates varied across anatomical location, surgical approach, and priority (i.e., planned, emergency). Multivariable meta-regression showed SSI is significantly associated with duration of surgery (estimate 1.01, 95% CI 1.00-1.02, P = .014).

CONCLUSIONS

and Relevance: 11 out of 100 general surgical patients are likely to develop an infection 30 days after surgery. Given the imperative to reduce the burden of harm caused by SSI, high-quality studies are warranted to better understand the patient and related risk factors associated with SSI.

The dilemma of the duplicated cystic duct: a case report

We present a rare case of a duplicated cystic duct encountered during an elective laparoscopic cholecystectomy in a patient with biliary colic. Prompt recognition of an intraoperative bile leak followed by thorough examination and recognition of the source allowed for timely and appropriate management of the affected patient with a satisfactory post-operative outcome. Our case is unique by the lack of availability of intraoperative cholangiogram at the time of surgery, which posed a significant diagnostic and therapeutic challenge, and by how aberrant anatomy was confirmed intraoperatively by reviewing prior cardiac magnetic resonance imaging. Unremarkable preoperative imaging does not rule out the presence of abnormal anatomy. Early involvement of a specialist hepatobiliary surgeon is essential in an unexplained bile leak, with a low threshold in converting to an open procedure if there is difficulty in clearly deciphering anatomy.

Postoperative Symptom Distress of Laparoscopic Cholecystectomy Ambulatory Surgery Patients

PURPOSE

The purposes of this study were to (1) identify symptoms that cause postoperative distress in ambulatory surgery patients; (2) identify symptom management techniques that effectively reduce distress of laparoscopic cholecystectomy (LC) postoperative symptoms at home after ambulatory surgery; and (3) identify facilitators and barriers to self-management of postoperative symptoms.

DESIGN

A qualitative descriptive study.

METHODS

Two focus groups of ambulatory surgery patients who had experienced a laparoscopic cholecystectomy procedure and their caregivers were queried to elicit understanding of postoperative symptoms and symptom management techniques.

FINDINGS

Themes identified included distressing symptoms and consequences of surgery, symptom management, and self-management facilitators and barriers. Pain was a major symptom after surgery and impacted mobility and sleep. Participants in our study wanted realistic information about symptoms and more specific information on symptom management. Caregivers were important to the success of symptom management but experienced their own stress.

CONCLUSIONS

Perianesthesia nurses should focus not only on the immediate recovery, but also prepare patients and their caregivers for the more prolonged issues of recovery at home.

The Influence of Clinical and Patient-Reported Outcomes on Post-surgery Satisfaction in Cholecystectomy Patients

BACKGROUND

Patient-reported outcomes (PROMs) and post-operative satisfaction have become a growing focus of surgical outcome evaluation and are considered key components of the movement towards patient-centred care. The aim was to compare the association of traditional clinical outcome measures and PROMs with post-surgery satisfaction in cholecystectomy patients.

METHODS

Patients who had undergone elective or emergency cholecystectomy for gallstone disease were sent validated PROM questionnaires, and telephone follow-up was performed in all cases. Categorical data were compared with the Chi-square and Fisher's exact tests. Satisfaction was investigated using a "top-box" approach, and multivariable logistic regression was performed for factors significantly (p < 0.05) associated with satisfaction in univariable analyses.

RESULTS

A total of 234 patients underwent cholecystectomy between 1 March 2014 and 1 May 2014, and 147 patients (63%) completed the questionnaire. 104/147 (71%) reported being "very satisfied" with their surgical outcome. In univariable analyses, satisfaction showed significant association with an absence of hospital-recorded 30-day complications (OR = 4.11, 95% CI 1.29-13.84), but not re-attendance, readmission, or length of stay. In a multiple regression analysis, no traditional clinical outcome measures were associated with satisfaction. By contrast, self-perceived health (OR = 4.04, 95% CI 1.44-11.86), the absence of patient-reported wound pain (OR = 6.11, 95% CI 1.83-21.74), and a return to normal leisure activities (OR = 11.14, 95% CI 2.61-55.26) were associated with satisfaction.

CONCLUSION

PROMs are the major determinants of patient satisfaction following cholecystectomy. When assessing outcomes following cholecystectomy, the measurement of clinical outcomes alone is inadequate and should be supplemented by the use of PROMs.

Evolution of Various Components of Pain After Laparoscopic Cholecystectomy: Importance of Its Prognostication for Effective Pain Control Using a Local Anesthetic and for Making a Valid Practical "Discharge Criteria" Model Predicting Early Discharge of Patients

OBJECTIVES

Pain continues to be the most important limiting factor affecting the early discharge of patients after laparoscopic cholecystectomy (LC). Our aim was to conduct a randomized case controlled study to predict the evolution of various components of postoperative pain by using ropivacaine 0.2% at intraperitoneal and intraincisional locations; and to further use this information to make a model predicting early discharge of patients.

METHODS

Two hundred forty-four patients underwent elective four-port LC. Patients were triple blindly randomized. All patients received ∼23 mL of solution, of which 20 mL was given intraperitoneally and ∼3 mL was given intraincisionally. Solution was either normal saline or drug (0.2% ropivacaine) depending on the group (controls [n = 77], intraperitoneal group [n = 80], and intraincisional group [n = 87]). Five different pain scales were used for assessment of overall pain. Only those patients with a Visual Analog Scale (VAS) ≤3, Numeric Rating Scale (NRS) ≤3, Visual Descriptor Scale (VDS) ≤ "Slight Pain," Faces Pain Scale-Revised (FPS-R) ≤2, and Activity Tolerance Scale (ATS) ≤ "Can Be Ignored" along with absence of use of rescue analgesia and shoulder pain were considered for "Discharge Criteria."

RESULTS

Incisional component of pain was found to be the main component of pain that predominated in the immediate postoperative period. However, it declined rapidly over 12 hours and was then dominated by the visceral component. Shoulder component peaked around the eighth postoperative hour. Seven percent of patients in controls could be discharged at the 12th postoperative hour and 18% at the 24th hour. In the intraperitoneal group, 18% and 61% patients could be discharged at the 12th and 24th hour, respectively, as compared with 57% and 78% in the intraincisional group using the "Discharge Criteria." "Discharge Criteria" was 100% effective in predicting patients' acceptance to go home.

CONCLUSION

The effect of local anesthetic at intraincisional and intraperitoneal sites is additive with drug catering to different components of pain. We recommend using the "Abbreviated Discharge Criteria" routinely in practice to check for patients' eligibility to be discharged.