Day case laparoscopic cholecystectomy in patients with high BMI: Experience from a UK centre

Comparative study of ambulatory versus inpatient laparoscopic cholecystectomy in Thailand: Assessing effectiveness and safety with a propensity score matched analysis

Backgrounds/Aims

Ambulatory laparoscopic cholecystectomy (LC) is increasingly recognized for its advantages over the inpatient approach, which advantages include cost-effectiveness and faster recovery. However, its acceptance is limited by patient concerns regarding safety, and the potential for postoperative complications. The study aims to compare the operative and postoperative outcomes of ambulatory LC versus inpatient LC, specifically addressing patient hesitations related to early discharge.

Methods

In a retrospective analysis, patients who underwent LC were divided into ambulatory or inpatient groups based on American Society of Anesthesiologists (ASA) classification, age, and the availability of postoperative care. Propensity score matching was utilized to ensure comparability between the groups. Data collection focused on demographic information, perioperative data, and postoperative follow-up results to identify the safety of both approaches.

Results

The study included a cohort of 220 patients undergoing LC, of which 48 in each group matched post-propensity score matching. The matched analysis indicated that ambulatory LC patients seem to experience shorter operative times and reduced blood loss, but these differences were not statistically significant (35 minutes vs. 46 minutes, p-value = 0.18; and 8.5 mL vs. 23 mL, p-value = 0.14, respectively). There were no significant differences in complication rates or readmission frequencies, compared to the inpatient cohort.

Conclusions

Ambulatory LC does not compromise safety or efficacy, compared to traditional inpatient procedures. The findings suggest that ambulatory LC could be more widely adopted, with appropriate patient education and selection criteria, to alleviate concerns and increase patient acceptance.

Critical values for body mass index related to morbidity in high-volume low-complexity general surgery: a systematic review and meta-analysis

INTRODUCTION

The aim of this study was to investigate the effect of body mass index (BMI, kg/m2) on outcomes of high-volume low-complexity (HVLC) general surgery procedures and to determine critical values for BMI when selecting patients into HVLC programmes.

METHODS

A systematic review was conducted of studies looking at patients in different BMI categories undergoing HVLC general surgery procedures (laparoscopic cholecystectomy, inguinal hernia repair and umbilical or paraumbilical hernia repair), in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. A comparison meta-analysis model was constructed to compare the outcomes using random-effects modelling. The QUIPS (Quality In Prognosis Studies) tool and GRADE (Grading of Recommendations Assessment, Development and Evaluation) system were used to assess bias.

RESULTS

A total of 26 studies including 486,392 patients were examined. In laparoscopic cholecystectomy, BMI ≥40 was associated with higher conversion to open surgery (odds ratio [OR]: 1.33, p=0.040) but did not affect complications (OR: 0.69, p=0.400) or length of hospital stay (mean difference [MD]: -0.01 days, p=0.900). In inguinal hernia repair, BMI ≥35 was associated with longer operative time (MD: 18.00 minutes, p<0.00001), and higher risk of wound complications (OR: 3.01, p<0.00001) and hospital readmission (OR: 1.46, p=0.0008). In umbilical or paraumbilical hernia repair, BMI ≥30 was associated with higher risk of wound complications (OR: 6.45, p<0.0001) and hospital readmission (OR: 5.56, p<0.00001), and longer operative time (MD: 4.01 minutes, p=0.030).

CONCLUSIONS

Obesity was associated with longer operative time (up to 23 minutes) and higher risk of postoperative morbidity (up to 4-fold) in HVLC procedures. BMI <40 (moderate GRADE certainty - laparoscopic cholecystectomy) and BMI <35 (moderate GRADE certainty - inguinal hernia) appear to represent optimal critical values for perioperative safety metrics.

Association between obesity and risk of delayed discharge and unplanned readmission for day surgery: A systematic review and meta-analysis

AIMS

This work aims to investigate the association between obesity and risk of delayed discharge and unplanned readmission in day surgery patients.

BACKGROUND

Day surgeries are well received and developing rapidly. Associations between obesity and delayed discharge and unplanned readmission, which are clinically relevant outcomes in day surgeries, are complex.

DESIGN

A systematic review and meta-analysis was conducted.

DATA SOURCES

The PubMed, Web of Science, EMBASE, Cochrane Library, CNKI, VIP, and Wan Fang databases were comprehensively searched from inception until January 2021.

REVIEW METHODS

Two independent reviewers assessed the studies and extracted data. Pooled estimates were obtained using a random-effects model.

RESULTS

Eleven articles published between 2007 and 2020 were finally included. Obesity appeared not to increase the risk of delayed discharge. However, morbid obesity seemed to be associated with a higher risk of delayed discharge. The meta-analysis revealed no relationship between higher body mass index (BMI) and unplanned readmission for day surgery patients.

CONCLUSIONS

Obesity appeared not to increase the risk of delayed discharge except in patients with morbid obesity. Additionally, a higher BMI was not associated with increased risk of unplanned readmission after day surgery. Future studies are required to address this issue further in different types of surgery and areas.

Accuracy of Self-Estimated BMI in the Context of Telephone Assessment Before Elective General Surgery

Background This study aimed to determine if self-estimated body mass index (BMI) from telephone consultation was accurate and useful for surgical planning prior to elective general surgery. Methods A prospective cohort study was performed under a single surgeon at a district general hospital in the United Kingdom. Estimated BMI was collected from consecutive patients attending a pre-operative telephone consultation. Actual BMI was measured on the day of surgery and compared. Patient age and gender were also collected. Results Data were collected from 124 participants (median age 59 years, 49.2% male). A total of 33 participants under-estimated, 53 over-estimated, and 38 accurately estimated their BMIs. The median change in BMI was 0.0 (IQR -0.1, 0.3, p = 0.003). The median change in males was 0.0 (-0.1, 0.2, p = 0.479) compared to 0.1 (0.0, 0.7, p = 0.002) in females. Those with an actual BMI > 29.9 had a significantly higher median change (0.2 {0.0, 1.1}) compared to those with BMI ≤ 29.9 (0.0 {-0.2, 0.1}; p <0.001). Only two patients could have required a change in surgeon on the day of the procedure and this was not statistically significant (p = 0.500). Conclusions Self-estimated BMI, collected via telephone consultation, is a suitable method for assessing patients for surgical planning ahead of elective general surgery procedures, particularly for males. However, it is important to be aware that those with higher BMIs, particularly females, may underestimate their BMIs.

Comparative Study of the Incidence of Port Site Infection in Disposable Ports and Reprocessed Disposable Ports in Laparoscopic Cholecystectomy

INTRODUCTION

Port site infection (PSI) is a rare complication of laparoscopic surgery that can reduce the benefits of this minimally invasive surgery and increase postoperative complications. As a variety of disposable ports (single-use ports) and reprocessed ports are used in laparoscopic surgeries, this study was conducted to compare the incidence of PSI in disposable ports and reprocessed disposable ports in laparoscopic cholecystectomy (LC).

MATERIALS AND METHODS

In this prospective cohort study, 473 patients were studied. Two hundred fifteen and two hundred fifty eight were in the disposable port group and reprocessed disposable port group, respectively. The demographic characteristics and incidence of superficial and deep infection were evaluated using the researcher-made checklist of infection assessment standards at intervals of 3 to 5 and 5 to 14 days following LC using call and physical examination on day 14. Data analysis was performed using descriptive statistics and statistical tests in SPSS software.

RESULTS

The incidence of PSI, 3 to 5 and 5 to 14 days after surgery in the reprocessed disposable port group was significantly higher than that in the disposable ports group. In both groups, all PSI accrued in the epigastric port area (where the gallbladder was removed) ( P < 0.05).

CONCLUSION

On the basis of the results, our study suggests using disposable ports instead, and in the case of using reprocessed disposable ports in LC, upgrading of disinfection and sterilization techniques is necessary.

Operative Difficulty, Morbidity and Mortality Are Unrelated to Obesity in Elective or Emergency Laparoscopic Cholecystectomy and Bile Duct Exploration

OBJECTIVES

The challenges posed by laparoscopic cholecystectomy (LC) in obese patients and the methods of overcoming them have been addressed by many studies. However, no objective tool of reporting operative difficulty was used to adjust the outcomes and compare studies. The aim of this study was to establish whether obesity adds to the difficulty of LC and laparoscopic common bile duct exploration (LCBDE) and affects their outcomes on a specialist biliary unit with a high emergency workload.

METHODS

A prospectively maintained database of 4699 LCs and LCBDEs performed over 19 years was analysed. Data of patients with body mass index (BMI) ≥ 35, defined as grossly obese, was extracted and compared to a control group.

RESULTS

A total of 683 patients (14.5%) had a mean BMI of 39.9 (35-63), of which 63.4% met the definition of morbidly obese. They had significantly more females and significantly higher ASA II classifications. They had equal proportions of emergency admissions, similar incidence of operative difficulty grades 4 or 5 and no open conversions and were less likely to undergo LCBDE than non-obese patients. There were no significant differences in median operative times, morbidity, readmission or mortality rates.

CONCLUSIONS

This study, the first to classify gall stone surgery in obese patients according to operative difficulty grading, showed no difference in complexity when compared to the non-obese. Refining access and closure techniques is key to avoiding difficulties. Index admission surgery for biliary emergencies prevents multiple admissions with potential complications and should not be denied due to obesity.

The obesity paradox: Underweight patients are at the greatest risk of mortality after cholecystectomy

BACKGROUND

Elevated body mass index is a risk factor for gallstone disease and cholecystectomy, but outcomes for low body mass index patients remain uncharacterized. We examined the association of body mass index with morbidity, mortality, and resource use after cholecystectomy.

METHODS

The 2005 to 2016 American College of Surgeons National Surgical Quality Improvement Program was retrospectively analyzed for adult patients undergoing laparoscopic and open cholecystectomy. Patients were stratified into 5 groups: body mass index <18.5 (underweight), body mass index 18.5 to 24.9 (normal weight), body mass index 25 to 29.9 (overweight), body mass index 30 to 34.9 (class I obesity), body mass index 35 to 39.9 (class II obesity), and body mass index ≥40 (class III obesity). Multivariable regressions identified independent associations of covariates with 30-day mortality, complications, and resource use.

RESULTS

Of 327,473 cholecystectomy patients, 1.0% were underweight, 19.5% normal weight, 30.3% overweight, 24.0% class I obesity, 13.5% class II obesity, and 11.7% class III obesity. After multivariable analysis, underweight patients had a higher risk of mortality (adjusted odds ratio = 1.53; P = .029) and postoperative bleeding (adjusted odds ratio = 1.45; P = .011) relative to normal weight patients. Conversely, class III obesity patients had lower mortality (adjusted odds ratio = 0.66; P = .005) but increased operative time (β = 10.2 minutes; P < .001), wound infection (adjusted odds ratio = 1.38; P < .001), and wound dehiscence (adjusted odds ratio = 2.20; P < .001). Hospital duration of stay and readmission rates were highest for underweight patients.

CONCLUSION

Underweight patients experience increased risk of mortality and readmission, while class III obesity patients have higher rates of wound infection and dehiscence as well as prolonged operative time. These findings may guide choice of intervention.

Day case laparoscopic cholecystectomy: Identifying patients for a 'COVID-Cold' isolated day-case unit during the pandemic

BACKGROUND

The UK practice of laparoscopic cholecystectomy has reduced during the COVID-19 pandemic due to cancellation of non-urgent operations. Isolated day-case units have been recommended as 'COVID-cold' operating sites to resume surgical procedures. This study aims to identify patients suitable for day case laparoscopic cholecystectomy (DCLC) at isolated units by investigating patient factors and unexpected admission.

METHOD

Retrospective analysis of 327 patients undergoing DCLC between January and December 2018 at Ysbyty Gwynedd (District General Hospital; YG) and Llandudno General Hospital (isolated unit; LLGH), North Wales, UK.

RESULTS

The results showed that 100% of DCLCs in LLGH were successful; 71.4% of elective DCLCs were successful at YG. Increasing age (p = 0.004), BMI (p = 0.01), ASA Score (p = 0.006), previous ERCP (p = 0.05), imaging suggesting cholecystitis (p = 0.003) and thick-walled gallbladder (p = 0.04) were significantly associated with failed DCLC on univariate analysis. Factors retaining significance (OR, 95% CI) after multiple regression include BMI (1.82, 1.05-3.16; p = 0.034), imaging suggesting cholecystitis (4.42, 1.72-11.38; p = 0.002) and previous ERCP (5.25, 1.53-18.00; p = 0.008). Postoperative complications are comparable in BMI <35kg/m² and 35-39.9kg/m².

CONCLUSIONS

Current patient selection for isolated day unit is effective in ensuring safe discharge and could be further developed with greater consideration for patients with BMI 35-39.9kg/m². As surgical services return, this helps identify patients suitable for laparoscopic cholecystectomy at isolated COVID-free day units.

The Cholecystectomy As A Day Case (CAAD) Score: A Validated Score of Preoperative Predictors of Successful Day-Case Cholecystectomy Using the CholeS Data Set

BACKGROUND

Day-case surgery is associated with significant patient and cost benefits. However, only 43% of cholecystectomy patients are discharged home the same day. One hypothesis is day-case cholecystectomy rates, defined as patients discharged the same day as their operation, may be improved by better assessment of patients using standard preoperative variables.

METHODS

Data were extracted from a prospectively collected data set of cholecystectomy patients from 166 UK and Irish hospitals (CholeS). Cholecystectomies performed as elective procedures were divided into main (75%) and validation (25%) data sets. Preoperative predictors were identified, and a risk score of failed day case was devised using multivariate logistic regression. Receiver operating curve analysis was used to validate the score in the validation data set.

RESULTS

Of the 7426 elective cholecystectomies performed, 49% of these were discharged home the same day. Same-day discharge following cholecystectomy was less likely with older patients (OR 0.18, 95% CI 0.15-0.23), higher ASA scores (OR 0.19, 95% CI 0.15-0.23), complicated cholelithiasis (OR 0.38, 95% CI 0.31 to 0.48), male gender (OR 0.66, 95% CI 0.58-0.74), previous acute gallstone-related admissions (OR 0.54, 95% CI 0.48-0.60) and preoperative endoscopic intervention (OR 0.40, 95% CI 0.34-0.47). The CAAD score was developed using these variables. When applied to the validation subgroup, a CAAD score of ≤5 was associated with 80.8% successful day-case cholecystectomy compared with 19.2% associated with a CAAD score >5 (p < 0.001).

CONCLUSIONS

The CAAD score which utilises data readily available from clinic letters and electronic sources can predict same-day discharges following cholecystectomy.

Predictive Factors for a Long Hospital Stay in Patients Undergoing Laparoscopic Cholecystectomy

Background. Although the advantages of laparoscopic cholecystectomy (LC) over open cholecystectomy are immediately obvious and appreciated, several patients need a postoperative hospital stay of more than 24 hours. Thus, the predictive factors for this longer stay need to be investigated. The aim of this study was to identify the causes of a long hospital stay after LC. Methods. This is a retrospective cohort study with 500 successful elective LC patients being included in the analysis. Short hospital stay was defined as being discharged within 24 hours after the operation, whereas long hospital stay was defined as the need for a stay of more than 24 hours after the operation. Results. Using multivariable analysis, ten independent predictive factors were identified for a long hospital stay. These included patients with cirrhosis, patients with a history of previous acute cholecystitis, cholangitis, or pancreatitis, patients on anticoagulation with warfarin, patients with standard-pressure pneumoperitoneum, patients who had been given metoclopramide as an intraoperative antiemetic drug, patients who had been using abdominal drain, patients who had numeric rating scale for pain > 3, patients with an oral analgesia requirement > 2 doses, complications, and private ward admission. Conclusions. LC difficulties were important predictive factors for a long hospital stay, as well as medication and operative factors.