Safety and effectiveness of day-surgery laparoscopic cholecystectomy is still uncertain: meta-analysis of eight randomized controlled trials based on GRADE approach

A German's Perspective on the Way toward Ambulatory Laparoscopic Cholecystectomy: A Postoperative Questionnaire

Introduction

Ambulatory surgeries are on the rise in recent years and can offer benefits to patients as well as healthcare providers. Laparoscopic cholecystectomy is one of the procedures commonly done in an ambulatory setting, in some European countries. This study aims to gather patients' perceptions towards ambulatory cholecystectomy after undergoing laparoscopic cholecystectomy in an inpatient setting.

Methods

A total of 300 patients from two different hospitals in Germany received a postoperative questionnaire aimed at evaluating their willingness to undergo an ambulatory surgery. Surgeries were performed between January 1, 2017, and July 11, 2018. Operation setting (acute vs. elective), ASA classification, length of hospital stay, age, sex, living situation and location (city vs. rural), as well as status of employment were documented.

Results

Overall, 23% of patients reported considering ambulatory laparoscopic cholecystectomy (ALC), while 77% rejected an ALC. Objections included fear of complications (69%), anticipated pain (65%), concerns about their living situation/home care (21%), other reasons (8%), nausea and vomiting (3.4%). Baseline characteristics of the participants provided no statistical significance on willingness to undergo ALC: acute versus elective (p = 0.22), ASA classification (p = 0.77), age ≥65 years versus <65 years (p = 0.60), gender (p = 0.07), living situation (p = 0.49), location (p = 0.15).

Conclusion

There is a willingness for ALC, albeit still limited. Chosen criteria did not show a significant association for positive perception of ALC.

[Outpatient cholecystectomy as the next step? : Discussion and possible criteria in the selection of patients]

BACKGROUND

While laparoscopic cholecystectomy has largely been performed in an outpatient setting in some countries for years, in Germany it is still generally performed on an inpatient basis; however, with the progressive ambitions for more outpatient treatment within the German healthcare system, laparoscopic cholecystectomy will (have to) increasingly be performed on an outpatient basis in the upcoming years.

AIM OF THE WORK

Presentation of the current framework conditions and the potential for outpatient performance of laparoscopic cholecystectomy in Germany. Presentation and discussion on the current state of knowledge regarding patient selection, treatment pathways and safety of outpatient laparoscopic cholecystectomy.

RESULTS

The potential for outpatient management of laparoscopic cholecystectomy in Germany is high. Based on the current literature, there are no safety concerns regarding outpatient performance of laparoscopic cholecystectomy in selected patients.

CONCLUSION

Outpatient management of laparoscopic cholecystectomy is inevitably heading our way in the next years. The key to successful change will be comprehensive patient information, patient selection and structured outpatient treatment pathways.

Ambulatory laparoscopic cholecystectomy: Systematic review and meta-analysis of predictors of failure

BACKGROUND

Outpatient laparoscopic cholecystectomy has proven to be a safe and cost-effective technique; however, it is not yet a universally widespread procedure. The aim of the study was to determine the predictive factors of outpatient laparoscopic cholecystectomy failure.

METHOD

A systematic review and meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis methodology. MEDLINE, Cochrane Library, Ovid, and ISRCTN Registry were searched. The main variables were demographic (age, sex), clinical (weight, American Society of Anesthesiologists classification, previous complicated biliary pathology, history of abdominal surgery in supramesocolic compartment, gallbladder wall thickness), and surgical factors (operative time, afternoon surgery). The secondary variables were the prevalence rates of outpatient laparoscopic cholecystectomy failure due to pain or postoperative nausea and vomiting.

RESULTS

Fourteen studies (4,194 patients) were included, with a mean outpatient laparoscopic cholecystectomy failure rate of 23.4%. The predictors of outpatient laparoscopic cholecystectomy failure were: age ≥65 years (odds ratio: 2.34; 95% confidence interval, 1.42-3.86; P = .0009), body mass index ≥30 (odds ratio: 1.6; 95% confidence interval, 1.05-2.45; P = .03), American Society of Anesthesiologists score ≥III (odds ratio: 2.89; 95% confidence interval, 1.72-4.87; P < .0001), previous complicated biliary pathology (odds ratio: 2.39; 95% confidence interval, 1.40-4.06; P = .001), gallbladder wall thickening (odds ratio: 2.33; 95% confidence interval, 1.34-4.04; P = .003), surgical time exceeding 60 minutes (mean difference: -16.03; 95% confidence interval,-21.25 to -10.81; P < .00001), and the beginning of surgery after 1:00 pm (odds ratio: 4.20; 95% confidence interval, 1.97-11.96; P = .007). Sex (odds ratio: 1.07; 95% confidence interval, 0.73-1.57, P = .73) and history of abdominal surgery in the supramesocolic compartment (odds ratio: 2.32; 95 confidence interval, 0.92-5.82, P = .07) were not associated with outpatient laparoscopic cholecystectomy failure.

CONCLUSION

Our meta-analysis allowed us to identify the predictors of outpatient laparoscopic cholecystectomy failure. The knowledge of these factors could help surgeons in their decision-making process for the selection of patients who are suitable for outpatient laparoscopic cholecystectomy.

Day Surgery Program at West China Hospital: Exploring the Initial Experience

Healthcare facilities in China are facing increasing demands as the country has the fastest aging populations in the world. Day surgery can be utilized to address some of these demands. Benefits of day surgery include shortened hospital stay, decreased risk of hospital-associated infections, and increased cost efficiency. We present a retrospective study of eight years of day surgery data from West China Hospital, one of the largest hospitals in China, with an emphasis on an examination of the growth in day surgeries. We examined patterns of utilization of day surgery versus inpatient surgery (including types of surgeries performed in the Day Surgery Center and the ratio of day surgery versus elective surgery), as well as unplanned readmission and return to inpatient department rates, and a comparison of average costs and length of stay for day surgery versus hospital surgery.

Day surgery has a safe and cost-effective way to alleviate the soaring healthcare demands in West China. There is potential opportunity to further address the ever-increasing demands on the healthcare system in this area by performing more complex surgeries as day surgeries. This article presents an effective organizational protocol and proposes a reliable medical quality assurance system, which prioritizes safety of the growing day surgery program; furthermore, it describes the factors and lessons learned from the successful implementation of a day surgery system.

Randomized controlled trial of single incision versus conventional multiport laparoscopic cholecystectomy with long-term follow-up

Background

Within the last years, single-incision laparoscopic cholecystectomy (SLC) emerged as an alternative to multiport laparoscopic cholecystectomy (MLC). SLC has advantages in cosmetic results, and postoperative pain seems lower. Overall complications are comparable between SLC and MLC. However, long-term results of randomized trials are lacking, notably to answer questions about incisional hernia rates, long-term cosmetic impact and chronic pain.

Methods

A randomized trial of SLC versus MLC with a total of 193 patients between December 2009 and June 2011 was performed. The primary endpoint was postoperative pain on the first day after surgery. Secondary endpoints were conversion rate, operative time, intraoperative and postoperative morbidity, technical feasibility and hospital stay. A long-term follow-up after surgery was added.

Results

Ninety-eight patients (50.8%) underwent SLC, and 95 patients (49.2%) had MLC. Pain on the first postoperative day showed no difference between the operative procedures (SLC vs. MLC, 3.4 ± 1.8 vs. 3.7 ± 1.9, respectively; p = 0.317). No significant differences were observed in operating time or the overall rate of postoperative complications (4.1% vs. 3.2%; p = 0.731). SLC exhibited better cosmetic results in the short term. In the long term, after a mean of 70.4 months, there were no differences in incisional hernia rate, cosmetic results or pain at the incision between the two groups.

Conclusions

Taking into account a follow-up rate of 68%, the early postoperative advantages of SLC in relation to cosmetic appearance and pain did not persist in the long term. In the present trial, there was no difference in incisional hernia rates between SLC and MLC, but the sample size is too small for a final conclusion regarding hernia rates.

Trial registration

German Registry of Clinical Trials DRKS00012447

The Safety of Laparoscopic Cholecystectomy in the Day Surgery Unit Comparing with That in the Inpatient Unit: A Systematic Review and Meta-Analysis

We aimed to perform a systematic review and meta-analysis on the safety of laparoscopic cholecystectomy performed in the day surgery unit versus those performed in the inpatient unit. Several databases including Ovid Embase, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar were searched from inception through February 2019. Our results revealed that laparoscopic cholecystectomy can be conducted safely and effectively in day surgery units, helping bed shortage.