Day case laparoscopic cholecystectomy: reducing the admission rate

Day case laparoscopic cholecystectomy: a review of patient selection factors and identification of potential barriers to same-day discharge

BACKGROUND

Day-case laparoscopic cholecystectomy (DCLC) is a useful tool for minimizing hospital admissions and prolonged presurgical wait times in suitable patient cohorts. There have been many international studies to support this finding and an increasing interest has grown in implementation in Australia. This review aims to provide clarity how to best implement this tool in gallbladder disease patient demographic.

OBSERVATIONS

This literature review evaluates studies on day-case cholecystectomy procedures, focusing on patient factors, procedural aspects, surgical morbidity, and systemic implications. It explores inclusion and exclusion criteria for day-case suitability, factors influencing same-day discharge, reasons for hospital admission, pain management, patient quality of life, patient satisfaction, and cost implications.

CONCLUSIONS

DCLC, when selected judiciously, is a safe alternative to overnight stay procedures for cholecystectomy with comparable surgical outcomes and patient satisfaction, affirming its viability. Strict patient selection criteria can aid in optimizing the successful implementation procedure, reducing unexpected admissions and readmissions and we have demonstrated useful criteria for guidance in establishing day-case laparoscopic cholecystectomy protocol at a hospital.

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.

Is fundus first laparoscopic cholecystectomy a better option than conventional laparoscopic cholecystectomy for difficult cholecystectomy? A systematic review and meta-analysis

The gallstone disease prevalence is up to 27% in the general adult population. Though most of the patients are asymptomatic, about 1-4% of these patients became symptomatic every year and will require treatment. Fundus first laparoscopic cholecystectomy (FFLC) was first reported by Cooperman in 1990 when he utilized the approach to safely perform LC for patients with acute cholecystitis and dense adhesion around the calot's triangle which precluded safe dissection. Some surgeons reported that the FFLC may be quicker than the traditional dissection starting at the Calot's triangle, although no randomized trial has been undertaken to confirm that. We aim to perform this systematic review and meta-analysis to compare outcome of fundal first laparoscopic cholecystectomy with conventional laparoscopic cholecystectomy. Three reviewers independently searched the Pubmed, medline, google schoolar, Cochrane library and Embase databases for prospective or retrospective articles comparing outcomes of fundus first LC and conventional LC. The search terms were "retrograde cholecystectomy", "antegrade cholecystectomy", "fundus first cholecystectomy", "fundus down cholecystectomy", and "dome down cholecystectomy". Studies were selected based on predetermined criteria and data were extracted from the study for meta-analysis. Twelve studies were included for meta-analysis. Our analysis revealed that FFLC is associated with less conversion to open surgery, less time of surgery, less risk of bile duct injuries and shorter duration of hospital stay compared conventional cholecystectomy in patients with difficult cholecystectomy. In conclusion, fundus first laparoscopic cholecystectomy is a safer alternative to conventional laparoscopic cholecystectomy in patients with difficult cholecystectomy.

The impact of case order and intraoperative staff changes on spine surgical efficiency

BACKGROUND CONTEXT

Despite concerted efforts toward quality improvement in high-volume spine surgery, there remains concern that increases in case load may compromise the efficient and safe delivery of surgical care. There is a paucity of evidence to describe the effects of spine case order and operating room (OR) team structure on measures of intraoperative timing and OR efficiency.

PURPOSE

This study aims to determine if intraoperative staff changes and surgical case order independently predict extensions in intraoperative timing after spinal surgery for spondylotic diseases.

STUDY DESIGN/ SETTING

Retrospective cohort analysis PATIENT SAMPLE: All patients over age 18 who underwent primary or revision decompression and/or fusion for degenerative spinal diseases between 2017 to 2019 at a single academic institution were retrospectively identified. Exclusion criteria included absence of descriptive data and intraoperative timing parameters as well as surgery for traumatic injury, infection, and malignancy.

OUTCOME MEASURES

Intraoperative timing metrics including total theater time, wheels in to induction, induction start to cut, cut to close, and close to wheels out. Postoperative outcomes included length of hospital stay and 90-day hospital readmissions.

METHODS

Surgical case order and intraoperative changes in staff (circulator and surgical scrub nurse or technician) were determined. Patient demographics, surgical factors, intraoperative timing and postoperative outcomes were recorded. Extensions in each operative stage were determined as a ratio of the actual duration of the parameter divided by the predicted duration of the parameter. Univariate and multivariate analyses were performed to compare outcomes within case order and staff change groups.

RESULTS

A total of 1,108 patients met the inclusion criteria. First, second, and third start cases differed significantly in intraoperative extensions of total theater time, wheels in to induction, induction start to cut, cut to close, and close to wheels out. On regression, decreasing case order predicted extension in wheels in to induction time. Surgeries with intraoperative staff changes were associated with increases in total theater time, induction start to cut time, cut to close time, close to wheels out time, and length of hospital stay. Switch in primary circulator predicted extended theater time and cut to close time. Relief of primary circulator or scrub predicted extended total theater time, induction start to cut time, cut to close time, and close to wheels out time.

CONCLUSIONS

Intraoperative staff change in spine surgery independently predicted extended operative duration. However, higher case order was not significantly associated with procedural time.

Patient selection for ambulatory laparoscopic cholecystectomy: A systematic review

Background

Currently, there is no consensus on patient selection for ambulatory laparoscopic cholecystectomy (LC). This study is a systematic review of previously published patient selection for ambulatory LC.

Methods

A comprehensive search was done in PubMed, Web of Science, Embase and Google Scholar Database up to March 2020 to summarise previously reported medical or surgical selection criteria used for inclusion and exclusion of patients, as well as successful same-day discharge rates and readmission rate after discharge.

Results

Fifty-nine studies with a total of 13,219 patients were included in this systematic review. In total, the median same-day discharge rate was 90% (range: 63%-99.4%), and median readmission rate was 2.22% (range: 0%-16.9%). The most considered medical criteria were American Society of Anesthesiologists classification I and II, age <70, and body mass index <35. Surgical criteria varied greatly. The top three accessible exclusion variables were (1) common bile duct stones, cholangitis, or jaundice (27 publications, 45.8%); (2) history of abdominal surgery (12 publications, 20.3%) and (3) history of pancreatitis (9 publications, 15.3%).

Conclusion

The results of the current study showed the variable patient selection in different centres, the medical aspect criteria may be expanded under adequate pre-anaesthetic assessment and preparation and the surgical aspect criteria should include more laboratory or imaging parameters to ensure the surgical safety.

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.

Association Between Preoperative Blood Glucose Level and Hospital Length of Stay for Patients Undergoing Appendectomy or Laparoscopic Cholecystectomy

OBJECTIVE

To evaluate the effect of preoperative blood glucose (POBG) level on hospital length of stay (LOS) in patients undergoing appendectomy or laparoscopic cholecystectomy.

RESEARCH DESIGN AND METHODS

We conducted a retrospective cohort study of patients aged ≥18 years who had undergone appendectomy or laparoscopic cholecystectomy procedures between 2005 and 2016 at a tertiary medical center in Taiwan. The association between POBG level and LOS was evaluated using a multivariable quasi-Poisson regression with robust variance. Multiple imputations were performed to replace missing values.

RESULTS

We included 8,291 patients; 4,025 patients underwent appendectomy (appendectomy group) and 4,266 underwent laparoscopic cholecystectomy (laparoscopic cholecystectomy group). In the appendectomy group, patients with POBG levels of ≥123 mg/dL (adjusted relative risk [aRR] 1.19; 95% CI 1.06-1.33) had a 19% higher risk of having a LOS of >3 days than did those with POBG levels of <106 mg/dL. In the laparoscopic cholecystectomy group, patients with POBG levels of ≥128 mg/dL also had a significantly higher risk of having a LOS of >3 days (aRR 1.17; 95% CI 1.07-1.29) than did those with POBG levels of <102 mg/dL. A positive dose-response curve between POBG and an adjusted risk of a LOS of >3 days was observed, although the curve starts to flatten at a POBG level of ∼130 mg/dL.

CONCLUSIONS

We demonstrated that a higher POBG level was significantly associated with a prolonged LOS for patients undergoing appendectomy or laparoscopic cholecystectomy. The optimal POBG level may be lower than that commonly perceived.

Same-day discharge protocol for laparoscopic treatment of adnexal disease: management and acceptance

OBJECTIVE

Develop a 'same-day discharge' setting for laparoscopic treatment of adnexal disease.

SETTING

Preventive Gynecology, European Institute of Oncology, Milan, Italy.

POPULATION

Two hundred patients undergoing laparoscopic procedures.

MATERIAL AND METHODS

Data were retrospectively collected through clinical, surgical and laboratory reports. After discharge patients were contacted by phone and e-mail.

MAIN OUTCOME MEASURES

The rate of discharge, adverse events and readmission was measured. The need for adjunctive care provided by our on-call service or by a primary care physician and the acceptability of the same-day discharge protocol were also investigated.

RESULTS

One hundred and sixty-five patients out of 200 were discharged on the same day. Of the 35 patients hospitalized, the most frequent causes for overnight admission were: uncontrolled pain, surgical length or complexity of the procedure in nine patients, nausea/vomit in four patients. One hundred and one out of 200 patients answered the mailed questionnaire. None of the discharged patients were readmitted. Eighty-five percent of the answering patients evaluated the length of their hospital stay as adequate or moderately adequate. Ninety-two percent of the patients would recommend the day surgery to other patients.

CONCLUSIONS

our experience demonstrates that the same-day discharge protocol for laparoscopic treatment of adnexal disease is safe and acceptable.

Day case laparoscopic cholecystectomy at Kilimanjaro Christian Medical Centre, Tanzania

INTRODUCTION

The Lancet Commission on Global Surgery has promoted the case for safe, affordable surgical care in low- and middle-income countries (LMICs). In 2017, Kilimanjaro Christian Medical Centre (KCMC) in Tanzania introduced a day case laparoscopic cholecystectomy (DCLC) service, the first of its kind in Sub-Saharan Africa (SSA). We aimed to evaluate this novel service in terms of safety, feasibility and acceptability by patients and staff.

METHODS

This study used mixed methods and was split into two stages. In stage 1, we reviewed records of all laparoscopic cholecystectomies (LCs) comparing day cases and admissions. These patients were followed up with a telephone questionnaire to investigate complication rates and receive service feedback. Stage 2 consisted of semi-structured interviews with staff exploring the challenges KCMC faced in implementing DCLC.

RESULTS

147 laparoscopic cholecystectomies were completed: 109 were planned for DCLC, 82 (75.2%) of which were successful, whilst 27 (24.8%) patients were admitted. No variables significantly predicted unplanned admission, the commonest causes for which were pain and nausea. In the DCLC group there was 1 readmission. 62 patients answered the follow up questionnaire, 60 (97%) of which were satisfied with the service. Stage 2 interviews suggested staff to be motivated for DCLC but revealed poor organisation of the day case pathway.

CONCLUSION

High rates of DCLC combined with low rates of complications and readmission suggests DCLC is feasible at KCMC. However, staff interviews alluded to administrative problems preventing KCMC from reaching its full DCLC potential. A dedicated day case surgery unit would address most of these problems.

Later Surgical Start Time Is Associated With Longer Length of Stay and Higher Cost in Cervical Spine Surgery

STUDY DESIGN

Retrospective study of a surgical cohort from a single, large academic institution.

OBJECTIVE

The aim of this study was to investigate associations between surgical start time, length of stay, cost, perioperative outcomes, and readmission.

SUMMARY OF BACKGROUND DATA

One retrospective study with a smaller cohort investigated associations between surgical start time and outcomes in spine surgery and found that early start times were correlated with shorter length of stay. No examinations of perioperative outcomes or cost have been performed.

METHODS

All patients undergoing anterior cervical discectomy and fusion (ACDF) and posterior cervical decompression and fusion (PCDF) were queried from a single institution from January 1, 2008 to November 30, 2016. Patients undergoing surgery that started between 12:00 AM and 6:00 AM were excluded due to their likely emergent nature. Cases starting before and after 2:00 PM were compared on the basis of length of stay and cost as the primary outcomes using multivariable logistic regression.

RESULT

The patients undergoing ACDF and PCDF were both similar on the basis of comorbidity burden, preoperative diagnosis, and number of segments fused. The patients undergoing ACDF starting after 2 PM had longer LOS values (adjusted difference of 0.65 days; 95% confidence interval [CI]: 0.28-1.03; P = 0.0006) and higher costs of hospitalization (adjusted difference of $1177; 95% CI: $549-$1806; P = 0.0002). Patients undergoing PCDF starting after 2 PM also had longer LOS values (adjusted difference of 1.19 days; 95% CI: 0.46-1.91; P = 0.001) and higher costs of hospitalization (adjusted difference of $2305; 95% CI: $826-$3785; P = 0.002).

CONCLUSION

Later surgical start time is associated with longer LOS and higher cost. These findings should be further confirmed in the spine surgical literature to investigate surgical start time as a potential cost-saving measure.

LEVEL OF EVIDENCE

3.

Is It Safe to Recommend Cholecystectomy Whenever Gallstones Develop After Bariatric Surgery?

BACKGROUND

Cholelithiasis (ChL) is common after bariatric surgery (BS). Laparoscopic cholecystectomy (LC), the preferential treatment, is usually recommended only to symptomatic patients. LC may be, however, beneficial to asymptomatic patients as well. A prerequisite to such a policy is that it must be safe. This study aimed to assess whether, in post-bariatric (Post-Bar) patients who develop gallstones, LC achieves the same results as those reported in the general population.

METHODS

A cohort of 376 patients undergoing elective LC had their medical records reviewed. Patients were divided into non-bariatric (Non-Bar) and Post-Bar groups, and then compared for characteristics and surgical outcomes.

RESULTS

The study included 367 patients, 292 Non-Bar and 75 Post-Bar. Considering characteristics, Post-Bar patients were younger (44.5 ± 11.8 vs 48.4 ± 14.1) and less symptomatic (2.4% vs 19.8%) and had a higher BMI (32.2 ± 4.8 vs 30.8 ± 4.4) than Non-Bar patients. Regarding surgical outcomes, mortality (none), morbidity (1%, only in Non-Bar patients), readmission (1%, only in Non-Bar patients), conversion to laparotomy (0.6%, only in Non-Bar patients) showed no difference between the groups. Operative time (42.6 ± 14.4 min in Non-Bar and 38.2 ± 12.6 min in Post-Bar patients) tended to be lower in Post-Bar patients, p = 0.054. Same-day discharge was higher in Post-Bar patients (98.6%) than in Non-Bar patients (90.4%), p = 0.03.

CONCLUSIONS

Compared with Non-Bar patients, LC in Post-Bar patients showed not only similar morbimortality, readmissions, and conversions but also even a higher same-day discharge rate and a trend to lower operative times.

Feasibility of Routine Ambulatory Laparoscopic Cholecystectomy in Brazil

Background and Objectives

In several developed countries, most laparoscopic cholecystectomies (LCs) are performed as an ambulatory operation (ALC) with a high rate of success. In Latin America, the experience with this procedure is still limited. Our objective is to evaluate the feasibility to implement ALC in a Brazilian teaching hospital.

Methods

Data obtained from electronic medical records and study protocols of all patients who underwent an LC between January 2011 and March 2018 were evaluated. All patients with chronic or acute cholecystitis were initially considered for an ALC.

Results

Of a total of 1645 patients who underwent LC, 1577 (95.9%) were discharged on the same day of the operation. The main reasons for hospital admission after ALC were patient refusal to be discharged (n = 23; 1.4%), nausea and vomiting (n = 15; 0.9%), and complicated acute cholecystitis. No patient was excluded from consideration for ALC based only on age, history of previous upper abdominal operation, and presence of comorbidity. Patient age ranged from 12 to 100 years, with a mean of 50.23 ± 15.35 years. Intraoperative and postoperative complication rates were 0.4% and 5.5%, respectively. Most perioperative complications were because of technical surgical difficulties and complications common to most abdominal operations (surgical site, pulmonary, urinary, and venous complications). Thirteen (0.8%) patients were readmitted to the hospital because of abdominal pain and fever (n = 4), pneumonia (n = 3), deep venous thrombosis (n = 3), or urinary retention (n = 3).

Conclusions

ALC may be performed in Brazil with low rates of morbidity, mortality, and hospital readmission. Its implementation should be stimulated in Latin America.

'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.

The clinical utility of pre-operative neutrophil-to-lymphocyte ratio as a predictor of outcomes in patients undergoing elective laparoscopic cholecystectomy

BACKGROUND

In recent years, there has been an increasing trend towards day-case surgery for patients undergoing laparoscopic cholecystectomy (LC). We investigated the predictive value that pre-operative neutrophil-to-lymphocyte ratio (PNLR) had on surgical outcomes.

METHODS

A review of all patients who underwent LC during a 6-year period in a single institution was performed and PNLR recorded. A PNLR cutoff value of 3 was utilised. We compared operation time, length of stay (LOS), and conversion to open between those with PNLR less and greater than 3.

RESULTS

A total of 567 patients underwent elective LC. Those with PNLR>3 had associated prolonged operation time (p < 0.005), prolonged LOS (p < 0.005), and higher rates of conversion to open surgery (p < 0.005).

CONCLUSIONS

PNLR correlates with outcomes following LC. It is useful in delineating patients that have higher risk of conversion or prolonged length of hospital stay and is helpful in assessing suitability of day-case surgery.

[First experience with outpatient laparoscopic cholecystectomy in Tunisia]

INTRODUCTION

Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstones. There is some debate as to whether it should be performed in outpatient surgery or in one-day surgery to improve patient safety. This study aimed to evaluate the impact of laparoscopic cholecystectomy performed in outpatient surgery versus one-day surgery on standards such as mortality, serious adverse events and quality of life.

METHODS

We conducted a cross-sectional descriptive study in the Department of General Surgery at the Habib Thameur Hospital over the period May 2009-February 2010. We here report 67 cases of symptomatic vesical lithiasis treated with outpatient laparoscopic cholecystectomy (OLC). ASA III and IV patients, diabetic patients treated with sulfonamides or insulin, severely obese patients, patients over 65 years of age and under 18 years of age, patients with a history of major abdominal surgery, patients with suspected lithiasis of the common bile duct, acute cholecystitis or pancreatitis were excluded from the study. Patients had to reside within 50 km of the hospital and be accompanied by an adult to undergo OLC.

RESULTS

Seventeen patients were included and then excluded from our study because of the perioperative detection of signs of acute cholecystitis or difficulties in dissection leading to subhepatic drainage using Redon catheter at the end of the intervention. Finally, our study included 50 patients, 7 men and 43 women; the average age was 48 years. Surgery was based on the most common procedures. After leaving the recovery room, patients were conducted in the outpatient sector where they received a liquid diet. The patients were examined before 7 o'clock in the evening and discharge was established on the basis of the possibility of establishing an oral analgesic treatment, patients tolerance to liquid diet, the lack of urinary disorder, patients acceptance for discharge and analgesic and anti-inflammatory treatment if needed. Thirty-nine patients (78%) were discharged from hospital and 11 were kept in hospital. Patients > 45 years of age, anesthesia duration > 70 minutes and post operative fatigue were identified as risk factors for unsuccessful discharge. No readmission was observed. Discharged patients were satisfied with the therapeutic protocol, resulting in excellent and good outcome in the majority of cases (94%).

CONCLUSION

Outpatient laparoscopic cholecystectomy seems to be as safe as day surgery laparoscopic cholecystectomy having low rate of complications and of hospital readmissions in some selected patients and lower surgery costs.

An Ambulatory Surgery Perioperative Surgical Home in Kaiser Permanente Settings: Practice and Outcomes

BACKGROUND

The aim of this study is to describe the design, implementation, and associated outcome changes of a Perioperative Surgical Home (PSH) for patients undergoing ambulatory laparoscopic cholecystectomy in a Kaiser Permanente practice model.

METHODS

A multidisciplinary planning committee of 15 individuals developed and implemented a new PSH program. A total of 878 subjects were included in the preimplementation period (T-fast), and 1082 patients were included in the postimplementation period (PSH) based on the date of their surgery. The primary goal of this report was to assess the changes in patient outcomes associated with this new PSH implementation on variables such as total length of stay and unplanned hospital admission (UHA).

RESULTS

Patients assigned to the PSH model had a significantly shorter mean length of stay compared with patients in the T-fast group (162 ± 308 vs 369 ± 790 minutes, P = .00005). UHA was significantly higher in the T-fast group as compared with the PSH group (8.5% [95% CI 6.6-10.4] vs 1.7% [0.9-2.5], P < .00005). There was no difference in the 7 days readmission rates between patients managed in the T-fast track and the PSH track (5.4% [3.8-7.0] vs 5.0% [3.6-6.3], P = .066).

CONCLUSIONS

Introduction of the PSH into a Kaiser Permanente model of care was associated with a simultaneous decrease of length of stay and UHA for laparoscopic cholecystectomy patients.

Effect of Surgery Start Time on Day of Discharge in Anterior Cervical Discectomy and Fusion Patients

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To compare time to discharge for anterior cervical discectomy and fusions (ACDF) when performed as either a first case versus later surgical start times.

SUMMARY OF BACKGROUND DATA

ACDF is a commonly performed spinal procedure that typically has a short acute recovery period. With an increasing focus on reducing hospital costs and a shift toward outpatient surgical practices, early patient discharge has become a priority for hospitals and physicians alike. However, the impact of surgery start time on the ability for same-day discharge has not been explored in spine surgery.

METHODS

A surgical database of patients who underwent ACDF from 2013 to 2015 was reviewed. Patients were stratified into two cohorts: those whose surgery was the first of the day (early cohort), and those who underwent later surgeries. Baseline patient characteristics and perioperative variables were compared between cohorts using Student t test and χ test. Same-day discharge was tested for association with surgical start time using Poisson regression with robust error variance controlling for preoperative variables.

RESULTS

A total of 106 patients, divided into early and late cohorts of 60 and 46 patients, respectively, were included in the analysis. There were no significant differences in pre- or perioperative characteristics between cohorts (). Same-day discharge was achieved in 36.8% (n = 39) of all ACDF patients. The later cohort was significantly more likely to require an overnight stay compared with the early cohort (RR = 1.61 ± 0.30; P = 0.010).(Table is included in full-text article.)CONCLUSION.: Patients undergoing ACDF later in the day are at a higher risk for staying overnight than those who have the first surgery of the day. These results may influence operative scheduling, as performing ACDFs early in the day may result in a greater likelihood of same-day discharge, eliminating the increased resource utilization associated with an overnight hospital stay.

LEVEL OF EVIDENCE

4.

Day-case laparoscopic cholecystectomy

Objectives:

To assess the safety and feasibility of laparoscopic cholecystectomy as a day-case procedure.

Methods:

All consecutive patients who were admitted to the day-surgery unit for laparoscopic cholecystectomy at the Department of Surgery, King Saud Medical City, Riyadh, Saudi Arabia from July 2009 to June 2013 were considered for this retrospective study. The medical records were reviewed for age, gender, presenting symptoms, laboratory findings, imaging studies, American Society of Anesthesiology (ASA) grade, anesthesia, conversion to open cholecystectomy, complications, the operating surgeons, pain management, nausea, and vomiting, overnight stay, readmission, morbidity, mortality, and outpatient follow up were collected and analyzed.

Results:

A total of 487 patients underwent laparoscopic cholecystectomy as a day case (ASA I=316, ASA II=171). Surgery was performed by high surgical trainees (HSTs) (n=417) and consultants (n=70) with conversion to open cholecystectomy in 4 patients. Twenty-two (5%) patients were admitted for overnight stay for different reasons, while 465 (95%) patients were discharged before 8 pm. Two patients (0.4 %) were re-admitted to the hospital due to abdominal pain. Five patients developed umbilical port site infection (1%). A total of 443 patients were satisfied (97%), while 14 (3%) were unsatisfied. There was no mortality or intra-abdominal septic collection.

Conclusion:

Day-case laparoscopic cholecystectomy is safe and feasible with optimal patient selection, education, and planned postoperative antiemetic and analgesia management.

AMBULATORY LAPAROSCOPIC CHOLECYSTECTOMY IS SAFE AND COST-EFFECTIVE: a Brazilian single center experience

ABSTRACT Background - Laparoscopic cholecystectomy is the treatment of choice for gallstone disease, and has been perfomed as an outpatient surgery in many Institutions over the last few years. Objective - This is a retrospective study of a single center in Brazil, that aims to analyze the outcomes of 200 cases of ambulatory laparoscopic cholecystectomy performed by the same Hepato-Pancreato-Biliary team, evaluating the safety and cost-effectiveness of the method. Methods - Two hundred consecutive patients who underwent elective laparoscopic cholecystectomy were retrospectively analyzed; some of them underwent additional procedures, as liver biopsies and abdominal hernias repair. Results - From a total of 200 cases, the outpatient surgery protocol could not be carried out in 22 (11%). Twenty one (95.5%) patients remained hospitalized for 1 day and 1 (4.5%) patient remained hospitalized for 2 days. From the 178 patients who underwent ambulatory laparoscopic cholecystectomy, 3 (1.7 %) patients returned to the emergency room before the review appointment. Hospital cost was on average 35% lower for the ambulatory group. Conclusion - With appropriate selection criteria, ambulatory laparoscopic cholecystectomy is feasible, safe and effective; readmission rate is low, as well as complications related to the method. Cost savings and patient satisfaction support its adoption. Other studies are necessary to recommend this procedure as standard practice in Brazil.

Safety of outpatient laparoscopic cholecystectomy in children: analysis of 2050 elective ACS NSQIP-pediatric cases

PURPOSE

Limited data exists evaluating the extent of utilization and safety of outpatient laparoscopic cholecystectomy (LC) in children. The aim of this study was to investigate the safety of outpatient LC in the pediatric population utilizing a national surgical quality improvement database.

METHODS

The National Surgical Quality Improvement Program-Pediatric (NSQIP-P) databases from 2012 and 2013 were queried to identify pediatric patients who underwent elective LC. Patients who underwent outpatient LC were compared with those who underwent inpatient LC. Outcomes of interest included 30-day overall morbidity, readmission, and reoperation.

RESULTS

A total of 2,050 LC were identified, 995 (48.5 %) were performed as an outpatient procedure and 1055 (51.5 %) as inpatient. Patients who underwent outpatient LC were more often white (79.6 vs. 69.2 %; p = <0.0001). Choledocholithiasis was more often treated in inpatient setting (12.5 vs. 1.7 %; p < 0.0001), while biliary dyskinesia was performed in outpatient setting (26.1 v. 12.6 %; p = 0.0001). Overall 30-day morbidity was greater in the inpatient group (2.5 vs. 0.8 %; p = 0.03). There were no differences in term of 30-day readmission rate and related reoperations (0.9 vs 0.3 % respectively; p = 0.09).

CONCLUSION

This analysis of a large multicenter dataset demonstrates that pediatric patients without significant associated comorbidities can safely undergo laparoscopic cholecystectomy as an outpatient procedure.

Thirty-day readmissions after inpatient laparoscopic cholecystectomy: factors and outcomes

BACKGROUND

30-day readmissions are a considerable financial burden on medical institutions due to penalties faced from the Centers for Medicaid and Medicare.

METHODS

A retrospective review of 30-day readmissions was performed. The data were subdivided into medical severity-diagnostic related groups 417, 418, and 419, as categorized by the Centers for Medicaid and Medicare. Perioperative variables, diagnostic workup, operative interventions, and postoperative morbidity and outcomes were analyzed.

RESULTS

Forty-four (5.9%) readmissions were recorded, of 747 inpatient discharges. The data were further divided into DRGs 417, 418, and 419 with readmission rates of 13.6, 3.6%, and 5.4%, respectively. The highest rate of readmission was within the first 7 days. Etiology was divided into surgical (54.5%) and nonsurgical (45.4%).

CONCLUSIONS

Patients with major comorbidities had a higher rate of readmission (P < .05). In 45.4% of the readmissions, the cause was found to be nonsurgical. The surgical team was not consulted in 31.8% of the readmissions.

Outpatient laparoscopic cholecystectomy and pain control: a series of 100 cases

INTRODUCTION

We present our experience of 100 consecutive cases that underwent ambulatory cholecystectomy using a standard protocol of anesthesia and surgery.

PATIENTS AND METHOD

Prospective study of 100 consecutive patients assessed in the surgery outpatient clinic in Torrevieja Hospital (September 2008-september 2009). Both anesthetic and surgical techniques were protocolized, standardized. The protocol included the use of intraperitoneal and parietal anesthesia.

RESULTS

One hundred patients were included. Average age was 53 years and average surgical time was 29±12 min. Day-case surgery rate was 96%. Postoperative pain (VAS scale) was less than 4 in all cases. Six patients complained of nausea that eased with the administration of ev metoclopramide. Average length of stay in the day-case surgery unit was 7.4h (maximum 9.6, minimum 7). Morbidity and mortality rates were 0%. No re-admission was registered and conversion rate was 0%. Postoperative follow-up was 100%. A total of 97% of the cases were fully satisfied with the procedure.

CONCLUSION

Ambulatory laparoscopic cholecystectomy is a feasible and safe technique. Postoperative pain has classically been the reason to not perform day-case surgery, but we achieved an excellent control by the combined use of local anesthetics and warm intraperitoneal saline solution.

Intent at day case laparoscopic cholecystectomy in owerri, Nigeria: initial experiences

BACKGROUND AND OBJECTIVE

Laparoscopic cholecystectomy has been the default operation for cholelithiasis at Federal Medical Centre, Owerri for the past 2 years and the outcomes have been good. The duration of post operative stay has been decreasing. We therefore initiated a preliminary 2-year prospective study in May 2010 to determine the feasibility of carrying out day case laparoscopic cholecystectomy in our hospital.

MATERIALS AND METHODS

PATIENTS UNDERGOING LAPAROSCOPIC CHOLECYSTECTOMY WERE INCLUDED IN THE STUDY IF THEY SATISFIED THE FOLLOWING CRITERIA: Age < 65 years, body mass index < 35 kg/m(2) , American Society of Anaesthesiology physical status class I and II, patient residence within 20 km radius of the hospital, patient acceptance of the procedure and absence of previous complicated upper abdominal surgery.

RESULTS

Twelve patients (10 females, 2 males) were worked up with the intent of achieving same-day discharge of the patients. Five of the patients (41.7%) were discharged on the day of operation. The reasons for overnight stay included inadequate pain control, insertion of drain and patient wishes. There was no conversion to open surgery, no major complications and no case of readmission to the hospital.

CONCLUSIONS

Day case laparoscopic cholecystectomy in our environment could be safely promoted but will depend on improved facilities and patient enlightenment.