Day case laparoscopic cholecystectomy: Safety and feasibility in obese patients

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.

[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.

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.

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.

One-stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiography bile duct stone extraction is a feasible option in Indonesia within the National Health Insurance System

INTRODUCTION AND IMPORTANCE

Bile duct stones are a widespread condition that can pose a significant risk to life due to the occurrence of complications. In recent years, there has been a growing inclination toward the use of one-stage minimally invasive procedures for the treatment of this condition. However, it is important to note that in developing countries, such as Indonesia, where the National Healthcare Insurance System is established, the implementation of these procedures is still relatively uncommon due to limitations in healthcare facilities.

CASE PRESENTATION

This study presents a case series involving 13 patients who underwent a consecutive initial attempt of one-stage Laparoscopic Cholecystectomy with subsequent Intraoperative Endoscopic Retrograde Cholangiopancreatography (LC-ERCP) for the extraction of bile duct stones. These patients were among the 124 individuals treated for bile duct stones at our hospital for one year (June 2022 to May 2023). All the participants in this study were covered by the National Health Insurance.

CLINICAL DISCUSSION

Among the 124 patients diagnosed with bile duct stones, thirteen (10.5 %) were subjected to an initial attempt of one-stage LC-ERCP procedure, which had a success rate of 76.4 %. However, three of them experienced difficulties during the cannulation of bile duct, leading to the failure of this approach. The patients included in the study had a mean age of 46.5 years, with average serum levels of total bilirubin and direct bilirubin measuring 2.1 and 1.4 mg/dL, respectively. The average duration of successful and unsuccessful procedures was 121.5 min and 183.3 min, respectively. The average length of postoperative hospital stay was 3.5 days, and no instances of mortality or complications were recorded during the study.

CONCLUSION

One-stage LC-ERCP procedure offered a promising treatment option for bile duct stones in Indonesia, particularly for patients registered under the National Healthcare Insurance System. This approach could serve as a viable alternative for facilities that lack proficiency in LC-CBDE skills. Furthermore, the ability to perform ERCP in a supine position is crucial in achieving a high success rate. The results of this study showed the need for advancements in Indonesian public healthcare facilities to meet the growing demand for improved treatment modalities.

Obesity and mid-term outcomes following robotic cholecystectomy

BACKGROUND

As obese adults often suffer from gallbladder disease, more data on postoperative outcomes following robotic cholecystectomy(RC) is needed.

METHODS

RC candidates with a body mass index(BMI) > 30 kg/m² were included. Postoperative course was documented and analyzed. A logistic regression analysis was performed to determine possible risk factors associated with complications.

RESULTS

617 patients with a BMI of 35.9 ± 6.4 kg/m² were included of which 65 had complicated gallbladders (gangrenous, fistulated, or abscessed). Eight cases were converted to open. Sixty-five(10.5%) patients revisited the emergency department within 30 days, and 35(5.7%) were readmitted to the hospital. Average follow-up time was 35 months. Fifty(9.1%) patients experienced complications, eight(1.5%) underwent reoperation. Postoperative complications were associated with chronic obstructive pulmonary disease[p < 0.001, Odds-Ratio(OR):8.418, 95%-Confidence-interval(CI):4.029-17.585], BMI(p < 0.024, OR:1.045, 95%-CI:[1.006-1.086]), class-III obesity (p < 0.021, OR:2.221, 95%-CI:[1.126-4.379], and complicated gallbladders (p < 0.001, OR:3.659, 95%CI:[1.665-8.041]).

CONCLUSION

This is the first study to establish a link between higher obesity classes and postoperative complications following RC.

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.

The effect of obesity in laparoscopic transperitoneal adrenalectomy

Objective: Laparoscopic adrenalectomy is the gold standard for the resection of adrenal tumors. However, there are some technical difficulties, which may be due to the fact that adrenalectomy is rarely encountered in general surgery practice and has a high learning curve. In addition to these, obesity is another problem in laparoscopic adrenalectomies. In the present study, it was aimed to evaluate whether obesity affects perioperative and postop- erative complications after laparoscopic adrenalectomy.

Material and Methods: This is a retrospective comparative study carried out between December 2008 and June 2018. A total of 65 patients who un- derwent laparoscopic transperitoneal adrenalectomy were divided into two groups according to their Body Mass Index (BMI). Patients’ demographic data, perioperative and postoperative results were analyzed from hospital medical records.

Results: There were 30 non-obese and 35 obese patients. There was no significant difference between obese and non-obese patients in terms of op- eration time, peroperative complications and length of hospital stay. However, there was a statistically significant difference between the two groups for postoperative complications (p< 0.031). There was conversion to open surgery in four obese patients and in one patient in the non-obese group.

Conclusion: In obese patients, technical difficulties may be encountered during surgery due to increased adipose tissue, and postoperative complica- tion rates may increase. Nevertheless, laparoscopic transperitoneal adrenalectomy can be performed safely paying attention to the management of obesity-related complications.

Predictors of Difficult Laparoscopic Cholecystectomy on Humanitarian Missions to Peru Difficult LC in Surgical Missions

BACKGROUND

Laparoscopic cholecystectomy (LC) is the gold standard treatment of gallstone disease. On short-term surgical missions (STSMs), it is unclear what factors can predict safety of LC. This study evaluates patient risk factors of difficult LC in Northern Peru, towards optimizing outcomes.

MATERIALS AND METHODS

A retrospective review was performed of patients who underwent LC during short-term surgical missions to Peru from 2016-2019 under the International Surgical Health Initiative (ISHI). Difficult and routine LC groups were compared for: age, weight, gender, symptom duration, pain on presentation, history of abdominal or pelvic surgery, diabetes and hypertension.

RESULTS

68 of 194 patients underwent LC; 42 patients (62%) were classified as difficult with OR (operating room) time > 70 min (90%), 2 cases converted to open (5%) and 2 aborted cases (5%). Higher weight class was found to correlate with difficult LC.

CONCLUSION

Increased patient weight was correlated to longer operative time during STSMs. Patients undergoing LC must be selected carefully to mitigate risks of difficult operations on STSMs.

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.

Challenging situations in cholecystectomy and strategies to overcome them

Background

Cholecystectomy may be difficult and hazardous, causing major morbidity and mortality. This review aims to identify situations increasing the probability of difficult gallbladders and present today’s best practice to overcome them.

Methods

Review of the literature and expert comment.

Results

One in six gallbladders is expected to be a difficult cholecystectomy. The majority can be predicted by patient history, clinical symptoms, and pre-existing comorbidities. Acute cholecystitis, mild biliary pancreatitis, prior endoscopic sphincterotomy, and liver cirrhosis are the predominant underlying diseases. Early or delayed cholecystectomy, percutaneous cholecystostomy, and pure conservative treatment are evidence-based options. Early laparoscopic cholecystectomy is of advantage in patients fit for surgery, with subtotal cholecystectomy or conversion to open surgery as bail-out strategies. The choice of the procedure depends on the experience of the surgeon.

Conclusion

Clinical decisions should follow a pathway based on patients’ risk, favoring laparoscopic cholecystectomy whenever possible. The implementation of an institutional pathway to deal with difficult gallbladders is recommended.

Ambulatory bariatric surgery: does it really lead to higher rates of adverse events?

BACKGROUND

Correlating patient outcomes with length of stay (LoS) is an important consideration in metabolic and bariatric surgery. At present, conflicting data exists regarding patient safety for ambulatory (AMB) metabolic and bariatric surgery.

OBJECTIVE

Outcomes for AMB-metabolic and bariatric surgery patients (LoS <1 d) undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) were compared with matched patients with LoS ≥1 day (non-AMB) using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry.

SETTING

MBSAQIP national database.

METHODS

The MBSAQIP registry was queried for patients undergoing SG or RYGB (2015-2017) and patients grouped as AMB/non-AMB. Exclusion criteria included LoS >4 days, age <18 or >75 years, revision surgery, gastric banding, body mass index <35 kg/m², and day of surgery mortality. Variables were combined into major/minor complications and 30-day mortality. Analysis was performed using univariate and multivariate logistic regression and propensity matching.

RESULTS

After exclusions were applied 408,895 patients remained (9973 AMB). Overall, 111,279 patients underwent RYGB (1032 AMB) and 297,616 underwent SG (8941 AMB), with similar demographic characteristics and co-morbidities between groups. For AMB patients, there was no increase in 30-day mortality, reoperation, or readmission, and fewer drains were placed versus matched non-AMB patients. In AMB-SG patients more surgical site infections were reported versus non-AMB-SG, although AMB-SG patients had fewer intensive care unit admissions. For AMB-RYGB, no differences in complications were detected versus non-AMB-RYGB.

CONCLUSION

Based on our analysis of the MBSAQIP database, patients undergoing laparoscopic RYGB or SG procedures can be safely discharged on the day of their procedure without increased incidence of mortality, reoperation, or readmission.

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.

Patient reported outcomes in elective laparoscopic cholecystectomy

BACKGROUNDS/AIMS

Traditional outcome measures (e.g., length of hospital stay, morbidity, and mortality) are used to determine the quality of care, but these may not be most important to patients. It is unclear which outcomes matter to patients undergoing elective laparoscopic cholecystectomy (ELC). We aim to identify patient-reported outcome measures (PROM) which patients undergoing ELC valued most.

METHODS

A 45-item questionnaire with Four-point Likert-type questions developed from prior literature review, prospectively administered to patients treated with ELC at a tertiary institution in Singapore.

RESULTS

Seventy-five patients participated. Most essential factors were technical skill and experience level of a surgeon, long-term quality of life (QoL), patient involvement in decision-making, communication skill of a surgeon, cleanliness of the ward environment, and standards of nursing care. Least important factors were hospitalization leave duration, length of hospital stay, a family's opinion of the hospital, and scar cosmesis. Employed patients were more likely to find hospitalization leave duration (p<0.001) and procedure duration (p=0.042) important. Younger patients (p=0.048) and female gender (p=0.003) were more likely to perceive scar cosmesis as important.

CONCLUSIONS

Patients undergoing ELC value long-term QoL, surgeon technical skill and experience level, patient involvement in decision-making, surgeon communication skill, cleanliness of the ward environment, and nursing care standards. Day-case surgery, medical leave, family opinion of hospital, and scar cosmesis were least important. Understanding what patients value will help guide patient-centric healthcare delivery.