Ondansetron versus placebo for prophylaxis of nausea and vomiting in patients undergoing ambulatory laparoscopic cholecystectomy

Palonosetron versus ondansetron for prophylaxis of postoperative nausea and vomiting in laparoscopic cholecystectomy: a non-inferiority randomized controlled trial

BACKGROUND

We tested the hypothesis that, within the margin of 15% of risk difference, palonosetron is not inferior to ondansetron in reducing the incidence of postoperative nausea and vomiting (PONV) in laparoscopic cholecystectomy.

METHODS

We conducted a double-blind, non-inferiority, randomized, controlled trial of 212 patients aged 18 to 65 years undergoing laparoscopic cholecystectomy under general anesthesia in two secondary care hospitals. Patients were randomly assigned to receive either palonosetron (0.075.ßmg) or ondansetron (8.ßmg) intravenously at induction of anesthesia. Ondansetron (8.ßmg) was also administered 8 and 16.ßhours postoperatively. All anesthetic and surgical procedures were standardized. Patients were evaluated for 24.ßhours postoperatively for the occurrence of PONV.

RESULTS

A high incidence of PONV was observed at 2...6.ßhours postoperatively, with a rate of 36.8% (95% confidence interval [CI] 28.2...46.3) in the palonosetron group, as compared to 43.4% (95% CI 34.4...52.9) in the ondansetron group. The risk difference (95% CI) between palonosetron and ondansetron for PONV was 0 (-10.9 to 10.9) at 0...2.ßhours, -6.6 (-19.4 to 6.5) at 2...6.ßhours, -0.9 (-11.0 to 9.2) at 6...12.ßhours, and -2.8 (-9.6 to 3.6) at 12...24.ßhours. There was no statistically significant difference between the palonosetron and ondansetron groups in the use of rescue medication (dimenhydrinate). There were no adverse events associated with the medications under study.

CONCLUSION

Palonosetron is not inferior to ondansetron in patients at risk of PONV undergoing laparoscopic cholecystectomy, providing a good option for PONV prophylaxis, as it can be administered in a single dose.

A randomized controlled trial comparing incidences of postoperative nausea and vomiting after laparoscopic cholecystectomy for preoperative intravenous fluid loading, ondansetron, and control groups in a regional hospital setting in a developing country

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common complication in inpatient and outpatient settings. Multimodal approaches have been pursued to minimize this undesirable outcome. Despite consensus guidelines for the management of PONV have been updated and published for many years, data from our pilot study showed that patients with high-risk surgeries for PONV, laparoscopic cholecystectomy (LC), still hardly received perioperative PONV prophylaxis. This study aimed to compare the incidences of PONV in adult patients undergoing elective LC who were administered preoperative intravenous fluid loading, ondansetron, or neither fluid nor ondansetron in the setting of a regional hospital in a developing country.

METHODS

The study was designed as a prospective randomized controlled trial. The total of 171 patients was allocated to three groups: one received fluid loading with Ringer's lactate solution before the operation; the second received ondansetron; and the third group received neither.

RESULTS

In total, 156 patients were analyzed. Their demographic data, history of motion sickness/PONV, and smoking status were not significantly different. The overall incidences of PONV within 24 hours of surgery were 29.1% in the fluid group, 18.4% in the ondansetron group, and 25% in the control group, but the difference was not statistically significant (P = .442). In subgroup analysis, the incidences of PONV and PON in patients younger than 50 years old were significantly different among the three groups (P = .008). A post hoc analysis showed that patients under 50 years in the ondansetron group had significantly lower incidences of PONV and PON than those in the control and fluid groups. However, the incidences of morphine consumption and dizziness in the ondansetron group were significantly higher than those of the two other groups.

CONCLUSIONS

Neither the preoperative intravenous fluid loading nor the ondansetron affected PONV in patients aged 50 and older undergoing LC, compared with control. Ondansetron was beneficial for PON prophylaxis in patients under the age of 50, whereas preoperative intravenous fluid loading was considered a risk factor for PON in this population.

The effects of acupressure on postoperative nausea and vomiting among patients undergoing laparoscopic surgery: A meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVE

Laparoscopic surgery is one of the most commonly performed surgeries in general surgery, with fewer side effects and rapid recovery. Postoperative nausea and vomiting (PONV) remains the main challenge that confronts the prognosis of this minimally invasive surgery. We aimed to evaluate the effect of acupressure, a nonpharmacological non-invasive method, on the incidence of nausea and vomiting following laparoscopic surgery within the early phase (first six hours postoperatively) and the extended phase (for at least 24 h postoperatively).

METHODS

We searched PubMed, Cochran, Scopus, Web of Science, Google scholar, and Wiley for randomized controlled trials that evaluated the effect of acupressure on PONV in patients undergoing laparoscopy. Data were extracted and analyzed in a random model, and pooled risk ratios (RRs) with their respective 95% confidence intervals (CIs) were calculated.

RESULTS

Eleven trials were included in the meta-analysis, comprising 941 patients. Most of the included patients were females undergoing gynecological laparoscopy or laparoscopic cholecystectomy. Acupressure significantly lowered the incidence of nausea and vomiting, within the early phase (RR = 0.62, 95% CI [0.44 to 0.88]; p = 0.008), (RR = 0.5, 95% CI [0.30 to 0.84]; p = 0.008), and the extended phase (RR = 0.65, 95% CI [0.52 to 0.83]; p = 0.0003), (RR = 0.44, 95% CI [0.32 to 0.61]; p < 0.00001), respectively. Moreover, acupressure significantly reduced the need for rescue antiemetic drugs in both phases (p < 0.05).

CONCLUSION

Acupressure is an effective procedure for reducing nausea, vomiting, and the need for antiemetic drugs after laparoscopic surgery.

Systematic review and meta-analysis of factors which reduce the length of stay associated with elective laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is a safe ambulatory procedure in appropriately selected patients; however, day case rates remain low. The objective of this systematic review and meta-analysis was to identify interventions which are effective in reducing the length of stay (LOS) or improving the day case rate for elective laparoscopic cholecystectomy.

METHODS

Comparative English-language studies describing perioperative interventions applicable to elective laparoscopic cholecystectomy in adult patients and their impact on LOS or day case rate were included.

RESULTS

Quantitative data were available for meta-analysis from 80 studies of 10,615 patients. There were an additional 17 studies included for systematic review. The included studies evaluated 14 peri-operative interventions. Implementation of a formal day case care pathway was associated with a significantly shorter LOS (MD = 24.9 h, 95% CI, 18.7-31.2, p < 0.001) and an improved day case rate (OR = 3.5; 95% CI, 1.5-8.1, p = 0.005). Use of non-steroidal anti-inflammatories, dexamethasone and prophylactic antibiotics were associated with smaller reductions in LOS.

CONCLUSION

Care pathway implementation demonstrated a significant impact on LOS and day case rates. A limited effect was noted for smaller independent interventions. In order to achieve optimal day case targets, a greater understanding of the effective elements of a care pathway and local barriers to implementation is required.

Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: a network meta-analysis

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common adverse effect of anaesthesia and surgery. Up to 80% of patients may be affected. These outcomes are a major cause of patient dissatisfaction and may lead to prolonged hospital stay and higher costs of care along with more severe complications. Many antiemetic drugs are available for prophylaxis. They have various mechanisms of action and side effects, but there is still uncertainty about which drugs are most effective with the fewest side effects.

OBJECTIVES

• To compare the efficacy and safety of different prophylactic pharmacologic interventions (antiemetic drugs) against no treatment, against placebo, or against each other (as monotherapy or combination prophylaxis) for prevention of postoperative nausea and vomiting in adults undergoing any type of surgery under general anaesthesia • To generate a clinically useful ranking of antiemetic drugs (monotherapy and combination prophylaxis) based on efficacy and safety • To identify the best dose or dose range of antiemetic drugs in terms of efficacy and safety SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, and reference lists of relevant systematic reviews. The first search was performed in November 2017 and was updated in April 2020. In the update of the search, 39 eligible studies were found that were not included in the analysis (listed as awaiting classification).

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing effectiveness or side effects of single antiemetic drugs in any dose or combination against each other or against an inactive control in adults undergoing any type of surgery under general anaesthesia. All antiemetic drugs belonged to one of the following substance classes: 5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, corticosteroids, antihistamines, and anticholinergics. No language restrictions were applied. Abstract publications were excluded.

DATA COLLECTION AND ANALYSIS

A review team of 11 authors independently assessed trials for inclusion and risk of bias and subsequently extracted data. We performed pair-wise meta-analyses for drugs of direct interest (amisulpride, aprepitant, casopitant, dexamethasone, dimenhydrinate, dolasetron, droperidol, fosaprepitant, granisetron, haloperidol, meclizine, methylprednisolone, metoclopramide, ondansetron, palonosetron, perphenazine, promethazine, ramosetron, rolapitant, scopolamine, and tropisetron) compared to placebo (inactive control). We performed network meta-analyses (NMAs) to estimate the relative effects and ranking (with placebo as reference) of all available single drugs and combinations. Primary outcomes were vomiting within 24 hours postoperatively, serious adverse events (SAEs), and any adverse event (AE). Secondary outcomes were drug class-specific side effects (e.g. headache), mortality, early and late vomiting, nausea, and complete response. We performed subgroup network meta-analysis with dose of drugs as a moderator variable using dose ranges based on previous consensus recommendations. We assessed certainty of evidence of NMA treatment effects for all primary outcomes and drug class-specific side effects according to GRADE (CINeMA, Confidence in Network Meta-Analysis). We restricted GRADE assessment to single drugs of direct interest compared to placebo.

MAIN RESULTS

We included 585 studies (97,516 randomized participants). Most of these studies were small (median sample size of 100); they were published between 1965 and 2017 and were primarily conducted in Asia (51%), Europe (25%), and North America (16%). Mean age of the overall population was 42 years. Most participants were women (83%), had American Society of Anesthesiologists (ASA) physical status I and II (70%), received perioperative opioids (88%), and underwent gynaecologic (32%) or gastrointestinal surgery (19%) under general anaesthesia using volatile anaesthetics (88%). In this review, 44 single drugs and 51 drug combinations were compared. Most studies investigated only single drugs (72%) and included an inactive control arm (66%). The three most investigated single drugs in this review were ondansetron (246 studies), dexamethasone (120 studies), and droperidol (97 studies). Almost all studies (89%) reported at least one efficacy outcome relevant for this review. However, only 56% reported at least one relevant safety outcome. Altogether, 157 studies (27%) were assessed as having overall low risk of bias, 101 studies (17%) overall high risk of bias, and 327 studies (56%) overall unclear risk of bias. Vomiting within 24 hours postoperatively Relative effects from NMA for vomiting within 24 hours (282 RCTs, 50,812 participants, 28 single drugs, and 36 drug combinations) suggest that 29 out of 36 drug combinations and 10 out of 28 single drugs showed a clinically important benefit (defined as the upper end of the 95% confidence interval (CI) below a risk ratio (RR) of 0.8) compared to placebo. Combinations of drugs were generally more effective than single drugs in preventing vomiting. However, single NK₁ receptor antagonists showed treatment effects similar to most of the drug combinations. High-certainty evidence suggests that the following single drugs reduce vomiting (ordered by decreasing efficacy): aprepitant (RR 0.26, 95% CI 0.18 to 0.38, high certainty, rank 3/28 of single drugs); ramosetron (RR 0.44, 95% CI 0.32 to 0.59, high certainty, rank 5/28); granisetron (RR 0.45, 95% CI 0.38 to 0.54, high certainty, rank 6/28); dexamethasone (RR 0.51, 95% CI 0.44 to 0.57, high certainty, rank 8/28); and ondansetron (RR 0.55, 95% CI 0.51 to 0.60, high certainty, rank 13/28). Moderate-certainty evidence suggests that the following single drugs probably reduce vomiting: fosaprepitant (RR 0.06, 95% CI 0.02 to 0.21, moderate certainty, rank 1/28) and droperidol (RR 0.61, 95% CI 0.54 to 0.69, moderate certainty, rank 20/28). Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol showed clinically important benefit, but low doses showed no clinically important benefit. Aprepitant was used mainly at high doses, ramosetron at recommended doses, and fosaprepitant at doses of 150 mg (with no dose recommendation available). Frequency of SAEs Twenty-eight RCTs were included in the NMA for SAEs (10,766 participants, 13 single drugs, and eight drug combinations). The certainty of evidence for SAEs when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to low. Droperidol (RR 0.88, 95% CI 0.08 to 9.71, low certainty, rank 6/13) may reduce SAEs. We are uncertain about the effects of aprepitant (RR 1.39, 95% CI 0.26 to 7.36, very low certainty, rank 11/13), ramosetron (RR 0.89, 95% CI 0.05 to 15.74, very low certainty, rank 7/13), granisetron (RR 1.21, 95% CI 0.11 to 13.15, very low certainty, rank 10/13), dexamethasone (RR 1.16, 95% CI 0.28 to 4.85, very low certainty, rank 9/13), and ondansetron (RR 1.62, 95% CI 0.32 to 8.10, very low certainty, rank 12/13). No studies reporting SAEs were available for fosaprepitant. Frequency of any AE Sixty-one RCTs were included in the NMA for any AE (19,423 participants, 15 single drugs, and 11 drug combinations). The certainty of evidence for any AE when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to moderate. Granisetron (RR 0.92, 95% CI 0.80 to 1.05, moderate certainty, rank 7/15) probably has no or little effect on any AE. Dexamethasone (RR 0.77, 95% CI 0.55 to 1.08, low certainty, rank 2/15) and droperidol (RR 0.89, 95% CI 0.81 to 0.98, low certainty, rank 6/15) may reduce any AE. Ondansetron (RR 0.95, 95% CI 0.88 to 1.01, low certainty, rank 9/15) may have little or no effect on any AE. We are uncertain about the effects of aprepitant (RR 0.87, 95% CI 0.78 to 0.97, very low certainty, rank 3/15) and ramosetron (RR 1.00, 95% CI 0.65 to 1.54, very low certainty, rank 11/15) on any AE. No studies reporting any AE were available for fosaprepitant. Class-specific side effects For class-specific side effects (headache, constipation, wound infection, extrapyramidal symptoms, sedation, arrhythmia, and QT prolongation) of relevant substances, the certainty of evidence for the best and most reliable anti-vomiting drugs mostly ranged from very low to low. Exceptions were that ondansetron probably increases headache (RR 1.16, 95% CI 1.06 to 1.28, moderate certainty, rank 18/23) and probably reduces sedation (RR 0.87, 95% CI 0.79 to 0.96, moderate certainty, rank 5/24) compared to placebo. The latter effect is limited to recommended and high doses of ondansetron. Droperidol probably reduces headache (RR 0.76, 95% CI 0.67 to 0.86, moderate certainty, rank 5/23) compared to placebo. We have high-certainty evidence that dexamethasone (RR 1.00, 95% CI 0.91 to 1.09, high certainty, rank 16/24) has no effect on sedation compared to placebo. No studies assessed substance class-specific side effects for fosaprepitant. Direction and magnitude of network effect estimates together with level of evidence certainty are graphically summarized for all pre-defined GRADE-relevant outcomes and all drugs of direct interest compared to placebo in http://doi.org/10.5281/zenodo.4066353.

AUTHORS' CONCLUSIONS

We found high-certainty evidence that five single drugs (aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron) reduce vomiting, and moderate-certainty evidence that two other single drugs (fosaprepitant and droperidol) probably reduce vomiting, compared to placebo. Four of the six substance classes (5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, and corticosteroids) were thus represented by at least one drug with important benefit for prevention of vomiting. Combinations of drugs were generally more effective than the corresponding single drugs in preventing vomiting. NK₁ receptor antagonists were the most effective drug class and had comparable efficacy to most of the drug combinations. 5-HT₃ receptor antagonists were the best studied substance class. For most of the single drugs of direct interest, we found only very low to low certainty evidence for safety outcomes such as occurrence of SAEs, any AE, and substance class-specific side effects. Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol were more effective than low doses for prevention of vomiting. Dose dependency of side effects was rarely found due to the limited number of studies, except for the less sedating effect of recommended and high doses of ondansetron. The results of the review are transferable mainly to patients at higher risk of nausea and vomiting (i.e. healthy women undergoing inhalational anaesthesia and receiving perioperative opioids). Overall study quality was limited, but certainty assessments of effect estimates consider this limitation. No further efficacy studies are needed as there is evidence of moderate to high certainty for seven single drugs with relevant benefit for prevention of vomiting. However, additional studies are needed to investigate potential side effects of these drugs and to examine higher-risk patient populations (e.g. individuals with diabetes and heart disease).

Outpatient laparoscopic cholecystectomy: Experience of a university group practice in a developing country

Aims: In developed countries, efforts to improve outcome and minimize costs prompted the performance of laparoscopic cholecystectomy as an outpatient procedure. In the Philippines and in most developing countries, most laparoscopic cholecystectomies are still performed on admitted patients who are discharged one or more days after the surgery. No local experience has been published in the Philippines demonstrating the safety and feasibility of outpatient laparoscopic cholecystectomy. Materials and Methods: This study is a retrospective study investigating the outcome of outpatient performed laparoscopic cholecystectomy in the University of the Philippines, Philippine General Hospital Faculty Medical Arts Building (UP-PGH FMAB), an ambulatory surgical facility within UP-PGH. The patients were admitted to the ambulatory facility on the day of surgery, underwent laparoscopic cholecystectomy under general anesthesia and discharged on the same day. Results: From June 2012 to June 2016, 122 patients underwent laparoscopic cholecystectomy at the UP-PGH Faculty medical arts building. There were 80 women (85%) and 42 men (15%) with a mean age of 46 years. The mean operating time was 58 minutes. The unplanned admission rate was 2.4% (two patients), one for conversion to open and two for unrelieved postoperative nausea and vomiting. Conclusion: Outpatient laparoscopic cholecystectomy is safe and technically feasible even in developing countries. It has potential for much economical and social benefit when employed judiciously. Prospective, randomized trials must be conducted in the local setting to refine technique, standardize patient selection and address system deficiencies to allow safe performance of outpatient laparoscopy in the Philippines.

WITHDRAWN: Drugs for preventing postoperative nausea and vomiting

BACKGROUND

Drugs can prevent postoperative nausea and vomiting, but their relative efficacies and side effects have not been compared within one systematic review.

OBJECTIVES

The objective of this review was to assess the prevention of postoperative nausea and vomiting by drugs and the development of any side effects.

SEARCH METHODS

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2004), MEDLINE (January 1966 to May 2004), EMBASE (January 1985 to May 2004), CINAHL (1982 to May 2004), AMED (1985 to May 2004), SIGLE (to May 2004), ISI WOS (to May 2004), LILAC (to May 2004) and INGENTA bibliographies.

SELECTION CRITERIA

We included randomized controlled trials that compared a drug with placebo or another drug, or compared doses or timing of administration, that reported postoperative nausea or vomiting as an outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted outcome data.

MAIN RESULTS

We included 737 studies involving 103,237 people. Compared to placebo, eight drugs prevented postoperative nausea and vomiting: droperidol, metoclopramide, ondansetron, tropisetron, dolasetron, dexamethasone, cyclizine and granisetron. Publication bias makes evidence for differences among these drugs unreliable. The relative risks (RR) versus placebo varied between 0.60 and 0.80, depending upon the drug and outcome. Evidence for side effects was sparse: droperidol was sedative (RR 1.32) and headache was more common after ondansetron (RR 1.16).

AUTHORS' CONCLUSIONS

Either nausea or vomiting is reported to affect, at most, 80 out of 100 people after surgery. If all 100 of these people are given one of the listed drugs, about 28 would benefit and 72 would not. Nausea and vomiting are usually less common and, therefore, drugs are less useful. For 100 people, of whom 30 would vomit or feel sick after surgery if given placebo, 10 people would benefit from a drug and 90 would not. Between one to five patients out of every 100 people may experience a mild side effect, such as sedation or headache, when given an antiemetic drug. Collaborative research should focus on determining whether antiemetic drugs cause more severe, probably rare, side effects. Further comparison of the antiemetic effect of one drug versus another is not a research priority.

The Intensity of Postlaparoscopic Shoulder Pain Is Positively Correlated with the Amount of Residual Pneumoperitoneum

STUDY OBJECTIVE

Residual carbon dioxide, which is inevitably retained in the abdominal cavity after laparoscopy, plays an important role in inducing postlaparoscopic shoulder pain (PLSP). The aim of this study was to determine the relationship between the volume of a residual pneumoperitoneum and the intensity of PLSP.

DESIGN

A prospective cohort study (Canadian Task Force classification II-2).

SETTING

A university hospital.

PATIENTS

A total of 203 patients undergoing laparoscopy for nonmalignant gynecologic diseases.

INTERVENTIONS

Gynecologic laparoscopy.

MAIN OUTCOME MEASURES

The volume of the residual pneumoperitoneum was measured by performing chest radiography 24 hours after surgery. The pneumoperitoneum was graded as high volume (defined as ≥the median volume of the pneumoperitoneum) and low volume (defined as <the median volume). Perioperative data including PLSP intensity scores were collected.

RESULTS

The median volume of the residual pneumoperitoneum was 17.0 mL (0.5-133.8 mL). The intensity of PLSP was significantly higher in the high-volume group compared with the low-volume group (p < .001). A lower volume of the pneumoperitoneum was associated with less analgesic requirement (p = .032), a shorter hospitalization period (p = .007), and higher satisfaction from the surgery (p = .005). The residual gas volume and PLSP score exhibited a positive correlation that was statistically significant (r = 0.735, p < .001).

CONCLUSION

The volume of the residual pneumoperitoneum was positively correlated with the intensity of shoulder pain after laparoscopy. Therefore, surgeons should release as much gas as possible from the peritoneal cavity at the end of laparoscopy.

Prospective survey to study factors which could influence same-day discharge after elective laparoscopic cholecystectomy in a tertiary care hospital of a developing country

All laparoscopic cholecystectomy (LC) patients in our hospital setting are admitted overnight. This article assesses the contribution of factors like postoperative nausea and vomiting (PONV), postoperative pain and surgical complications to overnight stay after elective LC. This 1-year observational study included patients having normal liver functions undergoing elective LC before 1400 h. The collected data included patient demographics, co-morbidities, PONV, pain scores, complications, surgical time, anesthesia technique, use of prophylactic antiemetics, analgesics, patient satisfaction and desire to have this surgery as day case or in-patient procedure. From 930 LC done per annum, 45.2 % (430/950) patients were included in this study. Prophylactic antiemetic was given in 91.6 %, intraoperative narcotics in 94.2 % patients and multimodal analgesia in 85.3 %. The mean pain score in the recovery and ward was maintained to <4. In the ward, 99.1 % patients were able to start oral fluids after 6 h and were started on oral non-steroidal anti-inflammatory drugs and paracetamol, and none required parental opioid. The PONV score of more than 2 was observed in only 3.2 % of patients in the ward requiring parenteral antiemetic. Surgical complications in the form of bleeding, visceral injury and bile duct leak were observed in 2 % of patients, which was treated intra-operatively. Satisfaction was observed in 99.3 % and desire to stay overnight in 87.4 % of patients. Factors like postoperative pain, PONV and surgical complications were well managed and were not associated with significant morbidity to justify routine overnight admission. However, majority of the patients desired to stay overnight, which could be improved by counseling and education.

Evidence-Based Practice in Laparoscopic Surgery: Perioperative Care

Best practices for reducing risks of postoperative infection, venous thromboembolism, and nausea and vomiting in patients undergoing laparoscopic surgery are uncertain. As a result, perioperative care varies widely. We reviewed evidence from randomized clinical trials on the effectiveness of interventions for postoperative infection, venous thromboembolism, and nausea and vomiting Data sources were the Cochrane Central Register of Clinical Trials, reference lists of published trials, and randomized clinical trials published in English since 1990. Trials were also limited to those focused on patients undergoing laparoscopic surgery. Data from 98 randomized clinical trials were included in the final analysis. Routine antibiotic use in laparoscopic cholecystectomy, and possibly other clean procedures not involving placement of prostheses, is likely unnecessary. Similarly, venous thromboembolism prophylaxis is probably unnecessary for low-risk patients undergoing brief procedures. Of a wide variety of methods for reducing postoperative nausea and vomiting, serotonin receptor antagonists appear the most effective and should be considered for routine prophylaxis.

Comparison of ondansetron and granisetron for antiemetic prophylaxis in maxillofacial surgery patients receiving general anesthesia: a prospective, randomised, and double blind study

Objectives

To compare the efficacy of intravenous ondansetron (4 mg, 2 mL) and granisetron (2 mg, 2 mL) for preventing postoperative nausea and vomiting (PONV) in patients during oral and maxillofacial surgical procedures under general anesthesia.

Materials and Methods

A prospective, randomized, and double blind clinical study was carried out with 60 patients undergoing oral and maxillofacial surgical procedures under general anesthesia. Patients were divided into two groups of 30 individuals each. Approximately two minutes before induction of general anesthesia, each patient received either 4 mg (2 mL) ondansetron or 2 mg (2 mL) granisetron intravenously in a double blind manner. Balanced anesthetic technique was used for all patients. Patients were assessed for episodes of nausea, retching, vomiting, and the need for rescue antiemetic at intervals of 0-2, 3, 6, 12, and 24 hours after surgery. Incidence of complete response and adverse effects were assessed at 24 hours postoperatively. Data was tabulated and subjected to statistical analysis using the chi-square test, unpaired t-test, or the Mann-Whitney U-test as appropriate. A P-value less than 0.05 was considered statistically significant.

Results

There was no statistically significant difference between the two groups for incidence of PONV or the need for rescue antiemetic. Both study drugs were well tolerated with minimum adverse effects; the most common adverse effect was headache. The overall incidence of complete response in the granisetron group (86.7%) was significantly higher than the ondansetron group (60.0%).

Conclusion

Granisetron at an intravenous dose of 2 mg was found to be safe, well tolerated, and more effective by increasing the incidence of complete response compared to 4 mg intravenous ondansetron when used for antiemetic prophylaxis in maxillofacial surgery patients receiving general anesthesia. Benefits of granisetron include high receptor specificity and high potency, which make it a valuable alternative to ondansetron.

Nausea, vomiting and return of bowel function after colorectal surgery

BACKGROUND

Although patterns of return of bowel function (ROBF) following colorectal surgery with enhanced recovery after surgery (ERAS) programmes have been well delineated, regular morphine use is uncommon. This study describes the patterns of post-operative nausea and vomiting (PONV) and ROBF in this context.

METHOD

Patients undergoing elective major colorectal surgery on an ERAS programme over 1 year were included. Patient details, intra-operative course, post-operative management, outcomes and complications were collected retrospectively from clinical records. Statistical analysis was performed using Stata version 12.

RESULTS

A total of 136/142 (96%) patients received morphine for post-operative analgesia. Most (112/142, 79%) experienced either no vomiting (87/142, 61%) or small amounts (25/142, 18%). On average, patients without an ileostomy passed flatus and opened their bowels after 2.4 and 4.3 days, those with an ileostomy taking 1.5 and 2.1 days. Vomiting was not related to ROBF (P = 0.370) or overall complications; wound complications (odds ratio (OR) = 8.1, 95% confidence interval (CI): 2.0-32.5), electrolyte abnormalities (OR = 2.9, 95% CI: 1.2-7.1) and length of stay (hazard ratio = 1.3, 95% CI: 1.2-1.5) were related.

CONCLUSION

Most patients do not experience PONV in this context. ROBF is predictable without prolonged delays. This information could be used to allow confident early discharge and identify patients whose deviation from normal may indicate complications.

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.

A systematic review of interventions to facilitate ambulatory laparoscopic cholecystectomy

OBJECTIVES

  We aimed to perform a systematic review of the literature to identify interventions that may facilitate ambulatory laparoscopic cholecystectomy (LC).

METHODS

The PubMed and CENTRAL databases were interrogated for key MeSH headings. To be eligible for systematic review, trials were required to include outcome measures of postoperative pain, nausea or vomiting and time to discharge following LC. Interventions were subsequently assessed for the level of evidence and grade of recommendation given.

RESULTS

A total of 331 trials were identified, 68 of which met the predefined study inclusion criteria. Interventions which met Level I, Grade A recommendation included the administration of 8 mg i.v. dexamethasone, preoperative administration of analgesia including the use of non-steroidal anti-inflammatory or COX II inhibitors, intraoperative use of an anti-emetic, pre-incisional use of bupivacaine, administration of intraperitoneal bupivacaine on establishment of pneumoperitoneum, and avoidance of drains.

CONCLUSIONS

  High-quality evidence describing interventions that minimize barriers to ambulatory LC exists. Further studies will be required to determine the optimal combination of these interventions.

Safety and effectiveness of outpatient laparoscopic cholecystectomy in a teaching hospital: a prospective study of 110 consecutive patients

BACKGROUND

The aim of this study was to evaluate the safety and efficacy of outpatient laparoscopic cholecystectomy (OLC) in a day surgery unit in a teaching hospital. OLC was offered to patients with symptomatic cholelithiasis who met the following established inclusion criteria: ASA (American Society of Anesthesiology) physical status classification class I and II; age: 18 - 70 years; body mass index (BMI) < 30 kg/m2; patient acceptance and cooperation (informed consent); presence of a responsible adult to accompany the patient to his residency; patient residency in Athens. The primary study end-point was to evaluate success rates (patient discharge on the day of surgery), postoperative outcome (complications, re-admissions, morbidity and mortality) and patient satisfaction. A secondary endpoint was to evaluate its safe performance under appropriate supervision by higher surgical trainees (HSTs).

FINDINGS

110 consecutive patients, predominantly female (71%) and ASA I (89%) with a mean age 40.6 +/- 8.1 years underwent an OLC. Surgery was performed by a HST in 90 patients (81.8%). A mean postoperative pain score 3.3 (range 0-6) occurred in the majority of patients and no patient presented postoperative nausea or vomiting. Discharge on the day of surgery occurred in 95 cases (86%), while an overnight admission was required for 15 patients (14%). Re-admission following hospital discharge was necessary for 2 patients (1.8%) on day 2, due to persistent pain in the umbilical trocar site. The overall rate of major (trocar site bleeding) and minor morbidity was 15.5% (17 patients). At 1 week follow-up, 94 patients (85%) were satisfied with their experience undergoing OLC, with no difference between grades of operating surgeons.

CONCLUSIONS

This study confirmed that OLC is clinical effective and can be performed safely in a teaching hospital by supervised HSTs.

Clipless laparoscopic cholecystectomy using the Harmonic scalpel for cirrhotic patients: a prospective randomized study

BACKGROUND

Improved laparoscopic experiences have made laparoscopic cholecystectomy (LC) feasible options for cirrhotic patients. This study aimed to compare the traditional method for LC with LC using the Harmonic scalpel in terms of safety and efficacy for cirrhotic patients.

METHODS

In this study, group A (60 patients) underwent LC by the traditional method (TM) with clipping of both the cystic duct and artery and dissection of the gallbladder by diathermy, and group B (60 patients) had LC performed using Harmonic scalpel (HS) closure and division of both the cystic duct and artery with dissection of the gallbladder by the HS. The perioperative data were recorded.

RESULTS

The operation with the Harmonic scalpel was performed in less time than TM (45.17 ± 10.54 vs. 69.71 ± 13.01 min; p = 0.0001). The intraoperative blood loss was significantly more with TM (133 ± 131.13 l vs. 70.13 ± 80.79 ml; p = 0.002). The conversion rate was 5% with TM and 3.3% with HS (p = 0.65). The incidence of gallbladder peroration was lower in the HS group (10% vs. 18.3%; p = 0.03). Bile leak was encountered in 1.7% with HS and 3.3% with TM (p = 0.45). The visual analog scale (VAS) for pain with HS on postoperative day 1 was (3.07 ± 2.02 vs. 4.4 ± 2.11 (p = 0.001).

CONCLUSION

For cirrhotic patients, LC still is more complicated and difficult than for patients without cirrhosis. The Harmonic scalpel provides complete hemobiliary stasis and is a safe alternative to the standard clipping of the cystic duct and artery for cirrhotic patients. It offers a shorter operative duration and less blood loss.

Comparative study between clipless laparoscopic cholecystectomy by harmonic scalpel versus conventional method: a prospective randomized study

BACKGROUND

This study was planned to compare the traditional method of laparoscopic cholecystectomy (LC) versus LC using harmonic as regard the safety and efficacy.

MATERIAL AND METHODS

This study included group A (70 patients) in whom LC was conducted using the traditional method (TM) by clipping both cystic duct and artery and dissection of gallbladder from liver bed by diathermy, and group B (70 patients) LC was conducted using harmonic scalpel (HS) closure and division of both cystic duct and artery and dissection of gallbladder from liver bed by HS. The intraoperative and postoperative parameters were collected including duration of operation, postoperative pain, and complications.

RESULTS

HS provides a shorter operative duration than TM (33.21 + 9.6 vs. 51.7 + 13.79, respectively, p = 0.001), with a significant less incidence of gallbladder peroration (7.1% vs. 18.6, p = 0.04) and less rate of conversion to open cholecystectomy but not reach a statistical significance. The amount of postoperative drainage is significantly less in HS (29 + 30 vs. 47.7 + 31, p = 0.001). No postoperative bile leak was encountered in HS, but it occurred in 2.9% of patients in TM. VAS in HS at 12 h postoperative was 3.25 + 1.84 vs 5.01 + 1.2 (p = 0.001) and at 24 h postoperative was 3.12 + 1.64 vs. 4.48 + 1.89 (p = 0.001).

CONCLUSION

HS provides a complete hemobiliary stasis and is a safe alternative to stander clip of cystic duct and artery. It provides a shorter operative duration, less incidence of gallbladder perforation, less postoperative pain, and less rate of conversion to open cholecystectomy.

Does auricular acupuncture reduce postoperative vomiting after cholecystectomy?

PURPOSE

To find the efficacy of auricular acupuncture for the prevention of postoperative nausea and vomiting after cholecystectomy.

MATERIALS AND METHODS

One hundred (100) female patients undergoing transabdominal cholecystectomy were randomly allocated to two groups of 50 (auricular acupuncture treatment group and nontreatment group) in order to test the effectiveness of auricular acupuncture. Statistical significance (p < 0.05) was determined using an unpaired t-test for age, weight, height, and duration of anesthesia; a chi-square test was used to analyze the incidence of vomiting.

RESULTS

There was no significant difference in age, weight, height, or duration of anesthesia among the two groups of patients. There was a significant difference between the control and auricular acupuncture treatment groups in the incidence of vomiting 24 hours after surgery (66% and 0%, respectively, p < 0.01). No noteworthy side effects from treatment were observed.

CONCLUSION

Auricular acupuncture is effective in reducing vomiting following transabdominal cholecystectomy in female patients.

Predictive factors of long hospital stay after laparoscopic cholecystectomy

OBJECTIVE

Laparoscopic cholecystectomy (LC) is the most common minimally invasive surgery in Hong Kong. However, ambulatory LC is not a common practice in Hong Kong. This study aims to identify the causes of long hospital stay after elective LC and to delineate a guideline for ambulatory LC.

METHODS

A retrospective analysis of 278 patients who underwent successful elective LC in a single unit between 1 January 2002 and 31 December 2003 was performed. They were divided into two groups: LS group had a long hospital stay (>24 hours after operation) and SS group had a short hospital stay. A total of 18 variables, including five patient variables, nine operative variables and four postoperative variables, were identified for univariate analysis. Significant pre- and postoperative factors were included in the multivariate analysis to identify independent predictive factors for long hospital stay.

RESULTS

Of the 278 patients, 118 (44.2%) could be discharged within 24 hours, while 149 (55.8%) had long hospital stay. Nine significant factors were identified in the univariate analysis; three independent factors were found to predict long hospital stay in the multivariate analysis. Patients with age more than 60 years had double risk of long hospital stay. Patients who could not tolerate diet within 8 hours or took more than two tablets of oral analgesia (dologesics) had a four- and threefold increase in risk of long hospital stay, respectively.

CONCLUSION

With careful patient selection, optimal postoperative pain control and early resumption of diet with better management of postoperative nausea and vomiting, ambulatory LC was feasible and safe.

Post-operative recovery profile after laparoscopic cholecystectomy: a prospective, observational study of a multimodal anaesthetic regime

BACKGROUND

Laparoscopic cholecystectomy is now often an ambulatory procedure, but dependent on short-term post-operative complaints of pain and post-operative nausea and vomiting (PONV). The efficacy of post-anaesthesia care units (PACUs) is therefore important to facilitate return to normal functions. We investigated the feasibility and efficacy of a standardized, evidence-based anaesthesia/analgesic regime to identify residual problems in the early post-operative phase.

METHODS

One hundred and thirty-four consecutive patients admitted for elective laparoscopic cholecystectomy at Hvidovre University Hospital between 15 March and 30 September 2005 were included in the study. The standardized, evidence-based regime consisted of total intravenous (i.v.) anaesthesia (propofol-remifentanil), well-defined fluid therapy, dexamethasone, ketorolac, ondansetron, sufentanil and incisional bupivacaine intra-operatively, and in the PACU on demand (prn) administration of sufentanil, morphine, paracetamol, ondansetron, droperidol, oral fluids and oxygen (if SpO(2) < 93%) with PACU discharge using a modified Aldrete score.

RESULTS

Protocol violations were moderate and occurred unsystematically, 8% had medical violations and 10% did not receive the pre-planned fluid amount. Severe PONV was seen in 2%. Thirteen per cent experienced severe pain, and the presence of any pain and/or PONV were predictors of an extended PACU stay. Mean oxygen demand was 46 min (range, 0-300 min), which influenced time to discharge (mean, 88 min). There were on average 2.7 treatment interventions (range, 0-11) before discharge.

CONCLUSION

An evidence-based, multimodal approach to the anaesthetic/analgesic management in laparoscopic cholecystectomy is feasible and advantageous in the early post-operative phase. Pain and PONV are predictors of a complicated recovery profile and deserve further attention. Transient oxygen desaturations postpone discharge from the PACU, but the clinical significance of this fact is questionable.

Drugs for preventing postoperative nausea and vomiting

BACKGROUND

Drugs can prevent postoperative nausea and vomiting, but their relative efficacies and side effects have not been compared within one systematic review.

OBJECTIVES

The objective of this review was to assess the prevention of postoperative nausea and vomiting by drugs and the development of any side effects.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2004), MEDLINE (January 1966 to May 2004), EMBASE (January 1985 to May 2004), CINAHL (1982 to May 2004), AMED (1985 to May 2004), SIGLE (to May 2004), ISI WOS (to May 2004), LILAC (to May 2004) and INGENTA bibliographies.

SELECTION CRITERIA

We included randomized controlled trials that compared a drug with placebo or another drug, or compared doses or timing of administration, that reported postoperative nausea or vomiting as an outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted outcome data.

MAIN RESULTS

We included 737 studies involving 103,237 people. Compared to placebo, eight drugs prevented postoperative nausea and vomiting: droperidol, metoclopramide, ondansetron, tropisetron, dolasetron, dexamethasone, cyclizine and granisetron. Publication bias makes evidence for differences among these drugs unreliable. The relative risks (RR) versus placebo varied between 0.60 and 0.80, depending upon the drug and outcome. Evidence for side effects was sparse: droperidol was sedative (RR 1.32) and headache was more common after ondansetron (RR 1.16).

AUTHORS' CONCLUSIONS

Either nausea or vomiting is reported to affect, at most, 80 out of 100 people after surgery. If all 100 of these people are given one of the listed drugs, about 28 would benefit and 72 would not. Nausea and vomiting are usually less common and, therefore, drugs are less useful. For 100 people, of whom 30 would vomit or feel sick after surgery if given placebo, 10 people would benefit from a drug and 90 would not. Between one to five patients out of every 100 people may experience a mild side effect, such as sedation or headache, when given an antiemetic drug. Collaborative research should focus on determining whether antiemetic drugs cause more severe, probably rare, side effects. Further comparison of the antiemetic effect of one drug versus another is not a research priority.

Randomized clinical trial of day-care versus overnight-stay laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy has been performed as a day-care procedure for many years. Few studies have been conducted with primary focus on patient acceptance and preferences in terms of quality of life for this practice compared with overnight stay.

METHODS

Data from 100 patients with symptomatic gallstones randomized to laparoscopic cholecystectomy performed either as a day-care procedure or with overnight stay were analysed. Complications, admissions and readmissions, quality of life and health economic aspects were assessed. Two instruments were used to assess quality of life, the Hospital Anxiety and Depression Scale (HADS) and the Psychological General Well-Being Index (PGWB).

RESULTS

Forty-eight (92 per cent) of 52 patients in day-care group were discharged 4-8 h after the operation. Forty-two (88 per cent) of 48 in the overnight group went home on the first day after surgery. The overall conversion rate was 2 per cent. Two patients had complications after surgery, both in the day-care group. No patient in either group was readmitted. There was no significant difference in total quality of life score between the two groups. The mean direct medical cost per patient in the day-care group (3085 Euros) was lower than that in the overnight group (3394 Euros).

CONCLUSION

Laparoscopic cholecystectomy can be performed as a day-case procedure with a low rate of complications and admissions/readmissions. Patient acceptance in terms of quality of life variables is similar to that for cholecystectomy with an overnight stay. The day-care strategy is associated with a reduction in cost.

Laparoscopic Cholecystectomy as a Day Surgery Procedure: Implementation and Audit of 136 Consecutive Cases in a University Hospital

Laparoscopic cholecystectomy (LC) has been routinely performed since 1989 at our institution, and patients were traditionally admitted for 2 days. In 1996 we implemented a protocol for LC as a day surgery procedure at our center. Although initially reported by others, it has not yet been introduced as routine in Switzerland. The objective of this prospective study was to determine acceptability and safety of LC as an outpatient procedure in a university hospital. Data were collected prospectively for 136 LCs between January 1996 and December 2001. Patients were selected for the study if they wanted to go home within less than 24 hours, had no previous jaundice, and had no anesthetic contraindication. Systematic preoperative liver function tests and hepatic ultrasonography were performed. All patients were admitted on the day of operation. LC was performed using a three-trocar technique. Systematic cholangiography was performed, and all the procedures were completed laparoscopically. There were no common bile duct explorations. Postoperative complications were the following: nausea in seven patients, a minor umbilical hematoma in two. According to patient preference, 101 (74%) were discharged after an overnight stay (less than 24 hours) and 32 (24%) on the same day. The unplanned admission rate was 2%, and none of the patients was subsequently readmitted. The reasons for unplanned admissions were two patients with persistent nausea and one patient for whom an overnight stay was scheduled who presented with a ruptured subcapsular hematoma of the liver. Altogether, 97% of the patients were satisfied with the care they received. Operative costs were not significantly different when comparing inpatient and outpatient LC. The main postoperative savings were in the postoperative costs. Our results confirm that LC as a day surgery procedure is safe, effective, and acceptable to patients and their relatives. These results were achieved by using selection criteria that considered not only the surgical pathology but also the individual and by using appropriate techniques and planned postoperative analgesia.

Day-only laparoscopic cholecystectomy in a regional teaching hospital

BACKGROUND

Day-only laparoscopic cholecystectomy (DOLC) has been demonstrated to be a safe and feasible procedure. The aim of the present study was to introduce DOLC to a busy teaching hospital without a separate day-surgery facility, to identify any problems associated with early discharge, and to determine patient satisfaction.

METHODS

Over a 2-year period, all patients undergoing elective laparoscopic cholecystectomy under one surgeon were prospectively studied. Patients satisfying criteria for DOLC were offered the procedure. All patients were sent anonymous satisfaction surveys postoperatively.

RESULTS

One hundred and one patients underwent elective laparoscopic cholecystectomies and 41 of these patients were booked for DOLC. Thirty-three (80%) were successfully discharged the same day and there were no complications related to early discharge. Only two of eight unplanned admissions were because of postoperative pain or nausea. Thirty-two (78%) of DOLC patients replied to our survey and of those, 24 (78%) were satisfied with their length of stay. The extra strain placed on day-stay ward resources was reflected in patient survey comments on their care.

CONCLUSIONS

Our findings support the evidence that DOLC is safe and feasible. However, in a busy teaching hospital with tight budget constraints and no separate day-surgery facility we found many patients satisfied with their length of stay but not always with the quality of care they received on the day-stay ward. The latter was insufficiently equipped to handle procedures of this complexity. So although in theory DOLC has many advantages, we are unable to institute this as routine practice at this time.

Effect of drainage on postoperative nausea, vomiting, and pain after laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is associated with a high incidence of postoperative pain, nausea, and vomiting. Pneumoperitoneum created during the operation and residual gas after the operation are two of the factors in postoperative pain and nausea. We studied the effects of a subdiaphragmatic gas drain, which is intended to decrease the residual gas, on postoperative pain, nausea, and vomiting after laparoscopic cholecystectomy.

PATIENTS AND METHODS

Seventy patients were randomized into two demographically and clinically comparable groups: drainage and control. Postoperative pain, nausea, and vomiting were measured by verbal grading and visual analog scale 2-72 h postoperatively. Analgesic and antiemetic use and incidence of retching, vomiting and other complaints were also recorded.

RESULTS

Subdiaphragmatic drain effectively reduced the incidence and amount of subdiaphragmatic gas bubble. The incidence and severity of nausea was lower in the drainage group at 72 h. Although severity of pain was lower at 8 and 12 h in the drainage group, the difference was not significant. There was also no difference between the groups in regard to analgesic and antiemetic use.

CONCLUSIONS

Subdiaphragmatic drain offers only minor, if any, benefit on postoperative pain, nausea, and vomiting after laparoscopic cholecystectomy, and this effect is probably clinically irrelevant.

Dolasetron, but not metoclopramide prevents nausea and vomiting in patients undergoing laparoscopic cholecystectomy

PURPOSE

Postoperative nausea and vomiting (PONV) is one of the most frequent complications of general anesthesia. The aim of the study was to compare the antiemetic efficacy of dolasetron and metoclopramide after inhalational or i.v. anesthesia (IVA).

METHODS

In a randomized, placebo-controlled, double-blinded trial we evaluated the efficacy of 12.5 mg dolasetron i.v. and 20 mg metoclopramide (MCP) i.v. in preventing PONV in 387 patients (ASA I-III) undergoing laparoscopic cholecystectomy. Patients were allocated randomly to one of three main groups: Group D (n = 129) received 12.5 mg dolasetron i.v., Group MCP (n = 129) 20 mg MCP i.v., and Group C (n = 129) saline as placebo i.v. Using a multifactorial study design, one third of each main group (n = 43) was further randomized to receive either general anesthesia with desflurane, isoflurane or IVA with propofol and remifentanil. PONV, postoperative piritramide and droperidol consumption were documented.

RESULTS

Independent from the anesthesia regimen chosen, dolasetron reduced PONV (19%) significantly compared to MCP (45%) and placebo (46%). Furthermore we could show a significant difference in the incidence of PONV between IVA (28%) and isoflurane (46%), but not in comparison to desflurane (36%). Patients receiving IVA had a higher postoperative piritramide consumption compared to the two other groups.

CONCLUSIONS

The results of our study suggest that dolasetron was more effective than MCP and placebo in preventing PONV. This action is independent of the anesthetic technique used.

Acupressure and ondansetron for postoperative nausea and vomiting after laparoscopic cholecystectomy

PURPOSE

To compare the efficacy of acupressure wrist bands and ondansetron for the prevention of postoperative nausea and vomiting (PONV).

METHODS

One hundred and fifty ASA I-II, patients undergoing elective laparoscopic cholecystectomy were included in a randomized, prospective, double-blind and placebo-controlled study. Patients were divided into three groups of 50. Group I was the control; Group II received ondansetron 4 mg iv just prior to induction of anesthesia; in Group III acupressure wristbands were applied at the P6 points. Acupressure wrist bands were placed inappropriately in Groups I and II. The acupressure wrist bands were applied 30 min prior to induction of anesthesia and removed six hours following surgery. Anesthesia was standardized. PONV were evaluated separately as none, mild, moderate or severe within six hours of patients' arrival in the postanesthesia care unit and then at 24 hr after surgery by a blinded observer. If patients vomited more than once, they were given 4 mg ondansetron iv as the rescue antiemetic. Results were analyzed by Z test. A P value of < 0.05 was taken as significant.

RESULTS

The incidence of PONV and the requirement of rescue medication were significantly lower in both the acupressure and ondansetron groups during the first six hours.

CONCLUSION

Acupressure at P6 causes a significant reduction in the incidence of PONV and the requirement for rescue medication in the first six hours following laparoscopic cholecystectomy, similar to that of ondansetron 4 mg iv.

The prevention of emesis in plastic surgery: a randomized, prospective study

Perhaps the most unpleasant experience following outpatient plastic surgery procedures is postoperative nausea and vomiting. Postoperative nausea and vomiting often results in delayed recovery time and unintended admission, and it can be a contributing factor to the formation of hematoma following rhytidectomy. Ondansetron (Zofran) has proven benefit in preventing postoperative nausea and vomiting if given before general anesthesia in a variety of surgical procedures. Its utility in cases performed under conscious sedation has not been determined. The purpose of this study was (1) to test the ability of prophylactic ondansetron to prevent postoperative nausea and vomiting in plastic surgery cases performed under conscious sedation, and (2) to determine relative risk factors for postoperative nausea and vomiting and a selection policy for the administration of antiemetic prophylaxis. This was a prospective, randomized, double-blind study. One hundred twenty patients were enrolled after giving informed consent. Patients received a single dose of either placebo or ondansetron (4 mg intravenously) before administration of sedation. Sedation administration followed a standardized institutional protocol, using midazolam and fentanyl. Data were recorded from a series of three questionnaires: preoperatively, immediately postoperatively, and at the time of the first office return. Data were confirmed by means of telephone interview, chart analysis, and nursing documentation. Multivariate analysis was conducted. Nausea and emesis occurred with an overall frequency of 33 percent and 22 percent, respectively. Postoperative nausea and vomiting was associated with statistically longer recovery periods. The incidence of emesis was statistically higher among women, among those undergoing facial rejuvenation, and among those with a history of opioid-induced emesis or postoperative nausea and vomiting following a previous operation (p < 0.05). The incidence of postoperative nausea and vomiting paralleled increases in case duration; the incidence of emesis was zero in cases less than 90 minutes in duration. Ondansetron significantly reduced the incidence of emesis overall (placebo, 30 percent; ondansetron, 13 percent; p < 0.05). Postoperative perception of nausea was significantly lower among those who had received ondansetron (p < 0.05). These results confirm the efficacy of ondansetron for the prevention of postoperative nausea and vomiting in plastic surgery cases under conscious sedation. In those who are at increased risk, prophylaxis should be considered. Such risks include female gender, facial rejuvenation procedures, and a patient history of opioid-induced emesis or postoperative nausea and vomiting following a prior operation. The zero incidence of emesis in cases less than 90 minutes does not support the routine use of prophylaxis in such cases. Patient satisfaction in plastic surgery is derived from the overall subjective experience of the event as much as by the final result. By remaining attentive to patient concerns and optimizing perioperative care, we can improve the subjective experience for our patients.

Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway

OBJECTIVE

To determine the success of a clinical pathway for outpatient laparoscopic cholecystectomy (LC) in an academic health center, and to assess the impact of pathway implementation on same-day discharge rates, safety, patient satisfaction, and resource utilization.

SUMMARY BACKGROUND DATA

Laparoscopic cholecystectomy is reported to be safe for patients and acceptable as an outpatient procedure. Whether this experience can be translated to an academic health center or larger hospital is uncertain. Clinical pathways guide the care of specific patient populations with the goal of enhancing patient care while optimizing resource utilization. The effectiveness of these pathways in achieving their goals is not well studied.

METHODS

During a 12-month period beginning April 1, 1999, all patients eligible for an elective LC (n = 177) participated in a clinical pathway developed to transition LC to an outpatient procedure. These were compared with all patients undergoing elective LC (n = 208) in the 15 months immediately before pathway implementation. Successful same-day discharges, reasons for postoperative admission, readmission rates, complications, deaths, and patient satisfaction were compared. Average length of stay and total hospital costs were calculated and compared.

RESULTS

After pathway implementation, the proportion of same-day discharges increased significantly, from 21% to 72%. Unplanned postoperative admissions decreased as experience with the pathway increased. Patient characteristics, need for readmission, complications, and deaths were not different between the groups. Patients surveyed were highly satisfied with their care. Resource utilization declined, resulting in more available inpatient beds and substantial cost savings.

CONCLUSIONS

Implementation of a clinical pathway for outpatient LC was successful, safe, and satisfying for patients. Converting LC to an outpatient procedure resulted in a significant reduction in medical resource use, including a decreased length of stay and total cost of care.

Metoclopramide versus ondansetron in prophylaxis of nausea and vomiting for laparoscopic cholecystectomy

BACKGROUND

Postoperative nausea and vomiting are significant problems in laparoscopic surgery. This double-blind, randomized, prospective trial compares the prophylactic use of metoclopramide, ondansetron, and placebo for the treatment of postoperative nausea and vomiting in patients undergoing outpatient laparoscopic cholecystectomy.

METHODS

Two hundred thirty-two patients aged 18 to 73 years were randomized into three groups. Patients received intravenously 10 mg of metoclopramide, 4 mg of ondansetron, or placebo in a double-blinded manner prior to surgery.

RESULTS

The incidence of nausea was 32% for metoclopramide, 45% for ondansetron, and 44% for placebo in the postanesthesia care unit or day surgery, which was not statistically significant. The incidence of vomiting was 8% for metoclopramide, 4% for ondansetron, and 22% for placebo in the postanesthesia care unit or day surgery. These differences were statistically significant when comparing both drugs to placebo but not when comparing both drugs to each other.

CONCLUSION

Prophylactic administration of metoclopramide or ondansetron significantly reduces the incidence of postoperative vomiting for laparoscopic cholecystectomy, but neither drug was found to be significantly more effective than the other. Metoclopramide is a more cost-effective treatment.

Ondansetron is no more effective than supplemental intraoperative oxygen for prevention of postoperative nausea and vomiting

Supplemental oxygen maintained during and for 2 h after colon resection halves the incidence of nausea and vomiting. Whether supplemental oxygen restricted to the intraoperative period is sufficient remains unknown. Similarly, the relative efficacy of supplemental oxygen and ondansetron is unknown. We tested the hypothesis that intraoperative supplemental oxygen reduces the incidence of postoperative nausea and vomiting. Patients (n = 240) undergoing gynecological laparoscopy were given a standardized isoflurane anesthetic. After induction, they were randomly assigned to the following three groups: routine oxygen administration with 30% oxygen, balance nitrogen (30% Oxygen group), supplemental oxygen administration with 80% oxygen, balance nitrogen (80% Oxygen group), and Ondansetron 8 mg (immediately after induction), combined with 30% oxygen, balance nitrogen (Ondansetron group). The overall incidence of nausea and/or vomiting during the initial 24 postoperative h was 44% in the patients assigned to 30% oxygen and 30% in the Ondansetron group, but only 22% in those given 80% oxygen. The incidence was thus halved by supplemental oxygen and was significantly less than with 30% oxygen. There were, however, no significant differences between the 30% oxygen and ondansetron groups, or between the ondansetron and 80% oxygen groups. We conclude that supplemental oxygen effectively prevents postoperative nausea and vomiting after gynecological laparoscopic surgery; furthermore, ondansetron is no more effective than supplemental oxygen.

IMPLICATIONS

Supplemental oxygen reduces the risk of postoperative nausea and vomiting (PONV) as well or better than 8 mg of ondansetron. Because oxygen is inexpensive and essentially risk-free, supplemental oxygen is a preferable method of reducing PONV.

MUTIRÕES DE COLECISTECTOMIA POR VIDEOLAPAROSCOPIA EM REGIME DE CIRURGIA AMBULATORIAL

Introdução: As listas de espera para colecistectomia, associadas à elevada demanda dos leitos e salas cirúrgicas dos Hospitais Universitários, são incentivos para adoção de novos programas de assistência. Objetivo: Avaliar o processo de organização e os resultados clínicos dos Mutirões de Colecistectomia por Videolaparoscopia, em regime de Cirurgia Ambulatorial. Pacientes e Métodos: Dentre os 314 pacientes portadores de colelitíase sintomática que aguardavam cirurgia no HCFMRP-USP, 160 foram selecionados para tratamento em regime ambulatorial. Uma equipe multiprofissional, formada por cirurgiões, anestesistas, enfermeiros e assistentes sociais, programou 4 mutirões para serem realizados em fins de semana, em função da disponibilidade do bloco cirúrgico e da sala de recuperação pós-anestésica. Mediante avaliação retrospectiva, foram analisados 79 prontuários dos pacientes operados nos Mutirões I e II (Grupo A) e 79 dos 80 operados nos Mutirões III e IV (Grupo B). Análise estatística: teste de Wilcoxon e exato de Fisher (p<0,05). Resultados: As co-morbidades foram registradas em 48 pacientes do Grupo A - (60,8%) e em 31 do Grupo B (39,8%) (p=0,007). A inflamação aguda e a escleroatrofia da vesícula foram observadas em 10 pacientes do Grupo A (12,7%) e em 2 do Grupo B (2,6%). A duração média das operações, em minutos, foi de 90 (25-240) no Grupo A e de 68,2 (20-180) no Grupo B (p=0,002). Houve uma conversão em cada Grupo (1,3%). A profilaxia da dor e dos vômitos foi realizada, respectivamente, em 13 (16,4%) e em 2 (2,5%) pacientes do Grupo A. No Grupo B, 63 pacientes (79,7%) receberam analgésicos e 73 (92,5%) antieméticos de forma profilática. A dor abdominal, os vômitos e os sintomas cardiorespiratórios, na recuperação pós-anestésica, acometeram, respectivamente, 34 (43%), 18 (22,6%) e 10 (12,6%) dos pacientes do Grupo A e 18 (22,8%), 14 (17,7%) e 3 (3,8%) do Grupo B. A necessidade de pernoite foi maior no Grupo A: 45 pacientes (50,7%) com permanência hospitalar média de 18,3 horas (8,2-26), enquanto no Grupo B houve 5 pernoites e a média de permanência foi de 7,5 horas (4-24) (p=0,000). Ocorreram 5 internações no Grupo A (6,3%) e 2 no Grupo B (2,5%). A reavaliação médica, na primeira semana, foi necessária em 8 pacientes do Grupo A (10,2%) e redundou em 3 readmissões (3,8%). No Grupo B, 2 pacientes (2,6%) procuraram o serviço de saúde e a readmissão não foi necessária. No Grupo A, 2 pacientes apresentaram coleperitônio e 1 foi reoperado; não houve óbitos em nenhum Grupo. Conclusão: O aprimoramento no processo de seleção e nos cuidados perioperatórios para colecistectomia videolaparoscópica, em regime ambulatorial, assegura o tratamento, na forma de mutirões, como estratégia eventual de redução das listas de espera.