Laparoscopic Cholecystectomy in Day Surgery

1. Search date: July, 2009

2. Search terms: “laparoscopic cholecystectomy hospital discharge”

3. Limits: English language, humans, and published within the last 5 years

4. Results: 58 articles, abstracts reviewed, 8 chosen as pertinent

Levels of evidence

I – Evidence from properly conducted randomized, controlled trials

II – Evidence from controlled trials without randomization or cohort or case-control studies or multiple time series, dramatic uncontrolled experiments

III – Descriptive case series, opinions of expert panels

Scale used for recommendation grading

Grade A – Based on high-level (level I or II), well-performed studies with uniform interpretation and conclusions by the expert panel

Grade B – Based on high-level, well-performed studies with varying interpretation and conclusions by the expert panel

Grade C – Based on lower-level evidence (level II or less) with inconsistent findings and/or varying interpretations or conclusions by the expert panel

These guidelines stated the following conclusions:

Patients undergoing uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis may be discharged home on the day of surgery [10]. (Level II, Grade B)
Control of postoperative pain, nausea, and vomiting is important to successful same-day discharge [11], and admission rates despite planned same-day discharge are reported to be 1–39 %; patients older than age 50 may be at increased risk for admission [11–17]. (Level II, Grade B)
Readmission rates range from 0 to 8 %; common causes for readmission after same-day discharge include pain, intra-abdominal fluid collections, bile leaks, and bile duct stones [10, 12]. (Level II, Grade B)
Time to discharge after surgery for patients with acute cholecystitis and bile duct stones or in patients converted to an open procedure should be determined on an individual basis. (Level III, Grade A)

10.2 Methods

Moving from these conclusions, we thought to analyze the available data in PubMed and to restrict the research just on specific papers concerning day-case or ambulatory LC within the last 20 years with the following queries:

Search date: March 2013.

Search terms:

“laparoscopic cholecystectomy
laparoscopic cholecystectomy and hospital discharge
laparoscopic cholecystectomy and day case
laparoscopic cholecystectomy and ambulatory procedures
laparoscopic cholecystectomy and hospital discharge and day case and ambulatory procedures”

Results:

laparoscopic cholecystectomy – 5,490 articles
laparoscopic cholecystectomy and hospital discharge – 138 articles
laparoscopic cholecystectomy and day case – 175 articles
laparoscopic cholecystectomy and ambulatory procedures – 137 articles
laparoscopic cholecystectomy and hospital discharge and day case and ambulatory procedures – 15 articles

All articles published in English were initially collected. From this huge pull of papers, the randomized clinical trials, multicenter studies, practice guidelines, systematic reviews and meta-analyses, and Cochrane Reviews were included for a deeper examination of their abstracts. Finally, we selected 35 papers for the most accurate and extensive research of the methods, the results, and the conclusive statements (Table 10.2).

Table 10.2

Selected studies and their level of evidence

N. 4	Meta-analysis and review of clinical trials [10, 18–20]	LoE 1
N. 5	Randomized controlled trial [21–25]	LoE 2
N. 12	Nonrandomized prospective cohort/observational study [12, 14–17, 26–32]	LoE 3
N. 12	Retrospective case series [11, 33–43]	LoE 4
N. 2	Questionnaire survey [44, 45]	LoE 5

The level of evidence of these selected papers was graded according to Oxford Centre for Evidence-Based Medicine 2011.

10.3 Discussion

During the years after the initial experiences, the surgeons have become more and more confident to suggest ever faster discharges. Ambulatory LC (ALC) has automatically been the next step in patients’ management. Nowadays day-case LC (DLC) has been adopted with different rates and it is not fully accepted by all surgeons. The main question concerns whether the DLC might be feasible for all or just for selected cases. So some aspects deserve to be deepened. First of all it is useful to point out our attention on its definition, safety in terms of surgical results, readmissions, eventual selective criteria for patients, the costs, patients’ satisfaction, and return to normal activities.

The day surgery is a model of care that allows to diversify the flow of surgical patients, allowing, in over half the cases, the discharge on the same day of admission or no later than the morning of the next day. First of all, we must pay attention to the definition of day surgery, because at the international level, different terms are used, such as ambulatory surgery, day surgery, day case, same-day surgery, 1-day surgery, office-based ambulatory surgery, and office-based surgery, with considerable difficulties of interpretation. The term ambulatory surgery must be considered synonymous with day surgery, day case, and/or same-day surgery and it should not include an overnight stay, which is expected in cases of extended recovery. The ambulatory/day surgery, with or without an overnight stay, must also be distinguished from office-based ambulatory surgery, or office-based surgery, namely, the ability to perform surgery or diagnostic procedures and/or treatment in the clinics, also placed away from shelter facilities.

The proportion of ambulatory management generally increases with experience [36] [LoE 4].

In some cases the hospital stay lasts until the day after the LC and the admission overnight after the operation can be due to different surgical, social, or logistic reasons [32] [LoE 3]: surgeon preference, operation late in the afternoon [40] [LoE 4], medical problems (i.e., nausea and vomiting, pain, urinary retention, intraoperative pneumothorax) [19, 40, 42, 43] [LoE1], doubt about reimbursement by insurance companies or psychological [43] [LoE 4], age (elderly patients showed a tendency to like to stay in the hospital rather than being a day case) [37] [LoE 4], medical observation, patient’s preference [40, 42] [LoE 4], and conversion to laparotomy [17] [LoE 3].

There are no significant differences between DLC and overnight lap cholecystectomy (ONLC) as regards to morbidity, prolongation of hospital stay, readmission rates, pain, quality of life, patient satisfaction, and return to normal activity and work [18] [LoE 1].

In the majority of papers, good results have been reported.

DLC is safe because its morbidity and mortality rates are low. Complications and mortality rates vary, respectively, from 0 to 11.6 % [12, 17, 21, 24, 36, 37, 41–43] [LoE 2] and from 0 to 0.13 % (0.08 in ALC and 0.5 % in ONLC) [27, 37] [LoE 3]. The overall conversion rate varies from 0 to 2 % [31, 32] [LoE 3]. Prolonged hospital stay and readmission are connected with minor and more easily controlled complications or social reasons [10] [LoE 1] and are a valid indicator of safety.

Some patients later can require admission to the inpatient department for conversion to the open procedure or relaparoscopy [12, 18, 19, 32, 34, 38] [LoE 1], but the readmission rate is low (0–10 %) [12, 16, 17, 22, 24, 27, 28, 33, 36, 37, 40, 42, 43] [LoE 2] and less frequent after ALC than in ONLC [27] [LoE 3].

It is common opinion that DLC is indicated for selected cases and the selection may concern medical and logistic criteria.

Some exclusion criteria may be considered advisable: common bile duct stones [10, 32, 43] [LoE 1], acute cholecystitis [10, 38, 43] [LoE1], pancreatitis [10, 43] [LoE1], patients’ age [11, 12, 16, 29, 32] [LoE 3], and intraoperative complications [11] [LoE 4].

In different experiences some inclusion criteria have been adopted and they concern:

(a)

Medical aspects: absence of symptomatic cholelithiasis [34] [LoE 4] or low risk for concomitant presence of bile duct stones [34] [LoE 4], preoperative workout (abdominal US, liver function tests, and routine preoperative tests) [10] [LoE 1], absence of other diseases [18, 19] [LoE 1], surgical risk measured by the ASA (American Society of Anesthesiologists) score [10] [LoE 1] (grade < II [12, 16, 32–34, 40, 43] [LoE 3] or < III [38] [LoE 4]), and body mass index (BMI) [10, 32, 34, 40] [LoE 1].

(b)

Logistic aspects: operation performed in the morning [32, 33] [LoE3], social aspect [10] [LoE 1], informed consent [38] [LoE 4], living in easy reach of the hospital [18, 19, 34] [LoE 1] (within 50 km [32] [LoE 4] or 100 km of the hospital [40] [LoE 4] or 1 h traveling time [12] [LoE 3]), willing to make their own arrangements for a return to hospital in case of problems [12] [LoE 3], and availability of a responsible carer [16, 18, 19, 34, 40, 43] [LoE 1].

(c)

Surgeon’s expertnesses: in the centers in which the trainees are involved in day DLC, there are no significant differences in terms of number of complications, patient outcomes, prolonged stay, and readmission [10] [LoE 1]. Many procedures (62 %) can be also performed by trainees in DLC, with statistically significant difference in operating time between consultants (41 min) and trainees (47 min) (p = 0.001), but clinical outcome or patient satisfaction is the same [30] [LoE 3].

The adoption of new devices might be important such as the use of the harmonic scalpel that is associated with a low complication rate and a high-same-day discharge rate when carried out as DLC [35] [LoE 4]. Sensible scheduling of operations and avoiding the use of drains may decrease unplanned admissions following DLC [40] [LoE 4].

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