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Revista Española de Enfermedades Digestivas

versión impresa ISSN 1130-0108

Rev. esp. enferm. dig. v.96 n.7 Madrid jul. 2004




Laparoscopic cholecystectomy and outpatient surgery


In recent years it may be safely stated that a major change in the understanding of surgery has taken place with laparoscopic surgery in the late 1980s. Indeed, the linking of technologic development circumstances to the will of a number of surgeons to offer less damaging surgery led to the notion of "minimally aggressive surgery", in which laparoscopic surgery is paradigmatic.

Laparoscopic surgery entailed a number of nowadays universally accepted benefits for patients. In fact, initial distrust regarding this way of surgery has led to a careful analysis of its results which we are convinced was unparalleled before for surgical techniques. Thus, not only has laparoscopy advanced in itself, but traditional techniques have also benefited from greater rigor in outcome studies, and healthy competition has shown up regarding "lesser invasion" with increasingly small incisions, and shorter stays and postoperative periods, all of which represents great value for patients.

Regarding laparoscopic cholecystectomy (LC), this procedure evolved in 6 years -from the time is was first used back in 1987- to become the gold-standard in the treatment of symptomatic cholethiasis. However, it should be noted that scientific evidence supporting its superiority versus traditional cholecystectomy as based upon controlled randomized studies is pretty scant, regardless its wide acceptance by the health-care community and patients as well.

Although many comparative studies exist on all sorts of partial aspects that clear-ly reveal the benefits of LC -from classic morbidity and mortality, and hospital stay studies to sophisticated studies on- say -post-procedural immune response- only two prospective, randomized, single-blind studies compared laparoscopic versus open cholescystectomy (1,2), and none showed clearly significant differences for either procedure. The importance of these studies is relative when compared to downpouring experience pointing that laparoscopy provides a far more benign immediate postoperative time. We should not be oblivious regarding the fact that the so-called "surgeon factor" may never be blind -and is difficult to assess- and therefore double-blind studies are not feasible.

This evidence regarding a generally benign postoperative period led to consider that this technique could be performed on an outpatient basis with no overnight hospital stay, in a search for cost savings, either institutional or private, in each procedure. We would like to stop here at any rate to superficially analyze concept differences amongst cultures and health-care models with respect to major outpatient surgery (MOS).

The North American model mainly attempts to reduce costs per procedure, which in financial terms will indirectly impact on users as regards medical insurance costs and of course by making private procedures cheaper. To this end hospitals usually rely on nearby hotels where patients may stay following hospital discharge, should they wish so, so that they may be cared for by their surgeon if needed.

The same goes for private surgery, but regarding public health-care, a universal, free-of-charge model such as the Spanish one is mainly concerned in hospital stay reduction in addition to reduced costs per procedure, in an attempt to free hospital beds for other procedures and send patients home upon surgery completion. Be-sides, health-care sectorialization renders distances to hospitals significant in the rural setting, and the sector cared for by a given hospital may include urban areas with deficient housing or serious social-financial difficulties. All these reasons together with a lack of perception of financial benefits by patients render day-care surgery more difficult to implement and their presence uneven.

Regarding other surgical procedures habitually included in MOS, LC has the differential characteristic of being a technique requiring general anesthesia for an approach of the peritoneal cavity. Thus, patients who are at high-risk regarding anes-thesia may not be included, where in addition to potential surgical complications an eye must be kept on potential anesthesia-related complications. On the other hand, potential cholecystitis or post-cholecystitis sequelae -which are often hard to predict- may render this procedure more complex.

In the present issue of our REED, two papers are published that relate to different outpatient LC-related topics. Whereas Vieira et al. (3) refer to the setting up of an outpatient LC program, Planells et al. (4) focus on patients with non-lithiasic cholecystopathies who undergo daily-care LC. The latter authors reported in 2001 on their experience along 4 years of outpatient LC in this same journal (5), and were understandably considered a pioneer group for LC in MOS in our country.

On the topic of alithiasic bladder conditions we will merely point out that, as in the authors’ experience, bladder conditions that are considered alithiasic very commonly share the etiology of lithiasic disease, be it because of the presence of undetected microlithiasis or cholesterolosis. An experience that is not uncommon in daily practice involves patients who are admitted with acute pancreatitis in whom no lithiasic condition is seen, and who are therefore referred to the Gastroenterology Unit for an etiologic study. After a variable lapse of time, and following new pancreatitis episodes, a percentage of these patients are sent back upon detection or suspicion of lithiasis in tests performed. Therefore, as Shaffer puts it (6), these patients must be separated from those suffering from true acalculous biliary dyskinesia, a distinct condition which commonly includes Oddi’s sphincter dysfunction, which in turn may lead to failed cholecystectomy management. The problem is that bladder and bile duct motility is difficult to acknowledge in daily practice (7), and disorders may be in combination with other gastrointestinal motility abnormalities (8).

Anyway, patients preoperatively labeled as having alithiasic cholecystopathies are overall excellent candidates to outpatient LC, at least regarding a lower likeliness of complicated surgical procedures.

Overall experience regarding LC in MOS is consistent with observations in other techniques, that is, that greater expertise in a procedure and its common daily-care use improve results. Recently, Oteiza et al. reported on an interesting study that compared hernia surgery outcomes between surgeons in one department (9). One group performed the procedure habitually and on an outpatient basis in most cases, whereas the other group performed the technique rather sporadically among their scheduled standard procedures. Outcomes were significantly better in the first group, whose procedures were seen to be also more deeply standardized.

This is, in our view, a scarcely mentioned benefit of daily-care LC, since a significant improvement in procedural quality most likely occurs through the specialization of team members and the careful care needed for early discharge.

But quality management is as important regarding "offered quality" as regarding "perceived quality", and this is often harder to convey so that early discharged patients perceive it, be it because of fear even in the absence of complications or because of a magnification of events that obviously might also have developed should the patient have stayed in hospital. In this regard information provided by Planells et al. in a paper published in 2002 (10) is in our view highly significant, as it states that 20% of their patients were very much in worry during their first night at home even when they had accepted the procedure and were satisfied with it.

In any case LC is no doubt an excellent procedure, currently the gold-standard in the treatment of symptomatic cholelithiasis, which may be performed as MOS in a high number of patients. For a group of patients it will not be the suitable technique due to medical reasons; for another, much more varying group of patients it will not be feasible because of social reasons. Similarly, a small number of failures from intra- or postoperative complications exist, which will diminish as experience is gain-ed in both patient selection and surgical, anesthetic and nursing management scheduling. Its feasibility has been demonstrated in all settings and differing countries with rather similar results (10-14).

The accounting peculiarities of the Spanish health-care system makes it very difficult to quantify presumed savings versus inpatient surgery, since the cost needed to set up a home care system infrastructure and that of readmissions should have to be subtracted from reduced costs per bed and day. It is however important to consider this procedure’s frequency, which has notably increased during the last years as a result of improved diagnostic procedures and a greater predisposition of patients to be operated on. It has been estimated that the number of procedures have increased from 500,000/year to above 800,000/year in the United States during the last decade; considering the population of the European Union, only in the Western, developed hemisphere the number of procedures is much higher than one million procedures per year. Thus, savings incurred will have a tremendous impact on health-care expense.

However, in the Spanish health-care system, which is in need of public beds in most regions, reductions in the hospitalization stay are also important besides savings, so that beds may be put to good use for other patients, which may be achieved via MOS programs including well trained teams in outpatient LC for feasible cases.

P. Rico Selas and A. Calle Santiuste

Service of General, Digestive and Transplant Surgery.
Hospital 12 de Octubre. Madrid. Spain



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