- Citado por SciELO
versión impresa ISSN 1130-0108
Rev. esp. enferm. dig. v.96 n.7 Madrid jul. 2004
Laparoscopic cholecystectomy in the treatment of biliary lithiasis:
outpatient surgery or short stay unit?
A. Martínez Vieira, F. Docobo Durántez, J. Mena Robles, I. Durán Ferreras, J. Vázquez Monchul,
F. López Bernal and E. Romero Vargas
Service of General Surgery and Digestive Diseases. University Hospital Virgen del Rocío. Sevilla, Spain
Objective: analysis of clinical and surgical factors in a series of patients subjected to laparoscopic cholecystectomy in an outpatient unit and their relationship with time of discharge and patient acceptance.
Patients and method: eighty one consecutive patients underwent to elective laparoscopic cholecystectomy during year 2002 within S.A.S. (Andalusian Health Service) from a surgical waiting list. Retrospective and comparative study between two groups: group A includes patients discharged between 24 and 48 hours after intervention; group B includes patients discharged in less than 24 hours. We analyse the clinical and surgical characteristics and post-operative outcome of both groups of patients.
Results: group A was composed of 53 patients and group B of 28 patients. Factors of clinical significance which determined discharge after 24 hours included: early post-surgical incidences or complications (p = 0.017), inability to tolerate oral diet (p = 0.002), and doubts and feelings insecurity of patients regarding discharge by traditional means 62.3% (p = 0.0003).
Conclusions: outpatient laparoscopic cholecystectomy is a safe and reliable procedure with a high acceptance rate and few complications. Perhaps traditional culture has to be changed to obtain better results.
Key words: Outpatient laparoscopic cholecystectomy. Perceived quality. Day surgery unit.
Martínez Vieira A, Docobo Durántez F, Mena Robles J, Durán Ferreras I, Vázquez Monchul J, López Bernal F, Romero Vargas E. Laparoscopic cholecystectomy in the treatment of biliary lithiasis: outpatient surgery or short stay unit? Rev Esp Enferm Dig 2004; 96: 452-459.
Correspondencia: Almudena Martínez Vieira. C/ Ceuta ,2, 3º D. 01010 Cádiz. Telf.: 670 448 600 - 686 439 002. e-mail: firstname.lastname@example.org
A Day Surgery Unit (DSU) is characterised by performing surgical procedures which, carried out using whatever type of anesthesia, require a short post-operative period, and therefore patients can be discharged a few hours after the procedure (1). When it is necessary for patients to have a recovery period of more than 24 hours in hospital, with the subsequent increase in costs, we are faced with the concept known as Short Stay Surgery (SSS).
Laparoscopic cholecystectomy has been improved in such a way that, used in the treatment of non-complicated biliary lithiasis, it has become a part of the service offered by the SSS units and, nowadays, by the DSUs (2,3). If this surgical activity is going to be carried out in a DSU as well as in Short Stay Units it is necessary an appropriate selection of patients, the establishment of protocols for each phase, and an adequate evaluation of the service offered. If these conditions are theoretically present in DSU as well as in SSS units, which factors will determine hospital stay and what makes a difference between both types of programs?
The aim of the present study was to analyse clinical and surgical factors in patients who underwent laparoscopic cholecystectomy in a DSU, which could be determinants in deciding to discharge patients on the same day of the procedure (DSU programme) or to discharge them after 24 hours of hospital stay (SSS Unit).
PATIENTS AND METHODS
We carried out a retrospective study on a series of patients who underwent laparoscopic cholecystectomy for uncomplicated biliary lithiasis during 2002 in the Day Surgery Outpatient Unit of the University “Hospital Virgen del Rocio”, Seville. All these patients were potential candidates for outpatient treatment.
Criteria necessary for inclusion in this program of outpatient laparoscopic cholecystectomy included: a) suffering from biliary pain or chronic lithiasic cholecystitis; b) ultrasonography showing cholelithiasis with permeable, non-dilated bile duct; c) normal liver tests including total bilirubin of less than 1 mg/dl; d) ASA I or II; and e) social conditions ensuring discharge accompanied by a responsible adult, telephone number, transport home and urgent evacuation.
All patients followed the normal procedures establi-shed by the DSU: signing of informed consent; performance and acceptance of a pre-anesthetic study; admittance to the unit one hour before the procedure in fasting conditions; blood reservation according to their blood group, and programmed pre-medication with midazolam and omeprazol. In the operating theatre they received a balanced general anesthetic. A prophylactic antibiotic, cefazoline, was administered, and a dressing was applied to the lower limbs of patients with distal vein problems or obesity. Laparoscopic cholecystectomy was carried out in all cases following the European technique. During the immediate post-operative period, monitoring was maintained in a recovery room; patients were then taken to hospital wards following anesthetic assessment, where normal nursing practices and a follow-up by the surgeon were carried out, the latter being also responsible for hospital discharge. Once this was decided, the patient and the person responsible for his/her care were properly informed on the treatment to be carried out (analgesia with ketorolac or paracetamol), and the instructions to follow during the post-operative period, as well as on contact phone numbers, a form to fill in to evaluate the process, and an outpatient clinic appointment for a check-up one month after the procedure.
The criteria for inclusion in our study were: a) conversion to laparotomy was not necessary; b) the procedure was performed by the same two surgeons; and c) the patients were discharged the same day or the day following the procedure.
Patients were divided into two groups (A and B), depending on the time when they were discharged. Group A patients were discharged between 24 and 48 hours after the procedure and required a one-day stay in hospital, and group B patients were discharged in less than 24 hours, without hospitalization. In both groups of patients, we analyzed: sex; age; distance from DSU to home (more or less than 20 kilometers); ASA; body mass index (BMI); total bilirubin; semester of the year in which the surgery was carried out; surgeon who performed the procedure (classified as I or II); time at which the patient tolerates oral diet; appearance of postoperative events (uncontrolled pain, vomiting) and complications (bleeding from surgical wounds, need for abdominal drainage, etc.); patient status within one month after the procedure, and pathological finding in the excised gallbladder.
Statistical analysis was aided by the SPSS program, version 11.0. Qualitative variables were compared using the Chi square test (Fisher’s exact test). The Student’s t test for unpaired samples was used to determine statistical difference between groups; p values <0.05 were considered significant.
Eighty one out of 91 patients who underwent laparoscopic cholecystectomy during year 2002 have been included in this study. All of them satisfied the following criteria: a) they were discharged between 24 and 48 hours after the procedure and therefore they did not require hospitalization [group A = 53 patients, (65%)]; or b) they were discharged in less than 24 hours, without need of hospitalization [group B = 28 patients ( 35%)].
In group A, 91% were women and 9% were men, with an average of 54 years; 41% of patients lived less than 20 kilometers away from the hospital; 38% were classified as ASA I, and 62% as ASA II. The mean BMI was 29 kg/m2, and mean total bilirubin was 0.69 mg/dl. Surgeon I carried out 60% of the cholecystectomies and surgeon II 40%; 65% of these patients underwent surgery during the first six months of the year, and 35% during the second half of 2002. Incidents and complications arose in 9 patients (16.9%) and included: uncontrollable pain (3 cases), vomiting (2 cases), placing of an abdominal drain, which was withdrawn the following day (2 cases), wound dressing stained with blood (1 case), and slight respiratory problem after extubation (1 case). Eleven patients (79.2%) tolerated an oral diet on the same day of the procedure. For the remaining 33 patients (62.3%), hospital stay was finally determined by social reasons, mainly by insecurity or doubts about being discharged. Within a month of the procedure, 93% of patients were asymptomatic. Two patients presented a complication derived from surgery. One of them developed an umbilical hernia across the trocar incision and another an infection of the surgical wound. The histopathological study of the excised gallbladder, whose results were available approximately twenty days after the procedure, reported: unspecific chronic cholecystitis in 84% of cases, cholesterosis, in 12%, and adenomiomatosis, in 4%. (table 2)
In group B, 64% of the patients were women, and 36% men. The median age was 50 years; 51% of patients lived less than 20 kilometers away from the hospital; 44% of patients were classified as ASA I, and 56% as ASA II. The mean BMI of patients was 31 kg/m2, and mean total bilirubin was 0.75 mg/dl. Surgeon I carried out 65% of cholecystectomies, while surgeon II performed 35% of the procedures. Thirty per cent of these patients underwent surgery in the first six months of the year, and 70% during the second half of 2002. No immediate postoperative incidents arose, and no patient expressed doubt or insecurity on the proposal of being discharged on the same day of surgery. In no case was it necessary to place an abdominal drain; 100% of patients tolerated an oral diet on the same day of the procedure. Mean discharge time was 10 hours after the procedure. Within a month of the procedure, only one patient had diarrhea. In the definitive histopathological report, 73% of patients had unspecific chronic cholecystitis, 18% cholesterosis, and 9% adenomiomatosis.
Regarding the sex variable, a larger percentage of females, as opposed to males, required hospitalization. However, this data reflects the greater number of women operated on, and the fact that group A contained more patients than group B (65 versus 35%).
Analyses of these data showed statistically significant differences in the following variables: a) the need for hospitalization decreased significantly during the second semester of the year, as opposed to the first semester, as should be expected due to the development of a learning curve; b) incidents and complications are the major causes of hospitalization (p = 0.002); and c) doubt and insecurity of patients regarding the proposal of being discharged on the same day of the procedure was a very significant reason for hospitalization (p = 0.0003).
The term DSU combines processes complementary to surgery performed using any type of anesthesia that require less intensive postoperative care and are of short duration; therefore patients do not need to stay in the hospital and can be discharged a few hours after the procedure (1).
A DSU permits an increase in surgical activity not limited by the number of beds, and reduces the cost of the process by 25-30%. Compared to inpatient surgery, it reduces the time a patient spends in hospital and therefore entails less interference in daily and working life (4).
The level of complexity of procedures that can be carried out in a DSU is increasing. But this advance means it will be necessary for patients to have a longer period of recovery, with a subsequent increase in costs. We are entering into what is known as a SSS, which may carry out surgical procedures with hospital stays between one and three days using hospital resources for the least time possible (5), although with greater financial cost when compared to a DSU.
Nowadays, for many authors, laparoscopic surgery for the treatment of uncomplicated biliary lithiasis is, along with the treatment of groin hernia, the laparoscopic procedure that can be carried out with greater safety and effectiveness on an outpatient basis (6,7).
For a DSU program to be implemented, the following conditions are necessary: appropriate selection of patients according to a series of clinical, laboratory, and social criteria; establishment of protocols for each phase of the process; appropriate postoperative evaluation, and an assessment of quality for offered services. To evaluate the latter point it is necessary to focus on morbidity markers and quality as perceived by patients (8). One of the most commonly used markers is the rate of events and complications arising during the postoperative period (9). From what emerges from our study, and from data offered by other authors (10,11), early postsurgical events (bleeding, vomiting, etc.) and clinical status of the patient after the procedure (pain, inability to tolerate food) are factors that most commonly determine the need for hospitalization and admission into a SSS, and consequently increasing the cost of the process. A prevention of such incidents is the best way to avoid hospital stays. To carry out this prevention, measures such as an exquisite and refined surgical technique to avoid, along with the appropriate analgesic procedures, the appearance of uncontrollable postoperative pain (12) are important, as is a rational use of antiemetics (13) with a gradual establishment of oral feeding, which should favor early tolerance to food. Other complications that lead to unexpected extension of the hospital stays (bleeding, drainage, etc.) could be avoided by careful hemostasis during surgery to avoid staining of cutaneous dressings; use of abdominal drains when necessary, strict antisepsis for the prevention of infections, use of antithrombotic agents on patients at risk, and an appropriate management of associated illnesses that frequently present these patients (diabetes mellitus, hypertension, asthma, etc.).
The experience of the surgeon who operates and discharges the patient is also important, as is that of all team involved in the unit, especially since the greater percentage of patients who remained in hospital had been operated on in the first months of 2002. Gradual staff learning accounted for a reduction in one-night admissions by 50%, in favor of discharging the same day of the procedure in the second half of 2002, without this involving an increase in postoperative complications or a decline in service quality. This fact demonstrates the importance of the so-called learning curve for attaining the fundamental objectives of a DSU: discharging without decreasing service quality as provided or perceived. Currently, our rate of discharges on the same day of the procedure is 73%, a level similar to that reported in other series (14-16).
Lastly, it is necessary that discharge, and the knowledge of how to continue recovery at home, is accepted by the patient, and instructions to follow must be very clearly laid out for both patients and their families. Also relevant are the availability of a functioning well-developed follow-up system (17), including complication identification via the telephone and their solution by a surgeon. Even so, many patients choose to stay in hospital one day for no apparent reason, since they prefer the direct observation and care of professionals. This “social” reason for staying in hospital is a factor which significantly increases the percentage of unexpected prolonged stays in a DSU. It is basically determined by the traditional belief that a longer period of health care provides better results than an outpatient regimen. How-ever, regardless of what surveys on satisfaction and perceived service quality indicate, discharging less than 24 hours after the procedure does not decrease quality or imply a greater number of complications in the following month. The only efficient way to prevent these hospital stays is comprehensive information and patient individualization.
We conclude that outpatient laparoscopic cholecystectomy is a safe and reliable procedure with a high level of acceptance. In general, events emerging in the early postoperative period can be considered a statistically significant determinant for patient admission. Variables such as doubt or insecurity of patients at discharge can be important factors when it comes to deciding on admission. Cultural tradition, i.e., that more time spent in hospital improves both quality of care and results, must change. Comprehensive information and patient individualization are efficient and valid measures to prevent admissions for social reasons (doubt and insecurity of patients at discharge). We believe that, as long as the clinical status is suitable in the postoperative period, discharge on the same day of the procedure should be the option of choice.
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