AUDIT OF OUTPATIENT LAPAROSCOPIC CHOLECYSTECTOMY

Background : Because the postoperative stay after laparoscopic cholecystectomy (LC) has shortened, it seemed that outpatient LC would be feasible. The aim of this study was to prospectively audit initial experience with outpatient LC at the Austin and Repatriation Medical Centre. We aimed to determine appropriate patient selection criteria, to devise anaesthetic and discharge protocols and to assess patient satisfaction at follow up. Method s: All patients presenting for LC were assessed for suitability, and those elective cases unlikely to have a duct stone and fulfilling the social criteria were studied. After standard anaesthetic and LC technique, patients recovered in the day surgery unit for up to 8 h and were discharged if stable. The hospital in the home nursing service monitored patients for 48 h and arranged readmission if needed. Patient satisfaction was assessed by independent telephone questionnaire 6 weeks postoperatively. Results : Forty‐five patients (median age 43 years) underwent outpatient LC with a discharge rate of 82.3%, resulting in a cost saving of $984 per patient treated. One patient was readmitted, giving an overall success rate of 80%. After stricter implementation of the protocol in the second half of the study, the discharge rate rose to 92%. Patient acceptance of the technique was high at 84.5%. Conclusions : The results of the first 45 patients show that it is possible to safely perform outpatient LC with a low admission rate in fit, elective patients who live close to medical care. Provided a strict anaesthetic protocol is followed, the technique has good patient acceptance and provides some economic benefit to the hospital.     

Audit of outpatient laparoscopic cholecystectomy. Universities of Melbourne HPB Group

BACKGROUND: Because the postoperative stay after laparoscopic cholecystectomy (LC) has shortened, it seemed that outpatient LC would be feasible. The aim of this study was to prospectively audit initial experience with outpatient LC at the Austin and Repatriation Medical Centre. We aimed to determine appropriate patient selection criteria, to devise anaesthetic and discharge protocols and to assess patient satisfaction at follow up. METHODS: All patients presenting for LC were assessed for suitability, and those elective cases unlikely to have a duct stone and fulfilling the social criteria were studied. After standard anaesthetic and LC technique, patients recovered in the day surgery unit for up to 8 h and were discharged if stable. The hospital in the home nursing service monitored patients for 48 h and arranged readmission if needed. Patient satisfaction was assessed by independent telephone questionnaire 6 weeks postoperatively. RESULTS: Forty-five patients (median age 43 years) underwent outpatient LC with a discharge rate of 82.3%, resulting in a cost saving of $984 per patient treated. One patient was readmitted, giving an overall success rate of 80%. After stricter implementation of the protocol in the second half of the study, the discharge rate rose to 92%. Patient acceptance of the technique was high at 84.5%. CONCLUSIONS: The results of the first 45 patients show that it is possible to safely perform outpatient LC with a low admission rate in fit, elective patients who live close to medical care. Provided a strict anaesthetic protocol is followed, the technique has good patient acceptance and provides some economic benefit to the hospital.     

An analysis of computer-assisted pre-screening prior to elective surgery

In order to assess the potential utility of guided patient self-assessment as an early preoperative triage tool, a computer-assisted questionnaire delivered by a non-clinician via telephone was 1) compared to face-to-face interview and examination by anaesthetists in outpatient clinics and 2) evaluated as a mechanism to stream patients to day of surgery assessment. In total, 514 patients scheduled for elective surgery in two tertiary public hospitals were assessed initially by telephone and then in an outpatient clinic. Both forms of assessment were marked by panels of specialist anaesthetists, who also provided an opinion on which patients would have been suitable to bypass preoperative anaesthetic outpatient assessment based upon information provided by the telephone interview. Overall, the quality of assessment provided by non-clinician telephone interview was comparable to face-to-face interview by anaesthetists, although more complex issues required face-to-face assessment. Panel review considered that 398 patients (60%) would not have required evaluation by an anaesthetist until the day of surgery, thus avoiding the need to separately attend a preoperative outpatient clinic. The sensitivity of telephone interview provided information to correctly classify patients as suitable for day of surgery evaluation was 98% (95% confidence interval 96 to 99%) with a specificity of 97% (95% confidence interval 92 to 98%). This study demonstrates that remote computer-assisted assessment can produce quality patient health information and enable early patient work-up and triage with the potential to reduce costs through more efficient use of resources.     

Laparoscopic cardiomyotomy for achalasia: long-term outcomes

BACKGROUND: Although the laparoscopic approach to oesophageal myotomy for achalasia is associated with reduced early postoperative morbidity compared with the open approach, most published reports describe relatively short-term follow up. For this reason, in a prospective cohort study, we determined the longer-term outcome for patients with uncomplicated achalasia who underwent a laparoscopic myotomy. In addition, we sought to identify preoperative factors predicting a good postoperative outcome. METHODS: The outcome for 167 patients who underwent a laparoscopic cardiomyotomy and anterior partial fundoplication at one of two teaching hospitals was determined. All patients underwent preoperative assessment with a contrast swallow radiology, gastroscopy and oesophageal manometry. Patients also underwent objective symptom evaluation before and after surgery using various outcome scales to determine dysphagia, reflux symptoms, side-effects and overall satisfaction with the clinical outcomes. Patients were followed prospectively at yearly time points and data were managed on a computerized database. Postoperative objective investigations were undertaken if clinically indicated. RESULTS: Median operating time was 78 min (range, 30-210 min). Most patients left the hospital within 72 h of surgery. Surgery was associated with a 5% complication rate and a 4% rate of conversion to open surgery. Five per cent of patients required a subsequent intervention during follow up. Over longer-term follow up (5 years or longer), 77% of patients had either no or minimal symptoms. At 1, 3 and 5 years, 96, 93 and 97% of patients indicated that they thought that they had made the correct decision to undergo surgery, although men consistently fared worse on their reported dysphagia outcome across a range of measures. CONCLUSION: Laparoscopic myotomy with anterior partial fundoplication achieves a good outcome for patients undergoing treatment of achalasia. Male patients do not perceive their outcome to be optimal in comparison with females but in the long term, they do not regret proceeding.     

The use of a local anesthetic foot block in patients undergoing outpatient bony forefoot surgery: A prospective randomized controlled trial

Foot blocks are known to prolong postoperative pain relief. Consequently, their use has been extended to patients having outpatient surgery, despite little evidence to show improved patient satisfaction. Indeed, patients having outpatient surgery actually may be less satisfied because they will first experience pain at home on the first postoperative night, which may be more severe than anticipated. In this prospective, randomized, blinded study, 42 patients having unilateral outpatient bony forefoot surgery were assigned randomly to either having the surgery under general anesthesia alone or under general anesthesia with supplementary foot block (0.5% bupivicaine). All patients were assessed at home by telephone interview on the first and second postoperative day. There was a significantly longer time to first perceived pain in the foot block group compared with the control group, but no difference in the number of postoperative analgesic tablets consumed, no difference in pain score on the first night, first postoperative or second postoperative day, or any difference in the overall patient satisfaction scores at 2 days. The authors conclude that a local foot block, although prolonging the time to first perceived pain, does not improve patient satisfaction and is not detrimental when used as analgesia in the outpatient setting.     

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.     

Hand-assisted laparoscopic sigmoid resection for diverticular disease: 100 consecutive cases

BACKGROUND: Hand-assisted laparoscopic surgery (HALS) has been proposed as a useful alternative to conventional laparoscopic and open surgery. As compared with conventional laparoscopic surgery, it offers the advantages of tactile feedback, better exposure, and a shorter learning curve. There is increasing evidence that HALS retains the advantages of minimal-access surgery. The aim of this study was to analyze the feasibility as well as the short- and medium-term outcomes of HALS sigmoid resection for diverticular disease. METHODS: The study included 100 consecutive patients between July 1999 and August 2004. Data were prospectively recorded. Follow-up evaluation was performed by standardized telephone interview after a mean postoperative period of 19 months (range, 2-55 months). RESULTS: Two major intraoperative complications occurred: splenic laceration requiring splenectomy and ureteral injury requiring suture. There were only three conversions: one case of pararectal incision and two cases of extended lower Pfannestiel incision. There was no single case of conversion to midline laparotomy. One patient died postoperatively of myocardial infarction. The postoperative complications included intraabdominal hematoma (2%), anastomotic leakage (3%), wound infection (11%) and bladder dysfunction (1%). The reoperation rate was 5%. The median hospital stay was 8 days. In terms of satisfaction with the results, 97% of patients would choose HALS again. CONCLUSIONS: When used for diverticular disease, HALS sigmoid resection has a low intra- and postoperative complication rate. The satisfaction rate among patients is high. Even in technically difficult cases, conversion to midline laparotomy can be avoided.     

Day case laparoscopic cholecystectomy — a feasibility study

The feasibility of performing laparoscopic cholecystectomy on an outpatient basis was evaluated in 55 selected patients who underwent the procedure with careful back-up. Nine per cent of patients required overnight hospitalization whereas 5% were readmitted at a later date. Fifty-nine per cent of patients described their postoperative pain as severe or moderately severe and 27% complained of vomiting or severe nausea. Despite these findings, 66% of patients expressed complete satisfaction with the procedure as performed and 82%, given the choice, would have opted for the same method again. The advantages to the patient are the high likelihood that the procedure will take place as planned and they are able to convalesce in familiar surroundings. The advantages to the hospital are the freeing up of inpatient beds and potential cost savings.     

Combined multichannel intraluminal impedance-pH monitoring to select patients with persistent gastro-oesophageal reflux for laparoscopic Nissen fundoplication

BACKGROUND: Combined multichannel intraluminal impedance-pH (MII-pH) monitoring detects gastro-oesophageal reflux and identifies acid and non-acid reflux events. It can be used in patients with persistent symptoms on proton-pump inhibitor (PPI) therapy. The aim of this study was to assess laparoscopic Nissen fundoplication as a treatment for patients with persistent symptoms associated with reflux despite acid suppression documented by MII-pH monitoring. METHOD: A prospectively maintained database identified patients with persistent symptoms of gastro-oesophageal reflux disease despite PPI therapy who had undergone MII-pH monitoring and this was cross-referenced with patients who had undergone fundoplication at this institution. Follow-up after fundoplication was by periodic telephone interview and review of clinical records. RESULTS: Of 200 evaluated patients, 19 (14 female; mean age 40 (range 0.7-78) years) underwent laparoscopic Nissen fundoplication. Before surgery, 18 of 19 patients had a positive symptom index (at least half of symptoms associated with reflux) and one, a negative symptom index. After a mean follow-up of 14 (range 7-25) months, 16 of 17 (94 per cent) patients with a positive symptom index were asymptomatic or markedly improved (one patient was lost to follow-up). Persistent symptoms occurred in the patient with a negative symptom index, and one patient had recurrent symptoms after 9 months. CONCLUSION: Patients with a positive symptom index resistant to PPIs with non-acid or acid reflux demonstrated by MII-pH monitoring can be treated successfully by laparoscopic Nissen fundoplication.     

腹腔镜胆囊切除日间手术在县级医院开展的安全性与成本效益分析

目的:分析腹腔镜胆囊切除日间手术在县级医院开展的安全性及成本效益分析。方法:回顾分析2017年1月1日至2017年6月30日由同一手术团队开展的18例腹腔镜胆囊切除日间手术,对患者术前准备、出院前评估及术后随访情况进行分析。结果:18例日间手术均获成功,入院24 h内出院,无延长出院病例,出院后1周预约复查,均保持随访,无相关并发症发生,住院费用降低,患者满意度100%。结论:采用合适的选择标准行腹腔镜胆囊切除日间手术是安全、可行、有效的,其再住院率低,并发症少,节约成本,提高了患者满意度,同时加快了目前分级诊疗制度的推进。     

Laparoscopic cholecystectomy as a "true" outpatient procedure: Initial experience in 130 consecutive patients

Laparoscopic cholecystectomy has received nearly universal acceptance and is currently considered the "gold standard" for the treatment of cholelithiasis. Many centers have employed "short-stay" units or "23-hour admissions" for postoperative observation following laparoscopic cholecystectomy. The practice of early discharge as "true" outpatients following this procedure has not been well defined. A retrospective analysis of 130 consecutive patients undergoing laparoscopic cholecystectomy in an outpatient surgery unit was performed. A follow-up telephone survey was carried out of patients who successfully completed the procedure as outpatients. One hundred thirty patients underwent outpatient laparoscopic cholecystectomy. The patient population consisted of 78% women, with an age range of 17 to 76 years (mean age 47.1 years). Symptomatic gallstone disease was the indication for laparoscopic cholecystectomy in 92 % of the patients. All patients underwent successful completion of laparoscopic cholecystectomy with no conversions to an open procedure. The mean length of operation was 75 ±23 minutes (range 25 to 147 minutes). The mean length of stay in the postanesthesia care unit (PACU) ranged from 95 to 460 minutes with a mean length of stay of 200 ±79 minutes. A total of eight patients (6.2%) were admitted to the hospital directly from the PACU in the immediate postoperative period. Six of these eight patients were discharged on the first postoperative day. Following discharge from the PACU, an additional six patients (4.6%) required hospital admission. Three of these six patients were discharged after a single day of hospitahlization. Ninety-eight of 116 eligible patients were available for follow-up telephone evaluation. The outpatient experience was rated as good by 75.5% of the patients, fair by 22.5%, and poor by 2%. In retrospect, 20.4% of the patients stated that they would have preferred an inpatient to an outpatient procedure. Laparoscopic cholecystectomy can be performed as a true outpatient procedure with patients discharged to home within hours of completion of the procedure. Less than 10% of patients will fail this protocol and another 5% of the patients may require hospitalization after returning to their homes. Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, La., May 17–20, 1998.     

Laparoscopic placement of a gastric stimulator for the treatment of gastroparesis: a pilot study technique and results

AIM: To evaluate the safety and outcomes of laparoscopic placement of a gastric stimulator for patients with gastroparesis. MATERIALS AND METHODS: Data of all patients who underwent laparoscopic placement of a gastric stimulator between 2003 and 2005 was retrospectively reviewed. Data included; demographics, perioperative course, and outcomes. A telephone follow-up questionnaire was conducted for all patients. Patient's satisfaction of their life after the procedure was evaluated on a scale from 0 to 10. RESULTS: Seven patients underwent the procedure. There were no conversions, no perioperative complications; all patients were discharged on the first postoperative day. There were no postoperative complications or mortality. Only 5 patients were available for a telephone interview. All patients indicated reduction of symptoms, 4 patients decreased or discontinued their drug therapy. Four patients indicated that they were tolerating regular diet. Three patients indicated an improvement in their general life satisfaction. CONCLUSIONS: Gastric electrical stimulator may improve gastrointestinal symptoms, reduce the use of drug therapy, and offer subsequent improvement in patients' general life satisfaction. This procedure is relatively safe for patients with refractory gastroparesis. Further studies are required to confirm these results.     

Results of laparoscopic Nissen fundoplication at 2-8 years after surgery

BACKGROUND: Although the long-term results of open fundoplication for gastro-oesophageal reflux disease are well documented, there have been few reports of the long-term results of laparoscopic fundoplication. METHODS: Between January 1993 and July 1999, 179 consecutive patients underwent laparoscopic floppy Nissen fundoplication. Of these, 175 were available for long-term follow-up. Structured symptom questionnaires were completed by 140 patients (80 per cent) at 2-5 years (n = 92) or 5-8 years (n = 48) after operation. RESULTS: Patient satisfaction with surgery was 91 per cent at a median follow-up of 48 (range 24-99) months. Visick scores of I or II were recorded by 84 per cent. Ninety per cent of patients remained free from significant reflux symptoms. Side-effects were common (22 per cent) but rarely affected patient satisfaction. Of the 19 patients (14 per cent) taking regular antireflux medication, eight used it for non-reflux symptoms and 12 had normal postoperative pH tests. CONCLUSION: Laparoscopic floppy Nissen fundoplication is an effective and durable treatment for gastro-oesophageal reflux disease. Longer-term follow-up of patients operated on beyond the learning curve can be expected to show further improvements in surgical outcome.     

Laparoscopic cholecystectomy as a ‘session’ surgery

Aims: To introduce laparoscopic cholecystectomy to our Day Surgery Unit and assess the implications of a 6 h postoperative stay in unselected patients. Methods: A retrospective analysis of data was performed in which the case notes of a series of 170 consecutive patients undergoing day case laparoscopic cholecystectomy were studied. All patients with symptomatic gallstones were considered for day case laparoscopic cholecystectomy. Patients were excluded if there was major medical co-morbidity but not solely on the basis of age or Body Mass Index (BMI). Surgery was performed in a dedicated Day Surgery Unit and cholangiography was performed selectively. All patients were assessed at 6 h postoperatively for discharge and followed up by telephone at 24, 48 h and 2 weeks postoperatively. Results: Of 170 patients 121 (71.1%) were discharged at 6 h, 116 reported no problems and were satisfied with day case treatment. Two (1.6%) patients required a GP visit at home within 24 h and three (2.5%) patients required readmission. Forty-nine (28.9%) patients required admission, the commonest cause for admission being postoperative pain and nausea (10.6%) in approximately equal proportions. Three were admitted as they had open surgery. One patient required further surgical intervention (laparoscopy). Conclusion: Laparoscopic cholecystectomy as a ‘session’ surgery, with planned discharge 6 h after operation, is successful in the majority of unselected patients even though a significant number of overnight admissions are to be anticipated.     

Intravenous narcotics for premedication in outpatient anaesthesia

One hundred adult female patients scheduled for outpatient laparoscopic procedures were studied. Each patient received intravenous premedication about 30 min before induction of anaesthesia. The premedications were given in a double-blind random order and were either a placebo, morphine (0.04 mg/kg), meperidine (0.35 mg/kg), fentanyl (0.75 microgram/kg) or sufentanil (0.15 microgram/kg). All patients received a standard anaesthetic regimen. Transient light-headedness was common following narcotic injections. Overall, sufentanil was superior to the placebo and to other narcotics in its ability to reduce preoperative anxiety and to provide more satisfactory induction, maintenance and recovery from anaesthesia. The incidence of postoperative nausea, vomiting and other side effects was not higher and discharge times were not longer after sufentanil compared to the placebo group. Complete recovery as assessed by telephone interview 24-48 h after the operation revealed no difference between the sufentanil and the other groups. The results of this study indicate that intravenous short-acting narcotics like fentanyl or sufentanil should be considered as an alternative premedicant for anxious patients who are scheduled for outpatient surgery.     

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.     

Predictive Factors in Global and Anesthesia Satisfaction in Ambulatory Surgical Patients

Background: Patient satisfaction is one of the variables that affect the outcome of health care and the use of health-care services. As more procedures are performed on an ambulatory basis, the role of the anesthesiologist becomes more important. To improve the delivery of care, the predictors of dissatisfaction with the entire process (global dissatisfaction) of ambulatory surgery and with anesthesia itself must be identified. The authors conducted a hypothesis-generating study to identify predictors; specifically, they hypothesized that satisfaction with anesthesia was a predictor of global satisfaction with ambulatory surgery and that 24-h postoperative symptoms were a predictor of satisfaction with anesthesia.

Methods: The authors prospectively studied 5,228 consecutive patients having surgery in the ambulatory setting during a 1-yr period. Preoperative, intraoperative, and postoperative variables were gathered and patient satisfaction was assessed using a postoperative telephone questionnaire administered 24 h after operation in 2,730 respondents. Significant univariate variables and clinically important variables were entered into multiple logistic regression models. Qualitative data on dissatisfaction were obtained by asking patients' reasons for dissatisfaction.

Results: Sixty-eight of the 2,730 respondents (2.5%) had global dissatisfaction with ambulatory surgery. Nine of these patients were dissatisfied with anesthesia. Dissatisfaction with anesthesia was associated with a 12-fold increase in global dissatisfaction (P = 0.0001). Thirty-one of the 2,730 respondents (1.1%) were dissatisfied with anesthesia. An increasing number of symptoms occurring 24 h after operation was associated with an exp(0.28 x N)-fold increase in dissatisfaction with anesthesia for N number of symptoms (P = 0.0001). Qualitative data showed that the most common reason for global dissatisfaction with ambulatory surgery was personal preference for inpatient care (26%), whereas intraoperative and postoperative adverse outcomes were the major causes of dissatisfaction with anesthesia (88%).     

A Study of Pain after Laparoscopic Gastric Banding

Background: The introduction of the laparoscopic approach to bariatric surgery has brought similar advantages as those seen in general surgery.There have been no trials assessing postoperative pain after laparoscopic adjustable silicone gastric banding (LASGB). We compared prospectively postoperative pain and outcome in LASGB and laparoscopic cholecystectomy (LC), to determine if morbidly obese patients can expect the same benefits from a laparoscopic approach in gastric banding as those which are known for LC in non-obese and obese patients. Methods: In a prospectively collected database of 80 patients undergoing LASGB, information including a survey assessing the postoperative pain, the amount of analgetic drugs used, operative reports, laboratory data, and follow-up data was collected. This was compared to an equal number of patients undergoing LC. Postoperatively,all patients received standardized pain medication of 150 mg tramadol per day. Pain was assessed twice on postoperative days 1-3 using a patient questionnaire. Results: Patient characteristics and duration of hospital stay were similar in the two groups. Although there was no significant difference in type and intensity of pain experienced by the patients in either group, the gastric banding patients reported less postoperative pain overall than those in the LC group. Conclusion: The analyzed data show that LASGB offers the same advantages as other laparoscopic operations, in that it induces less pain and enables the patient to return quickly to normal activity and work. The advantage over the compared LC group may be due to higher patient motivation, but was not statistically significant.     

Routine day-case laparoscopic cholecystectomy

BACKGROUND: A prospective study was carried out to assess the feasibility of performing true day-case laparoscopic surgery in a district general hospital. METHODS: All patients admitted consecutively under the care of one surgeon for laparoscopic cholecystectomy were included in the study. Selection criteria for a day-case procedure included an American Society of Anesthesiologists grade of I or II and the availability of a responsible carer at home. Patients were discharged 4-6 h after surgery with a standard analgesia pack and a contact number for advice. All patients were contacted by telephone on the day after discharge. A postal questionnaire was sent to the first 100 patients to assess satisfaction with the day-case process. RESULTS: Of 357 patients admitted for laparoscopic cholecystectomy over a 24-month period, 154 (43.1 per cent) were operated on as day cases on a morning theatre list. Twenty-two patients required an overnight stay (14.3 per cent), three because of conversion to an open procedure. One patient was readmitted for neck pain. Eighty-two (92.1 per cent) of 89 patients were either satisfied or very satisfied with the day-case procedure. CONCLUSION: This study has demonstrated a low rate of overnight stay (14.3 per cent) and readmission (1.9 per cent), and a high degree of patient satisfaction for day-case laparoscopic cholecystectomy.     

Enhanced recovery after laparoscopic colorectal resection with primary anastomosis: accelerated discharge is safe and does not give rise to increased readmission rates

Aims Enhanced recovery programmes after colorectal surgery are promoted to minimize complications and expedite recovery, thus reducing length of hospital stay where appropriate and improving the overall standard of patient care. There are few published trials of enhanced recovery programmes in the context of laparoscopic colorectal surgery. Methods Data were prospectively collected on all laparoscopic colorectal resections carried out in our institution from May 2004 to November 2009. An informal move to 48‐h discharge was introduced in May 2004 and the official enhanced recovery programme was launched in November 2008. We identified all patients with a primary anastomosis discharged within 3 days of surgery. Early outcomes – leaks, complications, readmission rates and returns to theatre – were analysed. Results In all, 606 resections were performed in this period. Median length of stay was 4 (0–52) days. Of these patients, 279 (46%) met the criteria of accelerated discharge by day 3: 2 (0.7%) were discharged on the day of surgery, 70 (25.1%) within 24 h, 116 (41.6%) within 48 h and 91 (32.6%) by 72 h. Age was not a significant factor in determining length of stay. Patients undergoing right hemicolectomy were more likely to be discharged by 24 h than those with left‐sided anastomoses, and patients having total mesorectal excision resections were more likely to stay 3 days. The readmission rate was 4%, regardless of day of discharge. Conclusion Accelerated discharge is feasible and safe. High readmission rates reported in enhanced recovery programmes after open colorectal surgery have not occurred in our laparoscopic experience.