Predictive factors for unanticipated admissions after ambulatory laparoscopic cholecystectomy

HYPOTHESIS: Analysis of the causes of unanticipated admission after ambulatory laparoscopic cholecystectomy may permit the identification of predictive clinical factors for postoperative admission. DESIGN: Univariate and multivariate analyses of clinical variables associated with unplanned admission in a retrospective case-control series of ambulatory laparoscopic cholecystectomies. SETTING: A major university-affiliated teaching hospital. PATIENTS: Seven hundred thirty-one consecutive patients who underwent ambulatory laparoscopic cholecystectomies between January 1, 1996, and December 31, 1999. INTERVENTION: Ambulatory laparoscopic cholecystectomy. MAIN OUTCOME MEASURES: Unplanned postoperative admissions. Univariate and multivariate analyses of 19 clinicopathologic factors were performed to identify independent predictive factors for these admissions. RESULTS: Seven hundred six patients were discharged on the day of operation. The remaining 25 required admission because of pain (n = 10), nausea and vomiting (n = 6), retention of urine (n = 5), patient preference (n = 3), and medical observation (n = 1), giving an unanticipated admission rate of 3.4%. Significant factors associated with unplanned admission included operative duration of longer than 60 minutes and thickened gallbladder wall on ultrasonographic and pathological findings. By means of logistic regression, length of operation was the only independent predictive factor. Operative time exceeding 60 minutes incurred a 4-fold increased risk for unanticipated admission. CONCLUSIONS: Operative duration was the best predictive factor for unplanned admission after ambulatory laparoscopic cholecystectomy. During selection of patients for day surgery, ultrasonographic demonstration of a thickened gallbladder wall should be taken into consideration.     

Predictive factors for conversion of laparoscopic cholecystectomy

BACKGROUND: Laparoscopic cholecystectomy has replaced open cholecystectomy for the treatment of gallbladder disease. However, certain cases still require conversion to open procedures. Identifying these patients at risk for conversion remains difficult. This study identifies risk factors that may predict conversion from a laparoscopic to an open procedure. METHODS: From January 1996 to January 2000, a total of 1,347 laparoscopic cholecystectomies were performed at the Cleveland Clinic Foundation (CCF). A retrospective analysis of 34 parameters including patient demographics, clinical history, laboratory data, ultrasound results, and intraoperative details was performed. Stepwise, multivariate logistic regression was used to determine those variables predicting conversion of laparoscopic cholecystectomy. RESULTS: Seventy-one (5.3%) laparoscopic cholecystectomies required conversion. Multivariate analysis revealed that for all cases, a white blood cell count >9 (2.9 greater odds ratio [OR] of conversion P = 0.006) and a gallbladder wall thickness >0.4 cm (7.2 OR, P <0.001) predicted conversion to open cholecystectomy. However, when patients with acute cholecystitis were evaluated only a body mass index >30 kg/m(2) (5.6 OR, P = 0.02) predicted conversion. For patients undergoing elective cholecystectomy, a body mass index >40 kg/m(2) (33.1 OR, P = 0.01) and a wall thickness >0.4 cm (24.7 OR, P <0.004) predicted conversion. Finally, an ASA >2 (5.3 OR, P = 0.01) predicted conversion in patients undergoing nonelective cholecystectomies. CONCLUSIONS: Obese patients with acute cholecystitis undergoing laparoscopic cholecystectomy have an increased chance of conversion. Likewise, patients with multiple comorbid diseases undergoing nonelective laparoscopic cholecystectomy are more likely to require conversion. Finally, in an elective laparoscopic cholecystectomy, morbidly obese patients with chronic cholecystitis and a thickened gallbladder wall are more likely to require conversion. These factors can help counsel patients undergoing laparoscopic cholecystectomy with regards to the probability of conversion to an open procedure.     

Contributing factors to postoperative length of stay in laparoscopic cholecystectomy

Background:

Laparoscopic cholecystectomy for gallbladder disease is a common surgical procedure performed in hospitals throughout the world. This study evaluates the major factors that contribute to postoperative length of stay for patients undergoing laparoscopic cholecystectomy.

Methods:

We analyzed data for patients undergoing laparoscopic cholecystectomy in a 5-hospital community health system from December 1, 2008 to January 31, 2009. The natural logarithm of postoperative length of stay was modeled to evaluate significant factors and contributions.

Results:

Included in the analysis were 232 patients. Three preoperative patient factors were significant contributors: body mass index was associated with decreased postoperative length of stay, while white blood cell count and the presence of biliary pancreatitis were associated with increased postoperative length of stay. The operative factors of fluids administered and ASA class were significant contributors to increased postoperative length of stay, with an increasing contribution with a higher ASA class. The utilization factor of nonelective status was a significant contributor to increased postoperative length of stay.

Conclusion:

Several factors were major contributors to postoperative length of stay, with ASA class and nonelective status having the most significant increased contribution. Efforts to optimize efficient elective care delivery for patients with symptomatic gallbladder disease may demonstrate a benefit of decreased hospital utilization.     

Short and long term outcome after laparoscopic cholecystectomy

BACKGROUND: As an audit of patients undergoing laparoscopic cholecystectomy this study not only reports the short term results, but attempted to assess the long term effect of the operation on the symptom profiles of the patients. METHODS: Three hundred unselected consecutive patients underwent elective laparoscopic cholecystectomy from January 1991 to July 1994. Short term outcome was analysed by reviewing patient files for operation details, postoperative morbidity, complications, and gallbladder histology. Long term (median 2 years) outcome was evaluated by a detailed postal questionnaire. Symptomatic benefit ratios (BR) accruing from the laparoscopic removal of the gallbladder were calculated. RESULTS: Twelve operations (4.0%) were converted to open surgery and were excluded from long term outcome analyses. Median operation time was 93 (range 40-245) minutes. There were no deaths. Overall morbidity was 13 %. Median postoperative hospital stay was 2 days (range 1-18 days) and median time-off work 15 days (range 2-49 days). The overall response rate to the questionnaire was 87%. Only one of the 261 patients (0.4%) suffered from recurrent common bile duct stones so far. As shown by the benefit ratios the symptoms most effectively relieved by laparoscopic cholecystectomy were biliary pain (0.97), nausea (0.95), vomiting (0.96) and jaundice (0.94). Most patients with diarrhoea (0.70) and heartburn (0.66) felt relief. Constipation (0.39) and food intolerance (0.57) were unaffected. Most patients (90%) felt that the operation-initiating symptom had disappeared and 98 percent of the patients considered that they had obtained overall symptomatic improvement by the operation. CONCLUSIONS: Laparoscopic cholecystectomy appears to be a safe and effective way of treating the most common symptoms related to gallstone disease.     

Factors associated with prolonged stay after laparoscopic cholecystectomy in elderly patients

Background Laparoscopic cholecystectomy in elderly patients has been linked to higher complication rates and longer lengths of stay. The purpose of this study was to identify risk factors associated with prolonged postoperative hospitalization in elderly patients undergoing laparoscopic cholecystectomy. Methods The records of 287 patients aged 65 years or older, who underwent successful laparoscopic cholecystectomy between January 2001 and July 2006, were retrospectively reviewed. Clinical data was abstracted from the chart and compared between patients with a shorter or longer postoperative stay. Results The median postoperative hospital stay was three days (interquartile range 3–5). Forty-eight patients had complications, with an overall morbidity of 16% and mortality of 0.7%. The only independent predictor of prolonged postoperative stay was the occurrence of any major complication [odds ratio, 3.144; 95% confidence interval (CI), 1.882–5.251]. The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and underlying chronic obstructive pulmonary disease were independently associated with major complications. Conclusions A major complication is the most important cause of prolonged hospital stay after laparoscopic cholecystectomy in the elderly. No specific comorbidity has direct impact on the duration of hospitalization, but pulmonary disease is associated with increased risk of major complications.     

胰腺神经内分泌肿瘤患者腹腔镜术后住院时间延长的危险因素分析

目的 探究胰腺神经内分泌肿瘤（pNETs）患者行腹腔镜手术后住院时间延长的危险因素。方法 回顾性分析2015年1月至2022年8月在浙江省人民医院行腹腔镜手术治疗的91例pNETs患者的临床资料。以术后住院时间是否超过中位住院时间12 d将患者分为住院时间正常组（NLOS组,≤12 d,n=50）和住院时间延长组（PLOS组,>12 d,n=41）。通过单因素和多因素Logistic回归分析患者术后住院时间延长的危险因素,用AUC和Brier分数评价区分度和校准度。结果 单因素及多因素分析显示,手术时间>210 min(OR=8.850,95%CI 2.699～29.013,P<0.001)和腹腔镜手术方式[腹腔镜胰十二指肠切除术（LPD）:OR=5.753,95%CI 1.062～31.155,P=0.042;腹腔镜胰腺体尾切除术（LDP:OR=8.547,95%CI1.908～38.291,P=0.005]是患者住院时间延长的独立危险因素。此时相应的AUC为0.785,Brier分数为0.182。结论 手术时间和手术方式是预测pNETs患者腹腔镜术后住院时间是否延...     

Predictive model of failure of outpatient laparoscopic cholecystectomy

INTRODUCTION: The aim of our study was to review our experience and to determine a predictive model of factors for unanticipated admissions after ambulatory laparoscopic cholecystectomy (LC). MATERIALS AND METHODS: Between January 1999 and June 2003, 410 consecutive LCs were performed as outpatient procedures. We performed univariate analysis and logistic regression models of preoperative and intraoperative variables. The scoring system developed allowed calculating the ambulatorization probability of LC in each patient. Validation and calibration of the model were realized by means of Hosmer-Lemeshow test. RESULTS: Three hundred sixty-three patients were strictly ambulatory (86.8%). Forty-two patients required overnight admission (10.2%), most of them because of social factors, and 5 patients were admitted. Predictive factors related to overnight stay or admission were: age of patient over 65 years [P=0.021; odds ratio (OR)=2.225; 95% confidence interval (CI), 1.130-4.381], operation duration superior to 60 minutes (P=0.046; OR=2.403; 95% CI, 1.106-5.685), and "dissection difficulty" intraoperative score superior to 6 (P=0.034; OR=3.063; 95% CI, 1.086-8.649). The right classification index of the predictive system was 91.7%, reaching a sensibility of 99.7% and specificity of 31.9%. CONCLUSIONS: Outpatient LC is safe and feasible. Age of the patient, operation duration, and complexity of surgical dissection during LC are independent factors influencing ambulatorization rate.     

Reduction of prolonged postoperative hospital stay after laparoscopic surgery for colorectal carcinoma

Background In evaluating the quality of laparoscopic surgery (LS) for colorectal carcinoma, many previous reports have used median or range values to assess the length of postoperative hospital stay and to show the complication and conversion rates separately. However, with this method, it is impossible to assess the proportion of patients who required prolonged postoperative hospital stay because of perioperative morbidities. This study investigated the proportion of patients who benefited from LS as minimally invasive surgery by assessing the percentage of patients who required prolonged postoperative hospital stay because of major perioperative morbidities. Methods A review of 202 patients who underwent LS for colorectal carcinoma at the authors’ hospital between January 2002 and December 2004 was performed. Short-term outcomes were compared among the patients who underwent LS in 2002, 2003, and 2004. Results No significant differences were observed in baseline characteristics among the groups, and all the procedures in this study were completed laparoscopically. There were no significant differences in the operative times and intraoperative blood losses among the groups. Most of the patients resumed liquid intake on postoperative day 1 and solid food on day 3. However, there was a significant difference in the rate of postoperative prolonged hospital stays by year of surgery. In 2004, 97.3% of the patients (72/74) undergoing LS could be discharged to home within 8 days postoperatively. Major complications occurred at a low rate of 1.4% (1/74) in 2004. Regarding the reasons for prolonged postoperative hospital stay, inappropriate judgment of the physician in charge, based primarily on requests from patients without medical necessity, disappeared in 2004. Conclusions When LS is performed properly by specialists who have accumulated sufficient experience in both LS and conventional open surgery for colorectal carcinoma, up to 97% of patients undergoing LS can benefit from minimally invasive surgery.     

腹腔镜胆囊切除术并发症相关因素分析

目的 探讨导致腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)并发症发生的危险因素。方法 回顾分析我院自1991年3月-2003年6月间11974例腹腔镜胆囊切除术患者中发生并发症的临床资料,采用X~2检验和Logistic回归方法对可能导致腹腔镜胆囊切除术并发症发生的15个临床病理相关因素,进行多因素回归分析。结果 本组资料LC术后并发症的发生率为1.896％(227/11 974),中转手术率为2.386％(286/11 974),其中因发生并发症而中转开腹65例,占22.727％(65/286)。Logistic回归分析显示,按作用强度,Calot三角粘连、病期、手术经验、胆囊壁厚度(B超)、胆囊与周围粘连依次为导致腹腔镜胆囊切除术并发症发生的主要危险因素。结论 加强医师的腹腔镜技术培训,正确掌握LC相关危险因素是提高LC手术成功率的关键,正确掌握中转开腹的时机及开腹后处理方法,是降低LC手术严重并发症发生和死亡的有效措施。     

Predictive factors of hospital length of stay in patients with operatively treated ankle fractures

Background

Operative fixation of ankle fractures is common. However, as reimbursement plans evolve with the potential for bundled payments, it is critical that orthopedic surgeons better understand factors influencing the postoperative length of stay (LOS) in patients undergoing these procedures to negotiate appropriate reimbursement. We sought to identify factors influencing the postoperative LOS in patients with operatively treated ankle fractures.

Materials and methods

Six hundred twenty-two patients with ankle fractures between January 1st, 2004 and December 31st, 2010 were identified retrospectively. Charts were reviewed for gender, length of operative procedure, method of fixation, American Society of Anesthesiologists (ASA) physical status score, medical comorbidities, and postoperative LOS. Both univariate and multivariate models were developed to determine predictors of patient LOS. Financial data for an average 24-h inpatient stay were obtained from financial services.

Results

Six hundred twenty-two patients were included. In a linear regression analysis, a statistically significant relationship was demonstrated between ASA status and LOS (P < 0.001). Multiple regression analysis further characterized the relationship between ASA and LOS: a 1-U increase in ASA classification conferred a 3.42-day increase in LOS on average (P < 0.001). Based on an average per-day inpatient cost of $4,503, each unit increase in ASA status led to a $15,490 increase in cost.

Conclusions

Our study demonstrates that ASA status is a powerful predictor of LOS in patients undergoing operative fixation of ankle fractures. More complete understanding of these factors will lead to better risk adjustment models for measuring outcomes, determining fair reimbursement, and potential improvements to the efficiency of patient care.

Level of Evidence

Level III retrospective comparative study regressing length of stay with many variables, including ASA physical status.

Electronic supplementary material

The online version of this article (doi:10.1007/s10195-013-0280-9) contains supplementary material, which is available to authorized users.     

Pain after laparoscopic cholecystectomy

BACKGROUND: Although laparoscopic cholecystectomy (LC) results in less pain than open chole-cystectomy, it is not a pain-free procedure. Many methods of analgesia for pain after laparoscopy have been evaluated. METHODS: Forty-two randomized controlled trials assessing interventions to reduce pain after LC are reviewed, as are the mechanisms and nature of pain after this procedure. RESULTS: Non-steroidal anti-inflammatory drugs, wound local anaesthetic, intraperitoneal local anaesthetic, intraperitoneal saline, a gas drain, heated gas, low-pressure gas and nitrous oxide pneumo-peritoneum have been shown to reduce pain after LC. The clinical significance of this pain reduction is questionable. CONCLUSION: Pain after LC is multifactorial. Although many methods of analgesia produce short-term benefit, this does not equate with earlier discharge or improved postoperative function. However, single trials evaluating low-pressure insufflation, heated gas and multimodal analgesia suggest that clinically relevant benefits can be achieved.     

Sleep after laparoscopic cholecystectomy

The sleep pattern and oxygenation of 10 patients undergoing laparoscopic cholecystectomy were studied on the night before operation and the first night after operation. Operations were performed during general anaesthesia and postoperative analgesia was achieved without the administration of opioids. There were no significant changes in the total time awake or the number of arousals on the postoperative night compared with the night before operation. During the postoperative night, we found a decrease (P = 0.02) in slow wave sleep (SWS) with a corresponding increase in stage 2 sleep (P = 0.01). SWS was absent in four of the patients after operation, whereas in six patients it was within the normal range (5-20% of the night). The proportion of rapid eye movement (REM) sleep was not significantly changed after operation. There were no changes in arterial oxygen saturation on the postoperative compared with the preoperative night. Comparison of our results with previous studies on SWS and REM sleep disturbances after open laparotomy, suggests that the magnitude of surgery or administration of opioids, or both, may be important factors in the development of postoperative sleep disturbances.      

Pain after laparoscopic cholecystectomy

It is postulated that laparoscopic cholecystectomy as patient-friendly surgery leads to more comfort and in particular to less pain. A prospective study on pain was performed on all patients undergoing the operation over the period of 1 year (n=382) out of a series of more than 1,000 patients who have undergone the operation in our clinic. Pain was measured by a 100-point visual analogue scale (VAS), by a five-point verbal rating scale, and by the consumption of analgesics. Pain was the most frequent symptom, both before and after the operation. The mean level of pain was 37 VAS points 5 h after the operation and declined to 16 points on the third day. In 106 patients (27.8%) the intensity of pain was higher than 50 VAS points. Analgesics were used by 282 patients (73.8%), opioids by 112 (29.3%). Pain was significantly higher in female than male patients (P<0.05), but consumption of analgesics was similar in both groups. The most severe pain was localized to the abdominal wall wounds by 157 (41.1%) and to the right upper abdomen by 138 patients (36.1%) on the first postoperative day. Patients who needed opioids and/or had a pain level of >50 VAS points (n=138) had higher preoperative pain levels (P=0.018) and preoperatively complained more frequently about nausea, vomiting, bloating, and a feeling of abdominal pressure (P=0.003–0.031). However, predictive values of these variables were too small to be of clinical benefit. The duration of operation, intraoperative events (loss of bile, blood, or gallstones), and additional laparoscopic procedures (adhesiolysis, lavage, extension of an incision, suture of fascia) did not influence the intensity of postoperative pain. We conclude that laparoscopic cholecystectomy did cause significant postoperative pain in one-third of our patients only up to the first postoperative day. As predictors for high intensity of pain were not identified, pain should be monitored and analgesics should be delivered liberally.     

Complications after laparoscopic cholecystectomy

The diagnostic and therapeutic approaches used for patients referred for bile duct injuries and other major complications after laparoscopic cholecystectomy (LC) were reviewed and the results of a coordinated radiologic, endoscopic, and surgical approach were assessed.From April 1991 to October 1993, 23 patients were observed. Seven patients had biliary strictures, five had biliary lesions, five presented with retained common bile duct (CBD) stones, and one had a minor cystic duct leak. Five patients had miscellaneous abdominal fluid collections; in addition, biloma or bile ascites were present in 10/23 cases. Correct definition of iatrogenic lesions was mainly made by endoscopic retrograde cholangiography (ERCP) (n=15), associated in six cases also with percutaneous cholangiography (PTC). Minimally invasive treatment included the full range of endoscopic and interventional radiological procedures. Six patients with biliary strictures, one patient with a biliary lesion, all five patients with residual CBD stones, and four patients with abdominal collections were treated by minimally invasive techniques: Therefore, laparotomy was avoided in 70% of cases (16/23 patients). Open surgery was necessary in 7/23 patients (30%), because of ductal lesion (n=4), ductal stricture by endoloop (n=1), iliac artery injury (n=1), and phlegmon of gallbladder bed (n=1).It appears that careful assessment of complications after LC is mandatory and often requires the combined use of ERCP/PTC and cross-sectional imaging. After a first diagnostic phase, complications should be managed by a multidisciplinary approach wherein the radiologist and the endoscopist strictly cooperate with the surgeon in order to obtain an immediate relief of the initial clinical problem, such as jaundice, bile leak, or infection, and then plan a definitive treatment which is tailored to each patient's problem. Using this approach the whole event of LC and its complications can be managed within the field of minimally invasive therapy in most cases.     

Impact of laparoscopic cholecystectomy on hospital utilization

OBJECTIVE: The objective of the present study was to assess the impact of laparoscopic cholecystectomy (LC) and associated endoscopic retrograde pancreatography (ERCP) on hospital utilization. BACKGROUND: Laparoscopic cholecystectomy (LC) has resulted in marked reductions in average length of hospital stay; but population-based studies of hospital utilization have generally not taken into account increased cholecystectomy rates or associated increases in pre and postoperative admissions. METHODS: We conducted a population-based study of all residents of Western Australia who underwent cholecystectomy in the period 1980-2000. Record linkage was used to identify pre and postoperative admissions, and to estimate aggregate length of stay per case based on all relevant admissions. We estimated trends in cholecystectomy rates, proportions of cases with related pre and postoperative hospital admissions, average aggregate length of stay per case and total bed utilization per unit of population. RESULTS: The introduction of LC was associated with a sustained increase in rates of cholecystectomy of 25%. Similar increases occurred in the percentage of cases with related preoperative and postoperative admissions. Average length of stay for index admissions declined by nearly 60% compared with 50% for all related admissions. Per capita hospital utilization for index admissions decreased by 45% compared with 38% for index and associated admissions combined, and 32% for all admissions for biliary disease. CONCLUSIONS: Reduced hospital utilization associated with LC was partly offset by increases in pre and postoperative admissions and a sustained increase in cholecystectomy rates. Record linkage is required to assess the true impact of new technologies on hospital utilization.