Is Outpatient Laparoscopic Cholecystectomy Safe and Cost-effective?: A Model to Study Transition of Care

Background: There is increasing pressure to perform traditional inpatient surgical procedures in an outpatient setting. The aim of the current trial was to determine the safety and cost savings of performing laparoscopic cholecystectomy in an outpatient setting using a "mock" outpatient setting.

Methods: Patients who were scheduled for laparoscopic cholecystectomy by four attending surgeons and for whom operating time was available in the outpatient center were studied. All patients received a standardized anesthetic, including ondansetron, and were discharged from the outpatient postanesthesia care unit if appropriate. At discharge, all patients were admitted to a clinical research center where they were observed in a "mock home" setting and monitored for complications that would have necessitated readmission. A decision analysis was created assuming all patients underwent outpatient surgery with either direct admission or discharge to home and readmission if complications developed.

Results: Of 99 patients who were enrolled in this study, 96 patients would have met the discharge criteria for home. No major complications were observed in these 96 patients. Eleven patients experienced postoperative nausea and vomiting, 3 of whom required an additional 24 h of hospital observation. In the decision model, the optimal strategy would be to perform the procedure on an outpatient basis and readmit patients only for complications, with an average baseline cost savings of $742/patient.     

Single-Incision Laparoscopic Cholecystectomy: Do Patients Care?

Introduction  

Single-incision approaches to laparoscopic cholecystectomy typically involve increasing the size of the umbilical incision and eliminating three smaller incisions, but it is not intuitive that patients would view this as a benefit. We hypothesize that when patient satisfaction with standard laparoscopic cholecystectomy is assessed, most dissatisfaction will be linked to the umbilical incision and, given the option, patients would actually wish to eliminate this incision.     

Laparoscopic Versus Open Cholecystectomy: A Cost–Effectiveness Analysis at Rwanda Military Hospital

Background

Laparoscopic cholecystectomy is first-line treatment for uncomplicated gallstone disease in high-income countries due to benefits such as shorter hospital stays, reduced morbidity, more rapid return to work, and lower mortality as well-being considered cost-effective. However, there persists a lack of uptake in low- and middle-income countries. Thus, there is a need to evaluate laparoscopic cholecystectomy in comparison with an open approach in these settings.

Methods

A cost–effectiveness analysis was performed to evaluate laparoscopic and open cholecystectomies at Rwanda Military Hospital (RMH), a tertiary care referral hospital in Rwanda. Sensitivity and threshold analyses were performed to determine the robustness of the results.

Results

The laparoscopic and open cholecystectomy costs and effectiveness values were $2664.47 with 0.87 quality-adjusted life years (QALYs) and $2058.72 with 0.75 QALYs, respectively. The incremental cost–effectiveness ratio for laparoscopic over open cholecystectomy was $4946.18. Results are sensitive to the initial laparoscopic equipment investment and number of cases performed annually but robust to other parameters. The laparoscopic intervention is more cost-effective with investment costs less than $91,979, greater than 65 cases annually, or at willingness-to-pay (WTP) thresholds greater than $3975/QALY.

Conclusions

At RMH, while laparoscopic cholecystectomy may be a more effective approach, it is also more expensive given the low caseload and high investment costs. At commonly accepted WTP thresholds, it is not cost-effective. However, as investment costs decrease and/or case volume increases, the laparoscopic approach may become favorable. Countries and hospitals should aspire to develop innovative, low-cost options in high volume to combat these barriers and provide laparoscopic surgery.

     

Laparoscopic Cholecystectomy for Acute Cholecystitis: Does Timing Matter?

Acute cholecystitis is a common cause of acute abdominal pain and the definitive treatment is laparoscopic cholecystectomy. When to perform surgery remains controversial. To find out whether laparoscopic cholecystectomy can be performed for acute cholecystitis irrespective of the time since onset of acute symptoms. A total of 200 laparoscopic cholecystectomies performed for acute cholecystitis were evaluated for duration of surgery, conversion rates, biliary and other organ injury, and postoperative stay. Kruskal–Wallis tests, Mann–Whitney tests, and paired t-tests using SPSS software. Thirty patients underwent laparoscopic cholecystectomy within 48 h of onset of symptoms (group 1), 60 patients underwent surgery between 48 h and 6 weeks of onset of symptoms (group 2), and 110 patients underwent surgery after 6 weeks of onset of symptoms (group 3). While the duration of surgery was significantly shorter in group 3 compared to groups 1 and 2 (57.5 min vs. 53.5 min vs. 34.2 min), there were no conversions or major biliary or other organ injury in any of the three groups. Postoperative stay was also comparable between the three groups (3 days vs. 3.1 days vs. 3.08 days). Laparoscopic cholecystectomy can safely be performed at any time after the onset of acute cholecystitis.     

The National Mortality Burden and Significant Factors Associated with Open and Laparoscopic Cholecystectomy: 1997–2006

Introduction  

This study aims to determine the mortality rate and significant factors associated with laparoscopic (LC) and open cholecystectomies (OC) over a 10-year period.     

Single-incision and NOTES Cholecystectomy, Are There Clinical or Cosmetic Advantages When Compared to Conventional Laparoscopic Cholecystectomy? A Case–control Study Comparing Single-incision, Transvaginal, and Conventional Laparoscopic Technique for Cholecystectomy

Background

The aim of the present study was to compare the clinical and cosmetic results of transvaginal hybrid cholecystectomy (TVC), single-port cholecystectomy (SPC), and conventional laparoscopic cholecystectomy (CLC). Recently, single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery have been developed as minimally invasive alternatives for CLC. Few comparative studies have been reported.

Methods

Female patients with symptomatic gallstone disease who were treated in 2011 with SPC, TVC, or CLC were entered into a database. Patients were matched for age, body mass index, and previous abdominal surgery. After the operation all patients received a survey with questions about recovery, cosmesis, and body image.

Results

A total of 90 patients, 30 in each group, were evaluated. Median operative time for CLC was significantly shorter (p < 0.001). There were no major complications. Length of hospital stay, postoperative pain, and postoperative complications were not significantly different. The results for cosmesis and body image after the transvaginal approach were significantly higher. None of the sexually active women observed postoperative dyspareunia.

Conclusions

Both SPC and TVC are feasible procedures when performed in selected patients. CLC is a faster procedure, but other clinical outcomes and complication rates were similar. SPC, and especially TVC, offer a better cosmetic result. Randomized trials are needed to specify the role of SPC and TVC in the treatment of patients with symptomatic gallstone disease.     

��AEIOU: the ABC's�� of Conversion from Laparoscopic to Open Cholecystectomy

Background and Objectives:

To examine and classify the reasons for conversion and the points at which laparoscopic cholecystectomies are converted to open procedures and whether these change over time.

Methods:

This is a retrospective study of all patients undergoing cholecystectomy from June 1, 1990 to June 30, 1995. Reasons for conversion were classified using the “AEIOU:ABC” system developed for this study and conversion points were assigned chronologically.

Results:

The “AEIOU:ABC” classification system was utilized. The most common reasons for conversion were: acute inflammation N=61 (26.1%); adhesions N=51 (21.8%); and organ system pathology N=39 (16.7%). The most common conversion points were; after visualization of the peritoneal cavity but prior to dissection of the cystic structures N=103 (44.0%); dissection of the cystic structures N=58 (24.8%); initial laparoscopy N=36 (15.4%). When the reasons for conversion were evaluated for changes over time there was no statistically significant change for the total group or any individual surgeon. Conversion points did not change with increasing operative experience.

Conclusion:

The “AEIOU:ABC” classification system is a simple, effective and easy to use system for classifying the myriad of reasons for conversion. The system needs to be validated prospectively not only for laparoscopic cholecystectomy but for possible application to other laparoscopic procedures.     

Elective Cholecystectomy During Laparoscopic Roux-En-Y Gastric Bypass: Is it Worth the Wait?

Background: Combined gastric bypass and cholecystectomy have been advocated for open bariatric procedures. Our goal was to evaluate the safety of this technique in laparoscopic bariatric surgery patients with gallstones diagnosed preoperatively. Methods: 94 out of 556 consecutive morbidly obese patients (16.9%) underwent laparoscopic gastric bypass with simultaneous cholecystectomy (LGBP/LC) for cholelithiasis. Results: 328 patients (59%) had a concomitant secondary procedure, most commonly cholecystectomy (28.7%). Preoperative BMI was 48.6±6.9 kg/m² for LGBP/LC patients and 48.8±7.3 kg/m² (P=0.85) for LGBP alone. 5 patients had preoperative biliary colic; the others were asymptomatic for cholelithiasis. Postoperatively, at a mean follow-up of 7.6±6.7 months, the percent excess weight loss (%EWL) was 46.1±0.25 for the combined procedure vs 50.2±63.0 (P=0.55) for LGBP alone. There were no conversions to open procedures for the LC. Port placement for the LGBP was not altered for LC. None required intraoperative cholangiography. Operative time for the combined procedure was 293.4±79.8 minutes vs 244.8±77.2 minutes for LGBP alone (P<0.0001). Length of stay for the combined procedure was 4.35±10.8 days vs 2.69±1.8 days for LGBP alone (P=0.0069).There were no postoperative bile leaks or bile duct injuries. Conclusion: Concomitant LGBP/LC is safe and feasible without altering port placement. Combining these procedures significantly increases operative time and nearly doubles the hospital stay.     

Robotic Versus Laparoscopic Cholecystectomy Inpatient Analysis: Does the End Justify the Means?

Background and Objectives

Robotic-assisted cholecystectomy (RAC) was introduced several years ago. With its more extensive use by surgeons, more information is needed regarding clinical and economic outcomes.

Methods

The Nationwide Inpatient Sample from the Health Cost Utilization Project was analyzed using HCUPnet, National Inpatient Sample (NIS) datasets and SAS 9.2 for the years 2010–2011. Queries were made for RAC and laparoscopic cholecystectomy (LC) procedures with a primary diagnosis of gallbladder disease. Overall charges, costs, number of chronic conditions, comorbidities, and length of stay were calculated.

Results

RAC was $7518, +54 % (p?p?p?=?0.27) between 2010 and 2011, even though RAC was still costlier than LC in 2011. There was no significant difference in the LOS between RAC and LC in either years. Patients undergoing RAC had an increased number of chronic conditions compared to patients undergoing LC in both 2010 and 2011.

Conclusion

LOS of RAC is similar to LC. Cost of RAC remains higher compared to LC although there was reduction in cost of RAC in 2011 versus 2010.     

Delayed Laparoscopic Cholecystectomy for Acute Calculous Cholecystitis: Is it Time for a Change?

Background

Our aim was to evaluate the advantages and limitations of delayed laparoscopic cholecystectomy (LC) in a tertiary center.

Materials and methods

A retrospective analysis of all patients admitted to our institution with acute calculous cholecystitis (ACC) between January 2003 and December of 2012 was performed. Data collected included patient demographics and comorbidities, presenting symptoms, laboratory findings, imaging results, length of stay (LOS), time to surgery, and surgical complications.

Results

A total of 1078 patients were admitted with ACC. There were 593 females (55%), and the mean age was 57 ± 0.6 years. Mean LOS at initial admission, re-admission until surgery, and following surgery was 7.9 ± 0.2, 1.5 ± 0.1, and 3.4 ± 0.2 days, respectively. Percutaneous cholecystostomy (PC) tube was inserted in 24% of the patients. Only 640 (59%) patients eventually underwent LC. Mean time to surgery was 97 ± 9.8 days, and 16.4% of patients were readmitted in this time period resulting in a mean total LOS of 10.6 ± 0.2 days. Conversion rate to open surgery was 5.8% and bile duct injury occurred in 1.1%. Postoperative complications occurred in 9.8% of the patients, and 30-day mortality was 0.6%. Patients with more severe inflammation according to Tokyo Criteria grade were more likely to undergo PC, were more likely to be readmitted while waiting for LC, and also had more postoperative complications.

Conclusions

Delayed LC is associated with significant loss of follow-up, long LOS, and higher than expected use of PC. Conversion rates are lower than in the literature while rates of bile duct injury and mortality are comparable. We believe these data as well as the available literature are sufficient to change our hospital policy regarding the surgical treatment of ACC from delayed to early same admission surgery in appropriate cases.

     

Endoscopic Sleeve Gastroplasty,Laparoscopic Sleeve Gastrectomy,and Laparoscopic Band for Weight Loss: How Do They Compare?

Background

Endoscopic sleeve gastroplasty (ESG) is a novel endobariatric procedure. Initial studies demonstrated an association of ESG with weight loss and improvement of obesity-related comorbidities. Our aim was to compare ESG to laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB).

Methods

We included 278 obese (BMI > 30) patients who underwent ESG (n = 91), LSG (n = 120), or LAGB (n = 67) at our tertiary care academic center. Primary outcome was percent total body weight loss (%TBWL) at 3, 6, 9, and 12 months. Secondary outcome measures included adverse events (AE), length of stay (LOS), and readmission rate.

Results

At 12-month follow-up, LSG achieved the greatest %TBWL compared to LAGB and ESG (29.28 vs 13.30 vs 17.57%, respectively; p < 0.001). However, ESG had a significantly lower rate of morbidity when compared to LSG or LAGB (p = 0.01). The LOS was significantly less for ESG compared to LSG or LAGB (0.34 ± 0.73 vs 3.09 ± 1.47 vs 1.66 ± 3.07 days, respectively; p < 0.01). Readmission rates were not significantly different between the groups (p = 0.72).

Conclusion

Although LSG is the most effective option for weight loss, ESG is a safe and feasible endobariatric option associated with low morbidity and short LOS in select patients.

     

Routine Testing of Liver Function Before and After Elective Laparoscopic Cholecystectomy: Is It Necessary?

Background and Objectives:

Liver function tests (LFTs) include alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transpeptidase (GGT), alkaline phosphatase (ALP), and bilirubin. The role of routine testing before and after laparoscopic cholecystectomy was evaluated in this study.

Patients and Methods:

A total of 355 patients were retrospectively analyzed by examining the LFTs the day before, the day after, and 3 weeks after the surgery. The Wilcoxon signed-rank test and Student t test were performed to determine statistical significance.

Results:

Alterations in the serum AST, ALT, and GGT were seen on the first postoperative day. Minor changes were seen in bilirubin and ALP. An overall disturbance in the LFTs was seen in more than two-thirds of the cases. Repeat LFTs performed after 3 weeks on follow-up were found to be within normal limits.

Conclusion:

Mild-to-moderate elevation in preoperative LFTs may not be associated with any deleterious effect, and, in the absence of clinical indications, routine preoperative or postoperative liver function testing is unnecessary.     

Post–Kidney-Transplant Diabetes: Evaluation of Risk Factors

IntroductionPost-transplant diabetes mellitus is a complication of kidney transplantation with deleterious effects on graft and patient survival and is associated with higher mortality. The goal of this paper is to identify risk factors that contribute to its development so that it can be avoided.MethodsWe performed a retrospective analysis of 659 kidney transplants performed in adult patients between January 2013 and December 2017. We excluded patients with a previous diagnosis of diabetes mellitus and identified 61 patients with post-transplant diabetes mellitus (10.6%), then compared them to a control group of 61 patients who did not suffer from the disease, namely the kidney transplant pair or the patient submitted for transplant immediately after.DiscussionA comparative analysis of the 2 groups revealed significant differences regarding the use of β-blockers, fasting glucose on the fifth day post-transplant, kidney recipient age, and body mass index. Using multivariate logistic regression methods, 2 variables with an impact on post-transplant diabetes development were found: fasting glucose on the fifth day post-transplant (odds ratio 1.044, 95% confidence interval 1.010–1.079, P = .010) and body mass index (odds ratio 1.130, 95% confidence interval 1.009–1.264, P = .034). We did not find any differences for other potential risk factors.ConclusionA high plasma glucose level on the fifth day after the transplant and a high body mass index in the setting of the transplant can potentially impact the transplant's outcomes, so it is important to identify these levels as soon as possible to take measures to prevent this disease.     

Laparoscopic Cholecystectomy: Is It a Conscious Preference among Turkish Patients with Symptomatic Gallstones? — Prospective Study

Laparoscopic cholecystectomy (LC) has the advantages of early return to full daily activity, early return to work, and better cosmetic result, as well as quickly resolving pain. Yet how this information about the procedure influences a patients attitude toward laparocopy is not known. In this study we analyzed the factors that play role in the decision-making process of patients who choose laparoscopic surgery, and we also evaluated patients knowledge of laparoscopy and their expectations. A questionnaire was used in evaluating 98 patients suffering from symptomatic cholelithiasis scheduled for elective laparoscopic cholecystectomy between January 2001 and January 2002. Females constituted 81% of the study population. Most of the patients (56%) were housewives. While 45% of the patients had an educational status of primary school degree only, 14% had graduated from a university. Forty-three patients described their level of knowledge about laparoscopy as low (had only heard about laparoscopy). In 61% of the patients the surgeon was the sole decision maker about the type of the operation. Almost none of the patients had a preference for the time of discharge from the hospital after surgery, and only three of the actively working patients offered a time interval for return to work. From this study we concluded that most patients have inadequate information about laparoscopic surgery, that the type of operation is dictated mostly by the surgeon, and that early discharge and early return to work are not important for many patients.     

Hand-Assisted Laparoscopic (HAL) Multiple Segmental Colorectal Resections: Are They Feasible and Safe?

The objective of this study was to evaluate the short-term outcomes of synchronous hand-assisted laparoscopic (HAL) segmental colorectal resections. The surgical options for synchronous colonic pathology include extensive colonic resection with single anastomosis, multiple synchronous segmental resections with multiple anastomoses, or staged resections. Traditionally, multiple open, synchronous, segmental resections have been performed. There is a lack of data on HAL multiple segmental colorectal resections. A retrospective chart review was compiled on all patients who underwent HAL synchronous segmental colorectal resections by all the colorectal surgeons from our Group during the period of 1999 to 2014. Demographics, operative details, and short-term outcomes are reported. During the period, 9 patients underwent HAL synchronous multiple segmental colorectal resections. There were 5 women and 4 men, with median age of 54 (24–83) years and median BMI of 24 (19.8–38.7) kg/m². Two patients were on long-term corticosteroid therapy. The median operative time was 210 (120–330) minutes and median operative blood loss was 200 (75–300) mLs. The median duration for return of bowel function was 2 days and the median length of stay was 3.5 days. We had 2 minor wound infections. There were no deaths. Synchronous segmental colorectal resections with anastomoses using the hand-assisted laparoscopic technique are safe. Early conversion to open and use of stomas are advisable in challenging cases.Key words: Hand assisted laparoscopic surgery, Synchronous, Colorectal anastomosesSynchronous colonic pathology affecting distant colonic segments, although uncommon, poses a management dilemma. The surgical options include extensive resections with single anastomosis or multiple segmental resections with synchronous multiple anastomoses. Extended colonic resections may alter bowel function and affect quality of life.¹ On the other hand, the risk of anastomotic leak maybe increased with multiple colonic anastomoses. Studies have shown that open synchronous multiple colonic anastomoses are safe.^2,3Traditionally, multiple segmental resections have been performed with open surgery. Hand-assisted laparoscopic (HAL) colectomy has an edge over open surgery with decreased postoperative pain, length of stay and wound, and pulmonary complications.⁴ The aim of this study is to evaluate the short-term outcomes in a cohort of patients who underwent synchronous HAL multiple segmental colorectal resections.