Day-Case Laparoscopic Cholecystectomy in Childhood: Outcomes from a Clinical Care Pathway

 

 Permissions and Reprints

Abstract

Aim The aim of this study was to report clinical outcomes following the use of a pediatric day-case laparoscopic cholecystectomy (DCLC) clinical care pathway. The pathway was modified in September 2009 and we compare the clinical outcomes before and after this modification.

Methods A care pathway for DCLC was introduced in 2008 with emphasis on the day of admission, timing of surgery, choice of anesthetic agents, analgesia, postoperative feeding, mobilization, and pain scoring. Demographic and clinical data were recorded prospectively from January 2008 to January 2012. In September 2009, two modifications were made to the pathway. Induction of anesthesia was changed to total intravenous anesthesia, using propofol (target 4 to 6 µg/mL) and remifentanil (target 3 to 5 ng/mL) and the use of the gaseous anesthetic sevoflurane was eliminated with the aim of reducing the risk of postoperative nausea and vomiting (PONV). The postoperative feeding regime was changed from unrestricted to light diet for 72 hours. The rest of the pathway was unchanged. Data before (group 1) and following the modifications (group 2) were compared.

Results We admitted 25 children with symptomatic cholelithiasis for DCLC under the care of one surgeon: 12 in group 1 and 13 in group 2. There were no significant differences in age between group 1 (median 13 [range 6 to 15] years) and group 2 (median 15 [9 to 16] years) (p = 0.07). There were no intra- or postoperative complications. The day-case rate increased from 6/12 (50%) in group 1 to 12/13 (92%) in group 2 (p = 0.03). The incidence of PONV reduced from 7/12 (58%) in group 1 to 0/13 in group 2 (p = 0.002). PONV in group 1 resulted in overnight stay (n = 6) and readmission (n = 1). One patient in group 2 had an overnight stay due to poor mobilization.

Conclusions Adoption of a DCLC pathway is feasible and safe for children. Emphasis on adequate pain management and avoidance of PONV results in a high rate of day-case surgery equivalent to that achieved in adult practice.

• References

• 1 Mjåland O, Raeder J, Aasboe V, Trondsen E, Buanes T. Outpatient laparoscopic cholecystectomy. Br J Surg 1997; 84 (7) 958-961
  CrossrefPubMedGoogle Scholar
• 2 Campanelli G, Cavagnoli R, Cioffi U, De Simone M, Fabbiani M, Pietri P. Can laparoscopic cholecystectomy be a day surgery procedure?. Hepatogastroenterology 1998; 45 (23) 1422-1429
  PubMedGoogle Scholar
• 3 Kiely JM, Brannigan AE, Foley E, Cheema S, O'Brien W, Delaney PV. Day case laparoscopic cholecystectomy is feasible. Ir J Med Sci 2001; 170 (2) 98-99
  PubMedGoogle Scholar
• 4 Ammori BJ, Davides D, Vezakis A , et al. Day-case laparoscopic cholecystectomy: a prospective evaluation of a 6-year experience. J Hepatobiliary Pancreat Surg 2003; 10 (4) 303-308
  CrossrefPubMedGoogle Scholar
• 5 Leeder PC, Matthews T, Krzeminska K, Dehn TC. Routine day-case laparoscopic cholecystectomy. Br J Surg 2004; 91 (3) 312-316
  CrossrefPubMedGoogle Scholar
• 6 Johansson M, Thune A, Nelvin L, Lundell L. Randomized clinical trial of day-care versus overnight-stay laparoscopic cholecystectomy. Br J Surg 2006; 93 (1) 40-45
  CrossrefPubMedGoogle Scholar
• 7 Metcalfe MS, Mullin EJ, Maddern GJ. Relaxation of the criteria for day surgery laparoscopic cholecystectomy. ANZ J Surg 2006; 76 (3) 142-144
  CrossrefPubMedGoogle Scholar
• 8 Kasem A, Paix A, Grandy-Smith S, El-Hasani S. Is laparoscopic cholecystectomy safe and acceptable as a day case procedure?. J Laparoendosc Adv Surg Tech A 2006; 16 (4) 365-368
  CrossrefPubMedGoogle Scholar
• 9 Berrevoet E, Biglari M, Sinove Y, De Baardemaeker L, Troisi R, de Hemptinne B. Outpatient laparoscopic cholecystectomy in Belgium: what are we waiting for?. Acta Chir Belg 2006; 106 (5) 537-540
  PubMedGoogle Scholar
• 10 Victorzon M, Tolonen P, Vuorialho T. Day-case laparoscopic cholecystectomy: treatment of choice for selected patients?. Surg Endosc 2007; 21 (1) 70-73
  CrossrefPubMedGoogle Scholar
• 11 Proske JM, Dagher I, Revitea C , et al. Day-case laparoscopic cholecystectomy: results of 211 consecutive patients. Gastroenterol Clin Biol 2007; 31 (4) 421-424
  CrossrefPubMedGoogle Scholar
• 12 Rathore MA, Andrabi SI, Mansha M, Brown MG. Day case laparoscopic cholecystectomy is safe and feasible: a case controlled study. Int J Surg 2007; 5 (4) 255-259
  CrossrefPubMedGoogle Scholar
• 13 Kavanagh T, Hu P, Minogue S. Daycase laparoscopic cholecystectomy: a prospective study of post-discharge pain, analgesic and antiemetic requirements. Ir J Med Sci 2008; 177 (2) 111-115
  CrossrefPubMedGoogle Scholar
• 14 Cassinotti E, Colombo EM, Di Giuseppe M, Rovera F, Dionigi G, Boni L. Current indications for laparoscopy in day-case surgery. Int J Surg 2008; 6 (6) (Suppl. 01) S93-S96
  CrossrefPubMedGoogle Scholar
• 15 Kow AW, Tan A, Chan SP , et al. An audit of ambulatory laparoscopic cholecystectomy in a Singapore institution: are we ready for day-case laparoscopic cholecystectomy?. HPB (Oxford) 2008; 10 (6) 433-438
  CrossrefPubMedGoogle Scholar
• 16 Cahill CJ. Basket cases and trolleys. Day surgery proposals for the Millenium. Journal of One-Day Surgery 1999; 9 (1) 11-12
  PubMedGoogle Scholar
• 17 Audit Commission. Day Surgery: Review of National Findings. London: Audit Commission Publications; 2001
  Google Scholar
• 18 Psaila J, Agrawal S, Fountain U , et al. Day-surgery laparoscopic cholecystectomy: factors influencing same-day discharge. World J Surg 2008; 32 (1) 76-81
  CrossrefPubMedGoogle Scholar
• 19 Briggs CD, Irving GB, Mann CD , et al. Introduction of a day-case laparoscopic cholecystectomy service in the UK: a critical analysis of factors influencing same-day discharge and contact with primary care providers. Ann R Coll Surg Engl 2009; 91 (7) 583-590
  CrossrefPubMedGoogle Scholar
• 20 Gurusamy KS, Junnarkar S, Farouk M , et al. Day-case versus overnight stay for laparoscopic cholecystectomy. Cochrane Database Syst Rev 2008; 3 (CD006798) 1469-1493
  PubMedGoogle Scholar
• 21 Méndez K, Sabater R, Chinea E, Lugo-Vicente H. Is there a safe advantage in performing outpatient laparoscopic cholecystectomy in children?. J Pediatr Surg 2007; 42 (8) 1333-1336
  CrossrefPubMedGoogle Scholar
• 22 McWhinnie D, Ellams J, Cahill J , et al. Daycase laparoscopic cholecystectomy. Available at: http://www.daysurgeryuk.net/bads/joomla/files/Handbooks/LaparoscopicCholecystectomy.pdf
  PubMedGoogle Scholar
• 23 Chase DM, Lopez S, Nguyen C, Pugmire GA, Monk BJ. A clinical pathway for postoperative management and early patient discharge: does it work in gynecologic oncology?. Am J Obstet Gynecol 2008; 199 (5) 541 , e1–e7
  PubMedGoogle Scholar
• 24 Joh YG, Lindsetmo RO, Stulberg J, Obias V, Champagne B, Delaney CP. Standardized postoperative pathway: accelerating recovery after ileostomy closure. Dis Colon Rectum 2008; 51 (12) 1786-1789
  CrossrefPubMedGoogle Scholar
• 25 Almond SL, Roberts M, Joesbury V , et al. It is not what you do, it is the way that you do it: impact of a care pathway for appendicitis. J Pediatr Surg 2008; 43 (2) 315-319
  CrossrefPubMedGoogle Scholar
• 26 Emil S, Taylor M, Ndiforchu F, Nguyen N. What are the true advantages of a pediatric appendicitis clinical pathway?. Am Surg 2006; 72 (10) 885-889
  PubMedGoogle Scholar
• 27 Wong DL, Baker CM. Pain in children: comparison of assessment scales. Pediatr Nurs 1988; 14 (1) 9-17
  PubMedGoogle Scholar
• 28 Huang A, Stinchcombe C, Davis M , et al. Prospective five-year audit for day-case laparoscopic cholecystectomy. Journal of One-Day Surgery 2000; 9 (4) 15-17
  PubMedGoogle Scholar
• 29 Akoh JA, Watson WA, Bourne TP. Day case laparoscopic cholecystectomy: reducing the admission rate. Int J Surg 2011; 9 (1) 63-67
  CrossrefPubMedGoogle Scholar
• 30 Patel SD, Patel H, Ganapathi S, Marshall N. Day case laparoscopic cholecystectomy carried out using the harmonic scalpel: analysis of a standard procedure. Surg Laparosc Endosc Percutan Tech 2010; 20 (1) 20-23
  CrossrefPubMedGoogle Scholar
• 31 Sinha S, Munikrishnan V, Montgomery J, Mitchell SJ. The impact of patient-controlled analgesia on laparoscopic cholecystectomy. Ann R Coll Surg Engl 2007; 89 (4) 374-378
  CrossrefPubMedGoogle Scholar
• 32 Cantore F, Boni L, Di Giuseppe M, Giavarini L, Rovera F, Dionigi G. Pre-incision local infiltration with levobupivacaine reduces pain and analgesic consumption after laparoscopic cholecystectomy: a new device for day-case procedure. Int J Surg 2008; 6 (Suppl. 01) S89-S92
  CrossrefPubMedGoogle Scholar
• 33 Roberts KJ, Gilmour J, Pande R, Nightingale P, Tan LC, Khan S. Efficacy of intraperitoneal local anaesthetic techniques during laparoscopic cholecystectomy. Surg Endosc 2011; 25 (11) 3698-3705
  CrossrefPubMedGoogle Scholar
• 34 Raeder JC, Mjåland O, Aasbø V, Grøgaard B, Buanes T. Desflurane versus propofol maintenance for outpatient laparoscopic cholecystectomy. Acta Anaesthesiol Scand 1998; 42 (1) 106-110
  PubMedGoogle Scholar
• 35 Gürkan Y, Kiliçkan L, Toker K. Propofol-nitrous oxide versus sevoflurane-nitrous oxide for strabismus surgery in children. Paediatr Anaesth 1999; 9 (6) 495-499
  CrossrefPubMedGoogle Scholar
• 36 Woodward WM, Barker I, John RE, Peacock JE. Propofol infusion vs thiopentone/isoflurane anaesthesia for prominent ear correction in children. Paediatr Anaesth 1997; 7 (5) 379-383
  CrossrefPubMedGoogle Scholar
• 37 Thagaard KS, Steine S, Raeder J. Ondansetron disintegrating tablets of 8 mg twice a day for 3 days did not reduce the incidence of nausea or vomiting after laparoscopic surgery. Eur J Anaesthesiol 2003; 20 (2) 153-157
  CrossrefPubMedGoogle Scholar