Is standardized care feasible in the emergency setting? A case matched analysis of patients undergoing laparoscopic cholecystectomy
Grass et al. BMC Surgery
Is standardized care feasible in the emergency setting? A case matched analysis of patients undergoing laparoscopic cholecystectomy
Fabian Grass 0
Matthieu Cachemaille 2
Catherine Blanc 2
Nicolas Fournier 1
Nermin Halkic 0
Nicolas Demartines 0
Martin Hübner 0
0 Department of Visceral Surgery, University Hospital CHUV , Bugnon 46, 1011 Lausanne , Switzerland
1 Institute for Social and Preventive Medicine, University Hospital CHUV , Lausanne , Switzerland
2 Department of Anaesthesiology, University Hospital CHUV , Lausanne , Switzerland
Background: Immediate laparoscopic cholecystectomy is the accepted standard for the treatment of acute cholecystitis. The aim of the present study was to evaluate the feasibility of a standardized approach with tailored care maps for pre- and postoperative care by comparing pain, nausea and patient satisfaction after elective and emergent laparoscopic cholecystectomy. Methods: From January 2014 until April 2015, data on pain and nausea management were prospectively recorded for all elective and emergency procedures in the department of visceral surgery. This prospective observational study compared consecutive laparoscopic elective vs. emergency cholecystectomies. Visual analogue scales (VAS) were used to measure pain, nausea, and satisfaction from recovery room until 96 hours postoperatively. Results: Final analysis included 168 (79%) elective cholecystectomies and 44 (21%) emergent procedures. Demographics (Age, gender, BMI and ASA-scores) were comparable between the 2 groups. In the emergency group, patients did not receive anxiolytic medication (0% vs.13%, p = 0.009) and less postoperative nausea and vomiting (PONV) prophylaxis (77% vs. 97% p = <0.001). Perioperative pain management was similar in terms of opioid consumption (median amount of fentanyl 450ug [IQR 350-500] vs. 450ug [375-550], p = 0.456) and wound infiltration rates (24% vs. 25%, p = 0.799). Postoperative consumption of paracetamol, metamizole and opiod medications were similar between the 2 groups. VAS scores for pain (p = 0.191) and nausea (p = 0.392) were low for both groups. Patient satisfaction was equally high in both clinical settings (VAS 8.5 ± 1.1 vs. 8.6 ± 1.1, p = 0.68). Conclusions: A standardized pathway allows equally successful control of pain and nausea after both elective and emergency laparoscopic cholecystectomy. This study was retrospectively registered by March 01, 2016 in the following trial register: www.researchregistry.com (UIN researchregistry993)
Cholecystectomy; Emergent; Elective; Postoperative; Pain management
Cholecystectomy is one of the most commonly
performed surgical procedures worldwide . In developed
countries, laparoscopic approach is nowadays standard
since it has been shown to reduce pain, cosmetic issues,
length of stay and morbidity . In the emergency
situation of calculous cholecystitis, prompt surgical
management has been shown to be equally feasible compared to
a wait and see approach . To facilitate and harmonize
care of patients undergoing laparoscopic
cholecystectomy, it might be beneficial to standardize both
procedure and perioperative management, regardless of the
clinical setting. Standardization was achieved by the use
of tailored caremaps in the present study, and the
surgical procedure was standardized in the setting of our
tertiary teaching Institution. Whether such standardization
is feasible in both the elective and the emergency
setting, however, needs to be proven.
The aim of the present study was to compare the
perception of nausea and pain and patient satisfaction
within the same standardized care pathway after elective
and emergent laparoscopic cholecystectomy.
This is a prospective observational study. Demographic
and surgical details and peri- and postoperative pain and
nausea management were compared between patients
undergoing elective and emergent cholecystectomy. The
study cohort included all consecutively operated
laparoscopic cholecystectomies between January 2014 and
April 2015 at the University Hospital of Lausanne
Switzerland (CHUV). Primary open or converted
procedures were excluded from this analysis.
Informed written consent regarding this observational
study was obtained from all patients before surgery, and
the study was approved by the Institutional Review
Board (Commission cantonale d'éthique de la recherche
sur l'être humain CER-VD). The study was designed
according to the STROBE criteria for observational studies
and registered under www.researchregistry.com (UIN
Surgery and perioperative care
Laparoscopic cholecystectomy was performed in a
standardized manner by a classic three- or four-ports
approach. The standardized approach was performed or
taught by senior staff members of the hepato-biliary unit
and all surgeons underwent specific training before
performing the procedure by themselves.
Induction of anaesthesia was generally performed with
propofol and maintained either by sevoflurane or
desflurane or by intravenous propofol in accordance
with patients’ pathologies. Rapid sequence induction was
performed for all patients suspected to have a full
stomach. Opiates (fentanyl or sufentanyl) were
administered to each patient intraoperatively associated
with paracetamol 1000 mg at the end of the
procedure. Non-depolarizing muscle relaxant was
administered as needed. As per anaesthetists or surgeons
discretion, patients received wound infiltration
(bupivacaine 0.25% or naropin 0.25%) or intravenous
lidocaine (1.5 mg/kg for induction, then 2 mg/kg/h until
recovery room). Postoperative nausea and vomiting
(PONV) prophylaxis consisted of administration of
dexamethasone 4 mg, droperidol 1 mg and
ondansetron 4 mg intraoperatively. Preoperative anxiolytic
medication (premedication) was given case by case
depending on anaesthesists’ appreciation.
Data was collected prospectively by a study nurse and
entered in a dedicated database by two members of the
anaesthesiology care team (MC and CB). All patients
were treated according to standardized care maps,
regardless of the setting (elective or emergent) of the
procedure, and no patient was excluded from this analysis,
with exception of open or converted cases that were not
included at all. In particular, these tailored care-maps for
laparoscopic cholecystectomy outlined pre-, peri- and
postoperative items such as medications and care
protocols for surgeons, anaesthesiologists and nursing staff
likewise (Additional file 1).
Baseline demographic (age, gender, body mass index
(BMI) and American Society of Anaesthesiologists
(ASA) score) and pertinent surgical and anaesthetic
information were recorded. These were in particular the
mode of surgery (elective vs. emergency) and the
duration of procedure and anaesthesia. Postoperative
consumption of paracetamol, metamizole, tramadol,
morphine and oxycodone (delayed-action; Oxycontin®
or short-action; Oxynorm®) was assessed and
administration of postoperative antiemetic medication
(ondansetron, metoclopramide) was recorded. Visual analogue
scales (VAS) were used to measure pain (1-10) and
patient satisfaction (1-10) from recovery room until
96 hours postoperatively at rest and mobilization.
Nausea was assessed and stratified in 4 groups: no nausea =
0, some nausea = 1, occasional (<3/day) vomiting = 2
and frequent (>3/day) vomiting =3. Length of stay
(LOS) and in-hospital complications were recorded for
The main outcomes of interest were the perception of
pain, nausea and satisfaction postoperatively.
Demographic and surgical details and peri- and
postoperative pain and nausea management were compared
Data analysis was performed using the Stata Software v.
14.1 (StataCorp, College Station, TX, USA).
Categorical data were summarized as raw frequencies
and group percentages. Differences in categorical data
distributions between groups were assessed using the
chi-squared test, or the Fisher’s exact test in case of
insufficient sample size. Confidence intervals for
proportions were obtained using the Clopper-Pearson exact
method. Continuous data distribution was analyzed
using Normal QQ-Plots. Gaussian data were
summarized as mean and standard deviation (SD), while
nonGaussian data were summarized as median, interquartile
range (IQR) and range. Differences in means between
two groups for Gaussian data were assessed using the
Student’s t-test. Differences in distribution between two
groups for non-Gaussian data were assessed using the
Wilcoxon-Mann-Whitney ranksum test. We used a
linear mixed-effect model to assess the effect of surgery
type on VAS scores, when correcting for time.
A p-value < 0.05 was considered statistically significant.
Two hundred and seventeen patients underwent
laparoscopic cholecystectomy during the study period. Three
elective (2%) and 2 emergency (4%) interventions needed
pre-emptive conversion to open approach for technical
reasons and were excluded, leaving 212 patients for final
Table 1 Demographics
analysis. One hundred and sixty-eight (79%) elective
cholecystectomies were compared to 44 (21%) emergent
procedures. Acute cholecystitis was the indication for 32
emergent procedures (73%) with the remaining (27%)
being symptomatic gallstone disease. Demographics
(Age, gender, BMI and ASA-scores) are outlined in
Table 1. After propensity score calculation, no
differences were found between these 4 parameters, and for
this reason case matching was not necessary and not
performed. Intraoperative pain management (amounts of
opioids and fentanyl, wound infiltration rates) did not
differ between the 2 groups, as demonstrated in Table 2.
In emergency situation, patients did not receive
anxiolytic medication (0% vs.13%, p = 0.009) and less
postoperative nausea and vomiting (PONV) prophylaxis (77%
vs. 97%, p = <0.001) (Table 2).
Postoperative consumption of paracetamol,
metamizole and opioid medications were similar between the 2
groups, as illustrated in Fig. 1. VAS scores for pain at
rest and under mobilization did not show significant
differences, as shown in Fig. 2. Nausea was rarely an issue
in both groups (Score ≥ 1 at 6 h: 7% vs. 6%, p = 0.362).
Postoperative antiemetic medication was rarely
administered in both groups (18% vs. 14%, p = 0.507). Patient
satisfaction was equally high in both groups (VAS 8.5 ±
1.1 vs. 8.6 ± 1.1, p = 0.68).
Six in-hospital complications (4%) were recorded in
the elective group. One patient presented with a
postoperative bile leak and needed endoscopic retrograde
cholangiopancreatography at postoperative day (POD) 12.
Another patient presented with postoperative bleeding
All patients (n = 212)
Duration of procedure [min]
Duration of anesthesia [min]
Comparison of baseline characteristics by comparing patients who underwent elective cholecystectomy with patients who underwent
BMI Body Mass Index, ASA American Society of Anesthesiologists
Elective (n = 168)
92 (54.8) 76 (45.2)
27 (61.4) 17 (38.6)
119 (56.1) 93 (43.9)
Elective (n = 168)
Emergency (n = 44)
All patients (n = 212)
155 (92.3) 13 (7.7)
194 (91.9) 17 (8.1)
Table 2 Intraoperative pain management
Administration of opiates
Comparison of intraoperative pain management by comparing elective cholecystectomies with emergency cholecystectomies
IV intravenous, PONV Postoperative Nausea and Vomiting
Bold characters indicate significant values (p < 0.05)
and needed arterial embolization at POD 4. The 4
remaining complications were general issues: one acute
myocardial infarction, one pneumonia, one allergic
reaction to metamizole and one case of postoperative nausea
and vomiting (PONV). After emergency
cholecystectomy, one patient (2%, p = 0.668) presented with
postoperative bleeding, needing laparoscopic re-intervention.
Median length of stay was 1 day [0-19] in the elective
and 2 days [0-8] in the emergency group (p = 0.072).
Pain management was similar after elective and
emergent laparoscopic cholecystectomy. Consecutively,
postoperative pain and nausea scores were similar
and patients’ satisfaction equally high. One single
standardized pathway appears to fit for laparoscopic
cholecystectomy in the elective but also in the
Standardized care maps for a specific procedure
might be a way to facilitate perioperative management
by standardising and ease pre-, intra- and
postoperative care . This standardization aims to simplify
work for caregivers and might be especially useful in
frequently performed surgical procedures like
laparoscopic cholecystectomy. The present study aimed to
assess patients’ postoperative perception of pain and
nausea within a standardized pathway comparing
elective and emergent laparoscopic cholecystectomies.
Few differences were observed in patient preparation
and perioperative pain management, and outcome in
terms of pain control and perception of nausea were
equally encouraging in both settings. These findings
emphasize the utility of care maps even in emergency
situation for one of the most commonly performed
procedures, resulting in high patient satisfaction.
Pain is obviously an important issue for the surgical
patient and adequate management of major concern
since it might delay patient discharge [5–7]. Several
manifestations of laparoscopic cholecystectomy related
postoperative pain were described: Visceral pain
related to tissue injury and stretching of nerve endings,
parietal pain related to port sites and referral
shoulder pain related to stretching and irritation of the
diaphragm by carbon dioxide gas [8, 9]. Ways to
minimize postoperative pain might thus be a
restricted number and size of ports  or the
avoidance of residual pneumoperitoneum at the end of the
Several pain management strategies have been
investigated for laparoscopic cholecystectomy. A recent
randomized controlled trial showed a benefit for
intravenous lidocaine infusion by reducing
postoperative pain and opioid consumption . Wound
infiltration by local anaesthetics is safe and might add
some reduction in pain. However, a recent
metaanalysis concluded that the quality of evidence was
very low and the clinical importance small . An
alternative might be Transversus Abdominis Plane
(TAP) block as an adjunct to multimodal
postoperative analgesia . In the present study, only a small
proportion of patients received local anesthetics either
by intravenous or local administration. Consequently,
comparison of these specific interventional techniques
was not performed.
Even if conversion rates are two- to three-fold
higher in emergently performed cholecystectomies, a
Fig. 1 Postoperative pain management. Comparison of proportion of patients receiving postoperative pain medication (subgraphs) at different
time points between patients who underwent elective cholecystectomy (white bars) and patients who underwent emergency cholecystectomy
(grey bars). For readability purpose, p values of > 0.05 not displayed. Subgraphs: a) Paracetamol b) Metamizole c) IV/SC morphium d) Tramadol e)
Oxycodone (Oxynorm®) f) Oxycodone (Oxycontin®). RR – recovery room, IV – intravenous, SC – subcutaneous
recent study showed no significant difference in
morbidity or mortality, supporting early surgical
management in emergency situations . These findings
have been confirmed by a recently performed
randomized clinical trial of our group, which showed
that prompt surgical management of acute
cholecystitis is feasible regardless of the onset of symptoms
(Roulin et al., 2016, Ann Surg, in press). However,
increased length of hospital stay has been described after
emergent cholecystectomy, whereas discharge at the first
postoperative day seemed realistic without negative
impact on outcomes . Median hospital stay was low in
both groups in the present study. Patients stayed one
more day after emergent cholecystectomy, assumingly to
extend the observation period in the context of
emergency, but these patients did not experience more pain or
nausea. Of note, the duration of the procedure was rather
long in both groups, a finding that might be explained by
the teaching tasks of our academic institution. In fact all
cholecystectomies were performed by residents under
supervision by a staff surgeon.
One reason for these positive results might be the use
of care maps, with standardized, peri- and postoperative
patient care regardless of the elective or emergent
setting. The beneficial effect of standardization has been
repeatedly shown within Enhanced Revovery After Surgery
(ERAS) pathways , coming along with decreased
nursing workload  and increased patient and
provider satisfaction . Further, besides clinical benefits,
economically relevant benefits for the utilization of
standardised clinical pathways with reduction in use of
resources have been described .
Fig. 2 Comparison of VAS scores. Comparison of VAS scores for pain at different time points postoperatively by comparing elective (n = 168,
continuous line) and emergent (n = 44, dashed line) cholecystectomy. a) at rest (p = 0.191, linear mixed model adjusted for time). b) at
mobilization (p = 0.16, linear mixed model adjusted for time). VAS – Visual Analogue Scale
Several limitations of this study need to be addressed.
The cohort is small, and the analysis was performed
retrospectively. Confirmation of our findings by
independent groups is therefore necessary.
A standardised pathway allowed equally successful
control of pain and nausea after elective and emergency
cholecystectomy resulting in high patient satisfaction in
Additional file 1: Institutional standardized care map for laparoscopic
cholecystectomy (DOCX 42 kb)
Availability of data and materials
The authors do not wish to share their data for the following reason:
- The dataset is part of ongoing study protocols
FG: conception and design, analysis and interpretation, drafting. MC: design,
analysis and interpretation, critical revision. CB: design, analysis and
interpretation, critical revision. NF: analysis and interpretation. NH: analysis
and interpretation, critical revision. ND: conception, analysis and
interpretation, critical revision. MH: conception and design, analysis and
interpretation, drafting. All authors approved the final version.
Consent for publication
Ethics approval and consent to participate
The study was approved by the Institutional Review Board (Commission
cantonale d'éthique de la recherche sur l'être humain CER-VD, www.cer-vd.ch)
and informed consent was obtained from all patients before surgery.
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