Is standardized care feasible in the emergency setting? A case matched analysis of patients undergoing laparoscopic cholecystectomy

BMC Surgery, Dec 2016

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)

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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 - Background Cholecystectomy is one of the most commonly performed surgical procedures worldwide [1]. In developed countries, laparoscopic approach is nowadays standard since it has been shown to reduce pain, cosmetic issues, length of stay and morbidity [2]. In the emergency situation of calculous cholecystitis, prompt surgical management has been shown to be equally feasible compared to a wait and see approach [3]. 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. Methods Study design 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 researchregistry993). 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 general (...truncated)


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Fabian Grass, Matthieu Cachemaille, Catherine Blanc, Nicolas Fournier, Nermin Halkic, Nicolas Demartines, Martin Hübner. Is standardized care feasible in the emergency setting? A case matched analysis of patients undergoing laparoscopic cholecystectomy, BMC Surgery, 2016, pp. 78, 16, DOI: 10.1186/s12893-016-0194-6