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
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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)