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 ¤ Introduction
 ¤ Methods
 ¤ Results
 ¤ Discussion
 ¤ Conclusion
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SYSTEMATIC REVIEW
Year : 2022  |  Volume : 18  |  Issue : 2  |  Page : 176-180
 

Patient selection for ambulatory laparoscopic cholecystectomy: A systematic review


Department of Hepatobiliary and Vascular Surgery, The First Affiliated Hospital of Chengdu Medical College, Xindu, Chengdu, China

Date of Submission31-Jul-2021
Date of Acceptance29-Oct-2021
Date of Web Publication11-Feb-2022

Correspondence Address:
Jingcheng Hao
Department of Hepatobiliary and Vascular Surgery, The First Affiliated Hospital of Chengdu Medical College, Baoguang Avenue 278#, Xindu, Chengdu 610500, Sichuan
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.jmas_255_21

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 ¤ Abstract 


Background: Currently, there is no consensus on patient selection for ambulatory laparoscopic cholecystectomy (LC). This study is a systematic review of previously published patient selection for ambulatory LC.
Methods: A comprehensive search was done in PubMed, Web of Science, Embase and Google Scholar Database up to March 2020 to summarise previously reported medical or surgical selection criteria used for inclusion and exclusion of patients, as well as successful same-day discharge rates and readmission rate after discharge.
Results: Fifty-nine studies with a total of 13,219 patients were included in this systematic review. In total, the median same-day discharge rate was 90% (range: 63%–99.4%), and median readmission rate was 2.22% (range: 0%–16.9%). The most considered medical criteria were American Society of Anesthesiologists classification I and II, age <70, and body mass index <35. Surgical criteria varied greatly. The top three accessible exclusion variables were (1) common bile duct stones, cholangitis, or jaundice (27 publications, 45.8%); (2) history of abdominal surgery (12 publications, 20.3%) and (3) history of pancreatitis (9 publications, 15.3%).
Conclusion: The results of the current study showed the variable patient selection in different centres, the medical aspect criteria may be expanded under adequate pre-anaesthetic assessment and preparation and the surgical aspect criteria should include more laboratory or imaging parameters to ensure the surgical safety.


Keywords: Ambulatory surgical procedures, laparoscopic cholecystectomy, systematic review


How to cite this article:
Chen W, Wu Q, Fu N, Yang Z, Hao J. Patient selection for ambulatory laparoscopic cholecystectomy: A systematic review. J Min Access Surg 2022;18:176-80

How to cite this URL:
Chen W, Wu Q, Fu N, Yang Z, Hao J. Patient selection for ambulatory laparoscopic cholecystectomy: A systematic review. J Min Access Surg [serial online] 2022 [cited 2022 May 16];18:176-80. Available from: https://www.journalofmas.com/text.asp?2022/18/2/176/337610





 ¤ Introduction Top


Laparoscopic cholecystectomy (LC) is the most used surgical procedure for symptomatic gallstones globally.[1] In comparison with open surgery, LC has been extensively accepted for its advantages of less invasiveness, post-operative pain, hospitalisation and recovery time.[2],[3],[4],[5]

In the early 1990s, some surgeons introduced the safety and feasibility of the performing of LC in ambulatory settings.[6],[7] Until now, ambulatory LC has not been extensively accepted, especially in developing regions. The main reticence is the concern of possible misdetection of the appearance of any vital complications during the post-operative period. Therefore, basic principles are necessary for determining the ambulatory process and ensuring the highest probability of success with the utmost safety for candidate patients. Nevertheless, currently, there are still no widely recognised patient selection criteria for ambulatory LC in the surgical community.

We conducted this systematic review to summarise previously reported selection criteria for ambulatory LC.


 ¤ Methods Top


Following the PRISMA guidelines, a comprehensive search was done in PubMed, Web of Science, Embase and Google Scholar Database up to March 2020 for all accessible publications to summarise the previously reported patient's selection criteria for ambulatory LC. We used the search terms (“Cholecystectomy, Laparoscopic” [Mesh] AND “Ambulatory Surgical Procedures”[Mesh]) to identify all potential records. We also included extra studies in relevant references. Following exclusion criteria were used: (1) published not in English; (2) not original research; (3) paediatric studies; (4) research in other topics, such as nursing, anaesthesiology or ecology; (5) full-text unavailable; and (6) no patient's selection criteria provided. The PRISMA flow chart is presented in [Figure 1].
Figure 1: PRISMA flow diagram for literature inclusion

Click here to view


After the stepwise exclusion investigation, from all available publications, we extracted the following data: the author's name, study regions, publication years, sample size, successful same-day discharge rates, readmission rate after discharge and medical or surgical selection criteria used for the inclusion and exclusion of patients.


 ¤ Results Top


As demonstrated in [Figure 1], 290 potentially available publications were included following the identification and implementation strategies. Two hundred and thirty-one records were excluded per the exclusion criteria listed in [Figure 1]. Eventually, 59 studies were included in this systematic review.

Altogether, the patient's selection criteria were provided in 59 publications, including 13219 patients. Most of the studies were performed in Europe and the Americas. In contrast, only ten studies, including 1444 patients, were analysed in the Asian area. The majority of the studies were published from 2000 to 2009 [Figure 2]. In total, the median same-day discharge rate was 90% (range: 63%–99.4%), and median readmission rate was 2.22% (range: 0%–16.9%).
Figure 2: Geographical (a) and temporal distributions (b) of included publications

Click here to view


Regarding the medical factors, the American Society of Anesthesiologists (ASA) Physical Status Classification was the most popular variable to identify the suitability of candidate patients (48 publications, 81.4%). Of the 48 publications that used the ASA classification, most (34 publications, 70.8%) restricted the candidate patients within ASA I and II; 14 studies relaxed the criteria to ASA III [Figure 3]. Age was also usually considered; 28 (47.5%) articles had the limitations of age, but only 19 of them defined the upper age limit; others just required the patients to be adults. Sixty-five and seventy were frequently adopted in most articles [Figure 3]. Twenty-seven (45.8%) studies clearly stated that the common bile duct (CBD) should be in absolute normal status in pre-operative evaluations. Twenty-four (40.7%) studies excluded the patients with ongoing or previous acute cholecystitis. In contrast, some research did not consider acute cholecystitis as a limiting factor. Body mass index (BMI) was also commonlypted for selection in 13 articles, and three other studies avoided obese patients by weight only. In the 13 studies that used BMI, 35 was the common cut-off value [Figure 3].
Figure 3: American Society of Anaesthesiologists classification (a), age upper limit (b), and Body mass index (c) cut-off values used in previous publications

Click here to view


Concerning the surgical factors, the top three accessible exclusion variables were (1) CBD stones, cholangitis or jaundice (27 publications, 45.8%); (2) history of abdominal surgery (12 publications, 20.3%) and (3) history of pancreatitis (9 publications, 15.3%). All detailed information was summarised in [Supplementary Table 1].




 ¤ Discussion Top


As per the suggested guidelines from the British Association of Day Surgery in 2019, the patient's selection criteria should fall into three major aspects: social, medical and surgical.[8] The present study summarised all previously reported medical or surgical selection criteria used for ambulatory LC.

Regarding the medical aspect, ASA grading, age and BMI are the three most considered variables in previous publications. With the development of modern anaesthesiology, higher ASA and age seem to carry no increased risk of post-operative risk.[9],[10] In 1997, Voitk also reported that ambulatory cholecystectomy is safe for the high-risk patient (ASA III and IV, or age >70).[11] Recently, Gregori et al. proved the safety of ambulatory LC in obese patients with a similar outcome in non-obese patients.[12] The British Association of Day Surgery also suggested that obesity itself is not a contraindication to the ambulatory procedure.[8] In addition, obese patients may even benefit from early mobilisation in the ambulatory procedure.[13],[14] Thus, we may suggest that, with adequate pre-anaesthetic assessment and preparation, elder or obese patients with stable medical conditions could be considered as candidates for ambulatory LC. More evidence for this opinion is needed.

In the surgical aspect, the patients with a high risk of severe post-operative complications should be excluded. Even though LC has experienced four decades of development, the difficulty of LC varies greatly, mainly depending on the inflammation degree of the gallbladder and the anatomy of the Calot's triangle.[15] Inadequate pre-operative evaluation often leads the serious complications such as iatrogenic bile duct injuries and post-operative bleeding. Hence, we highly suggest that the candidate patient should be carefully evaluated regarding the gallbladder inflammation and potential anatomical variation. According to our review, many researchers excluded the patients with acute cholecystitis, history of pancreatitis or abdominal surgery or clinical suspicion of CBD stones.[16],[17],[18],[19],[20],[21],[22],[23] In contrast, some other studies also reported acceptable outcomes with those patients.[24],[25],[26],[27],[28] Besides, abnormal laboratory tests, as well as thickening gallbladder wall in ultrasonography has been well known to be risk factors predicting complex operation.[29],[30],[31],[32] However, only a few studies considered them as patient's selection criteria.[33],[34],[35] We, therefore, propose more studies to validate the efficiency of these quantitative and objective parameters in patient selection. In addition, the intraoperative situation should also be considered for the timely interruption of the ambulatory procedure. Previous studies have shown that prolonged operation could predict the inabilities of ambulatory discharge.[36],[37] Thus, we recommended that unexpected difficult operation should be considered as an exclusion criterion.


 ¤ Conclusion Top


The results of the current study showed the variable patient selection in different centres, the medical aspect criteria may be expanded under adequate pre-anaesthetic assessment and preparation and the surgical aspect criteria should include more laboratory or imaging parameters to ensure surgical safety.

Acknowledgements

We thank the Department of Technology of our centre for administrative and financial support (CYFY-GQ20).

Financial support and sponsorship

Institutional Research Funding of The First Affiliated Hospital of Chengdu Medical College (CYFY-GQ20).

Conflicts of interest

There are no conflicts of interest.


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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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© 2004 Journal of Minimal Access Surgery
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