Técnica anestésica y calidad de la recuperación tras colecistectomía laparoscópica: ¿un caso cerrado? / Anesthesia technique and quality of recovery after laparoscopic cholecystectomy: Case closed?

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Réplica a la carta al editor «Técnica de la anestesia y calidad de recuperación después de la colecistectomía laparoscópica ¿caso cerrado?» / Response to the letter to the editor «Anesthesia technique and quality of recovery after laparoscopic cholecystectomy: Case closed?»

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Effects of Preoperative Oral Carbohydrates on Quality of Recovery in Laparoscopic Cholecystectomy: A Randomized, Double Blind, Placebo-Controlled Trial.

BACKGROUND: While carbohydrate loading is an important component of enhanced patient recovery after surgery, no study has evaluated the effects of preoperative carbohydrate loading after laparoscopic cholecystectomy (LC) on patient satisfaction and overall recovery. Thus, we aimed to investigate the impact of preoperative oral carbohydrates on scores from the quality of recovery 40-item (QoR-40) questionnaire after LC. METHODS: A total of 153 adults who underwent LC were randomized into three groups. Group MN-NPO was fasted from midnight until surgery. Group No-NPO received 400 mL of a carbohydrate beverage on the evening before surgery, and a morning dose of 400 mL was ingested at least 2 h before surgery. Group Placebo received the same quantity of flavored water as for group No-NPO. The quality of recovery after general anesthesia was evaluated using QoR-40 questionnaire. Intraoperative hemodynamics were also evaluated. RESULTS: There were no significant differences among the groups in terms of the pre- and postoperative global QoR-40 scores (P = 0.257). Group MN-NPO had an elevated heart rate compared to patients who ingested a preoperative beverage (groups No-NPO and Placebo; P = 0.0412). CONCLUSIONS: The preoperative carbohydrate beverage did not improve quality of recovery using the QoR-40 questionnaire after general anesthesia for laparoscopic cholecystectomy compared to placebo or conventional fasting. However, the preoperative fasting group had a consistently increased heart rate during changes in body position that induced hypotension, which is likely a result of depletion of effective intravascular volume caused by traditional fasting over 8 h. TRIAL REGISTRATION: Clinical trial.gov identifier: NCT02555020.

How to optimize the prescription of laboratory tests? Success and failures in an academic hospital.

In the context of the flat-rate reimbursements in healthcare, we reviewed physicians' behavior towards laboratory test ordering. We demonstrated how it could be improved when a specific stage of the patient management is considered. We took a multi-step approach to analyze the laboratory test orders in the context of planned laparoscopic cholecystectomy in a general teaching hospital. A reference order set was defined through a collaborative analysis between clinicians and laboratory physicians. The clinical and financial impacts were then evaluated over a period of 24 months. After the introduction of the reference order set, the number of laboratory tests per order decreased significantly for patients with cholecystitis of low severity. Above the monitoring of repeated orderings during a single stay, the major impacts were achieved by a drastic reduction of inappropriate orders, particularly in the field of bacteriology. The main effects of the order set were maintained throughout a follow-up period of 24 months. Our study demonstrated that, when considering laboratory test ordering optimization, reference order sets could achieve high levels of efficiency. To ensure high compliance to reference order sets, extensive collaboration between clinicians and laboratory physician is mandatory even if very sophisticated information systems are available.

POST-ANESTHETIC REHABILITATION PERIODS AND ANESTHESIA DOSAGE FOR LAPAROSCOPIC CHOLECYSTECTOMY: RELATIONSHIP TO THE TOTAL OXIDATIVE CAPACITY OF LIVER.

Analysis of the results of pharmacological phenotyping using antipyrine test prior to providing anesthesia for laparoscopic cholecystectomy showed that trimeperidine (promedol) dosing with allowance for the total oxidative capacity of liver and the patient mass allows the periods of post-anesthetic rehabilitation to be controlled. Clear algorithm of trimeperidine dosing based on established indices of the total oxidative capacity of liver and is yet nor developed because of restricted sampling set. The obtained results show expediency of using and studying antipyrine test as a simple, cheap, and informative method of individual anesthesia dosing for increasing the adequacy of general anesthesia.

[Periods of post-anesthetic rehabilitation and anesthesia dosage for laparoscopic cholecystectomy: retrospective investigation].

A retrospective descriptive nonrandomized cohort study of 585 anesthesia cards of patients who had undergone planned laparoscopic cholecystectomy showed no effect of the patient age and sex on the length of post-anesthetic rehabilitation period. The doses of sodium thiopental, ketamine, and trimeperidine affect the length of these periods by no more than 12%. Further search for and studying of factors affecting the duration of post-anesthetic rehabilitation is required in order to improve the safety and adequacy of general anesthesia.

Gallstone disease: diagnosis and management

This guideline covers diagnosing and managing gallstone disease in adults. It aims to reduce variation in care by promoting the most effective treatments, and to improve the advice given to people with gallstone disease before and after treatment.

The impact of varying post-operative dressing size on recovery from laparoscopic cholecystectomy.

This study aimed to explore the impact of the size of a post-operative dressing and the subsequent visibility of the wound on recovery from laparoscopic cholecystectomy (LC). A randomised controlled trial was conducted. Fourty-one patients (8 men and 33 women, mean age = 44 years) scheduled for LC were included. Participants were randomly assigned to receive either small gauze dressings (n = 19) or large gauze dressings (n = 22) which were directly applied on post-operative incisions. Patients' mood, psychological well-being, illness cognitions, and pain and recovery were assessed at three time points: baseline, immediately after the procedure and then two weeks later. The findings suggest that the management of post-surgical incisions influences patients' interpretation of their illness which in turn has an impact upon the process of recovery from LC. This implies that visual information available to patients after the procedure through the cognitive and emotional mechanisms involved in their processing can alter the process of convalescence from LC.

Single incision versus conventional laparoscopic cholecystectomy outcomes: a meta-analysis of randomized controlled trials.

BACKGROUND: Previous meta-analyses that compared the outcome of SILC and CLC have not presented consistent conclusions. This meta-analysis was performed after adding many recent RCTs, to clarify this issue. METHODS: Relevant articles published in English were identified by searching PubMed, Embase, Web of Knowledge, and the Cochrane Controlled Trial Register from January 1997 to February 2013. Reference lists of the retrieved articles were reviewed to identify additional articles. Primary outcomes (postoperative pain scores, cosmetic score, and length of incision) and secondary outcomes (operating time, blood loss, conversion rates, postoperative complications, postoperative hospital stay, time to initial oral intake, and time to resume work) were pooled. Quantitative variables were calculated using the weighted mean difference (WMD), and qualitative variables were pooled using odds ratios (OR). RESULTS: 25 appropriate RCTs were identified from 2128 published articles. 1841 patients were treated, 944 with SILC and 897 with CLC. SILC was superior to CLC in cosmetic score (WMD = 1.155, P<0.001), shorter length of incision (WMD = -3.285, P = 0.029), and postoperative pain within 12 h (VAS in 3-4 h, WMD = -0.704, P = 0.026; VAS in 6-8 h, WMD = -0.613, P = 0.010). CLC was superior to SILC in operating time (OT) (WMD = 13.613, P<0.001) and need of additional instruments (OR = 7.448, P<0.001). Other secondary outcomes were similar. CONCLUSIONS: SILC offered a better cosmetic result and less postoperative pain for patients with uncomplicated cholelithiasis or polypoid lesions of the gallbladder. However, SILC was associated with a longer OT and required additional instruments.

Health-related quality of life in patients undergoing cholecystectomy.

This large-scale prospective cohort study of a Taiwan population applied generalized estimating equations to evaluate predictors of health-related quality of life (HRQOL) after open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) procedures performed between February 2007 and November 2008. The Gastrointestinal Quality of Life Index and Short Form-36 were used in a preoperative assessment and in 3(rd) month and 6(th) month postoperative assessments of 38 OC and 259 LC patients. The HRQOL of the cholecystectomy patients were significantly improved at 3 months and 6 months postsurgery (p<0.05). At 3 months postsurgery, HRQOL improvement was significantly larger in LC patients than in OC patients. Patient characteristics, clinical characteristics, and health care quality were also significantly related to HRQOL improvement (p<0.05). Additionally, after controlling for related variables, preoperative health status was significantly and positively associated with each subscale of the Gastrointestinal Quality of Life Index and Short Form-36 throughout the 6 months (p<0.05). Patients should be advised that their postoperative HRQOL may depend not only on their postoperative health care but also on their preoperative functional status.

[Convalescence, sick leave and health economics]. / Rekonvalescens, sygemelding og sundhedsøkonomi.

National health policies have been proposed to reduce long-term absenteeism in order to increase labour supply. Convalescence interventions have been developed and optimised and shown to reduce long-term absenteeism and as such they form an integral part of the national health policy. We describe absenteeism and convalescence within an economic perspective. In Denmark, the economic costs of absenteeism amounted to more than 37 billion Danish kroner in 2006, including sick leave benefits and non-productive wage expenditure. Optimising convalescence interventions, if efficacious, is highly cost-effective.

Resumption of daily physical activity after day-case laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy has been proven to be safe and feasible as a day-case procedure. Few studies investigated postoperative activity resumption. The goal of this study was to objectively assess daily physical activity after day-case laparoscopic cholecystectomy and evaluate the effect of encouragement of patients. METHODS: This prospective controlled study measured daily physical activity in an unselected patient population undergoing day-case laparoscopic cholecystectomy by using an accelerometer for 1 week before surgery to 1 week after. First, a control group received standard care. Subsequently, an intervention group was encouraged to swift resumption of daily physical activity by means of standardized advice combined with individualized activity goals. Outcome measures were activity scores, visual analogue scores (VAS) for pain and nausea and subjective factors limiting activity. RESULTS: Sixty-four patients completed the study (n = 28 in the control group, n = 36 in the intervention group). In the control group, 36% of the patients reached their preoperative activity level after 1 week, as compared to 50% in the intervention group (p = 0.19). Resumption of daily physical activity during the first postoperative week in the intervention group was not significantly different from the control group [repeated measures analysis of variance (MANOVA), p = 0.05]. However, in contrast with men, women in the intervention group did show a faster recovery of daily physical activity as compared to the control group (MANOVA, p = 0.02). Although there was no significant difference in postoperative VAS scores for pain and nausea between both groups, patients in the intervention group experienced pain less often as a limiting factor (p = 0.006). CONCLUSION: Recovery of daily physical activity exceeded 1 week in most patients undergoing day-case laparoscopic cholecystectomy. The use of an accelerometer and standardized encouragement accelerated recovery in women.

The influence of alexithymia on persistent symptoms of dyspepsia after laparoscopic cholecystectomy.

OBJECTIVE: The aim of this study was to evaluate whether preoperative alexithymia might play a role in the persistence of gastrointestinal symptoms after laparoscopic cholecystectomy. METHODS: A sample of 52 consecutive patients with gallstone disease and symptoms of dyspepsia were assessed with validated scales for alexithymia (20-item Toronto Alexithymia Scale), and psychological (90-item Symptom Checklist) and gastrointestinal (GI) (Gastrointestinal Symptom Rating Scale) symptoms before surgery. GI symptoms were evaluated also one year after surgery. Change from preoperative to postoperative GI symptoms and level of GI symptoms after surgery were used to form groups of improved (n = 31) and unimproved (n = 21) patients. RESULTS: Unimproved patients had significantly higher preoperative alexithymia, psychological distress, and gastrointestinal symptom scores than patients who had improved. Regression analyses showed that alexithymia predicted the persistence of gastrointestinal symptoms more strongly than did psychological distress, even after controlling for preoperative gastrointestinal symptoms. CONCLUSION: Alexithymia played a substantial and predictive role in the persistence of GI symptoms in gallstone patients after surgery. Treatment planning and outcome of gallstone disease might be improved by preoperative assessment of alexithymia.

The effect of a multimedia health educational program on the postoperative recovery of patients undergoing laparoscopic cholecystectomy.

Aim of this study is the evaluation of the impact of preoperative informative session using a Multimedia Health Educational Program (MHEP) on patients undergoing elective Laparoscopic Cholecystectomy (LC) for cholelithiasis, preoperative anxiety and postoperative pain and nausea. Sixty consecutive patients scheduled for elective LC were considered for enrollment in the trial. Patients were assigned randomly to four groups: Group A included 15 patients, preoperatively informed regarding LC through the MHEP presented by a Registered Nurse (RN). Group B included 15 patients preoperatively informed through a leaflet (designed and developed using the exact contents of the MHEP). In Group C, there were 15 patients who were being informed verbally from the RN. Finally, the control Group D included 15 patients, who had the conventional preoperative information about the operation and postoperative course by the attending surgeon and anesthesiologist, as every other patient included in groups A, B, C. Preoperative assessment of patient's knowledge about cholelithiasis and LC was performed after informative session, and was based on a specifically developed "closed, true-false" questionnaire. Preliminary results suggest that conventional information provided by the attending surgeon (Group D) is inadequate. Specifically developed informative sessions with the contribution of MHEP seems to be effective on reducing preoperative anxiety and postoperative pain, in patients undergoing elective LC.

The effect of pre-admission education on domiciliary recovery following laparoscopic cholecystectomy.

OBJECTIVES: The objectives of this randomised controlled study were to determine if pre-admission patient education affects post-operative pain levels, domiciliary self-care capacity and patient recall following a laparoscopic cholecystectomy (LC). Participants were randomised to receive the standard preadmission program (SP) or an individualised, education intervention (El). DESIGN: A pre-operative questionnaire was administered in the pre-admission clinic to determine participants' knowledge of LC and post-operative management. Telephone follow-up and post-operative questionnaire were conducted approximately 14 days post discharge. SETTING: Preadmission clinic of a Sydney, Australia, tertiary referral hospital. SAMPLE: Ninety-three elective LC patients. RESULTS: EI participants experienced lower pain levels and had significantly greater recall of provided information. However, no significant differences were found between the control and intervention groups for domiciliary self-care. CONCLUSION: Pre-admission education intervention helps reduce post-operative pain levels following LC and significantly increases patients' knowledge of self-care and complication management.

[Experience of the 7th Central Military Clinical Aviation Hospital in early diagnostics, treatment, rehabilitation, and expert evaluation of cholelithiasis in flying personnel]. / Opyt raboty 7 Tsentral'nogo voennogo klinicheskogo aviatsionnogo gospitalia po rannei diagnostike, lecheniiu, reabilitatsii i ékspertnoi otsenke kholelitiaza u letnogo sostava.

The Seventh Central military clinical aviation hospital is experienced in performing laparocholecystectomy (LCE) in pilots afflicted with cholelithiasis (CL). In the period from 1990 to 2001, 92 operations were carried out after which 80 patients (87%) were permitted to fly. Medical discharge of 12 patients (13%) was associated not with CL but with some morphofunctional shifts caused by concomitant diseases. Seven to five-yr. follow-up of the 80 pilots who had returned their flying status after LCE showed their good tolerance for the flight loads.

Patients' experiences of laparoscopic cholecystectomy in day surgery.

Previous research has concentrated mainly on surgical aspects and postoperative complication rates after day surgery laparoscopic cholecystectomy (LC), and less on patients' experiences and nursing care aspects. A qualitative study was conducted aimed at investigating patients' experiences of LC in day surgery. Ten women and two men were interviewed. The material was coded, categorized and analysed using qualitative analysis. The findings demonstrate that individuals with gallstone disease experience limitations in their daily life and feelings of socially handicapped. Prior to surgery, the patients felt anxious and expressed a wish for tranquilizers, and to meet the surgeon responsible. At discharge after day surgery, amnesia was experienced and the respondents did not remember important information about the operation given by the surgeon. Experience of postoperative pain varied greatly. Several respondents had a relapse of pain on the third day lasting up to 1 week. The need for additional pain medication and a bloated feeling were reported. Some respondents reported nausea and vomiting, and most had questions about wound care. The need for additional telephone follow-up was mentioned, as was the fact that it was difficult to come home to small children. However, the great majority felt that returning home on the same day as the operation, was positive.

Low job satisfaction predicts delayed return to work after laparoscopic cholecystectomy.

We studied 102 consecutive employed patients treated by elective laparoscopic cholecystectomy to determine job characteristics and psychological factors that predict delay in return to work after their procedure. Median sick leave was 13 days, and five variables significantly added to a model predicting sick leave of at least 20 days (31.4% of the workers): low job satisfaction (odds ratio [OR], 12.56; 95% confidence interval [CI], 3.34 to 47.2); physical effort at work (OR, 4.99; 95% CI, 1.46 to 17.04); pain at 7 days (OR, 5.55; 95% CI, 1.56 to 19.76); patient's expectation of slow recovery (> 7 days) (OR, 6.12; 95% CI, 1.82 to 20.55); and patient's expectation of no financial loss (OR, 3.85; 95% CI, 1.14 to 12.50). The model was excellent (area under the receiver operating characteristic curve, 89.6%). We conclude that low job satisfaction is a major predictor of delayed return to work.

[Prediction of rehabilitation outcome after surgical interventions based on biochemical parameters: a new concept in mediator research]. / Prädiktion der Wiederherstellungsergebnisse nach operativen Eingriffen anhand biochemischer Parameter: Ein neues Konzept der Mediatorforschung.

The perioperative changes in epinephrin-, norepinephrine-, histamin-, C5a- and interleukin-6-levels were studied in 40 patients undergoing cholecystectomy for the diagnosis of acute cholecystitis. All relevant mediator levels could be determined in 38 patients. The outcome was not optimal in 16 of them (42%). In order to evaluate the predictive value of the mediators under investigation for the quality of the patients' outcome, a model based on the Bayes' theorem was developed. Using this model the outcome (optimal vs. not optimal) could be correctly predicted in 30 (79%) of our study patients. This kind of data analysis allows to define states of increased risk for a not optimal recovery based on biochemical parameters.