Day-surgery laparoscopic cholecystectomy: factors influencing same-day discharge.

BACKGROUND: Day-surgery laparoscopic cholecystectomy (LC) should be the procedure of choice in patients with symptomatic gallstone disease. This article assesses feasibility, patient outcome and predictive factors for successful day-case laparoscopic cholecystectomy. METHOD: A retrospective analysis of our prospective database of 176 patients following laparoscopic cholecystectomy in a day-surgery unit was performed. A telephone interview was conducted within 24 h after discharge and again after 3 weeks. RESULTS: Of the 176 cases included in this study, 74% had biliary colic, cholecystitis (16%), pancreatitis (8%), and jaundice (2%). In addition to LC, nine patients (5.1%) underwent laparoscopic bile duct exploration and ten (5.7%) had an additional procedure performed. Eighty-six percent of the patients were discharged the same day. Multivariate analysis identified risk factors affecting same-day discharge, including age greater than 50 years and intraoperative complications. Bile duct exploration reduced the odds of discharge but did not reach significance. Postoperative telephone interviews identified high patient satisfaction with 86% of respondents recommending LC as a day-surgery procedure. CONCLUSION: Day-surgery LC is a safe procedure with an acceptable rate of patient discharge. However, intraoperative complications or age over 50 years adversely affected the same-day discharge rate and as such should be taken into consideration when planning day-case laparoscopic cholecystectomy.

Undiagnosed myasthenia gravis unmasked by neuromuscular blockade.

Myasthenia gravis is an uncommon autoimmune disease resulting in destruction of the postsynaptic nicotinic receptors at the neuromuscular junction. We describe a 43-yr-old, 95 kg patient who presented for elective laparoscopic cholecystectomy. She was given vecuronium 10 mg to facilitate tracheal intubation. At the end of the procedure the patient could not maintain adequate spontaneous ventilation despite administration of two doses of neostigmine 2.5 mg. Subsequent investigation led to a diagnosis of myasthenia gravis. We discuss the investigation, diagnosis, and subsequent management of such a patient and emphasize that tactile estimation of the train-of-four ratio is not a reliable indicator of adequate recovery of neuromuscular function.

Delayed diagnosis of cardiac tamponade following isolated blunt abdominal trauma.

Traumatic haemopericardium is an uncommon but life threatening condition. It is usually caused by penetrating cardiac injuries or cardiac rupture from blunt chest trauma. We report haemopericardium and cardiac tamponade in a young girl after blunt abdominal trauma. She presented with mild upper abdominal pain, tachycardia and hypotension having been kicked in the abdomen by a horse. No damage was found at laparotomy and she remained haemodynamically unstable. Further investigation found cardiac tamponade and haemopericardium. This was managed by insertion of a pericardial drain using transthoracic echocardiogram guidance, with later drainage in the operating theatre using guidance with a transoesophageal echocardiogram.