|Year : 2016 | Volume
| Issue : 3 | Page : 75-78
Ambulatory open cholecystectomy and multimodal analgesia as the critical step: An observational study
Luis Angel Medina Andrade1, Lizette Blanco Aguilar1, Eduardo Vidrio Duarte2, Adriana Paz Mendoza2, Juan Josť Rodriguez Carrillo2, Carlos Eduardo Rodriguez Rodriguez2, Stephanie Serrano Collazos3, Jessica Gonzalez Noriega4, Uriel Maldonado Aparicio4, Israel Gonzalez Gonzalez5, Silva Gonzalez Misael6
1 Department of General Surgery, Mexican Institute of Social Security, Hospital General de Zona #30, Iztacalco, Mexico City, Mexico
2 Department of General Surgery, Hospital Angeles Metropolitano, Mexico City, Mexico
3 Department of General Surgery, Ecatepec Las Americas General Hospital, Mexico State, Mexico
4 Department of General Surgery, Zone #1 General Hospital, UNAM, Baja California Sur, Mexico
5 Department of General Surgery, The American British Cowdray Medical Center IAP, UNAM, Mexico City, Mexico
6 Department of General Surgery, Ixtapaluca High Speciality Regional Hospital, UNAM, Mexico State, Mexico
|Date of Submission||30-May-2016|
|Date of Acceptance||20-Jul-2016|
|Date of Web Publication||30-Sep-2016|
Luis Angel Medina Andrade
Department of General Surgery, Mexican Institute of Social Security, Hospital General de Zona #30, Plutarco Elias Calles avenue #209, Iztacalco, Mexico City 08300
Source of Support: None, Conflict of Interest: None
Aim: Cholecystectomy is the most frequent, nonurgent surgery in the surgical services around the world. The access to laparoscopic cholecystectomy is neither always available in health services nor indicated in every patient. For this reason, the open approach is still frequently utilized. The objective of this study is to confirm the safety and feasibility of an ambulatory open cholecystectomy. Methods: From August 2015 to December 2015, patients aged 18-60 years underwent open cholecystectomy in a rural hospital in Chiapas of Mexico were included in this operational study. A multimodal analgesia protocol was employed including presurgical nonsteroidal anti-inflammatories (NSAIs), interpleural blockade before surgery, skin infiltration with local anesthetic, and the use of NSAIs and avoidance of opioids in the postoperative period. The visual analog scale (VAS) was evaluated at 4 and 8 h after surgery. Feeding began 4 h after surgery and walking after feeding. Discharge criteria included feeding tolerance and VAS < 3 points at 8 h after surgery. Patients returned next day for evaluation. Pathologic background, surgical findings and outcomes, VAS score, and length of hospital stay were registered and analyzed. Results: A total of 90 patients with 78 females (86.7%) were included in the study. Moreover, 48 patients (53.3%) presented acutely (first episode of cholecystitis). Complicated cholecystitis was presented in 6 cases (6.7%). Surgical complications included hypovolemic shock in 2 patients (2.2%), and postsurgical complications were present in 10 patients (11.1%). At 4 h after surgery, a VAS < 2 was seen in 44 patients (48%), VAS = 3 in 42 patients (46.7%), and VAS > 6 in 4 patients (4.4%). A total of 62 patients (68.9%) were completely ambulatory in < 12 h after open cholecystectomy and were discharged at that time. A total of 81 (90%) patients were discharged by 48 h after surgery. Conclusion: Ambulatory cholecystectomy is a safe and feasible surgical approach in the era of enhanced recovery programs. Multimodal analgesia is the key factor to achieve early walking, intestinal movements, and early feeding, allowing discharge after an uncomplicated.
Keywords: Ambulatory surgery, enhanced recovery protocols, general surgery, multimodal analgesia, open cholecystectomy
|How to cite this article:|
Andrade LA, Aguilar LB, Duarte EV, Mendoza AP, Carrillo JJ, Rodriguez CE, Collazos SS, Noriega JG, Aparicio UM, Gonzalez IG, Misael SG. Ambulatory open cholecystectomy and multimodal analgesia as the critical step: An observational study. Transl Surg 2016;1:75-8
|How to cite this URL:|
Andrade LA, Aguilar LB, Duarte EV, Mendoza AP, Carrillo JJ, Rodriguez CE, Collazos SS, Noriega JG, Aparicio UM, Gonzalez IG, Misael SG. Ambulatory open cholecystectomy and multimodal analgesia as the critical step: An observational study. Transl Surg [serial online] 2016 [cited 2019 Jan 22];1:75-8. Available from: http://www.translsurg.com/text.asp?2016/1/3/75/191496
| Introduction|| |
In Mexico, cholecystitis prevalence is estimated at 14.3%. This is the most frequent pathology in general surgery consultation, and after cesarean section, the most frequent major surgery performed in the largest Mexican social security institution (Instituto Mexicano del Seguro Social). Totally, 47,147 cases of open cholecystectomies and 22,528 cases of laparoscopic procedures were performed in Mexico in 2010. Almost 500,000 cases of cholecystectomies are performed worldwide each year. ,,,
It is well known that the gold standard in surgical management of cholecystitis is laparoscopic cholecystectomy, but this procedure is not feasible in all medical centers, on all days or in all patients, and sometimes, the technique has to be changed to an open procedure. Traditionally, uncomplicated open cholecystectomy involves 48 h of hospital stay. Some protocols have demonstrated the safety and feasibility of ambulatory laparoscopic cholecystectomy; however, in the case of an open procedure, ambulatory approach has not been considered principally because of the associated intense pain. The objective of this study was to evaluate the safety and feasibility of open ambulatory cholecystectomy.
| Methods|| |
This was a retrospective, observational study realized in the Prospera Rural Hospital #1 in Chiapas of Mexico. From August 2015 to December 2015, the clinical records of patients who underwent open cholecystectomy were recorded. Inclusion criteria were patients aged 18-60 years of both genders, patients with acute or chronic presentation, and a single attending surgeon (the only on this rural medical center). Informed consent for the surgery and other interventions were obtained for each patient. The routine management of patients with cholecystitis, acute or chronic, for open cholecystectomy in this medical center included preoperative administration of metoclopramide 10 mg, ketorolac (1 mg/kg), and a third-generation cephalosporin (50 mg/kg) for antibiotic prophylaxis. After patient intubation, an interpleural blockade with 20 mL of bupivacaine 5% was administered in the fourth intercostal space in the medial axillary line. To diminish postoperative pain, the surgical incision site was infiltrated with ropivacaine 7.5%. A Kocher incision with pararectal approach (without muscular section) was used. Intravascular fluids were limited in all uncomplicated cases to < 1 L during surgery. After surgery, dexamethasone (8 mg), ketorolac (0.5 mg/kg), and acetaminophen (1 g) were administered. The visual analog scale (VAS) with values from 1 to 10 (1 represents small amount of pain, 10 represents most intense pain) was evaluated for patients at 4 and 8 h. Between 2 and 4 h after surgery, patients were encouraged to walk, and feeding was attempted in 4 h unless a patient refused it. At 8 h, if the patient had normal vital signs, had successfully ambulated, was feeding and VAS ≤ 3, discharge was authorized with nonsteroidal analgesics (ketorolac and acetaminophen). On the next morning, the patients came to hospital for a general evaluation at 8 am and were readmitted in case of any complication such as intense pain (VAS > 3), nausea, and vomiting or others.
Factors such as sex, comorbidities, acute or chronic presentation, complications, length of hospital stay, and readmission were evaluated and placed into a database. SPSS version 22.0 for Mac IOS 7.0 (IBM, New York, USA) was used to perform statistical data analysis. Complications and surgical and general characteristics were registered and compared between the groups of patients.
| Results|| |
A total of 90 patients with a median age of 39 ± 5 years who underwent open cholecystectomy were included in the study. Totally, 78 patients were female (86.7%) and 12 were male (13.3%). Acute presentation accounts for 48 patients (53.3%), and 42 patients (46.7%) were elective cases. Complicated cholecystitis was presented in 6 patients (6.7%), vesicular hydrops in 2 patients (2.2%), and pyogenic cholecystitis in 4 patients (4.4%) [Table 1].
Surgical complications included 2 patients (2.2%) with hypovolemic shock, secondary to profuse liver bed accessory arterial bleeding. Almost 10 patients (11.1%) presented with other complications including intense pain, nausea, or residual common bile ducts stones [Table 1]. No patients had complications associated with interpleural block. Totally, 19 acute cases could not be discharged secondary to pyogenic cholecystitis (4 cases), vesicular hydrops (2 cases), hypovolemic shock (2 cases), pain or nausea (8 cases), and surgery late in the day (3 cases). In the chronic cases, reasons unable to be discharged included surgery late in the day (7 cases) and intense pain (2 cases). These results confirmed the higher risk of increased length of hospital stay in acute cases.
In the postoperative period, 44 patients (49%) reported a VAS = 2 at 4 h, 42 patients (46.6%) had a VAS = 3, 2 patients (2.2%) had a VAS = 4, and 2 patients (2.2%) had a VAS = 6. The VAS < 3 was in 86 patients (95.6%) at 8 h [Table 2]. Moreover, 10 (11%) patients could not be considered for discharge secondary to late surgery performance after 3 pm. A total of 62 patients (68.9%) were discharged in < 12 h (ambulatory), and 82 patients (90%) were discharged in the first 48 h. The 8 patients (9%) who remained hospitalized for more than 48 h experienced hypovolemic shock (2 cases), persistent pain (4 cases), or nausea (2 cases) [Table 3]. At the 24-h postoperative evaluation, no patient was readmitted, but 2 patients returned at 72 h and 96 h, respectively, and secondary to abdominal pain and jaundice, with confirmed choledocholithiasis.
| Discussion|| |
Ambulatory cholecystectomy has been defined as a length of hospital stay of < 12 h (or < 24 h in some other protocols). In a meta-analysis including 429 patients with laparoscopic cholecystectomy, 78% were discharged in either < 12 h or < 24 h, without differences in complications in either group. Pain, anxiety, nausea, or vomiting was the principal complication that precluded discharge. In those studies, ambulatory cholecystectomy was recommended with Grade A evidence as a safe procedure. , The study by Akoh et al.  examined 258 patients with one-day cholecystectomy. In this study, 69% could be discharged in the period with intense pain or drain placement being the principal reasons for hospitalization. Patients in this study had similar results as in other similar clinical trials. ,
Only 1 previous study involving ambulatory open cholecystectomy has been reported in the literature. In the study by Basu et al.,  32 patients were included, and 78% were discharged in < 24 h, with pain and nausea as the principal factors that did not allow discharge. In this protocol, the analgesia included nonsteroidal anti-inflammatories and opioids without specification of doses or administration frequency.
The factor preventing ambulatory discharge connecting all these studies is the primary complaint after surgery in all patients of the intense pain preventing early mobilization, return of suitable intestinal movements, and feeding without nausea.
In the laparoscopic approach, some of the protocols included use of less CO 2 , low pneumoperitoneum pressure, and surgical site irrigation with bupivacaine to achieve adequate pain control and early discharge. Adoption of the techniques used in laparoscopic surgery in the open technique has not been addressed. However, in many countries such as Mexico, the reality is that open approach is still frequently used. Improvements in pain control in the open technique would be extremely useful until laparoscopic cholecystectomy could be accessible at all times and institutions. 
Multimodal analgesia has been introduced as a more effective approach to pain control for many surgical and medical conditions that previously could only be controlled by intravenous analgesics. These techniques introduce the combination of local, regional, and intravenous analgesics or inclusive sedation to achieve optimal pain control and allow patients to have a faster, safe, and comfortable recovery. 
In open cholecystectomy, the administration of interpleural local analgesics to achieve better outcomes has been described before but is not frequently applied. There is no reason in the literature to avoid this technique and all the advantages, including less use of analgesics, improvement in forced expiratory volume in 1 s and forced vital capacity, and decreased morphine requirement, early mobilization, and feeding that it can bring to patients' recovery. 
Interpleural block was first described in 1947 by Dravid and Paul  and published by Reiestad and Strømskag  in 1986 and Kvalheim and Reiestad  in 1984. The technique has been improved over time and as the result of several clinical trials. The technique is described as follows: The patient must be preferably under general anesthesia. A Touhy syringe is advanced in the fourth intercostal space in the anterior axillary line, testing for loss of resistance in the process. After resistance loss, 20 mL of bupivacaine 5% is administered in the interpleural space. It has been described to have effect for about 3-6 h in some trials and almost 8 h in others. The confirmed effects include ipsilateral somatic block, bilateral block of the thoracic sympathetic chains and the splanchnic nerves located between them and anterior to the spinal column, phrenic nerves, and the coeliac plexus and ganglia. Reiestad and Strømskag  showed that collection of the anesthetic agent in the paravertebral space occurs whether the patient is the supine or lateral position. Dravid and Paul  suggest that the collection in the paravertebral space is the reason that analgesia extends over several dermatomes.
Abdulatif et al.  reported in their study, using interpleural block in patients with cholecystectomy, that the use helps reduce mean arterial pressure, heart rate, and isoflurane requirements during surgery and that the preincision administration has better results than that seen in postoperative application. The use of less postoperative analgesics was reported also and the improvement of ventilator function reduced pulmonary complications as a consequence. ,
In the comparison between interpleural blockade with other locoregional techniques such as intercostal block, or the use of other analgesics such as morphine or intramuscular meperidine, interpleural blockade has better pain control and patient comfort, allowing early discharge. ,
Another local maneuver to diminish somatic pain is the infiltration of anesthetics in the incision site, with ropivacaine 7.5% as the best agent to achieve this objective, reducing inflammatory molecules release and postoperative infection rate by the changing of pH.
With the above-mentioned factors, we implemented a protocol of multimodal analgesia as the key to allow open ambulatory cholecystectomy in the patients who met the discharge criteria. The objective was to achieve optimal analgesia in the first 8 h of postoperative period, covering the visceral and somatic components, allowing early mobilization, returning bowel movements, and feeding in the first 2-4 h.
Based on the enhanced recovery after surgery protocols, we used a fast of no more than 6 h, intravenous liquids of 500 mL or less, prokinetics as metoclopramide, and early mobilization in the postoperative period to achieve the described results.
A potential source of bias is the fact that many patients could not be discharged because of surgery late in the day (after 3 pm). Although many of them met discharge criteria, they could not be discharged after 11 pm. Another fact is that patients who presented in an acute way have more probabilities for more pain than elective cases and do not complete discharge criteria more frequently.
Our results are similar to those reported in some other ambulatory cholecystectomy protocols, with 68.9% of patient discharged after open cholecystectomy in uncomplicated cases without complications or readmissions. Open cholecystectomy is a more aggressive procedure than a laparoscopic approach, but the present study confirms that it can achieve similar outcomes, hospital stay, and patient comfort with the use of all these measures and that some of them, like the pleural block, can be integrated in the laparoscopic cholecystectomy protocols and improve their results as well. Other applications could be in procedures such as cholecystostomy that allows management of obstructive jaundice unless definitive management because it implies considerable pain in this area. 
In conclusion, ambulatory cholecystectomy is a safe and feasible surgical approach in the era of enhanced recovery programs, with the multimodal analgesia as the key factor to achieve early ambulation, intestinal movements, and early feeding, thus allowing discharge in uncomplicated cases. This multimodal approach could be applied in other enhanced recovery programs, as laparoscopic cholecystectomy, integrating a pleural blockade to improve results.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]