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Day-case laparoscopic cholecystectomy in childhood: outcomes from a clinical care pathway
Girish Jawaheer1, Kathryn Evans, Ritchie Marcus
1Department of Pediatric Surgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, United Kingdom. girish.jawaheer@bch.nhs.uk
Insights
Implementing a pediatric day-case laparoscopic cholecystectomy (DCLC) pathway significantly improved day-case rates and reduced postoperative nausea and vomiting (PONV). This pathway is safe and effective for pediatric patients undergoing gallbladder removal.
Area of Science:
- Pediatric Surgery
- Anesthesiology
- Gastroenterology
Background:
- Laparoscopic cholecystectomy is a common procedure for symptomatic cholelithiasis in children.
- Optimizing clinical care pathways can enhance patient outcomes and surgical efficiency.
- Previous pathways may have limitations in achieving high day-case rates and minimizing postoperative complications.
Purpose of the Study:
- To evaluate clinical outcomes of a pediatric day-case laparoscopic cholecystectomy (DCLC) pathway.
- To compare outcomes before and after specific modifications to the DCLC pathway implemented in September 2009.
Main Methods:
- A DCLC care pathway was established in 2008, focusing on admission, surgery timing, anesthesia, analgesia, feeding, mobilization, and pain scoring.
- Pathway modifications in September 2009 included switching to total intravenous anesthesia (propofol/remifentanil) and altering the postoperative feeding regimen.
- Demographic and clinical data were prospectively collected from January 2008 to January 2012 for comparison between pre- and post-modification groups.
Main Results:
- Twenty-five children with symptomatic cholelithiasis underwent DCLC.
- The day-case surgery rate increased significantly from 50% (6/12) before modifications to 92% (12/13) after (p = 0.03).
- The incidence of postoperative nausea and vomiting (PONV) decreased from 58% (7/12) to 0% (0/13) (p = 0.002), eliminating PONV-related overnight stays and readmissions.
Conclusions:
- A pediatric DCLC pathway is feasible and safe for children.
- Emphasis on pain management and PONV avoidance is crucial for high day-case surgery rates.
- The modified pathway achieved day-case surgery rates comparable to adult practice.
Aim:
The aim of this study was to report clinical outcomes following the use of a pediatric day-case laparoscopic cholecystectomy (DCLC) clinical care pathway. The pathway was modified in September 2009 and we compare the clinical outcomes before and after this modification.
Methods:
A care pathway for DCLC was introduced in 2008 with emphasis on the day of admission, timing of surgery, choice of anesthetic agents, analgesia, postoperative feeding, mobilization, and pain scoring. Demographic and clinical data were recorded prospectively from January 2008 to January 2012. In September 2009, two modifications were made to the pathway. Induction of anesthesia was changed to total intravenous anesthesia, using propofol (target 4 to 6 µg/mL) and remifentanil (target 3 to 5 ng/mL) and the use of the gaseous anesthetic sevoflurane was eliminated with the aim of reducing the risk of postoperative nausea and vomiting (PONV). The postoperative feeding regime was changed from unrestricted to light diet for 72 hours. The rest of the pathway was unchanged. Data before (group 1) and following the modifications (group 2) were compared.
Results:
We admitted 25 children with symptomatic cholelithiasis for DCLC under the care of one surgeon: 12 in group 1 and 13 in group 2. There were no significant differences in age between group 1 (median 13 [range 6 to 15] years) and group 2 (median 15 [9 to 16] years) (p = 0.07). There were no intra- or postoperative complications. The day-case rate increased from 6/12 (50%) in group 1 to 12/13 (92%) in group 2 (p = 0.03). The incidence of PONV reduced from 7/12 (58%) in group 1 to 0/13 in group 2 (p = 0.002). PONV in group 1 resulted in overnight stay (n = 6) and readmission (n = 1). One patient in group 2 had an overnight stay due to poor mobilization.
Conclusions:
Adoption of a DCLC pathway is feasible and safe for children. Emphasis on adequate pain management and avoidance of PONV results in a high rate of day-case surgery equivalent to that achieved in adult practice.
