Patient selection for ambulatory laparoscopic cholecystectomy: A systematic review.

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.

INTRODUCTION

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.[2345]

In the early 1990s, some surgeons introduced the safety and feasibility of the performing of LC in ambulatory settings.[67] 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

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

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

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

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

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.

Supplementary Table 1

Detailed selection criteria extracted from 59 included publications

Author and years	Region	Patients number	Selection criteria	Discharge rate (%)	Readmission rate (%)
Qu et al. (2019)[1]	China	42	ASA ≤ SAn 18 <age <50, BMI <30, no AC, no atrophic cholecystitis, no intrahepatic gallbladder, no previous abdominal surgery, no cardiopulmonary comorbidities, no diabetes	97.6	0
Gregori et al. (2018)[2]	Italy	730	No cardiopulmonary comorbidities	85.7	3.4
Abet et al. (2017)[3]	France	102	ASA ≤ SA, age ≥ ge, no choledocholithiasis, no substance abuse, no antecedents of gastro-duodenal ulcers, no immune suppression, no need of analgesics, no ongoing pregnancy. No conversion to open	98.0	3.2
Tandon et al. (2016)[4]	UK	571	ASA ≤ SAI	78.0	11.7
Mattila et al. (2015)[5]	Finland	169	ASA ≤ SA, 18 <age <65, BMI <35, no AC, no choledocholithiasis, no previous abdominal surgery, no NSAIDs allergy. No previous pancreatitis. Normal liver function tests	87.0	4.0
Al-Qahtani et al.[6]	Kingdom of Saudi Arabia	487	ASA ≤ SA, AGE ≥ GE, BMI <35, no AC, no thickening gallbladder wall, no previous abdominal surgery, normal liver function tests. Normal liver function test, no thickening gallbladder wall, no insulin-dependent diabetes or epilepsy, no ongoing pregnancy, no upper respiratory tract infection, or uncontrolled hypertension	95.0	n.a.
Salleh et al. (2015)[7]	Malaysia	29	ASA ≤ SA, age <75, BMI <30, no AC, no chronic cholecystitis, no choledocholithiasis, no thickening gallbladder wall. No dilated CBD	n.a.	n.a.
Brescia et al. (2013)[8]	Italy	400	ASA ≤ SA, age <70, BMI <35, no AC, no atrophic cholecystitis, no choledocholithiasis. No previous jaundice, mental healthy	96.7	n.a.
Gelmini et al. (2013)[9]	Italy	43	ASA ≤ SAl 18 <age <70, BMI <35, no AC, no choledocholithiasis, no previous abdominal surgery, no coagulopathy	86.1	2.3
Khan et al. (2012)[10]	Bangladesh	210	ASA ≤ SA, no choledocholithiasis, no morbid obesity	97.6	0
Seleem et al. (2011)[11]	Egypt	210	ASA ≤ SA, no AC, no conversion to open	n.a.	n.a.
Akoh et al. (2011)[12]	UK	258	ASA ≤ SAI, no AC, no choledocholithiasis	69.0	5.0
Briggs et al. (2009)[13]	UK	106	ASA ≤ SA, BMI <38, no choledocholithiasis, no previous abdominal surgery, no previous ERCP, no previous PNOV	84.0	1.8
Lledó et al. (2008)[14]	Spain	410	ASA ≤ SAI, no choledocholithiasis	89.8	1.5
Chang and Tan (2008)[15]	Singapore	50	Normal liver function tests	92.4	4.0
Psaila et al. (2008)[16]	UK	176	Weight >120 kg, no asthmatic, no NSAIDs allergy	85.8	4.0
Bona et al. (2007)[17]	Italy	250	ASA ≤ SAI, age >18, no choledocholithiasis	82.4	n.a.
Rathore et al. (2007)[18]	UK	164	ASA ≤ SAI, no choledocholithiasis, no previous pancreatitis, normal-sized CBD	86.0	3.6
Proske et al. (2007)[19]	France	211	ASA ≤ SA, age <75, no coagulopathy, no sleep apnea	82.0	0
Topal et al. (2007)[20]	Belgium	117	ASA ≤ SA, 16 <age <75, no AC, no choledocholithiasis, no coagulopathy	94.0	4.3
Victorzon et al. (2007)[21]	Finland	567	ASA ≤ SA, BMI <35	63.0	2.0
Sherigar et al. (2006)[22]	UK	198	ASA ≤ SAI, no AC, no previous abdominal surgery	88.4	2.0
Kasem et al. (2006)[23]	UK	150	ASA ≤ SA, BMI <35, blood pressure <160/90 mmHg, no previous abdominal surgery, normal liver function tests, no previous anaesthetic complications, no previous difficult intubation. no previous severe AC	99.4	0
Metcalfe et al. (2006)[24]	Australia	33	ASA ≤ SAtrage >18	75.8	6.1
Johansson et al. (2006)[25]	Sweden	52	ASA ≤ SAd 18 <age <70, no AC, no choledocholithiasis, no previous abdominal surgery, no previous pancreatitis	92.0	0
Kaman et al. (2005)[26]	India	106	ASA ≤ SA, age <70	95.2	n.a.
Jain et al. (2005)[27]	UK	269	ASA ≤ SA, BMI <32	95.0	2.0
Chok et al. (2004)[28]	Hong Kong, China	73	ASA ≤ SAg age <70	88.0	2.7
Vuilleumier and Halkic (2004)[29]	Switzerland	136	ASA ≤ SA, no previous jaundice, no anaesthetic contraindication	98.0	n.a.
Fassiadis et al. (2004)[30]	UK	100	ASA ≤ SA, age <70, no AC, no morbid obesity, normal liver function tests	99.0	1.0
Skattum et al. (2004)[31]	Norway	1060	ASA ≤ SA0, mental health, no AC, no cholangitis, no pancreatitis	92.9	6.6
Leeder et al. (2004)[32]	UK	154	BMI <40, no cardiopulmonary comorbidity	85.7	0.7
Ammori et al. (2003)[33]	UK	140	ASA ≤ SA, 18 <age <75, no morbid obesity, no AC, no thickening gallbladder wall, no choledocholithiasis, no previous abdominal surgery, no previous constipation or abdominal pain	84.0	1.4
Bal et al. (2003)[34]	India	313	ASA ≤ SA, age <65, mental health	92.0	3.0
Blatt and Chen (2003)[35]	Australia	41	ASA ≤ Sat	80.0	2.4
Maggiore (2002)[36]	Italy	71	ASA ≤ SAly age <75, no gallbladder neoplasia	88.7	16.9
Lau and Brooks (2002)[37]	US	200	ASA ≤ SA, no adverse anaesthetic history, no significant comorbidities, operation time <90 min, no uncorrectable coagulopathy and diffuse intraperitoneal sepsis	95.5	3.0
Lau and Brooks (2002)[38]	US	888	ASA ≤ SA, no adverse anaesthetic history, no significant comorbidities, operation time <90 min	96.8	n.a.
Curet et al. (2002)[39]	US	43	Age >18, no AC, mental healthy	86.0	0
Siu et al. (2001)[40]	Hong Kong, China	60	ASA ≤ SA, no choledocholithiasis, no thickening gallbladder wall, no contracted gallbladder. No previous AC, abdominal surgery, cholangitis, or pancreatitis	90.0	1.7
Lau and Brooks (2001)[41]	US	731	ASA ≤ SA, no adverse anaesthetic history, no significant comorbidities, operation time <90 min	96.6	n.a.
Bringman et al. (2001)[42]	Sweden	100	ASA ≤ SA, no previous choledocholithiasis or pancreatitis, normal liver function tests. No CBD dilatation	88.0	n.a.
Richardson et al. (2001)[43]	US	847	ASA ≤ SAI, not extremely age	76.0	4.0
Young and Connell (2001)[44]	Australia	14	ASA ≤ SAtrage <50	95.0	n.a.
Fleming et al. (2000)[45]	Australia	45	ASA ≤ SAtrno choledocholithiasis, no coagulopathy, no previous jaundice or pancreatitis. No CBD dilatation	82.3	2.2
Voyles and Boyd (1999)[46]	US	100	Age <65, normal liver enzymes, CBD diameter ≤ 5 mm	74.0	n.a.
Hollington et al. (1999)[47]	Australia	67	ASA ≤ SAtrano previous abdominal surgery	89.6	3.0
Kumar et al. (1999)[48]	India	74	ASA ≤ SAiaage <65	92.0	5.4
Fleisher et al. (1999)[49]	US	96	ASA ≤ SA999age >18	96.9	n.a.
Keulemans et al. (1998)[50]	Netherlands	40	ASA ≤ SAheage ≤ geheno AC, no choledocholithiasis, no calcified gallbladder, no previous abdominal surgery	92.0	0
Voitk (1997)[51]	Canada	85	ASA III and IV, or age >70	72.0	8.2
		430	ASA I and II, and age <70	88.0	2.0
Voyles and Berch (1997)[52]	US	605	Age <65, no choledocholithiasis, no previous abdominal surgery	92.0-98.0	0.2
Narain and DeMaria (1997)[53]	US	60	ASA ≤ SA97no common bile duct dilatation, coagulopathy, pregnancy, or cirrhosis	97.0	5.0
Mjåland et al. (1997)[54]	Norway	200	ASA ≤ SAI, mental health	94.0	8.0
Lam et al. (1997)[55]	US	213	No AC, no clinically significant pain, normal leukocyte count, normal liver function test, no cardiopulmonary comorbidities	97.0	n.a.
Singleton et al. (1996)[56]	Australia	40	ASA ≤ SAtrano previous surgery, cholecystitis, jaundice, or pancreatitis	82.5	n.a.
Smith et al. (1994)[57]	Canada	98	No elderly, no significant commodities	80.6	1.0
Farha et al. (1994)[58]	US	55	No AC, no jaundice, CBD diameter <1 cm, no cardiopulmonary comorbidities	90.0	1.8
Stephensona et al. (1993)[59]	UK	15	ASA ≤ SA99age <70, BMI <35, no AC, no chronic cholecystitis. No previous jaundice. Mental healthy	80.0	n.a.

n.a.: Not available, ASA: American society of anesthesiologist physical status classification, BMI: Body mass index, AC: Acute cholecystitis, CBD: Common bile duct, UK: The United Kingdom, US: The United States, NSAIDs: Nonsteroidal anti-inflammatory drugs, ERCP: Endoscopic retrograde cholangiopancreatography, PONV: Postoperative nausea and vomiting

DISCUSSION

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.[910] 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.[1314] 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.[1617181920212223] In contrast, some other studies also reported acceptable outcomes with those patients.[2425262728] Besides, abnormal laboratory tests, as well as thickening gallbladder wall in ultrasonography has been well known to be risk factors predicting complex operation.[29303132] However, only a few studies considered them as patient's selection criteria.[333435] 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.[3637] Thus, we recommended that unexpected difficult operation should be considered as an exclusion criterion.

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 surgical safety.

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.