Affiliations
doi: 10.29271/jcpsppg.2025.01.94ABSTRACT
Objective: To analyse frequencies of preoperative, intra-operative, and postoperative factors that influence prolonged hospital stay after laparoscopic cholecystectomy (LC).
Study Design: An observational, cross-sectional study.
Place and Duration of the Study: Surgical Unit 3, Dr. Ruth K.M. Pfau Civil Hospital, Karachi, Pakistan, from January to June 2024.
Methodology: Data from 153 patients aged between 20 and 60 years were collected based on variables such as age, gender, ASA score, duration of hospital stay, presence of dense adhesions around Calot's triangle, use of abdominal drain, incidental gallbladder perforation, and postoperative nausea or vomiting. SPSS version 23 was used for data analysis. The descriptive statistics, including frequencies and percentages, were calculated for all categorical variables. The association of prolonged hospital stay with all variables was assessed using the Chi-square/Fisher's exact tests. A p-value of <0.05 was considered statistically significant.
Results: The most frequent age group was 31–40 years (34.6%), with a mean age of 38.9 ± 9.9 years. Among all patients, 86.3% were females and 13.7% were males. The majority of patients (54.2%) were classified as American Society of Anesthesiologists (ASA) 1. In 17% of patients, a prolonged hospital stay of >1 day after LC was observed. Dense adhesions around Calot’s triangle were found in 28.8% of patients. Drain placement was performed in 15.7% of patients. Incidental perforation of the gallbladder was found in 30.7% of patients. Dense adhesions around Calot’s triangle, use of abdominal drain, incidental gallbladder perforation, and nausea or vomiting on the 1st postoperative day were significantly associated with prolonged hospital stay.
Conclusion: This study identified that a prolonged hospital stay was significantly associated with dense adhesions around Calot’s triangle, use of abdominal drain, incidental gallbladder perforation and nausea or vomiting on the 1st postoperative day.
Key Words: Laparoscopic cholecystectomy, Length of hospital stay, Risk factors, Day care surgery, Abdominal drain, Perforation of the gallbladder.
INTRODUCTION
Routine admissions in the surgical wards include gallstones, which are common globally.1 The literature reports the prevalence of gallstones of about 6–11% in Western populations and 5–7% in African and Asian communities.2 Laparoscopic cholecystectomy (LC) is regularly performed in most hospitals, and after the 1980s, it has become the gold standard treatment for gall- stones worldwide.3
With recent advancements in surgical procedures, post- operative hospital stay remains one of the influential out- comes.
In the era of Enhanced Recovery After Surgery (ERAS), short stay minimises the hospital burden by reducing expenditures of surgery and also helps patients to continue their daily activities effectively. Prolonged hospital stay causes a surge in hospital and patients’ debts.4 Developed countries follow the protocol of day surgery in LC.5
Jeyalakshmi et al. in their study of 80 patients, concluded that 22.5% patients with adhesions intra-operatively (p <0.001) and 48.3% with drain placement (p <0.001) had a significant association with delayed discharge after LC.6 Morimoto et al. noted that among 353 patients, the American Society of Anesthesiologists (ASA) score (p = 0.000) and difficulty in performing LC (p = 0.001) were the most anticipating aspects on duration of hospital stay.7 Day-surgery procedures are popular in the context of their feasibility. Newer studies aimed to identify the predictive factors that promote LC in a day- surgery framework.8-10
Delayed discharges after surgery affect not only patients but also hospital resources and bed availability. The aim of this study was to identify factors that prolong hospital stay after LC.
METHODOLOGY
This observational and cross-sectional study was conducted at the Surgical Unit 3, Dr. Ruth K.M. Pfau Civil Hospital, Karachi, Pakistan, from January to June 2024. Ethical approval was obtained from the Institutional Review Board (IRB) of Dow University of Health Sciences [Ref: IRB-3093/DUHS/Approval/2023/360]. Patients meeting the inclusion criteria of age >20 years and <60 years, with an ASA score of 1, 2, or 3, and patients undergoing LC after confirmation of gallstones on ultrasound, and visiting the surgical outpatient department, were recruited for a period of six months. All cases converted from laparoscopic to open cholecystectomy and pregnant patients were excluded from the study. Informed consent was taken from patients after giving a detailed explanation about the purpose, procedure, potential risks, and benefits of the study. The sample size was calculated using the WHO sample size calculator (version 1.1) with a 95% confidence level and the anticipated population proportion of patients with drain placement of 0.112.6 Data of 153 patients were collected based on variables such as age, gender, ASA score, duration of hospital stay, presence of dense adhesions around Calot's triangle, use of abdominal drain, incidental gallbladder perforation, and post- operative nausea or vomiting.
SPSS version 23 was used for data entry and analysis. Descriptive statistics, including frequencies and percentages, were used for all categorical and numerical variables. Numerical variables, such as age, were reported as mean and standard deviation. Categorical variables included gender, ASA score, hospital stay after surgery, presence of dense adhesions around Calot’s triangle, use of abdominal drain, postoperative nausea or vomiting, and incidental perforation of the gallbladder. The association of prolonged hospital stay with all variables was assessed using the Chi-square/Fisher's exact tests. A p-value of <0.05 was considered statistically significant.
RESULTS
The study was conducted on 153 patients. The patients were categorised into four age groups: 20–30 years (20.9%), 31–40 years (34.6%), 41–50 years (28.1%), and 51–60 years (16.3%), with a mean age of 38.9 ± 9.9 years (Figure 1). Among all patients, 86.3% were females and 13.7% were males (Figure 2). The ASA scores of patients were ASA 1 (54.2%), ASA 2 (22.2%), and ASA 3 (23.5%). Prolonged hospital stay of >1 day after LC was observed in 26 (17%) of patients (Figure 3). Dense adhesions around Calot’s triangle were found in 44 (28.8%) patients. Drain placement was performed in 24 (15.7%) patients. Incidental perforation of the gallbladder was found in 47 (30.7%) patients, and 4 (2.6%) of patients had nausea or vomiting on the 1st postoperative day. Eleven (7.2%) of patients had empyema of the gallbladder, and 5 (3.3%) experienced intraoperative bleeding. On analysis of factors associated with prolonged hospital stay, gender distribution (p = 0.35), age group (p = 0.58), and ASA score (p = 0.184) were not statistically significant. However, dense adhesions around Calot’s triangle (p <0.001), use of abdominal drain (p <0.001), incidental perforation of the gallbladder (p <0.001), and nausea or vomiting on the 1st postoperative day (p <0.001) were significantly associated. Empyema of gallbladder and intraoperative bleeding were not statistically significant (p >0.99, Table I).
Figure 1: Distribution of age groups of all patients.
Figure 2: Gender-wise distribution of all patients.
Figure 3: Distribution of the length of hospital stay.
Table I: Factors affecting the length of hospital stay.
|
Factors |
Hospital stay <1 day (n = 127) |
Hospital stay >1 day (n = 26) |
p-values |
|
|
Age group (years) |
20-30 |
28 (87.5%) |
4 (12.5%) |
0.58 |
|
31-40 |
48 (90.6%) |
5 (9.4%) |
||
|
41-60 |
51 (75%) |
17 (25%) |
||
|
Gender |
Female |
111 (84.1%) |
21 (15.9%) |
0.359 |
|
Male |
16 (76.2%) |
5 (23.8%) |
||
|
ASA score |
1 |
73 (88%) |
10 (12%) |
0.184 |
|
2 |
27 (79.4%) |
7 (20.6%) |
||
|
3 |
27 (75%) |
9 (25%) |
||
|
Dense adhesions around Calot’s triangle |
Present |
26 (59.1%) |
18 (40.9%) |
<0.001 |
|
Absent |
101 (92.7%) |
8 (7.3%) |
||
|
Incidental perforation of the gallbladder |
Present |
31 (66%) |
16 (34%) |
<0.001 |
|
Absent |
96 (90.6%) |
10 (9.4%) |
||
|
Use of abdominal drain |
Present |
3 (12.5%) |
21 (87.5%) |
<0.001 |
|
Absent |
124 (96.1%) |
5 (3.9%) |
||
|
Nausea or vomiting on the 1st postoperative day |
Present |
0 |
4 (100 %) |
0.001 |
|
Absent |
127 (85.2%) |
22 (14.8%) |
||
|
Empyema of the gallbladder and intraoperative bleeding |
Present |
4 (36.4%) |
7 (63.6%) |
>0.99 |
|
Absent |
1 (20%) |
4 (80%) |
||
|
Note: Chi-square and Fisher’s exact tests were used to determine the p-values. |
||||
DISCUSSION
LC is the most commonly performed procedure in surgical wards. In the pursuit of day surgery guidelines, delayed discharge remains one of the important challenges for healthcare providers.11 The objective in the National Health System (NHS) plan in the UK was to increase day cases of LC up to 75%.12
A study conducted by Ripetti et al. on the existence of predictive factors aimed at facilitating cholecystectomy in a day-surgery setting included 985 consecutive patients who underwent elective LC for gallstone disease. They concluded that only age was a significant predictor of prolonged hospital stay.13 Similarly, a multivariate analysis concluded that age >50 years was significantly associated with extended hospita-lisation.14
In a study by Cao et al.15 on the safety of ambulatory LC in elderly patients, there were 7657 patients in the study cohort. The data were collected from a 10-year period (2009-2019). Male gender was found to be an independent factor for delayed discharge (p = 0.004). In contrast, in the present study, there was no association between gender and prolonged hospital stay (p = 0.35).
Morimoto et al. studied 370 patients of LC. They found that the ASA score had a significant association with prolonged hospital stay.7 In the current study, ASA score was not identified as a significant factor for prolonged hospital stay after LC (p = 0.184).
In a prospective observational study by Sarala et al. on 88 patients, factors affecting the dischargeability of patients were evaluated. Drain placement (p = 0.005) was found to be a significant factor for delayed discharge.16 The present study also showed that drain placement during LC had a significant association with prolonged hospital stay (p <0.001). However, routine placement of subhepatic drain after LC has not been shown to alter outcomes.17
Jeyalakshmi et al. in their study of 80 patients, concluded that 22.5% with adhesions intraoperatively (p <0.001) had a significant association with delayed discharge after LC.6 In the present study, dense adhesions also had a significant association with delayed discharge (p <0.001).
A prospective cohort analysis of the prevalence and predictive factors of delayed discharge after LC were evaluated in the DeDiLaCo study. This study was conducted in Italy by Cillara et al. They included 4,664 patients and found postoperative vomiting as an independent predictor of delayed discharge.18 Postoperative nausea and vomiting had a significant association with delayed discharge in the present study also (p = 0.001).
A retrospective study including 2,296 patients was conducted by Cheewatanakornkul et al.19 In their study, gallbladder perforation had no significant association with prolonged hospital stay (p = 0.787), whereas the present study showed a significant asso-ciation of the prolonged hospital stay in those patients who had perforation of gallbladder during surgery (p <0.001).
In the present study, other complications such as bleeding from the liver bed and cystic artery, and empyema of the gallbladder, no significant association with prolonged hospital stay was found (p >0.99).
A meta-analysis done by Zhang et al. on preoperative risk factors for delayed discharge in day-surgery included a total of nine studies involving 41,458 patients. No statistically significant differences between the delayed discharge group and the non-delayed discharge group in terms of the ASA classification were found. Older age and male gender were identified as significant variables for delayed discharge.20
The limitations of this study include a small study population and a lack of follow-up data. Studies suggest that factors such as older age and higher ASA score can prolong the hospital stay after LC. Further studies are recommended with a large sample size and more factors that can be modified, and the length of hospital stay can be minimised.
CONCLUSION
This study identified that prolonged hospital stay was signifi-cantly associated with dense adhesions around Calot’s triangle, use of abdominal drain, incidental perforation of the gall-bladder, and nausea or vomiting on the 1st postoperative day.
ETHICAL APPROVAL:
The approval for synopsis was obtained from the Institutional Review Board (IRB) of Dow University of Health Sciences [Ref. No: IRB-3093/DUHS/Approval/2023/360].
PATIENTS’ CONSENT:
Informed consent was taken from the patients after giving a detailed explanation about the purpose, procedure, potential risks, and benefits of the study.
COMPETING INTEREST:
The authors declared no conflict of interest.
AUTHORS’ CONTRIBUTION:
HMA, FJ: Contribution to the conception, design of the work, drafting, and critical revision of the manuscript for important intellectual content.
Both authors approved the final version of the manuscript to be published.
REFERENCES