Conference Coverage

Nighttime cholecystectomy may increase complication risk

Publish date: May 21, 2013
By
Sharon Worcester
MDedge News

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Evidence-based practice still not the rule

The report by Dr. Phatak and her colleagues

from the University of Texas (UT) Health

Science Center,

Houston, raises

a key issue with respect to the management of acute cholecystitis. Should these

operations be performed at night, especially in older patients? Multiple

prospective, randomized trials over the past 4 decades have concluded that

patients with acute cholecystitis who present within the first few days of the

illness should be managed urgently rather than undergo surgery 6 weeks later.

Nevertheless, a significant proportion of these operations are delayed in the United States.

The question then becomes why is evidence-based practice not being performed?

The answers probably include the surgeon’s schedule, daytime operating room

availability, and staff expertise and equipment availability at night. When an

urgent operation is delayed until the middle of the night, is the patient best

served if her surgeon is overly tired? Similarly, should the next morning’s

patient scheduled for an elective procedure undergo an operation by a surgeon

who has not had an adequate night’s sleep?

The obvious answers to these questions is no, but the

solutions are not simple. Multisurgeon groups and Acute Care Surgery services

may address these issues is schedules are constructed appropriately.

Similarly, efficient management of an operating room

during the day with flexibility for the add-on of urgent cases is ideal. In

addition, cross-training of operating room staff with knowledge and

availability of proper equipment at night is not trivial but is key for safe patient

care. Another important point is whether the findings of the report by Dr.

Phatak are generalizable. Certainly, her observations apply to safety-net

hospitals in cities with large Hispanic populations. However, a 60% incidence

of “nonelective” gallbladder surgery is unusual for the typical community

hospital, rural hospital, or academic medical center. In these settings,

appropriate management of acute cholecystitis is to have the patient take

nothing by mouth (NPO), to initiate appropriate medications, and to schedule

surgery semiurgently, ideally during the daytime. While this ideal situation

may not always be possible, insistence on daytime surgery should be a major

principle especially in older, more frail patients.

Dr. Henry

A. Pitt is an ACS Fellow and vice chairman of surgery at Indiana University, Indianapolis. Dr. Pitt has

no disclosures.


 

AT DDW 2013

ORLANDO – Older age and nighttime surgery were associated with an increased risk of complications in patients undergoing laparoscopic cholecystectomy at a high-volume safety net hospital, according to a retrospective study of cases.

Of 576 operations performed in consecutive patients for whom relevant data were available, 35% were performed at night, and although about 60% of procedures overall were nonelective, more than 90% of those performed at night were nonelective, meaning that most patients were admitted directly from the emergency department, Dr. Uma R. Phatak reported at the annual Digestive Disease Week.

A total of 35 complications occurred in 22 patients, including 18 undergoing nonelective surgery and 4 undergoing elective surgery.

Multivariate analysis demonstrated that age and nighttime surgery were significant predictors of complications, said Dr. Phatak of the University of Texas Health Science Center, Houston.

The probability of a complication increased with age for both the patients who underwent daytime surgery and those who underwent nighttime surgery, but the increase was greater in the nighttime surgery group, she said.

The predicted probability of a complication increased threefold for older patients who underwent surgery at night, according to an analysis by 10-year age intervals.

"At the upper end of the age spectrum, the predicted probability of a complication with surgery at night is about 30%, compared to about 10% in the daytime group," Dr. Phatak said.

This analysis did not adjust for disease severity, but a multivariate model that included the elective surgery patients showed that even in this group, an increased risk of a complication was associated with nighttime surgery and increasing age, she noted.

Patients included in the study underwent surgery during an 8-month period from October 2010 to May 2011 at a hospital with a large Hispanic population at high risk for gallstones where laparoscopic cholecystectomy is commonly performed at night. Most (84%) were women, and most (84%) were Hispanic.

The most common diagnoses were acute cholecystitis in the nighttime group and chronic cholecystitis in the daytime group.

Those who underwent nighttime surgery had a lower median age and a longer median length of stay, although it was unclear whether the length of stay was increased due to a delay in getting to the operating room.

The study is limited by its single-center retrospective design, which limits the generalizability. It also was underpowered to detect significant differences in complications other than surgical site infections, Dr. Phatak noted.

Nonetheless, the study demonstrates an increased risk of complications with nighttime surgery, suggesting that the benefits of early laparoscopic cholecystectomy for acute cholecystitis must be balanced against the risk of nighttime surgery, Dr. Phatak said.

"At our institution, new ambulatory operating rooms will be opening soon, decreasing the burden on the main operating room. This will allow for nonemergent cases to be booked during the daytime without imposing delays in the elective schedule," she said.

Providing increased space for elective operations, identifying high-risk patients, and prioritizing surgeries during the day for those patients may decrease the complication rate and improve outcomes, she concluded.

Dr. Phatak reported having no disclosures.

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