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Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet]. Chichester, UK: John Wiley & Sons, Ltd; 2003-.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet].

Day‐surgery versus overnight stay surgery for laparoscopic cholecystectomy

This version published: 2013; Review content assessed as up-to-date: October 13, 2012.

Link to full article: [Cochrane Library]

Plain language summary

This review compares same‐day discharge (day‐surgery) with overnight stay after keyhole removal of the gallbladder (laparoscopic cholecystectomy) for various conditions affecting the gallbladder but mainly for gallstones causing pain.

Stones that develop in the gallbladder can cause pain in the upper abdomen. This condition is treated by surgical removal of the gallbladder through keyhole surgery, a procedure that is known as laparoscopic cholecystectomy. This procedure may involve the person staying in hospital overnight, but increasingly it is possible to perform the operation and allow them to go home on the same day ('day‐surgery'). There is some controversy over whether performing laparoscopic cholecystectomy as day‐surgery is safe.

This review aims to investigate the current literature available and provides an overview of the evidence demonstrated in recent clinical trials on the subject. The review authors identified a total of six trials involving 492 participants. Two hundred and thirty‐nine people underwent planned laparoscopic cholecystectomy as day‐surgery and 253 participants stayed in the hospital overnight after the procedure. All the trials were at high risk of bias (methodological deficiencies that might make it possible to arrive at wrong conclusions by overestimating the benefit or underestimating the harm of the day‐surgery or overnight stay procedure). We looked at outcomes that are considered to be important from the perspective of the participant and also the healthcare provider. These outcomes include death, serious complication, quality of life following procedure, pain, how long it took for people to return to normal activity and to return to work, hospital readmissions, and failed discharges (failure to be discharged as planned). There was no significant difference in the proportion who died or the complication rate between the group who underwent day‐surgery and those who stayed overnight. Quality of life did not differ significantly between the two groups. There was no significant difference in the time taken for people to return to normal activity or to return to work. There was also no significant difference in the hospital readmission or failed discharge rates. The results suggest that day‐surgery is safe for patients. It is important to note that all trials were at risk of bias and the data were sparse, resulting in a considerable chance of arriving at wrong conclusions due to systematic errors (overestimating benefits or underestimating harms of day‐surgery or overnight stay) and random errors (play of chance). More randomised trials are needed to investigate the impact of day‐surgery and overnight stay on the quality of life and other outcomes of people undergoing laparoscopic cholecystectomy.

Abstract

Background: Laparoscopic cholecystectomy is used to manage symptomatic gallstones. There is considerable controversy regarding whether it should be done as day‐surgery or as an overnight stay surgery with regards to patient safety.

Objectives: To assess the impact of day‐surgery versus overnight stay laparoscopic cholecystectomy on patient‐oriented outcomes such as mortality, severe adverse events, and quality of life.

Search methods: We searched the Cochrane Hepato‐Biliary Group Controlled Trials Register and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and mRCT until September 2012.

Selection criteria: We included randomised clinical trials comparing day‐surgery versus overnight stay surgery for laparoscopic cholecystectomy, irrespective of language or publication status.

Data collection and analysis: Two authors independently assessed trials for inclusion and independently extracted the data. We analysed the data with both the fixed‐effect and the random‐effects models using Review Manager 5 analysis. We calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention‐to‐treat or available case analysis.

Main results: We identified a total of six trials at high risk of bias involving 492 participants undergoing day‐case laparoscopic cholecystectomy (n = 239) versus overnight stay laparoscopic cholecystectomy (n = 253) for symptomatic gallstones. The number of participants in each trial ranged from 28 to 150. The proportion of women in the trials varied between 74% and 84%. The mean or median age in the trials varied between 40 and 47 years.

With regards to primary outcomes, only one trial reported short‐term mortality. However, the trial stated that there were no deaths in either of the groups. We inferred from the other outcomes that there was no short‐term mortality in the remaining trials. Long‐term mortality was not reported in any of the trials. There was no significant difference in the rate of serious adverse events between the two groups (4 trials; 391 participants; 7/191 (weighted rate 1.6%) in the day‐surgery group versus 1/200 (0.5%) in the overnight stay surgery group; rate ratio 3.24; 95% CI 0.74 to 14.09). There was no significant difference in quality of life between the two groups (4 trials; 333 participants; SMD ‐0.11; 95% CI ‐0.33 to 0.10).

There was no significant difference between the two groups regarding the secondary outcomes of our review: pain (3 trials; 175 participants; MD 0.02 cm visual analogue scale score; 95% CI ‐0.69 to 0.73); time to return to activity (2 trials, 217 participants; MD ‐0.55 days; 95% CI ‐2.18 to 1.08); and return to work (1 trial, 74 participants; MD ‐2.00 days; 95% CI ‐10.34 to 6.34). No significant difference was seen in hospital readmission rate (5 trials; 464 participants; 6/225 (weighted rate 0.5%) in the day‐surgery group versus 5/239 (2.1%) in the overnight stay surgery group (rate ratio 1.25; 95% CI 0.43 to 3.63) or in the proportion of people requiring hospital readmissions (3 trials; 290 participants; 5/136 (weighted proportion 3.5%) in the day‐surgery group versus 5/154 (3.2%) in the overnight stay surgery group; RR 1.09; 95% CI 0.33 to 3.60). No significant difference was seen in the proportion of failed discharge (failure to be discharged as planned) between the two groups (5 trials; 419 participants; 42/205 (weighted proportion 19.3%) in the day‐surgery group versus 43/214 (20.1%) in the overnight stay surgery group; RR 0.96; 95% CI 0.65 to 1.41). For all outcomes except pain, the accrued information was far less than the diversity‐adjusted required information size to exclude random errors.

Authors' conclusions: Day‐surgery appears just as safe as overnight stay surgery in laparoscopic cholecystectomy. Day‐surgery does not seem to result in improvement in any patient‐oriented outcomes such as return to normal activity or earlier return to work. The randomised clinical trials backing these statements are weakened by risks of systematic errors (bias) and risks of random errors (play of chance). More randomised clinical trials are needed to assess the impact of day‐surgery laparoscopic cholecystectomy on the quality of life as well as other outcomes of patients.

Editorial Group: Cochrane Hepato‐Biliary Group.

Publication status: New search for studies and content updated (no change to conclusions).

Citation: Vaughan J, Gurusamy KS, Davidson BR. Day‐surgery versus overnight stay surgery for laparoscopic cholecystectomy. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD006798. DOI: 10.1002/14651858.CD006798.pub4. Link to Cochrane Library. [PubMed: 23904112]

Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

PMID: 23904112

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