Does Time of Day Matter for Acute Cholecystectomy in an Acute Care Surgery Model?
Rakitin I, Stanton C, Dix M, Ziegler N, Stassinopoulos J, Johnson J, Schmoekel N. Does Time of Day Matter for Acute Cholecystectomy in an Acute Care Surgery Model?. Surgical Endoscopy 2019; 33:P025.
Introduction: Prompt cholecystectomy for acute cholecystitis is well accepted; however, whether this warrants urgent nocturnal surgery remains a matter of debate. Differences in available resources, multitasking, and sleep hygiene may affect performance. This could impact conversion rates to open surgery, length of operation, hospital length of stay, and complications such as bile duct injury, blood loss, and major organ injury. Some evidence supports improved outcomes in patients who can avoid after-hour cholecystectomy. We aimed to determine if outcomes changed based on time of day for laparoscopic cholecystectomy. Our null hypothesis is that night time cholecystectomy is associated with worse outcomes.
Methods and Procedures: Retrospective analysis of 486 patients aged ≥ 18 years who underwent cholecystectomy in a large, urban level 1 tertiary care center with a longstanding acute care surgery model. Demographics, procedural information, time of day of surgery, and postoperative outcomes were collected and stratified over a 4-year period from 2013-2017. Sixty five percent of the patients were female with an average age of 49.6 years and an average BMI of 32.7 kg/m2. A total of 230 (47%) patients underwent laparoscopic cholecystectomy for acute cholecystitis. Almost half (45%) underwent nighttime operation defined as procedure start time between the hours of 19:00 to 07:00.
Results: Analysis of the 230 patients with acute cholecystitis revealed an overall conversion rate to open of 14% (n = 32), bile leak (duct of Luschka or cystic) 3.5% (n = 8), 30-day readmission rate of 7.4% (n = 17), and length of stay of 3.9 days. Subgroup analysis of patients having nighttime cholecystectomy for cholecystitis (N = 103) revealed 6.1% conversion to open, 0.9% (n = 2) bile leak, 2.6% (n = 6) 30-day readmission rate, and 3.43 days length of stay. Other outcomes including mortality, cardiac events, pneumonia, stroke, PE, blood loss requiring blood transfusion were not statistically significant. One patient had a common bile duct injury in the daytime group that required conversion to open and hepaticojejunostomy.
Conclusions: Despite prior evidence that favors delaying cholecystectomy until daytime to avoid complications, our study did not support this. We found no difference in outcomes between daytime and nighttime cholecystectomy and conclude that cholecystectomy can safely be performed during any time of the day with similar complication rates. This may reflect the volume of experience in after-hours acute care surgery at this regional referral center.