cholecystectomy as day-case.


With the advancement in laparoscopic techniques,increasing proficiency of Surgeons in their use and economic pressures there is an increasing trend of cholecystectomy (removal of gall bladder) being done in clinic procedures with the patients being discharged the same day. There is an interesting article in the recent British Journal of Surgery concluding day-case (i.e. no overnight stay in hospital) laparoscopic surgery to be safe and effective.

Meta-analysis of randomized controlled trials on the safety and effectiveness of day-case laparoscopic cholecystectomy.

Br J Surg. 2008; 95(2):161-8 (ISSN: 1365-2168)

Gurusamy K; Junnarkar S; Farouk M; Davidson BR
Hepatopancreatobiliary and Liver Transplant Surgery, University Department of Surgery, Royal Free and University College School of Medicine, University College London and Royal Free Hospital NHS Trust, London, UK. [email protected]

BACKGROUND: Although day-case laparoscopic cholecystectomy can save bed costs, its safety has to be established. The aim of this meta-analysis is to assess the advantages and disadvantages of day-case surgery compared with overnight stay in patients undergoing elective laparoscopic cholecystectomy.
METHODS: Randomized clinical trials addressing the above issue were identified from The Cochrane Library trials register, Medline, Embase, Science Citation Index Expanded and reference lists. Data were extracted from these trials by two independent reviewers. For each outcome the relative risk, weighted mean difference or standardized mean difference was calculated with 95 per cent confidence intervals based on available case analysis.

RESULTS: Five trials with 215 patients randomized to the day-case group and 214 to the overnight-stay group were included in the review. Four of the five trials were of low risk of bias. The trials recruited 49.1 per cent of patients presenting for cholecystectomy. There was no significant difference between day case and overnight stay with respect to morbidity, prolongation of hospital stay, readmission rates, pain, quality of life, patient satisfaction, and return to normal activity and work. In the day-case group 80.5 per cent of patients were discharged on the day of surgery.

CONCLUSION: Day-case laparoscopic cholecystectomy is a safe and effective treatment for symptomatic gallstones.

Such has been the practice at our center for 3 years now and there has been no cause of regret. In patient having excessive adhesions or difficult dissection or having anaesthesia related problems can be held back overnight. The patient can be assessed in the evening at the time of discharge and if comfortable can go home with instructions in case of any difficulty. I suppose the figure of 80 percent is about right.

As this study illustrates there is increasing trend towards shorter stay and early discharge. there are many centers in the US where such operations are done in office setting assisted by recent advances in intraoperative Ultrasound which is replacing cholangiography( unaware of such practice in India). Variations in the anatomy of cystic duct, hepatic duct and CBD and consequent mistakes while cutting the cystic duct can lead to dreadful and expensive complications.

Heart Diseases and Genetics.

As advances in genetics are made the influence of genes on individual’s health is all the more apparent. It is quite well known that people of South Asian origin are inordinately susceptible to heart diseases besides diabetes and associated metabolic syndromes.

Today’s Genetics Nature carries a paper delineating the high incidence of genetic mutation among Indians which is associated with Cardiomyopathy and heart failure.Heart failure is a leading cause of mortality in South Asians. However, its genetic etiology remains largely unknown1. Cardiomyopathies due to sarcomeric mutations are a major monogenic cause for heart failure (MIM600958). Here, we describe a deletion of 25 bp in the gene encoding cardiac myosin binding protein C (MYBPC3) that is associated with heritable cardiomyopathies and an increased risk of heart failure in Indian populations (initial study OR = 5.3 (95% CI = 2.3–13), P = 2 times 10-6; replication study OR = 8.59 (3.19–25.05), P = 3 times 10-8; combined OR = 6.99 (3.68–13.57), P = 4 times-11) and that disrupts cardiomyocyte structure in vitro. Its prevalence was found to be high (approx4%) in populations of Indian subcontinental ancestry. The finding of a common risk factor implicated in South Asian subjects with cardiomyopathy will help in identifying and counseling individuals predisposed to cardiac diseases in this region.

This article was further reported in Medical News Today

The Worst Luck In The World? The Heart Disease Mutation Carried By 60 Million

Heart disease is the number one killer in the world and India carries more than its share of this burden. Moreover, the problem is set to rise: it is predicted that by 2010 India’s population will suffer approximately 60% of the world’s heart disease. Today, an international team of 25 scientists from four countries provides a clue to why this is so: 1% of the world’s population carries a mutation almost guaranteed to lead to heart problems and most of these come from the Indian subcontinent, where the mutation reaches a frequency of 4%.

Considering that the mutation is so dangerous; how come it is so common? Well-

The combination of such a large risk with such a high frequency is, fortunately, unique. “How can such a harmful mutation be so common?” asks Chris Tyler-Smith from The Wellcome Trust Sanger Institute, Hinxton, UK. “We might expect such a deleterious change to have ‘died out’.

“We think that the mutation arose around 30,000 years ago in India, and has been able to spread because its effects usually develop only after people have had their children. A case of chance genetic drift: simply terribly bad luck for the carriers.”

The original advanced online paper is here( in pdf)

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