Although day case LC can save costs[3
], concerns remain about patient safety. The morbidity of LC has been reported to be 4%-20%[12
]. It is reported that about 50% of all complications during LC occur at the set-up of the pneumoperitoneum[13
]. Typical mishaps at the set-up period are bleeding from trocar sites and vascular injury[13
]. Other complications include bleeding from the liver bed, spillage of gallstones or bile, bowel injuries and so on.
It has been recommended that patients should be observed for at least 24 h so that an intervention can be performed quickly if major complications such as bleeding or bile duct injury occur[14
]. The incidence of major complications is substantially low. Arterial bleeding or hemorrhage generally becomes symptomatic during operation or within a few hours after surgery. On the other hand, bile duct injury becomes symptomatic during operation or several days after surgery.
In the present study, patients who underwent day case LC were observed for approximately 8 h after surgery. They had to meet MPADSS[11
] before discharge was allowed. No difference in the number of postsurgical complications was found between the day case LC group and the overnight stay LC group and none of complications manifested during the hospital stay. These results imply that the hospital stay did not reduce the detection and subsequent consequences of complications. Therefore, 8 h of observation after LC appears to be sufficient. Several studies have also demonstrated the safety of LC with discharge on the same day[15
In the present study, the vast majority of patients in both the day case LC group and the overnight stay LC group were successfully discharged and the proportion of people with unexpected or prolonged hospital stay was similar in both groups when patient’s request was excluded. In addition, the duration of any unexpected or prolonged hospitalization was similar between the groups, suggesting that the severity of the causative condition was neither increased nor reduced by an overnight stay. These results demonstrate that in patients with an overnight stay, there are many patients who can have a day case LC safely.
It is important to identify risk factors for admission preoperatively to avoid the disappointment and disruption of an unexpected admission. The present study demonstrated that LC can be performed in selected patients as a day case procedure without jeopardizing the safety of the patients. The absence of readmission indicates that the criteria in this study are appropriate and strict. A previous diagnosis of acute cholecystitis or biliary pancreatitis was reported to be a highly predictive factor of hospital admission and patients with ASA grade of more than II were more likely to require a postoperative stay of over 12 h[16
The only difference between the day case and overnight LC group was age. Age was also the only difference between the one night stay and more nights stay group. The mean age was gradually higher from day case to more nights stay as hospital stay became longer. This result demonstrates that elderly patients show a tendency to like to stay in hospital rather than be a day case. This is unique in Japan and has not been reported from any other countries. Maggiore[7
] reported that being 75 or older is a relative contraindication that led to exclusion in his criteria of patient selection. Some selection criteria for day case LC excludes patients older than 70 years[17
]. Of course, these exclusion criteria are derived from the fact that elderly patients have a high risk of postoperative complications. Not only so, elderly patients in Japan are likely to stay hospital longer after LC probably because the hospital cost is relatively lower in Japan and their anxiety due to fear of suffering complications and pain at home is strong. Therefore, we must take special care to give elderly patients adequate information before surgery and a support system after discharge.
Adequate pain relief is essential in day case surgery. Various methods, such as peritoneal instillation of local anesthetic agents[19
] and wound infiltration with local anesthetic agents[21
], have been attempted to decrease postoperative pain. But Hilvering et al[22
] reported the opposite result, that combined subcutaneous and intraperitoneal administration of levobupivacaine did not influence postoperative abdominal pain after LC. We innovated the TAP block as a postoperative pain block[10
] and after that no patients complained of postoperative pain.
Postoperative nausea and vomiting are other factors that may influence postoperative discharge and hospital stay[23
]. In this study, the most common reasons for unexpected or prolonged hospital stay were nausea and vomiting. Nearly half of unexpected or prolonged hospital stay patients in both day case and overnight LC groups were due to nausea and vomiting. Hereafter, an effective protocol for control of nausea and vomiting is an essential component in the day case LC service. The routine use of prophylactic anti-emetic agents such as ondansetron[5
] and preemptive analgesia with non-steroidal anti-inflammatory drugs[24
] may reduce the incidence of postoperative nausea and vomiting.