title: Day-case laparoscopic cholecystectomy in childhood: outcomes from a clinical care pathway.
abstract: OBJECTIVE
  The aim of this study was to report clinical outcomes following the use of a pediatric day-case laparoscopic cholecystectomy (DCLC) clinical care pathway. The pathway was modified in September 2009 and we compare the clinical outcomes before and after this modification.
  
  
  METHODS
  A care pathway for DCLC was introduced in 2008 with emphasis on the day of admission, timing of surgery, choice of anesthetic agents, analgesia, postoperative feeding, mobilization, and pain scoring. Demographic and clinical data were recorded prospectively from January 2008 to January 2012. In September 2009, two modifications were made to the pathway. Induction of anesthesia was changed to total intravenous anesthesia, using propofol (target 4 to 6 µg/mL) and remifentanil (target 3 to 5 ng/mL) and the use of the gaseous anesthetic sevoflurane was eliminated with the aim of reducing the risk of postoperative nausea and vomiting (PONV). The postoperative feeding regime was changed from unrestricted to light diet for 72 hours. The rest of the pathway was unchanged. Data before (group 1) and following the modifications (group 2) were compared.
  
  
  RESULTS
  We admitted 25 children with symptomatic cholelithiasis for DCLC under the care of one surgeon: 12 in group 1 and 13 in group 2. There were no significant differences in age between group 1 (median 13 [range 6 to 15] years) and group 2 (median 15 [9 to 16] years) (p = 0.07). There were no intra- or postoperative complications. The day-case rate increased from 6/12 (50%) in group 1 to 12/13 (92%) in group 2 (p = 0.03). The incidence of PONV reduced from 7/12 (58%) in group 1 to 0/13 in group 2 (p = 0.002). PONV in group 1 resulted in overnight stay (n = 6) and readmission (n = 1). One patient in group 2 had an overnight stay due to poor mobilization.
  
  
  CONCLUSIONS
  Adoption of a DCLC pathway is feasible and safe for children. Emphasis on adequate pain management and avoidance of PONV results in a high rate of day-case surgery equivalent to that achieved in adult practice.
authors.affiliation: Department of Pediatric Surgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, United Kingdom. girish.jawaheer@bch.nhs.uk
authors.forename: Girish
authors.initials: G
authors.lastname: Jawaheer
authors.forename: Kathryn
authors.initials: K
authors.lastname: Evans
authors.forename: Ritchie
authors.initials: R
authors.lastname: Marcus
mesh_terms: D000293:Adolescent; D000556:Ambulatory Surgical Procedures / Q000379:methods*; D002648:Child; D017081:Cholecystectomy, Laparoscopic / Q000379:methods*; D002769:Cholelithiasis / Q000601:surgery*; D019091:Critical Pathways; D005260:Female; D006801:Humans; D008297:Male; D019990:Perioperative Care / Q000379:methods; D020250:Postoperative Nausea and Vomiting / Q000453:epidemiology; D011446:Prospective Studies; D016896:Treatment Outcome