Nightime Cholecystectomy

[Dan Plainview]

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ACS posted this article: http://www.acssurgerynews.com/index.php?id=14929&tx_ttnews[tt_news]=143531&cHash=c89a633c5ce0d19494a229c2e0d844f9

Older age and nighttime surgery were associated with an increased risk of complications in patients undergoing laparoscopic cholecystectomy at a high-volume safety net hospital, according to a retrospective study of cases.

Of 576 operations performed in consecutive patients for whom relevant data were available, 35% were performed at night, and although about 60% of procedures overall were nonelective, more than 90% of those performed at night were nonelective, meaning that most patients were admitted directly from the emergency department, Dr. Uma R. Phatak reported at the annual Digestive Disease Week.

A total of 35 complications occurred in 22 patients, including 18 undergoing nonelective surgery and 4 undergoing elective surgery.

Multivariate analysis demonstrated that age and nighttime surgery were significant predictors of complications, said Dr. Phatak of the University of Texas Health Science Center, Houston.

The probability of a complication increased with age for both the patients who underwent daytime surgery and those who underwent nighttime surgery, but the increase was greater in the nighttime surgery group, she said.

The predicted probability of a complication increased threefold for older patients who underwent surgery at night, according to an analysis by 10-year age intervals.

At our place (large tertiary referral center), we do lap choles in the middle of the night pretty regularly. Is this the standard where you guys are training? What about in private practice? If appropriate do you just start IV abx and let them cool off? Have always wondered about this, it seems like a lot of these people can wait until the next day when we have our usual crew rather than an on-call, off-service night team of circulators/scrub techs, the operators are (usually) fresh, and we aren't tying up said on-call OR team when a potential true emergency comes in.

Thoughts?

 

[VisionaryTics]

The always great Skeptical Scalpel's thoughts.

The little blurb right there points out that they're comparing apples (elective, often interval choles) vs. oranges (hot GBs that need to come out now).

The significant complications were increased wound infection rates (probably related to operating on more hot GBs) and longer hospital course (3 days vs. 1 day). The scary stuff like CBD injuries, bile leak did not differ significantly.

 

[SLUser11]

ACS posted this article: http://www.acssurgerynews.com/index.php?id=14929&tx_ttnews[tt_news]=143531&cHash=c89a633c5ce0d19494a229c2e0d844f9



At our place (large tertiary referral center), we do lap choles in the middle of the night pretty regularly. Is this the standard where you guys are training? What about in private practice? If appropriate do you just start IV abx and let them cool off? Have always wondered about this, it seems like a lot of these people can wait until the next day when we have our usual crew rather than an on-call, off-service night team of circulators/scrub techs, the operators are (usually) fresh, and we aren't tying up said on-call OR team when a potential true emergency comes in.

Thoughts?

This is a common statistical scenario that comes up in retrospective studies, and I usually don't get too excited. Large databases only pick up certain data points, and often cannot truly stratify patients based on risk and severity. Cases are lumped into categories of elective, urgent, or emergent, although the practicing clinician knows that it's truly a continuous spectrum.

Another example is the trauma literature on leaving drains after bowel resections. The data shows that when surgeons leave a drain, there is an increased risk of morbidity, especially anastomotic leak and abscess. The authors then conclude that drains cause worse outcomes, when it's obvious that the more difficult or tenuous anastomoses in sicker patients are more likely to be allocated a drain by a responsible, safe surgeon.

One thing I will say, though, is that when all variables that can be controlled are truly controlled, there is literature showing that night surgeries and weekend surgeries have slightly worse outcomes........likely because it's a skeleton crew with the surgical B team doing the case, OR B team circulating, and anesthesia B team running the gas.

Monday morning at 8am, the world expert in cholecystectomies can come in and do a wonderful case (with his wonderful/experienced/unchanging assistant, and his hand-selected/experienced/unchanging OR staff eager to please, and his special restricted instruments). Perhaps that ends better for the patient, but I'm not sure it's always the night/weekend surgeon's fault, nor is it really an option for all patients.

 

[blue2000]

It depends on the case, but I typically avoid doing choles in the middle of the night unless the patient is systemically ill (tachy, febrile, septoid). If I see them in the ER and they have normal vital signs, their pain is controlled with IV pain meds, and there aren't extenuating circumstances (elderly, poorly controlled diabetic, severe findings on US) then I wont' start a GB after about 8 pm. We are a small hospital, and my on call crew is the same as my night crew -- we don't have a separate night shift, it's nurses taking call right along with the physicians. So I have to be sensitive to them too. Also, I can almost always get a room the following morning, so I'm putting these off 12 hours rather than 18-24. I haven't really regretted this strategy but this is how I trained as well (we didn't typically do GBs in the middle of the night without extenuating circumstances).

 

[SLUser11]

It depends on the case, but I typically avoid doing choles in the middle of the night unless the patient is systemically ill (tachy, febrile, septoid). If I see them in the ER and they have normal vital signs, their pain is controlled with IV pain meds, and there aren't extenuating circumstances (elderly, poorly controlled diabetic, severe findings on US) then I wont' start a GB after about 8 pm. We are a small hospital, and my on call crew is the same as my night crew -- we don't have a separate night shift, it's nurses taking call right along with the physicians. So I have to be sensitive to them too. Also, I can almost always get a room the following morning, so I'm putting these off 12 hours rather than 18-24. I haven't really regretted this strategy but this is how I trained as well (we didn't typically do GBs in the middle of the night without extenuating circumstances).

While I agree with that approach, I have a much-less-accomodating OR. This is partly because we're a big, busy med center with unpredictable trauma/transplant/etc, but also because that's just the culture here. I have a really hard time getting things on for the following morning, and I may get bumped by a transplant, etc, so I'm just operating the next night after 8pm instead. I remember how perplexed the OR charge nurse sounded on the phone when I casually asked her if I could do my 10pm appy admission at 7am the next day.....apparently they don't do that here.

In general, I'm forced to come in and just do cases as they arise. Otherwise, my entire elective schedule is screwed up the following day or two. Of course, I do very little general surgery, and colorectal emergencies are usually "true" emergencies, so the situation isn't too frequent.

 

[Dan Plainview]

While I agree with that approach, I have a much-less-accomodating OR. This is partly because we're a big, busy med center with unpredictable trauma/transplant/etc, but also because that's just the culture here. I have a really hard time getting things on for the following morning, and I may get bumped by a transplant, etc, so I'm just operating the next night after 8pm instead. I remember how perplexed the OR charge nurse sounded on the phone when I casually asked her if I could do my 10pm appy admission at 7am the next day.....apparently they don't do that here.

In general, I'm forced to come in and just do cases as they arise. Otherwise, my entire elective schedule is screwed up the following day or two. Of course, I do very little general surgery, and colorectal emergencies are usually "true" emergencies, so the situation isn't too frequent.

And I suppose that's the flip side to my question. While no one likes to operate in the middle of the night, putting off a case would seemingly throw off a day of clinic or operating. I guess you have to balance this against the pain/cost of calling in an OR team after hours. Things I don't think about as a resident but could have a big impact on my day-to-day as an attending.

 

[ESU_MD]

As a resident, i would love when we did gallbladders in the middle of the night with the trauma guy staff, they were inhouse anyway and would often just float in the OR for timeout and head back to bed, leaving us alone to struggle through the case.

However, if the private guys came in at night they were rarely in teaching mode, rather just getting the case done fast since they had a full day the next day

 

[maxheadroom]

While I agree with that approach, I have a much-less-accomodating OR. This is partly because we're a big, busy med center with unpredictable trauma/transplant/etc, but also because that's just the culture here. I have a really hard time getting things on for the following morning, and I may get bumped by a transplant, etc, so I'm just operating the next night after 8pm instead. I remember how perplexed the OR charge nurse sounded on the phone when I casually asked her if I could do my 10pm appy admission at 7am the next day.....apparently they don't do that here.

In general, I'm forced to come in and just do cases as they arise. Otherwise, my entire elective schedule is screwed up the following day or two. Of course, I do very little general surgery, and colorectal emergencies are usually "true" emergencies, so the situation isn't too frequent.

I had a similar problem at the place where I did my fellowship. It was hard to get urgent cases into the OR, so we did a lot of surgery at night on things that could have been done within the next 48 hours. My current practice has great access to the OR and I frequently can run two rooms. It makes it pretty easy to get things done 12-36 hours later during daylight hours, which I appreciate.

 

[45408]

The link doesn't work, but I thought this was going to link to the new study that they referenced in the April ACS News. There's a German randomized trial of ~600 patients in which they compared doing a chole within 24 hours of admission vs waiting 7-45 days after initial presentation. The patients who had the early cholecystectomy had morbidity of 10% compared to the late group which had morbidity of 30%.

http://www.acssurgerynews.com/specialty-focus/general-surgery/single-article-page/early-cholecystectomy-beats-delayed-in-acute-cholecystitis.html?tx_ttnews[sViewPointer]=1

At my program, we don't ever really do late-night gall bladders. Worst case scenario usually means getting to it by 3-4pm the next day, if you added it on the night before. However, we do routinely go for late-night appies, even at 3am....

 

[Smurfette]

I read this thread yesterday and figured it would be lead to something here....warning sign #2 was when the circulator saw me and said she was happy I added on a "quick one" for her last case of the day....

I generally do choles before about 10 pm or add them on for the next day, usually after clinic or to follow my scheduled cases. Appys I'll do up until about midnight since I don't like sitting on them more than 12 hours if possible. Getting a morning add-on just isn't going to happen here unless I bump someone else's cases.

So sure enough. Patient with normal CT and US in ER on Friday for severe RUQ pain, came back in yesterday still in horrible pain. wbc Friday was normal, Saturday was 13 and all other labs completely normal. Hida scan showed non-visualization of GB. I tell the RN supervisor to put lap chole on to follow the current case (some ortho thing) Sat night, figuring I'd just get it done. Go in to do the preop H&P just before surgery and the patient looks SICK, not just "looks uncomfortable but sleeps after getting pain meds" like the ER phrased it. Labwork was unimpressive, but pt just looked bad and was clearly not mentating well. Long story short, it was a pretty advanced gangrenous cholecystitis. No way to do it lap since the anatomy was too distorted and the GB was plastered down deep. Eventually managed to find the tiny, short cystic duct and got it done...but it was a long and difficult case for a late night.

If I admit someone for a chole/appy and I'm not going to do it until morning, I usually just give verbal orders and do the H&P in the AM (no residents here). Had I done that in this case (with the ER guy not realizing that this guy was sick and communicating that with me), I would've gotten a 2 am phone call that he crumped and things would have really been ugly with trying to resuscitate him, wait for the OR crew to get in from home and set up, etc.

Here, add-ons go in order as rooms finish for the day. After 5 pm, we only run one room once scheduled cases finish up (if there is a crash C-section or trauma, they will call in an emergency back up crew to allow that case to proceed). So it can be unpredictable as to when your case will go if other surgeons' cases run late and there are a lot of add ons.

 

[45408]

If I admit someone for a chole/appy and I'm not going to do it until morning, I usually just give verbal orders and do the H&P in the AM (no residents here). Had I done that in this case (with the ER guy not realizing that this guy was sick and communicating that with me), I would've gotten a 2 am phone call that he crumped and things would have really been ugly with trying to resuscitate him, wait for the OR crew to get in from home and set up, etc.

Here, add-ons go in order as rooms finish for the day. After 5 pm, we only run one room once scheduled cases finish up (if there is a crash C-section or trauma, they will call in an emergency back up crew to allow that case to proceed). So it can be unpredictable as to when your case will go if other surgeons' cases run late and there are a lot of add ons.

How common is this, both for you and for other folks out there in private practice?

 

[Smurfette]

How common is this, both for you and for other folks out there in private practice?

Do you mean how common is waiting to see them til AM? What I and my partners do (and the groups I interviewed with who don't take in-house call) is go in to see anybody who sounds sick/unstable/etc. or traumas. If anybody sounds like they may not be able to make it until morning without needing something done, or if something sets off that little voice in my head, I go in. Run-of-the-mill benign-appearing SBOs, appys, choles, etc. can generally wait until I come in and round in the morning. I have EMR access at home. I'm also a night owl, so I tend to go in up until a later hour than my partners since I prefer that over going in super early to get stuff done. During the day, I have a PA who can see patients while I'm stuck in the OR or in office.

Floor consults after "business hours" usually always wait until the next morning unless the consulting physician calls me directly (this is our hospital policy--if a patient needs to be seen urgently/emergently, it requires physician to physician contact). Because we don't have any residents, everybody is pretty conscious about not making people come in if it can wait until morning.

 

[filter07]

How do you trust people saying they are stable in light of the gangrenous cholecystitis case previously mentioned? I can never trust the ED or hospitalist. Granted we are dealing with residents but the attendings are not much more reassuring. If you get burned whose fault is it?

 

[blue2000]

Do you mean how common is waiting to see them til AM? What I and my partners do (and the groups I interviewed with who don't take in-house call) is go in to see anybody who sounds sick/unstable/etc. or traumas. If anybody sounds like they may not be able to make it until morning without needing something done, or if something sets off that little voice in my head, I go in. Run-of-the-mill benign-appearing SBOs, appys, choles, etc. can generally wait until I come in and round in the morning. I have EMR access at home. I'm also a night owl, so I tend to go in up until a later hour than my partners since I prefer that over going in super early to get stuff done. During the day, I have a PA who can see patients while I'm stuck in the OR or in office.

Floor consults after "business hours" usually always wait until the next morning unless the consulting physician calls me directly (this is our hospital policy--if a patient needs to be seen urgently/emergently, it requires physician to physician contact). Because we don't have any residents, everybody is pretty conscious about not making people come in if it can wait until morning.

This is my typical scenario too. In my hospital, the ER physicians are a strong group of physicians, and are pretty clear about "you don't need to come in, you do need to come in, or let me tell you about the patient and you decide." About 10% of the time, they'll underestimate the illness of the patient. If at any point during the conversation I think "hm, I might want to lay eyes on this patient" I get out of bed and see them. Trauma I come in and see, always (had an ER doc not realize the importance of a male high speed trauma with free fluid but no clear cut injuries by CT). I find SBOs to be somewhat challenging, and probably come in more often than I "need" to, but I really don't want to get burned by dead bowel in the morning.

Making the decision to come in at night isn't just about the physicians -- our sonographers are excellent, so if I got a call that they couldn't visualize a gallbladder, I'd know something was terrible and that would be reason enough to come in.

Our internists are pretty sharp, and I don't worry about whether they will call me or not. In the two years I've been at the hospital, I've never been called "too late" for a patient that needs an operation.

SLU -- my year as University faculty was just like your experience. I'd routinely book a case at 2pm and not do them til 3 AM. So painful.

 

[SLUser11]

How common is this, both for you and for other folks out there in private practice?

How do you trust people saying they are stable in light of the gangrenous cholecystitis case previously mentioned? I can never trust the ED or hospitalist. Granted we are dealing with residents but the attendings are not much more reassuring. If you get burned whose fault is it?

I've trained in several different practice environments at this point, and my experience is that in the community, surgeons would rarely get out of bed to see a patient unless that patient needs an emergent surgery. Otherwise, these community surgeons would never sleep. Instead, they give some orders over the phone, if necessary, and plan to see the patient the next day.

Practice environments that have trainees are different. The culture is different, and the accessibility/availability of consultants is different.

When it comes to trusting EPs and hospitalists, this is something that likely develops with time. The community surgeon learns how to interpret situations over the phone. Also, non-surgeons working in these environments develop the skills to better evaluate the surgical acuity of situations, which is a skill they don't need to possess if they know a resident will swing down and see the patient right away.

As a fellow in Houston, I spent 6 months fielding these phone calls and determining acuity over the phone. I found it to be a constant dilemma, and I always felt uneasy. Specifically, I had a couple times where I was reassured by the EP that the patient was okay to tuck in overnight and see in the morning, and I almost turned over and fell back asleep, but was compelled by some portion of the story to come see the patient, and disaster was averted.

This was one of several reasons that I chose an environment with residents. I feel more comfortable when someone lays hands on the patient prior to tucking in for the night. That being said, I've traded one dilemma for another, as I'm often fielding phone calls from the residents, and having to decide if I agree with their assessment. I believe there is a slight proclivity for residents to choose the easier/less painful treatment option that has the least potential to wreck the schedule or rob someone of sleep. I've often been reassured that a patient is fine, and nothing needs to be done, and we all turn over and go back to sleep.....except I'm not sleeping.....

 

[Smurfette]

How do you trust people saying they are stable in light of the gangrenous cholecystitis case previously mentioned? I can never trust the ED or hospitalist. Granted we are dealing with residents but the attendings are not much more reassuring. If you get burned whose fault is it?

I generally find that the ER tends to overcall things here....and I ask a lot of questions, because I am pretty paranoid about missing something. Better for them to overcall than undercall. The ER guys here don't like the fact that I am not an easy sell on the phone---other physicians tend to passively listen and agree to take the patient. I badger them with questions to make sure I don't get burned. And I'm harder on visiting residents in the ER and the ER PAs to make sure their inexperience doesn't get the best of me (and try to educate them as to WHY I want to know some things). When I first started, I came in more often. I still go in more often than other docs here (esp if I can't sleep after the call). Now I have learned who the good and bad ER docs/PAs are so that helps me better determine things as well. Although come July, there's always a couple new people I have to get used to....

I also think taking home call as a chief helped a bit before going into PP as far as triaging things by phone.

In the case of my gangrenous chole patient, I think the negative CT and US caused a bit of bias when it came to re-assessing the patient when he returned to the ER the following morning. It is unusual to get a gangrenous acalculous cholecystitis in a non-diabetic, able-bodied person without a ton of comorbidities. Also is unusual for their only lab abnormality to be the wbc. (Bicarb 24. LFTs fine. Lactate done at one point was even normal.)

 

[ESU_MD]

I also think taking home call as a chief helped a bit before going into PP as far as triaging things by phone)

I tottaly agree, having the priviledge of taking chief call as a resident helped me in practice. Its really funny what people will tell you in the middle of the night to get you to take over care.

All i will say is that if you think er docs are trying to dump folks, you have no idea how bad a dump from the cath lab is

 

[Thanatos]

Its not common I can convince a boss to come in at 2am for a gallbladder, we usually admit them for abx and some IV fluid and take them first thing in the morning, same with appys. The problem with that as others have mentioned is if trauma, ortho, or transplant try to bring something in the morning we get screwed and have to do the damn case at midnight anyway.

I find it comforting (or not) that everyone else outside of private practice is getting bumped around too, and its not just where I work.

I have a hard time trusting the people who call me for consults, which I think will lead to a lot of misery going forward when I'm not in house anyway and can go see for myself, hopefully this is something I can learn. I just get so many awful consults where I'm at, although they tend to round up the acuity rather than the other way. Its usually framed as someone literally dying and the person calling me is really worried about the patient, and I arrive at the bedside to find the guy watching tv and eating a sandwich, labs and imaging are from 2 days before, etc...I'm getting the impression that outside of residency this bs is less common.

 

[Arcan57]

From an ED perspective, it's vanishingly rare for a surgeon to come in after hours on anything that isn't a trauma activation. The crashing patient w/ surgical pathology is also rare so I don't think it's a matter of them inappropriately delaying. Appys, choles, SBO all routinely wait until am with holding orders until the surgeon evals.

 

[45408]

This was one of several reasons that I chose an environment with residents. I feel more comfortable when someone lays hands on the patient prior to tucking in for the night. That being said, I've traded one dilemma for another, as I'm often fielding phone calls from the residents, and having to decide if I agree with their assessment. I believe there is a slight proclivity for residents to choose the easier/less painful treatment option that has the least potential to wreck the schedule or rob someone of sleep. I've often been reassured that a patient is fine, and nothing needs to be done, and we all turn over and go back to sleep.....except I'm not sleeping.....

Then there's the resident that likes to operate every night if possible!!!

 

[Buzz Me]

Then there's the resident that likes to operate every night if possible!!!

Guilty as charged...especially when I was on the night team!

 

[JayDoc06]

I'm in an interesting environment that is a tertiary referral hospital for the medical system but it is nonacademic (read- intern, mid level, chief and attending rolled into one). We are very busy on call with ER consults and inpatient stuff plus cover some in house trauma for Level 1 status. Unless I am in house I do not see all consults immediately. BUT, that is only if I can convince myself the patient is OK usually with specific ?s to ED docs, looking at imaging/labs/records from home computer.

With respect to GB's- most of them need at least some IVF/abx and can be tucked in, even the ones who are "septic". The speed at which a problem needs to be addressed is proportionate to the time it took to develop- cholecystitis develops over days weeks compared to trauma- seconds. That doesn't mean ignore it but the body can handle an abscess which is basically what cholecystitis is. My only patient who needed something emergent had a GB perf into the liver with fever 106 and e coli bacteremia- perc tube took care of that.

I feel most SBOs need to be examined unless EVERYTHING is re-assuring because bad stuff can hide from ED physicians and xrays. HHad an old lady with llq pain and "normal CT" who had "invisible diverticulitis b/c no intra-abdominal fat...(gag)" well it was a gangrenous incarcerated obturator hernia. As the surgeon, patient is sick until proven otherwise; the burden of proof is on the surgeon to evaluate the urgency of the matter- you are the specialist in the care of these patients. The ER docs have done their appropriate eval and escalated the level of care to you for the issue- they are off the hook at that point and you better understand that they have documented speaking to you at 10:13 PM. I have found it tricky to put cases off til the next da,y same as mentioned before. Sometimes we can do an appy or GB at 6 am. Sometimes a partner of mine operating the next day will take care of it- we will help each other out like that. I believe GBs should be in OR (or ERCP for CBD issues) within 24 hours.

This is one of the challenging things about practice- managing your time efficiently.

Interesting thread.