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Journal of Minimally Invasive Surgery Vol. 7. No. 4, 4 pissn 4-778X, eissn 4-548 Original Article http://dx.doi.org/.76/jmis.4.7.4.8 복강경하담낭절제술에서재원일수를감소시키는인자분석 연세대학교의과대학외과학교실, 연세대학교원주의과대학외과학교실, 세브란스병원간호국간호담당부원장실 PA 파트 최정범 ㆍ임진홍 ㆍ김성훈 ㆍ이소영 ㆍ이수지 ㆍ김경식 Feasible Factors to Reduce Hospital Days after Laparoscopic Cholecystectomy Jung Bum Choi, M.D., Jin Hong Lim, M.D., Sung Hoon Kim, M.D., So Young Lee, R.N., Su Ji Lee, R.N., Kyung Sik Kim, M.D., Ph.D. Department of Surgery, Yonsei University College of Medicine, Seoul, Wonju Yonsei University College of Medicine, Wonju, PA (Physician Assistant) Part, Division of Nursing, Severance Hospital, Seoul, Korea Purpose: Under the proper program, day-case laparoscopic cholecystectomy is feasible in the aspect of postoperative recovery consisting of patient's satisfaction and postoperative complication. In this study, we plan a new protocol for laparoscopic cholecystectomy by analyzing factors that can reduce hospital days. Methods: A total of 75 patients who underwent three-day laparoscopic cholecystectomy were initially selected. Out of 75 patients, secondary selection was executed using inclusion criteria. The selected patients were scheduled for new two-day laparoscopic cholecystectomy, and 89 patients were included in the data analysis. This study elucidated the comparative analysis between the discharged in the postoperative day group and the postoperative day group. Results: The clinical characteristics were not significantly different between discharged in the postoperative day group and the postoperative day group. The combined diseases were not significantly different between the two groups. Post-operative complications in both groups were analyzed on the seventh day after the operation. No significant difference was observed between the two groups. Members of the patient group who were discharged on postoperative day were given a survey regarding post-operative pain, desirability of discharge, and the level of satisfaction with patient education. The average score was 8. out of points. In comparison of the total hospital cost between the two groups, the group discharged on postoperative day had lower cost in all factors. Conclusion: We conclude that day-case laparoscopic cholecystectomy is as safe and effective as routine clinical pathway applied laparoscopic cholecystectomy in stable cardiovascular disease, uncomplicated pulmonary disease, and controlled DM patients. Key words: Laparoscopic cholecystectomy, Clinical pathway, Hospital day 서 복강경하담낭절제술은 985년독일에서 Muhe에의해처음시행된이후로증상을동반한담석증과급성담낭염에서표준치료법으로사용되고있다. 현재복강경하담낭절제술은개복하담낭절제술에비해재원기간, 수술후회복기간, 병원비용, 수술후통증, 수술후상처면에서이득이있다고알려지면서개복하담낭절제술은합병증을동반한급성담낭염에서만제한되어시행되고있는실정이다. 최근에는표준진료지침 (clinical pathway, CP) 을이 Received September 5, 4, Revised st, September 9, 4; nd, October 6, 4; rd, October 8, 4, Accepted October, 4 Corresponding author:kyung Sik Kim Department of Surgery, Yonsei University College of Medicine, 5 Yonsei-ro, Seodaemun-gu, Seoul -75, Korea Tel:+8--8-5, Fax:+8---889 E-mail:kskim88@yuhs.ac 론 용한복강경하담낭절제술이병원비를감소시키고병상회전율을증가시키는이득이있다고알려지면서널리시행되고있는실정이다. 또한더나아가여러논문들에따르면적절히계획된환경하에실시되는복강경하담낭절제술후당일퇴원은수술후환자의만족도, 수술후합병증등의수술후회복면에서충분히시행가능하다고여겨지고있다. -7 이런배경을바탕으로이번연구는복강경하담낭절제술후재원일수를줄일수있는여러인자를분석하여복강경하담낭절제술의새로운지침 (protocol) 을확립하기위해진행하였다. 대상및방법 연세대학교의과대학세브란스병원간담췌외과 에서는표준진료지침의적용을위해서 년 6월부터적정관리실과환자의안정성에대한검증을지속해오고있다. 즉표준진료지침을이용한복강경하담낭절제술은 6세이상 7 This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/.) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Jung Bum Choi et al.: Feasible Factors to Reduce Hospital Days after Laparoscopic Cholecystectomy 8 세이하의환자, 담석이나담낭용종으로진단된환자, 외래경유하여담낭절제술을계획한환자, CP에동의한환자군을적용기준으로정하여진행하였으며, 합병증이동반된급성담낭염, 응급으로담낭절제술을시행한경우, 담관석이동반된경우, 개복술로전환한경우, 수술중혹은후에 Table. Inclusion and exclusion criteria for LC* with clinical pathway Inclusion criteria Exclusion criteria 6 age 7 Age<5, >7 GB stone, GB polyp Acute cholecystitis, GB empyema Visit via OPD CBD stone Discharge after consultation Agree with CP Visit via ER Co-operation case Cardiovascular disease Pulmonary disease Previous op.hx. affecting laparoscopic surgery Open conversion OP complication; biliary tract injury Drain insertion Post op hemodynamic unstable Refuse discharge POD# Disagree with CP *LC = laparoscopic cholecystectomy, GB = gall bladder, OPD = outpatient department, CBD = common bile duct. 합병증이발생한경우는제외하였다. 표준진료지침을이용한복강경하담낭절제술이결정되면고혈압, 당뇨등의수술전협진이필요한경우는수술전날입원, 수술다음날퇴원하는 박 일일정의복강경하담낭절제술을시행하고있으며, 수술전협진이필요없는경우수술당일입원하여수술다음날퇴원하는 박 일일정의복강경하담낭절제술을진행하였다 (Table, Fig. ). 이번연구는 년 월 일부터 년 월 일까지표준진료지침을이용하여 박 일일정의복강경하담낭절제술을시행하는 75명을대상으로진행하였으며, 75명환자중수술후안정적인활력징후, 수술후조절되는통증, 고혈압을포함하여안정적인심혈관질환을가진환자, 합병증이없는폐질환을가진환자, 조절되는당뇨환자를적용기준으로정하여이기준에해당하는환자들을대상으로수술당일퇴원하는새로운 박 일일정의복강경하담낭절제술을계획하였으며, 총 89명을선정하였다 (Table, Fig. ). POD 일째퇴원하는 89명의환자군과 POD 일 Table. Inclusion criteria for day-case LC Inclusion criteria 6 age 7 GB stone, GB polyp Visit via OPD Stable vital sign Tolerable postoperative pain Stable cardiovascular disease Uncomplicated pulmonary disease Controlled DM Agree with discharge Fig.. Protocol for clinical pathway in laparoscopic cholecystectomy. If patients agreed with clinical pathway applied laparoscopic cholecystectomy, we chose the suitable patients using inclusion criteria and classified two groups in days scheduled laparoscopic cholecystectomy (He/She admitted on operating day and discharged on postoperative day ) and days scheduled laparoscopic cholecystectomy (He/She admitted on the day before operation and discharged on postoperative day ) according to the necessarity of preoperative consultation. Fig.. Protocol for day-case laparoscopic cholecystectomy. In days scheduled laparoscopic cholecystectomy group, new days scheduled laparoscopic cholecystectomy was done using inclusion criteria containing post-operative stable vital sign status, post-operative tolerable pain, stable cardiovascular diseases, uncomplicated pulmonary diseases, controlled DM. In this group, patients discharged on operating day.

8 Journal of Minimally Invasive Surgery Vol. 7. No. 4, 4 째퇴원하는 86명의환자군을비교분석하였다. 후향적인의무기록분석을바탕으로하였으며, 통계학적방법은 SPSS software를이용하였다. 유의확률.5 미만 (p<.5) 을통계학적으로의미있게해석하였다. 모든수술은한명의전문의가집도하였으며, 두군모두수술전자정부터금식하였으며, 수술순서는모두첫번째혹은두번째로진행하였다. 수술중소견에서두군모두수술에영향을줄수있는해부학적변이나담낭의심한유착소견은보이지않았으며, 수술중담즙의유출은없었다. 또한, 두군모두수술후배액관삽입은시행하지않았다. 결과수술후당일에퇴원하는 89명의환자군 (Group A) 과수술후 일째퇴원하는 86명의환자군 (Group B) 을성별, 연령, American Society of Anesthesiologists (ASA) 점수, 체질량지수 (Body Mass Index, BMI), 수술전진단, 수술시간을 기준으로비교분석하였다. 두군간의성별과나이는통계학적인차이는없었으며 ( 성별 ( 여 / 남 ) A: 4/48, B: 45/4, p=.4, 연령 A: 47.4, B: 48.67, p=.45), 수술전 ASA 점수에도두군간의통계학적인차이는보이지않았다. 두군모두 ASA 점수 점이가장많은비율을차지하였다 (A: 46, B: 5, p=.5). BMI (A: 4.5, B: 4.7, p=.) 와수술시간 (A: 59., B: 6.47, p=.7) 에서도두군간의통계학적인차이는없었다. 두군모두담석으로복강경하담낭절제술을시행하는경우가가장많았다 (A: 5, B: 6, p=.5) (Table ). 두군을고혈압, 당뇨, 심혈관질환, 호흡기질환, 간염, 수술과거력, 혈청알부민치를기준으로동반된질병상태를비교분석하였으며, 모든기준에서두군간의차이점은보이지않았다 (Table 4). 두군모두고혈압이가장많은비중을차지하였다 (A: 45, B: 4, p=.4). 두군을수술후 7일째외래진료에서수술후호소하는증상및합병증을비교분석하였다. 두군모두에서장마 Table. Clinical and operative characteristics Group A (POD ) Group B (POD ) (n=75) Gender (F/M) Age (years) ASA score BMI (kg/m ) Diagnosis GB stone GB polyp Adenomyomatosis Operation time 4/48 47.4 8 46 5 4.5 5 4 59.8 45/4 48.67 5 4.7 6 6 6.47 86/89 47.84 7 98 7 4.4.45.7.5.4..5.4.46.7 Table 4. Associated comorbidities Group A (POD ) Group B (POD ) (n=75) Hypertension Diabetes mellitus Cadiovascular ds. Pulmonary ds. Hepatitis Previous operation Levelof albumin Smoking Emergency operation 45 8 9 8 4.56 4 4 5 6 4.85 9 86 6 5 9 4 9.4.76.5.54.69.4.56.4

Jung Bum Choi et al.: Feasible Factors to Reduce Hospital Days after Laparoscopic Cholecystectomy 8 Table 5. Postoperative patient characteristics Group A (POD ) Group B (POD ) (n=75) Ileus Nausea/vomiting Postoperative pain Flank pain RUQ pain Diarrhea Constipation Wound seroma Trocar site hematoma Follow up loss Re-admission Early OPD f/u 6 6 4.98.7..95.98..64.54.5. Table 6. Hospital total cost Group A (POD ) Group B (POD ) Number of days hospitalization (days) Total cost of medical services (won) Total insurance costs (won) Total non-insurance costs (won) Charging fees for selecting a doctor (won) Total costs of individual charges (won) Total costs of hospitalization (won) The costs of private ward (won) The costs of postoperative medication (won).77.78.8.68.948.8 5.995.7 59.77..68.74.8 86.4.4.9. 46.9.9.6.859.8.785.48. 697.988.7 579.88.6.558.896.9 59.95.6 4.4. 47.4.4...9.4....655 비, 오심과구토, 수술후통증, 설사, 변비, 상처부위장액종및혈종을보였으나, 두군간의통계학적인차이점은없었다 (Table 5). 우리는두군모두에서수술후통증을조절하기위해동일한약물 (Acetaminophen) 65 mg 8시간마다복용, 수술직후케토로락 (Ketolorac) mg 번정맥내주사 ) 을사용하였으며, 퇴원약으로타이레놀만 5일분처방하였다. 수술후당일퇴원군으로선정하였던환자중 명은수술후통증으로당일퇴원을거부하여수술다음날퇴원하였으나, 통증조절을위한추가적인정맥내주사는시행하지않았으며, 규칙적인타이레놀복용으로통증조절되어퇴원하였다. 또한, 수술후오심조절을위하여수술후메토클로프로마이드 (Metoclopramide) mg 번정맥내주사를사용하였으며, 두군모두오심의호소없이퇴원하였다. 수술후 일째퇴원환자군 (B군) 에서 명이술후담관석으로재입원하여내시경적역행성담관췌관조영술을시행하였으나, 수술당일퇴원환자군 (A군) 에서는재입원하는경우는없었다. 또한, 수술후 일째퇴원환자군 (B군) 에서 명이비특이적복통으로수술후 일째일찍외래방문하였다. 수술당일퇴원환자군을대상으로퇴원시설문지를이용하여술후통증, 퇴원의적절성, 퇴원후관리의교육을대상으로만족도를조사하였으며, 총점 점에평균 8.의만족도를보였다. 비록수술후 일째퇴원환자군과의만족도를비교하지못했으나, 다른논문의설문지를통한만족도조사를참고하였을때 8% 이상의만족도를의미있게본것을기준으로했을때수술당일퇴원환자군의만족도는적절한것으로판단할수있었다. 4 두군간의병원비용에대하여비교분석하였으며, 수술당일퇴원환자군에서통계학적으로유의있게병원비용감소효과가있는것을알수있었다. 그러나수술후사용된약물비용은두군에서통계학적으로유의있는차이가없는것을알수있었으며, 이결과는복강경하담낭절제술후당일퇴원이수술후회복면에서가능하다는사실을뒷받침해주었다 (Table 6).

84 Journal of Minimally Invasive Surgery Vol. 7. No. 4, 4 고 찰 결 론 복강경하담낭절제술은현재증상을동반한담석증과급성담낭염에서가장많이사용하고있는수술이다. 또한최근에는외래경유한복강경하담낭절제술이수술전적절한계획과준비하에여러병원에서시행되고있는실정이다. Tenconi 등 5 의연구에따르면외래경유한복강경하담낭절제술이성공적으로시행되기위해서는수술전환자선택의잘못을최대한줄여야하고, 수술전충분한상담을통하여외래경유한복강경하담낭절제술이입원을경유한복강경하담낭절제술과비교하여안전성과효과면에서차이가없다는사실을느끼도록하는것이중요하다고하였다. 복강경하담낭절제술후당일퇴원은현재적절한기준에의해선택된환자에게시행되고있다. Tenconi 등 5 의연구에서는복강경하담낭절제술후당일퇴원은적절한퇴원율, 퇴원후환자만족도면에서충분히시행가능하다고하였으며, 이를위한적절한환자선택과교육이필요하다고하였다. Jacob 등 6 의연구에서는적절한환자선택, 외과의의풍부한경험, 체계화된프로그램이있다면복강경하담낭절제술후당일퇴원은가능하다고하였다. Briggs 등 7 의연구에서도퇴원후환자의만족도, 상처문제, 수술후통증면에서복강경하담낭절제술후당일퇴원은안전하고효과적임을시사하였다. 우리는이번연구를통하여적절히선택된환자의수술후당일퇴원은수술다음날퇴원과비교하여수술후합병증에차이가없는것을확인하였다. 수술후당일퇴원에서재입원하는경우는없었으며, 예정된일정보다더일찍외래를방문하는경우도없었다. 이번연구에서는설사가수술후호소하는증상중가장많았으나, 다른저자는복강경하담낭절제술후당일퇴원이성공하기위해서는수술후오심과구토증상을조절하는것이중요하다고하였으며, 이를위한다각도적인접근이필요하다고하였다. 5,8 Tenconi 등 5 은오후 시이후에복강경하담낭절제술을시행할경우복강경하담낭절제술후당일퇴원은실패할가능성이높다고밝히고있어우리는이번연구를위해시행한모든복강경하담낭절제술을첫번째혹은두번째순서로정하여수술받는시간을비슷하게만드는것과동시에오전중에시행할수있도록노력을하였다. 이번연구를통하여고혈압을포함하여안정적인심혈관질환을가진환자, 합병증이없는폐질환을가진환자, 조절되는당뇨환자에서복강경하담낭절제술후당일퇴원은안전하고비용면에서효율적인것을확인할수있었다. 우리는설문지를통한환자만족도검사에서복강경하담낭절제술후당일퇴원의만족도는다른논문과비교해보았을때적절한것으로판단하였으나, 다른연구에비해설문지의양식이다르고, 더세부적이지못한것이사실이다. 추후더욱세부적인내용을바탕으로추가적인연구가필요할것으로보인다. 현재까지는적절히선택된제한적인환자에서만복강경하담낭절제술후당일퇴원이이루어지고있으나, 추후추가적인연구를통해환자를선택하는기준이더욱많아지기를기대해본다. REFERENCES ) Topal B, Peeters G, Verbert A, Penninckx F. Outpatient laparoscopic cholecystectomy: clinical pathway implementation is efficient and cost effective and increases hospital bed capacity. Surgical Endoscopy 7;(7):4-46. ) Cassinotti E, Colombo EM, Di Giuseppe M, Rovera F, Dionigi G, Boni L. Current indications for laparoscopy in day-case surgery. International Journal of Surgery (London, England) 8;6 Suppl :S9-96. ) Chang SK, Tan WB. Feasibility and safety of day surgery laparoscopic cholecystectomy in a university hospital using a standard clinical pathway. Singapore Medical Journal 8; 49(5):97-99. 4) Lezana Perez MA, Carreno Villarreal G, Lora Cumplido P, Alvarez Obregon R. Comparative study of ambulatory laparoscopic cholecystectomy versus management of laparoscopic cholecystectomy with conventional hospital stay. Cirugia Espanola ;9(7):44-4. 5) Tenconi SM, Boni L, Colombo EM, Dionigi G, Rovera F, Cassinotti E. Laparoscopic cholecystectomy as day-surgery procedure: current indications and patients' selection. International Journal of Surgery (London, England) 8;6 Suppl :S86-88. 6) Akoh JA, Watson WA, Bourne TP. Day case laparoscopic cholecystectomy: reducing the admission rate. International Journal of Surgery (London, England) ;9():6-67. 7) Briggs CD, Irving GB, Mann CD, Cresswell A, Englert L, Peterson M. Introduction of a day-case laparoscopic cholecystectomy service in the UK: a critical analysis of factors influencing same-day discharge and contact with primary care providers. Annals of the Royal College of Surgeons of England 9;9(7):58-59. 8) Robinson TN, Biffl WL, Moore EE, Heimbach JK, Calkins CM, Burch JM. Predicting failure of outpatient laparoscopic cholecystectomy. American Journal of Surgery ;84(6): 55-58.