Same-day discharge for laparoscopic Heller myotomy

Safety and Feasibility of Paediatric Day Case Laparoscopic Upper Gastrointestinal Surgery: Significance of Nurse-led Discharge

BACKGROUND

Day case (DC) surgery is defined as a surgical procedure that allows patients to go home the same day as their operation. Laparoscopic upper gastrointestinal surgery (LUGIS) has become the standard treatment for symptomatic gallstone disease, refractory gastroesophageal reflux disease, and achalasia cardia. This study aims to assess the feasibility and safety of performing paediatric DCLUGI surgery with discharge implemented by a nurse-led team according to preset criteria.

METHODS

Electronic records were evaluated for all neurologically normal patients who underwent LUGIS from July 2015 to July 2023 following a dedicated clinical care pathway. Data collection included demographics, length of stay (DC, ≤23-h, ≥24-h), surgeon level, complications and postoperative pain management. Nurse-led discharge (NLD) was implemented for all patients according to preset criteria.

RESULTS

Seventy-four patients underwent LUGIS (31 cholecystectomies, 31 fundoplications and 12 Heller myotomies) with a DC rate of 12 %. Twenty-five (34 %) patients were ≤23-h stay. All early discharge (DC and ≤23-h) patients (46 %) were safely managed according to the NLD criteria without postoperative medical review. There were no thirty-day readmissions.

CONCLUSIONS

DC or ≤23-h LUGIS can be performed safely in high-volume paediatric specialist centres with good outcomes. Implementing protocols that provide nursing staff with the necessary guidance to ensure timely discharge of children and young people is fundamental to achieving high levels of satisfaction and the delivery of an efficient service.

Same day discharge after minimally invasive adrenalectomy: a national study

BACKGROUND

Same day discharge (SDD) may be considered in some patients undergoing minimally invasive adrenalectomy (MIA). Recent studies have demonstrated similar outcomes between SDD and admitted patients; however, most excluded pheochromocytoma and adrenal metastases. This study evaluates 30-day complications and hospital readmission in a large cohort of patients undergoing MIA.

METHODS

Adult patients undergoing MIA (2010-2020) for benign adrenal disorders, pheochromocytoma, and adrenal metastases were identified within the ACS-NSQIP database. Comparisons between patients having SDD versus admission were performed. Factors associated with 30-day complications and unplanned readmission were evaluated by multivariable regression modeling.

RESULTS

Of 7316 patients who underwent MIA, 254 had SDD. Baseline characteristics were similar between groups, although SDD patients had lower ASA class (p < 0.001) and were more likely to undergo MIA for nonfunctioning adenoma or primary aldosteronism (p = 0.001). After adjusting for covariates, higher ASA class and presence of medical comorbidities were associated with increased complications (p < 0.001; p < 0.05) and unplanned readmission (p < 0.001; p < 0.05). Additionally, prolonged operative time was associated with 30-day complications (p < 0.001). Notably, SDD was not associated with increased complications (OR 0.78, 95% CI 0.38-1.61, p = 0.502) or unplanned readmission (OR 0.76, 95% CI 0.35-1.64, p = 0.490). The rate of SDD for MIA increased from 1.48% in 2017 to 10.81% in 2020.

CONCLUSIONS

Not all patients undergoing MIA should have SDD; however, the current analysis demonstrates a trend toward SDD and supports its safety in select patients with adrenal metastases and benign adrenal disorders including pheochromocytoma.

Same-Day Home Recovery for Benign Foregut Surgery

Importance

Same-day home recovery (SHR) is now the standard of care for many major surgical procedures and has the potential to become standard practice for benign foregut procedures (eg, hiatal hernia repair, fundoplication, and Heller myotomy).

Objective

To determine whether SHR for patients undergoing benign foregut surgery is feasible, safe, and effective.

Design, Setting, and Participants

This prospective cohort study took place across 19 medical centers within an integrated health care system in northern California from January 2019 through September 2021. Participants included consecutive patients undergoing elective benign foregut surgery.

Exposures

Standardized SHR program.

Main Outcomes and Measures

The primary end point was the rate of SHR. The secondary end points were 7-day and 30-day rates of postoperative emergency department visits, hospital readmissions, and reoperations.

Results

Of 1248 patients who underwent benign foregut surgery from January 2017 through September 2021, 558 were patients before implementation of the SHR program and 690 were patients postimplementation. The mean age of patients was 60 years, and 759 (59%) were female. The preimplementation SHR rate was 64 of 558 patients (11.5%) in 2018 and increased to 82 of 113 patients (72.6%) by 2021 (94/350 [26.9%] in 2019 and 112/227 [49.3%] in 2020; P < .001). There were no statistical differences in the 7-day and 30-day rates of postoperative emergency visits, hospital readmissions, and reoperations or 30-day mortality in the SHR vs non-SHR groups in the postimplementation era.

Conclusions and Relevance

In this study, implementation of a regional SHR program among patients undergoing elective benign foregut surgery was feasible, safe, and effective. The changes in perioperative care require comprehensive patient education and full multidisciplinary support. An SHR program for benign foregut procedures has the potential to improve patient care and cost-effectiveness in care delivery.

Medical disease and ambulatory surgery, new insights in patient selection based on medical disease

PURPOSE OF REVIEW

Improvements in perioperative care contributed to enlarge the eligibility criteria for day case surgery and more and more patients with comorbidities may be concerned. However, underlying medical diseases may influence postoperative outcomes, and therefore, must be considered when selecting patients to undergo ambulatory surgery.

RECENT FINDINGS

To limit postoperative complications, rigid patient selection criteria are often applied in ambulatory surgery. In practice, however, most of these criteria predict the occurrence of treatable perioperative adverse events but not the need for unanticipated admission or readmission.

SUMMARY

The underlying medical diseases should not be considered as sole criteria but they should rather be regarded as a dynamic process, which includes the surgical procedure as well as the experience and expertise of the perioperative setting.