Response to "Comments on 'Added Healthcare Charges Conferred by Smoking in Outpatient Plastic Surgery'"

A Procedure and Complication-Specific Assessment of Smoking in Aesthetic Surgery: A Systematic Review and Meta-Analysis

Background: The popularity of aesthetic surgery is on the rise, as is patients' expectations towards excellent surgical results. In order to meet these expectations, risk factors that hinder desired outcomes, such as smoking, need to be identified and addressed. To that end, the present study summarizes an updated systematic review focused on the effects of smoking on cosmetic surgical procedures and outcomes. Methods: A systematic review of studies comparing aesthetic surgical outcomes by procedure, between tobacco smokers and non-smokers was carried out, querying PubMed, Embase and the Cochrane databases. Data regarding surgical outcomes were extracted and meta-analyzed by a random effects model in conjunction with the Mantel-Haenszel statistical method. Results: Eighty-two studies were included in the final synthesis. Abdominoplasty/panniculectomy (n = 19 cohorts) and breast reduction (n = 27 cohorts) were the most common types of procedures included in this review. Other than mastopexy and rhinoplasty, smoking conferred a statistically significant increased risk of overall complications for all studied aesthetic procedures. Conclusions: The data demonstrates that smoking is a clear risk factor for the vast majority of aesthetic plastic surgeries studied. Although our meta-analysis suggests that smoking is not a risk factor for complications in mastopexies and rhinoplasties, these two specific analyses may have been biased, and should therefore be re-evaluated with future additional evidence. The results of this systematic review confirm the importance of smoking cessation and education relative to the outcomes of common cosmetic surgical procedures.

Enhanced recovery protocols for ambulatory surgery

INTRODUCTION

In the United States, ambulatory surgeries account for up to 87% of all surgical procedures. (1) It was estimated that 19.2 million ambulatory surgeries were performed in 2018 (https://www.hcup-us.ahrq.gov/reports/statbriefs/sb287-Ambulatory-Surgery-Overview-2019.pdf). Cataract procedures and musculoskeletal surgeries are the most common surgical interventions performed in ambulatory centers. However, more complex surgical interventions, such as sleeve gastrectomies, oncological, and spine surgeries, and even arthroplasties are routinely performed as day cases or in a model of an ambulatory extended recovery. (2-5) The ambulatory surgery centers industry has grown since 2017 by 1.1% per year and reached a market size of $31.2 billion. According to the Ambulatory Surgery Center Association, there is a potential to save $57.6 billion in Medicare costs over the next decade (https://www.ibisworld.com/industry-statistics/market-size/ambulatory-surgery-centers-united-states/). These data suggest an expected rise in the volume of ambulatory (same day) or extended ambulatory (23 h) surgeries in coming years. Similar increases are also observed in other countries. For example, 75% of elective surgeries are performed as same-day surgery in the United Kingdom. (6) To reduce costs and improve the quality of care after those more complex procedures, ambulatory surgery centers have started implementing patient-centered, high-quality, value-based practices. To achieve those goals, Enhanced Recovery After Surgery (ERAS) protocols have been implemented to reduce the length of stay, decrease costs, increase patients' satisfaction, and transform clinical practices. The ERAS fundamentals for ambulatory surgery are based on five pillars, including (1) preoperative patient counseling, education, and optimization; (2) multimodal and opioid-sparing analgesia; (3) nausea and vomiting, wound infection, and venous thromboembolism prophylaxis; (4) maintenance of euvolemia; and (5) encouragement of early mobility. Those pillars rely on interdisciplinary teamwork led by anesthesiologists, surgery-specific workgroups, and safety culture. (2) Research shows that a team of ambulatory anesthesiologists is crucial in improving postoperative nausea and vomiting (PONV) and pain control. (7) This review will summarize the current evidence on the elements and clinical importance of implementing ERAS protocol for ambulatory surgery.