Guidelines for day-case surgery 2019: Guidelines from the Association of Anaesthetists and the British Association of Day Surgery

Best practice recommendations for medically assisted reproduction in patients with known cardiovascular disease or at high risk of cardiovascular disease

Increasing numbers of people are seeking assisted conception. In people with known cardiac disease or risk factors for cardiac disease, assisted conception may carry increased risks during treatment and any subsequent pregnancy. These risks should be assessed, considered and minimized prior to treatment.

ORTHOPOD: Linking ambulatory future trauma injury distribution from fragility proximal femur fracture caseload

INTRODUCTION

The age of those experiencing traumatic injury and requiring surgery increases. The majority of this increase seen in older patients having operations after accidents is in fragility proximal femur fractures (FPFF). This study designed a model to predict the distribution of fractures suitable for ambulatory trauma list provision based on the number of FPFF patients.

METHODS

The study utilized two datasets which both had data from 64 hospitals. One derived from the ORTHOPOD study dataset, and the other from National Hip Fracture Database. The model tested the predictability of 12 common fracture types based on FPFF data from the two datasets, using linear regression and K-fold cross-validation.

RESULTS

The predictive model showed some promise. Evaluation of the model with mean RMSE and Std RMSE demonstrated good predictive performance for some fracture types, although the r-squared values showed that large variation in these fracture types was not always captured by the model. The study highlighted the dominance of FPFFs, and the strong correlation between these and numbers of ankle and distal radius fractures at a given unit.

DISCUSSION

It is possible to model the numbers of ankle and distal radius fractures based off the number of patients admitted with hip fractures. This has great significance given the drive for increased day case utilisation and bed pressures across health services. While the model's current predictability was limited, with methodological improvements and additional data, a more robust predictive model could be developed to aid in the restructuring of trauma networks and improvement of patient care and surgical outcomes.

Changing practices in septorhinoplasty: the Irish experience

PURPOSE

Septorhinoplasty (SR) is one of the most complex surgical procedures of the head and neck. As an elective procedure aiming to enhance patient quality of life, it can be difficult to perform in single-payer healthcare systems due to capacity pressures from acute and oncological surgical demand. We aimed to review national trends in the practice of SR to inform future healthcare planning.

METHODS

This was a cross-sectional, population-based, longitudinal study of SR cases in Ireland's single-payer (public) healthcare system from 2005 to 2021. Time-series analysis using a linear regression model was performed to analyse trends by operation type, revision rates and length of stay. The impact of the COVID-19 pandemic and introduction of national surgical guidelines was analysed.

RESULTS

1952 SR were performed. Annual mean cases declined in both real (r = - 0.76, p < 0.01) and relative (r = - 0.87, p < 0.01) terms by 31% and 43%, respectively. Ambulatory SR, while initially rarely performed, increased to account for 55% of cases performed. The mean hospital length of stay declined significantly (r = - 0.84, p < 0.01) by 44%.

CONCLUSIONS

SR increasingly struggles to find its place in Ireland's public healthcare system. New changes in SR practices including the rapid growth of ambulatory surgery and shorter lengths of hospital stay indicate positive responses to the mounting pressures faced by healthcare systems.

The development of day surgery in China and the effectiveness and reflection of day surgery in ophthalmology-specialized hospitals

This survey investigates the development of day surgery in China, and analyzes the national policy support, medical service management model, disease types of day surgery, medical insurance payment methods, and the medical service capacity, efficiency, quality and safety, health economics indicators, and patient satisfaction after the implementation of day surgery in a tertiary eye hospital. After more than 20 years of development, China's day surgery has shown a good development trend. The implementation of day surgery in eye hospitals accounts for more than 70% of elective surgery, and patients, medical institutions, and medical insurance institutions have all achieved good social benefits.

Comparison of Remimazolam Tosilate and Propofol Sedation on the Early Postoperative Quality of Recovery in Patients Undergoing Day Surgery: A Prospective Randomized Controlled Trial

Purpose

Remimazolam tosilate is a novel ultrafast-acting benzodiazepine that has a rapid emergence even after continuous infusion when using flumazenil. So far, relatively few articles are still focusing on the quality of recovery after general anesthesia with remimazolam, especially in day surgery. This study aimed to compare the early postoperative quality of recovery of remimazolam tosilate with flumazenil and propofol in patients undergoing day surgery.

Patients and Methods

137 patients scheduled for day surgery were randomly divided into the remimazolam tosilate or propofol group. The primary endpoint was the incidence of overall recovery assessed with the early postoperative quality of recovery scale (PostopQRS) on postoperative day 1 (POD 1). The Richmond Agitation-Sedation Scale (RASS) scores in the post-anesthesia care unit (PACU), extubation time, postoperative recovery profiles, and perioperative data were documented. Any adverse events were recorded.

Results

The incidence of overall recovery on POD1 was 47.7% in the remimazolam tosilate group and 65.1% in the propofol group (odds ratio, 0.52; 95% confidence interval (CI) 0.26 to 1.06; P = 0.072). In general, the overall recovery of the PostopQRS increased over time, and its interaction between time and group was significant (P = 0.003). Among the five dimensions of PostopQRS, there exist statistical differences between groups including emotional state and cognitive recovery. Upon arrival at the PACU, the remimazolam group was more sedated and took longer to recover to a RASS score similar to propofol. The frequency of application of vasoactive drugs during anesthesia was similar in both groups (P = 0.119). Despite rapid emergence with remimazolam after flumazenil reversal, re-sedation (10.8%) or somnolence (60%) in the PACU was observed, and the length of PACU stay in patients treated with remimazolam tosilate was longer than that of the propofol (35 min vs 30 min, P<0.001).

Conclusion

General anesthesia with remimazolam tosilate in conjunction with flumazenil reversal permits rapid recovery of consciousness in day surgery, but there was a notable occurrence of re-sedation or somnolence observed in PACU.

Quality of life, hearing results, patient satisfaction and postoperative complications of day-case versus inpatient unilateral cochlear implantation in adults: a randomized controlled, equivalence trial

OBJECTIVE

To investigate the hypothesis that day-case cochlear implantation is associated with equal quality of life, hearing benefits and complications rates, compared to inpatient cochlear implantation.

STUDY DESIGN

A single-center, non-blinded, randomized controlled, equivalence trial in a tertiary referral center.

METHODS

Thirty adult patients with post-lingual bilateral sensorineural hearing loss eligible for unilateral cochlear implantation surgery were randomly assigned to either the day-case or inpatient treatment group. The effect on general quality of life, patient satisfaction, (subjective) hearing improvement, postoperative complications and causes of crossover and/or readmission were assessed using questionnaires, auditory evaluations and patients' charts over a follow-up period of 1 year.

RESULTS

Overall quality of life measured by the HUI3 was equal between the day-case (n = 14) and inpatient group (n = 14). The overall patients' satisfaction showed a slight favor towards an inpatient approach. There was no significant difference in the subjective and objective hearing improvement between both treatment groups. During the 1-year follow-up period no major complications occurred. Minor complications occurred intraoperatively in three day-case patients resulting in three out of nine admissions of day-case patients. Other causes of admission of day-case patients were nausea and vomiting (n = 1), drowsiness (n = 1), late scheduled surgery (n = 2), social reasons (n = 1), or due to an unclear reason (n = 1). No patients required readmission.

CONCLUSION

We found equal outcomes of QoL, patient satisfaction, objective, and subjective hearing outcomes between day-case and inpatient unilateral cochlear implantation. Nine out of 14 day-case patients were admitted for at least one night postoperatively (crossover). No major complications occurred in both groups. A day-case approach seems feasible when using specific patient selection, surgical planning and the preoperative provision of patient information into account. Besides this, the familiarity with a day-case approach of both patient and the surgical team can increase the feasibility of day-case surgery.

LEVEL OF EVIDENCE: 1

Transfers and anesthesia-related postoperative outcomes after 3361 same-day cancer surgeries at a freestanding surgery center: An observational retrospective study

BACKGROUND AND OBJECTIVES

Expanding outpatient surgery to the increasing number of procedures and patient populations warrants continuous evaluation of postoperative outcomes to ensure the best care and safety. We describe adverse postoperative outcomes and transfer rates related to anesthesia in a large sample of patients who underwent same-day cancer surgery at a freestanding ambulatory surgery center.

METHODS

Between January 2017 and June 2021, 3361 cancer surgeries, including breast and plastic, head and neck, gynecology, and urology, were performed. The surgeries were indicated for diagnosis, staging, and/or treatment. We report the incidence of transfers and adverse postoperative outcomes related to anesthesia.

RESULTS

Breast and plastic surgeries were the most common (1771, 53%), followed by urology (1052, 31%), gynecology (410, 12%), and head and neck surgeries (128, 4%). Based on patients' first procedure, comorbidity levels were highest for urology (75% American Society of Anesthesiologists physical status score 3, 1.7% score 4) and lowest for breast surgeries (31% score 3, 0.2% score 4). Most gynecology surgeries used general anesthesia (97.6%), whereas breast surgeries used the least (38%). A total of seven patients (0.2%; 95% CI: 0.08%-0.4%) were immediately transferred to an outside hospital; four due to anesthesia-related reasons. Only 7 (0.2%) patients needed additional postoperative care related to anesthesia-related adverse events, specifically cardiac events (4), difficult intubations (2), desaturation (1), and agitation, nausea, and headache (1).

CONCLUSIONS

The incidence of anesthesia-related adverse postoperative outcomes is low in cancer patients undergoing outpatient surgeries at our freestanding ambulatory surgery center. This suggests that carefully selected cancer patients, including patients with metastatic cancer, can undergo anesthesia for same-day surgery, making cancer care accessible locally and reducing stress associated with travel for treatment. More research investigating complication rates related to surgery and to cancer disease trajectory are needed to establish a complete evaluation of safety for outpatient cancer surgery.

Turkish Cross-cultural Adaptation of the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery (PHBQ-AS)

PURPOSE

The purpose of this study is to cross-culturally adapt the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery (PHBQ-AS) to Turkish and test its validity and reliability.

DESIGN

This is a methodological study.

METHODS

This study was conducted with 121 children aged 1 to 12 years who underwent ambulatory surgery. The data of the study were collected using a Descriptive Information Form, PHBQ-AS, and the Parents' Postoperative Pain Measure. Data analysis and evaluation were performed using factor analysis, Cronbach's α analysis, item-total score correlation analysis, content validity, construct validity, and concurrent validity.

FINDINGS

PHBQ-AS showed a high level of internal consistency (Cronbach's α = 0.801). The item-total correlation values of PHBQ-AS were found to be 0.458 to 0.753. PHBQ-AS was determined to be a single-factor scale explaining 66% of the variance in the examined variable. PHBQ-AS and Parents' Postoperative Pain Measure scores were moderately correlated.

CONCLUSIONS

The Turkish version of PHBQ-AS was highly valid and reliable for the Turkish population. A recommendation for health care professionals in Turkey is to use the PHBQ-AS scale to evaluate posthospitalization behavioral changes in children who are admitted for ambulatory surgery.

Factors associated with conversion from day-case to in-patient elective inguinal hernia repair surgery across England: an observational study using administrative data

PURPOSE

Elective primary inguinal hernia repair surgery is increasingly being conducted as a day-case procedure. However, some patients planned for day-case surgery have to stay in hospital for at least one night. The aim of this study was to identify the factors associated with conversion from day-case to in-patient management for elective inguinal hernia repair surgery.

METHODS

This was an exploratory retrospective analysis of observational data from the Hospital Episode Statistics dataset for England. All patients aged ≥ 17 years undergoing a first elective inguinal hernia repair between 1st April 2014 and 31st March 2022 that was planned as day-case surgery were identified. The exposure of interest was discharged on the day of admission (day-case) or requiring overnight stay. The primary outcome of interest was 30-day emergency readmission with an overnight stay. For reporting, providers were aggregated to an Integrated Care Board (ICB) level.

RESULTS

A total of 351,528 planned day-case elective primary inguinal hernia repairs were identified over the eight-year study period. Of these, 45,305 (12.9%) stayed in hospital for at least one night and were classed as day-case to in-patient stay conversions. Patients who converted to in-patient stay were older, had more comorbidities, and were more likely to have bilateral surgery and be operated on by a low-annual volume surgeon. Post-procedural complications were strongly associated with conversion. Across the 42 ICBs in England, model-adjusted conversion rates varied from 3.3% to 21.3%.

CONCLUSIONS

There was considerable variation in conversion to in-patient stay rates for inguinal hernia repair across ICBs in England. Our findings should help surgical teams to better identify patients suitable for day-case inguinal hernia repair and plan discharge services more effectively. This should help to reduce the variation in conversion rates.

Preoperative Renin-Angiotensin System Antagonists Intake and Blood Pressure Responses During Ambulatory Surgical Procedures: A Prospective Cohort Study

BACKGROUND

There is limited evidence to inform the association between the intake of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs) and intraoperative blood pressure (BP) changes in an ambulatory surgery population.

METHODS

Adult patients who underwent ambulatory surgery and were discharged on the same day or within 24 hours of their procedure were enrolled in this prospective cohort study. The primary outcome of the study was early intraoperative hypotension (first 15 minutes of induction). Secondary outcomes included any hypotension, BP variability, and recovery. Hypotension was defined as a decrease in systolic BP of >30% from baseline for ≥5 minutes or a mean BP of <55 mm Hg. Four exposure groups were compared (no antihypertensives, ACEI/ARB intake <10 hours before surgery, ACEI/ARB intake ≥10 hours before surgery, and other antihypertensives).

RESULTS

Of the 537 participants, early hypotension was observed in 25% (n = 134), and any hypotension in 41.5% (n = 223). Early hypotension occurred in 30% (29 of 98) and 41% (17 of 41) with the intake of ACEI/ARBs <10 and ≥10 hours before surgery, respectively, compared to 30% (9 of 30) with other antihypertensives and 21% (79 of 368) with no antihypertensives ( P = .02). Those on antihypertensives also experienced any hypotension more frequently than those who were not on antihypertensives ( P < .001). After adjusting for age and baseline BP in a regression analysis, antihypertensive exposure groups were observed to be associated only with any intraoperative hypotension ( P = .012). In the ACEI/ARB subset, there was no evidence of an association between time since the last ACEI/ARB dose, and hypotension or minimum mean or systolic BP. Compared to normal baseline BP, BP ≥ 140/90 mm Hg increased the odds of early and any hypotension (odds ratio [OR], 3.9; 95% confidence interval [CI], 2.1-7.1 and OR, 7.7; 95% CI, 3.7-14.9, respectively; P < .001). Intraoperative variability in systolic and diastolic BP demonstrated significant differences with age, baseline BP, and antihypertensive exposure group ( P < .001).

CONCLUSIONS

Early and any hypotension occurred more frequently in those on antihypertensives than those not on antihypertensives. Unadjusted associations between antihypertensive exposure and intraoperative hypotension were largely explained by baseline hypertension rather than the timing of ACEI/ARBs or type of antihypertensive exposure. Patients with hypertension and on treatment experience more intraoperative BP variability and should be monitored appropriately.

Optimizing theatre utilization for abscess drainage: going beyond priority categories

BACKGROUND

Day-only emergency surgery for abscess drainage is poorly implemented in Australia. This study assessed the feasibility, outcomes, cost, and impact of an acute day-only surgery (ADOS) program.

METHOD

A retrospective pre-post implementation study of patients requiring abscess drainage in theatre was performed. Following implementation of an ADOS program for abscess management, eligible patients were discharged from the emergency department and prioritized first on the following day's emergency list. Outcomes from the first 12 months of the ADOS era were compared with those of the preceding 6 months (pre-ADOS). Primary outcome was length of hospital stay (LOS). Secondary outcomes included 30-day complications, admission costs, and impact on overall emergency theatre workflow (measured by emergency appendicectomy metrics).

RESULTS

Overall, 266 patients during the ADOS era (including 95 eligible for the ADOS pathway) were compared with 115 patients during the pre-ADOS era. Baseline characteristics were comparable. Median LOS was shorter during the ADOS era (21.9 h (IQR 11.8-43.3) vs. 30.1 h (IQR 24.7-48.8), P < 0.001). Median LOS was 10.2 h (IQR 8.9-13.1) for patients on the ADOS pathway. There were no significant differences in 30-day complications (9.3% vs. 9.5%), emergency department re-presentations (7.4% vs. 5.1%), or abscess recurrence (5.6% vs. 5.7%). Average cost per patient was lower during the ADOS era ($4155 vs. $4916, p = 0.005). ADOS did not appear to materially impact other emergency procedures.

CONCLUSION

ADOS for abscess drainage is feasible, safe, and produces cost savings, while being implemented without significant additional resources.

Risk Factors Leading to Overnight Stays in Pediatric Surgical Outpatients

BACKGROUND

Same-day surgery implies patient discharge on the same day after the surgery. The main aim of the research was to determine which predisposing factors lead to children treated with same-day surgery not being able to be discharged on the same day.

METHODS

For the purposes of this research, the electronic records of patients in the hospital information system were reviewed retrospectively. The search included patients who were surgically treated through the Day Surgery Unit at the Children's Hospital Zagreb with various diagnoses from 1 January 2021 to 31 December 2023. The target group consisted of patients who could not be discharged on the same day (n = 68), while for the purposes of the control group (n = 68), patients were randomly selected, comparable by age and gender, who were discharged from the hospital on the same day in accordance with the principles of same-day surgery.

RESULTS

In relation to the parameters of interest between the groups, statistically significant differences were observed in the type of general anesthesia (p = 0.027), the use of analgesics (p = 0.016), the time of entering the operating room (p = 0.000), the time of leaving the operating room (p < 0.0001) and the duration of surgery (76.81 ± 37.21 min vs. 46.51 ± 22.46 min, p < 0.0001). When explanatory variables were included in the regression model, they explained 38% of the variability in the dependent variable. Only the variable "duration of surgery" provided significant information to explain the variability in the dependent variable (p = 0.004).

CONCLUSIONS

Although the duration of surgery was imposed as the main predictor of hospitalization after same-day surgery, and considering the extremely small number of studies on the mentioned topic, especially in the pediatric population, further, preferably multicenter research on the mentioned topic is needed.

Impact of the coronavirus disease 2019 pandemic on equity of access to hip and knee replacements: a population-level study

PURPOSE

The COVID-19 pandemic had innumerable impacts on healthcare delivery. In Canada, this included limitations on inpatient capacity, which resulted in an increased focus on outpatient surgery for non-emergent cases such as joint replacements. The objective of this study was to assess whether the pandemic and the shift towards outpatient surgery had an impact on access to joint replacement for marginalized patients.

METHODS

Data from Ontario's administrative healthcare databases were obtained for all patients undergoing an elective hip or knee replacement between January 1, 2018 and August 31, 2021. All surgeries performed before March 15, 2020 were classified as "pre-COVID," while all procedures performed after that date were classified as "post-COVID." The Ontario Marginalization Index domains were used to analyze proportion of marginalized patients undergoing surgery pre- and post-COVID.

RESULTS

A total of 102,743 patients were included-42,812 hip replacements and 59,931 knee replacements. There was a significant shift towards outpatient surgery during the post-COVID period (1.1% of all cases pre-COVID to 13.2% post-COVID, p < 0.001). In the post-COVID cohort, there were significantly fewer patients from some marginalized groups, as well as fewer patients with certain co-morbidities, such as congestive heart failure and chronic obstructive pulmonary disease.

CONCLUSION

The most important finding of this population-level database study is that, compared to before the COVID-19 pandemic, there has been a change in the profile of patients undergoing hip and knee replacements in Ontario, specifically across a range of indicators. Fewer marginalized patients are undergoing joint replacement surgery since the COVID-19 pandemic. Further monitoring of access to joint replacement surgery is required in order to ensure that surgery is provided to those who are most in need.

The Influence of Preoperative Waiting Time on Anxiety and Pain Levels in Outpatient Surgery for Breast Diseases

OBJECTIVE

This study aims to examine the effects of different preoperative waiting times on anxiety and pain levels in patients undergoing outpatient surgery for breast diseases, providing insights for clinical interventions during the perioperative phase.

METHODS

Patients who underwent outpatient surgery at a hospital breast center in Ningbo between January 2021 and December 2021 were selected. Their anxiety levels at the time when they entered the preoperative preparation room and when they ended the postoperative waiting period for the rapid frozen section procedure were assessed using the State Anxiety Inventory (S-AI) questionnaire, and their pain levels at the end of the postoperative waiting period were assessed using the short-form McGill Pain Questionnaire. The patients enrolled were divided into 3 groups according to the preoperative waiting time: <2 hours (T1 group), 2 to 4 hours (T2 group), and >4 hours (T3 group); there were 150 patients in each group, and the anxiety and pain levels were compared between the groups.

RESULTS

At the time of entering the preoperative preparation room, patients' S-AI score T1 = T2 ( P > 0.05), both T1 and T2 < T3 ( P < 0.05); however, at the time of the postoperative waiting period, patients' S-AI score was T1 < T2 < T3 ( P < 0.05), and the postoperative waiting period patients' short-form McGill Pain Questionnaire scores were T1 = T2 < T3 ( P < 0.05).

CONCLUSIONS

The perioperative anxiety and pain levels of patients undergoing outpatient breast surgery increased with the prolongation of preoperative waiting time; 4 hours was the critical time point for change, after which the anxiety and pain levels of patients increased significantly.

The preparation of children for day surgery from the parent's viewpoint: A mixed methods study

AIM

The purpose of the study was to describe the preparation of children for day surgery from the parent's viewpoint.

DESIGN

Empirical Research Mixed Method.

METHODS

The research applied a mixed-methods study design. The study was conducted at the Paediatric Day Surgical Department of one REDACTED between 2018 and 2020 at the same time as an associated randomised controlled conduct trial. Parents of 41 children (ages 2-6 years) completed measures assessing their preparation for day surgery and satisfaction with the procedure. Semi-structured interviews were conducted with 15 parents to better understand their experiences.

RESULTS

According to the results, most of the parents (95%) told their children about the upcoming day surgery procedure. The child was prepared for the surgery with cognitive and sensory information, and the preparation usually started at home well before the surgery. The parents' experiences with the most critical aspects of preparing their child included three main categories: (1) usability of the preparation method; (2) content and timing of the preparation method and (3) consideration of the family perspective.

Effectiveness of bismuth subgallate for preventing bleeding following adenotonsillectomy: A multicentre study

BACKGROUND

Tonsillectomy and adenotonsillectomy are surgical procedures routinely performed worldwide, with various complications, including postoperative bleeding (PTH). Among haemostatic agents, bismuth subgallate (BS) has been employed in the past decades, but its use is controversial in children.

OBJECTIVE

This retrospective, multicentre study aims to evaluate the effectiveness and safety of BS in preventing PTH following tonsillectomy and adenotonsillectomy.

MATERIALS AND METHODS

Two cohorts of children between 0 and 18 years of age were compared in two different hospitals. The first (active) group of patients included children who underwent tonsillectomy/adenotonsillectomy performed using BS added to gauze swabs, whereas this agent was not administered to the second (control) group. The following variables were analysed: age, gender, degree of tonsillar hyperplasia, length of hospital stay, acute complications (including bleeding and infection), further admissions to the Paediatric Emergency Department (PED), and further hospital admissions in the 30 days postoperatively.

RESULTS

Four-thousand- seven hundred forty-four children were included in the study, 2598 in the active group and 2146 in the control group. The cases included in the active treatment group displayed a significantly reduced PTH prevalence, 1.4 versus 2.6 % (p < 0.05). No cases of neurological complications or aspiration pneumonia were detected.

CONCLUSIONS

This study supports BS as a safe and reliable option for preventing severe PTH following tonsillectomy/adenotonsillectomy.

Clinical application and nursing experience of the plan-do-check-act cycle in daytime varicocelectomy

BACKGROUND

Varicocele is the most prevalent correctable cause of male infertility. Currently, surgical treatment is the primary method to enhance fertility.For many young varicocele patients who have postponed surgery due to time constraints, daytime surgery is especially crucial. Thus, this study aims to investigate the clinical and nursing application value of the Plan-Do-Check-Act (PDCA) cycle in daytime varicocelectomy.

METHODS

Retrospective collection of clinical data was conducted on 130 patients undergoing laparoscopic varicocelectomy in the Third Affiliated Hospital of Southern Medical University, Guangzhou,China.Among them, 65 patients who underwent daytime surgery were assigned to the observation group, while 65 patients who underwent routine hospital surgeries were assigned to the control group.The former also implemented PDCA cycle management.A comparison was made between the two groups regarding hospitalization time, hospitalization costs, and patient satisfaction.

RESULTS

The observation group exhibited a shorter hospitalization time and lower hospitalization costs compared to the control group, with higher patient satisfaction and pre-discharge visual analog scale (VAS) scores noted (P < 0.05).No significant difference was observed in the incidence of postoperative complications between the two groups during hospitalization (P > 0.05). The implementation of the PDCA cycle in the observation group has demonstrated its effectiveness, ensuring the smooth conduct of the daytime varicocelectomy.

CONCLUSION

In conclusion,daytime varicocelectomy can reduce hospitalization time,lower hospitalization costs, improve patient satisfaction. The PDCA Cycle enhances the rationality and efficacy of the daytime varicocelectomy procedure and is highly recommended. Furthermore, it offers valuable reference for the application of the PDCA Cycle in various other diseases and nursing management approaches.

TRIAL REGISTRATION

The Trial Registration Number: ChiCTR2300077465;Date of registration: November 9, 2023.

International strategies, experiences, and payment models to incentivise day surgery

The importance of day surgery as a less costly alternative compared to conventional inpatient hospital stays is growing internationally. The rate of day surgery activities has increased across Europe. However, this trend has been heterogeneous across countries, and might still be below its potential. Since payment systems affect how providers offer care, they represent a policy instrument to further increase the rate of day surgeries. In this paper, we review international strategies to promote day surgery with a particular focus on payment models for 13 OECD countries (Australia, Austria, Canada, Denmark, England, Estonia, Finland, France, Germany, Netherlands, Norway, Sweden, Switzerland). We conduct a cross-country comparison based on an email survey of health policy experts and a comprehensive literature review of peer-reviewed papers and grey literature. Our research shows that all countries aim to strengthen day surgery activity to increase health system efficiency. Several countries used financial and non-financial policy measures to overcome misaligned incentive structures and promote day surgery activity. Financial incentives for day surgery can serve as a policy instrument to promote change. We recommend embedding these incentives in a comprehensive approach of restructuring health systems. In addition, we encourage countries to monitor and evaluate the effect of changes to payment systems on day surgeries to allow for more informed decision-making.

British Society of Gastroenterology guidelines on sedation in gastrointestinal endoscopy

Over 2.5 million gastrointestinal endoscopic procedures are carried out in the United Kingdom (UK) every year. Procedures are carried out with local anaesthetic r with sedation. Sedation is commonly used for gastrointestinal endoscopy, but the type and amount of sedation administered is influenced by the complexity and nature of the procedure and patient factors. The elective and emergency nature of endoscopy procedures and local resources also have a significant impact on the delivery of sedation. In the UK, the vast majority of sedated procedures are carried out using benzodiazepines, with or without opiates, whereas deeper sedation using propofol or general anaesthetic requires the involvement of an anaesthetic team. Patients undergoing gastrointestinal endoscopy need to have good understanding of the options for sedation, including the option for no sedation and alternatives, balancing the intended aims of the procedure and reducing the risk of complications. These guidelines were commissioned by the British Society of Gastroenterology (BSG) Endoscopy Committee with input from major stakeholders, to provide a detailed update, incorporating recent advances in sedation for gastrointestinal endoscopy.This guideline covers aspects from pre-assessment of the elective 'well' patient to patients with significant comorbidity requiring emergency procedures. Types of sedation are discussed, procedure and room requirements and the recovery period, providing guidance to enhance safety and minimise complications. These guidelines are intended to inform practising clinicians and all staff involved in the delivery of gastrointestinal endoscopy with an expectation that this guideline will be revised in 5-years' time.

Evaluation of the efficacy and safety of day surgery for cervical disc herniation treated with low temperature plasma radiofrequency ablation

PURPOSE

The purpose of this study was to evaluate and compare the clinical efficacy of patients with cervical disc herniation (CDH) treated by low-temperature plasma radiofrequency ablation (LTP-RFA) as day surgery with traditional inpatients.

METHODS

According to the selection criteria, single-segment mild to moderate CDH patients who received LTP-RFA from January 2020 to December 2021 were divided into day surgery procedure (DSP) group and a traditional inpatient procedure (TIP) group. The visual analogue score (VAS) and modified Japanese Orthopedic Association score (mJOA) of neurological function of patients in the two groups were recorded at the time of preoperative, and one day, three months, six months after surgery and the last follow-up respectively. The gender, age, responsible segment, surgical complications, hospitalization time, hospitalization expenses, and patient satisfaction were recorded and analyzed for both groups. The modified Macnab standard was used to evaluate the postoperative efficacy at one month and six months after operation.

RESULTS

A total of 127 patients (75 in DSP;52 in TIP) with complete data were enrolled and completed six month follow-up. There were no statistically significant pre-treatment VAS scores and mJOA scores in the two groups (P>0.05). The postoperative VAS and mJOA scores in both groups were improved after surgery (P<0.05). However, there was no significant difference in VAS scores and mJOA scores between the two groups in the same postoperative period (all P > 0.05). The efficacy of MacNab was similar one month and six months after operation (P > 0.05). The hospitalization time and hospitalization cost were significantly lower in DSP group (all P<0.05). As the treatment effects were comparable, patients in both groups were similarly satisfied at discharge.

CONCLUSION

LTP-RFA is an effective method for the treatment of mild to moderate CDH. We suggest that the application of LTP-RFA in DSP for mild to moderate CDH is worthy of wide application.

Trends in day-case bladder outflow obstruction surgery: a study using Hospital Episode Statistics

OBJECTIVES

To describe the contemporary evolution of day-case bladder outflow obstruction (BOO) surgery in England and to profile day-case BOO surgery practices across England in terms of the types of operation performed and their safety profiles.

MATERIALS AND METHODS

This was a retrospective observational analysis of Hospital Episode Statistics and UK Office for National Statistics data. All 111 043 recorded operations across 117 hospital trusts over 66 months, from 1 January 2017 to 30 June 2022, were obtained. Operations were identified as one of: transurethral resection of prostate (TURP); laser ablation or enucleation; vapour therapy; prostatic urethral lift (PUL); or bladder neck incision. Monthly day-case rate trends were plotted across the study period. Descriptive data, day-case rates and 30-day hospital readmissions were analysed for each operation type. Multilevel regression modelling with mixed effects was performed to determine whether day-case surgery was associated with higher 30-day hospital readmissions.

RESULTS

Day-case patients were younger, with fewer comorbidities. Time series analysis showed a linear day-case rate increase from 8.3% (January 2017) to 21.0% (June 2022). Day-case rates improved for 92/117 trusts in 2021/2022 compared with 2017. Three of the six trusts with the highest day-case rates performed predominantly day-case TURP, and the other three laser surgery. Nationally, PUL and vapour surgery had the highest day-case rates (80.9% and 38.1%). Most inpatient operations were TURP. Multilevel regression modelling found reduced odds of 30-day readmission after day-case BOO surgery (all operations pooled), no difference for day-case vs inpatient TURP, and reduced odds following day-case LASER operations.

CONCLUSIONS

The day-case rates for BOO surgery have linearly increased. Minimally invasive surgical technologies are commonly performed as day cases, whereas high day-case rates for TURP and for laser ablation operations are seen in a minority of hospitals. Day-case pathways to treat BOO can be safely developed irrespective of operative modality.

The Effects of Hypocapnia and Hypercapnia on Intraoperative Bleeding, Surgical Field Quality, and Surgeon Satisfaction Level in Septorhinoplasty: A Prospective Randomized Clinical Study

BACKGROUND

Septorhinoplasty (SRP) is one of the most commonly performed procedures in the world for functional and aesthetic purposes. The present study was aimed to compare the effects of hypocapnia and hypercapnia regarding the total amount of intraoperative bleeding, surgical field quality, and surgeon satisfaction level.

METHODS

In this randomized prospective clinical study, eighty patients with American Society of Anesthesiologists I-II and were 18-45 years old scheduled for septorhinoplasty were randomly allocated to group hypocapnia [end-tidal carbon dioxide (EtCO2) 30 ± 2 mmHg] and group hypercapnia (EtCO2 40 ± 2 mmHg). We evaluated the total amount of intraoperative bleeding, the surgical field quality, surgeon satisfaction level, hemodynamics and peri- and postoperative adverse events.

RESULTS

Group hypocapnia significantly reduced the total amount of intraoperative bleeding (p < 0.001). The surgical field quality and surgeon satisfaction level in group hypocapnia were significantly better than group hypercapnia (p < 0.001). EtCO2 levels of group hypocapnia were significantly lower than group hypercapnia at all time points (p < 0.001 for all time points). There were no significant differences between the groups in terms of heart rate and mean arterial pressure at all time points. There were no significant differences between the groups in terms of adverse events CONCLUSIONS: The results of this double-blind randomized clinical trial showed that reducing the amount of intraoperative bleeding for patients with hypocapnia undergoing SRP through known methods (e.g., reverse Trendelenburg head-up position, positive end-expiratory pressure limiting, controlled hypotension, and use of topical vasoconstrictors, corticosteroids, and tranexamic acid) would improve the quality of the surgical field and raise the surgeon satisfaction level.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Patients' experiences of day surgery and recovery: A meta-ethnography

AIM

To explore and synthesise findings from qualitative studies on adult patients' experiences of day surgery and the processes of recovery.

BACKGROUND

There has been a shift in the practice of elective surgery, from inpatient to ambulatory treatment. Accordingly, more patients are undergoing day surgery and expected to care for themselves at home. To our knowledge, an updated metasynthesis on patients' experiences of day surgery across diverse contexts and continents is lacking.

DESIGN

Meta-ethnography.

METHODS

MEDLINE, EMBASE and CINAHL were systematically searched for qualitative research in English published between 2006 and 2023. Noblit and Hare's meta-ethnographic approach guided the synthesis of findings from 12 qualitative studies, and the eMERGe Reporting Guidance was used in the writing of this article.

RESULTS

Four themes were revealed: (1) requests for tailored information, (2) challenges of recognising and understanding postoperative symptoms, (3) being dependent on continuous professional and personal support and (4) calling for individual adaptation.

CONCLUSION

Our meta-ethnography indicates there is a need to improve information provision to better prepare patients for the processes of day surgery and recovery and promote their self-care abilities. Our findings highlight the importance of ensuring adequate levels of individualised care and support throughout the treatment process.

RELEVANCE TO CLINICAL PRACTICE

To improve quality of care in day surgery practice, implementation of interventions to enhance information provision and promote self-care during recovery at home may be considered. Pre-admission appointments that incorporate provision of tailored information and assessment of the patients' individual needs of care and support, home conditions and access to assistance from family/friends can be recommended.

Environmental impact of the supervised toothbrushing programme amongst children in Scotland

OBJECTIVES

To understand the environmental impact of providing a nationwide supervised toothbrushing programme (Childsmile) for 5-year-old children in Scotland.

METHODS

A life cycle assessment was conducted to assess the annual environmental effects of the supervised toothbrushing programme in early years childcare, as well as each dental procedure (dental restoration under local anaesthesia (LA), single tooth extraction under LA, and multiple teeth extraction under general anaesthesia) spanning from 2001/02 to 2009/10. The expected savings in annual carbon dioxide equivalent (CO2e) emissions for all combined dental treatments in subsequent years were calculated compared to those in 2001/02.

RESULTS

An overall decrease in CO2e emissions was evident in the Childsmile programme and across all dental procedures. The estimated reduction in emissions across all procedures varied from 102.5 tonnes in 2002/03 to 461.1 tonnes in 2009/10 when compared to 2001/02. Within three years, the expected emissions savings from all combined dental procedures surpassed the emissions generated by implementing the Childsmile programme.

CONCLUSIONS

Over time, there was a significant reduction in annual CO2e emissions for all combined dental treatments in children. In the eighth year of the Childsmile, emissions savings were more than 4.5 times greater than the emissions generated during its implementation.

CLINICAL SIGNIFICANCE

The study highlights the importance of educating public by individual dentists about the environmental impact of caries prevention programmes and paediatric dental treatments as this may influence patient choice. It also encourages commissioners of community dental programmes to support the implementation of supervised toothbrushing programmes in early years childcare.

Ambulatory anesthesia: restructuring for success

PURPOSE OF REVIEW

We review current evidence about organizational structures, patient selection criteria, safety measures, economic considerations, quality management, and staffing challenges in ambulatory anesthesia. The focus is on the facilitators and barriers related to the peri-interventional period and the potential concepts and innovations for the future development of ambulatory anesthesia services.

RECENT FINDINGS

Recent findings shed light on organizational structures in ambulatory anesthesia, including hospital-based centers, freestanding ambulatory centers, and office-based practices. Patient selection for ambulatory anesthesia involves a two-step process, considering both surgical and anesthetic factors. Safety measures, such as standardized guidelines and scoring systems, aim to ensure patient well being during the perioperative course. Economic considerations pose challenges due to the complexities of managing operating room efficiency and the variations in reimbursement systems. Quality management in ambulatory anesthesia emphasizes the need for outcome studies and patient-centered quality indicators. Staffing requirements necessitate highly skilled professionals with both technical and nontechnical skills, and structured education and training are essential.

SUMMARY

Ambulatory anesthesia is gaining importance due to advancements in surgical techniques and peri-interventional care. The review highlights the need for addressing challenges related to organizational structures, patient selection, patient safety, economic considerations, quality management, and staffing in ambulatory anesthesia. Understanding and addressing these factors are crucial for promoting the further development and improvement of ambulatory anesthesia services.

Effect of general anaesthesia with remimazolam versus propofol on postoperative quality of recovery in patients undergoing ambulatory arthroscopic meniscus repair: a randomised clinical trial

Background

The type of anaesthesia and choice of anaesthetic drugs may affect the quality of recovery after surgery. Remimazolam is a new benzodiazepine with rapid onset and offset, specifically antagonised by flumazenil. This study aimed to compare remimazolam with propofol on the quality of recovery in patients undergoing ambulatory arthroscopic surgery.

Methods

Patients aged 18-65 yr and scheduled for ambulatory arthroscopic meniscus repair were recruited and randomly assigned to receive either continuous i.v. infusion of remimazolam or plasma target-controlled infusion of propofol. The quality of recovery-15 (QoR-15) scale was administered on postoperative day 1 (POD1) as the primary outcome. Secondary outcomes included the Athens Insomnia Scale (AIS) scores and cardiovascular variables.

Results

In total, 120 patients were randomly assigned to the remimazolam or propofol groups and 114 patients were included in the analysis. The remimazolam group had higher total QoR-15 scores on POD1 (125 [120-127.5] vs 121.5 [119-124], with a median difference of 3 (95% confidence interval: 1-5; P=0.002). Physical independence and psychological support were higher in the remimazolam group (8.5 [8-10] vs 8 [7-9], P=0.043; 17 [13-17] vs 12.5 [12-14], P<0.001). Remimazolam lowered the number of awakenings during the first postoperative night (P=0.042) and the incidence of hypotension (P=0.04).

Conclusions

Remimazolam-based total i.v. anaesthesia was associated with small improvements in the quality of recovery; however, the improvement was less than the minimally clinically important difference.

Clinical trial registration

ChiCTR2100053014.

Profile of orthopaedic day-case procedures at a district general hospital (retrospective study)

BACKGROUND

The outcomes of orthopaedic day-case procedures have been reported widely, but there is a lack of reports from secondary health facilities such as district hospitals.

AIM

We aimed to perform a retrospective analysis of patient records to capture the profile of day-case procedures performed.

MATERIALS AND METHODS

We conducted a retrospective analysis of day-case procedures at the dedicated Day Surgery Unit of a moderate-sized district hospital in Saudi Arabia between January 2021 and December 2022. The medical records of all the patients who had day-case procedures by the hospital's orthopaedic unit were analyzed.

RESULTS

Within the study period, 71 out of 914 elective orthopaedic procedures were carried out as day-cases, giving a day-case surgery rate of 7.8%. The mean age was 25.3 ± 12.2 (range, 4-55 years), and the male-to-female ratio was 6:1. The spectrum of the procedures was dominated by implant removal in 59 cases (83.1%). Whilst the anaesthetic technique varied, all the patients were ASA class I or II. There were minor complications in 10 patients (14.0%), with 7 of them (9.8%) needing inpatient admission. There was no cancellation of cases in our study.

CONCLUSION

We found day-case procedures to be safe and effective but with low utilisation of the Day Surgery Unit, which can be improved through the development of a detailed protocol for day surgery in the hospital.

Propensity score-matched comparison of safety outcomes between high-risk and low-risk patients towards early hospital discharge after laparoscopic cholecystectomy

Background

Laparoscopic cholecystectomy (LC), a common treatment for symptomatic gallstones, has demonstrated safety in low-risk patients. However, existing data are scarce regarding the safety of LC in high-risk patients and the feasibility of early hospital discharge.

Materials and methods

This retrospective study included 2296 patients diagnosed with symptomatic gallstones who underwent LC at a tertiary care centre from January 2009 through December 2019. The authors employed propensity score matching to mitigate bias between groups. Statistical significance was set at P less than 0.05.

Results

The median age of the patients was 56 years (range 46-67), with a mean BMI of 25.2±4.3 kg/m2. Patients were classified as: American Society of Anesthesiologists (ASA) I (19.7%), II (68.3%), III (12.0%), and IV (0%). ASA I-II included low surgical risk patients (88%) and ASA III-IV comprised high-risk patients (12%). The LC-related 30-day reoperative rate was 0.2% and the readmission rate was 0.87%. Nine patients (0.4%) sustained major bile duct injuries, resulting in a conversion rate of 2.4%. The postoperative mortality rate was 0.04%, and the mean hospitalization time was 3.5 days. Patients in the high-risk group with a history of acute cholecystitis exhibited greater estimated blood loss, longer operative times, and were significantly more likely to be in the longer-stay group.

Conclusion

These findings suggest that LC can be conducted safely on high-risk patients, and early hospital discharge is achievable. However, specific factors, such as a history of acute cholecystitis, may result in prolonged hospitalization owing to increased blood loss and longer operative times.

Safety and effectiveness of prilocaine for spinal anesthesia in day surgery setting: a retrospective study on a sample of 3291 patients

Spinal anesthesia is considered safe and reliable for most surgical procedures involving the lower part of the body, but its use in the ambulatory setting requires drugs with rapid onset and regression of the motor and sensory block-like prilocaine.The purpose of this study is to retrospectively analyze data from 3291 procedures recorded in our institutional database, to better define the safety profile of spinal prilocaine and the incidence of complications and side effects.All clinical data, prospectively collected from 2011 to 2019 in an Italian tertiary hospital, of patients treated with spinal anesthesia performed with 40 mg of hyperbaric 2% prilocaine, according to our internal protocol of day surgery, were analyzed.Surgical procedures included saphenectomy (28.5%, n = 937), knee arthroscopy (26.8%, n = 882), proctologic surgery (15.16%, n = 499), and inguinal canal surgery (14.9%, n = 491).Anesthesia-related complication was represented by urinary retention (1.09%, n = 36), lipotimia (0.75%, n = 25), and postoperative nausea (0.33%, n = 11); arrhythmic events were uncommon (0.18%, n = 6). One case of persistent hypotension and 2 cases of persistent hypertension were reported.Persistent motor or sensory block (lasting more than 5 h) was experienced by 7 patients. One patient (0.03%), who underwent knee arthroscopy, experienced pelvic pain lasting for 6 h, compatible with a transient neurological symptom.Proctologic surgery was a factor associated with unplanned admission due to anesthesia-related complications (OR = 4.9; 95% CI: 2-14%).The number of complications related to the method was low as well as the need for hospitalization. This drug is valid and safe for the most performed day surgery procedures; however, further trials are needed to investigate the incidence of complications in the days following the procedure.

Implementing an outpatient surgical management in moderated-high risk patients with groin hernia repair

PURPOSE

There is a growing trend to expand Ambulatory Surgery (AS) criteria in abdominal wall surgery. No Admission (NOADS) circuit. The present study aimed to assess the impact of classification criteria on postoperative results and hospital stays in a NOADS versus a conventional admission circuit to throw some light on surgical circuit inclusion.

METHODS

A retrospective analysis of a prospective;y maintained database was performed comparing groin hernia's interventions in a NOADS vs Admission circuit in our center in 2018-2021. A multiple regression predictive model followed by a retrospective retest were dessigned to assess the impact of each criterion on hospital stay. In total, 743 patients were included, 399 in the Admission circuit (ADC) and 344 in NOADS circuit (NOADS).

RESULTS

There were no statistical differences in complication or readmission rates (p = 0.343 and p = 0.563), nevertheless, a shorter hospital stay was observed in NOADS (p = 0.000). A hierarchical multiple regression predictive model proposed two opposite scenarios. The best scenario, not likely to need admission, was a female patient operated via the laparoscopic approach of a unilateral primary hernia (Estimated Postoperative Stay: 0.049 days). The worst scenario, likely to need admission, was a male patient operated via the open approach of a bilateral and recurrent hernia (Estimated Postoperative Stay: 1.505 Days).

CONCLUSION

Groin hernia patients could safely benefit from a No Admission (NOADS) circuit. Our model could be useful for surgical circuit decision-making, especially for best/worst scenarios.

Effectiveness of a Mobile App Intervention for Preparing Preschool Children and Parents for Day Surgery: Randomized Controlled Trial

BACKGROUND

Day surgery allows families to return home quickly. Only a few approaches to preparing for day surgery have demonstrated how digital solutions can support families and children.

OBJECTIVE

This study aims to evaluate the effectiveness of a mobile app intervention on preschool children's fear and pain and parents' anxiety and stress in preparing children for day surgery.

METHODS

This study was conducted at the Pediatric Day Surgical Department of a university hospital in Finland between 2018 and 2020. Parents of children (aged 2-6 y) who were in a queue for elective day surgery were randomized into the intervention group (IG; n=36) and control group (CG; n=34). The CG received routine preparations, whereas the IG was prepared using a mobile app. Parents' and children's outcomes were measured using validated scales at 4 different points: at home (T1 and T4) and at the hospital (T2 and T3) before and after surgery. Group differences were analyzed using statistical methods suitable for the material.

RESULTS

Before surgery, parents in both groups experienced mild anxiety, which decreased after surgery. Parental anxiety did not differ between groups preoperatively (P=.78) or postoperatively (P=.63). Both groups had less anxiety at home after surgery compared with before. The IG showed a significant decrease (P=.003); the CG also improved (P=.002). Preoperatively at home, most parents in both groups experienced no stress or mild stress (P=.61). Preoperatively at the hospital, parents in both groups experienced mild stress; however, parents in the IG experienced more stress during this phase (P=.02). Parents in the IG experienced significantly less stress postoperatively than those in the CG (P=.05). Both groups showed decreased stress levels from before to after surgery (IG: P=.003; CG: P=.004) within each group. There were no significant differences in children's pain levels between the groups and measurement points. This was observed before surgery at home (P=.25), before surgery at the hospital (P=.98), and after surgery at the hospital (P=.72). Children's fear decreased more in the IG (P=.006) than in the CG (P=.44) comparing the phases before and after surgery at home. Fear did not differ between the IG and CG preoperatively at home (P=.20) or at the hospital (P=.59) or postoperatively at the hospital (P=.62) or at home (P=.81).

CONCLUSIONS

The mobile app intervention did not reduce anxiety or pain. However, it was observed that parents in the IG experienced substantially heightened stress levels before surgery at the hospital, which decreased significantly after surgery at home. In addition, fear levels in children in the IG decreased over time, whereas no significant change was observed in the CG. These results are important for developing health care service chains and providing families with innovative and customer-oriented preparation methods.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03774303; https://classic.clinicaltrials.gov/ct2/show/NCT03774303.

Unplanned admissions after day-case surgery in an Italian third-level pediatric hospital: a retrospective study

BACKGROUND

Increasing procedures in day-case surgery can mitigate the costs of health service, without reducing safety and quality standards. The Ospedale Pediatrico Bambino Gesù has adopted an educational program for healthcare personnel and patients' families to increase the number of day-case surgery procedures performed without reducing the level of safety. The unplanned admission rate after day-case surgery can be a quality benchmark for pediatric day-case surgery, and in literature, there are no Italian data.

METHODS

We made a retrospective analysis of the hospital database and focused on children requiring unplanned admission to the central venue of the hospital for the night. The audit covered the period from September 2012 to April 2018.

RESULTS

We performed general anesthesia for 8826 procedures (urology 33.60%, plastic surgery 30.87%, general surgery 17.44%, dermatology 11.66%, dentistry 3.16%, orthopedics 1.64%, digestive endoscopy 1.63%). Unplanned admission for anesthetic reasons resulted in two cases: one case of syncope and one case of vomit (0.023% rate). No one major complication.

CONCLUSIONS

Good quality of patient selection, the safety of the structure, family education, and an efficient organizational model combined with an educational program for anesthesiologists can improve the safety of anesthesia for day-case surgery.

Does Immediate Postoperative Early Ambulation Affect Clinical Results of Full-Endoscopic Lumbar Discectomy? A Historical Control Study of Daytime Operation with a 8-Hour Hospital Stay versus Inpatient Operation

OBJECTIVE

Full-endoscopic lumbar discectomy (FELD) is a popular operation for the treatment of lumbar disc herniation (LDH) and day surgery mode is increasingly popular. However, only a few studies have reported about day surgery patients undergoing Percutaneous endoscopic lumbar discectomy (PELD). This retrospective study was to evaluate and analyze the clinical outcomes of patients undergoing FELD for LDH as day surgery versus inpatient surgery.

METHODS

From January 2020 to January 2022, a retrospective analysis of LDH patients treated with FELD either in day surgery unit (within 8-h hospital stay) or inpatient unit was carried out. All these patients were followed-up for at least 12 months, and were categorized into a FELD-I (inpatient surgery) group or a FELD-D (day surgery) group, according to where the surgical procedures were performed. We assessed and compared the postoperative stand and walk time, postoperative hospitalization stays, time of return to work, modified MacNab criteria, willingness to recommend surgery, complications, revision rate, as well as the visual analogue scale (VAS) and the Oswestry disability index score (ODI). Student t-test was used for continuous variables and chi-square test or Fisher's exact test was used for categorical variables.

RESULTS

There was no statistically significant difference in demographic data and baseline characteristics between two groups. And no significant differences were found in MacNab criteria between two groups. Postoperative VAS and ODI scores at one-day postoperation and final follow-up both improved significantly in both groups, as compared to the preoperative data (p < 0.001). However, no significant difference was found between the two groups on the pre, postoperative, or the last follow-up score for VAS and ODI (p > 0.05). The postoperative first ambulation time and postoperative hospital stays was much longer in FELD-I group than FELD-D group (p < 0.001). However, there were no significant differences in the perioperative complications, revision rate as well as satisfaction rate between two groups (p > 0.05). The overall time of return to work of young patients (<60 years-old) in the FELD-D group was significantly shorter than that in the FELD-I group (p = 0.001). Patients in the FELD-D group were more likely to recommend this kind of surgical model.

CONCLUSION

These data suggest that FELD-D can be effectively performed as day surgery (within 8 h hospital stay). Early ambulation after FELD-D did not affect the clinical outcomes and the revision rates. Day surgery patients are more likely to recommend this surgery mode to other patients and younger patients may be able to return to work earlier.

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.

Defining the feasibility of same day adrenalectomy - A prospective matched cohort study

Background

Despite technical advances, day surgery still accounts for <1 % of adrenal procedures. We investigated feasibility and safety of same day adrenalectomy (SDA).

Methods

Between We recruited 30 patients with primary hyperaldosteronism (PHA) or Cushing's syndrome (CS) into a prospective matched, single centre cohort study to evaluate the impact of exposure to a same day discharge pathway (SDA cohort; n = 10) or inpatient adrenalectomy (PIPA cohort; n = 20). We compared results to a matched cohort (n = 40) from our prospective in-patient adrenalectomy registry (RIPA cohort).

Results

Mean age was 51.3 ± 8.5 years, with 43 % female, 3.3 % ASA I and 96.7 % ASA II. Lesion size was 17 ± 9 mm (range 5-40 mm). 80 % of patients presented with PHA. The predefined primary endpoint (discharge on same calendar day without major complications, emergency presentation or readmission) was achieved in 100 % of SDA, but none of the in-patients (χ² = 57; p < 0.0001). The secondary endpoint (discharge within 23 h of surgery without major complications, emergency presentation or readmission) was achieved in 100 % of SDA, 90 % of PIPA (n.s.), 33 % of RIPA (33 %; χ2 = 14.6 p < 0.001), and 51.5 % of IPA patients (χ2 = 8.5 p < 0.01). Combining SDA and PIPA cohorts, 93.3 % of treatment episodes met widely used (WHO, United States) definitions of day surgery as completion of the hospital care episode within 23 h. Patients admitted for SDA were highly satisfied (100 %).

Conclusion

Same day discharge after adrenalectomy is feasible, safe, and well-perceived in appropriately selected patients with PHA and Cushing's syndrome.

The efficiency of quick response code versus telephone contact for post-discharge follow-up after ophthalmic day surgery: a randomized controlled trial

PURPOSE

To assess and compare the efficiency of quick response (QR) code versus telephone contact for post-discharge follow-up in patients receiving low-risk ophthalmic day surgery.

METHODS

One hundred and sixty patients undergoing strabismus day-care surgery with general anesthesia were randomly allocated to either the intervention group using QR code (QR group) or the control group receiving telephone call (TEL group) for post-discharge follow-up. The primary outcome was the follow-up overall attendance rate on the second postoperative day. Secondary outcomes included attendance rate at the first scheduled follow-up, number of text message reminders, elapsed time and estimated cost for follow-up, omission rate of follow-up responses, and patient satisfaction.

RESULTS

The overall attendance rate of follow-up was significantly higher in the QR group than that in the TEL group (97.5% vs. 87.5%, p = 0.016). As compared with the TEL group, the QR group significantly reduced the number of text message reminders with higher attendances at the first scheduled follow-up (p < 0.001, p =  0.001). Besides, the TEL group cost a median time of 258 s and a median cost of RMB 5.8 yuan to complete a follow-up consultant, but was associated with a significantly high omission rate of follow-up responses comparing to the QR group (p = 0.002). Patient satisfaction was comparable between two groups.

CONCLUSION

QR code follow-up can be more efficient than traditional telephone contact in assessing the post-discharge recovery after strabismus day surgery, which provides a safe and intuitively alternative follow-up pathway for identifying issues that may necessitate further clinical care for more low-risk ophthalmic day surgeries.

Application of a selective hospitalization model in the clinical practice of breast surgery

This study aimed to explore the clinical application of a selective hospitalization model in breast disease specialties and to evaluate its effectiveness. Information of patients registered in the selective hospitalization model and those registered in the direct model between October 1, 2020, and October 31, 2022, were collected. The hospitalization days and expenses of patients admitted through distinct modes and divergent medical categories were examined. After completing relevant examinations during the selected hospitalization period, 708 patients were admitted to our medical group for further treatment during the study period. Furthermore, 401 patients underwent hospitalization procedures immediately after the initial visit and received additional treatment after completing pertinent examinations during hospitalization. For patients who underwent benign surgery after admission, there was a significant difference in the length of hospital stay between patients admitted through selective hospitalization and those admitted directly (P < .001); however, there was no significant difference in total hospital expenses (P = .895). For patients who underwent malignant surgery after admission, there were significant differences in the length of hospital stay (P < .001) and total cost of hospitalization (P = .015). There was no significant difference in the length of hospital stay between the 2 groups of patients initially admitted for neoadjuvant chemotherapy (P = .589); however, the total cost of hospitalization significantly differed (P < .001). The selective hospitalization model can reduce medical expenses and the average length of hospital stay. This new hospitalization model is more flexible and allows for the inclusion of outpatient examination costs in subsequent hospitalization medical insurance reimbursement, greatly reducing the financial burden on patients. It is worthy of further exploration, optimization, and promotion.

Exploration and Application of the Peri-anesthesia Nursing Management Mode of the Five-Sphere Integrated Plan

Objectives: The objective of this research was to test the application of peri-anesthesia nursing management (anesthesia preparation room, operating room, recovery room, post anesthesia visit, and anesthesia general management) on hospital services. Methods: We used a quantitative research design to collect data from 311 nurses, with structural equation modeling used for data analysis. Results: The application of the peri- anesthesia nursing management mode of the five-sphere integrated plan impacted hospital services for patients. Conclusion: The practice of the five-sphere integrated mode not only highlighted the professional characteristics of anesthesia nursing, but also ensured the quality of medical treatment of patients during peri-anesthesia, and provided new ideas and references for nursing management of other specialties.

Introducing A Day-Case Shoulder Arthroplasty Pathway In The UK - How We Did It

Background

As the demand for elective orthopaedics grows, day-case arthroplasty is gaining popularity. The aim of this study was to create a safe and reproducible pathway for day-case shoulder arthroplasty (DCSA) based upon a literature review and discussion with the local multidisciplinary team (MDT).

Methods

A literature review was performed using OVID MEDLINE and Embase databases reporting 90-day complication and admission rates following DCSA. Minimum follow-up was 30 days. Day-case was defined as discharge on the same day of surgery.

Results

The literature review revealed a mean 90-day complication rate of 7.7% [range, 0-15.9%] and mean 90-day readmission rate of 2.5% [range 0-9.3%]. A pilot protocol was devised based upon the literature review and consisted of 5 phases: (1) pre-operative assessment, (2) intra-operative phase, (3) post-operative phase, (4) follow-up, and (5) readmission protocol. This was presented, discussed, amended, and ultimately ratified by the local MDT. In May 2021 the unit successfully completed its first day-case shoulder arthroplasty.

Discussion

This study proposes a safe and reproducible pathway for DCSA. Patient selection, well-defined protocols and communication within the MDT are important factors to achieve this. Further studies with extended follow-up will be needed to gauge long-term success within our unit.

Efficacy and safety of remimazolam tosilate versus propofol in patients undergoing day surgery: a prospective randomized controlled trial

BACKGROUND

Remimazolam tosilate (RT) is a novel short-acting GABA (A) receptor agonist that has a rapid recovery from procedural sedation and can be fully reversed by flumazenil. To date, there have been relatively few articles comparing RT and propofol for general anesthesia. This study aimed to assess the efficacy and safety of RT with or without flumazenil compared with propofol in general anesthesia for day surgery.

METHODS

115 patients scheduled for day surgery were randomized into three groups: RT (n = 39), RT + flumazenil (n = 38) and propofol (n = 38). The primary endpoints were anesthesia induction time and time until fully alert. Anesthesia success rate, bispectral index (BIS) values, injection pain, opioid and vasopressor dosages, postoperative recovery profiles and perioperative inflammatory and cognitive changes were assessed. Any adverse events were recorded.

RESULTS

Induction times were similar among the three groups (P = 0.437), but the median time until fully alert in patients treated with RT was longer than that of the propofol or RT + flumazenil groups (17.6 min vs. 12.3 min vs. 12.3 min, P < 0.001). The three groups had comparable postoperative recovery quality and inflammatory and cognitive state changes (P > 0.05). Smaller percentages of patients who received RT (26.3%) and RT + flumazenil (31.6%) developed hypotension during anesthesia maintenance compared with propofol (68.4%), and consequently less ephedrine (P < 0.001) and phenylephrine (P = 0.015) were needed in the RT group. Furthermore, serum triglyceride levels were lower (P < 0.001) and injection pain was much less frequent in the RT with or without flumazenil groups compared with the propofol group (5.3% vs. 0% vs. 18.4%).

CONCLUSION

RT permits rapid induction and comparable recovery profile compared with propofol in general anesthesia for day surgery, but has a prolonged recovery time without flumazenil. The safety profile of RT was superior to propofol in terms of hypotension and injection pain.

TRIAL REGISTRATION

The study was registered at Chinese Clinical Trial Registry http://www.chictr.org.cn/ (Registration date: 19/7/2021; Trial ID: ChiCTR2100048904).

Emergency versus semi-elective management of mandible fractures: a Maxillofacial Trainee Research Collaborative (MTReC) study

INTRODUCTION

Recent evidence suggests that acute emergency management of mandible fractures does not improve surgical outcomes yet is associated with increased financial burden. Current NHS policy advocating for increased adoption of day-case and semi-elective surgical procedures to reduce bed strain must be balanced with providing timely, effective treatment. Our research aims to determine patient groups currently managed via semi-elective admission and whether this can be extended to other groups to provide safe and effective management of mandible fractures.

METHODS

A multi-national trainee-led audit of mandibular fractures across 49 units was completed by the Maxillofacial Trainee Research Collaborative (MTReC). Each unit prospectively collected data on fractures on admission and at follow-up. Data collected included patient demographics, behaviour, health, injury, timing to intervention and surgical complications.

RESULTS

Data were collected on 947 mandibular fractures. Of the surgically managed patients, 649 (90%) were managed via acute emergency admission at the time of presentation, while 68 (10%) were managed semi-electively. Patient demographics, injury pattern and mechanism appeared to significantly affect timing of management, whereas patient behaviour, health status, timing of injury and presentation did not. Semi-elective management was associated with a significantly shorter inpatient duration (0.9 versus 1.9 days, p=0.000) with no differences in readmission, antibiotic usage or surgical complications (p=1.000, RR 1.030).

CONCLUSION

Our study demonstrates the efficacy of planned admissions and semi-elective management of mandibular fractures. Simple mandibular fractures in compliant patients are suitable for semi-elective treatment. Holistic patient assessment and tailored surgical planning is crucial in determining admission modality to effectively manage mandibular trauma.

Perceived barriers and facilitators of day-case surgery for major foot and ankle procedures? A cross-sectional survey of United Kingdom surgeons

BACKGROUND

Advances in minimally invasive surgery and improved post-operative pain management make it possible to consider performing even major foot/ankle operations as day-case. This could have significant benefits for patients and the health service. However there are theoretical concerns about post-operative complications and patient satisfaction due to pain.

AIM

To scope the current practice of foot and ankle surgeons on day-case surgery for major foot and ankle procedures in the United Kingdom (UK).

METHODS

An online survey (19 questions) was sent to UK foot and ankle surgeons via the British Orthopaedic Foot & Ankle Society membership list in August 2021. Major foot and ankle procedures were defined as surgery that is usually performed as an inpatient in majority of centres and day-case as same day discharge, with day surgery as the intended treatment pathway.

RESULTS

132 people responded to the survey invitation with 80% working in Acute NHS Trusts. Currently 45% of respondents perform less than 100 day-case surgeries per year for these procedures. 78% felt that there was scope to perform more procedures as day-case at their centre. Post-operative pain (34%) and patient satisfaction (10%) was not highly measured within their centres. Lack of adequate physiotherapy input pre/post-operatively (23%) and lack of out of hours support (21%) were the top perceived barriers to performing more major foot and ankle procedures as day-case.

CONCLUSION

There is consensus among UK surgeons to do more major foot/ankle procedures as day-case. Out of hours support and physiotherapy input pre/ post-op were perceived as the main barriers. Despite theoretical concerns about post-operative pain and satisfaction this was only measured by a third of those surveyed. There is a need for nationally agreed protocols to optimise the delivery of and measurement of outcomes in this type of surgery. At a local level, the provision of physiotherapy and out of hours support should be explored at sites where this is a perceived barrier.

Developing day-case units: imperative for optimal patient care in interventional radiology

As interventional radiology (IR) treatments have evolved, they have become less invasive, enabling rapid recovery, which expedites ambulation and promotes same-day discharge. As a result of this, a significant proportion of IR elective work can be provided using a day-case service model. Reconfiguration of IR services to increase day-case procedures using a dedicated IR day-case unit (RDU) to facilitate the passage of patients is vital to ensure best medical practice. The aim of this review is to discuss the benefits of day-case IR procedures, the optimal structure of an RDU, and to inform radiologists how to introduce and/or improve day-case IR services in their IR practice.

Postoperative acute kidney injury after volatile or intravenous anesthesia: a meta-analysis

Postoperative acute kidney injury (AKI) is a common complication after surgery. The pathophysiology of postoperative AKI is complex. One potentially important factor is anesthetic modality. We, therefore, conducted a meta-analysis of the available literature regarding anesthetic modality and incidence of postoperative AKI. Records were retrieved until January 17, 2023, with the search terms ("propofol" OR "intravenous") AND ("sevoflurane" OR "desflurane" OR "isoflurane" OR "volatile" OR "inhalational") AND ("acute kidney injury" OR "AKI"). A meta-analysis for common effects and random effects was performed after exclusion assessment. Eight records were included in the meta-analysis with a total of 15,140 patients (n = 7,542 propofol and n = 7,598 volatile). The common and random effects model revealed that propofol was associated with a lower incidence of postoperative AKI compared with volatile anesthesia [odds ratio: 0.63 (95% confidence interval: 0.56-0.72) and 0.49 (95% confidence interval: 0.33-0.73), respectively]. In conclusion, the meta-analysis revealed that propofol anesthesia is associated with a lower incidence of postoperative AKI compared with volatile anesthesia. This may motivate choosing propofol-based anesthesia in patients with increased risk of postoperative AKI due to preexisting renal impairment or surgery with a high risk of renal ischemia.NEW & NOTEWORTHY This study analyzed the available literature on anesthetic modality and incidence of postoperative AKI. The meta-analysis revealed that propofol is associated with lower incidence of AKI compared with volatile anesthesia. It might therefore be considerable to use propofol anesthesia in surgeries with increased susceptibility for developing renal injuries such as cardiopulmonary bypass and major abdominal surgery.

Study on the effectiveness and safety of ciprofol in anesthesia in gynecological day surgery: a randomized double-blind controlled study

BACKGROUD

ciprofol is a new type of intravenous anesthetic, which is a tautomer of propofol, with the characteristics of less injection pain, less respiratory depression and higher potency, but little clinical experience. The aim of this study was to observe the efficacy and safety of the application of ciprofol in ambulatory surgery anesthesia in gynecology.

METHODS

128 patients were selected to undergo gynecological day surgery under general anesthesia, and the patients were randomly divided into the ciprofol group and the propofol group, with 64 cases in each group. During anesthesia induction, the ciprofol group was infused at a time limit of 0.5 mg/kg for one minute, and the propofol group was infused at a time limit of 2 mg/kg for 1 min. The overall incidence of adverse events was the primary outcome for this study, while secondary outcomes included the success rate of anesthesia induction, the time of loss of consciousness, the time of awakening,top-up dose and frequency of use of rescue drugs.

RESULTS

The overall incidence of adverse events was significantly lower in the ciprofol group compared with the propofol group (56.2% vs. 92.2%,P < 0.05). The success rate of anesthesia induction of ciprofol and propofol group was 100.0%. The time of loss of consciousness of the ciprofol group was longer than that of the propofol group (1.6 ± 0.4 min vs. 1.4 ± 0.2 min, P < 0.05). The time of awakening was not statistically significant (5.4 ± 2.8 min vs. 4.6 ± 1.6 min, P > 0.05). The number of drug additions and resuscitation drugs used were not statistically significant.

CONCLUSIONS

Compared with propofol, ciprofol had a similar anesthetic effect in gynecological ambulatory surgery, and the incidence of adverse events in the ciprofol group was lower.

ORthopaedic trauma hospital outcomes - Patient operative delays (ORTHOPOD) Study: The management of day-case orthopaedic trauma in the United Kingdom

INTRODUCTION

ORTHOPOD: Day Case Trauma is a multicentre prospective service evaluation of day-case trauma surgery across four countries. It is an epidemiological assessment of injury burden, patient pathways, theatre capacity, time to surgery and cancellation. It is the first evaluation of day-case trauma processes and system performance at nationwide scale.

METHODS

Data was prospectively recorded through a collaborative approach. Arm one captured weekly caseload burden and operating theatre capacity. Arm two detailed patient and injury demographics, and time to surgery for specific injury groups. Patients scheduled for surgery between 22/08/22 and 16/10/22 and operated on before 31/10/22, were included. For this analysis, hand and spine injuries were excluded.

RESULTS

Data was obtained from 86 Data Access Groups (70 in England, 2 in Wales, 10 in Scotland and 4 in Northern Ireland). After exclusions, 709 weeks worth of data representing 23,138 operative cases were analysed. Day-case trauma patients (DCTP) accounted for 29.1% of overall trauma burden and utilised 25.7% of general trauma list capacity. They were predominantly adults aged 18 to 59 (56.7%) with upper limb Injuries (65.7%). Across the four nations, the median number of day-case trauma lists (DCTL) available per week was 0 (IQR 1). 6 of 84 (7.1%) hospitals had at least five DCTLs per week. Rates of cancellation (13.2% day-case; 11.9% inpatient) and escalation to elective operating lists (9.1% day-case; 3.4% inpatient) were higher in DCTPs. For equivalent injuries, DCTPs waited longer for surgery. Distal radius and ankle fractures had median times to surgery within national recommendations: 3 days and 6 days respectively. Outpatient route to surgery was varied. Dominant pathways (>50% patients listed at that episode) in England and Wales were uncommon but the most frequently seen was listing patients in the emergency department, 16 of 80 hospitals (20%).

CONCLUSION

There is significant mismatch in DCTP management and resource availability. There is also considerable variation in DCTP route to surgery. Suitable DCTL patients are often managed as inpatients. Improving day-case trauma services reduces the burden on general trauma lists and this study demonstrates there is considerable scope for service and pathway development and improved patient experience.

Comparison of day-case versus inpatient uni-compartmental knee replacement

BACKGROUND

Uni-compartmental knee replacement (UKR) is an alternative to total knee replacement for patients who have isolated compartment osteoarthritis. Studies have demonstrated that UKR can be safely performed as a day-case procedure without a negative impact on complication rates. The aim of this study was to compare the clinical outcomes between day-case and inpatient UKRs.

METHODS

A single surgeon prospective case-controlled study was performed, comparing data between day-case UKRs and inpatient UKRs. This included longitudinal analysis of patient reported outcome measures (PROMs); including the Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score, Short Form 12-item Health Survey, EQ-5D-5L and the Self-administered Comorbidity Questionnaire. Post-operative pain scores (visual analogue scale), unplanned post-operative hospital reattendance rates and complications were also analysed.

RESULTS

Overall, 100% of day-case patients were successfully discharged on the same day. Both inpatient (n = 23) and day-case (n = 23) UKRs demonstrated a significant within group longitudinal improvement of PROM scores (p < 0.05) following surgery. However, the post-operative PROM scores were significantly higher in the day-case group as compared to the inpatient group (p < 0.05). Both groups had comparable post-operative pain scores, but the day-case group demonstrated fewer unplanned reattendances and post-operative complications.

CONCLUSION

The clinical outcomes of day-case UKR are superior to inpatient UKR. Careful patient selection and a robust multidisciplinary patient pathway are the key components to success of day-case joint replacement surgery.

LEVEL OF EVIDENCE

Prospective Case-Control Study, level III.

Effectiveness of no drainage after elective day-case laparoscopic cholecystectomy, even with intraoperative gallbladder perforation: a randomized controlled trial

BACKGROUND

Laparoscopic cholecystectomy (LC) has been carried out as day-case surgery. Current guidelines do not mention the role of drainage after LC. In particular, data stay blank with no prospective study on drainage management when gallbladder perforation (GP) accidentally occurs intraoperatively.

METHODS

A randomized controlled trial was conducted to compare clinical outcomes of drainage and no drainage after elective day-case LC. Intraoperative GP was recorded. The primary and secondary outcomes were major and minor complications, respectively.

RESULTS

Two hundred patients were randomized. No major complications occurred in either group. In secondary outcomes, nausea/vomiting, pain, hospital stay, and cost were similar in the drainage group and no drainage group; postoperative fever, WBC, and CRP levels were significantly lower in the no drainage group. GP occurred in 32 patients. Male patients with higher BMI and CRP and abdominal pain within 1 month were more likely to occur GP. Subgroup analysis of GP, primary outcomes, and most secondary outcomes had no difference. Postoperative WBC and CRP were higher in the drainage group. Postoperative fever occurred in 63 patients. Univariate analysis of fever showed that blood loss, drainage, postoperative WBC, CRP, and hospital stay were significant. Multivariable logistic regression analysis demonstrated that drainage was an independent risk factor for fever after LC (OR 3.418, 95% CI 1.392-8.390; p = 0.007).

CONCLUSIONS

No drainage after elective day-case LC is safe and associated with fewer complications, even in intraoperative GP. The trial proves that drainage is an independent risk factor for postoperative fever. The use of a drain after LC may lead to an unsuccessful day-case procedure by causing fever, elevated CRP, and extended hospital stay (NCT03909360).

Early post-operative physiotherapy rehabilitation after primary unilateral unicompartmental knee replacement: a systematic review

BACKGROUND

Unicompartmental Knee Replacement (UKR) is an established treatment for end stage arthritis affecting one compartment of the knee. UKR lends itself to rapid recovery and early discharge. The content, type, timing and dose of early post-operative physiotherapy treatment has yet to be reviewed.

OBJECTIVE

To review the content of early physiotherapy in the first eight weeks following unilateral UKR.

DATA SOURCES

A literature search of Medline, CINAHL, AMED and PubMed and the Physiotherapy Evidence Database (PEDRo) plus citation searching.

ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) and observational studies reporting a physiotherapy intervention for UKR involving a form of post-operative exercise/education/advice delivered within the first eight weeks of surgery and commencing as an in-patient. Two reviewers independently performed screening, data extraction and risk of bias assessment.

DATA SYNTHESIS

Narrative syntheses were undertaken due to the heterogeneity of the primary outcomes.

RESULTS

Eleven studies were included (n = 1293 participants), three RCTs and eight observational studies. The dose and content of post-operative physiotherapy was highly variable with a move in recent years to rapid recovery and same day discharge with more self-directed rehabilitation. No studies had a low risk of bias.

LIMITATIONS

Small sample sizes and high heterogeneity limit our findings CONCLUSIONS: This review highlights the range of post-operative physiotherapy provision following UKR with a recent move to minimal physiotherapy input. Further research is required to identify those patients who may need additional physiotherapy above that now routinely provided, along with the most effective timing, type, and dosage of the intervention.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021243238. CONTRIBUTION OF THE PAPER.