Outpatient (same‐day discharge) versus inpatient parotidectomy: A systematic review and meta‐analysis

The timing of drain removal in parotidectomies: outcomes of removal at 4 h post-operatively and a Canadian survey of practice patterns

BACKGROUND

The post-operative management of parotidectomies is highly provider dependent. No guidelines are currently available for timing of parotid drain removal. This study aimed to assess: (1) outcomes and complications after early drain removal (< 4 h, post-operative day [POD] 0) versus late drain removal (POD ≥ 1); (2) current Canadian provider practices.

METHODS

A single surgeons ten-year parotidectomy practice was reviewed, spanning his practice change from routine POD ≥ 1 drain removal to POD 0 removal, with extraction of patient demographic, disease, and complication variables. An anonymous, cross-sectional survey on parotid drain practices was distributed to Canadian Society of Otolaryngology-Head and Neck Surgery members. Descriptive statistics, Wilcoxon Rank Sum, and unpaired student's t-tests were calculated.

RESULTS

In total, 526 patients were included and 44.7% (235/526) had drains removed POD 0. There was no significant difference in hematoma or seroma rates between the POD 0 and POD ≥ 1 drain removal cohorts. The national survey on parotid drain management had 176 responses. The majority (67.9%) reported routinely using drains after parotidectomy and 62.8% reported using a drain output based criteria for removal. The most common cut-off output was 30 ml in 24 h (range 5-70 ml).

CONCLUSION

There was no difference in hematoma or seroma rates for patients with parotid drains removed on POD 0 versus POD ≥ 1. Our national survey found significant variation in Canadian parotidectomy drain removal practices, which may be an area that can be further assessed to minimize hospital resources and improve patient care.

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.

Safety outcomes and patient convenience in outpatient parotidectomy

BACKGROUND

Parotidectomies have historically been performed on an inpatient basis despite being well-tolerated surgeries with minimal postoperative wound care and low rates of complications at high-volume institutions. Past studies have supported the safety of outpatient surgery for parotidectomy but have been limited to superficial parotidectomy and have not addressed the patient experience surrounding the surgical intervention such as pre-operative and post-operative care and communication.

PURPOSE

This study assesses the impact of outpatient superficial, deep, and partial parotid surgery on various parameters including surgical safety, distance traveled for care, utilization of telehealth, and patient-initiated communication.

MATERIALS AND METHODS

Retrospective study from January 2020 to October 2021. Patients undergoing superficial lobe, deep lobe, and partial parotidectomies for benign and malignant pathologies were divided into inpatient and outpatient cohorts. A multivariable model examined the relationship between admission status and surgical complications, adjusted for age, sex, and tumor size.

RESULTS

159 patients total, 94 outpatient and 65 inpatients. No statistical difference in rates of surgical complications with the exception of salivary leak. There was an increased rate of salivary leak reported in the inpatient group (OR 5.4, 95 % CI 1.6 to 18.0, p = 0.01). Mean patient travel distance of 354 miles one-way. Post-operatively, 76 % were evaluated via video visit. Following discharge, >55 % of patients initiated communication with the surgical team, which was not statistically different between the groups.

CONCLUSIONS

Outpatient parotidectomy is safe and can be more convenient, but telehealth communication must be balanced with rigorous attention to patient education.

Outpatient parotidectomy with or without the use of a post-operative drain: A retrospective bi-institutional study

OBJECTIVE

Parotid surgery is historically performed as an inpatient procedure and suctions drains are predominantly used during surgery. Recent literature provides evidence that outpatient parotid surgery is safe and effective. Our study aims to describe the results of drainless outpatient parotidectomy and outpatient parotidectomy with drain placement and compare their outcomes.

DESIGN

Retrospective cohort study.

SETTING

Bi-institutional retrospective cohort study.

PARTICIPANTS

Patients that underwent outpatient drain-less parotidectomy and patients that underwent outpatient parotidectomy with post-operative drain placement.

MAIN OUTCOME MEASURES

Complication rates, unplanned post-operative visits, unplanned prolonged stay.

RESULTS

Three hundred eighty patients underwent outpatient parotidectomy with drain placement and 31 patients underwent outpatient drainless parotidectomy in two different hospitals. The incidence of haematoma (drain: 3.1% vs. drainless: 0%, p = 1), infection (drain: 14.3% vs. drainless: 13.8%, p = 1) and salivary fistula (drain: 5.6% vs. drainless: 3.4, p = 1) were comparable between both groups. Seroma or sialocele was more frequently seen in the drain-less group (27.6% vs. 6.2%, p < .001), but were all managed conservatively. Within 10 days after surgery, unplanned visits seemed more frequent in the drain group, although the difference was not statistically significant (14.9% vs. 3.4%, p = .16).

CONCLUSIONS

Outpatient parotid surgery with or without the use of a post-operative drain is safe, practical and feasible. Same-day discharge with and without drain placement yield comparable outcomes. However, the results need to be interpreted cautiously as this study was limited by a small cohort of parotidectomies without drain placement. Future studies should further compare both approaches.

Outpatient Submaxillectomy Using Active Drains. Safety of the Procedure and Patient Satisfaction

Surgical interventions on an outpatient basis are defined as those procedures in which the patient is discharged the same day of the surgery after monitoring the subject during the immediate postoperative period. Submaxillectomies have conventionally been performed on an inpatient basis, and hospital stay was determined by the drain removal. This study aims to establish both safety and patient satisfaction following outpatient submaxillectomies using active drains. Fifteen patients between March 2016 and March 2020 underwent submaxillectomies using active drains in an outpatient basis. No patient had to be readmitted, and there were no complications that could be associated with the outpatient basis of this procedure, showing the safety of this surgical regimen. Patient satisfaction degree was high, with 86.7% of the patients declaring low or no pain as well as appropriate hospital stay. Most of the patients stated that they would accept the surgery in an outpatient basis once again. The performance of an outpatient submandibular gland removal is a safe and well-accepted procedure by the patient.

Outpatient Parotidectomy, a Safety and Financial Review

OBJECTIVE

The objective of this study is to investigate the safety, efficacy, and potential cost-savings of the outpatient parotidectomy procedure.

METHODS

This is a retrospective chart review of all patients who underwent a parotidectomy at a large academic center from 2015 through 2019 including demographic data, postoperative complications, drain placement, readmission, and financial cost. A comparison was performed between patients who underwent an outpatient vs inpatient parotidectomy.

RESULTS

A total of 335 patients underwent parotidectomy (136 outpatient; 199 inpatient). Comparison of patient demographics, common comorbidities, tumor size, tumor type, postoperative complications, and readmission rate was similar between the inpatient and outpatient cohorts. The overall mean cost difference between inpatient parotidectomy and outpatient parotidectomy for all years was $1528.58 (95%CI: $1139-$1916).

CONCLUSION

The outpatient parotidectomy procedure has a comparable safety profile to the inpatient procedure while providing a significant cost-savings benefit.

[Outpatient Surgery in German ENT]

Currently there is an intense discussion ongoing to enhance and expand outpatient surgery in the ENT in Germany, which is the intention by several politicians. The goal is to achieve a frequency of outpatient surgery comparable to an international level.To achieve this goal, acceptance of outpatient interventions by both, surgeons and patients is required, particularly in regard of equal quality standards and patient safety requirements.In the following review the organization, outcome, quality management and strategies for different ENT outpatient surgery worldwide is analyzed. Basically, outpatient surgery is organized in different ways: office-based-procedures in local anesthesia, procedures in ambulatory surgery center settings as standalone facilities or in connection with and adjacent to a hospital with possible inpatient treatment. Contact and resident times of the patients in the outpatient surgery centers differ between some hours through 23 hours. A deliberated and careful selection of patients which are suitable for outpatient procedures is required and should address comorbidities, medications, social circumstances, health literacy of the patient and its relatives, and distance from home to the hospital. A careful and strict quality management is mandatory which comprises the entire process from patient selection through patient entry, surgery, discharge and postoperative care in a multidisciplinary setting.Zur besseren Lesbarkeit des Textes wird bei geschlechterbezogenen Bezeichnungen die männliche Form benutzt. Es sind jedoch in gleicher Rangfolge auch das jeweilige weibliche Geschlecht oder andere Geschlechtsausprägungen gemeint.

Outpatient versus inpatient superficial parotidectomy: clinical and pathological characteristics

Background

Superficial parotidectomy has a potential to be performed as an outpatient procedure. The objective of the study is to evaluate the safety and selection profile of outpatient superficial parotidectomy compared to inpatient parotidectomy.

Methods

A retrospective review of individuals who underwent superficial parotidectomy between 2006 and 2016 at a tertiary care center was conducted. Primary outcomes included surgical complications, including transient/permanent facial nerve palsy, wound infection, hematoma, seroma, and fistula formation, as well as medical complications in the postoperative period. Secondary outcome measures included unplanned emergency room visits and readmissions within 30 days of operation due to postoperative complications.

Results

There were 238 patients included (124 in outpatient and 114 in inpatient group). There was no significant difference between the groups in terms of gender, co-morbidities, tumor pathology or tumor size. There was a trend towards longer distance to the hospital from home address (111 Km in inpatient vs. 27 in outpatient, mean difference 83 km [95% CI,- 1 to 162 km], p = 0.053). The overall complication rates were comparable between the groups (24.2% in outpatient group vs. 21.1% in inpatient, p = 0.56). There was no difference in the rate of return to the emergency department (3.5% vs 5.6%, p = 0.433) or readmission within 30 days (0.9% vs 0.8%, p = 0.952).

Conclusion

Superficial parotidectomy can be performed safely as an outpatient procedure without elevated risk of complications.

Graphical abstract

Day case superficial parotidectomy-does it work?

PURPOSE

To establish if day case superficial parotidectomy is feasible, safe and does not result in excess readmissions.

METHOD

A retrospective review was carried out of all patients listed for superficial parotidectomy with day case intent by a single surgeon between January 2016 and December 2019 inclusively. The reasons for failure of same day discharge were established. Postoperative complications and readmissions were recorded. Our approach for a superficial parotidectomy typically includes the use of a 10Fr suction drain which is removed at 4 h postoperatively if the output is less than 30 ml.

RESULTS

Ninety-one consecutive superficial parotidectomies listed for day case surgery were eligible for inclusion. Seventeen patients failed to be discharged on the same day and were admitted giving a day case success rate of 81%. Most of these (n = 9) occurred in the first year of adopting day case surgery. The most common reason to admit patients was a late finish (n = 8, 47%). Six patients (25%) were admitted due to anaesthetic complications. One patient had a surgical complication requiring admission.

CONCLUSION

Our series demonstrates that day case superficial parotidectomy using a surgical drain is feasible, safe and does not result in an unacceptable readmission rate. In our experience, surgical complications are an uncommon cause for day case failure. The most common cause for day case failure was a late finish. Postoperative complications including bleeding, seroma/salivary collection and facial nerve palsy were in keeping with or better than those quoted in the literature.

Offene Varizenchirurgie – wann ambulant, wann stationär?

Hintergrund Die offene Varizenchirurgie kann sowohl in einem ambulanten als auch in einem stationären Setting durchgeführt werden. Aktuelle Leitlinien zur Therapie der Varikose nehmen zu der Frage, welche Patienten ambulant und welche stationäre zu operieren sind, nicht Stellung.

Fragestellung Erarbeitung von Kriterienkatalogen zur Frage einer ambulanten oder stationären Varizenoperation.

Material und Methode PubMed-Recherche zur Fragestellung und basierend auf den Literaturdaten Erarbeitung eines Delphi-Konsensus der Autoren.

Ergebnisse Zur Frage, ob eine Varizenchirurgie ambulant oder stationär durchgeführt werden kann, existieren lediglich 2 monozentrische retrospektive Analysen sowie eine Registerstudie. In diesen Studien werden ambulante Operationen im Wesentlichen bei Patienten mit Normalgewicht und ASA-Stadium 1 durchgeführt. Gut geeignete Lokalbefunde für eine ambulante Operation sind Primäreingriffe und ein geringeres C-Stadium der CEAP-Klassifikation. Für eine stationäre Varizenoperation sprechen ausgedehnte Befunde, bei denen mehr als eine Crosse saniert werden muss, Rezidiveingriffe in der Leiste oder der Kniekehle, vorangegangene thromboembolische Ereignisse, eine erhöhte Blutungsneigung aufgrund monströser Varizen oder einer Antikoagulation, Hautkomplikationen wie ein Ulcus cruris oder eine schwere Stauungsdermatitis bzw. Dermatosklerose sowie ein BMI über 30 bei Crossektomie.

Schlussfolgerungen Basierend auf Literaturdaten und Expertenmeinungen konnten Kriterienkataloge für eine ambulante versus stationäre offene Varizenchirurgie erarbeitet werden.

Prospective outcomes following drainless superficial parotidectomy with sternocleidomastoid flap reconstruction

Background

Patients undergoing superficial parotidectomy for benign parotid lesions are at risk of postoperative complications, most notably cosmetic complications such as facial paralysis and contour defects, and functional complications including Frey’s syndrome. Traditionally, surgical drains have been placed at the end of surgery to prevent hematoma and sialocele formation. However, this can increase the risk of postoperative complications and contribute to a prolonged course in hospital. To try and prevent these risks and complications, we introduced a novel technique of a drainless parotidectomy by reconstructing the resulting parotid bed defect with a superiorly based sternocleidomastoid (SCM) rotational flap and by placement of gelfoam into the wound bed and a facelift dressing postoperatively to provide additional hemostasis and avoid drain placement.

Methods

All patients with benign parotid disease undergoing a drainless superficial parotidectomy and reconstruction with a superiorly based SCM rotational flap at our center were identified within a prospective cohort database between July 2010–2018. Primary outcomes included postoperative cosmetic and functional outcomes, complications and length of hospital stay. A secondary cost analysis was done to compare this novel technique to traditional superficial parotidectomy with surgical drain placement.

Results

Fifty patients were identified within the database and were included in the final analysis. The average length of hospital stay was 1.02 days. All patients were satisfied with their aesthetic outcome at 1 year. During long term follow-up, 63% of patients reported normal appearance of the operated side. Seven patient’s (14%) developed temporary facial paresis following surgery. All patients had resultant normal facial function at follow-up in 1 year. No patients developed subjective Frey’s Syndrome. Two patients (4%) developed a postoperative sialocele requiring drainage and one patient (2%) developed a hematoma on extubation requiring evacuation and drain placement. Cost analysis demonstrated a cost savings of approximately $975 per person following surgery.

Conclusion

In the current study, we introduced a novel approach of a drainless superficial parotidectomy using a superiorly based SCM flap, gelfoam and placement of a post-operative facelift dressing. This drainless approach was associated with good long-term cosmetic and functional outcomes with few postoperative complications. This new technique may also offer the potential for long-term savings to the health care system.