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.

AUDIT OF THE PRACTICE OF DAY CASE SURGERY IN THE DIVISION OF PAEDIATRIC SURGERY, UNIVERSITY COLLEGE HOSPITAL, IBADAN

Background

Paediatric day case surgery refers to planned procedures on patients on a non-resident basis but requires some facilities and time for recovery before discharge home on the day of surgery. This study was conducted to audit paediatric day case surgery practice at our centre, and to determine the outcome of day case surgeries.

Patients and Methods

This is a retrospective study of cases seen over a period of 12 years, 2010 to 2022. These patients' data were assessed from their case notes and information obtained for each of the patients included age, gender, diagnosis, type of operation, type of anesthesia and post operative complications. The data were analyzed using SPSS version 22.0 for windows.

Results

A total of 1,211 patients were recruited, with a M: F; 6: 1. The age of patients ranged from one week to 15 years with a median age of two years. A higher proportion of case load involved infants and toddlers compared to the other paediatric age groups. In this review, the largest volume of cases was seen in the last five years with the peak in 2018 (202). The right groin for an isolated diagnosis was operated in 381 (59 %) patients compared to the left 265 (41 %). The mean duration of surgery time was 40 minutes. Most of the patients had General Anesthesia (GA) with endotracheal tube, face mask, and laryngeal mask airway (LMA) using isoflurane, halothane and propofol at different times as anesthetic agents. There were no re admissions or mortality, however two of our patients had recurrence necessitating a re-do surgery.

Conclusion

Groin hernias are the most common day cases in children in our facility. Day case paediatric surgery is safe, and outcome is generally good, when well managed.

Potential Carbon Savings with Day-case Compared to Inpatient Transurethral Resection of Bladder Tumour Surgery in England: A Retrospective Observational Study Using Administrative Data

Background

The National Health Service (NHS) in England has set a net-zero target for carbon emissions by 2040. Increasing use of day-case surgery pathways may help in meeting this target.

Objective

To investigate the estimated difference in carbon footprint between day-case and inpatient transurethral resection of bladder tumour (TURBT) surgery in England.

Design setting and participants

This was a retrospective analysis of administrative data extracted from the Hospital Episode Statistics database for all TURBT procedures conducted in England from April 1, 2013 to March 31, 2022.

Outcome measurements and statistical analysis

Day-case and inpatient TURBT procedures were identified and the carbon footprint for key elements of the surgical pathway was estimated using data from Greener NHS and the Sustainable Healthcare Coalition.

Results and limitations

Of 209 269 TURBT procedures identified, 41 583 (20%) were classified as day-case surgery. The day-case rate increased from 13% in 2013-2014 to 31% in 2021-2022. The move from inpatient stays to day-case surgery between 2013-2014 and 2021-2022 demonstrates a trend toward a lower-carbon pathway, with an estimated saving of 2.9 million kg CO₂ equivalents (equivalent to powering 2716 homes for 1 yr) in comparison to no change in practice. We calculated that potential carbon savings for the financial year 2021-2022 would be 217 599 kg CO₂ equivalents (equivalent to powering 198 homes for 1 yr) if all hospitals in England not already in the upper quartile were able to achieve the current upper-quartile day-case rate. Our study is limited in that estimates are based on carbon factors for generic surgical pathways.

Conclusions

Our study highlights potential NHS carbon savings that could be achieved by moving from inpatient stays to day-case surgery. Reducing variation in care across the NHS and encouraging all hospitals to adopt day-case surgeries, where clinically appropriate, would lead to further carbon savings.

Patient summary

In this study we estimated the potential for carbon savings if patient undergoing bladder tumour surgery were admitted and discharged on the same day. We estimate that increasing use of day-case surgery between 2013-2014 and 2021-2022 has saved 2.9 million kg CO₂ equivalents. If all hospitals were to achieve day case-rates comparable to those in the highest quarter of hospitals in England in 2021-2022, then the carbon equivalent to powering 198 homes for 1 year could have been saved.

Costs and budget impact of collagen-based vascular closure device versus manual compression following peripheral endovascular procedures

OBJECTIVES

To evaluate the annual costs and budget impact of using a vascular closure device to achieve haemostasis following femoral access endovascular procedures in England, compared with manual compression.

METHODS

A budget impact model was developed in Microsoft® Excel, based on the estimated number of peripheral endovascular procedures eligible for day-case management performed annually by the National Health Service in England. The clinical effectiveness of vascular closure devices was captured based on the requirement for inpatient stays and the incidence of complications. Data for endovascular procedures, time to haemostasis, length of hospital stay, and complications were collected from public sources and the published literature. There were no patients involved in this study. Model outcomes are reported as estimated number of bed days and annual costs to the National Health Service for all peripheral endovascular procedures in England, and the average cost per procedure. The robustness of the model was tested in a sensitivity analysis.

RESULTS

The model estimated savings for the National Health Service of up to £4.5 million annually if vascular closure devices were used in every procedure instead of manual compression. The model estimated an average cost saving of £176 per procedure for vascular closure devices over manual compression, primarily due to fewer inpatient stays. The sensitivity analysis demonstrated that the proportion of day-case procedures for vascular closure devices and manual compression was a key driver of costs and savings.

CONCLUSIONS

The use of vascular closure devices for achieving haemostasis after peripheral endovascular procedures may be associated with lower resource use and cost burden, compared with manual compression, based on shorter time to haemostasis and ambulation and an increased likelihood of a day-case procedure.

Efficacy and safety of same-day discharge after atrial fibrillation ablation compared with post-procedural overnight stay: a systematic review and meta-analysis

AIMS

Catheter ablation for atrial fibrillation (AF) has historically required inpatient admission post-procedure, but same-day discharge (SDD) has recently been reported. We aimed to assess the efficacy and safety of SDD compared with overnight stay (OS) post-ablation.

METHODS AND RESULTS

We performed a systematic search of the PubMed database. Random-effects meta-analysis was performed to assess the efficacy (successful SDD) and safety (24 h complications, 30-day complications, 30-day re-admissions, and 30-day mortality) of a SDD AF ablation strategy. Fourteen non-randomized observational studies met criteria for inclusion, encompassing 26488 patients undergoing AF ablation, of whom 9766 were SDD. The mean age of participants was 61.9 years, and 67.9% were male. Around 61.7% underwent ablation for paroxysmal AF. The pooled success rate of SDD was 83.2% [95% confidence intervals (CIs): 61.5-97.0%, I2 100%]. The risk of bias was severe for all effect estimates due to confounding, as most cohorts were retrospectively identified without appropriately matched comparators. There was no significant difference in 30-day complications [odds ratio (OR): 0.95, 95% CI: 0.65-1.40, I2 53%] or 30-day re-admission (OR 0.96, 95% CI: 0.49-1.89, I2 82%) between groups. There were insufficient data for meta-analysis of 24 h complications and 30-day mortality. Where reported, no re-admissions occurred due to 24 h complications after SDD. Two deaths (0.04%) were reported in both SDD and OS groups.

CONCLUSION

Same-day discharge after AF ablation appears to be an effective and safe strategy in selected patients. However, the available evidence is of low quality, and more robust prospective studies comparing SDD to OS are needed.

Patient Satisfaction with Face-to-Face Follow-Up versus Telephone Follow-Up after Elective Day Case Hand Surgery

Background: There has been increasing amounts of work on the use of telephone follow-up (TFU) in trauma and orthopaedics, but little direct work on its use in the follow-up of elective day case hand surgery. The aim of this study is to compare patient satisfaction with face-to-face follow-up (FFU) and TFU after elective day case hand surgery. Methods: Sixty-four patients from an FFU and 61 patients from a TFU cohort were contacted by telephone at least 6 months after their last follow-up. A customized questionnaire with answers recorded on a Likert scale (0-10) was used to evaluate their satisfaction with the follow-up they received. Results: Data from 48 patients from the FFU and 52 patients from the TFU cohorts were available for the analysis. There were no statistically significant differences in patient demographics between the two cohorts. Patient satisfaction was significantly greater in all domains of the questionnaire in the TFU cohort. Most patients from both cohorts (71% face-to-face, 86% telephone) said they would prefer TFU if they were to have the same procedure again. Conclusions: Patients were more satisfied with TFU compared to FFU following elective day case hand surgery. Level of Evidence: Level III (Therapeutic).

Introduction of day case hip and knee replacement programme at an inpatient ward is safe and may expedite shortening of hospital stays of traditional arthroplasties

PURPOSE

We investigated the safety of primary hip and knee replacements with same day discharge (SDD) and their effect on length of stay (LOS) of traditional inpatient arthroplasties at our elective orthopaedic ward.

METHODS

200 patients underwent elective, unilateral primary day case total hip (THA, n = 94), total knee (TKA, n = 60) and unicondylar knee replacements (UKA, n = 46). SDD rates, reasons for failure to discharge, readmission, complication and satisfaction rates were recorded at 6-week follow up. Changes in LOS of inpatient arthroplasties (n = 6518) and rate of patients discharged with only one night stay treated at the same ward were tracked from 1 year prior to introduction of day case arthroplasty (DCA) program to the end of observation period.

RESULTS

166 patients (83%) had SDD while 34 (17%) needed overnight stay. Main reasons for failure to discharge were lack of confidence (4%) fainting due to single vasovagal episode (3.5%), urine retention (3%) and late resolution of spinal anaesthesia (3%). 5 patients (3%) had readmission within 6 weeks, including 1 (0.6%) with a partial and treated pulmonary embolism. 163 patients were satisfied with SDD (98%). After launching the DCA program, average LOS of inpatients was reduced from 2.3 days to 1.8 days and rate of discharge with only 1-night stay increased from 12% to around 60%.

CONCLUSION

Introduction of routine SDD hip and knee arthroplasty programme at an elective orthopaedic centre is safe and also may confer wider benefits leading to shorter inpatient hospital stays.

Day case unicompartmental knee replacement: An update of the Torbay experience

BACKGROUND

Hospitals throughout the United Kingdom face significant challenges in regards to inpatient bed capacity, leading to growing interest in day case arthroplasty. Day case Unicompartmental Knee Replacement (UKR) has been offered within our unit since 2010, with successive evaluations of pathway outcomes performed in 2011 and 2015. Since then, our day case UKR pathway has expanded. This study aims to evaluate the safety, efficiency and patient satisfaction with this expanded pathway.

METHODS

Data was prospectively collected for all patients undergoing a UKR between January 2017 and August 2019. Data collected included the pathway planned, date of admission, date of discharge and re-admissions to hospital within 30 days of surgery. Patient satisfaction was evaluated via a follow-up questionnaire.

RESULTS

109 patients underwent a UKR between January 2017 and August 2019. 83 patients (76%) were planned through the day case pathway. 63 patients were successfully discharged on the day of surgery. One day case pathway and two inpatient pathway patients were re-admitted within 30 days of surgery with medical conditions. A high level of patient satisfaction with our day case pathway was identified.

CONCLUSION

UKR with planned discharge on the day of surgery is possible for a large proportion of patients provided that robust pathway and protocol design is undertaken. Following 10 years' experience, our day case UKR pathway has increasingly become the default for the majority of our patients. We report high patient satisfaction and low 30-day re-admission rates. However, 100% success rate for day of surgery discharge remains challenging.

The safety and efficacy of day-case total joint arthroplasty

INTRODUCTION

The popularity of day-case arthroplasty has been fuelled by focus on its cost effectiveness for the healthcare system. Safety concerns still remain. The aim of this review was to compare readmission rates after total joint arthroplasty for patients undergoing day-case surgery and for inpatients.

METHODS

A comprehensive online search of databases was performed for all published articles in the English language evaluating readmission rates after total hip arthroplasty (THA) and total knee arthroplasty (TKA). Seventeen studies were deemed eligible and included in the meta-analysis.

RESULTS

All studies included in the meta-analysis described readmission rates following THA/TKA. The readmission rate for day-case patients was 1.9% (n=124) whereas for inpatients, it was 2.0% (n=12,399). Compared with inpatient arthroplasty, day-case arthroplasty was associated with lower total readmission rates (odds ratio [OR]: 0.77, 95% confidence interval [CI]: 0.63-0.94, p=0.01). Furthermore, day-case surgery conferred a decrease in readmission rates for both THA (1.3% vs 7.0%) and TKA (2.7% vs 4.3%). Moreover, day-case THA and TKA were both associated with a decreased chance of readmission (OR: 0.27, 95% CI: 0.17-0.42, p<0.00001; and OR: 0.55, 95% CI: 0.42-0.72, p<0.00001 respectively).

CONCLUSIONS

This review emphasises that with a thoughtful, designated protocol and with careful patient selection, day-case arthroplasty is a safe and effective option.

Improving the efficiency of ankle fracture care through home care and day-surgery units: Delivering safe surgery on a value-based healthcare model

OBJECTIVES

Preoperative home care for suitable patients with ankle fractures is becoming an increasingly common practice. It allows adequate time for reduction of ankle swelling following a decision to undertake operative fixation has been made. We aim to assess the safety, efficiency, cost-effectiveness and differences in clinical & patient outcomes of day surgery unit (DSU) care for ankle fracture treatment in selected patients. Our study combined home therapy treatment with DSU care for suitable ankle fractures.

DESIGN

Prospective cohort study.

SETTING

Trauma Centre.

PATIENTS

Fifty-three patients requiring operative fixation for an ankle fracture were divided into 2 groups. Patients in group 1 entered the home care combined with DSU treatment pathway whilst in group 2 were treated as in patient in the main trauma theatre in our standard pathway.

INTERVENTION

Comparison of Home Care & Day Case Surgery vs. in patient admission for patients requiring operative ankle fractures fixation.

MAIN OUTCOME MEASURES

Prospective data collection was undertaken over a 2-year period, on fracture type, logistical outcomes including time to surgery and total length of stay in the hospital and clinical outcomes including the rate of post-operative complications, incidence of unplanned surgical revisions and objective patient satisfaction. Economic analysis was performed to compare the marginal cost saving per case for group 1 vs. group 2.

RESULTS

There were 21 patients in group 1. They waited for on average 5.8 days at home for their operation and none were admitted pre or post operatively. There were no associated complications and the majority of patients were discharged from follow-up at 6 weeks post-surgery. In-group 2, there were 32 patients. They waited on average 2.4 days for their operation in the hospital and had an average length of stay of 4.9 days. One patient in group 2 suffered from a deep vein thrombosis. The benefit from our chargeable tariff for group 1 patients was £2295 per case while the margin for group 2 patients was £277 per case. The financial benefit to the health care provider was £2018 in favour of home care and DSU treatment, with high service satisfaction and low complication rates.

DISCUSSION

This study provides focused evidence supporting the use of home care for the management of ankle fractures. The DSU pathway improves the value in healthcare delivery with high patient satisfaction scores when compared to the traditional pathway. Our model demonstrates predictably good clinical outcomes with a financial cost benefit over in-patient admission care model for selected patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Day case laparoscopic cholecystectomy at Kilimanjaro Christian Medical Centre, Tanzania

INTRODUCTION

The Lancet Commission on Global Surgery has promoted the case for safe, affordable surgical care in low- and middle-income countries (LMICs). In 2017, Kilimanjaro Christian Medical Centre (KCMC) in Tanzania introduced a day case laparoscopic cholecystectomy (DCLC) service, the first of its kind in Sub-Saharan Africa (SSA). We aimed to evaluate this novel service in terms of safety, feasibility and acceptability by patients and staff.

METHODS

This study used mixed methods and was split into two stages. In stage 1, we reviewed records of all laparoscopic cholecystectomies (LCs) comparing day cases and admissions. These patients were followed up with a telephone questionnaire to investigate complication rates and receive service feedback. Stage 2 consisted of semi-structured interviews with staff exploring the challenges KCMC faced in implementing DCLC.

RESULTS

147 laparoscopic cholecystectomies were completed: 109 were planned for DCLC, 82 (75.2%) of which were successful, whilst 27 (24.8%) patients were admitted. No variables significantly predicted unplanned admission, the commonest causes for which were pain and nausea. In the DCLC group there was 1 readmission. 62 patients answered the follow up questionnaire, 60 (97%) of which were satisfied with the service. Stage 2 interviews suggested staff to be motivated for DCLC but revealed poor organisation of the day case pathway.

CONCLUSION

High rates of DCLC combined with low rates of complications and readmission suggests DCLC is feasible at KCMC. However, staff interviews alluded to administrative problems preventing KCMC from reaching its full DCLC potential. A dedicated day case surgery unit would address most of these problems.

Technique and outcome of day case laparoscopic hiatus hernia surgery for small and large hernias: a five-year retrospective review from a high-volume UK centre

INTRODUCTION

Laparoscopic anti-reflux surgery is the standard surgical treatment for gastro-oesophageal reflux disease in patients for who long-term pharmacotherapy is intolerable or ineffective. Advances in anaesthesia and minimally invasive surgery have led to day case treatment being adopted by some centres. The objective of this study is to describe our day case pathway and peri- and postoperative outcomes.

MATERIALS AND METHODS

This is a single centre, retrospective case series review of a prospectively collected database from October 2014 to August 2019 performed in a tertiary centre for upper gastrointestinal surgery. Data collected included demographics, comorbidities, indications, complications, length of stay and readmission.

RESULTS

A total of 362 patients underwent laparoscopic anti-reflux surgery with or without hiatus hernia repair of up to 10cm, with day case rates of 59%. Unplanned admission following day surgery was 5.1% (13/225) and 30-day readmission was 2.2% (8/362); 90.6% of patients remained in hospital for less than 24 hours. There was one intraoperative complication and one patient required revisional surgery within 30 days. The rate of all postoperative complications was 1.38% (5/362) with one postoperative mortality.

DISCUSSION

The inclusion of larger hernias is unusual, as most studies limit size to 5cm or less. Our results show the safety and feasibility of the procedure even when applied to hiatus hernias up to 10cm. Success was multifactorial and based on standardisation of procedures and support from dedicated specialist nursing staff.

CONCLUSION

Laparoscopic anti-reflux surgery can be performed safely as a day case procedure even in larger hiatus hernias, with a dedicated care pathway and specialist nurse practitioners to support it.

Day case vs inpatient total shoulder arthroplasty: A retrospective cohort study and cost-effectiveness analysis

BACKGROUND

Day case total shoulder arthroplasty (TSA) is a novel approach, not widely practiced in Europe. We conducted a retrospective cohort study of patients comparing elective day case and inpatient TSAs in our United Kingdom centre.

AIM

To evaluate the efficacy and cost-effectiveness of day case TSA compared to standard inpatient total shoulder arthroplasty.

METHODS

All patients undergoing TSA between January 2017 and July 2018 were included. Outcome measures were: Change in abduction and extension 3 mo postoperatively; 30-d postoperative adverse events and re-admissions in day case and inpatient groups. We also conducted an economic evaluation of outpatient arthroplasty. Multivariate linear and logistic regression were used to adjust for demographic and operative covariates.

RESULTS

Fifty nine patients were included, 18 d cases and 41 inpatients. There were no adverse events or re-admissions at 30 d postoperatively in either group. There were no significant differences in adjusted flexion (mean difference 16.4, 95%CI: 17.6-50.5, P = 0.337) or abduction (mean difference: 13.2, 95%CI: 18.4-44.9, P = 0.405) postoperatively between groups. Median savings with outpatient arthroplasty were £529 (interquartile range: 247.33-789, P < 0.0001).

CONCLUSION

Day case TSA is a safe, effective procedure, with significant cost benefit. Wider use may be warranted in the United Kingdom and beyond, with potential for significant cost savings and improved efficiency.

Day case paediatric tonsillectomy: a quality improvement project

Tonsillectomy is one of the commonest ENT paediatric procedures. Recovery is best achieved at home, and cost-effectiveness of the day case pathway is significant in tonsillectomy. This project scrutinised the local practice regarding the effectiveness of day case pathway in paediatric tonsillectomy in a large regional teaching hospital. The project aimed to improve the rates of day case tonsillectomy discharges, to increase compliance of postoperative care with guidelines, and to assess long-term sustainability of the new practice. The project looked prospectively at the pre-existing paediatric tonsillectomy day case practice (cycle 1) prior to implementing a multifaceted intervention. The intervention consisted of an evidence-based change to local day case tonsillectomy guidelines, improved lists' planning/management, and clinicians' education. Thereafter, the outcomes were measured in the short term (cycle 2-prospective data collection) and in the long term (cycle 3-retrospective data collection). The gathered data revealed an improvement in post-tonsillectomy day case discharge rates (both short and long term), without an increase in postoperative complications. Moreover, our intervention had effectively reduced sleep study requests and resulted in a significant increase in list profitability.Conclusion: The departmental practice in paediatric day case tonsillectomy was improved via evidence-based relaxation of day case criteria, improved list management, and clinicians' education. The interventions resulted also in a positive significant financial impact with no increase in postoperative complications. What is Known: • Tonsillectomy is a common paediatric ENT procedure, with significant applicability and cost-effectiveness of the day case pathway. • There is a lack of a clear general consensus on criteria for patients' suitability for day case tonsillectomy. What is New: • This quality improvement project carried out a methodical relaxation of day case criteria of day case tonsillectomy. • The new criteria along with enhanced list management and clinician education had safely improved the local post-tonsillectomy day case care.

Feasibility of early discharge following vaginal hysterectomy with a bipolar electrocoagulation device

OBJECTIVE

To evaluate the safety and efficacy of vaginal hysterectomy for benign conditions (excluding prolapse) using the BiClamp (Erbe Elektromedizin, Tübingen, Germany) bipolar electrocoagulation system.

METHODS

The present study was a prospective audit of a consecutive case series of patients who underwent vaginal hysterectomy for benign conditions, performed using the BiClamp between March 1, 2015, and June 30, 2016, at Norfolk and Norwich University Hospital, Norwich, UK. Surgeries performed for benign conditions were eligible, excluding prolapse; severe endometriosis with pelvic adhesions was an exclusion criterion. Patient demographics and past history were recorded, along with intraoperative findings and adverse events. Follow-up data were obtained via telephone interviews 24 hours after surgery and a nurse-led postoperative clinic 8 weeks postoperatively.

RESULTS

The series included 75 patients; 32 (43%) were discharged on the same day as surgery and 70 (93%) within 23 hours. There were two patients who experienced vault hematomas and remained admitted for more than 24 hours. There was one intraoperative bladder injury that was repaired vaginally. No delayed adverse events occurred within 8 weeks. No patient required patient-controlled analgesia or an epidural injection for postoperative analgesia.

CONCLUSION

Patients experienced low postoperative pain following BiClamp treatment and 93% were was discharged within 23 hours.

Safety and Efficacy of Day-case Percutaneous Nephrolithotomy: A Systematic Review from European Society of Uro-technology

CONTEXT

Day case or ambulatory percutaneous nephrolithotomy (PCNL) has risen over the last few years with the aim of discharging patients within 24h.

OBJECTIVE

We perform a systematic review of literature to evaluate the outcomes of day-case PCNL surgery.

EVIDENCE ACQUISITION

A Cochrane style search was performed and the following bibliographic databases were accessed: PubMed, Science Direct, Scopus, and Web of Science. This was carried out in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines. All studies in the English language reporting on PCNL patients discharged within 24h were included.

EVIDENCE SYNTHESIS

Based on the literature search of 97 articles, nine (502 patients) met the inclusion criteria (mean age: 47 yr), with a mean stone size of 20.5mm. The mean operating time was 66min, and over a mean hospital stay of 17.5h, the stone-free rate was 95%. The overall complication rate was 13.5%; the vast majority of these complications were Clavien I-II complications, with a readmission rate of 3%.

CONCLUSIONS

Day-case PCNL is a safe and feasible strategy in carefully selected cases. However, for its success, detailed planning and adherence to surgical protocol are paramount with strict criteria for inpatient admission and a thorough follow-up plan.

PATIENT SUMMARY

Day-case percutaneous nephrolithotomy procedure seems to be a safe procedure with good outcomes, and low risk of complications and readmissions. Detailed preoperative protocol and planning are paramount, with indications for inpatient admission as well as a thorough follow-up plan.

Elective ambulatory surgical care in Ireland-why it needs to be better coded, classified and managed

BACKGROUND

In the year to July 2017, surgical disciplines accounted for 73% of the total national inpatient and day case waiting list and, of these, day cases accounted for 72%. Their proper classification is therefore important so that patients can be managed and treated in the most suitable and efficient setting.

AIMS

We set out to sub-classify the different elective surgical day cases treated in Irish public hospitals in order to assess their need to be managed as day cases and the consistency of practice between hospitals.

METHODS

We analysed all elective day cases that came under the care of surgeons between January 2014 and December 2016 and sub-classified them into those that were (A) true day case surgical procedures; (B) minor surgery or outpatient procedures; (C) gastrointestinal endoscopies; (D) day case, non-surgical interventions and (E) unclassified or having no primary procedure identified.

RESULTS

Of 813,236 day case surgical interventions performed over 3 years, 26% were adjudged to accord with group A, 41% with B, 23% with C, 5% with D and 5% with E. The ratio of A to B procedures did not vary significantly across the range of hospital types. However, there were some notable variations in coding and practices between hospitals.

CONCLUSION

Our findings show that many day cases should have been performed as outpatient procedures and that there were variations in coding and practices between hospitals that could not be easily explained. Outpatient procedure coding and a better, more consistent, classification of day cases are both required to better manage this group of patients.

Results of day-case ureterorenoscopy (DC-URS) for stone disease: prospective outcomes over 4.5 years

Purpose

To investigate the prospective outcomes of day-case ureterorenoscopy (DC-URS) for stone disease. With the rising prevalence of stone disease in the face of finite resources, there is increasing pressure to undertake procedures as a day case avoiding in-patient stay. There are a limited number of studies reporting on the feasibility of ureteroscopy as a day-case procedure. This study aimed to investigate the prospective outcomes and predictors precluding to DC-URS for stone disease in patients treated in our university teaching hospital.

Materials and methods

Between March 2012 and July 2016, consecutive cases of adult stone ureteroscopy performed or supervised by a single surgeon were recorded in a prospective database. Patients underwent pre-operative counselling in a specialist stone clinic and were admitted to a dedicated ‘Surgical day unit’ on the day of surgery. A standardised anaesthetic protocol was adhered to in all cases. Data on patient demographics, stone parameters, pre-operative assessment, operative details, length of stay, stone-free rate and complication rates were collected and analysed.

Results

A total of 544 consecutive adult ureteroscopy for stone disease were conducted over the study period with a day-case rate of 77.7%. Thirty-nine percent of failed day-case ureteroscopy were due to late completion of ureteroscopy and due to associated social circumstances of patients. The mean stone size, operating time duration and post-operative stent insertion rates for DC-URS patients were 14 mm, 46 min and 96.5%, respectively. Post-operatively, the mean stone-free rate (SFR), unplanned re-admissions and complications for DC-URS patients were 95, 4 and 4%, respectively. A higher failure of DC-URS was related to patient’s age (p = 0.003), positive pre-operative urine culture (p < 0.001), elevated pre-operative serum creatinine (p < 0.001) and higher mean operating time (p < 0.02).

Conclusion

Based on our results, a day-case ureteroscopy rate of nearly 78% can be achieved. With its acceptable complication rate, and low re-admission rates, DC-URS is a safe and feasible option in a majority of patients with stone disease.

Lumbar microdiscectomy as a day-case procedure: Scope for improvement?

BACKGROUND AND PURPOSE

There are no significant differences in outcomes between patients receiving inpatient and day-case lumbar microdiscectomy, but the latter is still underused in the NHS. Here we aimed to identify factors contributing to successful same-day discharge in day-case patients.

METHODS

This was a retrospective observational study of patients undergoing elective lumbar microdiscectomy between August 2012 and December 2014. Age, gender, day of surgery, distance to hospital, ASA grade, regular opiate use, smoking status, order on the operating list, and side and level of surgery were examined by logistic regression to assess their influence on same-day discharge.

RESULTS

28/95 (29.5%) patients were discharged on the day of surgery. Age (p = 0.041), ASA grade (p = 0.016), distance to hospital (p = 0.011), and position on the list (p = 0.004) were associated with day-case discharge by univariate analysis. ASA grade (p = 0.032; OR 0.176), distance to hospital (p = 0.003; OR 0.965), and position on the operating list (morning case; p = 0.011; OR 8.901) remained significant in multivariate analysis. Thirteen (13.7%) patients were identified who could have been managed as day cases had they been listed for morning operations.

CONCLUSIONS

Day-case lumbar microdiscectomy is viable when patients are carefully selected. Younger, fit patients living close to the hospital and operated on in the morning are more likely to be discharged on the same day. Knowledge of these factors while planning elective lists can help optimise bed space and improve spinal services.

Single hospital visit elective day-case laparoscopic cholecystectomy without prior outpatient attendance

INTRODUCTION

Eighty percent of all UK elective laparoscopic cholecystectomies (LC) are performed as day-case procedures, but the pre-operative patient pathway has received little attention. In response to local patient feedback, we aimed to introduce a single hospital visit pathway for day-case LC.

METHODS

A single hospital visit pathway for elective LC was piloted alongside standard services. Following telephone consultation, a pack containing procedure information, knowledge questionnaire and consent form were sent. Patients were not excluded on age, BMI or co-morbidity criteria, but recent ultrasonography and liver function tests were required. Patients were operated without attending any clinic or pre-operative service. There was no restriction on surgical or anaesthetic technique. Early surgeon-led telephone follow-up was made post-operatively and patient satisfaction assessed at 3 months.

RESULTS

One hundred and sixty-six patients were referred with 92% transferred to day-case waiting lists following telephone consultation. One hundred and six patients underwent LC without previously visiting the hospital with 85% discharged the same day. Nine percent required post-operative primary care review primarily for wound reviews. Median patient-reported time to normal activities was 4 weeks (range 1-12). Ninety-nine percent reported being satisfied with the single-stop pathway.

CONCLUSIONS

Single hospital visit LC is feasible, safe and acceptable for primary care referral patients with symptomatic gallstone disease without evidence of common bile duct or LFT abnormalities.

Day case laparoscopic cholecystectomy in patients with high BMI: Experience from a UK centre

INTRODUCTION

Symptomatic gall stones may require laparoscopic cholecystectomy (LC), which is one of the most commonly performed general surgical operations in the western world. Patients with a high body mass index (BMI) are at increased risk of having gall stones, and are often considered at high risk of surgical complications due to their increased BMI. We believe that day case surgery could nevertheless have significant benefits in terms of potential cost savings and patient satisfaction in this population. We therefore compared the outcomes of day case patients undergoing LC stratified by BMI, with a specific focus on the safety and success of the procedure in obese and morbidly obese groups.

METHODS

We reviewed a database of day case procedures performed between January 2004 and December 2012, including all patients with symptomatic gall stone disease who underwent LC. The patients were divided in four BMI groups: less than 25 kg/m(2), 25-29 kg/m(2), 30-39 kg/m(2) and 40 kg/m(2) or above.

RESULTS

The overall success rate for day case surgery was 78%. There were no significant differences in rates of intra-abdominal collection or readmission with increasing BMI. However, increasing BMI was associated with a significant increase in the rate of wound infection.

CONCLUSIONS

LC in patients with a high BMI is safe and can be performed effectively as a day case procedure.

Single hospital visit day case laparoscopic hernia repair without prior outpatient consultation is safe and acceptable to patients

BACKGROUND

For some common conditions, pre-operative clinic visits are often of little value to the patient or surgeon with transfer to the waiting list being predictable. In response to local patient feedback, we introduced a single hospital visit laparoscopic hernia surgery pathway with focus on informed consent, patient-reported outcomes and post-operative interaction with primary care services.

METHODS

A single hospital visit service for elective hernia repairs was created. Patients were not excluded on age, BMI or co-morbidity. Following referral, patients were telephoned by a surgeon. If considered appropriate, a symptom assessment tool, procedure information and consent form were sent. All patients were operated without attending clinic or pre-operative assessment. Surgeon-led telephone follow-up was made at either 2 or 7 days post-operatively and patient satisfaction assessed at 3 months.

RESULTS

A total of 517 patients were referred for single-stop surgery between 2012 and 2015. Median age was 58 (range 20-92), 91 % were male, and mean BMI was 25.6 (17.4-52.0). No patient refused the single-visit pathway. Single-stop patients had higher knowledge questionnaire scores (mean 16 vs. 10, p = 0.01) than patients who had attended clinic. Nine (1.7 %) were requested to attend clinic to confirm diagnosis, and three (0.8 %) were cancelled by their surgeon on the operative day. A total of 393 hernia repairs (331 TEP, 63 open) were performed under general anaesthetic. 92 % were discharged on day zero. Telephone follow-up day two rather than seven decreased attendance to primary care services (25 % vs. 57 %, p = 0.001). At 3 months, 95 % were satisfied and symptom scores were reduced (median 5-0, p < 0.0001).

CONCLUSION

Single-visit surgery appears to extend the patient benefits of laparoscopy by reducing hospital visits without compromising safety. Single hospital visit hernia surgery for unselected primary care referrals is possible and acceptable to patients.

Independent predictors of delay in emergence from general anesthesia

Some patients with intellectual disabilities spend longer than others in emergence from ambulatory general anesthesia for dental treatment. Although antiepileptic drugs and anesthetics might be involved, an independent predictor for delay of the emergence remains unclear. Thus, a purpose of this study is to identify independent factors affecting the delay of emergence from general anesthesia. This was a retrospective cohort study in dental patients with intellectual disabilities. Patients in need of sedative premedication were removed from participants. The outcome was time until emergence from general anesthesia. Stepwise multivariate regression analysis was used to extract independent factors affecting the outcome. Antiepileptic drugs and anesthetic parameters were included as predictor variables. The study included 102 cases. Clobazam, clonazepam, and phenobarbital were shown to be independent determinants of emergence time. Parameters relating to anesthetics, patients' backgrounds, and dental treatment were not independent factors. Delay in emergence time in ambulatory general anesthesia is likely to be related to the antiepileptic drugs of benzodiazepine or barbiturates in patients with intellectual disability.

Intent at day case laparoscopic cholecystectomy in owerri, Nigeria: initial experiences

BACKGROUND AND OBJECTIVE

Laparoscopic cholecystectomy has been the default operation for cholelithiasis at Federal Medical Centre, Owerri for the past 2 years and the outcomes have been good. The duration of post operative stay has been decreasing. We therefore initiated a preliminary 2-year prospective study in May 2010 to determine the feasibility of carrying out day case laparoscopic cholecystectomy in our hospital.

MATERIALS AND METHODS

PATIENTS UNDERGOING LAPAROSCOPIC CHOLECYSTECTOMY WERE INCLUDED IN THE STUDY IF THEY SATISFIED THE FOLLOWING CRITERIA: Age < 65 years, body mass index < 35 kg/m(2) , American Society of Anaesthesiology physical status class I and II, patient residence within 20 km radius of the hospital, patient acceptance of the procedure and absence of previous complicated upper abdominal surgery.

RESULTS

Twelve patients (10 females, 2 males) were worked up with the intent of achieving same-day discharge of the patients. Five of the patients (41.7%) were discharged on the day of operation. The reasons for overnight stay included inadequate pain control, insertion of drain and patient wishes. There was no conversion to open surgery, no major complications and no case of readmission to the hospital.

CONCLUSIONS

Day case laparoscopic cholecystectomy in our environment could be safely promoted but will depend on improved facilities and patient enlightenment.

Randomised Controlled Trial of Day-Case Laparoscopic Cholecystectomy vs Routine Laparoscopic Cholecystectomy

Many randomised controlled trials conducted worldwide favours for day-case laparoscopic cholecystectomy, but questions have been raised regarding its application in developing country like ours. Hence, considering it a high time to review current practices, we conducted this trial to report our experience with day-case laparoscopic cholecystectomy and to access its feasibility and safety in our set-up. Data from 65 patients with symptomatic gallstone were randomised to perform laparoscopic cholecystectomy either as day-case procedure or as routine (conventional) procedure. Complication, quality of life, satisfaction, post-operative nausea and vomiting and pain were assessed. Ninety-seven per cent (31/32) of day-case laparoscopic cholecystectomy patients were successfully discharged with mean duration of 8.9 ± 4.54 h, which was 3.33 ± 1.45 days (72.92 ± 34.8 h) in routine (conventional) laparoscopic cholecystectomy group. There was no significant difference in complication, quality of life, satisfaction, post-operative nausea and vomiting and pain between the two groups. Day-case laparoscopic cholecystectomy is a safe, feasible and beneficial procedure in our set-up. Patient acceptance in terms of quality of life and satisfaction was similar to that of routine laparoscopic cholecystectomy.