Feasibility case‐controlled study of day‐case haemorrhoidectomy

Introduction: Haemorrhoidectomy is traditionally an inpatient procedure. With many benefits, the day‐surgery arrangement is an attractive alternative. The feasibility of day‐surgery haemorrhoidectomy was explored and the hospital days were calculated in a case controlled design. Methods: A single surgeon’s experience of day‐surgery haemorrhoidectomy between 1 July 1999 and 31 March 2000 was compared with inpatient haemorrhoidectomy during the same period. The operations were performed at United Christian Hospital Department of Surgery, Hong Kong (a government‐funded public hospital). Statistical tests were applied where appropriate. Results: There were 30 day‐surgery and 15 inpatient haemorrhoidectomies. The groups were comparable in terms of age, gender, severity of haemorrhoids, method and duration of haemorrhoidectomy, blood loss, residual haemorrhoids, duration of follow up and unplanned readmission rate. Significantly more day‐patients received general than spinal anaesthesia. Twenty‐six of 30 (87%) patients were successfully discharged after day surgery. Two were admitted for transient fever (< 24 h), one for micturition syncope and one for acute urinary retention. There were four unplanned readmissions after day surgery: one for pain and three for secondary bleeding. All stopped spontaneously. All three unplanned readmissions after inpatient surgery were for secondary bleeding. All stopped spontaneously. Patient stay was significantly shorter for day surgery (1 ± 1 day) than for the inpatient arrangement (4 ± 1.6 days). Conclusion: Day‐surgery haemorrhoidectomy is feasible. The significantly shorter hospital stay implies savings in public medical expenses.     

Feasibility of day‐care open cholecystectomy: Evaluation in an inpatient model

Background : Open cholecystectomy is still a fairly frequently performed operation worldwide, and is used where laparoscopic surgery has failed or is contraindicated, and where some surgeons do not operate laparoscopically for technical reasons. In developing countries laparoscopic cholecystectomy is costly and is available only in a few centres. The present study was conducted to assess the feasibility of day‐care open cholecystectomy using an inpatient model. Methods : Thirty patients were subjected to open cholecystectomy. Intraoperative nasogastric decompression and local wound infiltration with 0.25% bupivacaine was carried out. Postoperatively patients were encouraged to be ambulant, pass urine and start oral fluids. Intravenous fluids and parenteral medication were stopped at 8 p.m. when patients were assessed for feasibility for discharge. All patients were reassessed the next morning for any adverse effects that could have occurred had the patients been discharged on the evening of surgery. Results : Prospectively, 73.3% of patients were considered to be dischargeable on the evening of surgery; but on reassessment the next morning, retrospectively, 93.3% of patients were actually dischargeable on the evening of surgery. A total of 76.6% of patients was actually discharged within 24 h of surgery. No patient required readmission. On follow up there were no complications that could be attributable to early discharge. A total of 83.3% of patients approved of day‐care open cholecystectomy. Conclusions : Day‐care open cholecystectomy is safe and feasible. In developing countries, where the use of laparoscopic surgery is limited due to resource constraints, day‐care open cholecystectomy can lead to substantial savings in health‐care resources.     

Feasibility of day case laparoscopic cholecystectomy in unselected patients

The feasibility of clay ease laparoscopic cholecystectomy was assessed in unselected patients using a standard anaesthetic protocol. Postoperative pain and nausea were assessed at 6 and 24 h postoperatively (visual analogue scale, range 0-10). Thirty-two patients were studied (23 female. 9 male, mean age 49.6 years). The mean duration of surgery was 68 mitt. At 6 h after surgery, 10 patients (31%) had no pain at rest. For the group as a whole, the median pain score was 3 at rest (range 0-6), 4 on movement (0 9), and 5 on coughing (0 9) and eight patients (25%) were nauseated. At 24 It, 15 (46.9%) had no pain at rest. For the group as a whole, the median pain score was I at rest (0-7), 3 (0-6) on movement and 3 on coughing (0 9). The same eight patients were nauseated. Ten patients (31.3%) were judged fit for discharge at 6h, and 28 (87.5%) by 24h. There was no statistical difference in mean age or duration of surgery in those judged fit for early discharge compared to the study group as a whole. Nausea was an important factor in those unfit for discharge at 24 It. Selection criteria might improve these figures. Front the results of our study, 24 h admission is a more realistic goal and will be suitable for most patients requiring laparoscopic cholecystectomy.     

Modern paediatric day case anaesthesia: a review

The economic and psychological benefits of reducing the in-patient hospital stay are obvious advantages of day case surgery for children. Careful selection, pre-operative assessment and preparation of children and their parents for day case surgery are vitally important for success. Staffing levels, equipment and facilities must be clearly defined and costed. The implications for waiting lists and the alternative use of in-patient beds must be taken into account. New anaesthetic, analgesic and monitoring techniques have made intraoperative care for a wide range of paediatric surgical procedures safe and straightforward. Recovery is rapid, uncomplicated and comfortable for the majority of children. Post-operative care is simple, allowing early mobilization, oral intake and return home. Follow-up care at home is important and assists audit of the day surgery service. In certain cases, in-patient admission may be required and facilities for this should be immediately available.     

Safety of video-assisted thyroidectomy versus conventional surgery

BACKGROUND: Thyroid gland manipulation, surgical stress response, and postoperative outcome in cases of video-assisted thyroidectomy (VAT) and conventional thyroidectomy were compared to verify the safety of VAT. METHODS: Twenty consenting patients were randomly assigned to undergo VAT or conventional thyroidectomy. Serum thyroglobulin levels were monitored as indicators of thyroid manipulation, and C-reactive protein and white blood cell count were monitored to assess surgical stress response. Thyroid capsule integrity and the presence of spilled cells in the thyroid bed were verified. RESULTS: No significant differences were found in the indicators of thyroid gland manipulation and surgical stress response between groups. No thyroid capsules ruptured, and no spilled thyroid cells were found. Patients who had VAT experienced less pain, required fewer analgesics, and were more satisfied with the cosmetic result and the surgical outcome. CONCLUSIONS: VAT is as safe as conventional thyroidectomy and is characterized by a less painful postoperative course and by better cosmetic results and postoperative outcome.     

Paediatric day case surgery

Paediatric day surgery is common, and increasingly more challenging surgeries are being carried out on more complex children. The benefits to the child and parent/care-giver include less disruption to daily routines and fewer psychological and emotional effects than an overnight stay would incur. The use of day case services improves efficiency and is more cost effective for organizations. To deliver high-quality paediatric day surgery services there are several key components to address. This article discusses the role of preoperative assessment and the need to consider each case individually despite robust inclusion/exclusion criteria. Optimization of preoperative hydration, pain management and prevention of postoperative nausea and vomiting are highlighted as important factors to successful day case surgery.     

经口腔前庭入路腔镜与开放甲状腺切除术的临床研究

目的对比研究经口腔前庭入路腔镜甲状腺与开放甲状腺切除术的临床疗效。方法回顾性分析2016年3月至2017年6月在咸阳市第一人民医院就诊的68例甲状腺切除术临床资料。根据患者意愿,将患者分为经口腔前庭腔镜甲状腺组(观察组,32例)及开放甲状腺切除组(对照组,36例),对比分析两组手术时间、术中出血量、术后引流量、住院时间、甲状旁腺激素水平及美观满意度。结果两组术中出血量、住院时间、术后引流量、甲状旁腺激素水平无统计学差异,观察组的患者美观满意度明显高于对照组(P=0.035),但手术时间较对照组延长(P=0.015)。结论经口腔前庭入路腔镜甲状腺切除与开放甲状腺切除相比手术时间延长,但一样安全可靠,未增加手术风险,更符合年轻女性的美容要求,术后恢复快。     

Microlaryngeal surgery on a day case basis

The aim of this study was to assess the clinical safety of performing microlaryngeal surgery (MLS) under general anaesthesia in selected patients in the ambulatory setting. Twenty-two adult patients were scheduled to have tissue specimens of the larynx taken by biopsy (54%), for vocal cord polypectomy (41%) or for vocal cord cyst excision (5%). Twenty-one ASA I and II patients (95%) were discharged home the same day of the procedure. Two of them presented with laryngospasm after extubation of the trachea. One ASA III patient (5%) had to be admitted overnight because of severe laryngospasm and bronchospasm, but was discharged the day after the operation. None of the patients had significant complications after leaving the recovery room (mean stay 85 min). There were no re-admissions to the hospital. Our data suggests that microlaryngeal surgery in selected patients can be safely performed on a day case basis.     

A quality assurance initiative in day case surgery: general considerations

With the increasing demand for audit in the day surgery setting, a quality assurance initiative was implemented in a busy British day surgery unit. This paper outlines how such a programme was designed and established. The indicators of quality in day surgery and the standards of practice used are discussed. The results of the data collected are discussed and the recommendations for improvement are outlined. Hopefully this paper will serve as a concrete and practical guide for the implementation of a quality assurance programme in other day surgery facilities.     

Trends in colorectal day case surgery in NHS Trusts between 1998 and 2005

Objective Day case surgery is safe and offers potential benefits to both patients and healthcare providers. This study aimed to describe national changes in colorectal day case workload between 1998 and 2005. Methods Admission data relating to Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures (4th revision) (OPCS‐4) coloproctology operation codes were analysed using the Hospital Episode Statistics (HES) database. Day case rates (DCRs) were calculated as the proportion of elective cases performed on an ambulatory basis. Results In total, 3 119 058 colorectal admissions were recorded on the HES database between 1998 and 2005; 1 891 474 (61%) of these were for lower gastrointestinal endoscopies. Emergency cases accounted for 527 665 (17%), elective inpatient cases for 406 368 (13%) and elective day cases for 293 551 (9%) admissions. Throughout the study period the DCRs for five commonly performed elective colorectal procedures were: 0.70 for anal lesion excisions (OPCS‐4 codes: H48.1, H48.2 and H48.3); 0.16 for haemorrhoidectomy (OPCS‐4 code: H51.1); 0.63 for anal fissure procedures (OPCS‐4 codes: H56.2 and H56.4); 0.39 for elective procedures for anal fistula (OPCS‐4 codes: H55.1, H55.2, H55.3 and H55.4); 0.37 for elective pilonidal surgery (OPCS‐4 codes: H59 and H60.2). Two emergency operations, drainage of perianal and pilonidal abscesses (OPCS‐4 codes: H58.2 and H60.3 respectively), were identified as operations potentially amenable to day surgery. Over the seven study years, an annual average of 8559 (±SD 307) admissions were coded to drainage of a perianal abscess and 4676 (±SD 478) admissions to drainage of pilonidal abscess. The average annual bed usage associated with these procedures was 18 831 (±SD 718) and 7623 (±SD 436) bed days respectively. Conclusions Colorectal day case surgery is currently under‐exploited in the NHS. By lifting some of the barriers to day case surgery significant resource savings may be possible.     

腔镜与开放性甲状腺手术的对比研究

目的腔镜与开放性甲状腺手术临床效果的对比研究。方法回顾性分析2002年8月至2005年5月113例腔镜甲状腺切除术(腔镜组)和104例开放性甲状腺切除术(开放组)的临床资料。结果两组的手术时间、住院时间、术后住院时间差异无显著性意义。腔镜组失血量(42.5±62.8)mL明显少于开放组(118.2±120.8)mL,差异有显著性意义(P<0.05);而腔镜组引流量多于开放组(P<0.05);腔镜组术后恢复活动时间为(2.2±1.0)d,与开放组(2.5±1.1)d比较差异无显著性意义(P>0.05);腔镜组术后镇痛药需求比开放组明显减少,而住院费用高于开放组。术后并发症腔镜组以喉上和喉返神经损伤为主,且甲状腺功能亢进术后并发症发生率较高,而开放组主要是术后出血。结论选择合适的病例实施腔镜甲状腺手术是安全可行的,具有美容、疼痛轻、出血少的优点。     

Outcome of ASA III patients undergoing day case surgery

Background. Day case surgery is becoming more acceptable, evenfor patients with complex medical conditions. Current recommendationssuggest that patients who are graded as American Society ofAnaesthesiologists physical status (ASA) III may be suitablefor this approach. There is only a small amount of publisheddata available to support this. We present a retrospective reviewof ASA III patients who had undergone day surgical proceduresin our unit. Methods. We carried out a retrospective case controlled reviewof 896 ASA III patients who had undergone day case proceduresbetween January 1998 and June 2002 using the existing computerizedpatient information system. The system records admission rates,unplanned contact with healthcare services and post-operativecomplications in the first 24 h after discharge. Results. We demonstrated no significant differences in unplannedadmission rates, unplanned contact with health care services,or post-operative complications in the first 24 h after dischargebetween ASA III and ASA I or II patients. Conclusion. With good pre-assessment and adequate preparationASA III patients can be treated safely in the day surgery setting. Br J Anaesth 2004; 92: 71–4     

Video-assisted thyroidectomy: report of a 7-year experience in Rome

Background and aims We report on our series of patients selected for video-assisted thyroidectomy (VAT) over a 7-year period.Materials and methods VAT is a gasless procedure performed under endoscopic vision through a single 1×5×2.0-cm skin incision. The eligibility criteria are thyroid nodules ≤35 mm, thyroid volume <30 ml, and no previous conventional neck surgery. Small, low-risk papillary thyroid carcinomas (PTC) were considered eligible.Results There were 521 VATs attempted. Conversion was necessary six times (difficult dissection in one case, large nodule size in three, and gross lymph node metastases in two). Thyroid lobectomy was successfully accomplished in 113 cases, total thyroidectomy in 398, and completion thyroidectomy in 14. In 66 patients, the central neck nodes were removed through the same access. Pathology showed benign diseases in 313 cases, PTC in 187, and medullary microcarcinoma in 1. Postoperative complications included 9 transient recurrent nerve palsies, 73 transient hypocalcemias, 3 definitive hypoparathyroidisms, 1 postoperative haematoma, and 2 wound infections. The cosmetic result was excellent. In patients with PTC, no evidence of recurrent disease was shown.Conclusions The indications for VAT are still limited. Nonetheless, in selected patients, it seems a valid option for thyroidectomy and even preferable to conventional surgery because of its significant advantages, especially in terms of cosmetic result.Presented at the International Symposium “Modern Technologies in Thyroid Surgery”, 10–11 February 2006, Halle/Saale, Germany     

Post-operative pain in children after day case surgery

The increasing use of paediatric day case surgery requires assessment of the effectiveness of post-operative analgesia. A prospective epidemiological study of ninety-eight patients undergoing day case surgery looked at pain assessment using a self report Faces scale and a numerical rating scale for parents and nursing staff. An inpatient record was combined with a home questionnaire detailing pain assessment and analgesic use over a 48 h period. Patients undergoing circumcision with a penile ring block experienced significant degrees of post-operative pain, had high levels of use of paracetamol at home, and their first night of sleep was frequently disturbed. High levels of opioid use were found. Comparison between assessors indicated parents tended to score their child's pain higher than nursing staff in hospital. Minor paediatric surgical procedures, particularly circumcision, may be associated with considerable post-operative pain and assumptions must not be made about the effectiveness of analgesia, especially in the home.