Outpatient versus inpatient parotidectomy: Comparison of postoperative complication rates

Outpatient partial parotidectomies are feasible in a well-selected population: a French experience

PURPOSE

This study aimed to evaluate the feasibility, safety, and patient satisfaction of outpatient partial parotidectomies in a French university hospital, addressing the lack of national data on such procedures amidst a push for increased ambulatory surgeries.

METHODS

A prospective cohort study was conducted, involving patients undergoing partial parotidectomy for non-malignant tumors from March 2021 to May 2023. Inclusion was based on surgical, medical, and social criteria. A control group was also reviewed for comparison. The study followed a standardized surgical and anesthesia protocol, with patient satisfaction assessment.

RESULTS

From an initial pool of 104, 64 patients passed surgical screening, and 45 remained after anesthesia and social considerations, marking a 70% inclusion rate for outpatient care. The success rate of outpatient procedures stood at 98%, with complication incidences mirroring those of inpatient counterparts. 91% of participants expressed high satisfaction, scoring their experiences 7/10 or above.

CONCLUSION

Outpatient partial parotidectomies within the French health infrastructure are both viable and align with patient expectations, reinforcing the shift towards ambulatory surgery.

Outpatient parotidectomy: Outcomes, safety and satisfaction

PURPOSE

Parotidectomies are rarely performed on an outpatient basis. The specific perioperative outcomes and their management remains insufficiently described to change daily practice. The objectives were to study the outcomes, the complications and the patient satisfaction rate in parotidectomy performed on an outpatient basis.

MATERIALS AND METHODS

We conducted a retrospective monocentric database study on 85 patients who underwent parotidectomy as a first and sole procedure from 2015 to 2020. We analyzed perioperative outcomes between outpatients and inpatients.

RESULTS

Among 28 outpatients and 57 inpatients, no significant differences in total perioperative complications (p = .66; OR = 1.25; 95 % confidence interval (CI) [0.47; 3.36]), reoperations (p = .55), readmissions (p = 1), or unplanned visits (p = .52) were shown in multivariate analysis. The conversion rate for surgical reasons was 8.6 %, and the satisfaction rate was high.

CONCLUSION

Although outpatient parotidectomies should be as safe as for inpatients, the high rate of minor complications requires specific perioperative management, such as a systematic early postoperative visit and optimized preoperative information in order to be carried out with minimal issues.

Inpatient Versus Outpatient Surgery: A Comparison of Postoperative Mortality and Morbidity in Elective Operations

BACKGROUND

Operations performed outpatient offer several benefits. The prevalence of outpatient operations is growing. Consequently, the proportion of patients with multiple comorbidities undergoing outpatient surgery is increasing. We compared 30-day mortality and overall morbidity between outpatient and inpatient elective operations.

METHODS

Using the 2005-2018 ACS-NSQIP database, we evaluated trends in percent of hospital outpatient operations performed over time, and the percent of operations done outpatient versus inpatient by CPT code. Patient characteristics were compared for outpatient versus inpatient operations. We compared unadjusted and risk-adjusted 30-day mortality and morbidity for inpatient and outpatient operations.

RESULTS

A total of 6,494,298 patients were included. The proportion of outpatient operations increased over time, from 37.8% in 2005 to 48.2% in 2018. We analyzed the 50 most frequent operations performed outpatient versus inpatient 25-75% of the time (n = 1,743,097). Patients having outpatient operations were younger (51.6 vs 54.6 years), female (70.3% vs 67.3%), had fewer comorbidities, and lower ASA class (I-II, 69.3% vs. 59.9%). On both unadjusted and risk-adjusted analysis, 30-day mortality and overall morbidity were less likely in outpatient versus inpatient operations.

CONCLUSION

In this large multi-specialty analysis, we found that patients undergoing outpatient surgery had lower risk of 30-day morbidity and mortality than those undergoing the same inpatient operation. Patients having outpatient surgery were generally healthier, suggesting careful patient selection occurred even with increasing outpatient operation frequency. Patients and providers can feel reassured that outpatient operations are a safe, reasonable option for selected patients.

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.

Patient safety and quality improvements in parotid surgery

Parotidectomy is the mainstay treatment for tumors of the parotid gland. In an effort to improve clinical outcomes, several modern surgical techniques and perioperative interventions have been evaluated and refined. This review discusses current and actively debated perioperative interventions aimed at improving patient safety and the quality of parotidectomy. Relevant high-impact literature pertaining to preoperative diagnostic modalities, intraoperative surgical techniques, and postoperative care will be described.

Cost-analysis of in-office versus operating room sialendoscopy: Comparison of cost burden and outcomes

PURPOSE

Office-based procedures in otolaryngology are increasingly utilized to increase efficiency, reduce cost, and eliminate risks associated with surgery. Gland-preserving surgical management of sialadenitis and sialolithiasis are often performed in the operating room, although many surgeons are moving this practice to clinic. We aim to determine the difference in patient charges and perioperative outcomes for salivary gland procedures performed in the clinic versus the OR.

METHODS

Retrospective series of patients presenting with sialolithiasis, acute or chronic sialadenitis, and stricture between 2010 and 2019. Demographics, perioperative variables, setting, and charge data were collected.

RESULTS

528 patients underwent operative intervention (n = 427 office, n = 101 OR). Cohort demographics were comparable. Sialolithiasis was the most common presenting diagnosis in both cohorts. Both cohorts had similar rates of complete (p = 0.09) and partial (p = 0.97) response to treatment. A higher percentage of patients in the OR group reported no improvement (21.4 vs 12.2%, p = 0.034). Overall complications were similar (p = 0.582). Mean charges were statistically greater in the OR ($5560.35 OR vs $1298.33 office, p < 0.001). Operative time was significantly reduced in the office group (21.8 min vs 60.85 min, p < 0.001).

CONCLUSIONS

Appropriately selected patients can be successfully treated in outpatient clinic without compromising patient safety or quality while significantly reducing the financial burden to patients and the healthcare system.

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.

Is antibiotic prophylaxis expendable in parotid gland surgery? A retrospective analysis of surgical site infection rates

OBJECTIVES

To evaluate the rate of surgical site infection (SSI) and associated risk factors after parotid gland surgery including the impact of antibiotic prophylaxis.

DESIGN

Retrospective single-centre clinical study.

SETTING

Tertiary referral centre for head and neck surgery.

PARTICIPANTS

Seven hundred and fifty four patients who underwent parotid gland surgery at the University Hospital Heidelberg, Germany, between 2007 and 2014 were enrolled in this study. Data on patient age, American Society of Anesthesiologists (ASA) classification system, smoking status, diabetes mellitus, operation time, and antibiotic prophylaxis were collected. Additionally, the National Healthcare Safety Network (NHSN) risk index was calculated. Association of these factors with SSI was evaluated in univariate analyses and a multivariate logistic regression model.

MAIN OUTCOME MEASURES

Rate of SSI.

RESULTS

Twenty four patients (3.2%) had an SSI according to the NHSN definition. In univariate analyses, only smokers (P = .048) and male patients (P = .01) had a significantly higher rate of SSI. Since the majority of smokers were men (62.3%), the effect of male gender, smoking, together with the NHSN risk index was further investigated as predictors of SSI within a logistic regression model. All three predictors showed a significant effect on SSI.

CONCLUSIONS

Parotid gland surgery has a low rate of SSI. In our cohort, male gender, smoking and high NHSN risk index scores were significantly associated with SSI, whereas antibiotic prophylaxis had no protective effect.

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.

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.

Does neck dissection affect post-operative outcomes in parotidectomy? A national study

OBJECTIVE

To characterize post-operative complications in parotidectomy with neck dissection.

METHODS

Patients age ≥ 18 receiving a parotidectomy or parotidectomy with neck dissection between 2005 and 2017 were eligible for inclusion. Patients with unknown demographic variables were excluded. Univariate and multivariable logistic regression analyses were performed.

RESULTS

A total of 13,609 parotidectomy patients were analyzed, 11,243 (82.6%) without neck dissection and 2366 (17.4%) with neck dissection. Both length of surgery (mean minutes ± standard deviation [SD] = 335.9 ± 189.2 vs. 152.9 ± 99.0, p < 0.001) and length of hospital stay (mean days ± SD = 3.90 ± 4.76 vs. 1.04 ± 2.14, p < 0.001) were greater with dissection. 13.9% of parotidectomies with neck dissection and 3.5% without dissection (p < 0.001) had at least one complication, which remained significant after multivariable adjustment (Odds Ratio[OR] = 1.565 (95%CI = 1.279-1.914), p < 0.001). The increase in post-operative complications was predominately driven by an increased transfusion rate (7.4% vs. 0.5%, p < 0.001). Multivariable analysis also demonstrated no significant difference in rates of returning to the operating room (OR = 1.122 (95%CI 0.843-1.493), p > 0.05) or rates of readmission (OR = 1.007 (95%CI 0.740-1.369), p > 0.05). Parotidectomy with neck dissection was more likely to be inpatient (OR = 4.411 (95%CI 3.887-5.004), p < 0.001) and to be ASA class 3 (OR = 1.367 (95%CI 1.194-1.564), p < 0.001).

CONCLUSIONS

Nationwide data demonstrates that parotidectomy with neck dissection is associated with increased rates of post-operative complications; however, neck dissection did not significantly impact readmission or reoperation rates. These findings indicate that neck dissection is a relatively safe addition to parotidectomy and provide novel evidence in the management of parotid malignancies.

Outpatient Parotidectomy: A Retrospective Series

OBJECTIVES

Recent literature suggests that outpatient head and neck surgery is safe and may decrease costs. This study assesses whether outpatient parotidectomy differs in complication type and rate from inpatient surgery.

METHODS

Patients who underwent parotidectomy at our institution from 2011 to 2019 were retrospectively reviewed and divided by inpatient or outpatient status. Complications including infection, seroma, salivary fistula, hematoma, and flap necrosis, as well as readmission rates were tabulated. Drain placement, related to tumor size, was also analyzed using a receiver operating curve.

RESULTS

144 patients had available data for analysis. Nine of the 144 patients had complications. Seven of 98 outpatients and two of 46 inpatients had complications. There was no statistically significant difference in complication rate between the two groups (P = .518). Tumor size ≥4.62 cm³ was associated with drain placement (P = .044).

CONCLUSION

Outpatient parotidectomy is a safe and viable alternative for carefully selected patients.

Outpatient versus Inpatient Parotidectomy: A Systematic Review and Meta-analysis

OBJECTIVE

Parotidectomies are commonly performed procedures by head and neck surgeons. Although parotidectomies are historically inpatient procedures, recent observational evidence has highlighted the potential for parotidectomies to be performed on an outpatient basis. This systematic review and meta-analysis sought to compare complications and unplanned health care utilization between patients undergoing outpatient versus inpatient parotidectomy.

DATA SOURCES

A systematic review was performed using MEDLINE, EMBASE, and the Cochrane Library.

REVIEW METHODS

Studies comparing the outcomes of outpatient parotidectomy with those of inpatient parotidectomy were included. Risk of bias was assessed using the Newcastle-Ottawa Scale. Postoperative complications (hematoma, facial nerve dysfunction, seroma, fistulisation, Frey syndrome, and wound infection) and rates of 30-day readmission, reintervention, and emergency department presentation were compared.

RESULTS

We screened 1018 nonduplicate articles to include 5 studies, all of which were retrospective cohort studies. There were fewer complications found in the outpatient group (relative risk = 0.61, 95% confidence interval: 0.40-0.93). Outpatient procedures were more commonly performed on patients who lived close to the hospital, had fewer comorbidities, and had less extensive planned surgery.

CONCLUSION

Outpatient parotidectomy appears safe in select patients with outcomes comparable with inpatient surgery. However, evidence overall is of low quality, and further work is needed to delineate a satisfactory set of criteria for appropriate patient identification.

Understanding nationwide readmissions after parotidectomy

OBJECTIVES

To evaluate the incidence, causes, risk factors, and costs associated with 30-day readmissions in parotidectomy patients utilizing the Nationwide Readmissions Database (NRD).

STUDY DESIGN

Retrospective cohort study.

METHODS

We examined the NRD for patients who underwent parotidectomy between 2010 and 2014. Rates, causes, and costs of 30-day readmissions were determined. Multivariate logistic regression was used to identify risk factors for readmission.

RESULTS

Among 15,102 included patients, 594 (3.9%) were readmitted within 30 days. The average cost per readmission was $12,502. Infectious (22.7%) and wound (11.2%) complications were the two most common causes of readmission. After controlling for other covariates, significant predictors of readmission included advanced comorbidity (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.09-2.37), a malignant parotid tumor (OR, 2.37; 95% CI, 1.63-3.43), length of stay ≥2 days (OR, 1.54; 95% CI, 1.09-2.18), and nonroutine discharge destinations (home with care [OR, 1.88; 95% CI, 1.27-2.78] and nursing facility [OR, 2.69; 95% CI, 1.55-4.67]).

CONCLUSION

In this nationwide database analysis, we found that nearly 4% of all patients undergoing parotidectomy are readmitted within 30 days. Readmissions are commonly due to infections and wound complications. Quality improvement proposals targeting avoidable readmissions should focus on early recognition and prevention of infection and wound complications. Risk factors contributing to readmission include advanced comorbidity, malignant parotid tumor, prolonged index hospitalization, and nonroutine discharge destinations.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:1212-1217, 2020.