Same day discharge for benign laparoscopic hiatal surgery: a feasibility analysis

Ambulatory bariatric surgery: a prospective single-center experience

BACKGROUND

Ambulatory bariatric surgery has recently gained interest especially as a potential way to improve access for eligible patients with severe obesity. Building on our previously published research, this follow-up study delves deeper in the evolving landscape of ambulatory bariatric surgery over a 3-year period, focusing on predictors of success/failure.

METHODS

In a prospective single-center follow-up study, we conducted a descriptive assessment of all eligible patients as per our established protocol, who underwent a planned same-day discharge (SDD) primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between 03/01/2021 and 02/29/2024. Trends in SDD surgeries over time were assessed over six discrete 6 month intervals. Primary endpoint was defined as a successful discharge on the day of surgery without emergency department visit or readmission within 24 h. Secondary outcomes included 30-day postoperative morbidity.

RESULTS

A total of 811 primary SG and 325 RYGB procedures were performed during the study period. Among them, 30% (n = 244) were SDD-SGs and 6% (n = 21) were SDD-RYGBs, respectively. At baseline, median age of the entire SDD cohort was 43 years old, 81% were females, and body mass index (BMI) was 44.5 kg/m2. The planned SDD approach was successful in 89% after SG (n = 218/244) and in 90% after RYGB (n = 19/21). Nausea/vomiting was the main reason for a failed SDD approach after SG (46%). The 30-day readmission rate was 1.5% (n = 4) for the entire SDD cohort including only one readmission in the first 24 h. The percentage of SDD-SGs performed as a proportion of total SGs increased over the initial five consecutive six-month intervals (14%, 25%, 24%, 38%, and 49%).

CONCLUSION

Our SDD protocol for bariatric surgery demonstrates a favorable safety profile, marked by high success rate and low postoperative morbidity. These outcomes have led to a continued increase in ambulatory procedures performed over time especially SG.

Same day discharge after minimally invasive adrenalectomy: a national study

BACKGROUND

Same day discharge (SDD) may be considered in some patients undergoing minimally invasive adrenalectomy (MIA). Recent studies have demonstrated similar outcomes between SDD and admitted patients; however, most excluded pheochromocytoma and adrenal metastases. This study evaluates 30-day complications and hospital readmission in a large cohort of patients undergoing MIA.

METHODS

Adult patients undergoing MIA (2010-2020) for benign adrenal disorders, pheochromocytoma, and adrenal metastases were identified within the ACS-NSQIP database. Comparisons between patients having SDD versus admission were performed. Factors associated with 30-day complications and unplanned readmission were evaluated by multivariable regression modeling.

RESULTS

Of 7316 patients who underwent MIA, 254 had SDD. Baseline characteristics were similar between groups, although SDD patients had lower ASA class (p < 0.001) and were more likely to undergo MIA for nonfunctioning adenoma or primary aldosteronism (p = 0.001). After adjusting for covariates, higher ASA class and presence of medical comorbidities were associated with increased complications (p < 0.001; p < 0.05) and unplanned readmission (p < 0.001; p < 0.05). Additionally, prolonged operative time was associated with 30-day complications (p < 0.001). Notably, SDD was not associated with increased complications (OR 0.78, 95% CI 0.38-1.61, p = 0.502) or unplanned readmission (OR 0.76, 95% CI 0.35-1.64, p = 0.490). The rate of SDD for MIA increased from 1.48% in 2017 to 10.81% in 2020.

CONCLUSIONS

Not all patients undergoing MIA should have SDD; however, the current analysis demonstrates a trend toward SDD and supports its safety in select patients with adrenal metastases and benign adrenal disorders including pheochromocytoma.

Same-Day Home Recovery for Benign Foregut Surgery

Importance

Same-day home recovery (SHR) is now the standard of care for many major surgical procedures and has the potential to become standard practice for benign foregut procedures (eg, hiatal hernia repair, fundoplication, and Heller myotomy).

Objective

To determine whether SHR for patients undergoing benign foregut surgery is feasible, safe, and effective.

Design, Setting, and Participants

This prospective cohort study took place across 19 medical centers within an integrated health care system in northern California from January 2019 through September 2021. Participants included consecutive patients undergoing elective benign foregut surgery.

Exposures

Standardized SHR program.

Main Outcomes and Measures

The primary end point was the rate of SHR. The secondary end points were 7-day and 30-day rates of postoperative emergency department visits, hospital readmissions, and reoperations.

Results

Of 1248 patients who underwent benign foregut surgery from January 2017 through September 2021, 558 were patients before implementation of the SHR program and 690 were patients postimplementation. The mean age of patients was 60 years, and 759 (59%) were female. The preimplementation SHR rate was 64 of 558 patients (11.5%) in 2018 and increased to 82 of 113 patients (72.6%) by 2021 (94/350 [26.9%] in 2019 and 112/227 [49.3%] in 2020; P < .001). There were no statistical differences in the 7-day and 30-day rates of postoperative emergency visits, hospital readmissions, and reoperations or 30-day mortality in the SHR vs non-SHR groups in the postimplementation era.

Conclusions and Relevance

In this study, implementation of a regional SHR program among patients undergoing elective benign foregut surgery was feasible, safe, and effective. The changes in perioperative care require comprehensive patient education and full multidisciplinary support. An SHR program for benign foregut procedures has the potential to improve patient care and cost-effectiveness in care delivery.

Same day discharge does not lead to worse outcomes in patients undergoing uncomplicated laparoscopic foregut surgery

INTRODUCTION

With the advancement of minimally invasive surgical techniques surgeons have moved away from elective open foregut surgeries. Despite studies demonstrating the safety of same day discharge in appropriate patient populations, ambulatory surgery has yet to be established as the practice norm for patients undergoing uncomplicated laparoscopic foregut surgery.

METHODS

The ACS-NSQIP database was queried from 2005 to 2018 for patients who had undergone elective and non-emergent laparoscopic Heller myotomy, fundoplication, and paraesophageal hernia repairs with and without mesh. The primary endpoints in this study included number and severity of complications as classified by the Clavien-Dindo Classification, readmission, and return to the operating room.

RESULTS

6893 patients who met inclusion criteria were identified, 696 (10.1%) of which were discharged on the day of surgery. Patients who were discharged on post-operative day one were matched at a 3:1 ratio producing 2088 comparisons. There was no difference in overall morbidity (p = 0.264), readmission (OR 0.849, 95% CI 0.522-1.419), or return to the operating room (OR 1.15, 95% CI 0.531-2.761) between the two groups.

CONCLUSION

Same day discharge for patients without life threatening comorbidities undergoing elective minimally invasive Heller myotomy, Nissen and Toupet fundoplication, and paraesophageal hernia repairs is safe and feasible.

Same-day discharge for laparoscopic Heller myotomy

BACKGROUND

Laparoscopic Heller myotomy is an effective treatment for achalasia. There are little data on the safety and feasibility of same-day discharge after laparoscopic Heller myotomy.

OBJECTIVE

This study aimed to describe the experience with same-day discharge after laparoscopic Heller myotomy at one hospital.

METHODS

A retrospective cohort study including all patients who underwent laparoscopic Heller myotomy between 2007 and 2016 at University Health Network (UHN), Toronto, Canada. There was no consent required as the study was retrospective study. This study was approved by the UHN IRB. Planned same-day discharge patients were compared to planned inpatient with respect to post-op complications, length of stay, and number of emergency visits.

RESULTS

A total of 209 patients were identified. Same-day discharge was planned in 67 (33.5%) cases compared to 133 (66.5%) cases that were planned for inpatient. The study population was 49% male. On average, inpatients had 2.3 pre-operative comorbidities and same-day discharge patients had 1.6 pre-operative comorbidities. The average length of stay for the inpatient group was 3.5 days. Among the same-day surgery group, 15 had an unplanned admission following surgery (22%). Of those who were admitted, the average length of stay was 1.27 days. Only 1 same-day discharge was readmitted after hospital discharge, while 4 in inpatient group were readmitted. The post-operative complication rate was (15%) 20 of inpatient compared to four (6.0%) of same-day discharge. Number of emergency visits for inpatient group were 7 (5.3%) compared to 3 (4.5%) for same-day discharge group. There was one mortality case in inpatient group due to post-op complication.

CONCLUSION

Same-day surgery is feasible for laparoscopic Heller myotomy, with a similar complication and readmission rate as inpatient surgery.

Quality of recovery assessment of day case and multiday stay patients undergoing elective laparoscopic cholecystectomy

Objectives

Many laparoscopic cholecystectomy operations are performed with at least overnight admission. Current research shows that laparoscopic cholecystectomy is safe and feasible to do as a day case. Patient centred outcomes are less well understood.

Material and Methods

Elective laparoscopic cholecystectomy patients at a single metropolitan hospital in Melbourne, Australia were surveyed 24 hours after surgery using the 15-question Quality of Recovery (QoR-15) survey. A comparison was made between day case surgeries and multi-day surgeries.

Results

One hundred and eight patients were recruited consisting of 34 day case and 74 multi-day patients. Patient groups did not differ in terms of age, sex or postoperative morbidity. The multi-day group had a higher proportion of comorbid patients (p-value = 0.03). There was no significant dif- ference in overall QoR-15 score between the two groups, although there was an observed trend towards a higher score in the day case group (132.0 vs 127.9, p= 0.147). QoR-15 individual question results showed that day cases rated significantly better for sleep quality and for less feelings of anxiety or worry. The differences narrowed when comparing patient groups as they were booked (intention-to-treat). There were no identified sub-groups that had a significantly higher score if admitted multi-day.

Conclusion

Quality of recovery following day case laparoscopic cholecystectomy is just as good, if not better, than multi-day cases. Laparoscopic cholecystectomy as a day case is both safe and economically superior to multi-day management. This gives further weight to current recommendations suggesting that the majority of laparoscopic cholecystectomy operations could be performed as day cases.

Perioperative outcomes of inpatient laparoscopic Heller myotomy and per-oral endoscopic myotomy in the United States

BACKGROUND

Per-oral endoscopic myotomy is an alternative to pneumatic dilation and laparoscopic Heller myotomy to treat lower esophageal sphincter diseases. Laparoscopic Heller myotomy and per-oral endoscopic myotomy perioperative outcomes data come from relatively small retrospective series and 1 randomized trial. We aimed to estimate the number of inpatient procedures performed in the United States and compare perioperative outcomes and costs of laparoscopic Heller myotomy and per-oral endoscopic myotomy using a nationally representative database.

METHODS

Cross-sectional retrospective analysis of hospital admissions for laparoscopic Heller myotomy or per-oral endoscopic myotomy from October 2015 through December 2018 in the National Inpatient Sample. Patient and hospital characteristics, concurrent antireflux procedures, perioperative adverse events (any adverse event and those associated with extended length of stay ≥3 days), mortality, length of stay, and costs were compared. Logistic regression evaluated factors independently associated with adverse events.

RESULTS

An estimated 11,270 patients had laparoscopic Heller myotomy (n = 9,555) or per-oral endoscopic myotomy (n = 1,715) without significant differences in demographics and comorbidities. A concurrent anti-reflux procedure was more frequent with laparoscopic Heller myotomy (72.8% vs 15.5%, P < .001). Overall adverse event rate was higher with per-oral endoscopic myotomy (13.3% vs 24.8%, P < .001), and mortality was similar. Per-oral endoscopic myotomy had higher rates of adverse events associated with extended length of stay (9.3% vs 16.6%, P < .001), infectious adverse events (3.5% vs 8.2%, P < .001), gastrointestinal bleeding (3.4% vs 5.8%, P = .04), accidental injuries (3% vs 5.5%, P = .03), and thoracic adverse events (4.5% vs 9%, P < .01). Rates of adverse events of both procedures remained similar during the years of the study. Per-oral endoscopic myotomy was independently associated with adverse events. Length of stay (laparoscopic Heller myotomy: 3.2 ± 0.1 vs per-oral endoscopic myotomy: 3.7 ± 0.3 days, P = .17) and costs (laparoscopic Heller myotomy: $15,471 ± 406 vs per-oral endoscopic myotomy: $15,146 ± 1,308, P = .82) were similar.

CONCLUSION

In this national database review, laparoscopic Heller myotomy had a lower rate of perioperative adverse events at similar length of stay and costs than per-oral endoscopic myotomy. Laparoscopic Heller myotomy remains a safer procedure than per-oral endoscopic myotomy for a myotomy of the distal esophagus and lower esophageal sphincter in the United States.

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.

Feasibility analysis for the development of a video-assisted thoracoscopic (VATS) lobectomy 23-hour recovery pathway

Background

Video-assisted thoracoscopic (VATS) lobectomy has been demonstrated to offer several benefits over open surgery. The purpose of this study was to assess the feasibility and safety of an ultra-fast-track 23-hour recovery pathway for VATS lobectomy.

Methods

A prospectively maintained institutional database was queried for patients who underwent VATS lobectomy from 2006 to 2016 at the McGill University Health Centre in Montreal, Quebec, and data were supplemented with focused chart review. Patients discharged with a length of stay (LOS) of 23 hours or less were compared with those with an LOS of 2 days or more. Logistic regression was performed to identify predictors of LOS of 23 hours or less.

Results

Two hundred and five patients were included in the study. Perioperative 30-day mortality for our cohort was 0% and the major complication rate was 8.3%. The median LOS was 3 days (interquartile range [IQR] 2-4 d). Thirty-four patients were discharged within 23 hours and none of them required readmission; 171 patients were discharged on postoperative day 2 or later and 9 of them (5.3%) required readmission (p = 0.36). The proportion of patients discharged within 23 hours increased in 2016 compared with previous years (25.8% v. 12.0%, p = 0.05). Patients discharged within 23 hours had shorter chest tube duration (odds ratio [OR] 0.20, 95% confidence interval [CI] 0.09-0.46, p < 0.001), lower clinical stage disease (stages II-III v. stage I OR 0.07, 95% CI 0.01-0.52, p = 0.011), lower pathologic stage lesions (stages II-III v. stage I OR 0.26, 95% CI 0.07-0.91, p = 0.035), fewer surgical complications (OR 0.04, 95% CI 0.01-0.30, p = 0.002) and shorter operative time (surgery duration > 120 min OR 0.42, 95% CI 0.18-0.95, p = 0.04). Our exploratory prediction modelling showed that chest tube duration, clinical stage and surgeon were the most influential predictors of discharge within 23 hours.

Conclusion

The only preoperative factors that predicted shorter LOS in our cohort were clinical stage and surgeon. A significant proportion of patients can be discharged safely by adopting a VATS lobectomy 23-hour enhanced recovery pathway.

Retrospective Review and Prospective Follow-up of 85 Consecutive Patients Treated With a Novel Hepatic-derived Surgical Mesh for Hiatal Hernia Repair: Outcomes, Surgical Complications, and Revisions

This study examined outcomes, surgical complications, and revisions in patients treated with laparoscopic Nissen fundoplication for hiatal hernia and substantial gastroesophageal reflux disease. In total, 85 consecutive patients who underwent hernia repair with MIROMESH Biologic Matrix, a novel hepatic-derived surgical mesh served as subjects. Subjects were contacted by phone, consented, and participated in an Institutional Review Board-approved structured phone interview. Responses were acquired from 73 of the 85 patients. The gastroesophageal reflux disease health-related quality of life showed significant improvement postoperatively. Subjects reported high satisfaction with the procedure. The use of proton pump inhibitors was significantly reduced. Three minor complications were reported; these were quickly resolved without further sequelae. There were no mesh-related complications. No subjects reported further surgery. Placement of the surgical mesh, during surgery, to reinforce the hiatal repair was easy and safe. Excellent outcomes and no revisions a mean of 1.3 years after surgery suggest that a durable repair had been achieved.

Anesthetic Management for Paraesophageal Hernia Repair

Paraesophageal hernia repairs are complex surgical cases frequently performed on patients of advanced age with multiple comorbidities, both of which create difficulties in the anesthetic management. Preoperative evaluation is challenging because of overlapping cardiopulmonary symptoms. The patient's symptoms and anatomy lead to an increased aspiration risk and the potential need for a rapid sequence induction. Depending on the surgical approach, lung isolation may be required. Communication with the surgeon is vital throughout the case, especially when placing gastric tube and bougies. Multimodal analgesia should include regional and/or neuraxial techniques, in addition to the standard intravenous and oral pain medications.

Comparison of Dor and Nissen fundoplication after laparoscopic paraesophageal hernia repair

BACKGROUND

Fundoplication is performed routinely during laparoscopic repairs of a paraesophageal hernia, but the degree of fundoplication remains controversial. The purpose of this study is to assess postoperative dysphagia and reflux after a Dor versus a Nissen fundoplication in patients undergoing laparoscopic repair of giant paraesophageal hernias.

METHODS

We performed a retrospective cohort study of all patients undergoing laparoscopic repair of giant paraesophageal hernias with Nissen or Dor fundoplication between January 2012 and December 2017 at a high-volume center, excluding revisional and emergency cases. Primary outcomes were reflux and dysphagia at 1 and 6 months. Severe dysphagia was defined as intolerance to liquids. Balanced cohorts were created using coarsened exact matching.

RESULTS

A total of 106 patients were included, and 87 were matched (Dor = 48, Nissen = 58). Baseline characteristics were well balanced between matched groups. Mean follow-up duration was 17.7 months (standard deviation 16.4). The incidence of severe dysphagia at 1 month was less in the Dor group (0 of 48 vs 8 of 58, P = .02) with similar reflux symptoms. There was no difference in severe dysphagia and reflux symptoms at 6 months and at the latest visit.

CONCLUSION

Dor fundoplication is associated with less severe, early postoperative dysphagia. Future studies assessing the relative importance of dysphagia and reflux on quality of life should be conducted to tailor the operative technique and optimize patient satisfaction.

Post-operative complications and readmissions following outpatient elective Nissen fundoplication

INTRODUCTION

Traditionally, laparoscopic Nissen fundoplication (LNF) has been considered an inpatient procedure. Advances in surgical and anesthetic techniques have led to a shift towards outpatient LNF procedures. However, differences in surgical outcomes between outpatient and inpatient LNF are poorly understood. The objectives of this study were (1) to describe the frequency of outpatient LNF in a national cohort and (2) to identify any differences in complications or readmission rates between outpatient and inpatient LNF.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify elective LNF cases from 2012 to 2016. Patients discharged on the day of surgery were compared to those discharged 24-48 h post-operatively. Outcomes included 30-day readmission and death or serious morbidity (DSM). Bivariate analyses were completed with Chi squared testing for categorical variables and two sided t tests for continuous variables. Associations between outpatient surgery and outcomes were assessed using multivariable logistic regression. Differences in readmission were analyzed using Kaplan-Meier failure estimates and log-rank tests.

RESULTS

Of 7734 patients who underwent elective LNF, 568 (7.3%) were discharged on the day of surgery. The overall 30-day readmission rate was 4.1% (n = 316) and the overall rate of DSM was 1.0% (n = 79). The most common 30-day readmission diagnoses overall were infectious complications (16.1%), dysphagia (12.9%), and abdominal pain (11.7%). On multivariable analysis, there was no association between outpatient surgery and 30-day readmission (3.9% vs. 4.1%; aOR 0.97, 95% CI 0.62-1.52, p = 0.908) or DSM (1.1% vs. 1.0%; aOR 0.91, 95%CI 0.36-2.29, p = 0.848). Kaplan-Meier analysis showed no difference in rates of hospital readmission between groups at 30-days from discharge (3.9% vs. 4.1%, p = 0.325).

CONCLUSIONS

Among patients undergoing elective LNF, there were no significant differences in post-operative complications and 30-day readmission when compared to traditional inpatient postoperative care. Further consideration should be given to transitioning LNF to an outpatient procedure.

Patterns of hospital utilization after elective minimally invasive foregut surgery

INTRODUCTION

Post-operative non-urgent hospital visits (NUR-HV) are an important quality target for reducing unnecessary healthcare utilization. The primary objective of this study was to characterize 90-day post-operative hospital use and determine independent predictors for NUR-HV and urgent (UR)-HV after elective laparoscopic paraesophageal hernia repair (LPEHR) and Nissen Fundoplication (LNF).

METHODS

Five hundred and sixty-two primary LPEHR and LNF patients were retrospectively reviewed at a single institution. Ninety-day NUR-HV and UR-HV were compared to patients without post-operative HV using baseline medical and demographic data, preoperative work-up (manometry, pH testing, disease-specific quality of life and symptom scale scores (GERSS), and hospital course. Multiple logistic models were created using univariate associations (p < 0.1) to model independent predictors of NUR-HV and UR-HV.

RESULTS

NUR-HV accounted for 52% (n = 30) of all 90-HV, while the remaining were UR-HV (n = 28, 48.3%). Compared to controls, NUR-HV were younger (51.2 ± 16.8 years vs. 57.6 ± 15.2, p = 0.05), had a lower baseline BMI (28.2 ± 6.4 vs. 31.3 ± 5.4, p = 0.003) and ASA scores (p = 0.02), presented with higher GERSS (46 (28-60) vs. 35 (19-48), p = 0.02) and dysphagia scores (3 (1-5) vs. 2 (0-4), p = 0.02), were associated with LNF (77.7% vs. 54.6%, p = 0.02), and experienced more post-operative dysphagia (13.3% vs. 4.6%, p = 0.06). UR-HV were older (64.0 ± 13.2 vs. 57.6 ± 15.2, p = 0.03), associated with LPEHR (67.9% vs. 45.4%, p = 0.02), longer hospital stay (2 (1-3) vs. 1 (1-2), p = 0.003), and increased overall (39.3% vs. 15.1%, p = 0.001) and urgent complications (34.6% vs. 8.3%, p < 0.005). Positive predictors of NUR-HV included ASA score < 3 (OR 4.4, p = 0.02), increasing GERSS (1.04, p = 0.01), and reduced peristalsis (OR 4.7, p = 0.01), while UR-HV were independently predicted by urgent complications (5.0, p < 0.00005).

CONCLUSIONS

NUR-HV accounted for half of post-operative visits following LNF/LPEHR and were predicted by distinct characteristics compared to UR-HV. This stratification provides novel insight that will guide both preoperative counseling and post-operative quality initiatives.

Healthcare spending and utilization following antireflux surgery: examining costs and reasons for readmission

BACKGROUND

While clinical outcomes have been reported for anti-reflux surgery (ARS), there are limited data on post-operative encounters, including readmission, and their associated costs. This study evaluates healthcare utilization during the 90-day post-operative period following ARS including fundoplication and/or paraesophageal hernia (PEH) repair.

METHODS

Data were analyzed from the Truven Health MarketScan^® Databases. Patients older than 16 years with an ICD-9 procedure code or Common Procedural Terminology (CPT) code for ARS and a primary diagnosis of GERD during 2012-2014 were selected. Healthcare spending and utilization on emergency department (ED) visits, performance of outpatient endoscopy, and readmission were examined. Reasons for readmission were classified based on ICD-9 code.

RESULTS

A total of 40,853 patients were included in the cohort with a mean age of 49 years and females comprising 76.0%. Mean length of stay was 1.4 days, and 93.0% of patients underwent a laparoscopic approach. The mean cost of the index surgical admission was $24,034. Readmission occurred in 4.2% of patients, and of those, 26.3% required a surgical intervention. Patients requiring one or more related readmissions accrued additional costs of $29,513. Some of the most common reasons for readmission were related to nutritional, metabolic, and fluid and electrolyte disorders. Presentation to the ED occurred in 14.0% of patients, and outpatient upper endoscopy was required in 1.5% of patients, but with much lower associated costs as compared to readmission ($1175).

CONCLUSION

The majority of patients undergoing ARS do not require additional care within 90 days of surgery. Patients who are readmitted accrue costs that almost double the overall cost of care compared to the initial hospitalization. Measures to attenuate potentially preventable readmissions after ARS may reduce healthcare utilization in this patient population.

Clinic-day surgery for children: a patient and staff perspective

INTRODUCTION

For the past 3 years, our institution has implemented a same clinic-day surgery (CDS) program, where common surgical procedures are performed the same day as the initial clinic evaluation. We sought to evaluate the patient and faculty/staff satisfaction following the implementation of this program.

METHODS

After IRB approval, patients presenting for the CDS between 2014 and 2017 were retrospectively reviewed. Of these, patient families who received CDS were contacted to perform a telephone survey focusing on their overall satisfaction and to obtain feedback. In addition, feedback from faculty/staff members directly involved in the program was obtained to determine barriers and satisfaction with the program.

RESULTS

Twenty-nine patients received CDS, with the most commonly performed procedures being inguinal hernia repair (34%) and umbilical hernia repair (24%). Twenty (69%) patients agreed to perform the telephone survey. Parents were overall satisfied with the CDS program, agreeing that the instructions were easy to understand. Overall, 79% of parents indicated that it decreased overall stress/anxiety, with 75% saying it allowed for less time away from work, and 95% agreeing to pursue CDS again if offered. The most common negative feedback was an unspecified operative start time (15%). While faculty/staff members agreed the program was patient-centered, there were concerns over low enrollment and surgeon continuity, because there were different evaluating and operating surgeons.

CONCLUSION

This study successfully evaluated the satisfaction of patients and faculty/staff members after implementing a clinic-day surgery program. Our results demonstrated improved patient family satisfaction, with families reporting decreased anxiety and less time away from work. Despite this, faculty and staff members reported challenges with enrollment and surgeon continuity.

Gastrothorax: A case of mistaken identity

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Patients with a recent history of anti-reflux surgery, who present with a tension pneumothorax could be presenting with a gastrothorax.

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They should always be treated with an intercostal catheter if they are in respiratory distress.

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Follow up imaging with a CT scan is needed to confirm diagnosis.

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Gastrothorax should be urgently managed with the insertion of a nasogastric tube and surgical decompression.

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Good control of post- operative nausea and vomiting is essential in avoiding wrap failure and ensuing complications.

Introduction

Acute wrap failure post fundoplication is a rare but recognized complication and can be due to patient factors, disease factors and surgical factors. Herniation of the stomach into the thorax can mimic a pneumothorax clinically and radiologically and thus lead to bad outcomes for patients.

Presentation of case

We report the case of a 20-year-old male who presented to the emergency department with progressively worsening upper abdominal pain, nausea and vomiting followed by acute onset dyspnoea, six days post a laparoscopic repair of a small hiatus hernia and a Nissen fundoplication. His chest x-ray was consistent with that of a left sided pneumothorax and was therefore, appropriately resuscitated and treated with an intercostal catheter (ICC). A subsequent CT scan of the chest revealed a left gastrothorax. The patient was taken to theatre for the surgical reduction of the paraoesophageal hernia.

Discussion

Patients with a recent history of anti-reflux surgery, who present with a pneumothorax and respiratory distress or a tension pneumothorax should always be treated with an ICC. However, follow up imaging with a CT scan is essential to confirm diagnosis. Good control of post- operative nausea and vomiting is essential in avoiding wrap failure and ensuing complications.

Conclusion

A high index of suspicion for a gastrothorax mimicking a pneumothorax is important in the setting of recent anti-reflux surgery.