Cirugía endoscópica nasosinusal como cirugía mayor ambulatoria

Analysis of endonasal sinus surgery in a private outpatient setting in a tropical environment: A STROBE analysis

OBJECTIVES

To evaluate results and failure factors in endonasal surgery in a private outpatient setting in a tropical environment.

MATERIAL AND METHOD

A single-center observational study included 337 patients consecutively undergoing endonasal surgery in a private hospital on Réunion Island, a French overseas administrative Département in the Indian Ocean between 2019 and 2021. The main objective was to assess the success rate of the outpatient pathway. Secondary objectives comprised analysis of complications and identification and management of factors for failure of outpatient management. The study was conducted according to the STROBE editorial guideline.

RESULTS

The 337 surgeries notably comprised 112 septoplasties (37.5%), 104 meatotomies (30.3%), 15 unilateral total ethmoidectomies (4.6%), 48 bilateral total ethmoidectomies with sphenoidotomy (14.3%), and 18 Draf procedures (5.5%). Seventy-five percent of patients (252/337) were operated on as outpatients, with a success rate of 90% (227/252 patients). The rate of severe intraoperative complications was 1.5% (5/337). On multivariate analysis, 3 variables were identified as influencing risk of failure of the outpatient pathway: emergency analgesia in the operating room [odds ratio (OR): 91.61; 95% confidence interval (CI): 22.8-540.3], operating time (OR: 1.05; 95% CI: 1.01-1.09), and recovery room time (OR: 1.02; 95% CI: 1.01-1.03).

CONCLUSION

Our study in a tropical environment found eligibility and success rates for outpatient endonasal surgery similar to those in metropolitan France. This makes surgical and anesthesiological training a key factor in the success of outpatient care, while the location of the care structure and the climate seem to have little impact.

Outpatient bilateral ethmoidectomy in a private non-profit structure: Retrospective study of 204 patients

OBJECTIVES

The main objective of this study was to determine the rate of outpatient management in a population of patients undergoing bilateral ethmoidectomy. The secondary objectives were to evaluate the quality of outpatient management (rate of unscheduled overnight admission, readmission rate, complications) and to compare inpatient and outpatient groups to determine which elements of the phenotype and care pathway favored outpatient management.

MATERIALS AND METHODS

A single-center observational study included 204 patients operated on for bilateral ethmoidectomy. Study variables comprised: type of care pathway (outpatient/inpatient), outpatient quality indicators (unscheduled admission, readmission, complications), care pathway, and population characteristics.

RESULTS

One hundred and twenty (58.8%) outpatients were operated on. No deaths occurred. The unscheduled admission rate was 7.5%, and the readmission rate 4.1%; at the P<0.005 threshold, there were no significant differences between in- and out-patient groups. Outpatients had earlier surgery (P<0.005), and nasal packing rates and pain on VAS were lower (P<0.005).

CONCLUSION

Ethmoidectomy could be carried out as an outpatient procedure in 58.8% of cases, with acceptable quality of care. Selection of patients and the organization of a dedicated care pathway seem to be elements favoring this management.

Preoperative risk assessment for ambulatory sinonasal surgery

OBJECTIVES

An increasing proportion of patients who are candidates for endoscopic sinus surgery can be treated as an outpatient. A preoperative risk assessment is needed to evaluate eligibility for day surgery. This study analyses the effectiveness of a risk assessment scoring system which examines medical, procedure-related, and socioeconomic factors.

DESIGN

Prospective multicenter study.

SETTING

Three center study including Klinik Hirslanden, Zurich, Switzerland, Luzerner Kantonsspital, Lucerne, Switzerland and HNO-Klinik München-Bogenhausen, Munich, Germany.

PARTICIPANTS

Patients with endoscopic sinus procedures between January 1st, 2017 and December 31st, 2018.

MAIN OUTCOME MEASURES

The "day surgery risk score" consisted of three subgroups with medical, procedure-related and socioeconomic risk factors were assessed to determine if these predicted the severity of postoperative complications.

RESULTS

Three-hundred and one patients who underwent endoscopic sinus surgery were included. The score resulted in a median value of 5 [5, 5]. In the Receiver-Operating Curve (ROC-the true-positive rate against the false-positive rate), the Area Under the Curve (AUC) was 0.59 with 95% confidence interval from 0.49 to 0.69, indicating that the "day surgery risk score" may be no better at predicting the likelihood of a complication than a random classification model.

CONCLUSIONS

The "day surgery risk score" is a straightforward risk assessment which combines medical, procedure-related, and socioeconomic factors. The score is easy to use but in trying to decide whether a patient is eligible for ambulatory endoscopic sinus surgery it did not predict whether a complication was more likely to occur.

Assessment of quality and safety in rhinologic day surgery

OBJECTIVES

To assess and compare the safety and quality of the management of sinonasal surgery (all procedures) between day-case and traditional admission.

MATERIAL AND METHODS

A 2-year retrospective study included all patients undergoing functional septonasal surgery, ethmoidectomy, middle antrostomy, frontal sinusotomy or endoscopic sphenoidotomy, as day-surgery on inpatient admission. Demographic, operative, pre- and post-operative anesthetic data, complications, and rates of emergency consultation and readmission within 30 days were collected and compared between out- and in-patients.

RESULTS

Nine hundred and nine patients were included: 569 functional septonasal surgeries, 180 ethmoidectomies, 101 middle meatotomies, 40 Draf procedures and 19 sphenoidotomies; respectively 60%, 21%, 54%, 20% and 37% were performed in the day-surgery unit. There were no significant differences in number of emergency consultations or readmissions between the out- and in-patient groups. There were more complications in in-patients (P<0.0001) (4.9% anticoagulant and 12% antiplatelet treatments, 18% obstructive sleep apnea-hypopnea syndromes). The conversion rate to conventional admission was 4.6%. Antiplatelet treatment or postoperative nasal packing were not significant risk factors for complications or readmission.

CONCLUSION

Outpatient sinonasal surgery does not seem to incur extra risk for the patient or surgeon when eligibility criteria are met.

Feasibility study of bilateral radical ethmoidectomy in ambulatory surgery

OBJECTIVES

To assess the feasibility of bilateral radical ethmoidectomy in ambulatory surgery by risk analysis, and to calculate possible medico-economic savings.

METHODS

This study was performed retrospectively over a 2-year period and prospectively for 1 year. It included all patients undergoing bilateral ethmoidectomy, associated to sphenoidotomy and/or septoplasty or not, in a university hospital department. Data were collected on demographics, disease etiology, previous surgery, operative details, postoperative course, complications and satisfaction assessed by questionnaire at days 1 and 30. Ambulatory surgery eligibility criteria were applied to this population, and an economic analysis compared savings between inpatient and outpatient management.

RESULTS

Hundred and sixty-five patients were included. Surgical indications comprised nasal polyposis (87%), chronic sinusitis without nasal polyps (6%) or cystic fibrosis (7%). Seventy-five septoplasties were associated (45.5%). Operating time depended on associated septoplasty (P=0.005), surgeon experience (P<0.0001) and previous sinus surgery (P=0.041). Only 37% of the patients wished for same-day discharge; reasons for refusal were home-to-hospital distance and bleeding risk. Considering anesthesia contraindications, immediate complications and operating time, 107 patients were eligible for outpatient treatment, although only 13 patients underwent ambulatory surgery. Medical-economic savings with outpatient management would have been about €20,000 per year.

CONCLUSIONS

Bilateral radical ethmoidectomy, associated to septoplasty or not, could be performed on an outpatient basis in more than 60% of cases, without increased risk, and with cost savings of 28.4%.

Outcomes of endoscopic ethmoidectomy performed on a day-case basis: a prospective bi-centric study

Evaluation of endoscopic ethmoidectomy performed as a day-case in terms of security, quality, and satisfaction of the patient. This prospective observatory bi-centric study over 1 year included 74 patients undergoing an ethmoidectomy respecting the eligibility criteria of ambulatory care. We recorded patients' demographic data, operative details, satisfaction, postoperative course, and follow-up results. Nasal symptoms were evaluated by SNOT-22 on preoperative appointment and postoperatively at D30. No non-absorbable nasal packing was used, eventually in the case of preoperative-bleeding absorbable gelatine packing. The postoperative follow-up took place at D1 by phone call and at D10 and D30 to assess complications, Visual Analogue Scale, and state of ethmoidal corridors by endoscopic exam. Patients benefited of bilateral ethmoidectomy in 82.4 % cases associated with septoplasty in 42 %. The majority (95 %) was discharged on the same day. Only one patient had bleeding at D0 and was kept in standard hospitalization, such as three other patients for medical or organizational reasons not related to surgery. At D1, 23 % described postoperative light bleeding but needed no revisit and pain was estimated at 1.3 (VAS). No readmission was observed, and no major complication was noted. SNOT-22 decreased successfully by 56 %, statistically related to postoperative treatment of corticosteroids and in the case of Samter triad. 97 % of patients were satisfied of the ambulatory care. These results suggest that within an experienced and dedicated day-case medical and paramedical team, ethmoidectomy can be safely performed on a day-case basis with high quality of taking care and satisfaction of patients.

French Otorhinolaryngology Society guidelines for day-case nasal surgery

OBJECTIVES

The French Otorhinolaryngology Society (SFORL) set up a work group to draw up a consensus document on day-case surgery in four rhinologic procedures: endoscopic middle meatal antrostomy (French National Health Insurance (CCAM) code GBPE001), septoplasty (GAMA007), and reduction of nasal bone fracture using a direct approach (LAEA007) and using a closed technique (LAEP002).

MATERIALS AND METHODS

Methodology followed the French Health Authority (HAS) "Methodological Bases for Drawing Up Professional Guidelines by Formalized Consensus" published in January 2006; the method chosen was the short version of the RAND/UCLA Appropriateness Method (without editorial group), as the work group topic was highly specialized, with few experts available.

RESULTS

Ahead of any day-case sinonasal surgery, it is recommended that patient eligibility criteria be respected and hemorrhagic risk assessed; preference should be given to short procedures involving little variation in surgery time and minimizing blood-loss, and associated procedures (e.g., septoplasty+turbinectomy) should be avoided. The patient and family should be informed of specific hemorrhagic, orbital and/or neuromeningeal risks, onset of which may preclude discharge home. Uni- or bilateral postoperative nasal packing is not a contraindication to day-case management.

CONCLUSION

All four procedures may be performed on a day-case basis. Eligibility criteria should be systematically respected, but hemorrhagic risk, which is very specific to the sinonasal organ, is to be assessed on a case-by-case basis, as it is a major issue in this kind of management for a non-negligible number of patients.