Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children

OBJECTIVE

In previous clinical trials involving children severely affected with recurrent throat infection (7 or more well-documented, clinically important, adequately treated episodes of throat infection in the preceding year, or 5 or more such episodes in each of the 2 preceding years, or 3 or more such episodes in each of the 3 preceding years), we found tonsillectomy efficacious in reducing the number and severity of subsequent episodes of throat infection for at least 2 years. The results seemed to warrant the election of tonsillectomy in children meeting the trials' stringent eligibility criteria but also provided support for nonsurgical management. We undertook the present trials to determine 1) whether tonsillectomy would afford equivalent benefit in children who were less severely affected than those in our earlier trials but who nonetheless had indications for tonsillectomy comparable to those in general use, and 2) whether, in such children, the addition of adenoidectomy would confer additional benefit.

METHODS

We conducted 2 parallel randomized, controlled trials in the Ambulatory Care Center of Children's Hospital of Pittsburgh. To be eligible, children were required to have had a history of recurrent episodes of throat infection that met standards slightly less stringent than the standards used in our earlier trials regarding either the frequency of previous episodes or their clinical features or their degree of documentation, but not regarding >1 of those parameters. These reduced standards were nonetheless more stringent than those in current official guidelines, which list "3 or more infections of tonsils and/or adenoids per year despite adequate medical therapy" as an indication for tonsillectomy or adenotonsillectomy. Of 2174 children referred by physicians or parents, 373 met the current trials' eligibility criteria and 328 were enrolled. Of these, 177 children without obstructing adenoids or recurrent or persistent otitis media were randomized to either a tonsillectomy group, an adenotonsillectomy group, or a control group (the 3-way trial), and 151 children who had 1 or more such conditions were randomized to either an adenotonsillectomy group or a control group (the 2-way trial). Outcome measures were the occurrence of episodes of throat infection during the 3 years of follow-up; other, indirect measures of morbidity; and complications of surgery.

RESULTS

By various measures, the incidence of throat infection was significantly lower in surgical groups than in corresponding control groups during each of the 3 follow-up years. However, even among control children, mean rates of moderate or severe episodes were low, ranging from 0.16 to 0.43 per year. Adenotonsillectomy was no more efficacious than tonsillectomy alone. Of 203 children treated with surgery, 16 (7.9%) had surgery-related complications of varying types and severity.

CONCLUSIONS

The modest benefit conferred by tonsillectomy or adenotonsillectomy in children moderately affected with recurrent throat infection seems not to justify the inherent risks, morbidity, and cost of the operations. We conclude that, under ordinary circumstances, neither eligibility criteria such as those used for the present trials nor the criterion for surgery in current official guidelines are sufficiently stringent for use in clinical practice.

Optimizing outcomes in bariatric surgery: outpatient laparoscopic gastric bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is an effective treatment of severe obesity and one of the fastest growing surgical procedures in the United States.

METHODS

A single institution prospective database of patients undergoing outpatient laparoscopic (lap) RYGB over a 3-year period was reviewed. Study end points included hospital discharge within 23 hours, 30-day hospital readmission rate, early (<30 day) and late complication rates, and 30-day perioperative mortality. Variables assessed included surgeon experience, patient demographics, comorbidities, operative time, Roux limb pathway, intraoperative steroid bolus, and use of dexmedetomidine.

RESULTS

Two thousand consecutive patients undergoing outpatient lap RYGB were identified, and 84% (n = 1669) were discharged within 23 hours. Of these, 1.7% (n = 34) were readmitted within 30 days. The overall early and late complication rates were 1.9% (n = 38) and 4.3% (n = 86), respectively. The 30-day mortality rate was 0.1% (n = 2), and neither patient was discharged before death. Univariate analysis demonstrated surgeon experience (<50 cases), age (<56 years), body mass index (<60 kg/m), weight (400 lbs), comorbidities (<5), and intraoperative steroid bolus as predictive of successful outpatient discharge. Multivariate analysis revealed surgeon experience, comorbidities, body mass index, and steroid bolus as predictive variables.

CONCLUSIONS

These data suggest that outpatient lap RYGB can be performed with acceptable perioperative complication rates, hospital readmission, and mortality rates. Surgeon experience, careful patient selection, and the use of intraoperative steroid bolus predicted optimal patient outcomes.

Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway

OBJECTIVE

To determine the success of a clinical pathway for outpatient laparoscopic cholecystectomy (LC) in an academic health center, and to assess the impact of pathway implementation on same-day discharge rates, safety, patient satisfaction, and resource utilization.

SUMMARY BACKGROUND DATA

Laparoscopic cholecystectomy is reported to be safe for patients and acceptable as an outpatient procedure. Whether this experience can be translated to an academic health center or larger hospital is uncertain. Clinical pathways guide the care of specific patient populations with the goal of enhancing patient care while optimizing resource utilization. The effectiveness of these pathways in achieving their goals is not well studied.

METHODS

During a 12-month period beginning April 1, 1999, all patients eligible for an elective LC (n = 177) participated in a clinical pathway developed to transition LC to an outpatient procedure. These were compared with all patients undergoing elective LC (n = 208) in the 15 months immediately before pathway implementation. Successful same-day discharges, reasons for postoperative admission, readmission rates, complications, deaths, and patient satisfaction were compared. Average length of stay and total hospital costs were calculated and compared.

RESULTS

After pathway implementation, the proportion of same-day discharges increased significantly, from 21% to 72%. Unplanned postoperative admissions decreased as experience with the pathway increased. Patient characteristics, need for readmission, complications, and deaths were not different between the groups. Patients surveyed were highly satisfied with their care. Resource utilization declined, resulting in more available inpatient beds and substantial cost savings.

CONCLUSIONS

Implementation of a clinical pathway for outpatient LC was successful, safe, and satisfying for patients. Converting LC to an outpatient procedure resulted in a significant reduction in medical resource use, including a decreased length of stay and total cost of care.

Long-term outcome of a randomized study comparing three techniques of conization: cold knife, laser, and LEEP

OBJECTIVE

To evaluate the long-term recurrence rates and complication of different techniques of cervical ablation.

METHODS

A randomized trial of three techniques of conization (cold knife, laser, and loop electrosurgical excisional procedure (LEEP)) for cervical intraepithelial neoplasia (CIN) in which 110 patients had been recruited.

RESULTS

Eighty-six patients were followed-up for more than 3 years. Of these 28 had been treated with the cold knife, 29 with LEEP and 29 by laser. Five recurrences were observed, one in the cold knife group, two in the LEEP group and two in the laser group (P=NS). The only observed complication was cervical stenosis: zero cases in the laser group, one case in the LEEP group and four cases in the cold knife group (laser versus cold knife: P=0.03; LEEP versus cold knife: P=0.06). Fifty pregnancies were observed in 39 patients. First and second trimester outcomes of pregnancy were without complications. One patient treated with the LEEP presented with a premature rupture of membranes and premature labor at 36 weeks. A total of nine cesarean sections were performed with two cases for cervical dystocia.

CONCLUSION

There is no major difference in obstetrical outcome between the three techniques.

Adenotonsillectomy. A safe outpatient procedure

Traditionally, adenotonsillectomy in children and tonsillectomy in adults have been performed as inpatient procedures. Our experience with this procedure as outpatient started in 1975 at the University of Miami-Jackson Memorial Medical Center. From 1975 to 1987, 1428 cases performed in Florida and Cleveland were reviewed to evaluate the safety and efficacy of the technique used. Bismuth subgallate and epinephrine mixture for hemostasis is used without relying on electrocautery, ties, or suture technique to control bleeding. The incidence of immediate and delayed postoperative bleeding in a series of patients was extremely low (four [0.28%] of 1428 cases). Our technique has good hemostatic properties allowing vessels to contract and retract into the muscle of the tonsillar fossae and adenoid bed. Bismuth subgallate activates factor XII (Hageman factor) and, therefore, markedly accelerates the cascade of blood clotting. Outpatient adenotonsillectomy is safe, cost-effective, and minimizes psychologic implications, which may be an important factor, especially in children. Ambulatory adenotonsillectomy has not been well emphasized in the literature.

Enhanced Recovery and Surgical Optimization Protocol for Minimally Invasive Gynecologic Surgery: An AAGL White Paper

This is the first Enhanced Recovery After Surgery (ERAS) guideline dedicated to standardizing and optimizing perioperative care for women undergoing minimally invasive gynecologic surgery. The guideline was rigorously formulated by an American Association of Gynecologic Laparoscopists Task Force of US and Canadian gynecologic surgeons with special interest and experience in adapting ERAS practices for patients requiring minimally invasive gynecologic surgery. It builds on the 2016 ERAS Society recommendations for perioperative care in gynecologic/oncologic surgery by serving as a more comprehensive reference for minimally invasive endoscopic and vaginal surgery for both benign and malignant gynecologic conditions. For example, the section on preoperative optimization provides more specific recommendations derived from the ambulatory surgery and anesthesia literature for the management of anemia, hyperglycemia, and obstructive sleep apnea. Recommendations pertaining to multimodal analgesia account for the recent Food and Drug Administration warnings about respiratory depression from gabapentinoids. The guideline focuses on workflows important to high-value care in minimally invasive surgery, such as same-day discharge, and tackles controversial issues in minimally invasive surgery, such as thromboprophylaxis. In these ways, the guideline supports the American Association of Gynecologic Laparoscopists and our collective mission to elevate the quality and safety of healthcare for women through excellence in clinical practice.

Randomized clinical trial of one-day surgery. Patient satisfaction, clinical outcomes, and costs

One hundred and eighty-two patients undergoing tubal ligation, hernia repair, or meniscectomy were randomly assigned to either one-day or inpatient surgery. The study's objective is to compare these two modes of care with regard to patient satisfaction, clinical outcomes, and costs of the episode of care. A significantly higher proportion of one-day patients than their hospitalized counterparts found their stay to be too short and would prefer hospitalization as an alternative. Clinical outcomes were comparable in both groups. One-day tubal ligation and hernia repair were found to be cost-efficient and averaged hospital savings of $86.00 and $115.00 more than inpatient care. Meniscectomy deviated from this trend in that treatment costs were significantly higher for one-day surgery patients. Analysis of personal and physician costs did not show any significant difference between the two modes of care.

An audit of the complications of paediatric tonsillectomy, adenoidectomy and adenotonsillectomy

Tonsillectomy, adenoidectomy and adenotonsillectomy are among the commonest surgical procedures undertaken in children. The notes of 413 consecutive children having tonsillectomy, adenoidectomy or adenotonsillectomy were analysed retrospectively to determine complication rates. Of the total number of children, 5.6% had at least one complication, the most common of which was haemorrhage occurring as a first complication in 3.9% (16 children). Three children with bleeding required active treatment (0.7%), one requiring transfusion and two requiring a return to theatre, all within 3 1/2 hours of operation. The incidence of reactionary bleeding was not associated with the grade or seniority of the surgeon. Six children (1.5%) developed a fever post-operatively, of which one required antibiotic treatment. On the basis of these results it is feasible for such procedures to be carried out on a day-care basis.

Success rate and patient satisfaction with the Essure™ sterilisation in an outpatient setting: a prospective study of 857 women

After 857 women with Essure system inserted for tubal obstruction as a method of sterilization in an outpatient setting, insertion is achieved in close to 99% of the women. Physician described the procedure as very difficult in 15% of the cases, mainly due to anatomical tubal anomalis or tubal spasm, and women felt highly satisfied in all cases.

Day surgery in Scotland: patient satisfaction and outcomes

OBJECTIVE

To evaluate patients' views on the process and outcome of day surgery in Scotland, and to study patients' satisfaction with care in a range of specific procedures.

DESIGN

Questionnaires completed by a census of day case surgery patients within a band of 25 procedures under the umbrella of five broad groups: (1) general surgery; (2) urology; (3) gynaecology; (4) orthopaedics; (5) ear, nose, and throat; ophthalmology.

SETTING

13 hospitals in six health board areas in Scotland.

SUBJECTS

During the period 1995-6, 5069 day case patients were asked to complete a questionnaire within two weeks of their operation and discharge from hospital.

MAIN OUTCOME MEASURES

Arrangements before admission; immediate postoperative symptoms and complications; problems experienced after discharge; readmission after discharge.

RESULTS

A response rate of 68% was obtained from 13 sites ranging from 43% to 82%. The overall satisfaction score was 85. A total of 894 patients (26%) experienced pain after surgery and 783 (23%) had relatively minor medical problems after discharge. In total, 265 (7.8%) patients were readmitted to hospital after discharge. Few notable differences existed between specialties or hospitals in terms of satisfaction scores, although notable pain was experienced more frequently in gynaecology and general surgery patients. Readmission was more common for urological procedures.

CONCLUSION

Overall, patient satisfaction with day case surgery was high. Dissatisfaction was largely related to waiting times between admission, operation, and discharge. The amount of pain experienced also had a notable impact on the level of patient satisfaction. Day surgery is not without complications, with 26% of patients experiencing notable degrees of pain; 23% having minor medical problems after discharge; and 8% of respondents having to reattend hospital with problems relating to their original operations.

Safety of outpatient cardiac catheterizations

Since 1979 most of the cardiac catheterizations at the investigators' institution have been performed as outpatient procedures. All cardiac catheterizations performed over a 66-month period were analyzed. A total of 3,071 outpatient cardiac catheterizations (83% of all cardiac catheterizations) were performed. The percutaneous femoral technique was used in 98% of the procedures. Most patients (79%) had both right and left-sided cardiac catheterization and coronary angiography, which showed significant coronary artery disease (70.4%). Only 13.6% of the study results were normal. Thirty-four patients (1.1%) had major complications, including 4 deaths (0.13%). Seventy patients (2.3%) were admitted for observation only. More than 96% of all patients did not have a major complication and were discharged the same day. Thus, outpatient cardiac catheterization can be performed safely, with a potential reduction in hospital costs and better utilization of medical beds.

A randomised controlled trial comparing outpatient versus daycase endometrial polypectomy

OBJECTIVE

To evaluate outpatient versus daycase endometrial polypectomy by comparing success rate, complications, patient tolerance, pain score, analgesia requirement and recovery.

DESIGN

A randomised controlled trial.

SETTING

A large UK Teaching hospital.

POPULATION

Forty consecutive women diagnosed with an endometrial polyp at outpatient hysteroscopy were randomly assigned in equal proportions to outpatient or daycase polyp removal.

METHODS

The outpatient cohort underwent endometrial polypectomy either using grasping forceps or a bipolar electrode (Versapoint; Gynecare Inc., Menlo Park, CA, USA) introduced down the operating channel of a rigid hysteroscope (Versascope; Gynecare Inc.). The daycase cohort underwent traditional endometrial polyp resection using a hysteroscopic, monopolar, electrosurgical resecting loop, performed under general anaesthetic.

MAIN OUTCOME MEASURES

The main outcome measures were as follows: success rates and intra or postoperative complications, time away from home, analgesia requirements, pain scores on the day of and one day after endometrial polypectomy, return to work and preoperative fitness and preference for the location of a future endometrial polypectomy.

RESULTS

The majority of women from both cohorts were premenopausal (62.5%), parous (85%) and in paid employment (62.5%). One woman allocated to outpatient polypectomy had cervical stenosis and dilatation was unsuccessful in the outpatient setting. There were no other intra or postoperative complications in either arm of the study. The mean intraoperative visual analogue style (0-100 mm) pain score during outpatient polypectomy was 23.7 mm (1-62). A proportion of women (20%) described no intraoperative discomfort; however, the majority (75%) described mild or moderate intraoperative discomfort. More women in the outpatient cohort (58%) described themselves as pain free for the remainder of the day than in the daycase cohort (28%) (P= 0.09). The day after the procedure, all women from the outpatient group described slight or no discomfort compared with only 41% of women from the daycase group (P= 0.02). All women undergoing outpatient polypectomy had a significantly shorter mean time away from home (3.24 [1.5-5] hours) than women undergoing daycase polypectomy (7.42 [6-10.5] hours), P < 0.0005. Similarly, women from the outpatient cohort had a significantly faster mean return to preoperative fitness (1 [0-4] day versus 3.2 [1-13] days; P= 0.001) and required less postoperative analgesia than the daycase cohort. Ninety-five percent of women from the outpatient cohort and 82% of women from the daycase cohort stated they would prefer to undergo an endometrial polypectomy in the outpatient setting should they require a further polyp removal.

CONCLUSION

Endometrial polypectomy can be successfully performed in the outpatient setting with minimal intraoperative discomfort, a significantly shorter time away from home and faster recovery and is preferred by women when compared with daycase polypectomy. Resources need to be made rapidly available to undertake larger scale research and develop this service across the UK.

Meta-analysis of the timing of haemorrhage after tonsillectomy: an important factor in determining the safety of performing tonsillectomy as a day case procedure

OBJECTIVES

To perform a meta-analysis of studies of the timing of primary tonsillectomy haemorrhage. In particular to compare the difference in risk between 0-8 and 8-24 h; that is whether overnight inpatient tonsillectomy is required.

DESIGN

Medline search of all tonsillectomy studies to perform a meta-analysis of the timing of primary haemorrhages.

SETTING

Literature-based study.

PARTICIPANTS

All adult and paediatric tonsillectomy studies giving the absolute number and timing of all primary haemorrhages.

MAIN OUTCOME MEASURES

The overall incidence of haemorrhage occurring between 0-8 and 8-24 h. The overall incidence of haemorrhage for each of the first 24 h after operation. Compare risk of a bleed occurring 0-8, 8-24 and >24 h where data were available.

RESULTS

From a 1.4% overall risk of a primary haemorrhage only one in 14 occur after 8 h, i.e. 0.1% (95% CI=0.08-0.16%). A total of 833 patients would require to be kept overnight in order to identify one case of bleeding after 8 h.

CONCLUSIONS

Little benefit was conferred from overnight admission from the point of view of monitoring for primary haemorrhage. A case can be made for either day-case tonsillectomy (hospital stay over the period in which 93% of primary haemorrhages would occur) or the 'belt-and-braces' approach of a 1-week stay (during which all haemorrhages would occur) but current 24-h admission appears illogical.

Impact of new guidelines on physicians' ordering of preoperative tests

OBJECTIVE

To compare the number of preoperative tests ordered for elective ambulatory surgery patients during the 2 years before and the 2 years after the establishment of new hospital testing guidelines.

MEASUREMENTS

The patterns of preoperative testing by surgeons and a medical consultant during the 2 years before and the 2 years after the establishment of new guidelines at one orthopedic hospital were reviewed. All tests ordered preoperatively were determined by review of medical records. Preoperative medical histories, physical examinations, and comorbidities were obtained according to a protocol by the medical consultant (author). Perioperative complications were determined by review of intraoperative and postoperative events, which also were recorded according to a protocol.

MAIN RESULTS

A total of 640 patients were enrolled, 361 before and 279 after the new guidelines. The mean number of tests decreased from 8.0 before to 5.6 after the new guidelines ( p =.0001) and the percentage decrease for individual tests varied from 23% to 44%. Except for patients with more comorbidity and patients receiving general anesthesia, there were decreases across all patient groups. In multivariate analyses only time of surgery (before or after new guidelines), age, and type of surgery remained statistically significant ( p =.0001 for all comparisons). Despite decreases in surgeons' ordering of tests, the medical consultant did not order more tests after the new guidelines ( p =.60) The majority of patients had no untoward events intraoperatively and postoperatively throughout the study period, with only 6% overall requiring admission to the hospital after surgery, mainly for reasons not related to abnormal tests. Savings from charges totaled $34,000 for the patients in the study.

CONCLUSIONS

Although there was variable compliance among physicians, new hospital guidelines were effective in reducing preoperative testing and did not result in increases in untoward perioperative events or in test ordering by the medical consultant.

International comparisons of patients' views on quality of care

PURPOSE

To compare patients' views on quality of care in different countries using a theory-based instrument, while at the same time controlling for the following potential confounders: type of care system (private vs public), type of care (kind of health problem), gender, age, and subjective wellbeing.

DESIGN/METHODOLOGY/APPROACH

Patients capable of communicating in wards (medical and surgical departments) and day surgery departments in England, France, Norway, and Sweden were recruited consecutively, to participate in a programme run by the health-care company Capio. Ward patients: England (n=1236), France (n=1051), Norway (n=226), and Sweden (n=428). Day surgery patients: England (n=887), France (n=544), Norway (n=101), and Sweden (n=742). Average response rate across settings: approximately 75 per cent. Patients evaluated the quality of the care they actually received and the subjective importance they ascribed to different aspects of care. The questionnaire "Quality from the patient's perspective" (QPP) was used (modified short version).

FINDINGS

Cross-national comparisons were made within each of the two care contexts (wards and day surgery) separately for men and women. Quality of care evaluations were adjusted for age and subjective wellbeing. English and French patients scored significantly higher than Norwegian and Swedish on both kinds of ratings (perceived reality and subjective importance), in both kinds of care contexts, and in both sexes.

ORIGINALITY/VALUE

Cross-national comparisons of patients' views on care can give meaningful guidance for practitioners only if they are context-specific and if well-known confounders are controlled for.

Patient Safety in the Office-Based Setting

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Discern the importance of the physician's office administrative capacity. 2. Recognize the necessity of a system for quality assessment. 3. Assess which procedures are safe in the office-based setting. 4. Know the basic steps to properly evaluate patients for office-based plastic surgery.

BACKGROUND

At least 44,000 Americans die annually as a result of preventable medical errors. Medical mistakes are the eighth leading cause of death in the United States, costing between $54.6 billion and $79 billion, or 6 percent of total annual national health care expenditures. Office-based procedures comprise a 10-fold increase in risk for serious injury or death as compared with an ambulatory surgical facility.

METHODS

This article reviews the literature on office-based patient safety issues. It places special emphasis on the statements and advisories published by the American Society of Plastic Surgeons' convened Task Force on Patient Safety in Office-Based Settings. This article stresses areas of increased patient safety concern, such as deep vein thrombosis prophylaxis and liposuction surgery.

RESULTS

The article divides patient safety in health care delivery into three broad categories. First, patient safety starts with emphasis at the administrative level. The physician or independent governing body must develop a system of quality assessment that functions to minimize preventable errors and report outcomes and errors. Second, the clinical aspects of patient safety require that the physician evaluate whether the procedure(s) and the patient are proper for the office setting. Finally, this article gives special attention to liposuction, the most frequently performed office-based plastic surgery procedure.

CONCLUSIONS

Patient safety must be every physician's highest priority, as reflected in the Hippocratic Oath: primum non nocere ("first, do no harm"). In the office setting, this priority requires both administrative and clinical emphasis. The physician who gives the healing touch of quality care must always have patient safety as the foremost priority.

Outpatient tonsillectomy and adenoidectomy: complications and recommendations

An example of cost-effective alternatives in medical care is the increasing use of out-patient surgery for those children requiring tonsillectomy, or tonsillectomy with adenoidectomy rather than an in-patient procedure. Two studies were carried out to answer questions about the complications, in addition to post-operative hemorrhage, and also the questions about the parental views and concerns relating to providing at-home care for their children following surgery. A triad, including recent history of upper airway infection, knife dissection technique, and increased intra-operative blood loss of 100 ml or more should be used to help identify the risk of post-operative hemorrhage.

Children in day surgery: clinical practice and routines. The results from a nation-wide survey

BACKGROUND

Day surgery is common in paediatric surgical practice. Safe routines including parental and child information in order to optimise care and reduce anxiety are important. Most day surgery units are not specialised in paediatric care, which is why specific paediatric expertise is often lacking.

METHODS

We studied the practice of paediatric day surgery in Sweden by a questionnaire survey sent to all hospitals, obtaining an 88% response rate. Three specific paediatric cases were enquired for in more detail.

RESULTS

The proportion of paediatric day surgery vs. in-hospital procedures was 46%. Seventy-one out of 88 responding units performed paediatric day surgery. All units had anxiolytic pre-medication as a routine in 1-6-year-olds, and in 7-16-year-olds at 60% of the units. Most units performed circumcision and adenoidectomy, while 33% performed tonsillectomy. Anaesthesia induction was intravenous in older children, and also in 1-6-year-olds at 50% of the units. Parental presence at induction was mandatory. Post-operatively, 93% of units routinely assessed pain. Paracetamol and NSAIDs were the most common analgesics, as monotherapy or combined with rescue medication in the recovery as IV morphine. At 42% of units, take-home bags of analgesics were provided, covering 1-3 days of treatment. Pain was the most frequent complaint on follow-up. Micturition difficulties were common after circumcision, nausea after adenoidectomy and nutrition difficulties after tonsillectomy.

CONCLUSIONS

In Sweden, most day surgery units perform paediatric surgery, most children receive pre-medication, anaesthesia is induced IV and take-home analgesics paracetamol and or NSAIDs are often provided. Still, pain is a common complaint after discharge.

Patient selection in ambulatory anesthesia — An evidence-based review: part II

PURPOSE

This is the second of two reviews evaluating the management of patients with selected medical conditions undergoing ambulatory anesthesia and surgery. Conditions highlighted in this review include: diabetes mellitus; morbid obesity; the ex-premature infant; the child with an upper respiratory infection; malignant hyperthermia; and the use of monoamine oxidase inhibitors.

SOURCE

Medline search strategies and the framework for the evaluation of clinical evidence are presented in Part I.

PRINCIPAL FINDINGS

Diabetes mellitus has not been linked with adverse events following ambulatory surgery. The morbidly obese patient is at an increased risk for minor respiratory complications in the perioperative period but these events do not increase unanticipated admissions. The ex-premature infant may be considered for ambulatory surgery if post-conceptual age is > 60 weeks and hematocrit is > 30%. The child with a recent upper respiratory tract infection is at an increased risk for perioperative respiratory complications, particularly if endotracheal intubation is required. Patients with malignant hyperthermia may undergo outpatient surgery but require four hours of postoperative temperature monitoring. Sporadic cases of drug interactions have been reported when meperidine and indirect-acting catecholamines are administered in the presence of monamine oxidase inhibitors. Ambulatory anesthesia and surgery is safe if these combinations of drugs are avoided.

CONCLUSION

Ambulatory anesthesia can be performed in, and is being offered to, a variety of patients with significant coexistent disease. In many cases there is little evidence documenting the outcomes expected in such patients. Prospective observational and interventional trials are required to better define perioperative management.

Day surgery: patients' perceptions of a nurse-led preadmission clinic

BACKGROUND

Previous research studies have demonstrated that nursing intervention is often lacking in the provision of adequate information and psychological support, and fails to meet the holistic needs of patients in the preassessment for day surgery.

AIM

The aim of this study was to elicit patients' perceptions of the preassessment preparation they received prior to day surgery.

METHOD

A hermeneutic phenomenological research approach was utilized to elucidate the participants' experiences of the preassessment process and to collect data. Qualitative data were collected using face-to-face interviews and analysed thematically following procedures expounded by Colaizzi and van Manen.

SAMPLE

The sample included 30 patients undergoing day surgery in a large teaching hospital in the north of England. The day unit built for this purpose consisted of a preassessment unit, a seated preoperative area, three theatres, a six space first stage recovery area, a 24 space second stage recovery area and a separate seated recovery area. The patient groups focused on individuals scheduled for general surgery, gynaecology and urology procedures.

RESULTS

Findings suggest that the nurse-led clinic appeared to function effectively; most patients felt they were adequately assessed and prepared for day surgery. The majority reported receiving comprehensive information about procedures, appreciated health education interventions and had opportunity to ask questions. A few patients pointed to deficits in information giving, indicating that their individual needs were not met, leaving them feeling anxious. Others alluded to problems associated with unexpected cancellation of procedures, which threw them into states of disequilibrium.

RELEVANCE FOR CLINICAL PRACTICE

The findings indicate that information giving, psychological support and person-centred care could be strengthened in the preassessment preparation of patients undergoing day surgery.

Melanoma excision by general practitioners in north-east Thames region, England

A retrospective study of pathology reports of melanomas excised by general practitioners (GPs) was undertaken in the course of a population-based study of melanoma, with a telephone survey of the current practice of those GPs who had excised melanomas. The objectives of this study were to identify all cases of cutaneous melanoma excised by GPs in the North-East Thames Region between 1989 and 1993, and to review the management of those patients. The main outcome measures of the study were: (i) the patterns of distribution of GP excisions within the region; (ii) the histological subtypes of melanomas excised, the accuracy of the pre-excision clinical diagnosis and the adequacy of treatment of the GP-treated tumours compared with the control group; and (iii) the reported current practice in the management of pigmented skin lesions by the GPs who had excised melanomas. Eight hundred and nineteen melanomas were excised in the region during the study period, of which 59 were excised by GPs. The Breslow thickness of tumours was similar in both GP-excised and non-GP-excised groups. Tumours were more likely to be amelanotic in the GP-excised group (P < 0.001). Incomplete excision was significantly more likely in the GP group (P < 0.001). The GPs made a confident clinical diagnosis of melanoma in only 17% of patients prior to surgery. The reported referral rate to specialists by this subset of GPs of patients with pigmented lesions was low, and at interview half of the GPs reported that they felt confident enough to manage patients with suspected skin cancers on their own. The majority of the GPs did not routinely obtain histological examination of skin lesions they believed to be benign. In conclusion, there are problems with the accuracy of clinical diagnosis and inadequacy of excision of melanomas removed in primary care. In the majority of cases, however, patients were subsequently appropriately treated by referral to specialist units. There was an under-usage of pathological examination of samples by the GPs interviewed.

Day-case laparoscopic Nissen fundoplication

BACKGROUND

The aim was to assess the acceptability and safety of day-case laparoscopic fundoplication for gastro-oesophageal reflux disease (GORD).

METHODS

This prospective study commenced in December 1999 and lasted for 18 months. All patients had proven symptomatic GORD. Inclusion criteria were American Society of Anesthesiologists grade I or II with adequate home support. A standard anaesthetic, analgesic and antiemetic protocol was used. Patients were contacted by telephone on the night of discharge and arrangements were made for a nurse to visit the following day. Postoperative pain and nausea were assessed using visual analogue scores (scale 0-10) on a self-completion questionnaire.

RESULTS

Twenty patients were included. There were no postoperative complications. All patients were discharged on the day of surgery. Median time to discharge was 6 h 30 min (range 4.5 to 9 h). One patient reattended casualty the following morning but none required readmission. There was no significant difference in median pain or nausea scores the evening after surgery or the next morning. All patients were satisfied with the information given and aftercare provided. All would recommend it to a friend and 19 of 20 would undergo the procedure as a day case again.

CONCLUSION

This study suggests that day-case laparoscopic fundoplication is feasible. Patients find it acceptable and it appears safe.