Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (15 page)
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Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
Precise patient selection should ensure that postoperative morbidity is minimised, but complications do occur and can be classified into major and minor problems.
63
Major complications occur less often than anticipated in the day surgery patient population with an incidence of 1 in 1455
64
and are independent of ASA status. Mortality is low and varies between 1 in 66 500 and 1 in 11 273.
Minor complications are more common and may precipitate unplanned overnight admission; these range from 0.1% to 5% depending on case mix.
65
Postoperative morbidity is usually related to the procedure undertaken and the anaesthetic agent used rather than the ASA status, which predicts complications in major inpatient surgery but not in day surgery patients. Surgical causes account for 60–70% of unplanned admissions and are usually the result of the surgeon embarking on a more extensive procedure than planned rather than surgical misadventure. Day surgery lists require careful planning, with the more major surgical procedures performed earlier in the day to allow adequate recovery time. Failure to adhere to this policy often leads to unplanned admissions.
66
The more lengthy and invasive surgical procedures tend to increase postoperative pain, PONV and drowsiness, and preclude safe discharge. Even once the patient has returned home, PONV may return and last up to 5 days in 35% of patients
67
and is often severe. Readmission rates are similar to unplanned admission rates (0.7–3.1%) and again are most often from surgically related causes.
Children find surgery and hospital visits a daunting and stressful prospect, and are therefore treated both separately and differently from adults. In 1991, the National Association for the Welfare of Children in Hospital published quality standards for care of paediatric day cases and suggested that children should be managed by staff trained in their care, in a child-safe and child-friendly environment with open access to the conscious child for the parents.
68
As a result, excellent results have been reported from non-specialised District General Hospitals as long as regular auditing of quality is practised.
69
Most children are fit and healthy ASA class I patients. ASA class II and III patients are not excluded but an anaesthetist with paediatric expertise is recommended.
15
Procedures for children with respiratory infections should be postponed for 2–4 weeks depending on severity, but after measles or whooping cough this should be extended to 6 weeks because of irritability of the respiratory tract.
70
In many units, children under the age of 6 months are considered unsuitable for day surgery, but if specialist facilities are available, full-term neonates are acceptable provided inpatient neonatal care is available. Premature babies are excluded up to 60 weeks after conception because of the risk of postoperative apnoea.
71
Many units also exclude children who are less than 5 kg because of the risk of hypothermia or hypoglycaemia associated with their physical status.
Psychosocial factors also determine a child's suitability for day surgery, and may limit access to day surgery especially in single parents with many children and little support, or very timid children with overly anxious parents.
Therefore, while the range of surgical procedures undertaken is similar to adult day surgery, in children it is often confined to a more restricted list (
Box 3.4
). In the anaesthetic room, venous access is obtained after the application of topical local anaesthetic 1 hour before; parental presence in the anaesthetic room is useful, especially in the preschool group. Postoperative pain relief is obtained first through adjunctive local or regional anaesthesia. NSAIDs cannot be given to children under 1 year of age or 10 kg in weight because of their immature kidneys, but paracetamol is effective if given in a premedication dose of 20 mg/kg. Before discharge, the parents require clear instructions regarding pain control, wound care, mobilisation and resumption of normal activities.
Box 3.4
Paediatric day surgery procedures
General surgery
Herniotomy, hydrocele excision, examination under anaesthesia, anal stretch, excision of minor lumps and bumps, ingrowing toenail treatment, endoscopy, biopsy (rectal, skin, lymph node)
Urology
Circumcision and associated procedures, orchidopexy
ENT
Myringotomy/grommets, adenoidectomy, tonsillectomy
Dental
Extractions
Ophthalmology
Correction of squint
Orthopaedic
Change of plaster cast
The shift of elective surgery from the inpatient setting to short stay and eventually day care is now inexorable and will continue to be driven by three factors. The first and most important is the natural dislike in most people of in-hospital stays, accelerated by the growing fear of hospital-acquired infections; most people prefer to be at home, and as soon as a day surgery procedure can be shown to be performed as safely and effectively as in the traditional inpatient setting, most of us will opt for the former.
The second drive for change is the continued growth of minimal access techniques, including the use of robotics and the development of natural orifice transluminal endoscopic surgery (NOTES).
72
These techniques are associated with less surgical trauma and reduced postoperative pain both in the short and medium term, and have led to the concept of ‘fast-track’ surgery for inpatient procedures.
54
The concomitant development of better anaesthetic and pain-relieving techniques will further reduce the need for inpatient postoperative care.
The third and greatest factor currently driving change is that of healthcare costs. By dispensing with inpatient hotel costs including staffing, procedures performed as day cases offer significant cost savings to healthcare providers and purchasers, and the impact of this can be seen in many areas:
Emergency surgery.
There has been a significant growth in emergency and urgent surgery now being performed in the ambulatory setting, which reduces costs as well as avoiding the reported postponements that occur in the inpatient setting. Recent studies have shown that care of these patients in the day unit can be preferable to inpatient care.
73
,
74
Short stay and enhanced recovery.
New research and developments in enhanced recovery are enabling the performance of more complex and advanced day surgery in patients who are anaesthetically more challenging.
54
–
59
,
75
This allows the high standards of care explicit in day surgery to be applied to early recovery and mobilisation, and discharge in these cases can usually take place in under 72 hours.
Tariffs and commissioning.
We have seen how much variability in day case rates persists across the UK.
13
New funding rules are likely to have beneficial effects on this ‘postcode lottery’. The impact of payment by results is already changing the way in which hospital trusts perceive day surgery, and its role in the delivery of elective care.
76
The added impact of both primary care commissioning
77
and tariffs that financially penalise organisations performing inpatient rather than day case procedures is accelerating the shift to day care.
78
,
79
Key points
The UK government targeted 75% of all elective surgery to be performed on a day case basis by the end of 2005.
All elective surgical patients should be pre-assessed by a nurse-led pre-assessment team who make the decision to allocate the patient to 12-hour, 23-hour or inpatient surgery.
Day surgery should be independent and separate from the inpatient infrastructure as successful day surgery depends on day of surgery admission, pre-assessment and nurse-led discharge.
Regional and local anaesthetic block techniques are ideal for day surgery but are currently underutilised.
Major surgical procedures, such as laparoscopic cholecystectomy, TURP, bilateral varicose vein surgery and arthroscopic procedures, can now be performed safely and routinely as day cases.
1.
Department of Health. The NHS plan: a plan for investment, a plan for reform. London: Department of Health, 2000.
2.
Department of Health. Day surgery: operational guide. London: Department of Health, 2002.
The Department of Health operational guide for day surgery helps day surgery units achieve 75% elective surgery on a day case basis and covers aspects of patient selection, day surgery activity, day surgery accommodation, management and staffing.
3.
Nicholl, J.H. The surgery of infancy.
Br Med J
. 1909;ii:753–756.
4.
Waters, R.M. The downtown anesthesia clinic.
Am J Surg
. 1919;33(Suppl):71–73.
5.
Asher, R.A.J. The dangers of going to bed.
Br Med J
. 1947;ii:967–968.
6.
Palumbo, L.T., Laul, R.E., Emery, F.B. Results of primary inguinal hernioplasty.
Arch Surg
. 1952;64:384–394.
7.
Farquharson, E.L. Early ambulation with special references to herniorrhaphy as an outpatient procedure.
Lancet
. 1955;ii:517–519.
8.
Baskerville, P.A., Jarrett, P.E.M., Day case inguinal hernia repair under local anaesthetic.
Ann R Coll Surg Engl
1983;65:224–225.
6870127
9.
Royal College of Surgeons of England. Report of the working party for day case surgery. London: RCS, 1992.
10.
NHS Management Executive.
A study of the management and utilisation of operating departments
. London: HMSO; 1989.
11.
Audit Commission. A short cut to better services: day surgery in England and Wales. London: HMSO, 1990.
12.
Audit Commission. Measuring quality: the patient's view of day surgery. London: HMSO, 1991.
13.
NHS Institute for Innovation and Improvement. Website:
www.productivity.nhs.uk/Dashboard/For/National/And/25th/Percentile
[accessed 01.08.12].
This section enables comparative assessments between health authority sites in England (not Scotland or Wales) for a large number of procedures.
14.
British Association of Day Surgery. BADS directory of procedures, 3rd ed. London: BADS, 2009.
15.
Verma, R., Alladi, R., Jackson, I., et al, Day case and short stay surgery: 2.
Anaesthesia
2011;66:417–434.
21418041
16.
Fogg, K.J., Saunders, P.R.I. Folly! The long distance day surgery patient.
Ambul Surg
. 1995;3:209–210.
17.
National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults – evidence report.
Obesity Res
. 1998;6(Suppl. 2):51S–209S.
18.
Department of Health. Annual health statistics. London: Department of Health, 2010.
19.
Miller, J.M. Selection and investigation of adult day cases. In: Miller J.M., Rudkin G.E., Hitchcock M., eds.
Practical anaesthesia and analgesia for day surgery
. Oxford: BIOS Scientific; 1997:5–16.
20.
Davies, K.E., Houghton, K., Montgomery, J., Obesity and day case surgery.
Anaesthesia
2001;56:1090–1115.
11703243
21.
Myles, P.S., Iacono, G.A., Hunt, J.O., et al, Risks of respiratory complications and wound infection in patients undergoing ambulatory surgery: smokers versus non-smokers.
Anesthesiology
2002;97:842–847.
12357149
22.
Buist, A.S., Sexton, G.J., Magy, J.M., et al, The effect of smoking cessation and modification on lung function.
Am Rev Respir Dis
1976;114:115–122.
937828
23.
Stechman, M.J., Healy, J., McMillan, R., et al. Is current advice on smoking prior to day surgery in the UK appropriate?
J One Day Surg
. 2004;14:5–8.
24.
American Society of Anesthesiology. ASA classification of surgical patients. Chicago: American Society of Anesthesiology, 1991.
A definitive classification of comorbidity by the American Society of Anesthesiology that has become universally accepted to assess fitness for anaesthesia.
25.
Ansel, G.L., Montgomery, J., Outcome of ASA III patients undergoing day case surgery.
Br J Anaesth
2004;92:71–74.
14665556
26.
Watson, B., Smith, I., Jennings, A., et al. Day surgery and the diabetic patient. London: British Association of Day Surgery, 2002.
27.
Howell, S.J., Sear, J.W., Foex, P. Hypertension, hypertensive heart disease and perioperative cardiac risk.
Br J Anaesth
. 2004;92:570–583.
A systematic review and meta-analysis of 30 observational studies demonstrated no association between admission arterial pressure when less than 180 mmHg systolic and 110 mmHg diastolic and perioperative complications. This evidence indicates that patients whose blood pressure is elevated within these limits can undergo routine safe surgery without cancellation.
28.
Committee on Safety of Medicines. Avoid all NSAIDs in aspirin sensitive patients.
Curr Prob Pharmacovig
. 1993;19:8.
29.
Li, J.T., The quality of caring.
Mayo Clin Proc
2006;81:294–296.
16529130
30.
Carlisle, J., Guidelines for pre-operative testing.
J One Day Surg
2004;14:13–16.
10946772
31.
Gold, B.S., Young, M.L., Kinman, J.L., et al, The utility of preoperative electrocardiograms in the ambulatory surgical patient.
Arch Intern Med
1992;152:301–305.
1739358
32.
Aldrete, B.A., The Post-anaesthesia Recovery Score revisited.
J Clin Anesth
1995;7:89–91.
7772368
33.
Cahill, H., Jackson, I., McWhinme, D.
Ready to go home?
. London: British Association of Day Surgery; 2000. [p. 1–8].
34.
Mackenzie, J.W., Day case anaesthesia and anxiety.
Anaesthesia
1989;44:437–440.
2787129
35.
Wylie report, Report of the Working Party on Training in Dental Anaesthesia.
Br Dent J
1981;151:385–388.
6946813
36.
Bell, G.D., McCloy, R.F., Charlton, J.E., et al, Recommendations for standards of sedation and patient monitoring during gastrointestinal endoscopy.
Gut
1991;32:823–827.
1855692
37.
Watson, B., Allen, J., Smith, I.
Spinal anaesthesia: a practical guide
. London: British Association of Day Surgery; 2004.
38.
Yogendran, S., Asokumar, B., Cheng, D.C., et al. A prospective randomised double blinded study of the effect of intravenous fluid therapy on adverse outcomes on outpatient surgery.
Anaesth Analg
. 1995;80:682–686.
Two hundred ASA grade I–III ambulatory surgical patients were prospectively randomised into two groups to receive high (20 mL/kg) or low (2 mL/kg) prospective isotonic infusion over 30 minutes preoperatively. The incidence of thirst, drowsiness and dizziness was significantly lower in the high-infusion group 60 minutes after surgery, confirming an advantage to routine perioperative intravenous fluid administration.
39.
Department of Health. 10 high impact changes for service improvement and delivery. NHS Modernisation Agency, 2004.
40.
NHS Institute for Innovation and Improvement. Focus on: Cholecystectomy, 2007.
41.
Association of Anaesthetists of Great Britain and Ireland. Preoperative assessment and patient preparation – the role of the anaesthetist 2. London: AAGBI, 2010.
42.
Orchard, M., Ellms, J., McWhinnie, D. What do we mean by ‘theatre utilisation’?
J One Day Surg
. 2010;20:4–6.
43.
Department of Health. Tackling hospital waiting: the 18 week patient pathway. London: Department of Health, 2006.
44.
Robinson, T.N., Biffl, W.L., Moore, E.E., Predicting failure of outpatient laparoscopic cholecystectomy.
Am J Surg
2002;184:515–518.
12488152
45.
Lau, H., Brookes, D.C., Predictive factors for unanticipated admission after ambulatory laparoscopic cholecystectomy.
Arch Surg
2001;136:1150–1153.
11585507
46.
Jackson, S.A., Lawrence, A.S., Hill, J.C., Does post laparoscopy pain relate to residual carbon dioxide?
Anaesthesia
1996;51:485–487.
8694166
47.
Mjaland, O., Raeder, J., Aasboe, V., et al, Outpatient laparoscopic cholecystectomy.
Br J Surg
1997;84:958–961.
9240135
48.
Keoghane, S.R., Millar, J.M., Cranston, D.W., Is day case prostatectomy feasible?
Br J Urol
1995;76:600–603.
8535679
49.
Gomez Sancha, F., Bachmann, A., Choi, B.B., et al, Photoselective vaporization of the prostate (Greenlight PV): lessons learnt after 3500 procedures.
Prostate Cancer Prostatic Dis
. 2007;10(4):316–322.
17622237
50.
, Urological recommended lengths of stay. BADS directory of procedures. 2nd ed. 2007. [p. 16–7].
51.
Dennis, S., Georgallow, M., Elcock, L., et al. Day case tonsillectomy: the Salisbury experience.
J One Day Surg
. 2004;14:17–22.
52.
Parameswaram, R., Allouni, K., Varghese, P., et al. Day case parathyroidectomy in a district hospital: safe and feasible.
J One Day Surg
. 2010;20(1):20–22.
53.
Dunsire, M.F., Patel, A.G., Awad, N., et al. Laparoscopic gastric banding for morbid obesity in the day surgery setting.
J One Day Surg
. 2007;17:1.
54.
Kehlet, H., Wilmore, D.W. Fast track surgery.
Br J Surg
. 2005;92:3–4.
55.
Houghton, K. Enhanced recovery and ray surgery: the ultimate partners for elective surgery.
J One Day Surg
. 2010;20:4–6.
56.
Salman, R., Salman, A., Outpatient abdominoplasty: is it a safe practice?
J One Day Surg
. 2009;(Suppl):28.
57.
Wong, T., Shekouh, A., Wilkin, R., et al, Day case colon and rectal cancer surgery: are we ready for take-off?
J One Day Surg
. 2009;(Suppl.):A23.
58.
Chieza, J.T., Found, P., Rajagopal, K., et al, Ambulatory thoracic surgery: setting up a service and the first 100 cases.
J One Day Surg
. 2010;(Suppl.):A10.
59.
Flindall, I.R., Ward, S., Day, A., et al, EVAR – reducing length of stay and costs.
J One Day Surg
. 2009;(Suppl.):A21.
60.
Association of Anaesthetists of Great Britain and Ireland. Immediate postanaesthetic recovery. London: AAGBI, 2002.
61.
Chung, F., Kayumov, L., Sinclair, D.R., et al. What is the driving performance of ambulatory surgical patients after general anaesthesia?
Anesthiology
. 2005;103:951–956.
62.
Crook, T.B., Banerjee, S., De Souza, K., et al. Supplementary preoperative information encourages return to work after inguinal hernia repair.
J One Day Surg
. 2005;15(1):18–20.
63.
Natof, H.E. Complications. In: Wetcher B.V., ed.
Anaesthesia for ambulatory surgery
. Philadelphia: Lippincott; 1985:321.
64.
Hitchcock, M. Postoperative morbidity following day surgery. In: Millar J.M., Rudkin G.E., Hitchcock M., eds.
Practical anaesthesia and analgesia for day surgery
. Oxford: BIOS Scientific; 1997:205–211.
65.
Levy, M.L. Complications: prevention and quality assurance.
Anesth Clin North Am
. 1987;5:137–166.
66.
Twersky, R.S., Abiona, M., Thorne, A.C., et al. Admissions following ambulatory surgery: outcome in seven urban hospitals.
Ambul Surg
. 1995;3:141–146.
67.
Carrol, N.V., Miederhoff, P., Cox, F.M., et al, Postoperative nausea and vomiting after discharge from outpatient surgery centres.
Anesth Analg
1995;80:903–909.
7726432
68.
Thornes, R.
Just for the day
. London: National Association for the Welfare of Children in Hospital; March 1991.
69.
Rees, S., Stocker, M., Montgomery, J. Paediatric outcomes in a District General Hospital Day Surgery Unit.
J One Day Surg
. 2009;19:92–95.
70.
McEwan, A.I., Birch, M., Bingham, R., The preoperative management of the child with a heart murmur.
Paediatr Anaesth
1995;5:151–155.
7489433
71.
Steward, D.J., Preterm infants are more prone to complications following minor surgery than are term infants.
Anesthesiology
1982;56:304–306.
7065438
72.
Buyske, J., Natural orifice transluminal endoscopic surgery.
JAMA
2007;298:1560–1561.
17915355
73.
Conaghan, P.L., Figueira, E., Griffin, M.A., et al, Randomised clinical trial of the effectiveness of emergency day surgery against standard inpatient treatment.
Br J Surg
2002;89:423–427.
11952581
74.
Mayall, A.C., Barnes, S.J., Stocker, M.E. Introducing emergency surgery to the day case setting.
J One Day Surg
. 2009;19:23–26.
75.
Smith I., McWhinnie D., Jackson I., eds. Day case surgery. Oxford: Oxford Specialist Handbooks, 2011.
76.
Department of Health. Payment by Results 2010/11.
http://www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/NHSFinancialReforms/index.htm
[accessed 01.08.12].
77.
British Association of Day Surgery. Commissioning day surgery. London: BADS, 2003.
78.
Howard, D., Yao, S., Wasey, J., et al. Incentivising day-case laparoscopic surgery.
J One Day Surg
. 2011;21:4–7.
79.
Kreckler, S., McWhinnie, D., Khaira, H., et al, Running a financially viable hernia service in the era of best practice tariffs.
J One Day Surg
2012;22:20–22.
23046081
