Ambulatory Surgical Setting Research Articles

109. Influence of preoperative symptom duration on clinical outcomes after lumbar decompression in the ambulatory surgical setting

109. Influence of preoperative symptom duration on clinical outcomes after lumbar decompression in the ambulatory surgical setting

Volume and Practice-Setting Shift of Laryngology Procedures During the COVID-19 Pandemic: A Reg-ENT Database Analysis.

The onset of the coronavirus disease 2019 (COVID-19) pandemic changed practice patterns throughout medicine. The purpose of this study is to evaluate changes in the volume and location setting of laryngology procedures after the onset of COVID-19. Retrospective database cohort study. Reg-ENT registry. Retrospective review from 2017 to 2022 of patients who underwent a laryngology procedure identified by procedure code categorized by site of service code-"ambulatory surgical" versus "office" setting. Based on March 2020 as the cutoff point, the procedures were designated as pre-COVID versus COVID time period. A total of 5989 patients underwent laryngology procedures. Forty-two percent more procedures were performed in the COVID period (n = 3780) versus pre-COVID (n = 2209). Pre-COVID, the procedure distribution between office and ambulatory surgical setting was 70% (n = 1546) compared with 30% (663). This shifted to 77% (n = 2920) and 23% (n = 860) during COVID, P = .9. The most common diagnoses associated with laryngology procedures during the study period were vocal fold paralysis 47% (n = 2831), dysphonia 33% (n = 1392), and laryngotracheal stenosis 14% (n = 838). These trends remained in both pre-COVID and COVID time periods. After the start of the pandemic, among patients undergoing laryngology procedures, there was a 93% increase (n = 284-549) in the diagnosis of laryngotracheal stenosis, 70% increase (n = 520-882 patients) in dysphonia and 69% increase (n = 1054-1777) in vocal fold paralysis. An increase in laryngology procedures performed after the onset of the COVID-19 pandemic was identified with an overall procedural shift to the office-setting.

Business and Corporate Models for Interventional Radiology in the Office Based Lab and Ambulatory Surgical Center Setting

The landscape of healthcare is shifting towards outpatient settings such as Office-Based Labs (OBLs) and Ambulatory Surgery Centers (ASCs). This transition, driven by the Centers for Medicare & Medicaid Services (CMS), presents various business and corporate models for interventional radiologists seeking to practice outside traditional hospital environments. The role of private equity and management services in facilitating these transitions is highlighted, offering opportunities for growth, efficiency, and enhanced control over practice operations. The document also discusses the financial aspects of establishing an OBL or ASC, the benefits of outpatient procedures, and the adaptability of private equity deals to the specific needs of medical practices. It concludes by emphasizing the potential for long-term wealth creation and the adaptability of these models to individual physician needs.

A Prospective Multicenter Standard of Care Study of Outpatient Laparoscopic Sleeve Gastrectomy

A global shift is occurring as hospital procedures move to ambulatory surgical settings. Surgeons have performed outpatient sleeve gastrectomy (SG) in bariatric surgery since 2010. However, prospective trials are needed to ensure its safety before widespread adoption.PurposeThe study aimed to present a comprehensive report on the prospective data collection of 30-day outcomes of outpatient primary laparoscopic SG (LSG). This trial seeks to assess whether outpatient LSG is non-inferior to hospital-based surgery in selected patients who meet the outpatient surgery criteria set by the American Society for Metabolic and Bariatric Surgery.Materials and MethodsThis study is funded by the Society of American Gastrointestinal and Endoscopic Surgeons and has been approved by the Advarra Institutional Review Board (Pro00055990). Cognizant of the necessity for a prospective approach, data collection commenced after patients underwent primary LSG procedures, spanning from August 2021 to September 2022, at six medical centers across the USA. Data centralization was facilitated through ArborMetrix. Each center has its own enhanced recovery protocols, and no attempt was made to standardize the protocols.ResultsThe analysis included 365 patients with a mean preoperative BMI of 43.7 ± 5.7 kg/m2. Rates for 30-day complications, reoperations, readmissions, emergency department visits, and urgent care visits were low: 1.6%, .5%, .2%, .2%, and 0%, respectively. Two patients (0.5%) experienced grade IIIb complications. There were no mortalities or leaks reported.ConclusionThe prospective cohort study suggests that same-day discharge following LSG seems safe in highly selected patients at experienced US centers.Graphical

Success of Same-Day Discharge Total Hip and Knee Arthroplasty: Does Location Matter?

BackgroundSame calendar day discharge (SCDD) following total joint arthroplasty is desirable for patients and surgeons alike. The aim of this study was to compare the success rate of SCDD in an ambulatory surgical center (ASC) versus hospital setting. MethodsA retrospective analysis was performed on 510 patients who underwent primary hip and knee total joint arthroplasty over a 2-year period. The final cohort was divided into 2 groups based on location of surgery: ASC (N = 255) or hospital (N = 255). Groups were matched for age, sex, body mass index, American Society of Anesthesiologists score, and Charleston Comorbidity Index. Successes of SCDD, reasons for failure of SCDD, length of stay (LOS), and 90-day readmission and complication rates were recorded. ResultsAll SCDD failures were from the hospital setting (36 [65.6%] total knee arthroplasty [TKA] and 19 [34.5%] total hip arthroplasty [THA]). There were no failures from the ASC. The main causes of failed SCDD in both THA and TKA included failed physical therapy and urinary retention. Regarding THA, the ASC group had a significantly shorter total LOS (6.8 [4.4 to 11.6] versus 12.8 [4.7 to 58.0] hours, P < .001). Similarly, TKA patients had a shorter LOS in the ASC (6.9 [4.6 to 12.9] versus 16.9 [6.1 to 57.0], P < .001). Total 90-day readmission rates were higher in the ASC group (2.75% versus 0%), where all but 1 patient underwent TKA. Similarly, complication rates were higher in the ASC group (8.2% versus 2.75%), where all but 1 patient underwent TKA. ConclusionTJA performed in the ASC, compared to the hospital setting, allowed for reduced LOS and improved success of SCDD.

ERAS Protocol Options for Perioperative Pain Management of Substance Use Disorder in the Ambulatory Surgical Setting.

Even prior to the COVID-19 pandemic, rates of ambulatory surgeries and ambulatory patients presenting with substance use disorder were increasing, and the end of lockdown has further catalyzed the increasing rates of ambulatory patients presenting for surgery with substance use disorder (SUD). Certain subspecialty groups of ambulatory procedures have already established protocols to optimize early recovery after surgery (ERAS), and these groups have subsequently enjoyed improved efficiency and reduced adverse outcomes as a result. In this present investigation, we review the literature as it relates to substance use disorder patients, with a particular focus on pharmacokinetic and pharmacodynamic profiles, and their resulting impact on the acute- or chronic user ambulatory patient. The systematic literature review findings are organized and summarized. We conclude by identifying areas of opportunity for further study, specifically with the aim of developing a dedicated ERAS protocol for substance use disorder patients in the ambulatory surgery setting. - Healthcare in the USA has seen an increase in rates of both substance use disorder patients and separately in ambulatory surgery cases. - Specific perioperative protocols to optimize outcomes for patients who suffer from substance use disorder have been described in recent years. - Agents of interest like opioids, cannabis, and amphetamines are the top three most abused substances in North America. - A protocol and recommend further work should be done to integrate with concrete clinical data, in which strategies should be employed to confer benefits to patient outcomes and hospital quality metrics like those enjoyed by ERAS protocol in other settings.

Completion of an Enhanced Recovery Program in a Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative.

Enhanced Recovery After Surgery (ERAS) was first established in 2001 focusing on recovery from complex surgical procedures in adults and recently expanded to ambulatory surgery. The evidence for ERAS in children is limited. In 2018, recognized experts began developing needed pediatric evidence. Center-wide efforts involving all ambulatory surgical patients and procedures have not previously been described. A comprehensive assessment and gap analysis of ERAS elements in our ambulatory center identified 11 of 19 existing elements. The leadership committed to implementing an Enhanced Recovery Program (ERP) to improve existing elements and close as many remaining gaps as possible. A quality improvement (QI) team was launched to improve 5 existing ERP elements and to introduce 6 new elements (target 17/19 ERP elements). The project plan was broken into 1 preparation phase to collect baseline data and 3 implementation phases to enhance existing and implement new elements. Statistical process control methodology was used. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify countermeasure plans as needed. The primary outcome measure selected was mean postanesthesia care unit (PACU) length of stay (LOS). Secondary outcomes measures were mean maximum pain score in PACU and patient/family satisfaction scores. The team had expanded the pool of active ERP elements from 11 to 16 of 19. The mean PACU LOS demonstrated significant reduction (early in phase 1 and again in phase 3). No change was seen for the mean maximum pain score in PACU or surgical complication rates. Patient/family satisfaction scores were high and sustained throughout the period of study (91.1% ± 5.7%). Patient/family and provider engagement/compliance were high. This QI project demonstrated the feasibility of pediatric ERP in an ambulatory surgical setting. Furthermore, a center-wide approach was shown to be possible. Additional studies are needed to determine the relevance of this project to other institutions.

Novel Techniques for Acute Lengthening of Metatarsal for Treatment of Brachymetatarsia with 2cm and More Shortening

Category: Midfoot/Forefoot Introduction/Purpose: Previous acute lengthening of metatarsal for the treatment of brachymetatarsia has been limited to 1cm. The success of acute lengthening has not been as predictable. I have successfully been able to acutely lengthen up to 2.2 cm with the use of allograft. I have successfully done this in 10 patients for the last 2 years. Methods: The method involves acute lengthening and transfer of the extensor longus and Brevis. A complete release of the MPJ which involves the entire capsule as well as the lumbricles and interosseus medial and lateral. Also I have created a 'joint spacer ' by using a fiber tape (Arthrex) which is made in to a donut shape and placed in the joint and held in placed with a k wire that is passed through the digit then through the spacer and further advanced to the metatarsal. This k wire is removed 6 weeks post op. I also use a temporary external fixator to distract the metatarsal segments after doing an Osteotomy at the base or the metatarsal. Once the appropriate length is achieved the allograft is cut to size and placed and secured with screws and an 8 hole plate. Then the temporary ex fix is removed. Tendons sutured and secured. Skin is closed. The only hardware that is exposed is the .062 k wire. 6 weeks post op. The k wire is removed and a Stab incision is made at the level of the MPJ and the spacer is removed. This will keep the joint space maintained which make the digit be able to move after such a large acute lengthening. Part of the Peotocol is to have the foot in good compression by using a 3M 2 layer compression system. Which keeps the incision from opening. Results: For the past 2 years I have performed 10 acute metatarsal lengthening successfully with minimal complications. This method is reproducible by any foot and ankle surgeon Conclusion: Using this step by step technique has resulted in a predictable and successful outcome. Previously the lengthening of a short metatarsal has been limited to 1cm and below if you wanted to outcome to be good and without major complications such as MPJ subluxation and digital deformity and most importantly not being able to lengthen the metatarsal to its appropriate length. This novel technique can be done in any ambulatory surgical setting. It also uses allograft which makes its less painful for the patient and decreases the complication rate when compared to using autograft

Early Real-World Physician Experience with an Intracanalicular Dexamethasone Insert.

PurposeTo describe the early real-world experience of physicians with an intracanalicular dexamethasone insert (DEX) in patients undergoing cataract surgery and to capture the clinical impact of adopting this therapy.Patients and Methods23 United States sites including Ambulatory Surgical Center Setting (ASC) and Outpatient Clinical settings. Respondents were physicians who had early experience with DEX in cataract surgery patients. This was a Phase 4 experiential cross-sectional survey study comprised of 3 sequential online physician surveys. Descriptive statistics summarized the surveys’ responses to determine the early impressions of the respondents.ResultsForty-two physicians completed surveys. On average, physicians reported feeling comfortable administering DEX after placing 3 inserts (mean 2.7; standard deviation 1.9). Most physicians (92%) were satisfied with DEX, and all physicians (100%) reported that DEX improved patient compliance. Most physicians (62.5%) indicated they would highly prefer DEX over traditional steroid eyedrops for the management of post-surgical inflammation and pain.ConclusionThe surveys exploring the early use of DEX suggest that DEX is a clinically effective treatment with a rapid initial learning curve and integrates well into clinical use. Physicians had a very positive early experience with DEX, including comfort with insertion and satisfaction. DEX shows promise as a primary treatment choice of physicians for ocular inflammation and pain following cataract surgery by offering patients a hands-free innovative therapy that delivers a preservative-free steroid to the ocular surface over approximately 30 days.

Integration of Face-to-Face Screening With Real-time Machine Learning to Predict Risk of Suicide Among Adults

Understanding the differences and potential synergies between traditional clinician assessment and automated machine learning might enable more accurate and useful suicide risk detection. To evaluate the respective and combined abilities of a real-time machine learning model and the Columbia Suicide Severity Rating Scale (C-SSRS) to predict suicide attempt (SA) and suicidal ideation (SI). This cohort study included encounters with adult patients (aged ≥18 years) at a major academic medical center. The C-SSRS was administered during routine care, and a Vanderbilt Suicide Attempt and Ideation Likelihood (VSAIL) prediction was generated in the electronic health record. Encounters took place in the inpatient, ambulatory surgical, and emergency department settings. Data were collected from June 2019 to September 2020. Primary outcomes were the incidence of SA and SI, encoded as International Classification of Diseases codes, occurring within various time periods after an index visit. We evaluated the retrospective validity of the C-SSRS, VSAIL, and ensemble models combining both. Discrimination metrics included area under the receiver operating curve (AUROC), area under the precision-recall curve (AUPR), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The cohort included 120 398 unique index visits for 83 394 patients (mean [SD] age, 51.2 [20.6] years; 38 107 [46%] men; 45 273 [54%] women; 13 644 [16%] Black; 63 869 [77%] White). Within 30 days of an index visit, the combined models had higher AUROC (SA: 0.874-0.887; SI: 0.869-0.879) than both the VSAIL (SA: 0.729; SI: 0.773) and C-SSRS (SA: 0.823; SI: 0.777) models. In the highest risk-decile, ensemble methods had PPV of 1.3% to 1.4% for SA and 8.3% to 8.7% for SI and sensitivity of 77.6% to 79.5% for SA and 67.4% to 70.1% for SI, outperforming VSAIL (PPV for SA: 0.4%; PPV for SI: 3.9%; sensitivity for SA: 28.8%; sensitivity for SI: 35.1%) and C-SSRS (PPV for SA: 0.5%; PPV for SI: 3.5%; sensitivity for SA: 76.6%; sensitivity for SI: 68.8%). In this study, suicide risk prediction was optimal when leveraging both in-person screening (for acute measures of risk in patient-reported suicidality) and historical EHR data (for underlying clinical factors that can quantify a patient's passive risk level). To improve suicide risk classification, prediction systems could combine pretrained machine learning with structured clinician assessment without needing to retrain the original model.

Comparative Cost Analysis of Single-use Sterile versus Reprocessed Distal Radius Volar Plate Sets.

With the rise in distal radius fracture (DRF) incidence and treatment through open reduction internal fixation, there are increasing concerns in the current medical cost containment climate. To help reduce costs, manufacturers are introducing sterile packed kits. The purpose of this study is to compare the costs of the single use kit (SK) against conventional reprocessed DRF surgical sets (RS). A four-year retrospective review at three surgical centers was performed to determine a company's RS average sterilization and processing costs. RS instrumentation cost was estimated by straight-line depreciation from the original purchase price. RS implant costs were calculated from the list price. SK list cost was obtained from the same company. Incidence of surgical delays was estimated by a survey of 23 hand surgeons and cost of delays was obtained from surgical center reports. Sensitivity analysis on delay frequency was performed to assess a range of overall costs. OR delays were estimated at one out of 100 cases, with an average cost of $11 per case. For RS, average instruments, implants, and sterilization costs per case was $47, $2882, and $39. The total RS cost of $2,978 and the SK was $1,667 with a difference of $1,313 per case. RS was found to cost $1,313 more per case than the SK in an ambulatory surgical setting and potentially more cost effective. Ultimately, pricing is highly variable at each center based on negotiated and contractual pricing.

Dexmedetomidine and Clonidine as Adjuvants to Ropivacaine in Adductor Canal Block for Postoperative Analgesia in Patients Undergoing Arthroscopic Anterior Cruciate Ligament Reconstruction

Abstract Background: Patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction experience significant postoperative pain, which could lead to a delay in recovery and discharge from an ambulatory surgical setting. Adductor canal block (ACB) has been used to offer effective postoperative analgesia after ACL repair. We compared the analgesic efficacy of alpha-2 agonists clonidine and dexmedetomidine as adjuvants to local anesthetics in ACB. Patients and Methods: Sixty subjects scheduled for elective arthroscopic ACL reconstruction were randomized into two groups of 30 patients each. Group 1 patients received US-guided ACB with 20 mL of 0.5% ropivacaine with 1 μg/kg clonidine as an adjuvant; group 2 patients received ACB with 20 mL of 0.5% ropivacaine with 1 μg/kg dexmedetomidine as an adjuvant. Demographic data, pain scores, motor and sensory block, postoperative tramadol consumption, time to rescue analgesia, and adverse events were compared. Results: The demographic data were comparable between both groups. The patients in group 2 when compared with group 1 had increased time for request to rescue analgesic (488.83 ± 67.934 min compared with 975.07 ± 90.251 min, P &lt; 0.001), reduced tramadol consumption (179.33 ± 44.095 mg compared with 179.33 ± 44.095 mg, P &lt; 0.001), and better pain scores at 12 and 18 h. Postoperative nausea and vomiting was less in group 2 compared with group 1. Conclusion: Dexmedetomidine, when added as an adjuvant to 0.5% ropivacaine in ACB, leads to increased time to first request of tramadol, reduced postoperative tramadol requirement, and decreased NRS scores when compared with clonidine.

Abstract 10427: Length of Stay After Atrial Fibrillation Ablation in a U.S. Ambulatory Surgical Setting Compared to a Hospital Setting

Introduction: Atrial ablation for the treatment of atrial fibrillation has traditionally been performed in the hospital setting. Recently, the Centers for Medicare and Medicaid Services (CMS) announced the Hospitals Without Walls program, allowing ambulatory surgery centers (ASCs) to conduct procedures such as atrial ablations. As a result, the first cases of ablations in an ASC have recently been completed. This study aimed to compare patient length of stay (LOS) and between the ASC setting to a traditional hospital setting. Hypothesis: LOS in the ASC setting is shorter than in the traditional hospital. Methods: Data from all patients treated with cryoballoon pulmonary vein isolation (PVI) in a single ASC were analyzed. A random sample of patients treated by the same provider during the same timeframe in the hospital setting were then acquired and compared. Procedural approaches were similar, with transeptal puncture performed under intracardiac echo, contrast venography and pressure waveform analysis performed prior to ablation to ensure good venous seal. No 3D mapping was used at either site. Intraprocedural emergency protocols were established prior to ablations. Results: A total of 13 patients received treatment in the ASC, with a mean age of 71 ± 8 years, 38% female, 9 patients had paroxysmal atrial fibrillation and 4 persistent atrial fibrillation. The mean number of cryoablation applications per pulmonary vein was 1.4 ± 0.7 with average application duration of 187 ± 37 seconds. The mean procedural duration was 52 ± 10 minutes and mean time in the ASC was 5.4 ± 1.5 hours. No acute adverse events occurred; however, one patient later presented with a sore throat and a groin hematoma without active bleeding or pseudoaneurysm. A total of 13 patients were analyzed in the hospital setting. Mean time in the hospital was longer than in the ASC (13.0 ± 13.0 hours, p&lt;0.01). This is inclusive of 2 patients staying overnight. The mean hospital length of stay was also longer than in the ASC for the 11 patients with same day discharge (8.2 ± 6.6 hours, p&lt;0.01). Conclusions: Cryoballoon PVI performed in an ASC setting resulted in a shorter overall length of stay than in the traditional hospital setting, with no acute complications occurring.

Neuromuscular Blockade and Reversal Practice Variability in the Outpatient Setting: Insights From US Utilization Patterns.

Neuromuscular blockade (NMB) is a critical part of many surgical procedures. Data on practice patterns of NMB agents (NMBAs) and NMB reversal in recent years in the US ambulatory surgical care setting are limited. This retrospective analysis of US adult outpatients was conducted using the Premier Healthcare Database. We describe anesthesia practice trends in NMB management and assess the association of patient, procedural, and site characteristics with NMB reversal approach using multivariable logistic regression. Approximately 5.2 million outpatient surgical encounters involving NMB and 4.6 million involving rocuronium or vecuronium between January 2014 and June 2019 were included. Following the introduction of sugammadex to US clinical practice (~2016), there was an increased use of rocuronium or vecuronium and a decrease in succinylcholine alone. Before 2016, NMB was pharmacologically reversed with neostigmine in approximately two-thirds of outpatient encounters. Over time, active reversal increased; by 2019, 42.3% and 36.0% of encounters were reversed by neostigmine and sugammadex, respectively, with 21.7% undergoing spontaneous recovery. Choice of NMBA (rocuronium or vecuronium alone), time since 2016, obesity, peripheral vascular disease, and procedures on the digestive, ocular, and female genital systems (vs musculoskeletal procedures) were independently and positively associated with pharmacologic reversal (versus spontaneous reversal). Conversely, advanced age; Western geography; and cardiovascular, endocrine, hemic/lymphatic, respiratory, and ear, nose, and throat procedures were independently and negatively associated with pharmacologic reversal of NMB.Among pharmacologic reversals, time since 2016 was positively and independently associated with sugammadex compared with neostigmine (odds ratios [ORs], ranged from 1.8 in 2017 to 3.2, P < .0001 in 2019). Those administered rocuronium or vecuronium without succinylcholine, with increased age and history of certain comorbidities, and those undergoing ocular or respiratory procedures (compared with musculoskeletal) were positively associated with reversal with sugammadex and endocrine procedure negatively and independently associated with reversal with sugammadex. There was variability in the association of several factors with NMB reversal choices by geographic region, particularly in patients' race, ethnicity, and size of affiliated hospital. Overall, active pharmacological reversal of NMB increased in US adult outpatients following the introduction of sugammadex, although there remains significant practice variability. The multifactorial relationship between patient-, procedural-, and environmental-level characteristics and NMB management is rapidly evolving. Additional research on how these anesthesia practice patterns may be impacted by the shift to the ambulatory care setting and how they may impact patient outcomes and health disparities is warranted.

MP31-10 A COST EFFECTIVE OFFICE BASED TECHNIQUE FOR ULTRASOUND GUIDED PERI-SPERMATIC CORD CRYOABLATION FOR CHRONIC SCROTAL CONTENT PAIN

You have accessJournal of UrologyInfertility: Therapy (MP31)1 Sep 2021MP31-10 A COST EFFECTIVE OFFICE BASED TECHNIQUE FOR ULTRASOUND GUIDED PERI-SPERMATIC CORD CRYOABLATION FOR CHRONIC SCROTAL CONTENT PAIN Sijo Parekattil, Ahmet Gudeloglu, Onuralp Ergun, Alex Galante, Mohammed Etafy, and Richard Mendelson Sijo ParekattilSijo Parekattil More articles by this author , Ahmet GudelogluAhmet Gudeloglu More articles by this author , Onuralp ErgunOnuralp Ergun More articles by this author , Alex GalanteAlex Galante More articles by this author , Mohammed EtafyMohammed Etafy More articles by this author , and Richard MendelsonRichard Mendelson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002035.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prior publications have demonstrated the efficacy of ultrasound guided peri-spermatic cord cryoablation (PSC) as a salvage treatment for patients who failed microsurgical denervation of the spermatic cord (MDSC) for the treatment of chronic scrotal content pain (CSP). This previously published technique was performed in the hospital or ambulatory surgery center setting. Office based techniques offer the advantage of significantly reducing medical charges to the patient, since there are no facility fees. This study was designed to assesses an office based technique (OPSC) for PSC that may offer similar clinical outcomes at a significantly reduced cost to the patient. METHODS: A retrospective review of 35 OPSC cases (26 patients, 9 bilateral cases) between November 2020 to February 2021, performed by one fellowship trained microsurgeon. OPSC was performed under IV sedation in the office using a micro cryoablation needle (Cooper Surgical, Inc., Trumbull, CT). Branches of the genitofemoral, ilioinguinal and inferior hypogastric nerves were cryoablated medial and lateral to the spermatic cord at the level of the external inguinal ring. The level of pain was measured preoperatively and postoperatively using the Visual Analog Scale (VAS) and a validated Chronic Orchialgia Symptom Index (COSI). Median total surgical charges for the OPSC were analyzed for the office, ambulatory surgical center and hospital settings for comparison. RESULTS: Median patient age was 50. Median post-operative follow up was 1 month (1-3). 87% of the patients had a significant reduction in pain (19% complete resolution and 68% had a greater than 50% reduction in pain). No complications were reported. Table 1 below illustrated the median total surgical charges (including anesthesia charges) for the various clinical settings in our county region for PSC. The total surgical and anesthesia insurance charges for OPSC was significantly lower than in the ambulatory and hospital based settings (utilizing IV sedation in all these settings). CONCLUSIONS: Office based ultrasound guided peri-spermatic cord cryoablation (OPSC) is a safe, cost effective treatment option for the salvage management of persistent CSP in patients who have failed MDSC. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e558-e559 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sijo Parekattil More articles by this author Ahmet Gudeloglu More articles by this author Onuralp Ergun More articles by this author Alex Galante More articles by this author Mohammed Etafy More articles by this author Richard Mendelson More articles by this author Expand All Advertisement Loading ...

Predictors of Extended Hospitalization and Early Reoperation After Elective Lumbar Disc Arthroplasty

Lumbar disc arthroplasty (LDA) has emerged as a motion-sparing alternative to lumbar fusion. Although LDA may be amenable to the ambulatory surgical setting, to date no study has identified the factors predisposing patients to extended hospital stay. A national surgical quality improvement database was queried from 2011 to 2019 for patients undergoing elective, single-level, primary LDA. Univariate and multivariate logistic regression analyses were performed to elucidate predictors of length of stay (LOS) at or above the 90th percentile of the study population (3 days). Secondary study endpoints included rates of complications, as well as predictors and reasons for unplanned reoperation within 30 days. A total of 630 patients met eligibility criteria for the study, of whom 517 (82.1%) had LOS <3 days and 113 (17.9%) had LOS ≥3 days. Multivariate logistic regression revealed associations between prolonged hospitalization and postoperative diagnosis of degenerative disk disease, obesity, Hispanic identity, and operation length >120 minutes. Before discharge, patients with LOS ≥3 days were more likely to have venous thromboembolisms, pneumonia, surgical site infections, and reoperations. Independent predictors of reoperation were wound infections, diabetes, and smoking. Complications following elective single-level LDA are relatively rare, with few extended hospitalizations being attributable to any specific complication. Risk factors for prolonged LOS appear to be related to diagnosis and surgical time rather than to modifiable preoperative comorbidities. Conversely, unplanned reoperations within 30 days are associated with optimizable perioperative factors such as smoking, diabetes, and surgical site infection.

Spine Surgery Complications in the Ambulatory Surgical Center Setting: Systematic Review.

This was a systematic review study. This study aims to review current literature to determine the rates of complications in relation to spine surgery in ambulatory surgery centers (ASC). Recent improvements in anesthesia, surgical techniques, and technological advances have facilitated a rise in the use of ASC. Despite the benefits and lower costs associated with ASCs, there is inconsistent reporting of complication rates. This systematic review was completed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Pertinent studies were identified through Embase and PubMed databases using the search string ((("ambulatory surgery center") AND "spine surgery") AND "complications"). Articles were excluded if they did not report outpatient surgery in an ASC, did not define complications, were in a language other than English, were non-human studies, or if the articles were classified as reviews, book chapters, single case reports, or small case series (≤10 patients). The primary outcome was the frequency of complications with respect to various categories. Our query identified 150 articles. After filtering relevance by title, abstract, and full text, 22 articles were included. After accounting for 2 studies that were conducted on the same study sample, a total of 11,245 patients were analyzed in this study. The most recent study reported results from May 2019. While 5 studies did not list their surgical technique, studies reported techniques including open (6), minimally invasive surgery (2), endoscopic (4), microsurgery (1), and combined techniques (4). The following rates of complications were determined: cardiac 0.29% (3/1027), vascular 0.25% (18/7116), pulmonary 0.60% (11/1839), gastrointestinal 1.12% (2/179), musculoskeletal/spine/operative 0.59% (24/4053), urologic 0.80% (2/250), transient neurological 0.67% (31/4616), persistent neurological 0.61% (9/1479), pain related 0.57% (20/3479), and wound site 0.68% (28/4092). After literature review, this is the first study to comprehensively analyze the current state of literature reporting on the complication profile of all ASC spine surgery procedures. The most common complications were gastrointestinal (1.12%) and the most infrequent were vascular (0.25%). Case reports varied significantly with regard to the type and rate of complications reported. This study provides complication profiles to assist surgeons in counseling patients on the most realistic expectations.

Cost-Effectiveness of Propofol (Diprivan) Versus Inhalational Anesthetics to Maintain General Anesthesia in Noncardiac Surgery in the United States

ObjectivesIt is not known whether using propofol total intravenous anaesthesia (TIVA) to reduce incidence of postoperative nausea and vomiting (PONV) is cost-effective. We assessed the economic impact of propofol TIVA versus inhalational anesthesia in adult patients for ambulatory and inpatient procedures relevant to the US healthcare system. MethodsTwo models simulate individual patient pathways through inpatient and ambulatory surgery with propofol TIVA or inhalational anesthesia with economic inputs from studies on adult surgical US patients. Efficacy inputs were obtained from a meta-analysis of randomized controlled trials. Probabilistic and deterministic sensitivity analyses assessed the robustness of the model estimates. ResultsLower PONV rate, shorter stay in the post-anesthesia care unit, and reduced need for rescue antiemetics offset the higher costs for anesthetics, analgesics, and muscle relaxants with propofol TIVA and reduced cost by 11.41 ± 10.73 USD per patient in the inpatient model and 11.25 ± 9.81 USD in the ambulatory patient model. Sensitivity analyses demonstrated strong robustness of the results. ConclusionsMaintenance of general anesthesia with propofol was cost-saving compared to inhalational anesthesia in both inpatient and ambulatory surgical settings in the United States. These economic results support current guideline recommendations, which endorse propofol TIVA to reduce PONV risk and enhance postoperative recovery.

Using Predictive Modeling and Machine Learning to Identify Patients Appropriate for Outpatient Anterior Cervical Fusion and Discectomy.

Retrospective, case-control. The aim of this study was to use predictive modeling and machine learning to develop novel tools for identifying patients who may be appropriate for single-level outpatient anterior cervical fusion and discectomy (ACDF), and to compare these to legacy metrics. ACDF performed in an ambulatory surgical setting has started to gain popularity in recent years. Currently there are no standardized risk-stratification tools for determining which patients may be safe candidates for outpatient ACDF. Adult patients with American Society of Anesthesiologists (ASA) Class 1, 2, or 3 undergoing one-level ACDF in inpatient or outpatient settings were identified in the National Surgical Quality Improvement Program database. Patients were deemed as "unsafe" for outpatient surgery if they suffered any complication within a week of the index operation. Two different methodologies were used to identify unsafe candidates: a novel predictive model derived from multivariable logistic regression of significant risk factors, and an artificial neural network (ANN) using preoperative variables. Both methods were trained using randomly split 70% of the dataset and validated on the remaining 30%. The methods were compared against legacy risk-stratification measures: ASA and Charlson Comorbidity Index (CCI) using area under the curve (AUC) statistic. A total of 12,492 patients who underwent single-level ACDF met the study criteria. Of these, 9.79% (1223) were deemed unsafe for outpatient ACDF given development of a complication within 1 week of the index operation. The five clinical variables that were found to be significant in the multivariable predictive model were: advanced age, low hemoglobin, high international normalized ratio, low albumin, and poor functional status. The predictive model had an AUC of 0.757, which was significantly higher than the AUC of both ASA (0.66; P < 0.001) and CCI (0.60; P < 0.001). The ANN exhibited an AUC of 0.740, which was significantly higher than the AUCs of ASA and CCI (all, P < 0.05), and comparable to that of the predictive model (P > 0.05). Predictive analytics and machine learning can be leveraged to aid in identification of patients who may be safe candidates for single-level outpatient ACDF. Surgeons and perioperative teams may find these tools useful to augment clinical decision-making.Level of Evidence: 3.

Transcervical Fibroid Ablation (TFA) in an Ambulatory Surgical Center Setting: Utility during the COVID-19 Pandemic

Study ObjectiveTo describe the experience of TFA with the Sonata® system in the ambulatory surgicenter (ASC) setting, relative to current recommendations by medical societies for elective procedures during the COVID-19 pandemic.DesignProspective, longitudinal, multicenter controlled trial.Setting22 clinical sites in the US and Mexico.Patients or Participants147 premenopausal women between the ages of 25 and 50 with heavy menstrual bleeding secondary to nonpedunculated fibroids.InterventionsTranscervical, intrauterine ultrasound-guided radiofrequency ablation with the Sonata system. Pain scores were recorded after each procedure using a scale from 0-10. Length of stay (LOS) was measured from procedure start through discharge.Measurements and Main ResultsOf 147 treated patients, 49 were treated in an ASC setting and 98 were treated in other outpatient settings. Fifty-five percent of patients treated in an ASC had general anesthesia and 45% had conscious sedation vs 48% and 52%, respectively for non-ASC population. Average number of fibroids treated per patient was 3.2±2.0 and 2.9±2.1 in ASC and non-ASC, respectively. Mean LOS was 2.1±0.9 hours vs. 2.8±1.3 hours for ASC and non-ASC patients, respectively. Mean procedure pain scores were 0±0% for the ASC patients (0.4±1.1 for non-ASC patients). Mean return to normal activity for patients treated in ASC was 1.7±1.4 days (2.4±2.5 for non-ASC patients). Mean 12-month improvements in SSS and HRQL scores were -34.8±23.9 and 48.6±26.2 points, respectively, in ASC patients (-30.4±19.3 and 41.0±23.0, respectively, in non-ASC patients).ConclusionCurrent surgical guidance during the COVID-19 pandemic encourages avoidance of endotracheal intubation when appropriate and minimizing exposure time for patients and staff. Transcervical Fibroid Ablation with the Sonata system is performed without pneumoperitoneum or a requirement for intubation, providing short LOS, minimal pain scores and improved outcomes while potentially reducing risk to healthcare personnel and patients alike.