Day-case Group Research Articles

The cost evaluation of day-case compared to inpatient cochlear implantation in adults: subanalysis of a randomized controlled trial

ObjectiveTo investigate the assumption that day-case cochlear implantation is associated with lower costs, compared to inpatient cochlear implantation, while maintaining equal quality of life (QoL) and hearing outcomes, for the Dutch healthcare setting.Study designA single-center, non-blinded, randomized controlled trial in a tertiary referral center.MethodsThirty adult patients with post-lingual bilateral sensorineural hearing loss eligible for unilateral cochlear implantation surgery were randomly assigned to either the day-case or inpatient treatment group (i.e., one night admission). We performed an intention-to-treat evaluation of the difference of the total health care-related costs, hospital and out of hospital costs, between day-case and inpatient cochlear implantation, from a hospital and patient perspective over the course of one year. Audiometric outcomes, assessed using CVC scores, and QoL, assessed using the EQ-5D and HUI3 questionnaires, were taken into account.ResultsThere were two drop-outs. The total health care-related costs were €41,828 in the inpatient group (n = 14) and €42,710 in the day-case group (n = 14). The mean postoperative hospital stay was 1.2 days (mean costs of €1,069) in the inpatient group and 0.7 days (mean costs of €701) for the day-case group. There were no statistically significant differences in postoperative hospital and out of hospital costs. The QoL at 2 months and 1 year postoperative, measured by the EQ-5D index value and HUI3 showed no statistically significant difference. The EQ-5D VAS score measured at 1 year postoperatively was statistically significantly higher in the inpatient group (84/100) than in the day-case group (65/100). There were no differences in postoperative complications, objective hearing outcomes, and number of postoperative hospital and out of hospital visits.ConclusionA day-case approach to cochlear implant surgery does not result in a statistically significant reduction of health care-related costs compared to an inpatient approach and does not affect the surgical outcome (complications and objective hearing measurements), QoL, and postoperative course (number of postoperative hospital and out of hospital visits).Level of evidence1.

Hearing Results, Quality of Life, Patient Satisfaction, and Postoperative Complications of Day-case Versus Inpatient Stapes Surgery for Otosclerosis in Adults: A Randomized Controlled Trial.

To investigate the effect of day-case stapes surgery on hearing results, quality of life, patient satisfaction, and complications rates, compared with inpatient stapes surgery. A single-center, nonblinded, randomized controlled trial in a tertiary referral center. One hundred twelve adult patients planned for primary or revision stapes surgery were randomly assigned to either the day-case or inpatient treatment group. The effect on hearing outcomes (primarily), hearing benefits, quality of life, patient satisfaction, postoperative complications, and causes of crossover or readmission (secondarily) were assessed using auditory evaluations, questionnaires, and patients' charts over a follow-up period of 1 year. Audiometric measurements and postoperative success rates were not different between the inpatient and day-case group. There were no statistically significant differences between both groups regarding the overall quality of life (QoL) (HUI3), disease-specific QoL (GHSI), change in postoperative health status (GBI), and postoperative complications rate. We found a high patient satisfaction toward the day-case approach. Six patients allocated to the inpatient group requested same-day discharge. Of the day-case patients, there was a crossover rate to inpatient care of 38% (20 patients), mainly due to postoperative nausea and vomiting (25%), vertigo (20%), or dizziness (40%). We found no significant differences in outcomes of audiometric measurements, QoL, patient satisfaction and postoperative complications following day-case, and inpatient stapes surgery. Therefore, stapes surgery in a day-case setting seems to be a feasible approach in terms of postoperative outcome, safety, and desirability when taking patient selection and surgical planning into account. Besides this, the familiarity with a day-case approach of both patient and the surgical team, will increase the acceptance and feasibility of day-case stapes surgery.

Comparison of day-case versus inpatient uni-compartmental knee replacement.

Uni-compartmental knee replacement (UKR) is an alternative to total knee replacement for patients who have isolated compartment osteoarthritis. Studies have demonstrated that UKR can be safely performed as a day-case procedure without a negative impact on complication rates. The aim of this study was to compare the clinical outcomes between day-case and inpatient UKRs. A single surgeon prospective case-controlled study was performed, comparing data between day-case UKRs and inpatient UKRs. This included longitudinal analysis of patient reported outcome measures (PROMs); including the Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score, Short Form 12-item Health Survey, EQ-5D-5L and the Self-administered Comorbidity Questionnaire. Post-operative pain scores (visual analogue scale), unplanned post-operative hospital reattendance rates and complications were also analysed. Overall, 100% of day-case patients were successfully discharged on the same day. Both inpatient (n=23) and day-case (n=23) UKRs demonstrated a significant within group longitudinal improvement of PROM scores (p<0.05) following surgery. However, the post-operative PROM scores were significantly higher in the day-case group as compared to the inpatient group (p<0.05). Both groups had comparable post-operative pain scores, but the day-case group demonstrated fewer unplanned reattendances and post-operative complications. The clinical outcomes of day-case UKR are superior to inpatient UKR. Careful patient selection and a robust multidisciplinary patient pathway are the key components to success of day-case joint replacement surgery. Prospective Case-Control Study, level III.

Re-intervention and patient satisfaction rates following office radiofrequency endometrial ablation: a comparative retrospective study of 408 cases

This retrospective study assessed the efficacy and long-term satisfaction of radiofrequency endometrial ablation outside the context of clinical trials in 408 women, and compared the outcome between office-setting (211, 52%) and day-case procedures under general anaesthetics (197, 48%). The Kaplan Meir time-to-event analysis showed that the cumulative number of women undergoing surgical re-intervention was 32 with a probability of 9.4% (95% CI: 6.3 − 12.5%) at 2–years, and 45 with a probability of 14.5% (95% CI: 10.3 − 18.2%) at 5–years. There was no statistically significant difference in the re-intervention rate between office and day-case groups (HR = 0.7, 95% CI: 0.68 − 3.1, p = .3). The satisfaction rate, measured by Visual Analogue Scale, was not statistically different (p = .5) between office (109; 80.7%) and day-case (96; 82.8%) groups. This study showed lower surgical re-intervention rate than previously reported in observational studies, and high rates of long-term women satisfaction. The outcomes were similar in office and day-case settings. Impact statement What is already known on this subject? Previous studies have shown the safety and effectiveness of radiofrequency endometrial ablation for treating heavy periods. However, studies investigating it, outside clinical trials, either included a small sample size, a short-term follow-up, poor reporting so that it is impossible to judge whether some women underwent re-intervention in another centre, failed to discriminate in analysis between second-generation techniques, or assessed only short-term satisfaction. What do the results of this study add? This is the largest series reported from a single centre and the first study reporting long-term satisfaction in women, outside clinical trials. Surgical re-intervention was used as the primary outcome measure which is an objective measure rather than the change in the monthly flow which is rather subjective. More importantly, the study records the similarity, in the outcome and women’s satisfaction rate, between office and day-case procedures under general anaesthetics. What are the implications of these findings for clinical practice and/or further research? Endometrial ablation service is widely implemented in office-setting in the UK. We hope the result of this study encourages implementation on a larger scale in office across centres in the world with its multiple advantages both to women and service alike.

Day Case GreenLight Laser Photoselective Vaporisation of the Prostate (GL-PVP)

Background and Objective In recent years, GreenLight laser photoselective vaporisation of the prostate (GL-PVP) has emerged as the primary ablative surgical treatment option for symptomatic bladder outlet obstruction (BOO) secondary to benign prostatic enlargement (BPE). Unlike the reference procedure, monopolar-transurethral resection of the prostate (M-TURP), GL-PVP can be performed as a day case. As waiting list pressures continue to burden health boards across the UK, exacerbated by the COVID-19 pandemic, enhanced access to day case surgery to optimise patient flow is now of paramount importance. We evaluated the safety and feasibility of day case GL-PVP at our high-volume UK centre and identified predictors of a postoperative overnight stay. Material and Methods We performed a retrospective observational cohort study of all patients who underwent primary GL-PVP at a single institution between October 2016 and June 2021. All procedures were performed utilising the 180W GreenLight XPS™ laser therapy system. Various clinical, operative and functional data were collated, and outcomes were compared between patients who underwent day case surgery and those admitted overnight postoperatively. Results In all, 538 patients underwent GL-PVP during the study period. Median patient age was 72 (interquartile range (IQR) 66–77), and median prostate volume was 62.5cc (IQR 45–90). Five hundred nineteen patients (96.5%) were discharged within 23 hours of admission, and 366 patients (68.0%) were managed as a true day case. Operative and functional outcomes were comparable between patients managed as a day case and those admitted overnight. There was higher patient-reported satisfaction and a lower rate of early hospital readmission in the day-case group. On univariate logistic regression analysis, patients aged ≥80 years (Odds Ratio 2.64 [95% Confidence Interval 1.65– 4.24], p = &lt; 0.001), those with American Society of Anaesthesiologists (ASA) physical status classification score ≥3 (OR 1.92 [95% CI 1.33–2.78], p = &lt; 0.001), those with prostate volume ≥80cc (OR 1.62 [95% CI 1.00–2.61], p = 0.05) and those in whom the operation time ≥60 minutes (OR 1.66 [95% CI 1.10–2.52], p = 0.02) were more likely to be admitted overnight following GL-PVP. On multivariate logistic regression analysis, age ≥80 (OR 2.64 [95% CI 1.47–4.73], p = 0.001) and ASA score ≥3 (OR 2.03 [95% CI 1.28–3.22], p = 0.003) remained predictive variables of an overnight stay. Conclusion From our observations of a large cohort of patients over a study period of almost five years, day case GLPVP is a feasible concept and does not appear to compromise perioperative outcomes. With appropriate service redesign and optimisation of postoperative patient pathways, day case GL-PVP can be established in other centres and may have a role in alleviating waiting list pressures.

952 In-Patient Trauma Surgery in COVID-19 Positive Patients Carries A Significantly Higher Mortality Risk When Compared to In-Patient Covid-19 Negative Patients and Day Case Trauma Patients

IntroductionCovid-19 caused many service changes, yet Trauma surgery continued throughout. We compare mortality rates from In-Patient (IP) and Day Case (DC) trauma patients and compare the mortality rates of patients who tested positive or negative for Covid-19.MethodWe reviewed all trauma admissions that underwent surgical intervention in both our IP and DC services during 31 days from March 23rd 2020. We recorded their sex, age, operation, Covid-19 symptoms, Covid-19 test results and mortality. The findings were compared between the groups.ResultsIn total 127 patients underwent surgery (66 IP; 61 DC). There were 6 deaths (9.1%) within the IP group and 0 deaths in the DC group (p = 0.006). In the IP group 8 patients (12.1%) tested positive for Covid-19 of which 4 died (50%) compared to the remaining 58 patients (87.9%) of which 2 (3.4%) died (p < 0.001). A higher mortality rate was observed in patients with symptoms but a negative Covid-19 test (6.7%) than patients in whom a test was never indicated (2.3%).ConclusionCovid-19 positive patients requiring in-patient admission for trauma surgery have a significantly higher mortality rate than both in-patient admissions that were Covid-19 negative or asymptomatic and patients that were treated with Day Case Trauma surgery.

Day Ward Glaucoma Patients Have Lower Depression Levels and Higher Glaucoma Knowledge Levels than Inpatients.

Importance Psychological factors and glaucoma knowledge are closely related to the effects of glaucoma treatment. Background Studies comparing anxiety and depression levels and glaucoma knowledge between glaucoma day-case patients and inpatients are limited. Design Randomized clinical trial. Participants Consecutive patients undergoing surgery were prospectively enrolled. Methods Patients were randomized into the day-case group or the inpatient group. All of the patients underwent corresponding procedures for treatment, care, and education. All participants were asked to complete the General Condition Questionnaire, the Hospital Anxiety and Depression Scale (HADS), and the Gray Glaucoma Knowledge Questionnaire (GGKQ) at admission and the HADS and GGKQ at discharge. Main Outcome Measures The scores for the General Condition Questionnaire, the HADS, and the GGKQ. Results In total, 216 patients were enrolled in this study, including 119 day ward patients and 97 inpatients. There were no significant differences between the two groups in terms of their baseline demographic and clinical data (P > 0.05). The baseline HADS-anxiety (HADS-A), HADS-depression (HADS-D), and GGKQ scores were similar in both groups (P > 0.05). Before discharge, the difference in HADS-A scores between the two groups was not significant; however, the HADS-D scores of the day-case inpatients were significantly lower (α = 0.05, P < 0.001), and the GGKQ scores of day-case inpatients were significantly higher than those of the inpatients before discharge (α = 0.05, P < 0.001). Conclusions and Relevance Day ward patients had lower levels of depression and higher levels of glaucoma knowledge.

Day-case tonsillectomy in children: Experience from a Teaching Hospital in Jordan

ObjectivesThis study has been conducted for the first time in Jordan to investigate safety issues relating to day-case tonsillectomies in childrens and to study the post-operative complication rate compared to tonsillectomies carried out with inpatient admission to hospital. Materials and methodsRetrospective review of medical charts of 419 pediatric patients who had undergone tonsillectomies. Patients were divided into two groups, with 103 patients in the inpatient group and 316 patients in the day-case group. A comparison is made between the clinical and demographic data of the patients studied and the postoperative complication rate. ResultsThe two main indications for tonsillectomy in all patients were recurrent infection and tonsillar hypertrophy. For instances of day-case tonsillectomy, only one patient had secondary post-tonsillectomy bleeding (0.32%); likewise, there was only one case of this reported for the inpatient group (1%), and there were no cases of reactionary hemorrhage reported in either groups. Statistical analysis failed to show a significant association between the inpatient and day-case surgery groups (P > 0.05) in terms of post-tonsillectomy bleeding. ConclusionWe found day-case tonsillectomy to be a safe procedure in children if the inclusion and exclusion criteria followed properly. The observation time following tonsillectomy is crucial to avoid the postoperative complications.

Day-case surgery is possible in the majority of men undergoing transurethral resection of the prostate – a report on over 1000 cases

Objective: We describe our experience of performing bipolar transurethral resection in saline (Olympus Medical) as a day-case procedure over an initial five-year period. Patients and methods: All procedures coded as transurethral resection of the prostate over a 60-month period were analysed to determine whether the procedure was planned as a day-case or as an inpatient admission, and whether post-operative discharge proceeded as intended. Re-admission rates, reasons for re-admission and transfusion rates were also recorded. Results: Of the 1035 operations, 689 (66.57%) were planned as a day-case procedure (mean age 70.5 years) with 176 (25.5%) requiring inpatient admission, and 346 (33.43%) were planned for inpatient admission (mean age 73.6) but 58 (16.8%) were discharged the same day. Overall 571 (55.17%) procedures were performed as day cases. Readmission rates for day-case and inpatient procedures were 7.4%, and 6.3% respectively ( p=0.48). Transfusion rates were lower in the day-case group (0.7% vs 3.7%, p&lt;0.05). Day-case rates improved from 48.70% in 2011 to 75.22% in 2016. Conversion from day case to inpatient fell from 34.6% in 2011 to 14.8% in 2016. Conclusions: Our experience indicates that day-case transurethral resection of the prostate can be performed safely in appropriately selected patients, without increased rates of re-admission or complications. Level of evidence: 4 (Oxford Centre for Evidence-Based Medicine (CEBM)).

Day-case device implantation-A prospective single-center experience including patient satisfaction data.

Many centers perform day-case cardiac rhythm management (CRM) device implantation. However, there is a paucity of prospective data concerning this approach. We performed a prospective single-center study of day-case device implantation, including data on patient satisfaction. All patients scheduled for a new elective device were considered for a day-case procedure. Exclusion criteria were living alone or without a suitable carer, advancing age/frailty, a metallic valve, and persistent complete heart block. Following discharge, patients were reviewed in device clinic at 6weeks with an anonymized questionnaire. During the study period (May 2014-August 2016), 797 new CRM devices were implanted. Of these, 232 were elective and included in the analysis; 101 were planned to be day-case and 131 scheduled for overnight stay. Of the 101 day-case patients, 52 had a pacemaker, 28 an implantable cardioverter defibrillator (ICD), 16 a cardiac resynchronization therapy pacemaker/defibrillator, and five a subcutaneous-ICD. Complications were similar in the day-case (n=12, 12%) and overnight stay (n=15, 11%) groups (P=0.92). In the day-case group, 93 (92%) patients went home the same day. An estimated 111 overnight bed days were saved, translating to a cost saving of £61,912 (euro 70,767, $79,211). Note that 99% (n=100) of patients returned the questionnaire. Patient satisfaction was universally high. The majority (n=98, 98%) felt ready to go home on discharge; only a minority (n=5, 5%) would have preferred an overnight stay. A significant proportion of elective new CRM device implants can be performed as day-case procedures. With appropriate selection patient acceptability of same-day discharge is high.

PTU-331 Day case oesophageal self expanding metallic stent (sems) placement is safe and saves bed days:

<h3>Introduction</h3> SEMS is an accepted endoluminal palliative treatment for symptom control in patients with oesophageal cancer. Current practice of SEMS placement including techniques, pre and post procedure care varies widely across the UK; with many hospitals admitting patients both pre and post procedure.¹ <h3>Aim</h3> To evaluate the safety and effectiveness of day case SEMS placement for oesophagogastric cancer. <h3>Method</h3> Retrospective case note review of all patients undergoing SEMS placement from Jan 2012 to Dec 2014 was performed. Day case patients were admitted to the endoscopy unit in the morning, standard consent and sedation procedures was followed. SEMS inserted under radiological and endoscopic or endoscopic guidance alone. Patients were monitored for 1.5–2 hrs post procedure, nurse led discharge with a prescription for oral liquid opiates, antiemetics and Proton pump inhibitors. All had telephonic access to a dedicated cancer specialist nurse during working hours and on call team out of hours. Inpatients needing stenting followed similar protocol for post-procedure care. Relevant outcomes data was collected and statistical analyses were performed on GraphPad Prism Version 6 and Epi Info 7. <h3>Results</h3> 138 procedures were carried out on 127 patients (41 women, 86 men) with a median age 78.2 (IQR 69–83.25, Range 52–96). 93 patients had adenocarcinoma, 26 squamous cell carcinoma, 6 extrinsic compression and 2 benign diseases. SEMS deployment was successfully achieved in all 138 procedures, 79 as day case (DC) and the rest 59 as inpatients (IP). Median stent length used was comparable in the groups DC 11 cm (IQR 10–12), IP 11 cm (IQR 10–12.5). Good dysphagia alleviation was obtained in both groups (dysphagia scores: IP cohort pre-stent 2.7 ± 0.16, post-stent 0.57 ± 0.66 P &lt; 0.001; DC cohort pre-stent 2.63 ± 0.11, post-stent 0.48 ± 0.17 P &lt; 0.001). Median survival was 136 days (IQR 43–171) in IP group and 125 days (IQR 29.65–183.5) in DC group. DC cohort reported more post procedure pain requiring analgesia and reflux symptoms as compared to IP. Bleeding (minor), stent migration and 30 day mortality was comparable in the two groups. No major procedure related complications reported. <h3>Conclusion</h3> SEMS placement as day case is safe and complication rates and mortality is equivalent to inpatients. In our hospital, the basic cost of a general medical hospital bed day is £330, thereby equating to a £26000 in total cost saving per day of admission in bed cost. Day case SEMS produced a reduction in hospital admissions and hospital bed day occupancy with major cost savings. <h3>Disclosure of interest</h3> None Declared. <h3>Reference</h3> The Royal College of Surgeons of England, National Oesophago-gastric Cancer Audit, 2013

Day-case versus inpatient laparoscopic fundoplication: outcomes, quality of life and cost-analysis

Day-case laparoscopic Nissen-Rossetti fundoplication (LF) has been demonstrated to be safe in small, prospective cohorts. The purpose of the study was to compare postoperative course, functional results, quality of life, and healthcare costs in patients undergoing LF in a day-case surgical unit with same-day discharge and patients undergoing LF as an inpatient. All consecutive patients in our department who underwent a primary LF for symptomatic uncomplicated gastroesophageal reflux disease from 2004 to 2011 were entered into a prospective database (n = 292). From 101 same-day discharge patients (day-case group), control inpatient procedures were randomly matched by age, gender, body mass index, American Society of Anesthesiologists classification, and presence of a hiatal hernia (inpatient group, n = 101). No postoperative deaths occurred and postoperative morbidity occurred in 9.4% of patients. When comparing day-case and inpatient groups, postoperative morbidity rates were 9.9 vs. 8.9% (p = 0.81) with median hospital stays and readmission rates of 1 vs. 4 days (p < 0.001) and 7.9 vs. 0% (p < 0.001), respectively. Gastrointestinal Quality of Life Index was significantly enhanced due to surgery (p < 0.001) and comparable in the two groups. Estimated direct healthcare costs per patient were 2,248 euros in the day-case group vs. 6,569 euros in the inpatient group (p < 0.001), equivalent to a cost saving of 3,921 euros. Day-case and inpatient approaches after LF give similar results in terms of postoperative mortality and morbidity, functional outcomes and quality of life, with a substantial cost saving in favor of a day-case procedure.

Day Case Hemithyroidectomy: The Scottish Experience

Objectives: Analyze our new patient pathway that practices day-case hemithyroidectomy. Methods: Prospective re-audit of patients undergoing primary hemithyroidectomy over 2 years (January 2010-January 2011) and compared it to the first cycle in January 2008-January 2009. Procedures were done by a single surgeon and anaesthetist in a district general hospital. Drains were never used. In the latest audit cycle, all patients underwent standardized anaesthesia and surgical procedures, including pain and nausea management. Patients completed questionnaires at discharge and follow-up 1-2 weeks postoperatively. Hospital stay, complications, and patient satisfaction scores were recorded. Results: The first cycle (54 patients) demonstrated that a third of patients stayed at least 1 night and two thirds stayed 2 nights or more. Following a new protocol, the latest audit cycle (62 patients) demonstrated a 75% day-case rate (P &lt; 0.0001). 98% of day-case patients were happy (questionnaire scoring 8/10 or greater) to be discharged on day of surgery. Of the 25% who stayed overnight, 50% had surgery in the afternoon compared to 21% in the day-case group (P =0.015). 80% of all patients did not need opioid analgesia. 5% had problems with postoperative pain and nausea and were likely to stay overnight. There were no readmissions. Subjective and objective patient experience data will be discussed as well as our hemithroidectomy patient pathway. Conclusions: Successful day case hemithyroidectomy relies on preoperative counseling, specific anaesthesia techniques, meticulous surgery. and careful patient selection. Day case hemithyroidectomy can be safely undertaken in the vast majority and is highly desirable by patients.

Day-Case Laparoscopic Nissen Fundoplication: A Default Pathway or Is Selection the Key?

In recent years, day-case laparoscopic Nissen fundoplication (LNF) has became popular. Our study aims to evaluate the effect of patient factors and severity of gastroesophageal reflux disease measured by DeMeester score on the success of day-case LNF. We conducted a retrospective case series review of patient demographics (age, gender, body mass index [BMI], and smoking status) and DeMeester score over a 5-year period. Between 2005 and 2010, 112 patients had day-case LNF. Same-day discharge was achieved in 80.3%. Twenty-two patients (19.7%) required postoperative admission ("failed day-case surgery"), with a resultant mean length of stay of 1.41 days. Univariate analysis showed that female gender had a significantly higher incidence of postsurgical admission (30.76% females versus 13.69% males, P=.03 by Mann-Whitney U test). Compared with the same-day discharge group, the failed day-case group has a higher mean DeMeester score (50.89 versus 36.03, P=.021 by t test) and BMI (28.71±0.778 kg/m(2) versus 26.79±0.3737 kg/m(2), P=.023). Age and smoking status were not significant determining factors in postoperative admission rates. Using multivariable analysis and logistical regression, we derived a model based on gender, BMI, and DeMeester score to predict the probability of admission following day-case LNF. We conclude that day-case LNF is a safe, feasible procedure in the appropriately selected patient population. Our novel finding of higher admission rates in females, high DeMeester score, and high BMI should be used in planning perioperative hospitalization in this cohort.

A randomized trial of day-case vs inpatient laparoscopic supracervical hysterectomy

To determine whether women having day-case laparoscopic supracervical hysterectomy are more or less satisfied with the length of hospital stay compared with women who stayed overnight after the procedure. An randomized control trial of 49 women randomized to day-case or overnight hospital stay after laparoscopic supracervical hysterectomy. Satisfaction with length of hospitalization and quality of life were compared using the Mann-Whitney U test. No group differences were found in satisfaction with length of hospital stay (P = .13). There was a nonsignificant trend toward greater anxiety in the day-case group (P = .06 on day 1 postoperative). Quality of life was lower in the day-case group on days 2 (P = .02) and 4 (P = .03), postoperatively. Women having a day-case hysterectomy were discharged after median of 5 hours postoperative and were similarly satisfied as women hospitalized overnight. Quality of life, however, does appear to be compromised by day-case surgery.

Meta-analysis of randomized controlled trials on the safety and effectiveness of day-case laparoscopic cholecystectomy

Although day-case laparoscopic cholecystectomy can save bed costs, its safety has to be established. The aim of this meta-analysis is to assess the advantages and disadvantages of day-case surgery compared with overnight stay in patients undergoing elective laparoscopic cholecystectomy. Randomized clinical trials addressing the above issue were identified from The Cochrane Library trials register, Medline, Embase, Science Citation Index Expanded and reference lists. Data were extracted from these trials by two independent reviewers. For each outcome the relative risk, weighted mean difference or standardized mean difference was calculated with 95 per cent confidence intervals based on available case analysis. Five trials with 215 patients randomized to the day-case group and 214 to the overnight-stay group were included in the review. Four of the five trials were of low risk of bias. The trials recruited 49.1 per cent of patients presenting for cholecystectomy. There was no significant difference between day case and overnight stay with respect to morbidity, prolongation of hospital stay, readmission rates, pain, quality of life, patient satisfaction, and return to normal activity and work. In the day-case group 80.5 per cent of patients were discharged on the day of surgery. Day-case laparoscopic cholecystectomy is a safe and effective treatment for symptomatic gallstones.

Randomized controlled trial comparing Thermachoice III* in the outpatient versus daycase setting

To evaluate outpatient versus daycase Thermachoice III endometrial ablation. Randomized, controlled trial. Large United Kingdom teaching hospital. Seventy-three women with menorrhagia. In the outpatient cohort (n = 39), women took ibuprofen 800 mg the evening before, and 1 hour before, performing Thermachoice III. Intraoperatively, they were offered "rescue analgesia" in the form of inhaled nitrous oxide. Postoperatively, women were offered oral tramadol 50-100mg. Neither local anesthetic nor IV sedation was used. In the daycase cohort (n = 34), women underwent a general anesthetic, i.e., propofol and inhalation gases. Intraoperatively, intravenous fentanyl 100 microg and rectal diclofenac 100 mg were administered. Main outcome measures included overall discomfort following Thermachoice III; intraoperative pain scores and a need for rescue analgesia during outpatient Thermachoice III; nausea and vomiting rates; and total time in hospital and the need for an overnight stay. Eighty-seven percent (n = 34) of women in the outpatient cohort completed the full 8-minute treatment. The remaining five women requested the procedure be stopped because of pain. The mean intraoperative pain scores for the outpatient cohort remained below 45 mm (range, 0-100 mm) for every stage of treatment. The majority (64%) of women from the outpatient cohort required no rescue analgesia whatsoever. There was no significant difference between the overall mean pain score following Thermachoice III for either the outpatient (59 mm; range, 0-100 mm) or daycase (53 mm; range, 0-100 mm) cohorts. However, women from both cohorts reported wide ranges of pain scores (0-100 mm). There was no significant difference between the Likert -style descriptions of overall discomfort between the two groups, with the majority of women rating the pain as none to moderate. The presence of severe dysmenorrhea was statistically significantly correlated with higher overall visual analogue-style pain scores and Likert-style descriptions of discomfort. Significantly fewer women in the outpatient group experienced nausea (13% versus 65% in the daycase group) or vomiting (0 versus 24% in the daycase group), or required postoperative antiemetics (0 versus 56% in the daycase group). The mean total time spent in hospital was significantly shorter for the outpatient cohort at 1 hour and 40 minutes, versus 8 hours 12 minutes for the daycase group. Outpatient Thermachoice III could be performed in the majority (87%) of women, and was associated with similar overall pain scores as daycase Thermachoice III, however, the range was wide. Outpatient Thermachoice III was associated with significantly less nausea, vomiting, need for antiemetics, and time spent in hospital than was the daycase procedure.

A randomised controlled trial comparing outpatient versus daycase endometrial polypectomy

To evaluate outpatient versus daycase endometrial polypectomy by comparing success rate, complications, patient tolerance, pain score, analgesia requirement and recovery. A randomised controlled trial. A large UK Teaching hospital. Forty consecutive women diagnosed with an endometrial polyp at outpatient hysteroscopy were randomly assigned in equal proportions to outpatient or daycase polyp removal. 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. 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. 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. 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.

Randomized clinical trial of the effectiveness of emergency day surgery against standard inpatient treatment

The aim of this study was to assess the feasibility of treating patients with minor and intermediate general surgical emergency conditions as day cases. Emergency referrals for minor and intermediate general surgical conditions were assessed by a surgeon. Those fitting day-case criteria and requiring operation under general anaesthesia were randomized to receive standard inpatient care or day surgery. Patients in the latter group were booked on to day-case lists or gaps on inpatient elective lists for surgery within 48 h. The process was coordinated by an experienced theatre sister. One hundred patients were randomized. There was a reduction in the number of nights spent in hospital in the day-case group (median 0 versus 2 nights; P < 0.001). The median time from diagnosis to treatment was 1 day in both groups, although there was a small but significant delay in the day-case group (P = 0.018). There was no significant difference in postoperative outcome or patient and general practitioner satisfaction. The day-case option had no increased impact on primary care services but was associated with a significant saving of about pound sterlings 150 per patient (P < 0.001). Certain general surgical emergencies may be managed as day cases with cost saving but without detriment to patient care.

Day-case adenoidectomy: how popular and safe in a rural environment?

In spite of previously favourable reports on day-case adenoidectomy, there are still worries amongst otolaryngologists that such practice is unsafe, especially in a rural environment. A national survey was therefore carried out which shows that only 41 per cent of respondents perform adenoidectomy routinely as day-case, and even fewer in rural areas. A regional audit on day-case adenoidectomy, covering five hospitals, was conducted in East Anglia. Between 1994 to 1995, 73 day-case adenoidectomies were performed and the outcome was compared to those of 183 in-patient adenoidectomies during the same period. The children in the day-case group recovered post-operatively even better than the in-patient group. None of them stayed overnight or required re-admission. There was no increased in post-operative consultation to the general practitioner. The parents in the day-case group were mostly in favour of the day-case arrangement (88 per cent). The results suggest that day-case adenoidectomy is safe and popular with parents even in a rural environment.