Day Care Basis Research Articles

English

Day Care Surgery conducted under general anaesthesia, largely depends on anaesthetic agents which have shorter duration of action and hence are able to provide rapid recovery. In the present study we intend to compare the recovery profile of the two easily available agents in India i.e. isoflurane and halothane and compare their usefulness in day care surgery. MATERIALS AND METHODS: 50 patients were randomly divided into two groups of 25 each in age group of 18 to 60 years, of either sex, of American Society of Anaesthesiologists (ASA) grade I or II undergoing different surgeries of short duration up to half an hour, after proper preoperative screening. In both the groups induction was done with propofol 2 mg/kg. In group I patients, 1.0 Minimum Alveolar Concentration (MAC) halothane and in group II 1.0 MAC isoflurane was used for maintenance of general anesthesia along with mixture of oxygen and nitrous oxide in the ratio of 40: 60. Narcotics and anti sialogogues that cross blood brain barrier were avoided, which may interfere with the recovery patterns. Postoperative recovery was divided into two phases and both the groups were compared by means of various clinical tests. RESULT: We found that early recovery following Isoflurane was more rapid compared to Halothane. The psychomotor tests to assess the intermediate recovery also showed the significant difference between the two groups with P value <0.001. More number of patients was able to sit up at half an hour and stand at two hours in the isoflurane group compared to halothane group. CONCLUSION: Isoflurane is a useful and better anesthetic over halothane and offers a clear advantage when used for maintenance of anaesthesia for operations performed on a day-care basis.

126 Randomized Controlled Trial of Day-Care and Hospitalized Management of Severe Pneumonia with Severe Acute Malnutrition in Children in Bangladesh

Background and aimsSevere childhood pneumonia and severe acute malnutrition (SAM) require hospitalized management but inadequate pediatric beds limits hospital-care in Bangladesh. As two prospective observational studies showed that day-care facility-based...

Removal of metallic tracheobronchial stents in lung transplantation with flexible bronchoscopy

BackgroundAirway complications are among the most challenging problems after lung transplantation, and Self-Expandable Metallic Stents (SEMS) are used to treat airway complications such as stenosis or malacia at the bronchial anastomosis sites. Several transplantation centers are reluctant to use SEMS since their removal is sometimes needed and usually requires the use of rigid bronchoscopy under general anesthesia. The objective of the current report is to describe our experience in SEMS retrieval by flexible bronchoscopy under conscious sedation.MethodsA retrospective review was done of patients requiring tracheobronchial stent placement after lung transplantation in which the SEMS had to be removed. The retrieval procedure was done by flexible bronchoscopy on a day-care ambulatory basis.ResultsBetween January 2004 and January 2010, out of 305 lung transplantation patients, 24 (7.8%) underwent SEMS placement. Indications included bronchial stenosis in 20 and bronchomalacia in 4. In six patients (25%) the SEMS had to be removed due to excessive granulation tissue formation and stent obstruction. The average time from SEMS placement to retrieval was 30 months (range 16-48 months). The stent was completely removed in five patients and partially removed in one patient; no major complications were encountered, and all patients were discharged within 3 hours of the procedure. In all procedures, new SEMS was successfully re-inserted thereafter.ConclusionsThe retrieval of SEMS in patients that underwent lung transplantation can be effectively and safely done under conscious sedation using flexible bronchoscopy on a day-care basis, this observation should encourage increasing usage of SEMS in highly selected patients.

A True Laparoscopic Herniotomy in Children: Evaluation of Long-Term Outcome

Thirteen years of experience with a laparoscopic technique mimicking, as closely as possible, the classical open technique are presented in this report. Consecutive laparoscopic herniotomies in 385 children (178 girls and 207 boys; age 0.13 to 16.8 years) with a total of 525 hernia repairs were included into a retrospective review. Overall, 95% of children were treated on a day-care basis; all operations were completed laparoscopically. Mean operation time was 32.1 minutes (26.2 for unilateral hernias and 34.5 for bilateral). In total, 10.1% of children presented with clinically bilateral hernias, whereas 29.2% of clinical unilateral hernias had a patent contralateral processus vaginalis. We discovered femoral hernias in 2.6% and direct inguinal hernias in 0.5% of the cases. In 79 cases, a concomitant of umbilical herniorraphy was performed. There were no cases of testicular malposition or atrophy. We had a 1% hernia recurrence rate. Cosmetic outcome was excellent. Laparoscopy provides the surgeon with a superior diagnostic tool, facilitating the diagnosis of any kind of inguinal hernia or controlateral patent processus vaginalis and its repair in the same session; surgery- and anesthesia-related stress is minimized. This makes it an interesting alternative to the open repair of inguinal hernias in children, providing an excellent view on the cord structures and leaving them, as well as the testis, untouched.

Treatment of Hemorrhoids in Day Surgery: Stapled Hemorrhoidopexy vs Milligan–Morgan Hemorrhoidectomy

BackgroundRecently, it has been demonstrated that surgical treatment of hemorrhoids in a day-care basis is possible and safe. The aim of this study was to compare the Longo stapled hemorrhoidopexy (SH) and the Milligan–Morgan hemorrhoidectomy (MMH). MethodsOne hundred seventy one patients (95 cases in SH group and 76 cases in MMH group) entered the study: 83 cases were III degree hemorrhoids, 88 IV degree. A priori and a post hoc power analysis were performed. Results, prospectively collected, were compared using chi squared test and student t test. Visual analog scale was used for pain evaluation. Postoperative pain, duration of pain, wound secretion, bleeding, resumption of a normal lifestyle, and postoperative complication were evaluated. ResultsSurgical time was 28.41±10.78 for MMH and 28.30±13.28 min in SH (P = 0.94). Postoperative pain was not different between MMH and SH during the first two postoperative days (4.73±2.91 vs 5.1 ± 3.048; P = 0.4), during the following 6 days, patients treated with SH had less pain (4.63±2.04 in MMH vs 3.60±2.35 in SH; P = 0.006). In the SH group, seven patients needed further hospital stay for complicated course. SH showed higher incidence of anal fissure compared with MMH (6.3% vs 0%; P = 0.025) but no differences in urinary retention, anal stricture, urgency, or anal hemorrhage. ConclusionsThis study confirms that SH is associated with less postoperative pain and shorter postoperative symptoms, compared with MMH. SH may be a viable addition to the therapy for hemorrhoids with some advantages in early postoperative pain and some disadvantages in postoperative complications and costs.

Female genital mutilation: Experience in a West London clinic

SummaryIn 1997, a new clinic was established at the Central Middlesex Hospital to serve the needs of a mainly Somali population who had suffered genital mutilation in childhood. Between June 1997 and January 2005, 4,125 clinic attendances were recorded. A total of 215 reversals of circumcision were carried out (FGM 3), all on a day-care basis. In the majority of cases, an intact and undamaged clitoris was found under the scar tissue. The clinic staff were able to draw attention to cultural and religious issues which proved important in the medical management of these women. The experience of this clinic has shown that where there is a large immigrant population of women from the Horn of Africa, clinics such as this are efficient and cost-effective and encourage women to attend with a variety of health concerns. The clinic also encourages these women to take their health concerns seriously.

P153 Management of the N0 Neck: Failure Rates and Salvageability After Surgery, Irradiation, or Observation

and is preceded in most cases by premalignant lesions. An approach to cancer control is to identify potentially malignant or premalignant lesions where treatment of these lesions may prevent transformation to cancer. The present study was carried out to evaluate the clinical and molecular response of intralesional tetra-O-methyl nordihydroguaiaretic acid in oral premalignant lesions. Design: Single group. Setting: Tertiary cancer center, India. Main Outcome Measures: Toxic effects were monitored by World Health Organization criteria. Response was recorded as change in surface area, necrosis, pathologic response, molecular response (CDC2 and survivin), complications, and recurrences. Results: All 4 lesions were located on the buccal mucosa; 3 lesions were excised, while the fourth completely regressed with tetra-O-methyl nordihydroguaiaretic acid treatment alone. At the end of 27 months, 1 patient developed a new lesion on the same side, and at 33 months, 1 patient developed a new lesion on the opposite side. Downregulation of CDC2 was seen in 3 and of survivin in 2 patients. Both the patients who developed new lesions showed CDC2 down-regulation, while 1 showed downregulation of survivin. Conclusions: Intralesional tetra-O-methyl nordihydroguaiaretic acid appears to be well tolerated at doses of up to 100 mg (20 mg/d) with no evidence of acute or delayed toxic effects. The drug has demonstrated inhibition of cellular production of CDC2 and survivin, a strongly proapoptotic response. The advantage of the present technique is in its simplicity of administration: these intralesional injections can be administered on a day-care basis.

Reconstruction of postleishmaniasis scar with lateral cheek rotation flap.

the aim of this study was to find a simple and economical technique to remove postleishmaniasis scar from the face. a non-randomized descriptive case series. the study was conducted between 1st January 1998 to 31st July 2000 in a private hospital of D.I.Khan. Ten patients with postleishmaniasis scar on the face were selected for excision and reconstruction in this study. They were operated as day care under local anesthesia. Their age ranged between 18-30 years, with an average of 23.5 years. The size of scar varied from 2 cm2 to 6 cm2 with an average of 4.1 cm(2). After scar excision, lateral cheek rotation flap (reverse face-lift) was used to reconstruct the defect. Results were statistically analyzed. No major complications were encountered. However, minor complications like edema of the flap, seroma under the flap, flap tip necrosis and temporary neurapraxia were noted in two patients. This is an excellent technique, which can be done on a day care basis under local anesthesia. Larger studies will help to explore this technique further.

Groin and scrotal swellings in children aged 5 years and below: a review of 535 cases.

There is limited literature dedicated to the surgical problems of infants and childhood, especially diseases of the groin and scrotum, in the setting of sub-Saharan Africa. We do not know the morbidity and mortality rates associated with surgical conditions of the groin and scrotum in children of our sub-region. This study was carried out among children aged 5 years and below in a regional referral hospital in Kumasi, Ghana, to determine the surgical conditions of the groin and scrotum treated at elective surgery. Inguinal hernias constituted 74% of the children with groin and scrotal diseases; this was followed by hydroceles - 14.2%; then undescended testis - 10.5%; and inguinal lymphadenopathy - 0.7%. The rest were testicular abscess, seminoma and cystic lymphangioma, representing 0.2% each of groin and scrotal conditions treated in this hospital among this age group. The last three are rare conditions of the groin and scrotum as shown by our data. The recurrence rate after herniotomy was 0.7%. Orchidopexy was successfully performed in 89% of children with undescended testes; in 7.1% of cases, orchidectomy was carried out for rudimentary and small, dysplastic testes. Over 98% of the children with groin and scrotal surgical problems were treated on day-care basis. There were no recorded deaths in the series.

Hypoxaemia During Gynaecological Laparoscopy Under Local Anaesthesia and Sedation

Context: Laparoscopy is a procedure with significant potential for hypoxaemia due to the respiratory changes accompanying pneumoperitoneum and the Trendelenberg position used. Hypoxaemia may be critical when the procedure is conducted under local anaesthesia and conscious sedation. Objective: The aim of this study was to determine the extent to which hypoxaemic episodes occurred during gynaecological laparoscopy performed under conscious sedation. Study Design, Setting and Subjects: This was a cross-sectional study of consecutive patients undergoing investigative laparoscopy at the University College Hospital, Ibadan. Informed consent was obtained from patients and they were prepared for the procedure on a day-care basis. The demographic data and vital signs were recorded. Pentazocine (60 mg) and diazepam (10 mg) were administered intravenously. Main Outcome Measures: The respiratory rate, pulse rate, blood pressure and oxygen saturation were measured pre-, intra-, and post-operatively. Results: Thirty-two patients were recruited into the study. They had no intercurrent medical diseases. Mean age was 33 years (SD 4.2) and mean Body Mass Index (BMI) was 24.49 (SD 2.87). Oxygen saturation was normal in every patient pre-sedation. Post sedation, 19 (54%) of the patients desaturated in the period before surgical stimulation. Oxygen saturation remained between 90% and 95% in 6 (19 %) patients intraoperatively. There were no postoperative episodes of desaturation. There was no correlation between the BMI and the degree of desaturation. Conclusion: A significant degree of desaturation occurs during gynaecologic laparoscopy under pentazocine and diazepam sedation. It is recommended that oxygen should be administered to all patients during the procedure. Key Words: Gynaecological Laparoscopy, Sedation, Hypoxaemia. [Trop J Obstet Gynaecol, 2002, 19: 4-7].

Fulguration of posterior urethral valves using the Nd:YAG laser.

Endoscopic management is the accepted form of treatment for posterior urethral valves (PUV). The Nd:YAG laser has been in clinical use for many decades, but has been used only sporadically for ablating PUV. In this study, PUV were diagnosed by micturating cystourethrogram (MCU). In the 9-month period beginning March 1997, 23 boys 3 months to 9 years of age underwent endoscopic Nd:YAG laser surgery for PUV using a 600 quartz bare fibre through the catheter channel of an 8.5 F cystoscope. The laser power and total energy delivered ranged from 20 to 50 W and 50-1085 J, respectively. Type I PUV were present in 20 boys; 1 had type III, and in 1 boy each there were residual valves and a urethral stricture from a previous electrocautery ablation. All operations were done with the patient under general anaesthesia supplemented by caudal morphine. Routine postoperative cystoscopy was done in the first 5 cases only. All patients had a good stream of urine without bleeding or any other complication after valve ablation. Mucosal tags seen on follow-up cystoscopy in 5 patients were fulgurated by laser. In 4 other patients recystoscopy was required for deterioration of the urinary stream and persistent posterior urethral dilatation on MCU; residual valves were refulgurated by laser. An indwelling catheter was left in only 4 patients, 2 of whom were primarily operated and 2 following refulguration. All except the first 2 were treated as out-patients. Application of the Nd:YAG laser has added a new dimension for treating PUV. The initial experience has been very encouraging: the destruction of valves is precise, there are no complications, and it can be practised on a day-care basis without indwelling catheterisation. The bare fibre can be used repeatedly, thus reducing the cost of treatment.

A Multicenter Study of Tension-Free Vaginal Tape (TVT) for Surgical Treatment of Stress Urinary Incontinence

The aim of the study was to evaluate the safety and efficacy of TVT (tension-free vaginal tape) for the surgical treatment of stress urinary incontinence. The design was a prospective open multicenter study including six centers, each operating an approximately 20 patients. In total 131 patients suffering from genuine stress incontinence were included. They were followed for at least 1 year using a specific protocol for objective and subjective evaluation of the outcome. All patients underwent the operation under local anesthesia. Mean operation time was 28 minutes (range 19–41 minutes); 119 (91%) of the patients were cured according to the protocol and another 9 (7%) were significantly improved. There were 3 (2%) failures. The majority of the patients (about 90%) were operated upon on a day-care basis, which implied that they were released from the hospital within 24 hours, with no postoperative catheterization. No defect healing and no tape rejection occurred. Three patients needed an indwelling catheter for 3 days. In 1 patient catheterization was necessary for more than 10 days. Two uncomplicated hematomas and one uncomplicated bladder perforation occurred. Based on the results, we conclude that TVT is a safe and effective ambulatory procedure for surgical treatment of genuine stress urinary incontinence.

Child psychiatric day treatment centers in Quebec for children 0-12 years of age

The review lists the child psychiatry day-care centres in Quebec, evaluates their capacity, and describes them according to the age range for admission, the psychopathologies treated, and the parent involvement required. The 26 programs selected, which are all associated with a hospital centre, assess and treat children aged 0 to 12 years on a day-care basis. Organization, clinical operation, and research are addressed during a semisupervised interview. The average capacity is 18 children (4 to 40), with a total capacity of 454 children. The number of preschool patients can be compared with the number of school patients. Few programs are dedicated to invasive development disorders, and one-third treat behavioural or emotional disorders. The larger capacity programs treat patients of both genders. Most programs are eclectic and encourage but do not require parental involvement. Results take into account different theoretical influences, the controversy about integration criteria and parent involvement, and the specificity of the child psychiatry mission.

Postoperative Patient-Controlled Local Anesthetic Administration at Home

Postoperative Patient-Controlled Local Anesthetic Administration at Home

Treatment for Advanced Hepatocellular Carcinoma by Transarterial Chemotherapy Using Reservoirs or One-Shot Arterial Chemotherapy

A prospective trial was performed in patients with advanced hepatocellular carcinoma to assess the therapeutic efficacy of transcatheter arterial chemotherapy using implanted reservoirs (12 patients) or conventional transcatheter arterial chemotherapy (8 patients). Epirubicin at a dose of 40 mg/m2 was given every month in the former, while epirubicin at a dose of 60 mg/m2 was administered every 3 months in the latter. During the 6 months from the introduction of these therapies, hospitalized periods were shorter and total hospital costs were less in the reservoir group than in the conventional chemotherapy group (p<0.05 and p<0.01, respectively). Transcatheter arterial chemotherapy using implanted reservoirs can be carried out on a day-care basis and may be beneficial for the treatment of patients with advanced hepatocellular carcinoma.

Pratique de l'anesthésie ambulatoire dans un CHU : ce qui est fait, ce qui pourrait être fait

To estimate the number and type of patients, who could be managed on a day-care basis in a University Hospital. Cases of ambulatory anaesthesia (AA) which could be managed in optimal conditions and current AA practice. To assess patients' opinion on inpatient or outpatient practices. Prospective survey over 8 weeks in 21 medical units potentially concerned by ambulatory practice. Series of 1,396 patients undergoing an operation included in a previously established list of outpatient procedures. A questionnaire was completed for each patient, from preoperative anaesthesia consultation until discharge. Thereafter patients were contacted after home discharge by telephone or mail. In the group of the 1,396 selected patients, 301 (22%) were contra-indicated for AA. In optimal conditions AA was indicated in 20% of all patients treated in these units. At the time of the survey there were 285 outpatients (26% of potential AA, 5% of all patients). Complications were uncommon. Ninety-eight percent of them would choose day surgery again. Among the 810 inpatients, 279 responded: 53% would prefer to be an ambulatory patient. At the time of this survey only one fourth of the possible oupatients for AA had in fact been treated on a day-case basis. Its development requires an improvement of the structures, team organisation and patients' information.

Day-case adenoidectomy — safety and cost effectiveness

In order to evaluate the safety, economics and cost effectiveness of performing adenoidectomy as a day-case surgical procedure, collected data from theatre register, medical and nursing case notes were analysed with the safety results and costings were detailed of day-care cases in relation to inpatient results. Over the 2 yr period between October 1991 and September 1993 out of 2229 ear, nose and throat (ENT) procedures, 993 were day cases under the care of one consultant surgeon where the procedures were carried out by senior house officers, staff grade, clinical assistant and the consultant. Of these, 332 intended day-case adenoidectomies were performed either as part of multiple day-case procedures, 310 cases; or adenoidectomy alone, 22 cases. The age range was 2–15 yr. A morbidity rate of 16.57% (55 cases) requiring overnight stay was recorded, mainly due to clinical or social reasons. No cases of bleeding requiring return to theatre and no mortalities were reported. The calculated cost of treating the 332 patients on an intended day-care basis, less 55 cases kept overnight, has shown that a saving of over £27500 per annum over the cost of inpatient treatment is attainable by one surgical firm. It is concluded that performing adenoidectomy as a day-case compared with inpatient procedure is surgically and clinically safe with no mortality and minor morbidity and is also cost effective with an average saving of 43.6%.

Induction of second trimester abortion with mifepristone and gemeprost

Objective To determine the efficacy of a new regimen of the antiprogestogen mifepristone and gemeprost for midtrimester abortion. Design Prospective study. Setting Medical Termination Unit, Simpson Memorial Maternity Pavilion, Edinburgh. Subjects One hundred women undergoing midtrimester abortion. Interventions Women were pretreated with 200 mg mifepristone 36 h before prostaglandin; 1 mg gemeprost was administered every 6 h for the first 24 h. If abortion had not occurred, 1 mg gemeprost was administered 3 hourly over the next 12 h. Measurement and main results Ninety-six percent and 99% women aborted within 24 h and 48 h, respectively. The median prostaglandin-abortion interval was significantly shorter in multigravidae compared to primigravida (6.6 vs 8.2 h, P<0.01). The median number of gemeprost pessaries to induce abortion was only two and 47% of women required one pessary. The incidence of vomiting and diarrhoea was 31% and 5%, respectively. Eighty-four percent of women required intramuscular diamorphine for analgesia. Thirty-three percent of women required an evacuation of the uterus following abortion. Conclusions The shortened induction-delivery interval following pretreatment with mifepristone makes it possible to conduct midtrimester abortion on a daycare basis.

Induction of second trimester abortion with mifepristone and gemeprost.

To determine the efficacy of a new regimen of the antiprogestogen mifepristone and gemeprost for midtrimester abortion. Prospective study. Medical Termination Unit, Simpson Memorial Maternity Pavilion, Edinburgh. One hundred women undergoing midtrimester abortion. Women were pretreated with 200 mg mifepristone 36 h before prostaglandin; 1 mg gemeprost was administered every 6 h for the first 24 h. If abortion had not occurred, 1 mg gemeprost was administered 3 hourly over the next 12 h. Ninety-six percent and 99% women aborted within 24 h and 48 h, respectively. The median prostaglandin-abortion interval was significantly shorter in multigravidae compared to primigravida (6.6 vs 8.2 h, P < 0.01). The median number of gemeprost pessaries to induce abortion was only two and 47% of women required one pessary. The incidence of vomiting and diarrhoea was 31% and 5%, respectively. Eighty-four percent of women required intramuscular diamorphine for analgesia. Thirty-three percent of women required an evacuation of the uterus following abortion. The shortened induction-delivery interval following pretreatment with mifepristone makes it possible to conduct midtrimester abortion on a daycare basis.

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

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