Office-based Procedures Research Articles

Improving Laryngeal Procedure Workflow: Moving From the Operating Room to the Outpatient Setting.

Laryngology disease burden is growing while theater capacity is falling. Over half a million patients are waiting for ENT care in England alone (1). The demand for laryngology services has continued to grow significantly, particularly post-COVID (2). Meanwhile, the number and efficiency of ENT theater lists are reduced (3). To tackle the growing backlog, NHS England has emphasized the need for innovative strategies by separating elective from emergency services and by increasing the resilience of elective delivery (4). The establishment of an office-based laryngology procedure clinic is a potential solution. We offer a narrative review and audit of our experience in founding an in-office laryngology procedure service within a tertiary NHS center with the aim of streamlining this setup process for other interested ENT units. We outline an in-depth exploration of the personnel, equipment, and processes necessary to establish an in-office procedure clinic. Our experience showed that the procedure clinic functions well when implemented within the framework of existing ENT elective and emergency services. Although there is initial investment required in terms of money, effort, and time, our outcomes show that the clinical and economic benefits of the clinic outweigh the costs, also allowing for patients to access investigations and treatments reliably and efficiently. Setting up a laryngology in-office procedure clinic within the NHS confers patient, organizational, and economic benefits. It provides a novel and resilient approach in addressing the growing backlog of patients awaiting laryngology care and should be popularized in the current health care environment. Level 4 Laryngoscope, 2024.

Defining the urology nurse practitioner in Australia and New Zealand: A Delphi study.

Nurse practitioners with roles in specialty environments face challenges including uncertain role expectations and achieve urology expertise with on-the-job training, mentoring, and independent study. This creates a wide variety of preparation and role descriptions. This study employed Delphi methodology to identify essential components of the urology nurse practitioner (NP) role in Australia and New Zealand, representing an inaugural description of the role. This Delphi study was completed in two rounds. Participants were a nonrandom panel of experts with experience as a full-time urology NP. A definition for the urology NP in Australia and New Zealand is proposed: "The urology nurse practitioner uses critical thinking, complex decision-making, clinical reasoning, advanced assessment skills and clinical expertise, offering acute and chronic care to individuals needing urologic health care, including office-based urology procedures as appropriate. This care is provided in an environment of autonomous practice, with a basis of graduate education and relevant specialty clinical experience, and this practice can extend across health care settings and serve as a model to the wider NP profession." Outpatient urology procedures were ranked highly and deemed integral to the Urology NP role. This may reflect the declining number of urologists and efforts to maintain urology access for local populations. Professional roles of the NP were given less weight by participants. The project offers a contemporary definition of the urology NP role that can be offered to educators and other stakeholders as the role continues to evolve in Australia and New Zealand.

National Trends in Laryngeal Laser Surgery: Comparison of Operative Versus Office-Based Procedures.

To analyze national trends in the prevalence of office-based laryngeal ablative procedures and compare those with traditional operative excisional procedures utilizing direct laryngoscopy. For years 2013-2022, the US Medicare Part B claims database was searched for Current Procedural Terminology (CPT) codes 31572 (flexible laryngoscopy with laser ablation of lesion), 31540 (operative direct laryngoscopy with excision of lesion), 31541 (operative direct microlaryngoscopy with excision of lesion), and 31545 (operative direct microlaryngoscopy with excision of lesion and local tissue flap reconstruction). For each CPT code, the total number of charges billed to the Medicare database in each calendar year was recorded and annual trends were analyzed. Biopsy procedures were not included. The annual number of office-based laser procedures (CPT 31572) remained relatively constant since the CPT code was introduced in 2017 (range: 18887-25241 procedures annually, trendline slope = +16, R2:0.02). Office-based laser procedures comprised a small portion of total laryngeal excisional procedures (range: 8.4%-12.1%). The total number of operative laryngeal excisions, billed by CPT 31540 and 31541, declined over the studied time frame (Trendline slope = -132, R2:0.93; Trendline slope = -950, R2: 0.93 respectively). Office-based laser procedures comprise a small fraction of procedures to remove laryngeal lesions. The number of office-based laser procedures has been relatively stable over the last 5 years. This finding contrasts with the prevailing health care trend toward office-based procedures. Further research is needed to understand the decrease in operative laryngeal lesion excision procedures observed over the last 10 years. 4 Laryngoscope, 2024.

Treatment of Hemorrhoidal Disease in Patients with Liver Cirrhosis: A Systematic Review

<b><i>Introduction:</i></b> The incidence of hemorrhoidal disease (HD) in cirrhotic patients is similar to that of general population, varying between 21% and 79%. Managing this clinical condition in these patients is challenging, due to the need to differentiate between bleeding originating from hemorrhoids or anorectal varices, and the unique hemostatic balance of each patient, which can lead to a decompensation of liver function and subsequently increase the anesthetic risk. To date, there are no systematic reviews specifically addressing this topic. <b><i>Methods:</i></b> This was a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were retrieved from three electronic databases. Efficacy (symptomatic improvement, patient satisfaction, quality of life improvement, disease recurrence/need for surgery and/or hemorrhoidal prolapse reduction in anoscopy) and safety (reported adverse events) outcomes were evaluated. Data from each study were initially described individually, followed by a comparative analysis for procedures applied in multiple studies. <b><i>Results:</i></b> Six studies were included – 1 randomized clinical trial (RCT), 2 prospective cohort studies, 1 retrospective cohort study, and 2 case series. The considered techniques encompassed rubber band ligation (RBL), injection sclerotherapy (IS) using 3 agents – aluminum potassium sulfate and tannic acid (ALTA), ethanolamine oleate 5% (EAO), or N-butyl-cyanoacrylate, hemorrhoidopexy, and emborrhoid technique. RBL showed great symptomatic improvement and patient satisfaction in 63% and 73% of patients, respectively, and in 90% was associated with one-grade prolapse reduction after only one session. The most frequently reported adverse events included pain (16%) and ulceration/fissure (1–17%). Concerning IS, symptomatic improvement was observed in all patients. Recurrence rates varied with the agent used (EAO: 13% at 12 months; N-butyl-cyanoacrylate: 40% at 12 months; ALTA: 18% at 5 years), and 86.7% of patients exhibited more than one-grade reduction after the initial session. The most frequent adverse event was pain (EAO: 63%; N-butyl-cyanoacrylate: 60%). Stapled hemorrhoidopexy resulted in symptomatic improvement in all patients, although associated with a recurrence rate of 25% within 4 months. With an emborrhoid technique, 80% of the patients showed clinical improvement at a 3-month follow-up, without significant adverse events, at the cost of a 40% recurrence rate. <b><i>Conclusions:</i></b> All the treatment methods assessed in the included studies appear to be effective and safe in cirrhotic patients. This assumption challenges previous concerns regarding significant bleeding after office-based procedures like RBL in this population. Future research should prioritize RCT to thoroughly assess the management of HD in these patients, particularly addressing polidocanol foam sclerotherapy, a minimally invasive technique that has previously been shown to be more effective than RBL in the general population and in patients with bleeding disorders.

Impact of the in-office surgical activity on the classical phonomicrosurgical interventions in a laryngology referral center.

Office-based laryngology procedures evolved in the recent years with all the technology advances and have gained popularity among laryngologists. The indications enlarged, making it a valid surgical option for almost all voice disorders. This emerging technique raise the question of the place left for traditional phonosurgeries in the operating room under general anesthesia. We reviewed our surgical activity in our laryngology referral center from 2018 to 2023. Since we started the in-office procedures in 2018, the number of these interventions significantly increased, accompanying a significant increase in our total surgical activity. We noted no significant decrease in the number of interventions done in the operating room, which made us consider the office-based procedures as a complimentary and not a competitive option for traditional surgeries, helping us increase our total number of interventions, and thus offer patients more opportunities for a quicker medical care. Our register review showed also a change of treatment trends for unilateral vocal fold paralysis, with office-based interventions becoming the first-line treatment.

Recurrent respiratory papillomatosis: comparing in-office and operating room treatments.

We report the management of recurrent respiratory papillomatosis (RRP) employing a protocol that includes both office-based (OB) and general anaesthesia (GA) procedures. Quality of life (QoL) outcomes in the OB cohort were compared to those obtained from an historical cohort treated only under GA. Patients affected by RRP from 2019 until 2023 ("new protocol") and from 2012 to 2019 ("historical protocol") were enrolled. In both groups the Derkay site score (DSS) was calculated. In patients adhering to the new protocol, questionnaires measuring QoL were prospectively administered (voice handicap hindex-10 [VHI-10] along with a specific questionnaire to measure the tolerance to the OB procedures). A cost analysis was also performed. In all, 35 patients composed the new protocol cohort and 13 the historical. In the first group, patients underwent a median of 4 treatments. At 2 years, 68% of patients were treated exclusively in the office. Overall, for the new protocol, median DSS and VHI-10 after one year were both significantly lower than those at baseline [2 vs 4 and 3 vs 14, respectively; p < 0.001]. No differences were found between the new and the historical protocol cohorts considering DSS over time. Treatment of RRP may be conducted successfully in an office-based setting reducing healthcare costs.

Preprocedural Paracetamol Reduces Pain Scores in Patients Undergoing in-Office Laryngeal Procedures.

To investigate the utility of preprocedural paracetamol on reducing pain scores post office-based laryngeal procedures. Prospective, controlled before-after comparative study. Controlled prospective before-after study. A retrospective analysis was performed of 100 patients who underwent office-based laryngeal procedures without preprocedural analgesia at our center to establish a control group. Age, sex, procedure type, and amount of substance used were documented as well as postprocedural pain score. Pain scores were recorded every 5 minutes for 30 minutes following office-based laryngeal procedures. A prospective arm of this study was then performed in which every patient undergoing office-based laryngeal procedures at our center between September 2019 and December 2020 was administered 1000 mg of paracetamol prior to their procedure. The postprocedure pain scores of the 2 groups were then compared. A hundred patients were included in the retrospective arm and 75 patients were included in the prospective arm, receiving 1000 mg of paracetamol a median of 45 (interquartile range: 30-53) minutes prior to their procedure. The 2 groups were matched for age, sex, and type of laryngeal procedure. Both nonanalgesia and analgesia groups demonstrated a similar proportion of patients who experienced any pain (47% and 48%, respectively) postprocedurally. The prospective arm of this study however reported a statistically significant reduction in the magnitude of their pain scores at all points postprocedurally (P = .005). Paracetamol preprocedurally reduces the severity of pain in office-based laryngeal procedures and would be a useful consideration for patients who are likely to experience significant postprocedural pain. Level 3.

Efficacy of EMLA for Office-based Andrology Procedures Under Local Anesthesia: A Randomized Control Trial

ObjectiveTo evaluate the effectiveness of Eutectic Mixture of Local Anesthetic (EMLA), a topical anesthetic cream, in office-based invasive andrological procedures such as hydrocelectomy, spermatocelectomy, and others, aimed at minimizing pain perception and enhancing the overall patient experience. MethodsA double-blinded randomized controlled trial was conducted for patients undergoing scrotal andrology surgeries under LA. Power calculation was performed with an estimated sample size of 72. Participants were randomly assigned in a 1:1 ratio to topical EMLA + LA vs LA alone. In the post-operative recovery area, patient will be asked to complete a VAS questionnaire rating pain with LA administration and pain with procedure. Analysis comparing VAS pain scores of both groups was performed using the independent sample t-test method. Results72 patients were included in our analysis, with 36 in the control and 36 in the intervention arm. For patient pain with administration of LA, the control arm reported an average VAS pain score of 4.31, compared to 3.72 in the intervention arm (p=0.319). For patient pain with procedure, patients in the control arm reported a median VAS pain score of 3.47 compared to 3.03 (p=0.432) in the intervention arm. Overall, 86% (62/72) of patients reported that they would either be “very likely” (4/5) or “highly likely” (5/5) to undergo future procedures under local anesthetic. ConclusionsWhile performing scrotal surgeries under LA appears to be well tolerated and a feasible option, the application of EMLA cream does not appear to significantly alter patient-reported outcomes.

Office-based pediatric urology procedures.

Office-based procedures under local anesthesia are not a popular and well-accepted concept in pediatric urology except for newborn circumcision. There is limited literature on the utilization of office-based procedures under local anesthesia in pediatric urology. In this study, we present our experience of office-based procedures under local anesthesia from a tertiary center. This is a retrospective study of the patients who underwent meatotomy and penile adhesion release in the clinic under local anesthesia between January 2017 and August 2022 by a single surgeon in a tertiary center. A total of 92 patients were included in this study. There were 65 patients diagnosed with meatal stenosis and 27 patients diagnosed with penile adhesion. The overall incidence of recurrence was noted in four patients. Only one patient had minimal complications. The overall average follow-up was 5.39 months (1-10 months). Selective office-based procedure (meatotomy and penile adhesion release) under topical local anesthesia is a simple, safe, and effective method to treat such conditions with a high success rate, especially with financial and time constraints on health care nowadays.

WALANT office based endoscopic cubital tunnel release

Background: Cubital tunnel syndrome is a common condition caused by compression of the ulnar nerve around the medial elbow. Surgical treatment usually involves open in situ ulnar nerve decompression unless ulnar nerve instability is noted. Endoscopic techniques for cubital tunnel release have been developed and implemented with excellent patient and surgeon satisfaction. Endoscopic cubital tunnel release can be performed in an office based procedure room under wide awake local anesthesia no tourniquet principles. We present our setup and technique for performing an endoscopic cubital tunnel release procedure in an office based setting under local anesthesia. Methods: Local anesthesia is injected along the course of the ulnar nerve on the medial arm and forearm extending 10 cm proximal and distal to the medial epicondyle. After allowing approximately 30 min for appropriate vasoconstriction, the patient is placed in a supine position with the arm abducted and externally rotated position. The endoscopic cubital tunnel release is then performed. Discussion: Our described technique eliminates the need for placement of a prophylactic tourniquet and thereby the need for the procedure to be performed within an OR setting. It also utilizes a single-stage anesthetic administration, which facilitates ease of completion and performance in an office based setting. There is a significant cost savings when endoscopic cubital tunnel release is performed in an office-based procedure room compared to in the operating room. Conclusions: Office-based endoscopic cubital tunnel release can be safely performed utilizing WALANT techniques, leading to high patient satisfaction and decreased overall cost of care. Level of Evidence: Therapeutic IV

Augmented and Virtual Reality Applications in Rhinology: A Scoping Review.

Virtual reality (VR) and augmented reality (AR) are innovative technologies that have a wide range of potential applications in the health care industry. The aim of this study was to investigate the body of research on AR and VR applications in rhinology by performing a scoping review. PubMed, Scopus, and Embase. According to PRISM-ScR guidelines, a scoping review of literature on the application of AR and/or VR in the context of Rhinology was conducted using PubMed, Scopus, and Embase. Forty-nine articles from 1996 to 2023 met the criteria for review. Five broad types of AR and/or VR applications were found: preoperative, intraoperative, training/education, feasibility, and technical. The subsequent clinical domains were recognized: craniovertebral surgery, nasal endoscopy, transsphenoidal surgery, skull base surgery, endoscopic sinus surgery, and sinonasal malignancies. AR and VR have comprehensive applications in Rhinology. AR for surgical navigation may have the most emerging potential in skull base surgery and endoscopic sinus surgery. VR can be utilized as an engaging training tool for surgeons and residents and as a distraction analgesia for patients undergoing office-based procedures. Additional research is essential to further understand the tangible effects of these technologies on measurable clinical results. Laryngoscope, 134:4433-4440, 2024.

Office-based Oculoplastic Procedures That Make a Difference!

Office-based Oculoplastic Procedures That Make a Difference!

Imaging for Hemorrhoidal Disease: Navigating Rectal Artery Embolization from Planning to Follow-up.

Hemorrhoid disease is very common, affecting greater than one-third of adults. Conservative management and several office-based procedures are useful in the treatment of internal hemorrhoids. Patients with refractory hemorrhoid disease have traditionally been treated with surgical hemorrhoidectomy. Rectal artery embolization has emerged as an alternative to surgical hemorrhoidectomy and has been shown to be safe and effective in case series and clinical trials completed over the past decade. Embolization has significantly less postprocedure pain when compared with surgical hemorrhoidectomy with similar outcomes. Pre- and postprocedure imaging are not routinely performed. Intraprocedural imaging consists of selective catheterization of the superior rectal arteries from the inferior mesenteric artery, and the middle rectal arteries from the internal iliac artery. The inferior rectal artery is seldom embolized due to the supply of the levator ani muscle and skin. To date, intermediate and large particles and fibered and nonfibered coils have been used successfully.

Mindfulness in Facilitating Pelvic Floor Botulinum Toxin Injection in Women with Chronic Pelvic Pain.

Botulinum toxin (BoNT) injection can safely be done as an office-based procedure, but can be painful itself, especially when injecting pelvic floor muscles to treat chronic pelvic pain (CPP). Mindfulness interventions may reduce procedure-associated acute anxiety and pain. We applied mindfulness techniques to increase the tolerability of office-based pelvic floor BoNT injections in women with CPP. Women enrolled in a clinical trial of BoNT for endometriosis-associated CPP were offered a brief, guided mindfulness session before and/or after transvaginal injection. Anxiety, pain, and dysphoria were rated on a 0-10 numerical rating scale (NRS) before and after each mindfulness session. Eight women underwent mindfulness sessions. Five participants had a session before and two after the transvaginal injection. One participant had two sessions: one before and one after separate injections. All six women completing a session prior to injection had at least moderate anxiety, which lessened after the mindfulness session (median NRS change: -3.3/10). All three women reporting injection-associated pain experienced less intense pain following the post-injection session (median NRS change: -3/10). Three women experiencing dysphoria improved after the session (median NRS change: -3/10). A brief, guided mindfulness session may lessen acute pain, anxiety, and dysphoria associated with office-based transvaginal BoNT injection.

Family Physicians as Proceduralists for Medicare Recipients.

Procedures are manual technical skills clinicians perform for their patients. Family physicians (FPs) acquire these skills during residency; most are undertaken in outpatient settings. We performed a retrospective observational cohort study to describe the extent to which FPs perform the core procedures recommended by the Council of Academic Family Medicine (CAFM) and how this might have changed over time. The CAFM recommended a list of procedures all FP residents should perform competently after graduation. We modified this list for Medicare beneficiaries to enable matching with Current Procedural Terminology codes. We probed Medicare Part B databases for modified CAFM procedure claims submitted by FPs in 2021 and how these claims changed from 2014 to 2021. In 2021, there were 904,278 modified CAFM procedures filed by 9,410 FPs in the outpatient setting. All procedures were clustered with respect to organ system (eg, musculoskeletal, skin, pulmonary). Beginning in 2014 and continuously through 2021, there was a 33% decrease in outpatient procedures filed and a 36% decrease in the number of FPs filing them. Office-based procedures are integral to a primary care physician's role, although the activity is rarely analyzed. At a time when the Medicare population is growing, the number of available FPs and the number of procedures they perform are not. This decrease might result from the changing scope of FP practice, new referral patterns, task shifting, and/or increased delegation to physician associates and nurse practitioners.

Pediatric Plastic Surgery Under Local Anesthesia.

Increasing research has shown that select surgical procedures can be performed in an office-based environment with low complication rates. Within the field of plastic surgery, these findings have mainly been studied in adult populations. However, studies regarding the safety and efficacy of office-based plastic surgery in the pediatric population are lacking. In the present study, we demonstrate that appropriately selected office-based pediatric plastic surgery procedures can be performed under local anesthesia for a variety of common surgical indications with low complication rates. A retrospective case series of pediatric plastic surgery patients who underwent in-office procedures under local anesthesia at a single academic institution from September 2014 to June 2020 was performed. Five hundred nine patients were treated in an office setting for various etiologies over the study period. A total of 48.9% of the patients were male and 51.1% were female. Patient age at time of procedure ranged from 24 days to 17 years of age with a median age of 13 years. A total of 778 lesions were treated. There were 10 total complications (1.29%) over the study period with only one surgical site infection that resolved with antibiotic treatment. Our work indicates that select pediatric plastic surgery procedures can be performed under local anesthesia with low complication rates.

Usage of Virtual Reality Headsets During Office-Based Procedures to Lower Patient Anxiety and Pain

Usage of Virtual Reality Headsets During Office-Based Procedures to Lower Patient Anxiety and Pain

Assessing the safety and tolerability of rhinologic surgery under local anesthetic: an 8-year retrospective analysis.

Office-based rhinologic procedures (OBRP) have become widely available in North America due to technological advances and appropriate patient selection. Nevertheless, the literature exploring the safety of these procedures remains limited. The objective of this study was to further evaluate the safety, tolerability and efficacy of these procedures with a more robust sample size to allow for capture of rare events. A retrospective chart review of all patients who underwent OBRP from May 2015 to March 2023. Information regarding patient demographics, the indication for surgery, wait time, tolerability, intra- and postoperative complications, need for revisions, and type of revision (if applicable) was recorded. 1208 patients underwent OBRP during the study period. No patients were excluded. These included turbinoplasties (35%), endoscopic sinus surgeries (ESS) (26%), septoplasties (15%), nasal fracture reductions (7%), and a variety of other procedures. For ESS procedures, the anterior ethmoids and the maxillary sinuses were the most common sinuses treated. 1.1% of procedures were aborted prior to completion. The post-operative complication rate was 3.2%, with 2 major complications (significant bleeding and sepsis) encountered. The mean follow-up overall was 11months and for ESS it was 15.8months. Office-based rhinologic procedures are well tolerated and safe for the appropriate patient and associated with shorter wait-times as well as avoidance of general anesthesia. The complication rates are similar to or lower than previously reported rates for rhinologic surgeries done in the operating room. The low rates of revision surgery also demonstrate the efficacy of these procedures.

Workflow and Patient Satisfaction in Treating Peripheral Arterial Disease in the Office-Based Setting

Contemporary concepts in health care reform promote a shift in the provision of care away from hospitals in favor of the more cost effective and efficient use of outpatient facilities including ambulatory surgery centers and office-based procedure centers particularly in the care of cardiovascular disease. This article reviews the experience of patients and specialists in caring for patients with peripheral arterial disease in an office-based care setting.

A Review of 1228 In-Office Hand Surgery Procedures With Wide Awake Local Anesthesia No Tourniquet (WALANT) at a Single Private Practice.

This study examined the complication rate of Wide Awake Local Anesthesia No Tourniquet (WALANT) technique in the clinic setting with field sterility at a single private practice. We hypothesized that WALANT is safe and effective with a low complication rate. This retrospective chart review included 1228 patients who underwent in-office WALANT hand procedures at a single private practice between 2015 and 2022. Patients were divided into groups based on type of procedure: carpal tunnel release, A1 pulley release, first dorsal compartment release, extensor tendon repair, mass excision, foreign body removal, and needle aponeurotomy. Patient demographics and complications were recorded; statistical comparisons of cohort demographics and risk factors for complications were completed, and P < .05 was considered significant for all statistical comparisons. The overall complication rate for all procedures was 2.77% for 1228 patients including A1 pulley release (n = 962, 2.7%), mass excision (n = 137, 3.7%), extensor tendon repair (n = 23, 4.3%), and first dorsal compartment release (n = 22, 8.3%). Carpal tunnel release, foreign body removal, and needle aponeurotomy groups experienced no complications. No adverse events (e.g. vasovagal reactions, digital ischemia, local anesthetic toxicity, inadequate vasoconstriction) were observed in any group. Patients with known autoimmune disorders and those who were currently smoking had a statistically significant higher complication rate. Office-based WALANT procedures with field sterility are safe and effective for treating common hand maladies and have a similar complication profile when compared to historical controls from the standard operating room in an ambulatory center or hospital.