Outpatient Procedure Research Articles

Dental trauma in endoscopy: A systematic review and experience of a tertiary endoscopy centre.

Dental injury is the leading cause of litigation in anaesthesia but an underrecognized preventable complication of endoscopy. To determine frequency and effects of dental injury in endoscopy, we present findings from an audit of outpatient endoscopy procedures conducted at a tertiary university hospital and a systematic review of literature. Retrospective review of 11265 outpatient upper endoscopy procedures over the period of 1 June 2019 to 31 May 2021 identified dental related complications in 0.284% of procedures. Review of literature identified a similar rate of 0.33%. Pre-existing dental pathology or the presence of prostheses makes damage more likely but sound teeth may be affected. Pre-endoscopic history and tooth examination are key for risk stratification and may be conducted succinctly with limited time outlay. Tooth retrieval should be prioritized in the event of dental injury to minimize aspiration and be followed by prompt dental consultation for specific management. Dental complications occur in approximately 1 in 300 of upper endoscopy cases. These are easily preventable by pre-endoscopy screening. Protocols to mitigate dental injury are also suggested.

Opioid Use, Disposition, and Parent Satisfaction Following Common Pediatric Surgical Procedures.

There is wide variability in prescribing practices among providers, even for patients undergoing the same operations. Our study aims to analyze the variation in opioid prescription practices using a patient-centered approach to establish more appropriate prescribing guidelines for health care providers. We conducted phone surveys 30days after surgery to assess patient-reported opioid use. Over a two-year collection period, we identified patients that had undergone common outpatient pediatric surgery procedures in our 4-surgeon group. Included in the survey tool was the narcotic prescribed (if any), the amount used, and patient/family rating of pain control. We collected data for 189 separate procedures (88 umbilical hernias, 30 laparoscopic inguinal hernias, 2 open inguinal hernias, 41 appendectomies, 15 laparoscopic cholecystectomies, and 13 pectus bar removals). Patient age ranged from less than 1month to 246months. 83.5% of patients had a narcotic prescribed. The average number of doses used was 4, ranging from 0 (11.3%) to 30 (1.5%). 72.6% of families surveyed felt pain control was appropriate. However, 19.6% did feel they received too much pain medication. 10.6% reported completing their entire prescription; however, only 13.6% of families with excess narcotics reported proper disposal. Despite heightened awareness of the opioid epidemic, there is still a poor understanding of appropriate pain control regimens in the pediatric surgical population. We demonstrate that most patients are discharged home with excess opioids and that many families save the leftover pills/liquid. Further research and education are encouraged to limit the use of opioids in standard pediatric surgical procedures.

Outpatient compared to inpatient thyroidectomy on 30-day postoperative outcomes: a national propensity matched analysis

BackgroundTo address the postoperative outcomes between outpatient and inpatient neck surgery involving thyroidectomy procedures.MethodsA cohort analysis of surgical patients undergoing primary, elective, total thyroidectomy from multiple United States medical institutions who were registered with the American College of Surgeons National Surgical Quality Improvement Program from 2015 to 2018. The primary outcome was a composite score that included any 30-day postoperative adverse event.ResultsA total of 55,381 patients who underwent a total thyroidectomy were identified comprising of 14,055 inpatient and 41,326 outpatient procedures. A cohort of 13,496 patients who underwent outpatient surgery were propensity matched for covariates with corresponding number of patients who underwent inpatient thyroidectomies. In the propensity matched cohort, the occurrence of any 30-day after surgery complications were greater in the inpatient group, 424 out of 13,496 (3.1%) compared to the outpatient group, 150 out of 13,496 (1.1%), P < 0.001. Moreover, death rates were greater in the inpatient group, 22 out 13,496 (0.16%) compared to the outpatient group, 2 out of 13,496 (0.01%), P < 0.001. Similarly, hospital readmissions occurred with greater frequency in the inpatient group, 438 out of 13,496 (3.2%) compared to the outpatient group, 310 out of 13,496 (2.3%), P < 0.001.ConclusionThyroidectomy procedures performed in the outpatient setting had less rates of adverse events, including serious postoperative complications (e.g., surgical site infection, pneumonia, progressive renal insufficiency). In addition, patients who had thyroidectomy in the outpatient setting had less 30-day readmissions and mortality. Surgeons should recognize the benefits of outpatient thyroidectomy when selecting disposition of patients undergoing neck surgery.

Anesthesia Workspaces for Safe Medication Practices: Design Guidelines.

Studies show that workspace for the anesthesia providers is prone to interruptions and distractions. Anesthesia providers experience difficulties while performing critical medication tasks such as medication preparation and administration due to poor ergonomics and configurations of workspace, equipment clutter, and limited space which ultimately may impact patient safety, length of surgery, and cost of care delivery. Therefore, improving design of anesthesia workspace for supporting safe and efficient medication practices is paramount. The objective of this study was to develop a set of evidence-based design guidelines focusing on design of anesthesia workspace to support safer anesthesia medication tasks in operating rooms (ORs). Data collection was based on literature review, observation, and coding of more than 30 prerecorded videos of outpatient surgical procedures to identify challenges experienced by anesthesia providers while performing medication tasks. Guidelines were then reviewed and validated using short survey. Findings are summarized into seven evidence-based design guidelines, including (1) locate critical tasks within a primary field of vision, (2) eliminate travel into and through the anesthesia zone (for other staff), (3) identify and demarcate a distinct anesthesia zone with adequate space for the anesthesia provider, (4) optimize the ability to reposition/reconfigure the anesthesia workspace, (5) minimize clutter from equipment, (6) provide adequate and appropriately positioned surfaces for medication preparation and administration, and (7) optimize task and surface lighting. This study finds many areas for improving design of ORs. Improvements of anesthesia work area will call for contribution and cooperation of entire surgical team.

Inpatient vs outpatient arthroplasty: A in-state database analysis of 90-day complications

IntroductionAn increase in the number of policy initiatives, such as alternative payment models, have prompted healthcare providers to examine health-care expenditures while seeking to improve quality of care. Performing total joint arthroplasty (TJA) in the outpatient setting is an attractive option in driving costs down and providing psychological benefits to patients. Concerns regarding the safety and effectiveness of same-day discharge protocols warrants further investigation, especially on the state level. Due to the lack of consensus, we aimed to compare: (1) risk factors for outpatient arthroplasty and (2) incidences of postoperative complications between inpatient vs outpatient arthroplasty using an in-state database. MethodsPatients who underwent total knee or hip arthroplasty between January 1, 2022 and December 31, 2022 were identified. Data was drawn from the Maryland State Inpatient Database (SID) and Maryland State Ambulatory Surgery and Services Database (SASD). A total of 7817 patients had TJA within this time. Patients were divided into inpatient arthroplasty (n = 1429) and outpatient arthroplasty (n = 6338). Demographic variables, medical comorbidities, and 90-day complication rates were compared between inpatient and outpatient procedures. Additional independent variables included: marital status, primary language, race, and median household income. A multivariate logistic regression analysis was performed to identify independent risk factors for complications following TJA after controlling for risk factors and patient comorbidities. ResultsArthroplasty in the outpatient setting were more likely to be married (61.3% vs. 51.2%, p < 0.001), white (75.5% vs. 60.9%, <0.001), speak English as primary language (98.7% vs. 88.6%, p < 0.001), and have lower rates of diabetes (4.8% vs. 9.7%, p < 0.001), chronic obstructive pulmonary disease (16.3% vs. 21.8%, p < 0.001), and obesity (30.0% vs. 45.2%, p < 0.001) compared to arthroplasty in the inpatient setting, respectively. There were lower incidences of acute kidney injury (0.2 vs. 0.8%, p < 0.001) and infection (0.3% vs. 1.1%, p < 0.001) in the outpatient cohort compared to the inpatient cohort, respectively. Inpatient arthroplasty (Odds Ratio (OR) 1.98, 95% CI 1.30–3.02, p = 0.002) and hypertension (OR 2.12, 95% CI 1.23–3.64, p = 0.007) were independent risk factors for total complications following TJA. ConclusionArthroplasty in the outpatient setting showed fewer complications than compared to patients in the inpatient setting. Although multiple factors should guide the decision for arthroplasty, outpatient arthroplasty may be a safe option for select, healthier patients without the increased burden of increased complications.

Initiative for a shift from inpatient to outpatient treatment

Ashift from inpatient to outpatient treatment is necessary to offset the severe lack of nursing staff in Germany. Acentral role is played by the catalogue announced for outpatient surgical procedures, which will contain many formerly inpatient procedures. Context factors have been defined to make the decision for inpatient treatment more reproducible. In the end, the remuneration of outpatient procedures will decide whether the infrastructural changes will be successful in daily practice.

Efficacy of Loop Electrosurgical Excision Procedure in the Management of Cervical Intraepithelial Neoplasia (CIN) –in A Tertiary Level Hospital

Background: Cervical intraepithelial neoplasia (CIN) is the potentially premalignant transformation and abnormal growth of surface epithelial cells of the cervix. CIN is a precancerous condition and curable. Loop electrosurgical excision procedure (LEEP) is a simple, outpatient procedure of removing the transformation zone of cervix. The aim of our study was to evaluate the efficacy of large loop electrosurgical excision procedure (LEEP) as a treatment procedure for cervical intraepiethelial neoplasia. Methods: This prospective observational study was conducted at Colposcopy clinic of Bangabandhu Sheikh Mujib Medical University (BSMMU) from June, 2017 to May, 2019. All consecutive patients having colposcopicaly and histopathologicaly proven high grade lesion by colposcopy directed punch biopsy were included in this study. All eligible patients with high grade lesion were underwent LEEP and followed up on 15 days post-procedure, 6 months, 12 months with colposcopy. Results: Sixty (60) cases were undergone LEEP, among them 48 (80%) cases were diagnosed as CIN2 and 12 (20%) cases were CIN3 by colposcopy- directed biopsy. One patient (1.7%) needed hospital admission to controll intra-operative bleeding and in postoperative period 7 (11.7%) patients had mild to moderate post-operative bleeding which was controlled well after application of morsel’s pastes and electro-cautery, one patient (1.7%) had pelvic infection. On 6 months follow-up, in case of CIN2 patients, cure rate was 93.5% (43 of 46) and 1 (2.2%) patient had persistent CIN-2. Patient with persistent CIN2 had re-excision and followed up at 12 month with colposcopy. Among case of CIN-3, the cure rate was 81.8% (9 of 11) and 1 (9.1%) case had CIN2. P-value was 0.244, which was not statistically significant. Overall cure rate on 6 month follow-up was 91.2%. On 12 months follow-up cure rate for CIN2 was 97.8% and for CIN3 was 90.9%. Overall cure rate was 96.5%. P-value was 0.352, which was not statistically significant. Conclusion: Loop electrosurgical excision procedure (LEEP) has a good outcome as a diagnostic and treatment procedure for cervical intraepithelial neoplasia. Bangladesh Medical Res Counc Bull 2023; 49(2): 113-119

How we can improve the appropriateness of ambulatory gastrointestinal endoscopy: the lesson of the COVID-19 outbreak.

The coronavirus disease 2019 (COVID-19) outbreak has significantly modified hospital and outpatient activities. To assess the pandemic's impact on the appropriateness of outpatient gastrointestinal (G.I.) endoscopy in a southern Italy Region. Between 1 January 2019 and 31 December 2022, we compared the number, the type of activities, and the appropriateness of the G.I. endoscopy procedures in the four territorial gastroenterology and digestive endoscopy services of the Apulia region. In 2019, 11 173 outpatient procedures were provided, which dropped by about 44% (P < 0.05) during 2020. The endoscopic activity was slightly reduced during 2020 (-18.77%), while every other activity dropped significantly. During 2021-2022, the overall activities slightly increased but remained below the number of activities provided before the pandemic (P < 0.05). However, the endoscopic activity increased by +6.86% from 2019 to 2022, mainly due to more colonoscopies. During the 4 years analysed, the overall appropriateness rate of the endoscopic examinations increased during 2020 (2019: 67%; 2020: 81%) while dropping again in the following years (2021: 75%; 2022; 69%). The appropriateness of the G.I. endoscopic procedures in the territorial gastroenterology services in the Apulia Region has improved during the acute phase of the COVID-19 pandemic, dropping again in the following years. Overall, the appropriateness of endoscopic procedures remains suboptimal; thus, educational activities are needed to improve the appropriateness rate to optimise the limited resources.

Study to establish fiberoptic laryngoscopy as a diagnostic and investigation tool for laryngotracheal stenosis and to use the same for prognosis of the disease: retrospective analysis

Background: Laryngotracheal stenosis is a common benign condition of airway obstruction in both the pediatric and adult age group. This could either be acquired or congenital, in which there is narrowing of either the portions of the larynx or trachea making it difficult to breathe. This condition can be managed by several operative and endoscopic procedures. Flexible fiber optic laryngoscope is an excellent tool in the diagnostic investigation of laryngotracheal stenosis. Methods: This is a retrospective study that was done with data collected from the medical records department of patients diagnosed with laryngotracheal stenosis in a tertiary care hospital in the last 10 years. Results: A total of 22 patients who underwent FFL exam were taken for this retrospective study and the results were analyzed. Conclusions: This study proves that Fiberoptic laryngoscopy is a single modality diagnostic tool, which is useful in diagnosing, and localizing stenotic lesions in the Laryngotracheal region. It is cheap, less invasive and trained Otolaryngologist can perform this as an outpatient procedure. This therefore reduces the exposure to harmful radiation caused by repeated computed tomography scans.

Patients Have Poor Postoperative Recall of Information Provided the Day of Surgery but Report Satisfaction With and High Use of an E-mailed Postoperative Digital Media Package

To understand what portions of the surgical day patients remember, what parts of an e-mailed media package regarding their surgery patients are used, and how that information affects their surgical experience. Patients undergoing an outpatient arthroscopic procedure were approached in the preoperative area and asked to remember 3words. Postoperatively, they were seen by the surgeon to discuss surgical findings and instructions. They were then e-mailed a multimedia package containing a thank you letter, postoperative instructions, annotated arthroscopy images, and a personalized video from the surgeon. Patients were called 2 to 5 days after surgery to answer survey questions and recall the 3 words they were told on the day of surgery. Of the 160 patients, 100% received and accessed the e-mail. When asked if they remembered the postoperative conversation, 125 (78.1%) patients responded yes and 35 (21.9%) responded no. When asked to rate how well they remembered the postoperative conversation, 75.2% patients rated their memory very poor (48, 38.4%) or poor (46, 36.8%). Similarly, 129 (80.6%) patients were unable to remember the 3 surgeon-related words. One hundred percent of patients strongly agreed (145, 90.6%) or agreed (15, 9.4%) the e-mail package enhanced their experience. In addition, 100% of patients strongly agreed (150, 93.8%) or agreed (10, 6.2%) the surgeon video enhanced their experience. The average e-mail shares per patient was 2.5, with 158 (98.7%) of patients sharing the e-mail at least once. This study shows that patients had poor memory of in-person conversations on the day of surgery. However, patients were satisfied with a postoperative multimedia package provided via e-mail after surgery. Patients interacted with the e-mail primarily on their cell phones, liked the surgeon video, and shared the e-mail with others. Level IV, therapeutic case series.

Real-World Immunosuppressant Treatment Patterns for Patients with Lupus Nephritis in the United States.

Lupus nephritis (LN) treatment aims to control and prevent flares and irreversible kidney damage. Around 30% of patients are unresponsive to treatment; however, real-world LN treatment patterns have not been reported. Objectives of this retrospective cohort study (GSK 209758) were to quantify the time to switching/re-initiating induction therapy in patients with LN initiating immunosuppressant therapy and conversion from induction to maintenance immunosuppressant therapy, and to assess corticosteroid use. Patients with LN initiating induction or maintenance immunosuppressant therapy were identified using claims data. Patients were followed up from the index date (immunosuppressant initiation date) until treatment discontinuation, death, disenrollment, administrative censoring, or the end of follow-up period. The cumulative incidence of switching/re-initiating induction therapy and conversion to maintenance therapy was estimated using outpatient pharmacy claims and procedure codes. Corticosteroid use was estimated using pharmacy claims; a mean daily dose of ≥ 7.5mg/day was considered high. In total, 5000 patients with LN contributed 5516 treatment episodes (induction cohort, N = 372; maintenance cohort, N = 5144). In the induction cohort, the cumulative incidence (95% confidence interval) of switching between induction therapies was 24.6% (20.1-30.0) at 12months, while 59.6% (52.4-66.1) of patients converted to maintenance therapy at 12months. In the maintenance cohort, 21.2% (19.9-22.5) re-initiated induction therapy at 12months. Oral corticosteroid use decreased during the follow-up in both cohorts, but 21.5% of patients remained on a high dose at 12months in the induction cohort, while 15.8% in the maintenance cohort were taking a high dose at 24months. Around a quarter of patients with LN initiating immunosuppressant therapy switched within 12months, while a fifth re-initiated induction therapy within 12months. Use of high corticosteroid doses were observed during 24months of follow-up. These data suggest that many patients do not respond to existing standard LN therapies.

Analysis of Ambulatory Proctologic Surgery for Simple Anal Fistulas in Terms of Recovery, Complications, Recurrence, and Cost.

Background Ambulatory anorectal surgeries have increased in the last few years. This clinical study aimed to compare general operating room conditions with outpatient procedures for simple anal fistulas in terms of healing success, recurrence, cost, complications, and sustainability. Methodology Only primary fistulotomy and seton application for simple anal fistulas were retrospectively analyzed. Results Two-hundred fifty patients (73.7%) were male, and 89 (26.3%) were female. Sixty patients (17.7%) were treated in the operating room, and 279 (82.3%) were treated in the outpatient clinic conditions. Of the ambulatory surgeries, 160 patients underwent fistulotomy and 119 patients loose seton. On the other hand, 34 patients underwent fistulotomy and 26 patients loose seton in operating room conditions. No significant difference was found between the groups according to the distribution of age, gender, complications, and recurrence (P> 0.05). Cost-effectiveness assessment according to the place (ambulatory/operating room) and type of operation (fistulotomy/loose seton) reveals that ambulatory surgery provides significantly more savings (P< 0.001). Conclusions For simple anal fistulas, ambulatory anorectal surgery is a safe approach that can be performed at a lower cost than operating room conditions.

The Impact of COVID-19 after one year on the orthopedic spine service at the Orthopedic Center Hospital in Indonesia

link of Video Abstract: https://youtu.be/-6sruWeh-_Q Introduction: Coronavirus-2 (SARS-COV2) is the agent that causes Coronavirus Disease (COVID-19), an acute respiratory tract illness. Early in December 2019, COVID-19 was created in Wuhan, China. On March 11th, 2020, COVID-19 was classified as a pandemic by WHO. As a result, the Indonesian government enacted extensive social restrictions on March 31, 2021. This rule prohibits unnecessary public actions. This study aimed to ascertain how COVID-19 affected This study sought to ascertain how COVID-19 affected orthopedic treatments provided in the spine area at the Orthopaedic Center Hospital in Indonesia. Methods: This research is cross-sectional and comparative. The population in Indonesia during the COVID-19 epidemic was compared to the same population one year earlier in the research. This report covers every patient who visited Prof. Dr. R. Soeharso Orthopaedic Hospital with a spine-related diagnosis from the emergency room, an outpatient clinic, or an inpatient setting. Patients with other orthopedic subspecialty diagnoses and those registered at orthopedic service support facilities like radiography, laboratories, or physiotherapy were excluded. SPSS version 26 was used to analyze the data. Results: The overall number of spine patients decreased significantly (30%) from 2440 (pre-covid) to 1695 (during covid). Additionally, there was a significant decline in outpatient visits and surgical procedures (p≤0.05). Patients with trauma reported a crucial decrease during outpatient visits and during surgery (p≤0.05). Conclusions: During the COVID-19 pandemic, the overall number of spine patients from outpatient visits and patient surgery decreased significantly. Additionally, orthopedic care provided during outpatient visits and surgeries decreased.

Endometrial Aspiration Cytology: A Cross-Sectional Comparative Study of Its Efficacy and Sensitivity in Diagnosing Gynecological Disorders.

Introduction Endometrial aspiration cytology (EAC) is a noninvasive, rapid, and cost-effective procedure for diagnosing gynecological disorders. This study aimed to validate endometrial aspiration as a routine, safe, and efficient outpatient diagnostic procedure, correlating its findings with histopathology evaluations to facilitate early surgical planning for patients with abnormal uterine bleeding. Materials and methods This cross-sectional study involved patients of reproductive, menopausal, and postmenopausal age groups who presented with diverse gynecological concerns that required dilatation and curettage. Endometrial aspiration was performed using a Karmancannula (Angiplast Pvt. Ltd., Vatva, India), and the obtained material was prepared into smears and stained for evaluation. Sampling adequacy, the nature of glandular and stromal cells, phasing of the endometrium, and other abnormalities were assessed and correlated with histology to examine the diagnostic utility of endometrial cytology. Results EAC showed 90.66% sampling adequacy with the Karmancannula. The sensitivity of EAC for diagnosing benign and malignant conditions was 88.7% and 100%, respectively. Conditions including secretory endometrium, proliferative phase, tuberculous endometritis, and glandular hyperplasia were diagnosed using EAC and confirmed by histopathology. Six malignancies were successfully diagnosed on cytology smears, while challenges in differentiation and sampling errors were recognized as limitations of the technique. Conclusions This study established EAC as a highly sensitive, minimally invasive preliminary diagnostic tool for gynecological disorders, particularly effective in diagnosing malignancy. Despite certain limitations, the procedure's ease, cost-effectiveness, and safety underscore its potential for routine use by surgeons.

Pilot Study: Personalized Medicine in Endoscopy, Can Pharmacogenomics Predict Response to Conscious Sedation?

Adequate response to moderate (conscious) sedation varies significantly between individuals. Polymorphisms in genes encoding drug metabolizing enzymes can lead to inter-individual variability in drug efficacy, potentially influencing sedation requirements during endoscopic procedures. The aim of this study was to assess the potential role of inter-individual variation in inherited polymorphisms of drug-metabolizing enzymes, cytochrome P450 (CYP450), specifically CYP3A4 and CYP3A5, in sedation requirements for outpatient endoscopic procedures. A retrospective analysis of sedation requirements and pharmacogenomics data in 106 unique patients who received outpatient esophagogastroduodenoscopy (EGD), colonoscopy, or both between December 2011 and February 2019 was conducted. Patients were divided into two groups based on their sedation requirements during endoscopy (high vs. normal sedation). Patients with reduced a CYP2C19 metabolism (poor + intermediate metabolizers) (odds ratio [OR] = 0.38, 95% confidence interval [CI]: 0.16-0.91, p = 0.03), poor CYP3A5 metabolism (OR = 0.25, 95% CI: 0.095-0.65, p = 0.0046), and poor UGT1A1 (OR = 2.76, 95% CI: 1.07-7.13, p = 0.08) had higher odds of requiring normal sedation compared to those with CYP2C19 increased metabolism, CYP3A5 intermediate metabolism, and UGT1A1 intermediate metabolism. Information about inter-individual variation in (CYP450) genes may be useful for determining the sedation requirements for outpatient endoscopic procedures. We found that patients with reduced CYP2C19 metabolism, poor CYP3A5 metabolism, and poor UGT1A1 metabolism were more likely to require normal sedation requirements during outpatient endoscopic procedures.

The effect of music intervention in decreasing pain and anxiety during outpatient hysteroscopy procedure: a systematic review and meta-analysis of randomized control trials

BackgroundHysteroscopy is a common outpatient procedure but procedural pain limits its use. Music could be used as a pain-relieving intervention. We performed a systematic review and meta-analysis to investigate the effect of music on pain and anxiety during outpatient hysteroscopy.MethodsFour electronic databases were searched: PubMed, Scopus, Web of Science, and Cochrane Library, from inception to September 2022. We included only the Randomized Controlled Trials (RCTs) that investigated the effect of music on women who underwent outpatient hysteroscopy in reducing pain and anxiety levels compared to no music. We assessed the quality of included RCTs using the risk of bias tool 1 reported in the Cochrane Handbook of Systematic Reviews of Interventions. Data were pooled as the Mean Differences (MDs) with a 95% Confidence Interval (CI) in a random-effects model, using Review Manager 5.3 software. Also, we assessed the evidence of the results using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).ResultsThree RCTs (540 women) were included. Music significantly reduced visual analogue scale (VAS) pain scores as well as State-Trait Anxiety Inventory (STAI) scores compared to controls (MD = -1.28; 95% CI [-2.19, -0.36]; P = 0.007) and (MD = -3.91; 95% CI [-6.98, -0.85]; P = 0.01) respectively. Also, the decrease in VAS score for pain was significantly greater in the music group (MD = 1.44; 95% CI [0.44, 2.45]; P = 0.005). However, the change in STAI showed no significant difference between the two groups. The GRADE ratings for all outcomes were very low.ConclusionMusic is a potentially promising method for controlling pain for patients undergoing outpatient hysteroscopy; however, its effect in controlling anxiety is controversial.

Predicting successful outpatient total shoulder arthroplasty.

Total shoulder arthroplasty (TSA) is increasingly performed safely and efficiently as an outpatient procedure in certain patients. Patient selection is often based on surgeon choice, surgeon expertise, or institutional guidelines. One orthopedic research group released a publicly available shoulder arthroplasty outpatient appropriateness risk calculator that considers patient demographic characteristics and comorbidities with the aim of helping surgeons to predict successful outpatient TSA. This study aimed to retrospectively assess the utility of this risk calculator at our institution. Records were obtained for patients undergoing procedure code 23472 at our institution between January 1, 2018, and March 31, 2021. Patients undergoing anatomic TSA in the hospital setting were included. Records were reviewed for demographic characteristics, comorbidities, American Society of Anesthesiologists classification, and surgery duration. These data were entered into the risk calculator to calculate the likelihood of discharge by postoperative day 1. Charlson Comorbidity Index, complications, reoperations, and readmissions were also collected from patient records. Statistical analyses assessed the model's fit with our patient cohort and compared outcome measures between inpatient and outpatient groups. Of the 792 patients whose records were initially obtained, 289 met the inclusion criteria of anatomic TSA performed in the hospital setting. Of these patients, 7 were excluded because of missing data, leaving 282 patients: 166 (58.9%) in the inpatient group and 116 (41.1%) in the outpatient group. We found no significant differences in mean age (66.4 years in inpatient group vs. 65.1 years in outpatient group, P=.28), Charlson Comorbidity Index (3.48 vs. 3.06, P=.080), or American Society of Anesthesiologists class (2.58 vs. 2.66, P=.19). Surgery time was longer in the inpatient group than the outpatient group (85 minutes vs. 77 minutes, P=.001). Overall complication rates were low (4.2% in inpatient group vs. 2.6% in outpatient group, P=.07). Readmissions and reoperations did not differ between groups. There was no difference in the average percentage likelihood of same-day discharge (55.4% in inpatient group vs. 52.4% in outpatient group, P=.24), and a receiver operating characteristic curve to assess fit with the risk calculator demonstrated an area under the curve of 0.55. The shoulder arthroplasty risk calculator performed similarly to chance when retrospectively predicting discharge within 1 day after TSA in our patients. Complications, readmissions, and reoperations were not higher after outpatient procedures. Risk calculators for determining whether a patient should be admitted after TSA should be used cautiously because they may not provide measurable benefit over the use of surgeon experience and expertise in discharge decision making, and other factors may be relevant in the decision to perform outpatient TSA.

The Effect of Early Feeding of Full Liquids on Postoperative Infants

Abstract There is a lack of evidence-based guidance for postoperative feeding of infants after outpatient surgeries. This randomized controlled trial tested the hypothesis that infants, aged ≤12 months who are fed formula or milk at home, will have more oral intake, less pain, and less emergence delirium when fed formula/milk as compared with clear liquids in the postanesthesia care unit. Infants were randomized to receive formula/milk or clear liquids as first feeding after outpatient myringotomy and tube insertion. Pain (Faces, Legs, Activity, Cry, and Consolability) and emergence delirium (Pediatric Anesthesia Emergence Delirium) scores were recorded and compared immediately and again 15 and 30 minutes after arrival in the postanesthesia care unit. Infants randomized to the formula/milk first-feeding group had significantly more volume of oral feeding intake than infants randomized to the clear liquid first-feeding group (M = 80.5 ml, 95% CI [15, 146], p = .017). There was no significant difference in vomiting, pain scores, or emergence delirium scores between groups. These results support the practice of ad lib feeding of infants who preferred full liquids after outpatient surgical procedures.

Incidence of retained biopsy specimens after esophagogastroduodenoscopy and colonoscopy.

Background and study aims In gastrointestinal endoscopy, biopsies must transit through the accessory channel and cap, presenting an opportunity for loss of tissue. We sought to determine the incidence of specimen retention in the accessory channel or cap and identify procedure characteristics associated with specimen retention. Patients and methods After completion of standard endoscopic procedures in which biopsies were obtained, the biopsy cap and accessory channel were inspected, brushed, and irrigated for any retained biopsy specimens according to a standard protocol. For controls, the same protocol was applied to procedures in which biopsies were not obtained. Specimen bottles from the recovery protocol were sent for pathological examination regardless of whether any visible tissue was present. Results A total of 216 outpatient procedures were included: 55 esophagogastroduodenoscopies (EGDs) and 50 colonoscopies in which biopsies were obtained and 56 EGDs and 55 colonoscopies in the control group. Retained specimens were found in either the cap or channel in 50 of 105 (48%). In 20 of 105 (19%), retained specimens were found just in the cap, in six of 105 (5.7%), retained specimens were found just in the channel, while in 24 of 105 (23%), retained specimens were found in both the cap and channel. Retained specimens were more likely to be found in EGDs compared to colonoscopies (58% vs. 36%, P = 0.031). No retained specimens were found in the control group. Conclusions Retained specimens are startingly common in standard gastrointestinal endoscopic procedures and could potentially change diagnoses and management. Quality improvement measures should be instituted to monitor prevalence of retained biopsies and methods to prevent them should be developed.

Outcomes of an enhanced recovery after surgery (ERAS) program to limit perioperative opioid use in outpatient minimally invasive GI and hernia surgeries.

Perioperative pain management is important for patient satisfaction while returning to homeostasis in the safest way possible. Studies show that patients don't require as much opioids as once thought. The benefits of ERAS pathways extend beyond enhancement of patients' perioperative experience, and include reducing opioid prescriptions in the face of the ongoing nationwide opioid crisis and evidence of prescription opioids as a contributor. We performed a retrospective cohort study of patients undergoing same day minimally invasive surgery (MIS) procedures for GI and hernia disease using a minimal-opioid ERAS protocol at two community hospitals between January 2020 and May 2022. We included elective laparoscopic cholecystectomy (LC), laparoscopic appendectomy (LA) for acute appendicitis without perforation, and minimally invasive (laparoscopic and robotic) inguinal and ventral hernia repair or abdominal wall reconstruction (AWR). Primary outcome was postoperative opioid use. A total of 509 patients were included, undergoing procedures of MIS hernia repair (52.5%), LC (43.6%), and LA (7.9%). Only 9.4% of patients received opioid prescriptions at discharge, with no difference between groups. Among the patients receiving a prescription at discharge, there was a significant difference in morphine milligram equivalents (MME) prescribed (25.0 ± 0.0 in the LA group, 65.0 ± 41.4 in the LC group, 100.6 ± 46.2 in the MIS hernia/AWR group; P = 0.015). Nine percent of patients called with pain management concerns postoperatively. ASA score ≥ 3 was associated with increased odds for postoperative opioid prescription (OR 2.084; P = 0.014). We demonstrate that an opioid-sparing ERAS program effectively manages pain for patients undergoing multiple outpatient MIS GI/hernia procedures, and suggests generalizability across a diverse range of operations. Therefore, the use of ERAS may safely and effectively expand beyond inpatient MIS and open surgeries that target reduced length of stay to also minimize opioids for outpatient procedures.