Outpatient Surgical Setting Research Articles

This Month in Anesthesiology

This Month in Anesthesiology

Practice Guidelines for Perioperative Blood Transfusion and Adjuvant Therapies

Practice Guidelines for Perioperative Blood Transfusion and Adjuvant Therapies

Pain management in the outpatient surgical setting

Extracted from text ... COMMENTARY 24 Pain management in the outpatient surgical setting Robert S. Wolf MD American Sports Medicine Institute Birmingham, AL USA emptive and post-operative setting. These medications inhibit prostaglandin synthesis, promote analgesia, and consequently decrease the post-operative demand for opioids. This is beneficial as excess opioid use can result in significant morbidity in terms of gastrointestinal side effects, mental status changes, and potential for addiction. However, traditional non-steroidal anti-inflammatory drugs (NSAIDs) have side effects including platelet inhibition and gastric ulceration which may prevent their use in the pre-operative setting. Moreover, ketorolac is contraindicated before major operations due to the increased ..

Two-Stitch Technique for Distal Shaft Hypospadias Repair

The authors present a new technique for distal shaft hypospadias repair using a flip flap fashioned with only two stitches. In raising the flap, the tissues lateral and proximal to the flap are undermined but there is no undermining beneath the flap. The flap is sutured up to the glans with two 4-0 Vicryl sutures. No sutures are placed at the lateral edges of the flap to create the "tube" of the neo-urethra, and no postoperative urinary drainage is used. Thirty-three children with distal shaft hypospadias underwent the "two-stitch" flip flap operation. The complications were one fistula and one case of urinary retention. The technique is an easy method for reconstructing distal penile hypospadias with a very low rate of complications and is suitable for an outpatient surgical setting.

PROSTATE CANCER DIAGNOSIS USING A SATURATION NEEDLE BIOPSY TECHNIQUE AFTER PREVIOUS NEGATIVE SEXTANT BIOPSIES

We hypothesized that markedly increasing the number of cores obtained during prostate needle biopsy may improve the cancer detection rate in men with persistent indications for repeat biopsy. We performed saturation ultrasound guided transrectal prostate needle biopsy in 224 men under anesthesia in an outpatient surgical setting in whom previous negative biopsies had been performed in the office. The mean number of previous sextant biopsy sessions plus or minus standard deviation before saturation biopsy was 1.8 (range 1 to 7). A mean of 23 saturation biopsy cores (range 14 to 45) were distributed throughout the whole prostate, including the peripheral, medial and anterior regions. Indications for repeat biopsy were persistent elevated serum prostate specific antigen (PSA) in 108 cases, persistent elevated PSA and abnormal rectal examination in 27, persistent abnormal rectal examination in 4, high grade prostatic intraepithelial neoplasia in the previous biopsy in 64 and atypia in the previous biopsy in 21. Cancer was detected in 77 of 224 patients (34%). The number of previous negative sextant biopsies was not predictive of subsequent cancer detection by saturation biopsy. Median PSA was 8.7 ng./ml. and median PSA velocity was 0.63 ng./ml. yearly. Of the 77 patients in whom cancer was detected radical prostatectomy was performed in 52. Pathological stage was pT2 in 48 patients and pT3 in 4, while Gleason score was 4 to 5, 6 to 7 and 8 in 5, 46 and 1, respectively. At prostatectomy median cancer volume was 1.04 cc and 85.7% of removed tumors were clinically significant, assuming a 3-year doubling time. The overall complication rate for saturation needle biopsy was 12% and hematuria requiring hospital admission was the most common event. Saturation needle biopsy of the prostate is a useful diagnostic technique in men at risk for prostate cancer with previous negative office biopsies. This technique allows adequate sampling of the whole prostate gland and has a detection rate of 34% in this cohort of patients.

Adenotonsillectomy in the very young patient: cost analysis of two methods of postoperative care

Postoperative management of the patient younger than 36 months undergoing adenotonsillectomy has been the subject of many debates. Concerns for early postoperative complications such as airway obstruction, emesis, dehydration, and hemorrhage have led many physicians to consider overnight hospitalization following adenotonsillectomy in very young children. Trends in health care management have had increasing focus on cost effective means of treating patients to limit unnecessary expenditure on the part of the patient, physician, and hospital facility. The purpose of this retrospective review was to analyze two methods of early postoperative management in children less than 36 months old undergoing adenotonsillectomy at the Children’s Hospital, San Diego from 1992 to 1997. Three hundred and seven cases were reviewed. Same-day discharge was compared with overnight inpatient observation based on the cost analysis of these two methods of postoperative care. Postoperative care was based on length of stay in the recovery room and as an inpatient. Expense of postoperative care was based on cost calculation for the recovery room and overnight hospitalization. Of the 307 patients, 194 went home the day of surgery and 113 were observed overnight in the hospital. Average hospital cost was higher in the outpatient group than in the inpatient group ( P<0.001). This difference reflects longer recovery room stay (350 min) in the outpatient group compared to the inpatient group (108 min) ( P<0.001). Outpatient adenotonsillectomy in the patient under 36 months may be safe; however, prolonged recovery room stays may actually make outpatient surgery less cost-effective than overnight admission. Recovery room costs are significantly higher per unit time than costs of inpatient hospitalization. Further investigation of cost-effective outpatient observation units may improve cost containment in the outpatient surgical setting.

Health care utilization by persons with severe and persistent mental illness.

Claims for physical health care among 220 Medicaid enrollees with severe mental illness and 166 Medicaid enrollees who were not enrolled in the public mental health system were compared. Claims for the mentally ill group were 18 percent less than for the group without severe mental illness. Twenty-eight percent of claims for mentally ill patients were for treatment in emergency rooms and ambulances, compared with 11 percent for patients without mental illness; 26 percent of claims for patients without mental illness were for care in outpatient surgical and outpatient hospital settings, compared with 14 percent for mentally ill patients. Results suggest inefficient use of the health care system by mentally ill patients and highlight the need for coordination of care.

One Hundred Consecutive Advanced Breast Biopsy Instrumentation Procedures: Complications, Costs, and Outcome

Needle localization and excision have been the preferred techniques for treating nonpalpable mammographic abnormalities. Recently, a less invasive approach, using the Advanced Breast Biopsy Instrumentation (ABBI) system, was introduced. This study was undertaken to determine the feasibility, utility, and cost of this new alternative approach. Between April 1996 and May 1997, 100 consecutive women underwent excisional breast biopsies using the ABBI system. Demographic information, mammographic findings, pathological findings, hospital/professional fees, complications, and subsequent interventions were documented. Excisional biopsies using the ABBI system were successful for 99 women (average age, 62 years; range, 34-87 years). Of the 99 lesions removed with the ABBI system, 27 were microcalcifications, 60 were suspicious solid nodules, and 12 were nodules with microcalcifications. The ABBI system was used in an outpatient surgical setting, with only one patient requiring sedation (because of anxiety). Cancer was seen in the biopsy specimens for 18 patients, seven of whom (35%) exhibited no residual tumor at the time of definitive treatment. Postoperative hematomas occurred in two patients; one hematoma required surgical drainage. One missed cancer was detected in follow-up mammograms 6 months after biopsy. The total average procedural cost was $3406.44 +/- 486.63. Excisional breast biopsy using the ABBI system is an effective diagnostic method. It has a low complication rate, and its cost is comparable to that of classical needle localization.

Pterygium recurrence rate at the Princess Alexandra Hospital

Over two separate time periods, 136 consecutive pterygium operations in 103 patients were performed at the Princess Alexandra Hospital. These patients were evaluated for recurrence of their pterygia in a retrospective study by chart review and re-examination. In 136 eyes there was an overall recurrence rate of 46% using a number of therapies. This study highlights the relatively unsatisfactory result of pterygium removal in a day surgery and eye outpatient department surgical setting by a number of trainee ophthalmologists, and stresses the need for a reassessment of pterygium and its treatment.

Current Surgical Management of Skin Cancer in Dermatology

Skin cancer has become a major public health problem in the United States and worldwide. Epidemiologic studies confirm a continued increase in the number of basal cell carcinomas, squamous cell carcinomas, and malignant melanomas. Dermatologists, the primary caretakers of the skin, manage skin cancer with various modalities that have been time tested and found reliable, including excision, electrosurgery, cryosurgery, and Mohs micrographic surgery. Extirpative procedures for basal cell carcinoma and squamous cell carcinoma are considered with attention to cure, restoration of function, and cosmesis--in that order. The dermatologic management of melanoma is critical because early diagnosis and treatment of thin lesions has been the only effective improvement in melanoma management in the last several decades. Wide excision, with a 1-3-cm margin, of thin stage I melanoma has moved surgical management from the operating room to the outpatient surgical setting. Management of these increasingly common problems, as reviewed here, is principally responsible for the growth of surgical practice as a subspecialty of dermatology.

The Selection of Drugs in Office Surgery

The aim of this article is to suggest a rational, effective, and safe drug regimen that will satisfy the needs of both patients and surgeons in an outpatient ambulatory surgical setting. Commonly used drugs and local anesthetics are discussed.