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Original Papers

Day care surgery

Jarrett, P. E. M.

Author Information
European Journal of Anaesthesiology: November 2001 - Volume 18 - Issue - p 32-35

Abstract

Introduction

One of the most significant, yet least sung, changes in surgical practice over the last 20 years has been the growth of day or ambulatory surgery. This has particularly occurred in Australasia, Europe and North America. Day surgery as a percentage of elective surgery has risen in England from 34% in 1989–90 to 65% in 1998–99 [1]. In the USA the figure at present is over 70%. However, the headline figures are relatively meaningless and individual procedures need to be looked at. For example, in England inguinal hernia repair and varicose vein surgery rates have risen from 6% and 16%, respectively, in 1990–91, to 35% and 48%, respectively, in 1998–99 [1]. Yet some hospitals at present carry out no hernia repairs on a day basis and others will not undertake bilateral varicose vein surgery in this way. Other units achieve rates of over 80% for both procedures. International figures, although difficult to validate and compare, show wide variations in day surgery activity between countries. In 1996–97, day case rates for inguinal hernia repair were 6–7% in Belgium and France compared with 83% in the USA. For varicose vein surgery, 12% in Australia and France compares with 88% in the USA [2]. Inaccuracies in data collection and the fact that some units and countries count a 23 h stay as day surgery alone cannot account for the wide variation in day surgery activity that is seen between countries and between hospitals in the same country.

The future

The greatest potential at present for the development of day surgery both globally and in individual countries is for all hospitals to achieve the activity levels of the present top quartile of performers [3]. Clearly this would require no new technology, only a change in attitude of the practitioners and the provision of adequate facilities. Future developments in surgery, anaesthesia, analgesia and management are likely to bring the treatment of a greater range of conditions into the ambit of day surgery.

Surgery

In surgery, new techniques applied to established procedures may allow a move to day surgery. For instance, in the north island of New Zealand, the technique of laser prostatectomy techniques have been developed allowing a high proportion of cases to be managed on a day basis (personal communication, M. R. Fraundorfer, 1998).

In recent years, the development of minimally invasive surgical techniques has facilitated the growth of day surgery, particularly in gynaecology (e.g. diagnostic laparoscopy and laparoscopic sterilization) [4] and orthopaedic surgery (e.g. diagnostic arthroscopy and arthroscopic meniscectomy) [5]. Further endoscopic procedures in these specialities are being developed and introduced into the day unit. In gynaecology, these include lysis pelvic adhesions, salpingostomy, ovarian cystectomy, oophorectomy, myomectomy, laser ablation endometriosis and assisted vaginal hysterectomy [4]. Among the procedures in orthopaedics are arthroscopic cruciate ligament repair, arthroscopic synovectomy and endoscopic subacromial decompression [5–8]. To date, minimally invasive surgery has had little effect on day surgery rates in general surgery. Most interest has focused on day case laparoscopic cholecystectomy [9–11], but the overall rates for this are still low outside North America – 3.4% in Denmark, 0.8% in England and 0.5% in the Netherlands in 1997 [2]. In the United States in 1996 the rate was 51% [2], but some cases included in this figure stay for 23 h in a recovery unit. However, even in countries where the overall rate is low, some units achieve rates of over 60% for true day case cholecystectomy. Other general surgery laparoscopic procedures that have been undertaken on a day basis include appendectomy, hiatus hernia repair [12,13], inguinal hernia repair [14] and splenectomy [15]. Although minimally invasive surgery causes less tissue damage and thus less postoperative disturbance, it must not automatically be assumed that a move from an open to a minimally invasive approach for a particular procedure makes it either better for the patient or more suitable for day surgery. Open ‘mini-lap’ cholecystectomy has been carried out on a day basis with, in skilled hands, results equivalent to laparoscopic cholecystectomy [16]. Laparoscopic inguinal hernia repair may take longer than an open repair and is more expensive [17]. It also requires a general anaesthetic, whereas an open repair can be performed under local anaesthesia. Laparoscopic inguinal hernia repair in the day unit should be reserved for bilateral hernias or recurrent hernias [14,18].

In vascular surgery thoracoscopic cervical sympathectomy is established as a day surgery procedure and subfascial endoscopic perforator vein surgery [19] is being developed. Some traditional open arterial bypass surgery has been replaced by the endovascular approach of angioplasty with or without stenting, allowing many cases to be treated on a day basis. Perhaps in the not-too-distant future some elective aortic aneurysms will be treated as day cases.

The range of day surgery can also be increased by replacing habit with logic. Most surgeons outside North America will not discharge home patients with drains or indwelling catheters. With modern appliances this is illogical. Drains and catheters are not a barrier to discharge [20]. Thus, thyroidectomy and parotidectomy become possible on a day basis, together with a larger range of genitourinary procedures.

The day surgeon should not only be considering those cases that can be moved from the inpatient setting to the day unit, but also those that can be moved out of the day unit to the outpatient department. For instance, diagnostic arthroscopy has fallen by 30% in England in the last 5 years [1] as it is replaced by magnetic resonance imaging, and it is likely that three-dimensional ultrasound imaging will supersede diagnostic endoscopic procedures, such as colonoscopy, in the near future.

Anaesthesia

Day case anaesthesia has advanced greatly over the last 20 years, particularly with the introduction of the newer volatile inhalational agents, propofol, the laryngeal mask airway and the short-acting opioids. Quite simply, what the surgeon requires from a day case general anaesthetic is rapid induction and rapid recovery with minimal morbidity. The surgeon can help achieve this goal, for instance, by blocking pain sensation from all wounds when possible with a long-acting local anaesthetic. Even so-called postoperative anaesthetic complications are not entirely caused by anaesthesia: all involved in the care of the day case patient can contribute to and help to prevent these. For example, postoperative nausea and vomiting can be caused by poor preoperative assessment, slow or rough surgery, surgeons ignoring procedure-specific measures (e.g. the removal of blood or bile following laparoscopic procedures), asking patients to drink or eat too quickly after their operation and poor postoperative information, apart from the inappropriate choice of anaesthetic and analgesic regimens.

Where possible, a greater use of local anaesthesia will not only reduce morbidity but will also allow a number of American Society of Anesthesiologists (ASA) grade III–IV patients to be treated on a day basis. The use of local anaesthesia is facilitating the development of carotid endarterectomy as a day case procedure in a number of units.

Anaesthetic considerations for day care surgery are discussed in detail elsewhere in this issue.

Analgesia

Adequate postoperative analgesia is a prerequisite for successful day surgery. As with anaesthesia, analgesic drugs have improved over the years and the most widely used today are the non-steroidal anti-inflammatory drugs. These, like the opioids, contribute to constipation in a significant number of patients, approximately 10% in a recent audit (author's own research) of some 400 consecutive patients following a broad range of day surgery procedures undertaken in the Kingston Hospital day unit. The ideal analgesic has yet to be found. Postoperative pain control is more than just prescribing the appropriate drug, patients need to be informed about the level of discomfort to expect, and what and what not to do.

General management

Provision of information is one of the mainstays of effective day surgery management. This needs to cover not only what to do preoperatively and postoperatively, but also what will happen on the day of surgery. Verbal information alone is inadequate and must be reinforced with well-presented printed material [21]. At present, interactive computer programmes are being developed by some units so that patients can access the information they require either from a disk they are given or via the internet. Similarly, electronic communication is being used increasingly to send information about the surgical procedure and postoperative care to the patient's general practitioner. The most essential communication link for patients is a 24-h helpline staffed by appropriate nurses who can advise patients on any problems they might have.

The ideal day unit in terms of quality of care and cost effectiveness is one that is self-contained [21–23]. That is, it has its own operating theatres, wards, reception areas, staff and management. With the potential for 80% or more of elective surgery to be undertaken on a day basis, many day units are now too small. In the future, it is not unrealistic to predict that the day unit operating theatres will outnumber the inpatient ones. The future day unit will not only undertake surgery, but also medical day care (e.g. chemotherapy, transfusions, pain control, etc.) and thus evolve into a day hospital or ambulatory care centre. Hospitals will then be ring-fenced in three areas only, namely emergency care, elective inpatient care and ambulatory care.

The future also presents potential problems for day surgery. There is a trend in the United States, Australia and, to a lesser extent, the UK towards including patients staying for up to 23 h after operation as day cases. This has occurred for financial and/or bureaucratic reasons. If allowed to progress, the move to true day surgery (admission, operation and discharge during the same working day) will slow down or, as has happened in one UK unit, be reversed as a result of this practice. Twenty-three-hour surgery is less cost-effective than true day surgery and should be regarded as inpatient treatment [24]. A further trend, which is more worrying to European surgeons and anaesthetists, is the growth of office-based surgery in the United States [24]. Office-based general anaesthesia in the UK has been banned from the beginning of this year because of unacceptable morbidity and mortality rates. Even intermediate and major surgery using local anaesthesia is not without its problems and there are risks if such procedures are not carried out in facilities that are adequately staffed and properly equipped, and have resuscitation facilities. Once a unit matches these requirements, it is no longer an office but a free-standing day unit that should be properly inspected and accredited. To do less is regarded in Europe as dangerous surgical and anaesthetic practice, and would be indefensible in a court of law. Such practice runs the risk of bringing day surgery into disrepute.

Conclusion

Day surgery is quality care that is cost effective. It has not yet reached its full potential. To do so will require the combined efforts of anaesthetists, surgeons and nurses working together, developing and refining their skills and techniques for the benefit of the day surgery patient. There is no reason why overall day surgery rates for elective surgery should not approach 80% in the near future.

References

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Keywords:

SURGERY; day care; new procedures; developments

© 2001 European Society of Anaesthesiology