ASSESSMENT OF THE LEVEL OF SATISFACTION OF PATIENTS SUBMITTED TO LATARJET SURGERY UNDER OUTFIT SYSTEM COMPARED TO HOSPITAL SYSTEM.

Anterior shoulder instability causes functional changes that affect patients' quality of life. The Latarjet procedure is one of the most frequently performed surgeries for cases of recurrent shoulder instability. Objective: To assess the level of satisfaction of patients who underwent the Latarjet procedure in outpatient settings (day hospital) compared with inpatient settings. Methods: A questionnaire was administered to both groups and a descriptive analysis of the results was performed. Results: 51 patients were included, with a mean age of 29.9 years, 82.3% men and 17.6% women. Of the patients who underwent surgery in the day hospital, 46.1% were operated within 100 days of their first outpatient visit; among those in the inpatient group, 76.3% underwent surgery more than 200 days later. Delays occurred in 15.3% of cases in the day hospital compared with 68.4% in the inpatient group. Of the patients in the day hospital, 92.3% felt comfortable contacting the medical team in case of complications and would perform the procedure again in the same setting. Moreover, 63.2% of inpatients would have preferred to have been discharged on the same day. The final satisfaction rate for both groups was 100%. Conclusion: Outpatient surgery guarantees more patient comfort, safety, and can be performed in a timely manner and with fewer delays, which has influenced patients' decision to have surgery during the COVID-19 pandemic. Level of Evidence V, Cross-sectional Study.

A instabilidade anterior do ombro acarreta alterações funcionais que impactam a qualidade de vida do paciente. A cirurgia de Latarjet é um dos procedimentos mais executados para casos de instabilidade recorrente de ombro. Objetivo: Comparar o grau de satisfação dos pacientes submetidos ao procedimento de Latarjet no regime ambulatorial (hospital dia) com o dos operados no regime hospitalar. Métodos: Um questionário foi aplicado em ambos os grupos e uma análise descritiva dos resultados foi realizada. Resultados: Foram incluídos 51 pacientes, com idade média de 29,9 anos, sendo 82,3% homens e 17,6% mulheres. Dos submetidos à cirurgia no hospital dia, 46,1% operaram em até 100 dias depois do primeiro atendimento ambulatorial; já entre os do grupo hospitalar, 76,3% operaram mais de 200 dias depois. O atraso na cirurgia ocorreu com 15,3% dos pacientes do hospital dia contra 68,4% do grupo hospitalar. Do hospital dia, 92,3% pacientes sentiram-se confortáveis em contatar a equipe médica em caso de intercorrências e fariam novamente o procedimento de forma ambulatorial. Além disso, 63,2% dos internados gostariam de ter recebido alta no mesmo dia. O grau de satisfação final em ambos os grupos foi de 100%. Conclusão: A cirurgia ambulatorial garante mais conforto para o paciente, mostrando-se segura e podendo ser performada em tempo hábil e com menos atrasos, o que influenciou a decisão dos pacientes em operar durante a pandemia de COVID-19. Nível de Evidência V, Estudo Transversal.

Unilateral Thyroid Lobectomy as Day Care Procedure: A Cross Sectional Study with Literature Review on the Safety and Cost Effectiveness.

Introduction Thyroid nodules are common globally in almost one fifth of the adult population. The gold standard treatment for thyroid nodule is thyroid lobectomy or total thyroidectomy depending upon the diagnosis. Thyroidectomy has a few known complications but, as per the ATA consensus statement, it is a safe surgery to be done as a day care procedure. Objective To access the feasibility and safety of thyroid lobectomy as a day care surgery and its effect on decreasing overall financial burdens. Methods This retrospective chart review was done from 2006 to 2022. A total of 736 patients underwent thyroid lobectomy among which only 56 were done as day care surgery. Data analysis was done using the IBM SPSS Statistics for Windows, Version 23.0 (IBM Corp., Armonk, NY, USA). Results A total of 40% of the population was male. The mean age of the study population was 42 years. Bethesda II was the most encountered diagnosis, with a rate of 69%. The majority of patients were discharged after 6 hours of postoperative observation. The only complication encountered was seroma, which was seen in two patients. Conclusion Thyroid lobectomy appears to be a safe procedure with a drastic difference in overall cost as a day care procedure. We recommend switching the practice of inpatient thyroid lobectomy to a day care procedure in carefully selected candidates. The major hurdle in day care lobectomy can be approval from insurance.

Assessment of the level of satisfaction of patients submitted to latarjet surgery under outfit system compared to hospital system / Avaliação do grau de satisfação do paciente submetido à cirurgia de latarjet em regime ambulatorial em comparação com o regime hospitalar

ABSTRACT Anterior shoulder instability causes functional changes that affect patients' quality of life. The Latarjet procedure is one of the most frequently performed surgeries for cases of recurrent shoulder instability. Objective: To assess the level of satisfaction of patients who underwent the Latarjet procedure in outpatient settings (day hospital) compared with inpatient settings. Methods: A questionnaire was administered to both groups and a descriptive analysis of the results was performed. Results: 51 patients were included, with a mean age of 29.9 years, 82.3% men and 17.6% women. Of the patients who underwent surgery in the day hospital, 46.1% were operated within 100 days of their first outpatient visit; among those in the inpatient group, 76.3% underwent surgery more than 200 days later. Delays occurred in 15.3% of cases in the day hospital compared with 68.4% in the inpatient group. Of the patients in the day hospital, 92.3% felt comfortable contacting the medical team in case of complications and would perform the procedure again in the same setting. Moreover, 63.2% of inpatients would have preferred to have been discharged on the same day. The final satisfaction rate for both groups was 100%. Conclusion: Outpatient surgery guarantees more patient comfort, safety, and can be performed in a timely manner and with fewer delays, which has influenced patients' decision to have surgery during the COVID-19 pandemic. Level of Evidence V, Cross-sectional Study.

RESUMO A instabilidade anterior do ombro acarreta alterações funcionais que impactam a qualidade de vida do paciente. A cirurgia de Latarjet é um dos procedimentos mais executados para casos de instabilidade recorrente de ombro. Objetivo: Comparar o grau de satisfação dos pacientes submetidos ao procedimento de Latarjet no regime ambulatorial (hospital dia) com o dos operados no regime hospitalar. Métodos: Um questionário foi aplicado em ambos os grupos e uma análise descritiva dos resultados foi realizada. Resultados: Foram incluídos 51 pacientes, com idade média de 29,9 anos, sendo 82,3% homens e 17,6% mulheres. Dos submetidos à cirurgia no hospital dia, 46,1% operaram em até 100 dias depois do primeiro atendimento ambulatorial; já entre os do grupo hospitalar, 76,3% operaram mais de 200 dias depois. O atraso na cirurgia ocorreu com 15,3% dos pacientes do hospital dia contra 68,4% do grupo hospitalar. Do hospital dia, 92,3% pacientes sentiram-se confortáveis em contatar a equipe médica em caso de intercorrências e fariam novamente o procedimento de forma ambulatorial. Além disso, 63,2% dos internados gostariam de ter recebido alta no mesmo dia. O grau de satisfação final em ambos os grupos foi de 100%. Conclusão: A cirurgia ambulatorial garante mais conforto para o paciente, mostrando-se segura e podendo ser performada em tempo hábil e com menos atrasos, o que influenciou a decisão dos pacientes em operar durante a pandemia de COVID-19. Nível de Evidência V, Estudo Transversal.

Unilateral Thyroid Lobectomy as Day Care Procedure: A Cross Sectional Study with Literature Review on the Safety and Cost Effectiveness

Abstract Introduction Thyroid nodules are common globally in almost one fifth of the adult population. The gold standard treatment for thyroid nodule is thyroid lobectomy or total thyroidectomy depending upon the diagnosis. Thyroidectomy has a few known complications but, as per the ATA consensus statement, it is a safe surgery to be done as a day care procedure. Objective To access the feasibility and safety of thyroid lobectomy as a day care surgery and its effect on decreasing overall financial burdens. Methods This retrospective chart review was done from 2006 to 2022. A total of 736 patients underwent thyroid lobectomy among which only 56 were done as day care surgery. Data analysis was done using the IBM SPSS Statistics for Windows, Version 23.0 (IBM Corp., Armonk, NY, USA). Results A total of 40% of the population was male. The mean age of the study population was 42 years. Bethesda II was the most encountered diagnosis, with a rate of 69%. The majority of patients were discharged after 6 hours of postoperative observation. The only complication encountered was seroma, which was seen in two patients. Conclusion Thyroid lobectomy appears to be a safe procedure with a drastic difference in overall cost as a day care procedure. We recommend switching the practice of inpatient thyroid lobectomy to a day care procedure in carefully selected candidates. The major hurdle in day care lobectomy can be approval from insurance.

A Retrospective Review of Opioid Prescribing Practices for At-Risk Pediatric Populations Undergoing Ambulatory Surgery.

OBJECTIVE: Pediatric patients with sleep-disordered breathing (SDB) and obesity are at risk for opioid-induced respiratory depression. Although monitoring in the inpatient setting allows for early recognition of opioid-related adverse events, there is far less vigilance after ambulatory surgery as patients are discharged home. Guidelines for proper opioid dosing in these pediatric subsets have not been established. We sought to determine if at-risk children were more likely to receive doses of opioids outside the recommended range. METHODS: Baseline opioid prescribing data for all outpatient surgery patients receiving an opioid prescription between January 2019 and June 2020 were retrospectively reviewed. Patients with SDB or obesity were identified. To obtain more information about prescribing practices, we analyzed patient demographics, size descriptors used for calculations, and prescription characteristics (dose, duration, and prescribing surgical service). RESULTS: A total of 4674 patients received an opioid prescription after outpatient surgery. Of those, 173 patients had SDB and 128 were obese. Surgical subspecialties rendering most of the opioid prescriptions included otolaryngology and orthopedics. Obese patients were more likely (64%) to be prescribed opioids using ideal weight at higher mg/kg doses (>0.05 mg/kg; 83.3%; p < 0.0001). When providers used actual body weight, lower mg/kg doses were more likely to be used (53.7%; p < 0.0001). No prescriptions used lean body mass. CONCLUSIONS: Overweight/obese children were more likely to receive opioid doses outside the recommended range. Variability in prescribing patterns demonstrates the need for more detailed guidelines to minimize the risk of opioid-induced respiratory complications in vulnerable pediatric populations.

Optimizando seguridad para cirugía mayor ambulatoria y anestesia fuera de pabellón en niños / Optimizing safety in pediatric ambulatory surgery and non operating room anesthesia

While Non Operating Room Anesthesia (NORA) and Pediatric Ambulatory Surgery (CMA) are increasing not only in numbers but also in new different procedures, we need to know how to optimize safety so we can have the same quality standards needed in theaters. We need to get involved in patient and procedure selection as well as risk assessment. In CMA such selection seeks for healthy or low risk patients, in NORA the assessment makes the provider look for the best conditions minimizing risks. To be successful in both programs we need to work with high standards and safety while Teamwork is necessary.

Todo indica que tanto los procedimientos Cirugía Mayor Ambulatoria (CMA) como Anestesia fuera de Pabellón (NORA) seguirán aumentando, no solo en número sino también en tipo de procedimientos a realizar. Involucrarnos en los procesos previos de selección de pacientes, evaluación preanestésica y estratificación de riesgo manteniendo la misma rigurosidad con que se realiza para los niños que van a pabellón es parte de nuestra tarea. Si en CMA, la selección busca incluir pacientes de bajo riesgo, en NORA la evaluación busca la mejor adaptación para realizar el procedimiento de un paciente complejo minimizando sus riesgos. Calidad y seguridad en estos programas son fundamentales para su éxito, así como el trabajo en equipo.

Resultados clínicos del tratamiento de pacientes con hernia inguinal unilateral mediante cirugía ambulatoria

Objetivo: Describir los resultados clínicos del tratamiento de pacientes con hernia inguinal unilateral (HIU) realizados en una unidad de cirugía mayor ambulatoria de un hospital de nivel III. Material y métodos: Se revisaron las historias clínicas de los pacientes operados de HIU en la Unidad de Cirugía Mayor ambulatoria (UCMA) del Hospital Cayetano Heredia (HCH) entre julio del 2013 y junio del 2016. Resultados: El número final de pacientes incluidos fue 154. La edad promedio fue 43 años; 101 (65,6%) fueron varones; 104 (67,5%) tenían riesgo quirúrgico ASA I; 12 (7,8%) tenían enfermedades asociadas; 94 (61,0%) se operaron con la técnica abierta, y 60 (39,0%) por la vía laparoscópica. La cirugía laparoscópica fue usada con más frecuencia en las mujeres (p=0.037). El tiempo operatorio fue mayor en la cirugía laparoscópica (p=0.033). No hubo diferencia significativa con respecto a la edad, riesgo quirúrgico, complicaciones anestésicas y complicaciones quirúrgicas entre pacientes operados con cirugía abierta y con cirugía laparoscópica. En total 34 (22%) pacientes no salieron de alta el mismo día de la cirugía: Ocho (5,2%) pacientes por presentar complicaciones y 26 (16,8%) pacientes por razones administrativas/ sociales. Conclusión: La cirugía ambulatoria de HIU en adultos realizada por la técnica abierta o laparoscópica, es un procedimiento seguro que permite el alta del paciente el mismo día de la cirugía.

SUMMARY Objective: To describe the clinical outcomes of patients with unilateral inguinal hernia (UIH) treated in an ambulatory surgical unit (ASU) of a level III hospital. Methods: The clinical charts of patients treated at the ASU of Cayetano Heredia Hospital from July 2013 to June 2016 were reviewed. Results: 154 patients were included, mean age was 43 years; 101 (65.6%) were males; 104 (67.5%) had ASA I risk; 12 (7.8%) had underlying diseases; 94 (61.0%) undergone the open technique and 60 (39.0%) undergone laparoscopy. Laparoscopy was most frequently applied in women (p=0.037). Surgical time was higher in laparoscopic procedures (p=0.033). No significant differences were observed in variables such as age, surgical risk, anesthetic and surgical complications between open and laparoscopic procedures. Thirty-four (22%) patients were not discharged the day of the procedure: 8 (5.2%) presented complications and 26 (16.8%) had administrative or social reasons. Conclusion : Ambulatory surgery of UIH in adults either by open or laparoscopic procedures is safe and allows discharging patients the day of the procedure.

Resultados y repercusión clínico-anestésica de los exámenes complementarios preoperatorios en pacientes ASA I para cirugía ambulatoria / Results and clinical-anesthetic repercussion of preoperative complementary tests in Asa-I patients scheduled for ambulatory surgery

Introducción: La selección de exámenes laboratorios preoperatorios (test específicos o exámenes por imágenes) debe hacerse como medida complementaria en el caso de sospecha clínica. La solicitud indiscriminada y de rutina es innecesaria e implica costos adicionales para la institución, además de la posibilidad de resultados falsos positivos, con repercusiones más o menos graves para los pacientes. Objetivo: Destacar los resultados y la repercusión clínico-anestésica de los exámenes complementarios preoperatorios en pacientes ASA I para cirugía ambulatoria que llegan a cirugía ambulatoria en el Hospital General Docente Comandante Pinares del municipio de San Cristóbal, Artemisa durante el año 2017. Método: Se realizó un estudio observacional de tipo descriptivo, de corte transversal en el Hospital General Docente Comandante Pinares del municipio de San Cristóbal, Artemisa, durante el año 2017. El universo se representa por 823 pacientes que se sometieron a cirugía ambulatoria, la muestra fue de 394 pacientes, según criterio de selección no probabilístico, intencional. Resultados: El sexo con mayor predominio en las cirugías fue el femenino 65,98 por ciento, las edades más frecuentes fue de 18-30 años. La cirugía electiva que más se realizó fue la colecistectomía 43,18 por ciento. En cuanto a los exámenes paraclínicos realizados, se detectó una baja incidencia de alteraciones, la complicación perioperatoria detectada fue la crisis hipertensiva 0,50 por ciento. Conclusión: Los resultados de los exámenes complementarios fueron normal en la mayoría de los pacientes, sin repercusiones o cambios en la conducta clínico anestésica. Además, generaron un elevado gasto a la institución de salud(AU)

Introduction: The selection of preoperative laboratory tests (specific tests or imaging tests) should be done, as a complementary measure, in the case of clinical suspicion. Indiscriminate and routine request is unnecessary and implies additional costs for the institution, in addition to the possibility of false positive results, with more or less serious repercussions for patients. Objective: To highlight the results and the clinical-anesthetic repercussion of complementary preoperative examinations in ASA-I patients who arrive for ambulatory surgery at Commandant Pinares General Teaching Hospital in San Cristóbal Municipality, Artemisa Province, during the year 2017. Method: An observational, descriptive, cross-sectional study was carried out at Commandant Pinares General Teaching Hospital in San Cristóbal Municipality, Artemisa Province, during the year 2017. The universe was represented by 823 patients who underwent ambulatory surgery. The sample consisted of 394 patients, following nonprobabilistic, intentional selection criteria. Results: The sex with the highest prevalence of surgeries was the female sex (65.98 percent). The most frequent ages were between 18 and 30 years. The most performed elective surgery was cholecystectomy (43.18 percent). Regarding the paraclinical examinations performed, a low incidence of alterations was detected; the perioperative complication detected was hypertensive crisis (0.50 percent). Conclusion: The results of the complementary examinations were normal in most of the patients, without repercussions or changes in the clinical anesthetic behavior. In addition, they generated high expenses for the health institution(AU)

Impact of Ambulatory Surgery for Hemorrhoidal Disease on Clinical Outcomes and Institutional Costs / Impacto da cirurgia ambulatória para patologia hemorroidária nos resultados clínicos e custos

Abstract Objective Transanal hemorrhoidal artery ligation with mucopexy (ligation anopexy [LA]) and open hemorrhoidectomy (OH) can both be performed under local anesthesia. The aim of the present study was to analyze the impact and the cost-effectiveness of performing these techniques in an ambulatory setting of an Italian academic center on the postoperative outcome. Methods A series of 122 consecutive patients with grades II and III hemorrhoidal disease undergoing ambulatory surgical treatment of hemorrhoids in 2015 to 2018 (group A) was comparedwith 122 patients operated at the same institution in the same period (group H) in a hospital setting. The primary outcome was the number of days required to return to work/daily activities. Secondary outcomes included postoperative pain and complications, costeffectiveness, patient satisfaction, and recurrence at 12 months. In group A, all the procedures were performed under local anesthesia with early discharge. In group H, the procedureswere performed under general or loco-regional anesthesia with hospital admission. Results The mean number of days required to return to work/daily activities was 8.4 ± 4.8 days in group A, compared with 12.5 ± 3 days in group H (p<0.001). The visual analog scale (VAS) pain score at 1 week, 2 and 3 weeks, and 1 month after surgery was lower for patients undergoing LA in the ambulatory setting (p<0.01). We observedmore postoperative complications in hospitalized (12.5%) than in ambulatory patients (7.5%) (p<0.001). The total mean direct costs per patient were significantly lower in the ambulatory setting versus the hospital stay group (351.3 versus 1,746 euros). Conclusion Implementing ambulatory surgery for hemorrhoids is feasible, safe, and cost-effective.

Resumo Objetivo A ligação transanal da artéria hemorroidária com mucopexia e a hemorroidectomia aberta (HA) podem ser realizadas em anestesia local. O objetivo do presente estudo foi analisar o impacto no resultado pós-operatório e a relação custo-eficácia da realização destas técnicas em ambiente ambulatorial de um centro acadêmico italiano no desfecho pós-operatório. Métodos Uma série de 122 pacientes consecutivos com patologia hemorroidária de graus II e III submetidos a cirurgia de hemorroidas em regime ambulatório de 2015 a 2018 (grupo A) foi comparada com 122 pacientes operados na mesma instituição no mesmo período (grupo H) por hospitalização. O desfecho primário foi o número de dias necessários para regressar ao trabalho/atividades diárias. Os desfechos secundários incluíram dor e complicações pós-operatórias, custo-eficácia, satisfação do paciente, e recidiva aos 12 meses. No grupo A, todos os procedimentos foram realizados em anestesia local. No grupo H, os procedimentos foram realizados em anestesia geral ou loco-regional. Resultados A espera média para o regresso ao trabalho foi de 8,4 ± 4,8 dias no grupo A em comparação com 12,5 ± 3 dias no grupo H (p<0,001). A pontuação na escala visual analógica (EVA) da dor 1 semana, 2 e 3 semanas, e 1 mês após a cirurgia foi mais baixa para os pacientes submetidos a cirurgia de ligadura com anopexia em ambiente ambulatorial (p<0,01). Observamosmais complicações pós-operatórias empacientes hospitalizados (12,5%) do que em pacientes ambulatórios (7,5%) (p<0,001). Os custos diretosmédios totais por paciente foram mais baixos em ambiente ambulatório do que no grupo de hospitalização (351,3 contra 1.746 euros). Conclusão A implementação da cirurgia ambulatória para hemorroidas é possível, segura e rentável.

[A long distance between home and hospital does not bother ambulatory surgery for ureteroscopy in French Guyana]. / Une grande distance entre le domicile et l'hôpital ne contre-indique pas l'ambulatoire pour urétéroscopie en Guyane française.

INTRODUCTION: French Guyana is 83,500 km2 wide (equivalent to 1/6 of France). Communes are distant. Public urology is set in Kourou only. These particularities led to develop ambulatory urological surgery including for patients living far away from the reference centre. We report our experience with patient ureteroscopy (URS). MATERIAL: The study is retrospective (2018-2019), and includes 125 patients. Among these patients, 19.2% live in Kourou, 71.1% live 40 to 100km from the hospital and 9.7% beyond 100km. Every patient had an outpatient procedure for rigid and/or flexible URS to treat stone disease, including in lower calyx [LC] (38.4%). Ambulatory surgery was also proposed to the patients living away with the usual restrictions. Complications, results and switch to conventional hospitalisation (CH) were studied. RESULTS: Mean stone size was 10,5mm (4-30), stone density was 1030 UH (470-1700). The postoperative complication rate was 4%. There were 90.4% 'stone free' patients (85.4% for LC). One patient was rehospitalised within 48hours for acute flank pain and 9 patients had a switch of ambulatory to CH: 6 for discharge too late and 3 for complication (fever and/or pain). Distance between home and hospital was linked neither to complication rate, nor to switch to CH. CONCLUSION: Ambulatory URS is possible without further complications in selected patients living beyond 100km from the hospital, because of a specific organisation and an appropriate training of the caregivers involved in postoperative patient care. LEVEL OF PROOF: 3.

Outcomes of Orthopedic Hand Surgeries in Minor Procedure Rooms at a Veterans Affairs Medical Center.

Purpose: There is a high demand for minor hand surgeries within the veteran population. The objective of this study was to compare clinical outcomes and resource use at a Veterans Affairs Medical Center (VAMC) of hand surgeries performed in minor procedure rooms (MPR) and operating rooms using local anesthesia with or without monitored anesthesia care. Methods: We retrospectively evaluated all patients undergoing carpal tunnel release, de Quervain's release, foreign body removal, soft tissue mass excision, or A1 pulley release at a VAMC over a 5-year period. Data collected included demographic information, mental health comorbidities, presence of preoperative and postoperative pain, complications after surgery, time to surgery, number of personnel in surgery, turnover time between cases, and time spent in the postanesthesia care unit. Statistical analysis included Fisher exact or chi-square analysis to compare MPR versus operating room groups and Student t test or Mann-Whitney test to compare continuous variables. Results: In this cohort of 331 cases, 123 and 208 patients underwent surgery in MPRs and operating rooms, respectively. Preoperative and postoperative pain were similar between the MPR and operating room groups. Complications were slightly lower in the MPR group versus the operating room group (0% MPR vs 2.9% operating room). Median time from surgical consult to surgery was 6 days less for MPR patients (15 vs 21). The MPR cases also used fewer personnel during surgery, averaging 4.76 versus 4.99 people. The MPR patients spent 9 minutes less in the postanesthesia care unit (median, 36 vs 45 minutes) and turnover time between cases was nearly 8 minutes faster in MPRs than in operating rooms (median, 20 vs 28 minutes). Conclusions: Minor procedure rooms at a VAMC allow more veteran patients to be scheduled for minor hand surgeries within a shorter time frame, utilize less staff and postoperative monitoring, and maintain excellent outcomes with limited complications. Clinical relevance: Minor hand surgeries in MPRs have outcomes equivalent to those of operating rooms with improved time savings and resource use.

Severe acute postoperative pain self-reported by children after ambulatory surgeries: a cohort study / Dor aguda pós-operatória intensa autorreferida por crianças após cirurgias ambulatoriais: um estudo de coorte / Dolor postoperatorio agudo severo autoinformado por niños después de cirugías ambulatorias: un estudio de cohort

ABSTRACT Objectives: to estimate the incidence and the risk factors for severe acute postoperative pain self-reported on the first day after hospital discharge. Methods: cohort study with 279 children from both sexes (5-12 years old), indicated for ambulatory surgery in two Brazilian hospitals. Children were assessed at the pre-surgery, immediate postoperative and first postoperative day. Faces Pain Scale-Revised and Yale Preoperative Anxiety Scale Modified were used. Severe postoperative pain was defined as score ≥6. Cox regression analyses were used. Results: the incidence of severe postoperative pain was 15.8% (95%CI:10.7%-20.4%) on the first postoperative day. Preoperative anxiety (HR=2.23; p=0.049), severe preoperative pain (HR=2.78; p=0.031) and having undergone two surgical procedures (HR=2.91; p=0.002) were associated with severe postoperative pain. Conclusions the incidence of severe postoperative pain self-reported after hospital discharge was high. Anxiety and severe preoperative pain, in addition to performing two surgical procedures at the same time were confirmed as risk factors.

RESUMO Objetivos: estimar a incidência e os fatores de risco para dor pós-operatória intensa autorreferida no primeiro dia pós-alta. Métodos: estudo de coorte com 279 crianças de ambos os sexos (5-12 anos), com indicação para cirurgia ambulatorial em dois hospitais brasileiros. As crianças foram avaliadas no pré-operatório, pós-operatório imediato e primeiro dia pós-alta. As Escala de Faces de Dor Revisada e Escala de Ansiedade Pré-operatória de Yale Modificada foram utilizadas. Dor aguda pós-operatória foi definida como pontuação ≥6. Análises de regressão de Cox foram realizadas. Resultados: a incidência de dor pós-operatória foi de 15,8% (IC95%: 10,7%-20,4%) no primeiro dia pós-alta. Ansiedade pré-operatória (HR=2,23; p=0,049), dor préoperatória intensa (HR=2,78; p=0,031) e ter sido submetido a dois procedimentos cirúrgicos (HR=2,91; p=0,002) foram associados à dor pós-operatória. Conclusões: a incidência de dor intensa autorreferida no pós-operatório foi elevada. Ansiedade, dor pré-operatória intensa e submissão a dois procedimentos cirúrgicos foram confirmados como fatores de risco.

RESUMEN Objetivos: estimar la incidencia y los factores de riesgo de dolor postoperatorio agudo severo autoinformado el primer día después del alta hospitalaria. Métodos: estudio de cohorte con 279 niños de ambos sexos, 5-12 años, indicados para cirugía ambulatoria en dos hospitales brasileños, evaluados en el preoperatorio, inmediato y el primer día posoperatorio. Se utilizaron: Faces Pain Scale-Revised y Modified Yale Preoperative Anxiety Scale. Dolor posoperatorio agudo fue una puntuación ≥6. Se utilizó el análisis de regresión de Cox. Resultados: la incidencia de dolor postoperatorio agudo fue del 15,8% (IC 95%: 10,7%-20,4%) en el primer día postoperatorio. Ansiedad preoperatoria (HR=2,23; p=0,049), dolor preoperatorio agudo (HR=2,78; p=0,031) y haber sido sometido a dos procedimientos quirúrgicos (HR=2,91; p=0,002) se asociaron con dolor postoperatorio agudo. Conclusiones la incidencia de dolor agudo autoinformado en el postoperatorio después del alta hospitalaria fue alta. Ansiedad, dolor preoperatorio agudo y haber realizado dos intervenciones quirúrgicas al mismo tiempo fueron factores de riesgo.

Severe acute postoperative pain self-reported by children after ambulatory surgeries: a cohort study / Dor aguda pós-operatória intensa autorreferida por crianças após cirurgias ambulatoriais: um estudo de coorte / Dolor postoperatorio agudo severo autoinformado por niños después de cirugías ambulatorias: un estudio de cohort

ABSTRACT Objectives: to estimate the incidence and the risk factors for severe acute postoperative pain self-reported on the first day after hospital discharge. Methods: cohort study with 279 children from both sexes (5-12 years old), indicated for ambulatory surgery in two Brazilian hospitals. Children were assessed at the pre-surgery, immediate postoperative and first postoperative day. Faces Pain Scale-Revised and Yale Preoperative Anxiety Scale Modified were used. Severe postoperative pain was defined as score ≥6. Cox regression analyses were used. Results: the incidence of severe postoperative pain was 15.8% (95%CI:10.7%-20.4%) on the first postoperative day. Preoperative anxiety (HR=2.23; p=0.049), severe preoperative pain (HR=2.78; p=0.031) and having undergone two surgical procedures (HR=2.91; p=0.002) were associated with severe postoperative pain. Conclusions the incidence of severe postoperative pain self-reported after hospital discharge was high. Anxiety and severe preoperative pain, in addition to performing two surgical procedures at the same time were confirmed as risk factors.

RESUMO Objetivos: estimar a incidência e os fatores de risco para dor pós-operatória intensa autorreferida no primeiro dia pós-alta. Métodos: estudo de coorte com 279 crianças de ambos os sexos (5-12 anos), com indicação para cirurgia ambulatorial em dois hospitais brasileiros. As crianças foram avaliadas no pré-operatório, pós-operatório imediato e primeiro dia pós-alta. As Escala de Faces de Dor Revisada e Escala de Ansiedade Pré-operatória de Yale Modificada foram utilizadas. Dor aguda pós-operatória foi definida como pontuação ≥6. Análises de regressão de Cox foram realizadas. Resultados: a incidência de dor pós-operatória foi de 15,8% (IC95%: 10,7%-20,4%) no primeiro dia pós-alta. Ansiedade pré-operatória (HR=2,23; p=0,049), dor préoperatória intensa (HR=2,78; p=0,031) e ter sido submetido a dois procedimentos cirúrgicos (HR=2,91; p=0,002) foram associados à dor pós-operatória. Conclusões: a incidência de dor intensa autorreferida no pós-operatório foi elevada. Ansiedade, dor pré-operatória intensa e submissão a dois procedimentos cirúrgicos foram confirmados como fatores de risco.

RESUMEN Objetivos: estimar la incidencia y los factores de riesgo de dolor postoperatorio agudo severo autoinformado el primer día después del alta hospitalaria. Métodos: estudio de cohorte con 279 niños de ambos sexos, 5-12 años, indicados para cirugía ambulatoria en dos hospitales brasileños, evaluados en el preoperatorio, inmediato y el primer día posoperatorio. Se utilizaron: Faces Pain Scale-Revised y Modified Yale Preoperative Anxiety Scale. Dolor posoperatorio agudo fue una puntuación ≥6. Se utilizó el análisis de regresión de Cox. Resultados: la incidencia de dolor postoperatorio agudo fue del 15,8% (IC 95%: 10,7%-20,4%) en el primer día postoperatorio. Ansiedad preoperatoria (HR=2,23; p=0,049), dolor preoperatorio agudo (HR=2,78; p=0,031) y haber sido sometido a dos procedimientos quirúrgicos (HR=2,91; p=0,002) se asociaron con dolor postoperatorio agudo. Conclusiones la incidencia de dolor agudo autoinformado en el postoperatorio después del alta hospitalaria fue alta. Ansiedad, dolor preoperatorio agudo y haber realizado dos intervenciones quirúrgicas al mismo tiempo fueron factores de riesgo.

Cirugía Mayor Ambulatoria en un Servicio de Cirugía General: cinco años de experiencia / Five-year experience with major ambulatory surgery in a department of general surgery

RESUMEN Antecedentes: como Cirugía Mayor Ambulatoria (CMA) se designan procedimientos quirúrgicos te rapéuticos o diagnósticos, realizados con anestesia general, locorregional o local, con sedación o sin ella, que requieren cuidados posoperatorios de corta duración, por lo que no necesitan ingreso hos pitalario. Objetivo: analizar la experiencia de la Unidad de Cirugía Mayor Ambulatoria integrada al Servicio de Cirugía del Hospital Avellaneda, de San Miguel de Tucumán, en el período enero 2014- diciembre 2018. Material y métodos: estudio descriptivo, retrospectivo, de corte transversal, de asociación cruzada. Pacientes entre 14 y 75 años. Los datos fueron recolectados de una base prospectiva implementada desde el inicio de una experiencia piloto. Resultados: se realizaron 3827 intervenciones quirúrgicas, de las cuales 2327 fueron procedimientos quirúrgicos bajo la modalidad de CMA; 1514 correspondieron al sexo femenino; prevaleció el rango de 45 a 54 años de edad. Los procedimientos quirúrgicos realizados fueron: colecistectomía laparoscópi ca, patología de la pared abdominal, patologías orificiales, procedimientos combinados. Indicadores de calidad: la tasa de cancelación, valor atribuible a la ausencia del paciente el día de la cirugía, y de suspensión, debido a la modalidad selección del paciente y de infraestructura, ambas tasas mostraron una disminución estadísticamente significativas entre los años 2014 y 2018. La tasa de reintervención fue en el último año de 0,35%; los ingresos y reingresos disminuyeron a 1,6% y 1,07%, respectivamen te al año 2018. Se presentaron 52 complicaciones, 13 mayores y 39 menores. El grado de satisfacción fue elevado: un 99,5%. Conclusión: la CMA es un proceso seguro, con tasas de complicaciones bajas.

ABSTRACT Background: Major ambulatory surgery is defined as therapeutic or diagnostic surgical procedures, performed under general, regional or local anesthesia, with or without sedation, which require short-term postoperative care, and therefore do not require hospital admission Objective: The aim of this study is to analyze the experience of the same day unit integrated to the Department of General Surgery and Gastrointestinal Surgery at Hospital de Clínicas Pte. Avellaneda in San Miguel de Tucumán between January 2014 and December 2018. Material and methods: We conducted a descriptive and retrospective cross-sectional study. Patients between 14 and 75 years were included. Data were collected from a prospective database implemented for the beginning of a pilot experience. Results: A total of 3827 surgeries were performed; 2327 corresponded to MAS procedures; 1514 patients were women, and aged ranged between 45 and 54 years. The surgical procedures corresponded to laparoscopic cholecystectomy, abdominal wall defects, perianal diseases and combined procedures. Quality indicators: the cancellation rate, which indicates the percentage of patients who did not attend the day surgery unit, and the rate of procedures suspended due to issues associated with patient selection and infrastructure, showed a statistically significant reduction between 2014 and 2018. Unplanned repeated surgery rate was 0.35% in 2018, and unplanned admissions and readmissions decreased to 1.6% and 1.07%, respectively, in 2018. Major complications occurred in 13 patients and 39 patients presented minor complications. Patient's satisfaction was 99.5%.. Conclusion: MAS is a safe process, with low rate of complications.

Cirugía mayor ambulatoria: antecedentes, evolución y logros / Major ambulatory surgery: history, evolution and achievements

RESUMEN Fundamento: La cirugía mayor ambulatoria comprende los procedimientos o intervenciones mayores en los que, con anestesia general o regional y tras un tiempo variable de control y observación, el paciente regresa a su domicilio el mismo día de la intervención. Objetivo: Exponer los antecedentes históricos de la cirugía mayor ambulatoria a nivel internacional y en Cuba. Metodología: Se realizó una revisión sobre los antecedentes históricos de la cirugía mayor ambulatoria mediante la búsqueda bibliográfica en Infomed, en las bases de datos Pubmed y SciELO, así como en memorias de eventos científicos y tesis. Resultados: Aunque la cirugía ambulatoria es la forma más antigua de cirugía que se conoce, desde el pasado siglo se ha popularizado y difundido y actualmente representa hasta el 80 % de la cirugía mayor electiva. En Cuba los primeros acercamientos a esta modalidad se realizaron a finales de la década de los 70 del pasado siglo con un desarrollo ascendente. Tanto a nivel internacional como en Cuba una parte de los profesionales de la salud han comprendido la necesidad de la cooperación entre los niveles primario y secundario de atención para esta actividad. Conclusiones: La cirugía mayor ambulatoria se ha convertido en una modalidad quirúrgica imprescindible en la práctica asistencial cotidiana, que ha perdurado y se ha arraigado por las innegables ventajas que ofrece a todos los involucrados en el proceso de atención y que es perfectible sobre la base de postulados de colaboración entre los niveles de atención primario y secundario de salud.

ABSTRACT Background: Major ambulatory surgery includes procedures or major interventions in which, with general or regional anesthesia and after a variable time of monitoring and observation, the patient returns home the same day of the intervention. Objective: To expose the historical background of major ambulatory surgery internationally and in Cuba. Methodology: A review of the historical background of the major ambulatory surgery through the bibliographic searching in Infomed, Pubmed and SciELO databases, as well as in scientific event memories and theses was made. Results: Although mayor ambulatory surgery is the oldest form of surgery known, since the last century it has become popular and widespread and it currently represents up to 80 % of elective major surgery. In Cuba the first approaches to this modality were made at the end of the 70s of the last century having an upward development. Both, internationally and in Cuba, the need for cooperation between the primary and secondary health care levels for this activity has been understood by health professionals. Conclusions: Major ambulatory surgery has become an essential surgical modality in everyday health care practice, which has endured and grew up due to the undeniable advantages that it offers to all those involved in the care process and which is perfectible based on the collaborative postulates between primary and secondary health care levels.

Cirugía ambulatoria electiva en patología proctológica: experiencia prospectiva de 14 años en un hospital público docente / Elective ambulatory surgery in proctological pathology: 14 years of prospective experience in a public teaching hospital

INTRODUCCIÓN: Se presenta nuestra experiencia en cirugía ambulatoria en patología proctológica. MATERIALES Y MÉTODO: La serie corresponde al análisis de 1.399 pacientes tratados entre agosto de 2003 y diciembre de 2017 en forma prospectiva, RESULTADOS: Fueron intervenidos por fístula anorrectal (20%), enfermedad hemorroidaria (19%), enfermedad pilonidal sacro coccígea (EPSC) (15%), fisura anal (13%), biopsia rectal quirúrgica o resección local endoanal (12%), condilomas (10%) y otras (10%). La morbilidad inmediata es de un caso, por un hematoma luego de una cirugía por EPSC que requirió hemostasia y cierre primario. La tasa de hospitalización inmediata fue de 0,3% y corresponde a 5 casos de retención aguda de orina. La hospitalización tardía fue de un 1,6% y corresponde a 22 pacientes, hospitalizados por sangrado tardío (9), dolor intratable (9) y fiebre (4). Todos fueron tratados en forma conservadora con resolución entre los 2 y 5 días. No se registra morbilidad mayor en esta serie. CONCLUSIONES: La cirugía ambulatoria en patología proctológica es factible y segura.

INTRODUCTION: We present our prospective experience in ambulatory anorectal surgery between August 2003 and December 2017. MATERIALS AND METHOD: The series corresponds to the analysis of 1399 patients treated between August 2003 and December 2017 prospectively. RESULTS: The etiology of the surgerys were anal fistula (20%), hemorrhoidal disease (19%), sacrococcygeal pilonidal disease (15%), anal fissure (13%), rectal surgical biopsy or local resection (12%), condylomata (10%) and others (10%). The immediate morbidity was seen one case, a hematoma after an EPSC surgery that required hemostasis and primary closure. The immediate hospitalization rate was 0.3% and corresponds to 5 cases of acute urinary retention. The late hospitalization was 1.6% and corresponds to 22 patients, due to late bleeding (9), severe pain (9) and fever (4). All were treated conservatively with resolution between 2 and 5 days. No major morbidity is recorded in this series. CONCLUSION: We concluded that outpatient surgery in proctologic pathology is feasible and safe.

Feasibility of Routine Ambulatory Laparoscopic Cholecystectomy in Brazil.

BACKGROUND AND OBJECTIVES: In several developed countries, most laparoscopic cholecystectomies (LCs) are performed as an ambulatory operation (ALC) with a high rate of success. In Latin America, the experience with this procedure is still limited. Our objective is to evaluate the feasibility to implement ALC in a Brazilian teaching hospital. METHODS: Data obtained from electronic medical records and study protocols of all patients who underwent an LC between January 2011 and March 2018 were evaluated. All patients with chronic or acute cholecystitis were initially considered for an ALC. RESULTS: Of a total of 1645 patients who underwent LC, 1577 (95.9%) were discharged on the same day of the operation. The main reasons for hospital admission after ALC were patient refusal to be discharged (n = 23; 1.4%), nausea and vomiting (n = 15; 0.9%), and complicated acute cholecystitis. No patient was excluded from consideration for ALC based only on age, history of previous upper abdominal operation, and presence of comorbidity. Patient age ranged from 12 to 100 years, with a mean of 50.23 ± 15.35 years. Intraoperative and postoperative complication rates were 0.4% and 5.5%, respectively. Most perioperative complications were because of technical surgical difficulties and complications common to most abdominal operations (surgical site, pulmonary, urinary, and venous complications). Thirteen (0.8%) patients were readmitted to the hospital because of abdominal pain and fever (n = 4), pneumonia (n = 3), deep venous thrombosis (n = 3), or urinary retention (n = 3). CONCLUSIONS: ALC may be performed in Brazil with low rates of morbidity, mortality, and hospital readmission. Its implementation should be stimulated in Latin America.

Enhanced recovery after surgery protocol allows ambulatory laparoscopic appendectomy in uncomplicated acute appendicitis: a prospective, randomized trial.

BACKGROUND: Previous observational studies have demonstrated the safety of discharging patients after laparoscopic appendectomy within the same day without hospitalization. The application of Enhanced Recovery After Surgery (ERAS) guidelines has resulted in shorter length of stay, fewer complications, and reduction in medical costs. The aim of this study was to investigate if ERAS protocol implementation in patients with acute uncomplicated appendicitis decreases the length of stay enough to allow for ambulatory laparoscopic appendectomy. METHODS: In this prospective, randomized controlled clinical trial, 108 patients were randomized into two groups: laparoscopic appendectomy with ERAS (LA-E) or laparoscopic appendectomy with conventional care (LA-C). The primary endpoint was postoperative length of stay. The secondary end points were time to resume diet, postoperative pain, postoperative complications, re-admission rate, and reoperation rate. RESULTS: From January 2016 through May 2017, 50 patients in the LA-E group and 58 in the LA-C were analyzed. There were no significant differences in preoperative data. Regarding the primary end point of the study, the ERAS protocol significantly reduced the postoperative length of stay with a mean of 9.7 h (SD: 3.1) versus 23.2 h (SD: 6.8) in the conventional group (p < 0.001). The ERAS protocol allowed ambulatory management in 90% of the patients included in this group. There was a significant reduction in time to resume diet (110 vs. 360 min, p < 0.001) and less moderate-severe postoperative pain (28 vs. 62.1%, p < 0.001) in the LA-E versus LA-C group. The rate of complications, readmissions, and reoperations were comparable in both groups (p = 0.772). CONCLUSIONS: ERAS implementation was associated with a significantly shorter length of stay, allowing for the ambulatory management of this group of patients. Ambulatory laparoscopic appendectomy is safe and feasible with similar rates of morbidity and readmissions compared with conventional care.

Pain Distraction During Ambulatory Surgery: Virtual Reality and Mobile Devices.

Virtual reality (VR) pain distraction has been applied across medical, surgical, and behavioral healthcare domains, marking a shift in pain attenuation practices. However, there is little research that has been performed to compare the efficacy of traditional head-mounted displays (HMDs) versus portable VR devices. The present study evaluated 44 outpatients in need of lipoma resection. Randomized into two groups-HMD versus mobile phone VR-participants navigated pain distraction virtual environments while undergoing surgery. Vital signs and subjective pain measurements via a visual analog scale were taken before, during, and after the surgery. Results indicate that the HMD group reported greater pain reduction than the Mobile group. Overall, this study points to the efficacy of nonpharmacological pain attenuation practices. Although both systems reduced pain during surgery, the clinically validated VR environments seen in the HMD group were more effective. This study does show that inexpensive solutions can work in surgical settings. Future research should be performed to identify the most effective VR pain distraction systems.

Wide Awake Hand Surgery Under Local Anesthesia No Tourniquet in South America.

The authors report the introduction and development of wide awake hand surgery under local anesthesia no tourniquet (WALANT) in South America, specifically in Brazil, where thousands of cases have already been performed with this technique. This was largely stimulated by Dr Lalonde's first visit to Brazil in 2012. The authors began with smaller procedures such as trigger fingers and carpal tunnels, which were easily implemented. There has been an increase in the number of more complex procedures, such as flexor tenolysis or tendon transfers, in which patient cooperation can help improve results.