Proyecto DUCMA 2.0. Puesta al día sobre la situación actual de las unidades de Cirugía Mayor Ambulatoria en España / DUCMA 2.0 project: Update on the current situation of the outpatient surgery units in Spain

Introducción: La cirugía mayor ambulatoria (CMA) es un sistema de gestión seguro y eficiente para resolver los problemas quirúrgicos, pero su implantación y desarrollo ha sido variable. El objetivo de este estudio es describir las características, la estructura y el funcionamiento de las unidades de Cirugía Mayor Ambulatoria (UCMA) en España. Métodos: Estudio observacional, transversal, multicéntrico basado en una encuesta electrónica, con recogida de datos entre abril y septiembre de 2022. Resultados: En total, 90 UCMA completaron la encuesta. La media del índice de ambulatorización (IA) global es de 63%. Más de la mitad de las UCMA (52%) son de tipo integrado. La mitad las unidades imparte formación para médicos (51%) y personal de enfermería (55%). Los indicadores de calidad más utilizados son la tasa de suspensiones (87%) y de ingresos no previstos (80%). Conclusiones: Se necesita mayor coordinación entre administraciones para obtener datos fiables. Asimismo, se deben implementar sistemas de gestión de calidad en las unidades y desarrollar herramientas para la formación adecuada de los profesionales implicados.(AU)

Introduction: Ambulatory surgery is a safe and efficient management system to solve surgical problems, but its implementation and development has been variable. The aim of this study is to describe the characteristics, structure and functioning of ambulatory surgery units (ASU) in Spain. Methods: Multicenter, cross-sectional, observational study based on an electronic survey, with data collection between April and September 2022. Results: In total, 90 ASUs completed the survey. The mean overall ambulatory index is 63%. More than half of the ASUs (52%) are integrated units. Around half of the units provide training for physicians (51%) and for nurses (55%). The most frequently used quality indicators are suspension rate (87%) and the rate of unplanned admissions (80%). Conclusions: Greater coordination between administrations is needed to obtain reliable data. It is also necessary to implement quality management systems in the different units, as well as to develop tools for the adequate training of the professionals involved.(AU)

DUCMA 2.0 project: Update on the current situation of the outpatient surgery units in Spain.

INTRODUCTION: Ambulatory surgery is a safe and efficient management system to solve surgical problems, but its implementation and development has been variable. The aim of this study is to describe the characteristics, structure and functioning of ambulatory surgery units (ASU) in Spain. METHODS: Multicenter, cross-sectional, observational study based on an electronic survey, with data collection between April and September 2022. RESULTS: In total, 90 ASUs completed the survey. The mean overall ambulatory index is 63%. More than half of the ASUs (52%) are integrated units. Around half of the units provide training for physicians (51%) and for nurses (55%). The most frequently used quality indicators are suspension rate (87%) and the rate of unplanned admissions (80%). CONCLUSIONS: Greater coordination between administrations is needed to obtain reliable data. It is also necessary to implement quality management systems in the different units, as well as to develop tools for the adequate training of the professionals involved.

Implementación de un programa de cirugía bariátrica sin ingreso hospitalario y seguimiento con plataforma de telemonitorización / Implementation of a same-day discharge bariatric surgery program and follow-up with a telemonitoring platform

Introducción: Existe experiencia previa en programas de cirugía bariátrica ambulatoria en pacientes seleccionados, que reportan buenos resultados tras gastrectomía vertical. Estudios recientes demuestran que la cirugía ambulatoria también es factible y segura en el bypass gástrico en Y de Roux. El objetivo del presente trabajo es describir y analizar los resultados de nuestra experiencia inicial tras la implementación de un programa de cirugía bariátrica sin ingreso hospitalario, con la utilización del sistema de telemonitorización. Métodos: Estudio observacional prospectivo con 14 pacientes consecutivos seleccionados, intervenidos de cirugía bariátrica primaria (gastrectomía vertical o bypass gástrico en Y de Roux) en un único centro, desde abril de 2021 hasta febrero 2023, con seguimiento en domicilio mediante la plataforma de telemonitorización REVITA® (HI Iberia, S.A.) y la unidad de hospitalización a domicilio. Resultados: Desde abril de 2021 a febrero 2023 fueron seleccionados para este programa 14 pacientes, lo cual significa el 7,3% del total de 191 pacientes intervenidos de cirugía bariátrica durante este periodo. Llegaron a completar el circuito 10 de los 14 pacientes seleccionados (71,4%). Cuatro de los 10 pacientes que completaron el circuito consultaron a urgencias en las primeras 24h (40%). No hubo complicaciones graves, reingresos, ni reintervenciones propias de la cirugía bariátrica. Se ha estimado un ahorro de 762€ por cada paciente que completa el circuito. Conclusiones: La cirugía bariátrica sin ingreso hospitalario es factible y segura en pacientes seleccionados usando una plataforma de telemonitorización y con el apoyo de una unidad de hospitalización a domicilio. (AU)

Introduction: Some groups have initiated outpatient bariatric surgery programs in selected patients, publishing good results after sleeve gastrectomy. Recent studies show that outpatient surgery is also feasible and safe in Roux-en-Y gastric bypass. The aim of this paper is to describe and analyze the results of our initial experience after the implementation of a same-day discharge bariatric surgery program using a telemonitoring system. Methods: We have completed a prospective, observational study with 14 consecutive, selected patients undergoing primary bariatric surgery (sleeve gastrectomy or Roux-en-Y gastric bypass) at a single center from April 2021 to February 2023, with home follow-up using the REVITA® telemonitoring platform (HI Iberia, S.A.) and the home hospitalization unit. Results: From April 2021 to February 2023, 14 patients were selected for this program, which meant 7.3% of the total of 191 patients who underwent bariatric surgery during this period. Ten out of the 14 patients selected completed the circuit (71.4%), 4 of whom consulted the emergency department within the first 24h (40%). There were no serious complications, readmissions or re-operations typical of bariatric surgery. The estimated savings per patient who completed the circuit was €762. Conclusion: Bariatric surgery without hospital admission is feasible and safe in selected patients using a telemonitoring platform and with the support of a home hospitalization unit. (AU)

Formación en cirugía mayor ambulatoria. Una asignatura pendiente en nuestro país / Training in ambulatory surgery. A pending subject in our country

La implantación y generalización a nivel mundial de la cirugía mayor ambulatoria (CMA) es una realidad patente en la actualidad y se espera un crecimiento progresivo de la misma a corto plazo, pero esta globalización también puede afectar de forma negativa a la docencia y el entrenamiento de los futuros médicos y aquellos que están en formación, si no se estandariza y regula, ya que una parte importante de la gestión de la patología más frecuente subsidiaria de ser realizada en CMA, acaba fuera de los circuitos del hospital donde el médico residente se está formando. (AU)

The implantation and generalization of ambulatory surgery worldwide is currently a clear reality and its progressive growth is expected in the short term, but this globalization can also negatively affect the teaching and training of future doctors and those who are in training, if it is not standardized and regulated, since an important part of the management of the most common pathology that could be performed in ambulatory surgery finish outside the circuits of the hospital where the resident doctor is training. (AU)

Training in ambulatory surgery. A pending subject in our country.

The implementation and generalized use of Ambulatory Surgery worldwide is currently a clear reality. Its progressive growth is expected in the short term, but this globalization can also negatively affect the education and training of future doctors, as well as those who are being trained now, if it is not standardized and regulated, since a significant part of the management of the most common pathology that could be performed in Ambulatory Surgery is completed outside the training circuits of hospitals where resident doctors are trained.

Implementation of a same-day discharge bariatric surgery program and follow-up with a telemonitoring platform.

INTRODUCTION: Some groups have initiated outpatient bariatric surgery programs in selected patients, publishing good results after sleeve gastrectomy. Recent studies show that outpatient surgery is also feasible and safe in Roux-en-Y gastric bypass. The aim of this paper is to describe and analyze the results of our initial experience after the implementation of a same-day discharge bariatric surgery program using a telemonitoring system. METHODS: We have completed a prospective, observational study with 14 consecutive, selected patients undergoing primary bariatric surgery (sleeve gastrectomy or Roux-en-Y gastric bypass) at a single center from April 2021 to February 2023, with home follow-up using the REVITA® telemonitoring platform (HI Iberia, S.A.) and the Home Hospitalization Unit. RESULTS: From April 2021 to February 2023, 14 patients were selected for this program, which meant 7.3% of the total of 191 patients who underwent bariatric surgery during this period. Ten out of the 14 patients selected completed the circuit (71.4%), 4 of whom consulted the emergency department within the first 24 h (40%). There were no serious complications, readmissions or re-operations typical of bariatric surgery. The estimated savings per patient who completed the circuit was 762. CONCLUSION: Bariatric surgery without hospital admission is feasible and safe in selected patients using a telemonitoring platform and with the support of a home hospitalization unit.

Preliminary results of the implementation of robotic radical prostatectomy in a major ambulatory surgery regimen.

OBJECTIVE: To report our initial experience with robotic radical prostatectomy as an outpatient procedure. MATERIAL AND METHODS: Retrospective analysis of patients who underwent RRP as MAS (Major Ambulatory Surgery) at our center between March 2021 and May 2022. We collected baseline patient characteristics, intraoperative outcomes and postoperative data (need for unplanned medical care and complications at one month after surgery). Oncologic characteristics at disease diagnosis (PSA, staging, ISUP, MRI) and postoperative pathologic outcomes were collected. RESULTS: We identified a total of 35 patients with an average age of 60,8 ± 6,88 years and a BMI of 27 ± 2,9 Kg/m2. All patients had a low anesthetic risk and 25.71% had undergone previous abdominal surgery. The surgical time was 151,66 ± 42,15 min and the average blood loss was 301,2 ± 184,38 mL. Two patients (5.7%) were admitted for one night and 7 patients (20%) consulted the emergency department in the following month, of which 3 (8.57%) were readmitted. We recorded one intraoperative complication, seven mild postoperative complications (Clavien I-II) and one severe complication (Clavien IIIb). The severe complication occurred on the eighth postoperative day and was not related to the procedure being ambulatory. CONCLUSION: The absence of serious complications in the immediate postoperative period supports RRP in MAS as a safe technique for selected patients.

Resultados preliminares de la implementación de la prostatectomía radical robótica en régimen de cirugía mayor ambulatoria / Preliminary results of the implementation of robotic radical prostatectomy in a major ambulatory surgery regimen

Objetivo Reportar nuestra experiencia inicial de prostatectomía radical robótica (PRR) en régimen ambulatorio. Material y métodos Análisis retrospectivo de los pacientes intervenidos de PRR en cirugía mayor ambulatoria (CMA) en nuestro centro entre marzo de 2021 y mayo de 2022. Recopilamos las características basales de los pacientes, los resultados intraoperatorios y los datos del postoperatorio (necesidad de asistencia médica no planificada y complicaciones al mes de la cirugía). Se recogieron las características oncológicas al diagnóstico de la enfermedad (PSA, estadificación, ISUP, RMN) y el resultado anatomopatológico tras la intervención. Resultados Identificamos un total de 35 pacientes, con una edad promedio de 60,8 ±6,88 años y un IMC de 27 ±2,9kg/m2. Todos presentaban un riesgo anestésico bajo y un 25,71% tenían alguna cirugía abdominal previa. El tiempo quirúrgico fue de 151,66 ±42,15 minutos y el sangrado promedio fue de 301,2 ±184,38mililitros. Dos pacientes (5,7%) ingresaron la primera noche de la cirugía y 7 pacientes (20%) consultaron en urgencias en el mes siguiente, de los cuales 3 (8,57%) reingresaron. Registramos una complicación intraoperatoria, 7 complicaciones postoperatorias leves (ClavienI-II) y una complicación grave (ClavienIIIb). La complicación grave transcurrió al octavo día postoperatorio y no tuvo relación con la ambulatorización del procedimiento. Conclusión La ausencia de complicaciones graves en el postoperatorio inmediato avala la PRR en régimen de CMA como una técnica segura dirigida a pacientes seleccionados (AU)

Objective To report our initial experience with robotic radical prostatectomy (RRP) as an outpatient procedure. Material and methods Retrospective analysis of patients who underwent RRP as major ambulatory surgery (MAS) at our center between March 2021 and May 2022. We collected baseline patient characteristics, intraoperative outcomes and postoperative data (need for unplanned medical care and complications at one month after surgery). Oncologic characteristics at disease diagnosis (PSA, staging, ISUP, MRI) and postoperative pathologic outcomes were collected. Results We identified a total of 35 patients with an average age of 60,8 ±6,88years and a BMI of 27 ±2,9kg/m2. All patients had a low anesthetic risk and 25.71% had undergone previous abdominal surgery. The surgical time was 151,66 ±42,15minutes and the average blood loss was 301,2 ±184,38milliliters. Two patients (5.7%) were admitted for one night and 7 patients (20%) consulted the emergency department in the following month, of which 3 (8.57%) were readmitted. We recorded one intraoperative complication, 7 mild postoperative complications (ClavienI-II) and one severe complication (ClavienIIIb). The severe complication occurred on the eighth postoperative day and was not related to the procedure being ambulatory. Conclusion The absence of serious complications in the immediate postoperative period supports RRP in MAS as a safe technique for selected patients (AU)

Siete años de experiencia en pacientes intervenidos por patología proctológica bajo modalidad cirugía mayor ambulatoria y estudio del grado de satisfacción usuaria

Objetivo: Exponer los resultados de 7 años de cirugía proctológica por cirugía mayor ambulatoria (CMA) y determinar el grado de satisfacción usuaria. Material y Método: Se realizó un estudio observacional descriptivo de pacientes sometidos a cirugía proctológica bajo modalidad CMA en el Hospital Regional de Concepción entre los años 2012 y 2019. Se realizó la encuesta telefónica de satisfacción SUCMA-14. Resultados: Se evaluaron a 632 pacientes en el período de estudio. Con diferencias estadísticamente significativas entre patologías para edad, género e IMC. Se aplicó la encuesta a 270 pacientes que contestaron y respondieron. Los resultados mostraron que en general la percepción de los pacientes es positiva salvo puntuales excepciones, como el dolor postoperatorio para condilomas y hemorroides, y las complicaciones postoperatorias para la enfermedad pilonidal. Cuando se realiza el análisis multivariado a los datos correspondientes a la encuesta, no se logran diferencias significativas entre los diagnósticos, pero al aplicarlo a las variables clínico-quirúrgicas se evidencia, claramente, que existe una distinción entre éstas, en especial para la enfermedad pilonidal. Discusión: Las diferencias en términos de tiempos quirúrgicos, complicaciones y re-hospitalizaciones, no necesariamente afectan la percepción que los pacientes tienen de la CMA, ya que ésta depende de otros factores y no solo de los resultados quirúrgicos. Conclusión: Se obtuvieron resultados acorde a la literatura internacional, con peores resultados para enfermedad pilonidal. La satisfacción usuaria fue positiva en general, sin una clara distinción por patologías. Creemos que la CMA es recomendable en patología proctológica tanto por sus resultados, como por la satisfacción que genera en los pacientes.

Objective: To present the results of 7 years of colorectal surgery on mayor ambulatory surgery (MAS) and to determine patient satisfaction. Methods: A descriptive observational study of patients undergoing proctological surgery under the MAS modality was carried out at Regional Hospital of Concepción between 2012 and 2019. The SUCMA-14 satisfaction survey was applied. Results: 632 patients were evaluated in the study period. With statistically significant differences between pathologies for age, gender and BMI. The survey was applied to 270 patients who answered and responded. The results showed that, in general, the perception of the patients is positive, with exceptions, such as postoperative pain for warts and hemorrhoids, and postoperative complications for pilonidal disease. When the multivariate analysis corresponding to the survey is performed, it does not allow distinguishing between the diagnoses, but when applied to the surgical variables, it clearly shows that there is a distinction between them, with a disadvantage for pilonidal disease. Discussion: The differences in terms of surgical times, complications and re-hospitalizations do not necessarily affect the perception that patients have of the MAS, since it depends on other factors and not only on the surgical results. Conclusion: Results were concordant to what is described in the international literature, with worse results for pilonidal disease. Patient satisfaction was positive in general, without a clear distinction by pathology. We believe that MAS is recommended in proctological pathology both for its results and for the satisfaction it generates in patients.

Evaluación de los indicadores de calidad en cirugía mayor ambulatoria pediátrica. Influencia de la pandemia por COVID-19 / Assessment of quality indicators in pediatric major outpatient surgery. Influence of the COVID-19 pandemic

Introducción. La cirugía mayor ambulatoria (CMA) es un modelo de gestión de asistencia quirúrgica que permite tratar de forma eficiente y segura a pacientes seleccionados. Nuestro objetivo es evaluar la calidad de esta actividad a través de indicadores de calidad estandarizados, analizando si se han visto modificados durante la pandemia por COVID-19. Material y métodos. Estudio descriptivo observacional y comparativo entre 2019 y 2020 de los indicadores de calidad (IC) de CMA de nuestra unidad de Cirugía Pediátrica. De acuerdo con la International Association for Ambulatory Surgery (IAAS) y las recomendaciones del Ministerio de Sanidad y Consumo, valoramos los indicadores de calidad básicos para CMA, así como el grado de satisfacción de las familias depacientes intervenidos en este régimen. Resultados. En total 848 y 652 intervenciones realizadas en 2019 y 2020, respectivamente, con edad media de 6 y 7 años. 539 (índice de ambulatorización (IA) 63,6%) y 465 (IA 71,3%) cirugías en régimen de CMA en 2019 y 2020. En 2019, índice de sustitución (IS) global 96,8%, índice de hospitalización (IH) 1,67%, índice de suspensión 5,94% e índice de reingreso 1,48%. En el año 2020, IS global 98,3%, IH 0,86%, índice de suspensión 4,73% e índice de reingreso 1,72%. No hemos encontrado diferencias en el grado de satisfacción entre ambos años. Conclusiones. Los IC permiten conocer y analizar el funcionamiento y los resultados de las distintas unidades de gestión. En nuestra Unidad, la pandemia por COVID-19 no ha reducido la calidad de la asistencia en régimen de CMA.(AU)

Introduction: ajor Outpatient Surgery (MOS) is an organizational and management model for surgical care that allows selected patients to be treated efficiently and safely. Our objective was to evaluate the quality of the different activities through standardized quality indicators, analyzing whether they have been modified during the COVID-19 pandemic. Materials and methods: An observational and comparative descriptive study of the quality indicators (QI) of MOS in our Pediatric Surgery Department from 2019 to 2020 was carried out. In accordance with the International Association for Ambulatory Surgery (IAAS) and the recommendations of the Spanish Ministry of Health and Consumer Affairs, we assessed the basic quality and the degree of family satisfaction of patients undergoing MOS. Results: A total of 848 and 652 interventions were performed in 2019 and 2020, respectively, with a mean age of 6 and 7 years. 539 (ambulatory rate (AR) 63.6%) and 465 (AR 71.3%) MOS surgeries were conducted in 2019 and 2020. In 2019, the overall substitution rate (SR) was 96.8%, hospitalization rate (HR) was 1.67%, suspension rate was 5.94%, and readmission rate was 1.48%. In 2020, the overall IS was 98.3%, HR was 0.86%, suspension rate was 4.73%, and readmission rate was 1.72%. No differences were found in terms of satisfaction between 2020 and 2019. Conclusions: QI allow us to know and analyze the performance and results of the different management units. In our department, the COVID-19 pandemic has not reduced the quality of CMA care.(AU)

Ambulatory surgery for strabism and its relationship with the different techniques / Cirugía ambulatoria del estrabismo y su relación con las diferentes técnicas

Objective: To assess the functionality and usefulness of ambulatory surgery in pediatric patients operated on for strabismus, as well as the incidence of postoperative complications or hospital admission. Material and methods: A descriptive observational retrospective study was carried out with 92 patients operated on at a tertiary hospital between January 2017 and December 2018. Results: Most patients were ASA I. A laryngeal mask was used in 69.6 % of patients with a prevalence of use of sevoflurane (in 94.6 % of patients) and muscle relaxant (rocuronium in 96.7 % of patients). From the point of view of strabismus surgery, 72.8 % of patients presented with horizontal strabismus, and were esotropias. Most of them with 2 muscles intervened and undergoing surgery for the first time. 21.7 % of patients, presented with other types of strabismus such as IV nerve palsy, Duane or Brown Syndrome. With regard to the results, the admission rate was 4.3 %. In the immediate postoperative period in the Postanesthesic Care Unit (PACU), they did not present with pain and only 6.5 % of the patients suffered Postoperative nausea or vomiting (PONV). Regarding the presence of complications (pain, significant discomfort, tearing, difficulty opening the eyes…), in the ophthalmology consultation on the first postoperative day, they were noted in 2.2 % of the patients. Conclusion: Uniformity criteria such as handling by the same surgeon and the same anesthetic protocol have been essential. Regarding the results, we observed that the number of surgeries performed, the type of strabismus and certain techniques such as Faden, had an effect on the presence of pain. In our study, the low complication rate and low admission rate confirm the success of the ambulatory surgery for this type of surgery (AU)

Objetivo: Evaluar el funcionamiento y utilidad de la cirugía mayor ambulatoria (CMA) en pacientes pediátricos intervenidos de estrabismo, así como la incidencia de complicaciones postoperatorias o ingreso hospitalario. Material y métodos: Se ha realizado un estudio retrospectivo observacional descriptivo, con 92 pacientes intervenidos en el Hospital Álvaro Cunqueiro de Vigo; entre enero de 2017 y diciembre de 2018. Resultados: La mayor parte de los pacientes eran ASA I. Se utilizó mascarilla laríngea en el 69,6 % con prevalencia de empleo de sevoflurano (94,6 %) y relajante muscular (rocuronio en un 96,7 %) Desde el punto de vista de la cirugía estrabológica, el 72,8 % de los pacientes presentaron estrabismo horizontal, tratándose en su mayoría de una primera intervención, endotropias y afectación de hasta dos músculos. El 21,7 % de los pacientes presentaron otros tipos de estrabismo como: paresia IV, síndrome de Duane o Brown, etc. En cuanto a los resultados, la tasa de ingresos fue de un 4,3 %. En el postoperatorio inmediato en la CMA, no presentaron dolor y solo el 6,5% de los pacientes presentaros náuseas o vómitos. En cuanto a la presencia de complicaciones, en la consulta oftalmológica en el primer día postoperatorio (dolor, molestias importantes, lagrimeo, dificultad apertura ocular, etc.), fueron recogidas en un 2,2 % de los pacientes. Conclusión: Han resultado esenciales unos criterios de uniformidad como el manejo por el mismo cirujano y un mismo protocolo anestésico. En cuanto a los resultados, observamos influencia en la presencia de dolor según el número de intervenciones, tipo de estrabismo o técnicas (como Faden). En nuestro estudio, la baja tasa de complicaciones y baja tasa de ingreso confirman el éxito de la CMA para este tipo de intervenciones (AU)

Corporoplasty under local anesthesia: Cost-effective improvement of the surgical treatment of Peyronie's disease / Corporoplastia bajo anestesia local: mejora del coste-efectividad del tratamiento quirúrgico de la enfermedad de Peyronie

Introduction and objectives: Peyronie's disease produces penile curvature that leads, in certain cases, to difficulties in having satisfactory sexual relations. The objective of this study is to evaluate the functional and cost-effectiveness results obtained in the surgical treatment of penile curvature due to Peyronie's disease under local anesthesia, comparing them with those performed under a general–spinal anesthesia regimen. Material and methods: Two groups of patients undergoing corporoplasty are compared according to the type of anesthesia used. Group 1 consists of 32 patients who underwent major outpatient surgery and under local anesthesia from June 2016 to June 2019. Their data are collected prospectively. Group 2 consists of 30 patients who underwent surgery under general/spinal anesthesia with hospital admission, from January 2013 to December 2015, with their data collected retrospectively. Anesthetic and surgical procedure, postoperative functional results, degree of satisfaction and hospital costs between both groups are analyzed, considering p≤0.05 as statistical significance and analyzing the results with the SPSS 20.0 program. Results: Of the 32 patients included in group 1, none required admission for intra or postoperative complications. In both groups, an improvement of the PDQ-test was observed without statistically significant differences, with the degree of global satisfaction above 95% in both groups. There were also no differences in the appearance of complications secondary to the anesthetic procedure or the hospital regime. We observed differences in hospital costs, being 44% lower for the group performed with local anesthesia. (AU)

Introducción y objetivos: La enfermedad de Peyronie produce una curvatura del pene que conduce, en ciertos casos, a dificultades para tener relaciones sexuales satisfactorias. El objetivo de este estudio es evaluar los resultados funcionales y de coste-efectividad obtenidos en el tratamiento quirúrgico de la curvatura peneana por enfermedad de Peyronie bajo anestesia local, comparándolos con los conseguidos bajo un régimen de anestesia general-raquídea. Material y métodos: Se comparan 2 grupos de pacientes sometidos a corporoplastia según el tipo de anestesia utilizada. El grupo 1 está formado por 32 pacientes que se sometieron a cirugía mayor ambulatoria y bajo anestesia local desde junio de 2016 a junio de 2019. Sus datos se recogen de forma prospectiva. El grupo 2 está formado por 30 pacientes intervenidos bajo anestesia general/raquídea con ingreso hospitalario, desde enero de 2013 hasta diciembre de 2015, con sus datos recogidos de forma retrospectiva. Se analiza el procedimiento anestésico y quirúrgico, los resultados funcionales postoperatorios, el grado de satisfacción y los costos hospitalarios entre ambos grupos, considerando p≤0,05 como significación estadística y analizando los resultados con el programa SPSS® 20.0. Resultados: De los 32 pacientes incluidos en el grupo 1, ninguno requirió ingreso por complicaciones intra o postoperatorias. En ambos grupos se observó una mejora en el test PDQ sin diferencias estadísticamente significativas, con un grado de satisfacción global superior al 95% en ambos grupos. Tampoco hubo diferencias en la aparición de complicaciones secundarias al procedimiento anestésico o al régimen hospitalario. Observamos diferencias en los costos hospitalarios, siendo un 44% menor para el grupo en el que se utilizó anestesia local. (AU)

Costos de las diversas modalidades posoperatorias de la colecistectomía laparoscópica. Cooperativa Médica de Florida (COMEF), 2016-2021 / Cost effectivenes of the different postoperative management modalities in laparoscopic cholecystectomy Florida Medical Cooperative (COMEF) 2016-2021 / Custos das várias modalidades pós-operatórias do colecistectomia laparoscópica. Cooperativa Médica da Flórida (COMEF). 2016-2021

Introducción: la colecistectomía laparoscópica constituye el patrón oro en el tratamiento de la litiasis biliar. Bajo una estricta selección de pacientes, la modalidad ambulatoria ha demostrado ser factible y segura. En COMEF se realiza desde el año 2016. El posoperatorio transcurrió por diferentes etapas, internación en cuidados moderados, internación en sala de cirugía del día más internación domiciliaria, internación únicamente en sala de cirugía del día y finalmente alta domiciliaria desde block quirúrgico. El objetivo del trabajo es calcular los costos de cada una de las modalidades posoperatorias de la colecistectomía laparoscópica en el período 2016-2021. Materiales y método: se realizó un estudio de costos de cada una de las modalidades posoperatorias mediante la determinación del costo del día cama ocupada en cuidados moderados e internación domiciliaria, así como la retribución de un auxiliar de enfermería encargado de la sala de cirugía del día. Los datos fueron obtenidos de la Estructura de Costos de Atención a la Salud y la producción de cada servicio. Resultados: el costo del día cama ocupada en cuidados moderados es de $15.056, el de internación en sala de cirugía del día y luego internación domiciliaria $4.953,69, únicamente en sala de cirugía del día $807,69 y finalmente el alta domiciliaria desde block quirúrgico $33. Conclusiones: los costos del posoperatorio de la colecistectomía laparoscópica en modalidad ambulatoria son menores que los que requieren internación en cuidados moderados, y dichos costos se reducen progresivamente cuando se pasa de la internación domiciliaria al alta sin internación domiciliaria y sin recuperación en sala de cirugía del día.

Introduction: laparoscopic cholecystectomy constitutes the gold standard to treat gallstones. Ambulatory treatment has proved to be feasible and safe for carefully selected patients. At COMEF, laparoscopic cholecystectomies have been performed since 2016, and postoperative management has covered different stages: intermediate care during hospitalization, admission in day surgery units plus home care or home admissions, hospitalization in day surgery units and discharge directly after surgery, directly from the ER. The study aims to calculate the cost of each one of the different postoperative management modalities for laparoscopic cholecystectomies between 2016 and 2021. Method: a cost study was conducted for each one of the postoperative management modalities by calculating the cost of the hospital bed day in intermediate care and house care, as well as the salary of the nurses' staff at the day surgery unit. Data was obtained from the Healthcare Services Cost Structure and the production of each one of the services mentioned. Results: the daily bed day cost in intermediate care is $ 15,056, the daily cost of day surgery unit plus home care afterwards is $ 4,953.69, the cost of surgery admission in the day surgery unit is $ 807.69 and discharge directly from the OR is $ 33. Conclusions: the postoperative cost of ambulatory laparoscopic cholecystectomy is lower than that requiring interaction in intermediate care and these costs are progressively reduced when moving from home care with and without interaction upon discharge towards no recovery in the day surgery unit.

Introdução: a colecistectomia laparoscópica é o padrão ouro no tratamento da litíase biliar. Com uma rigorosa seleção de pacientes, a modalidade ambulatorial tem se mostrado viável e segura. Na COMEF é realizada desde 2016, com o pós-operatório passando por diferentes etapas: internação em cuidados moderados, internação na sala de cirurgia do dia mais internação domiciliar, internação apenas na sala de cirurgia no dia e finalmente alta domiciliar do bloco cirúrgico. Objetivo: calcular os custos de cada uma das modalidades pós-operatórias de colecistectomia laparoscópica no período 2016-2021. Materiais e método: foi realizado um estudo dos custos de cada uma das modalidades pós-operatórias determinando o custo do dia de leito ocupado em cuidados moderados e internação atendimento domiciliar, bem como a remuneração de um auxiliar de enfermagem responsável pela cirurgia do dia. Os dados foram obtidos da Estrutura de Custos de Assistência à Saúde e da produção de cada serviço. Resultados: o custo do leito de dia ocupado em cuidados moderados, em é de $ 15.056, a hospitalização na sala de cirurgia de dia e depois internação domiciliar $ 4.953,69, apenas na sala da cirurgia de dia $ 807,69 e finalmente alta domiciliar do bloco cirúrgico $ 33 (valores em pesos uruguaios). Conclusões: os custos pós-operatórios da colecistectomia laparoscópica na modalidade ambulatorial são menores do que aqueles que requerem interação em cuidados moderados e são progressivamente reduzidos quando passa da internação em casa à alta sem interação em casa e sem recuperação na sala de cirurgia no dia.

Corporoplasty under local anesthesia: Cost-effective improvement of the surgical treatment of Peyronie's disease.

INTRODUCTION AND OBJECTIVES: Peyronie's disease produces penile curvature that leads, in certain cases, to difficulties in having satisfactory sexual relations. The objective of this study is to evaluate the functional and cost-effectiveness results obtained in the surgical treatment of penile curvature due to Peyronie's disease under local anesthesia, comparing them with those performed under a general-spinal anesthesia regimen. MATERIAL AND METHODS: Two groups of patients undergoing corporoplasty are compared according to the type of anesthesia used. Group 1 consists of 32 patients who underwent major outpatient surgery and under local anesthesia from June 2016 to June 2019. Their data are collected prospectively. Group 2 consists of 30 patients who underwent surgery under general/spinal anesthesia with hospital admission, from January 2013 to December 2015, with their data collected retrospectively. Anesthetic and surgical procedure, postoperative functional results, degree of satisfaction and hospital costs between both groups are analyzed, considering p≤0.05 as statistical significance and analyzing the results with the SPSS 20.0 program. RESULTS: Of the 32 patients included in group 1, none required admission for intra or postoperative complications. In both groups, an improvement of the PDQ-test was observed without statistically significant differences, with the degree of global satisfaction above 95% in both groups. There were also no differences in the appearance of complications secondary to the anesthetic procedure or the hospital regime. We observed differences in hospital costs, being 44% lower for the group performed with local anesthesia. CONCLUSIONS: Surgical treatment of penile curvature under local anesthesia improves the cost-effectiveness ratio with the same quality of care, degree of satisfaction and postoperative functional results, maintaining a similar rate of intra/postoperative complications. For this reason, we consider that corporoplasty can be successfully performed under local anesthesia.

Flexible Ureteroscopy as a Major Ambulatory Surgery Procedure. Single Center Experience and Analysis of Variables Related to Hospital Readmission

Objective: To assess our experience in flexible ureteroscopy (fURS) in major ambulatory surgery (MAS) and to detect variables related to unplanned medical assistance after surgery. Material & Methods: We conducted a retrospective study among patients with renal stones undergoing a fURS from 2014 to 2019 in MAS at our hospital. Variables: Age, gender, ASA physical status, type of anesthetic technique performed, stone characteristics, influence of double J stent before or after surgery, and postoperative complications according to the Clavien-Dindo modified classification. We evaluated variables related to hospital readmission or visit to the emergency room after surgery. Results: A total of 222 consecutive fURS for stone disease were performed in MAS. Patients’ average age was 52.9 ± 13.91 years old. The mean operating time was 57.86 ± 21.11 minutes. The mean stone size was 1.92 ± 1.43 with a diameter of 10.01 ± 4.24 mm. 47.3% of patients had a double J stent before fURS, and in 35.14% of cases, a stent was placed after surgery. 7.65% of patients required unplanned hospitalization. 14.86% of patients presented to the emergency room in the following month after surgery. Among them, one-third consulted for symptoms related to the double J. Patients who carried a double J stent before the fURS had 64% less risk of visiting the emergency department in the following month after surgery [OR = 0,363; IC95% (0.153-0.798)]. All other variables (age, gender, operating time...) did not modify the risk of unplanned medical assistance. Conclusion: The low complication rate following flexible ureteroscopy allows its performance as an ambulatory surgery. Patients who carry double J stent before the procedure have less risk of requiring unplanned medical assistance after the surgery (AU)

Objetivos: Evaluar nuestra experiencia con laureterorrenoscopia flexible (Uflex) en régimen de cirugíamayor ambulatoria (CMA) e identificar variables predictoras de asistencia médica no programada en el postoperatorio.Material y Métodos: Estudio retrospectivo de los pacientes afectos de litiasis renal intervenidos mediante Uflexen régimen de CMA entre 2014 y 2019 en nuestro centro.Variables: Edad, género, medicación antitrombótica, categoría del paciente según la clasificación de la SociedadAmericana de Anestesistas (ASA), tipo de anestesia empleada, características de la litiasis, influencia del cateterismo doble J y pre y postcirugía y complicaciones postoperatorias según la clasificación Clavien-Dindo modificada.Investigamos que variables puedan asociarse a requerir ingreso o consulta a urgencias tras la intervención quirúrgica.Resultados: Un total de 222 pacientes consecutivosafectos de litiasis renal fueron intervenidos mediante Uflexen régimen de CMA. La edad de los pacientes fue de 52,9 ±13,91 años. El tiempo quirúrgico fue de 57,86 ± 21,11 minutos. El número de litiasis fue de 1,92 ± 1,43 y el tamañode la litiasis fue de 10,01 ± 4,24 mm. El 47,3% de los pacientes tenían un catéter doble J previo a la Uflex y se dejóposteriormente a la misma en un 35,14% de los casos. Un7,65% de los pacientes requirieron ingreso hospitalario. El14,86% de los pacientes acudió a urgencias en el mes siguiente a la cirugía. De ellos, un tercio consultó por sintomatología relacionada con el doble J. Los portadores de dobleJ previo a la cirugía tuvieron un 64% menos de probabilidadde consultar en urgencias en el mes siguiente [OR = 0,363;IC95% (0.153-0.798)]. El resto de variables (edad, sexo,tiempo quirúrgico…) no modificaron el riesgo de consultaen urgencias ó de ingreso hospitalario... (AU)

Documento de posicionamiento respecto a las fracturas de tobillo en cirugía mayor ambulatoria / Position statement relating ankle fractures in major outpatient surgery

Introducción: El aumento de la prevalencia de osteoporosis asociado al envejecimiento y a los accidentes deportivos y de tráfico, son los responsables del incremento de las fracturas de tobillo. Este hecho pone de manifiesto la necesidad de protocolizar su asistencia para proporcionar un mayor beneficio clínico al paciente y una disminución de costes al sistema. Objetivo y métodos: En la actualidad, no existe un marco común para la implantación de protocolos y circuitos internos en los centros españoles para la realización de fracturas de tobillo por la vía de la cirugía mayor ambulatoria (CMA), objetivo que persigue el presente documento de posicionamiento. Para ello se revisa la evidencia clínica y económica de la CMA, el entorno local y las estrategias para su implementación, haciendo referencia a las fracturas de tobillo. Evidencia clínica y económica: Los resultados mostraron una mejor relación coste-beneficio en pacientes ambulatorios respecto a la tradicional hospitalización, con complicaciones y tasas de reingreso menores y, por tanto, ahorro de costes significativos. Barreras y estrategias: Se revisan las barreras generales y específicas, así como las estrategias y los circuitos para la correcta implementación. Resultados: Los resultados muestran una reducción de las tasas de complicaciones y reingresos, así como un ahorro de costes. Supone una mejor relación coste-beneficio en la atención ambulatoria en comparación con la hospitalización tradicional. Posicionamiento: La implantación de la CMA contribuye a mejorar la calidad asistencial, la satisfacción del paciente y del equipo asistencial, así como la optimización de recursos. Las fracturas de tobillo en pacientes seleccionados tanto por la patología de base, riesgo anestésico y tipo de fractura pueden intervenirse de manera satisfactoria en régimen de CMA.(AU)

Introduction: The increase in the prevalence of osteoporosis associated with ageing, and sports and traffic accidents, are responsible for the increase in ankle fractures. This fact emphasises the need to protocolise their care in order to provide greater clinical benefit to patients, and better cost–benefit ratios to the health system. Aim and method: At present, there is no common framework for implementation of protocols and internal circuits of the Spanish centres for ankle fractures by means of major outpatient surgery (MOS), which is the final objective of this position paper. For this, the clinical and economic evidence of MOS, the local environment and the strategies for its implementation are reviewed, related to ankle fractures. Clinical and economic vidence: The results showed a better cost–benefit ratio in outpatients compared to traditional hospitalisation, with lower complications and readmission rates and therefore significant cost savings. Barriers and strategies: General and specific barriers are reviewed, as well as strategies and circuits for proper implementation. Results: The results show lower complication and readmission rates together with significant cost savings. It entails a better cost–benefit ratio in outpatient care compared to traditional hospitalisation. Position statement:The implementation of MOS contributes to improve the quality of care, and the satisfaction of both, patient and health care team, while optimising the utilisation of resources. Ankle fractures in patients selected for both the underlying pathology, anaesthetic risk, and the type of fracture can be operated satisfactorily under the MOS.(AU)

Position statement relating ankle fractures in major outpatient surgery / Documento de posicionamiento respecto a las fracturas de tobillo en cirugía mayor ambulatoria

Introduction: The increase in the prevalence of osteoporosis associated with ageing, and sports and traffic accidents, are responsible for the increase in ankle fractures. This fact emphasises the need to protocolise their care in order to provide greater clinical benefit to patients, and better cost–benefit ratios to the health system. Aim and method: At present, there is no common framework for implementation of protocols and internal circuits of the Spanish centres for ankle fractures by means of major outpatient surgery (MOS), which is the final objective of this position paper. For this, the clinical and economic evidence of MOS, the local environment and the strategies for its implementation are reviewed, related to ankle fractures. Clinical and economic vidence: The results showed a better cost–benefit ratio in outpatients compared to traditional hospitalisation, with lower complications and readmission rates and therefore significant cost savings. Barriers and strategies: General and specific barriers are reviewed, as well as strategies and circuits for proper implementation. Results: The results show lower complication and readmission rates together with significant cost savings. It entails a better cost–benefit ratio in outpatient care compared to traditional hospitalisation. Position statement:The implementation of MOS contributes to improve the quality of care, and the satisfaction of both, patient and health care team, while optimising the utilisation of resources. Ankle fractures in patients selected for both the underlying pathology, anaesthetic risk, and the type of fracture can be operated satisfactorily under the MOS.(AU)

Introducción: El aumento de la prevalencia de osteoporosis asociado al envejecimiento y a los accidentes deportivos y de tráfico, son los responsables del incremento de las fracturas de tobillo. Este hecho pone de manifiesto la necesidad de protocolizar su asistencia para proporcionar un mayor beneficio clínico al paciente y una disminución de costes al sistema. Objetivo y métodos: En la actualidad, no existe un marco común para la implantación de protocolos y circuitos internos en los centros españoles para la realización de fracturas de tobillo por la vía de la cirugía mayor ambulatoria (CMA), objetivo que persigue el presente documento de posicionamiento. Para ello se revisa la evidencia clínica y económica de la CMA, el entorno local y las estrategias para su implementación, haciendo referencia a las fracturas de tobillo. Evidencia clínica y económica: Los resultados mostraron una mejor relación coste-beneficio en pacientes ambulatorios respecto a la tradicional hospitalización, con complicaciones y tasas de reingreso menores y, por tanto, ahorro de costes significativos. Barreras y estrategias: Se revisan las barreras generales y específicas, así como las estrategias y los circuitos para la correcta implementación. Resultados: Los resultados muestran una reducción de las tasas de complicaciones y reingresos, así como un ahorro de costes. Supone una mejor relación coste-beneficio en la atención ambulatoria en comparación con la hospitalización tradicional. Posicionamiento: La implantación de la CMA contribuye a mejorar la calidad asistencial, la satisfacción del paciente y del equipo asistencial, así como la optimización de recursos. Las fracturas de tobillo en pacientes seleccionados tanto por la patología de base, riesgo anestésico y tipo de fractura pueden intervenirse de manera satisfactoria en régimen de CMA.(AU)

Position statement relating ankle fractures in major outpatient surgery. / Documento de posicionamiento respecto a las fracturas de tobillo en cirugía mayor ambulatoria.

INTRODUCTION: The increase in the prevalence of osteoporosis associated with ageing, and sports and traffic accidents, are responsible for the increase in ankle fractures. This fact emphasises the need to protocolise their care in order to provide greater clinical benefit to patients, and better cost-benefit ratios to the health system. AIM AND METHOD: At present, there is no common framework for implementation of protocols and internal circuits of the Spanish centres for ankle fractures by means of major outpatient surgery (MOS), which is the final objective of this position paper. For this, the clinical and economic evidence of MOS, the local environment and the strategies for its implementation are reviewed, related to ankle fractures. CLINICAL AND ECONOMIC EVIDENCE: The results showed a better cost-benefit ratio in outpatients compared to traditional hospitalisation, with lower complications and readmission rates and therefore significant cost savings. BARRIERS AND STRATEGIES: General and specific barriers are reviewed, as well as strategies and circuits for proper implementation. RESULTS: The results show lower complication and readmission rates together with significant cost savings. It entails a better cost-benefit ratio in outpatient care compared to traditional hospitalisation. POSITION STATEMENT: The implementation of MOS contributes to improve the quality of care, and the satisfaction of both, patient and health care team, while optimising the utilisation of resources. Ankle fractures in patients selected for both the underlying pathology, anaesthetic risk, and the type of fracture can be operated satisfactorily under the MOS.

Consensus of the ambulatory surgery commite section of the Spanish Association of Surgeons on the role of ambulatory surgery in the SARS-CoV-2 pandemic.

The current situation of the SARS-CoV-2 pandemic has paralyzed non-urgent and/or oncological surgery in many hospitals in our country with what it means for the health of citizens who are awaiting a surgical procedure. Outpatient Surgery can afford more than 85% of the surgical procedures that are performed in a surgical department and is presented as a feasible and safe alternative at the present time since it does not require admission and decreases clearly the risk of infection. In addition, it is the tool that should be generalized to solve the accumulation of patients on the waiting list that the pandemic is generating, so it seems appropriate that the Ambulatory Surgery section of the Spanish Association of Surgeons present a series of recommendations for the implementation of outpatient surgery in these exceptional circumstances that we have to live.

Consenso de la sección de cirugía mayor ambulatoria de la Asociación Española de Cirujanos sobre el papel de la cirugía mayor ambulatoria en la pandemia SARS-CoV-2 / Consensus of the ambulatory surgery commite section of the Spanish Association of Surgeons on the role of ambulatory surgery in the SARS-CoV-2 pandemic

La situación actual de la pandemia por SARS-CoV-2 tiene paralizada la cirugía no urgente y/u oncológica en muchos hospitales de nuestro país con lo que esto conlleva para la salud de los ciudadanos que están pendientes de una intervención quirúrgica. La cirugía mayor ambulatoria puede abarcar en su cartera de servicios más del 85% de los procedimientos quirúrgicos que se realizan en un servicio de cirugía y se presenta como una alternativa factible y segura en el momento actual ya que no requiere camas de ingreso y disminuye claramente el riesgo de infección. Además, es la herramienta que debería generalizarse para solucionar la acumulación de pacientes en lista de espera que la pandemia está generando, por lo que parece oportuno que desde la sección de Cirugía Mayor Ambulatoria de la Asociación Española de Cirujanos se presente una serie de recomendaciones para la implementación de la misma en estas circunstancias excepcionales que nos toca vivir.(AU)

The current situation of the SARS-CoV-2 pandemic has paralyzed non-urgent and/or oncological surgery in many hospitals in our country with what it means for the health of citizens who are awaiting a surgical procedure. Outpatient Surgery can afford more than 85% of the surgical procedures that are performed in a surgical department and is presented as a feasible and safe alternative at the present time since it does not require admission and decreases clearly the risk of infection. In addition, it is the tool that should be generalized to solve the accumulation of patients on the waiting list that the pandemic is generating, so it seems appropriate that the Ambulatory Surgery section of the Spanish Association of Surgeons present a series of recommendations for the implementation of outpatient surgery in these exceptional circumstances that we have to live.(AU)