Introduction

In 1909, James Nicoll presented “The Surgery of Infancy” in the British Medical Journal, a report of the experience of the Glasgow Hospital for Sick Children and the lack of need for hospitalization, considering that most pediatric patients undergoing a surgical procedure could be discharged and sent home^1,2.

This study represented a milestone for introducing the concept of ambulatory surgery or day case surgery, which was defined by James E. Davis 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^3,5. This term is accepted worldwide as improvements in anesthesia and surgical techniques allow the patient to go home on the same day^3-5.

The question was if this procedure should be renamed major ambulatory surgery, considering medico-legal issues regarding the necessary period the patient must stay to recover before discharge. Major ambulatory surgery (MAS) is a treatment modality used for certain patients and diseases under appropriate circumstances, and the choice remains at the discretion of the attending team, regardless of the terminology used; a wrong decision would be considered reckless ⁶.

In Europe, this health care model has undergone considerable development over the past years. For example, a study performed in Spain comparing ambulatory laparoscopic cholecystectomy with conventional hospital stay showed that there were no differences in mortality rate, unplanned repeated surgery and readmissions, with better patient satisfaction in the ambulatory arm ⁷.

In 2017, a report of the US stated that of 22.5 million ambulatory surgeries performed, only 2% were admitted to the hospital. The significant increase in the number of patients using this modality could be attributed to advances in surgical and anesthetic care, expanded use of minimally invasive surgery with better management of pain and early discharge⁸.

In Latin America, the development of MAC was slower; in Chile, the initial studies describing ambulatory laparoscopic cholecystectomy were published in 2000. An important aspect was that patients were reluctant to go home soon after surgery⁹.

Other countries in the region, like Colombia, and of Central America like Guatemala, Nicaragua and Mexico, published series of laparoscopic surgeries -mainly cholecystectomies and hernia repair- performed in both outpatient and inpatient settings; these publications emphasize that ambulatory procedures are safe for the patient when they are correctly selected and the quality of care is maintained in the outpatient setting^10-13. In Argentina, in his Official Report, P. A. Ferraina emphasized the usefulness and benefits of this modality ⁶; however, at present, there are not many institutions with ambulatory surgery centers integrated to the hospital facility, since ambulatory surgery had not gained enough impulse. Some causes could be the lack of information about the benefits of this modality, surgeons’ reluctance, lack of safe support in case of possible complications, and even the patient’s preference for staying at hospital for at least one night ¹⁴.

In 2010, our day surgery unit (DSU) was launched in the Department of General Surgery, Hospital de Clínicas Pte. Dr. N. Avellaneda as an integrated hospital facility.

The introduction of the MAS modality produced changes in the organization of health services due to the introduction of innovations in care aimed at reducing costs without modifying the quality of care¹⁵, which consists of organizing surgical patients care so that they can return home on the same day of the intervention with no additional risks¹⁶.

Adequate pathways are necessary in the SDU to achieve this target. The first step is patient’s selection, which is initially evaluated in the outpatient clinic by staff surgeons who decide if the patient and his/her disease are suitable for this type of surgical modality. The second step is based on providing the patient with detailed verbal and written (through leaflets) information, and with the requirements before and after the procedure. The patient is re-evaluated 72 hours before surgery to check the preoperative tests and admission processes and reconfirm the date of the procedure.

The aims of this study are:

General aim:

▪▪To analyze the experience of the SDU integrated to the Department of General Surgery and Gastrointestinal Surgery at Hospital de Clínicas Pte. Dr. N. Avellaneda in San Miguel de Tucumán between January 2014 and December 2018.

Specific aims:

▪▪To analyze to global impact of the activity performed at the SDU using quality indicators.

▪▪To determine major and minor complications.

▪▪To evaluate patients’ satisfaction.

Material and methods

We conducted a descriptive and retrospective cross-sectional study to analyze the surgical activity of the SDU of the Department of General Surgery and Gastrointestinal Surgery at Hospital de Clínicas Pte. Dr. N. Avellaneda.

The criteria for inclusion of patients should include the aspects indicated below:

▪▪Medical aspects: age between 14 and 75 years, body mass index (MI) < 35 and absence of associated comorbidities or critical conditions.

▪▪Surgical aspects: operative time < 90 minutes, post-operative pain easily managed with oral analgesia at home, simple postoperative care and low risk of complications. The diseases included are some of those mentioned in the Guideline for the Organization and Procedures in Ambulatory Surgery of Asociación Argentina de Cirugía) ¹⁷.

▪▪Anesthesia aspects: ASA grade 1 and 2.

▪▪Personal aspects: patient’s willingness to enter the program after having received detailed information and understanding it; adequate health literacy for understanding the indications and warning signs.

▪▪Social aspects: adult support for the first 48 postoperative hours, with a distance from home to hospital < 60 km and availability of communication and transportation.

Exclusion criteria:

▪▪Medical issues: uncontrolled associated comorbidities or those requiring multiple medications, morbid obesity, or history of psychiatric disorders or substance abuse.

▪▪Surgical issues: acute severe infection.

▪▪Anesthesia issues: ASA grade > 3.

▪▪Personal issues: inability to provide a valid informed consent of inadequate health literacy.

▪▪Social issues: patients who do not fulfill the requirements previously described.

According to the ethical regulations, the Ethics Committee of the Provincial Health System and the institutional Teaching and Research Committee were asked to authorize this type of procedure. All the patients were informed about the method to be used and its objectives and were asked to sign an informed consent form. The identity of the patients was preserved ensuring the confidentiality of the information.

Data were collected from a prospective database implemented for the beginning of a pilot experience. The level of satisfaction was evaluated using a validated questionnaire modified by the authors with 22 variables (SUCMA 14) that was completed a week after the intervention, when the patient answered whether he/she was not satisfied, satisfied or very satisfied with each item asked ¹⁸.

The following variables were analyzed: cancellation of procedure, rate of suspended interventions, same-day unplanned repeated surgery, unplanned admission, readmission, percentage of ambulatory surgery of overall surgical procedures, substitution rate (percentage of ambulatory procedures performed/ambulatory procedures scheduled) and patient satisfaction index.

The statistical analysis was performed using Microsoft Excel 2010® spreadsheet. Descriptive statistics was used for variables of interest. The statistical analysis was performed with the chi-square test.

Results

Between January 2014 and December 2018, 3827 surgeries were performed; 2327 (61) corresponded to MAS; the mean number of procedures per year was 465.4, with a minimum of 325 in 2014 and a maximum of 556 in 2018.

Of the 2327 patients, 1512 (65%) were women and age ranged between 45 and 54 years.

There were 3156 patients scheduled for MAS but were fully completed as ambulatory surgery in only 74% of the cases (2327). In the remaining 829 patients (26%), the procedures were canceled or suspended.

The surgical procedures were the following (Figure 1):

a. Laparoscopic cholecystectomy: 1675 (72%).

b. Abdominal wall surgery: 473 (20%).

c. Perianal procedures: 101 (4.3%).

d. Combined procedures: 78 (3.3%). Combined procedures include two different MAS procedures within the same intervention, as laparoscopic cholecystectomy and umbilical hernia repair.

The quality indicators depend on the structural and organizational characteristics of the Department of Surgery (considering those described in Table 1).

The cancellation rate (p = 0.0013) and the rate of surgeries suspended (p = 0.0037) had a statistically significant decline between 2014 and 2018.

A total of 163 (7%) procedures were canceled due to the patient. In 157 (6,7%) cases, the procedures were suspended due to administrative and organizational issues described in Figure 2.

The complications were categorized in minor and major, and included those occurring at the post-anesthesic care unit (PACU) or immediate postoperative recovery. Fifty-two patients presented complications (13 major and 21 minor complications) which are described on Table 2.

Patient’s satisfaction, evaluated on postoperative day 7, was very satisfactory in 1268 (54.5) and satisfactory in 1049 (45%) (Figure 3).

Discussion

Our SDU, a hospital integrated facility depending on the Department of General Surgery and Gastrointestinal Surgery of Hospital de Clínicas Avellaneda in San Miguel de Tucumán, started working in a rudimentary fashion in September 2010 and, after an initial period characterized by several difficulties, it was officially launched in September 2013. For this reason, we present our experience starting in January 2014.

Major ambulatory surgery includes diverse categories of facility:

a. Hospital integrated facility: in such facilities, day sur gery patients and inpatients share the same opera ting area.

b. Self-contained unit on hospital site or autonomous unit: such units are dedicated to day surgery and functionally separated from the inpatient sections of a hospital.

c. Satellite units: located at a distance from the gene ral hospital but administratively dependent on the hospital.

d. Free-standing units: fully independent, in regards with both organization and structure, of a general hospital, represents the best example of “day sur gery center”.

In Spain, the rate of ambulatory surgeries was 30.14% in 2014¹⁹. In the United States, approximately 35 million MAS procedures were performed within hospital integrated facilities and free-standing units in 2016 ¹².

Irrespective of the type of facility, the quality indicators must be continuously evaluated, as they are necessary to monitor and assess the different activities. Thus, they must be measured periodically and systematically recorded. Our study shows a decrease in the cancellation rate from 9.21% in 2014 to 3.31% in 2018, which explains the continuous improvement of our processes. Initially, this was due to patients’ failure to attend the surgery day unit, that was attributed to lack of information. For this reason, at present patients visit the clinic 72 hours before their scheduled surgery to verify their status. It is important to identify the reasons why the patient decides to postpone the intervention, as these reasons have a negative impact on the model ²⁰. Martínez Guillén demonstrated that the main reasons are intercurrent diseases and patient’s decisions, which could be avoided ²¹.

The rate of suspended procedures showed a statistically significant decline, from 8.13% to 3.6% over the study period. The following factors contributed to this improvement: better selection of patients, resolution of union conflicts (2014 and 2015), and improvement of infrastructure (elevators). Other studies have demonstrated that this rate increases due to higher operative time or by selecting patients with emergency conditions ²².

Unplanned repeated surgery rate evaluates those patients who undergo MAS and develop a complication during their stay at the anesthesia recovery unit or pre-discharge recovery area and require same-day repeated surgery. In our study, unplanned repeated surgery occurred in 0.35% (n = 2) of the patients in 2018 due to hemoperitoneum after laparoscopic cholecystectomy in one patient and recurrent inguinal hernia in the immediate postoperative period in the other. Several studies have associated same-day repeated surgery with coagulation disorders ²³.

Readmission rate decreased from 2.7% to 1.6%; the most common causes were nausea and vomiting, uncontrolled pain and urinary retention, particularly after blocks. This decrease is due to the fact that our patients received leaflets with information about the indications and phone numbers to contact in case any complication developed. Jimenez et al. considered that this indicator was directly related to the experience of the DSU, and improvements were detected when the number of patients intervened was higher. In their study, they demonstrated that the most common causes of unplanned admission after major outpatient surgery are dizziness, hemodynamic instability and those related to the surgical wound, while vomiting, postoperative pain or social causes have decreased, due to the instructions received by patients and their families about the characteristics of the intervention and the type of care required ^24,25.

The readmission rate was 1% and was due to postoperative pain. Chiringiallo et al. reported and incidence of readmissions between 0.3% and 3%, particularly due to postoperative pain, as in our study ²⁶. Sobrino reported that postoperative pain in patients undergoing MAS was statistically significant more common in women, in < 65 years and in general surgery interventions compared with the other surgical specialties ²⁷. In a study performed in 25,553 patients, Sáenz et al. found a readmission rate of 0.83%; the most common cause was bleeding of the surgical bed for all the surgical specialties evaluated in the hospital ²⁸.

Martínes Rodenas considers that the percentage of ambulatory surgery and the substitution rate put in evidence the efficiency of ambulatory surgery and allows benchmarking between the different DSUs ²⁴. In this series, these indicators were 63% and 73,5%, respectively. The percentage of ambulatory surgery has a direct association with the organization and logistics of corresponding DSU and an inverse relation with the complexity of the institution ²⁹.

Ortega et al, recommend evaluating the substitution rate with other indicators of patient’s complexity independently of the type of hospital. These changes may have an impact on this index, helping in the design of future health policies ²⁰.

The safety of MAS is reflected by the low rate of complications: 52 (2.2%) of 2327 interventions, mainly seroma in 22 (0.95%) patients as a minor complication, followed by residual lithiasis in 6 (0.26%) patients as a major complication. In this case, selective colangiography was performed, while the other cases where resolved by ERCP at the institution. Other studies reported that surgical site infections were the most common complications ^30,31. However, the complications described in this series could have occurred even if the surgeries were performed on an inpatient basis.

Patient’s satisfaction was high, almost 100%, as reported by other studies. Valla Vicente considers that providing detailed and precise preoperative explanation and ensuring that the patient can manage postoperative pain at home are essential ³². The survey conducted on postoperative day 7 shows that 99.5% of the patients are satisfied, reflecting that they accept this type of care. Other studies reporting similar results, indicate the importance of returning home on the same day of the intervention and to be in constant communication with the hospital ^33,34.

Conclusion

▪▪Ambulatory surgery is a safe and efficient modality with high surgical quality.

▪▪The indicators evaluated reflect improvement of pro cesses, corrective actions implemented since the be ginning of the activity and the low number of compli cations.

▪▪We emphasize the need for adequate selection of pa tients, type of surgery, discharge criteria and postope rative follow-up.

▪▪We recommend this type of DSU integrated to the hospital facility for the reasons previously exposed, the feasibility of implementation in Argentina and the low operating cost.