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Outpatient thoracic surgery

Laureano Molins, Juan J. Fibla and Jorge HernÁNdez

INTRODUCTION

The term “ambulatory surgery” was coined by J. E. Davis in 1986. Outpatient surgery, also called “major ambulatory surgery” or “day surgery,” can be defined as a surgical or diagnostic procedure performed under general, locoregional, or local anesthesia with or without sedation, requiring post-operative care and returning home the same day of surgery. It must be distinguished from “short-stay surgery” in which a major surgical procedure stay lasts between 1 and 3 days. Other terms such as “early discharge surgery” have been discarded for being inaccurate or confusing terms.

The classification of levels of surgery, according to Davis, are:

• Level I: procedures performed on an outpatient basis under local anesthesia requiring no special postoperative care (minor surgery)
  
• Level II: major surgical procedures requiring specific postoperative care without hospitalizing (outpatient/ ambulatory surgery)
  
• •• Level III: surgery that requires hospitalization
  
• •• Level IV: surgery that requires highly specialized or critical care

“Major surgery” is a variety of surgery with a complexity that requires special or intensive postoperative care. However, thanks to advances in surgical and anesthetic techniques, some of these procedures can now be performed on an outpatient basis without an overnight stay in the hospital. According to the International Association for Ambulatory Surgery, such procedures should not be urgent; be performed within a normal working day; and not exceed a duration of 12 hours, including postoperative recovery.

Several potential advantages of these procedures arise: decreased costs through more efficient resource use; increased hospital bed availability; lower risk of resistant bacterial strain transmission; and quicker return to family, social, and working life. Outpatient surgery must meet all these goals, offering the same guarantees and quality of care as conventional surgery for the same type of surgical procedure.

Outpatient surgery was born in the United Kingdom in the mid-twentieth century under the auspices of the public health system. Its original purpose was to reduce surgical waiting times. One of the first experiences was reported in 1909 by James H. Nicoll who, at the Glasgow Royal Hospital for Sick Children, performed 8988 operations on children without hospitalization.

This system of surgical activity was quickly built on and developed in the United States, powered by a health care system based on private hospitals and insurance companies. Before long, it proved not only to be a cost-effective and safe therapeutic modality but also improved patient care by simplifying the administration of diagnostic and therapeutic processes.

OUTPATIENT THORACIC SURGERY

Ambulatory surgery has gained wide popularity and satisfaction among patients. As an alternative to conventional hospitalization, outpatient surgery has grown internationally over the past 20 years. However, there has been little on outpatient thoracic surgery in the international medical literature since the first publication by Vallieres et al. in 1991 detailing outpatient mediastinoscopy.

Thoracic surgery as a specialty has been slow to get into the dynamics of outpatient surgery. This low use of outpatient surgery programs appears to be due to several causes. The anatomical complexity of the chest, the requirement for prolonged postoperative recovery, significant postoperative pain, the possibility of serious complications, and the frequent need to leave a postoperative chest drain, in addition to other factors, has limited the number of thoracic procedures that may safely be done in an outpatient setting. The pressure of waiting lists, the concern regarding legal liability and low demand by patients are other nonmedical reasons causing this phenomenon.

The last 25-30 years has seen significant technological advances. First, the appearance of videothoracoscopic approaches has led to the realization of many surgical procedures replacing more aggressive and traumatic approaches with minimally invasive techniques. Second, minimally invasive surgery often causes less postoperative pain, which results in better postoperative rehabilitation and earlier return of the patient to their daily activities. Third, advances in the anesthetic field, such as improved selective endobronchial intubation devices as well as the optimization of anesthetic drugs used during surgery, can greatly facilitate the work of the surgeon. Today, we can objectively quantify postoperative pulmonary air leak with new drainage systems available on the market, and the use of postoperative chest X-rays may be replaced by other imaging techniques. Specifically, the use of the portable chest ultrasound technique allows for the examination of the patient at the bedside, in the operating room, or in the recovery room, with the ability to safely repeat the examination as often as necessary without relying on the radiology department and without additional exposure to x-irradiation.

With all these innovations, there has been a gradual reduction in the length of stay following surgical procedures for which, years ago, prolonged postoperative care that increased hospital stay was required. Short-stay units and outpatient surgery, previously found exclusively in other surgical specialties, have allowed the inclusion of programs in outpatient thoracic surgery, adding different surgical procedures progressively.

REGULATION

Ambulatory surgery programs aim to meet the demand of patients suffering from various pathologies quickly and efficiently, reducing cost without decreasing the benefit of the treatment given to the patient, yet allowing for maximum safety and satisfaction.

These programs require specific, strict, and rigorous regulation. In the United Kingdom, certification of ambulatory surgical programs is controlled through various regulations within the National Health Service. European countries such as Spain also have established regional or national standards for regulation. A consequence of this regulation requires specific valid indicators documenting the optimization and quality management of the offered day surgery:

• The substitution index (SI) is defined as the ratio of the number of outpatients to the total number of procedures, expressed as a percentage.
  
• The admission rate (AR) is defined as the ratio of the number of unplanned admissions (any reason) to the total number of outpatient procedures, expressed as percentage.
  
• The readmission rate (RR) is defined as the ratio of the number of unplanned admissions after discharge from the total number of outpatient procedures, expressed as percentage.

Patient and procedure selection are the most important determinants to a safe and effective outpatient thoracic surgical program. Proper selection decreases the number of unplanned hospitalizations. Therefore, strict procedure selection criteria should be established in relation to the pathology present while also taking into account the experience of each thoracic unit.

SURGICAL PROCEDURES

Currently, potential cases amenable to outpatient surgery include:

• Video-mediastinoscopy and anterior mediastinotomy for surgical staging of lung cancer and/or biopsy of a mediastinal mass/lymphadenopathy
  
• Video-assisted thoracoscopic surgery (VATS) bilateral sympathectomy/clipping to treat palmar/axillary hyperhidrosis and facial blushing
  
• Video-assisted thoracoscopic surgery lung biopsy (VATS-LB) for interstitial lung disease
  
• VATS resection/biopsy of lung nodules (with/without previous hookwire localization)
  
• VATS staging of lung cancer (lymph node biopsy of lymph node stations 5, 6, 7, 8, 9; VATS exploration of the pleural cavity in pleural effusions; biopsy/excision of pleural masses
  
• VATS biopsy/resection of mediastinal tumors
  
• Limited chest wall procedures: rib resection/extraction of Nuss bar
  
• Other: diagnostic-therapeutic bronchoscopy; supraclavicular lymph node biopsy; computed-tomography (CT)-guided fine needle aspiration (FNA) of lung, mediastinal, chest wall and pleural nodules /masses

All these procedures are included within the level II classification of Davis. With the exception of supraclavicular lymph node biopsy, pleural biopsy, and endobronchial explorations that can be accomplished with local anesthesia and sedation, all other procedures are performed under general anesthesia. Thoracoscopic techniques require selective bronchial intubation and lung collapse and, in most cases, a chest tube postoperatively that will be withdrawn in the recovery room.

SELECTION CRITERIA

Each thoracic surgical unit should establish the criteria for the selection of patients in its ambulatory surgery program. Most of the previously named surgical procedures may be included in a program of ambulatory thoracic surgery, but in order to accomplish it, first, one has to keep this possibility in mind, and, second, the team must have the necessary motivation and involvement.

Medical criteria

The program should maintain quality of care. Patients classified according to the American Society of Anesthesiology (ASA) physical status classification system as ASA I and II should be included regardless of age. Patients who are judged ASA III should be selected only after taking into account the extent and type of comorbidity.

Personal criteria

The patient must understand and accept the conditions and be motivated to be included in a program of outpatient surgery. It is vital to have their complete involvement in the process, actively collaborating in the operation, reflected by signing the surgical consent following a thorough discussion informing them of the proposed procedure and the implications of doing it in an outpatient setting.

Socio-familiar criteria

The patient should have the support of a family member or friend, who is capable and responsible, to assist them during the first 24-48 hours postoperation. The patient should be provided with a phone number to communicate with the unit if necessary. Usually, outpatient programs include exclusion criteria, limiting the distance between home and hospital or the time taken to cover that distance (1-2 hours).

It is of vital importance to evaluate these general rules in each particular case before deciding if the patient should participate in the outpatient program.

OUR OUTPATIENT THORACIC SURGERY PROGRAM

Our outpatient thoracic surgery program (OTSP) at Sagrat Cor University Hospital, Barcelona, began in April 2001 and, as of December 2013, 814 patients have participated. The program is composed of a multidisciplinary team of surgeons; anesthesiologists; nurses; administrative staff; and, of course, most important, patients. In our view, preoperative, intraoperative, and immediate postoperative anesthetic management is a fundamental part of the process of outpatient surgery. The aim is the early awakening of the patient in the surgical theater in order to facilitate a quick recovery and discharge within a few hours of the surgical procedure with less pain and anxiety. This requires preoperative sedation (diazepam 5-10 mg) and a combination of anesthetic agents, including short-acting relaxants (atracurium, succinylcholine), inhalation agents (sevoflurane, nitrous oxide), intravenous anesthetic drugs (propofol), short-acting opioids (alfentanil, remifentanil), and intercostal nerve blocks. Postoperative analgesia is administered in the recovery room, avoiding derivatives of morphine and meperidine, which delay the recovery process. The patient remains at the recovery room for 20-40 minutes prior to being transferred back to the major ambulatory unit (see Figure 2 6.1a and b) where they remain for 4-6 hours, until they meet the criteria required to be discharged home—specifically, normal values of blood pressure, heart rate, and oxygen saturation; full recovery of consciousness; tolerance to oral liquids; ambulation without assistance; spontaneous voiding; absence of, or moderate pain; and no signs of decompensation of associated comorbidities. The patient is provided with a phone number so they can call the anesthesiologist on call to ask any questions. Our nurses contact the patient the morning after, and the patient is visited by a member of the surgical team within 1 week.

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