OBJECTIVE: To explore the recent developments and trends in the anesthetic and surgical practices for total hip and total knee arthroplasty and discuss the implications for further outpatient total joint arthroplasty procedures.
RESULTS: Between 2012 and 2017 there was an 18.9% increase in the annual primary total joint arthroplasty volume. Payments to physicians falling by 7.5% (14.9% when adjusted for inflations), whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively. Total knee arthroplasty and total hip arthroplasty surgeries were removed from the Medicare Inpatient Only in January 2018 and January 2020, respectively leading to same-day TKA surgeries increases from 1.2% in January 2016 to 62.4% by December 2020 Same-day volumes for THA surgery increased from 2% in January 2016 to 54.5% by December 2020. Enhanced Recovery After Surgery (ERAS) protocols have revolutionized modern anesthesia and surgery practices. Centers for Medicare Services officially removed total joint arthroplasty from the inpatient only services list, opening a new door for improved cost savings to patients and the healthcare system alike. In the post-COVID healthcare system numerous factors have pushed increasing numbers of total joint arthroplasties into the outpatient, ambulatory surgery center setting. Improved anesthesia and surgical practices in the preoperative, intraoperative, and postoperative settings have revolutionized pain control, blood loss, and ambulatory status, rendering costly hospital stays obsolete in many cases. As the population ages and more total joint procedures are performed, the door is opening for more orthopedic procedures to exit the inpatient only setting in favor of the ambulatory setting.

Postoperative neurocognitive disorders (PoNCDs), such as postoperative delirium and cognitive dysfunction or decline can occur after surgery, especially in older patients. This significantly affects patient morbidity and surgical outcomes. Among various risk factors, recent studies have shown that preoperative frailty is associated with developing these conditions. Although the mechanisms underlying PoNCDs remain unclear, neuroinflammation appears to play an important role in their development. For the prevention and treatment of PoNCDs, medication modification, a balanced diet, and prehabilitation and rehabilitation programs have been suggested. The risk of developing PoNCDs is thought to be lower in ambulatory patients. However, owing to technological advancements, an increasing number of older and sicker patients are undergoing more complex surgeries and are often not closely monitored after discharge. Therefore, equal attention should be paid to all patient populations. This article presents an overview of PoNCDs and highlights issues of particular interest for ambulatory surgery.

Ambulatory laparoscopic colectomy (ALC), meaning discharge within 24 h of surgical colonic resection, has recently been proposed in a few, selected patients. This systematic review was performed with the aim of reviewing protocols for ALC and assessing feasibility, safety and outcomes after ALC.
A PRISMA-compliant systematic review and pooled analysis was performed searching all English studies published until October 2022 in PubMed, Cochrane Library, Web of Science (PROSPERO, CRD42022334463). Inclusion criteria were original articles including patients undergoing ALC, specifying at least one outcome of interest. Exclusion criteria were articles reporting a robotic-assisted procedure; unable to retrieve patient data from articles; the same patient series included in different studies. Primary outcomes were success, overall complications and readmission rates. Secondary outcomes included mortality and specific complications such us surgical site infection, anastomotic leak, ileus, bleeding, rate of ALC acceptance, and unscheduled consultation and reoperation rate.
Among 1087 studies imported for screening, 11 were included (1296 patients). The success rate was 47% with an overall morbidity of 14%. Readmission and reoperation rates were 5% and 1%, respectively. No mortality was recorded. Protocols of ALC differ significantly among published studies.
Overall, ALC appears to be safe and feasible in selected cases with an acceptable success rate and a low risk of readmission after hospital discharge. Future studies should evaluate patients\' benefits and discharge criteria, as well as uniformity and standardization of eligibility criteria. This systematic review may help inform on ALC adoption in clinical practice.

To evaluate the effect of preoperative web-based information to parents of children undergoing elective ambulatory surgery performed with anesthesia. Outcome measures were parental anxiety, knowledge, and satisfaction.
The review followed the PRISMA statement. A systematic search of six databases was conducted. Randomized controlled trials, cluster-randomized trials and quasi-randomized controlled trials were eligible for inclusion.
Eight studies were included. An effect in favour of web-based information compared to standard information was observed for parental anxiety measured before separation from child (SMD=-0.66, 95% CI=-0.92 to -0.40) and after surgery (SMD=-0.55, 95% CI=-0.95 to -0.16), for parental knowledge measured in-hospital (SMD=1.10, Cl 95%=0.37-1.82), and parental satisfaction after discharge (SMD=1.03, 95% Cl=0.41-1.65). No effect was observed for anxiety at separation, and for satisfaction in-hospital. The certainty of the evidence varied from very low to moderate.
Depending on the timing of assessment, web-based information before pediatric surgery may reduce the level of parental anxiety and increase the level of parental knowledge and satisfaction more than standard care.
Web-based routines can be used to convey pre-operative information to parents before paediatric ambulatory surgery. Still, standardized research that enables further comparison across studies is needed.

UNASSIGNED: Worldwide, there is an increasing trend of performing more complex operations in a day care setting, usually driven by economic considerations. Provision of appropriate pain relief is still inadequate in this setting. Poor pain control and adverse effects of opioids provided for pain control are common reasons for readmission, with human and economic consequences. The aim of this review was to develop evidence-based protocol for pain management of day surgery in a resource limited setting.
UNASSIGNED: After formulating the key questions, scope, and eligibility criteria for the articles to be included, advanced search strategy of electronic sources from data bases and websites was conducted. Screening of literatures was conducted with proper appraisal checklist. This review was reported in accordance with preferred reporting items for systematic reviews and meta-analysis (PRISMA) 2020 statement.
UNASSIGNED: A total of 333 articles were identified from data bases and websites using an electronic search. 45 articles were removed for duplication and 87 studies were excluded after reviewing titles and abstracts. At the screening stage, 73 articles were retrieved and evaluated for eligibility. Finally, 40 studies met the eligibility criteria and were included in this systematic review.
UNASSIGNED: Day surgery encourages patients to mobilize soon after surgery and empowers them to manage their own pain. Thus, preoperative patient education and high-quality perioperative pain management are paramount. With increasing healthcare demands for more day-case procedures, multi-modal analgesic techniques in the perioperative period with good extension of analgesia into the postoperative discharge period are essential.

To review experience with outpatient spinal anesthesia (SA) from a single center in infants ≤6 months of age.
Retrospective review of all SAs performed in the ambulatory setting in the outpatient surgery centers in infants ≤6 months of age from 2016 to 2020, focusing on success rate, adverse events, post-anesthesia care unit (PACU) times, and emergency department (ED) or urgent care (UC) returns within 7 days of the operation.
The study cohort included 175 SAs performed on 173 patients ≤6 months of age. One hundred and sixty-two patients (93%) were able to undergo their respective surgical procedures under SA without conversion to general anesthesia. One hundred and thirty-six patients (78%) did not require additional sedation or analgesic agents. The median time from entering the operating room until the start of surgical procedure was 17 min. One hundred and twenty-six patients (72%) were able to bypass Phase I of the PACU. One hundred and forty-seven patients (86%) were discharged in less than two hours postoperatively. Only one complication related to SA was noted. This was a patient who returned on postoperative day 2 with a possible CSF leak noted by ultrasound. After overnight hospital floor admission, he was discharged the next day after receiving intravenous fluids without further sequelae.
SA is a viable option for anesthetic care in infants ≤6 months of age presenting for outpatient surgery. Advantages included the ability to bypass PACU Phase I and facilitation of hospital discharge.
IV. Retrospective cohort treatment study.

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.

BACKGROUND: A number of papers have been published comparing the safety and efficacy of day case and inpatient anatomic or reverse total shoulder arthroplasty. However, no systematic review of the literature has been published to date. The aim of this review was to determine if day case total shoulder arthroplasty (length of stay <24 h) leads to similar outcomes as standard-stay inpatients (length of stay ≥24 h).
METHODS: The US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviewers were queried for publications utilizing keywords that were pertinent to total shoulder arthroplasty, day case, outpatient and inpatient, clinical or functional outcomes, and complications. In order to determine the quantitative impact of day case total shoulder arthroplasty on readmission and revision rate, a meta-analysis was performed on articles that observed 30- or 90-day readmission or revision.
RESULTS: Eight articles were found to be suitable for inclusion in the present study which included 6103 day case total shoulder arthroplasty and 147,463 inpatient total shoulder arthroplasty. Following meta-analysis, there was no significant difference among patients who underwent day case total shoulder arthroplasty compared to inpatient total shoulder arthroplasty regarding revision rates (OR: 1.001; 95% CI: 0.721-1.389; p = 0.995) and 30-day readmission rates (OR: 0.940; 95% CI: 0.723-1.223; p = 0.646). In contrast, patients who underwent day case total shoulder arthroplasty were less likely to have a readmission within 90 days compared to their inpatient counterparts (OR: 0.839; 95% CI: 0.704-0.999; p = 0.049). Two out of eight studies reported comparable baseline clinical characteristics among groups, while five studies reported significant differences and one study did not provide information regarding clinical characteristics, such as medical comorbidities or American Society of Anaesthesiologists\'(ASA) score. No significant difference among groups was found in all or almost all studies regarding mortality rates, and rates of cardiac complications, cerebrovascular events, thromboembolic events, pulmonary complications, cardiac complications, and nerve complications. Finally, results were rather conflicting regarding the correlation of day case total shoulder arthroplasty to the rate of surgical site infections.
CONCLUSIONS: This study showed that day case total shoulder arthroplasty might lead to similar rates of mortality, complications, revisions, and readmissions compared to inpatient total shoulder arthroplasty when used in a selected population of younger, healthier, and more male patients. In contrast, there was no consensus regarding the impact of day case total shoulder arthroplasty on the rate of surgical site infections. Finally, further research of higher quality is required to establish patient demographic criteria, ASA score, or comorbidity index cut off that might be used to define day case-treated patients who seem to have equivalent outcomes compared to inpatient-treated patients.Level of evidence: Systematic review of level III studies (lowest level included).

OBJECTIVE: Hemorrhoidectomy remains the gold standard treatment for grade III-IV hemorrhoids. However, despite strong recommendations for the suitability of outpatient surgery, post-operative pain has been a limitation to the widespread inclusion of this condition in day surgery programs. The aims of the study were to analyze and compare the post-operative pain of conventional open hemorrhoidectomy, considered the reference technique, against other surgical procedures such as closed hemorrhoidectomy, open hemorrhoidectomy using bipolar or ultrasonic sealant, hemorrhoidopexy, or HAL-RAR, when performed exclusively as outpatients.
METHODS: A systematic review and meta-analysis was conducted according to PRISMA methodology. All prospective and randomized studies of patients operated on for hemorrhoids in day surgery and specifying the value of post-operative pain, using a validated scale, were included. Conventional meta-analyses and a random-effects network meta-analysis were carried out.
RESULTS: Twenty-nine studies were included (3309 patients). None of the procedures described severe pain in the post-operative period. Hemorrhoidopexy was the least painful. Conventional open hemorrhoidectomy was the most painful on the first and seventh post-operative days. Pain was reduced after closed hemorrhoidectomy technique and when bipolar or harmonic scalpel was used. Furthermore, transfixive ligation of the hemorrhoidal pedicle was associated with increased post-operative pain.
CONCLUSIONS: Hemorrhoidal surgery is feasible in day surgery units and post-operative pain can be adequately managed in an outpatient setting. Hemorrhoidopexy was the least painful; however, data should be carefully evaluated by the high rate of long-term recurrence described in literature. Closed hemorrhoidectomy, performed with bipolar or ultrasonic sealing, avoiding transfixive ligation of the hemorrhoidal pedicle, may improve post-operative pain control.
BACKGROUND: CRD42020185160.

UNASSIGNED: Outpatient thyroid surgery is gaining popularity as it can reduce length of hospital stay, decrease costs of care, and increase patient satisfaction. There remains a significant variation in the use of this practice including a perceived knowledge gap with regards to the safety of outpatient thyroidectomies and how to go about implementing standardized institutional protocols to ensure safe same-day discharge. This review summarizes the information available on the subject based on existing published studies and guidelines.
UNASSIGNED: This is a scoping review of the literature focused on the safety, efficacy and patient satisfaction associated with outpatient thyroidectomies. The review also summarizes and editorializes the most recent American Thyroid Association guidelines.
UNASSIGNED: In total, 11 studies were included in the analysis: 6 studies were retrospective analyses, 3 were retrospective reviews of prospective data, and 2 were prospective studies. The relative contraindications to outpatient thyroidectomy have been highlighted, including: complex medical conditions, anticipated difficult surgical dissection, patients on anticoagulation, lack of home support, and patient anxiety toward an outpatient procedure. Utilizing these identified features, an outpatient protocol has been proposed.
UNASSIGNED: The salient features regarding patient safety and selection criteria and how to develop a protocol implementing ambulatory thyroidectomies have been identified and reviewed. In conclusion, outpatient thyroidectomy is safe, associated with high patient satisfaction and decreased health costs when rigorous institutional protocols are established and implemented. Successful outpatient thyroidectomies require standardized preoperative selection, clear discharge criteria and instructions, and interprofessional collaboration between the surgeon, anesthetist and same-day nursing staff.