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Live Event Content
Update Course 2023 - Who to Send Home from the OR
With Dr. Justin Huntington
Chapter 1 of 8 · Surgical Management
GC fistula closure
Gastrocutaneous Fistula Closure - Same Day Discharge
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What the experts said
Non-operative management of appendicitis has approximately 30% recurrence rate at 2 years
Recurrence rate for non-operative appendicitis management is much higher in patients with appendicolith
Published protocol for laparoscopic G-tube placement with same-day discharge showed 82% discharged same day when feeds started within 4 hours without waiting for goal feeds
98% of families were satisfied with same-day discharge after laparoscopic G-tube placement
Less than 5% of patients return to ED after same-day discharge following laparoscopic G-tube placement, and returns occur beyond the 24-hour period they would have been kept in hospital
One institution achieved 65-68% same-day discharge for pectus excavatum repair using ERAS protocol with cryoablation alone (no intercostal nerve blocks), with median length of stay 11-12 hours
Most pectus excavatum patients stop using opioids by day 6 post-operatively and are just on Tylenol and Motrin as needed
Modern energy devices like cool seal or ultrasonic energy have reduced bleeding complications after thyroidectomy, making same-day discharge safer
Walter Kane in Birmingham used to cauterize gastrocutaneous fistulas in the office with a bedside cautery device and some of them closed
NSQIP data from 2012-2015 showed 80% of gastrocutaneous fistula closures were discharged same day versus 20% going home day one or two or later
Colorectal surgeons teach that perianal abscesses in children less than 1 year old can be treated with antibiotics alone and will resolve without surgical drainage, and operating on them makes fistula development more likely
Retrospective review of 3-4 year olds with perianal abscess showed failure rate of 2.3% in 30 days with same-day discharge
Higher white blood cell count correlated with treatment failure in perianal abscess drainage
Study of 92 patients aged 3 months to 6 years with perianal abscess showed only one treatment failure when discharged home with no IV antibiotics
In Los Angeles, 2/3 of eligible patients chose non-operative management for appendicitis, and more than 50% of those were able to be sent home from the ED
In Seattle, 95% or more of patients choose surgery over non-operative management for appendicitis
NSQIP data from 2012-2015 showed 22% of acute appendicitis cases were discharged same day, with no increased risk of readmission or complications
A California healthcare system with lack of pediatric beds implemented same-day discharge protocol for uncomplicated appendectomy and increased rate from 45.5% to 84.4% with no difference in 30-day readmission or ED visits
NSQIP data shows same-day discharge for appendectomy increased from 22% (2012-2015) to mid-30% and then to 43% (2017-2021)
Implementation of ERAS protocol for cholecystectomy at one institution increased same-day discharge from 2% to 77% with no significant difference in 30-day ED visits
Risk factors for overnight hospital stay after cholecystectomy include later surgery time, higher ASA class, and longer operative time
NSQIP data from 2017-2021 shows about 35% of laparoscopic cholecystectomies in pediatric population are discharged same day
Cryoablation representatives say it takes 6 to 8 hours for cryoablation to fully take effect, which is why they recommend doing rib blocks at the same time
American Society of Anesthesiologists recommends each institution develop their own protocols for apnea monitoring in premature infants rather than providing a general guideline
NSQIP data shows same-day discharge for pyloromyotomy increased from 1.5% to 4.5% in recent years
Ad-lib feeding protocol for pyloromyotomy allowing discharge after tolerating 3 feeds results in discharge around 11 hours post-operatively
Study of 55 pediatric thyroidectomy patients (36 total, 13 lobectomy, some with neck dissections) showed all went home after 2 hours with 10% transient hypoparathyroidism, 3.8% permanent hypoparathyroidism, and 1.8% post-op hematoma requiring reoperation on post-op day 6
American Thyroid Association has published guidelines supporting outpatient thyroidectomy and encouraging consideration of clinical, social, and procedural factors to determine safety of same-day discharge