Ambulatory surgery was initially limited to procedures performed under local or regional anaesthesia, which required minimal postoperative monitoring. Anesthesia techniques and perioperative management have evolved ever since such that low risk surgeries performed under general anaesthesia can now also be performed in the ambulatory setting. Patients undergoing breast cancer surgery seldom develop serious complications and most return to their preoperative function soon after the surgery, making them ideal candidates for ambulatory surgery. In spite of this, many patients have been managed in the past as inpatients due to concerns about drain care and the lack of structured outpatient follow-up care. This has gradually changed over the years. After sentinel lymph node biopsy (SLNB) was adopted as the standard of care, full axillary lymph nodal dissection (ALND), and consequently the use of surgical drains, became less common. This, together with the establishment of specialised breast units in many centres to provide continuity of care after hospital discharge, has led to a greater push towards ambulatory breast cancer surgery.
Early discharge has been shown to contribute to greater healthcare efficiency without compromising the quality of care. Studies have consistently affirmed the safety and benefits of ambulatory surgery, even in patients discharged with surgical drains
In March 2004, our institute introduced a 23-hour ambulatory surgery service (AS23). The AS23 unit functions as an independent facility from the inpatient wards, with its own bed capacity and staff complement. Strict admission criteria ensure that only patients undergoing low risk surgeries under general anaesthesia and who require only basic postoperative monitoring and care are admitted. Patients are typically admitted to the unit after surgery and are monitored until they are discharged home, either later on the same day or the following morning. Patients who develop perioperative complications requiring more intensive monitoring or who cannot be discharged by the following morning are transferred to the inpatient wards. Women undergoing breast cancer surgery were among the first to be included in this service. Prior to this, all women were admitted to the inpatient wards after breast cancer surgery. In this study, we reviewed the outcomes of women who underwent breast cancer surgery at our institute over a 7-year period, starting from the implementation of the AS23 service. In order to determine the safety and feasibility of ambulatory breast cancer surgery, we evaluated the frequency of postoperative complications, the frequency of unplanned prolonged hospital stays, and the readmission rate within 30 days of surgery. Patient and disease factors favouring ambulatory surgery were also identified.
A retrospective review was performed of 1742 women who underwent definitive breast cancer surgery at our institute from 1 March 2004 to 31 December 2010. This study has ethical committee approval (2011/00410). A total of 1822 breast cancer surgeries were performed during this period. These included 18 bilateral procedures (bilateral mastectomy or wide local excision (WLE), with or without SLNB or ALND) and 62 repeat surgeries for mastectomy or ALND. Those who underwent immediate breast reconstruction were also included. Surgeries were performed either as a day surgery (DS) procedure (with patients being discharged on the same day of surgery), an AS23 procedure (patients were discharged the following morning), or as an inpatient procedure (patients were discharged more than 24 hours after surgery). Both DS and AS23 procedures were considered ambulatory surgery. A single drain would be inserted under the skin flaps following a mastectomy, and another into the axilla following ALND. Surgical drains were not inserted if a WLE or a SLNB was performed.
Following surgery, all patients were transferred and monitored in the Postanesthesia Care Unit (PACU). After the discharge criteria were satisfied, patients were then transferred to the AS23 unit or inpatient wards. Diet and long-term medications, with the exception of anticoagulants and antiplatelet agents, were resumed once the patients were fully awake. Oral analgesia was prescribed for pain relief, while antiemetics were given on a
The decision for surgery was made following discussions between the patient and surgeon. Patients were scheduled for ambulatory surgery unless they had existing medical conditions that necessitated more intensive postoperative monitoring or if they were undergoing immediate breast reconstruction (breast reconstruction with autologous myocutaneous flaps is standard at our institute). Those with poor family or social support and who were residents of nursing homes or mental institutes were also managed as inpatients. Specialist breast care nurses would then engage patients and their families in preoperative counselling sessions, where the surgical process, postoperative recovery, and concerns regarding early discharge were discussed. Thereafter, patients were evaluated by the anaesthesia team to assess the suitability for ambulatory surgery and to optimise the control of any existing comorbidities.
Data collected included age, ethnicity, preexisting medical conditions, tumor characteristics, surgical procedure, and postoperative outcomes including complications, length of hospital stay, and readmissions within 30 days of discharge. Comparison was made between those who had undergone ambulatory versus inpatient surgery. Correlation analyses were performed using the chi-square test or Fisher’s exact test where appropriate; the Mann Whitney
A total of 1742 women underwent definitive breast cancer surgery at our institute in the 7-year period. Median patient age was 54 years (ranging from 20 to 94 years) and ethnic distribution reflected that of local population demographics (Table
Correlation analyses comparing between women who had undergone ambulatory surgery and women who had undergone inpatient surgery (
Characteristics | Ambulatory surgery |
Inpatient surgery |
|
---|---|---|---|
Median age (years) (range) | 53 (20–91) | 57 (23–94) | <0.01 |
Ethnicity | 0.29 | ||
Chinese | 975 | 414 | |
Malay | 107 | 58 | |
Indian | 62 | 33 | |
Others | 63 | 30 | |
Tumour type | 0.18 | ||
DCIS | 237 | 60 | |
IDC | 857 | 422 | |
ILC | 56 | 26 | |
Others | 57 | 27 | |
Disease stage | <0.01 | ||
DCIS | 237 | 60 | |
I | 326 | 120 | |
II | 391 | 165 | |
III | 176 | 140 | |
IV | 25 | 27 | |
Surgical procedure | <0.01 | ||
WLE with or without SLNB | 415 | 27 | |
WLE with ALND | 235 | 61 | |
Mastectomy with or without SLNB | 224 | 80 | |
Mastectomy with ALND | 314 | 232 | |
Bilateral proceduresa | 18 | 17 | |
Mastectomy with immediate reconstruction | 1b | 118c | |
Disease recurrence | <0.01 | ||
Yes | 110 | 89 | |
No | 1097 | 446 |
WLE: wide local excision; SLNB: sentinel lymph node biopsy; ALND: full axillary lymph node dissection. aBilateral mastectomy or WLE. bInsertion of implant. cAutologous flap reconstruction or insertion of implant.
Details of surgical procedures performed as ambulatory surgery (
Day surgery | AS23 | |
---|---|---|
WLE with or without SLNB | 309 | 127 |
WLE with ALND | 37 | 206 |
Mastectomy with or without SLNB | 19 | 243 |
Mastectomy with ALND | 7 | 311 |
Bilateral proceduresa | 0 | 18 |
WLE: wide local excision; SLNB: sentinel lymph node biopsy; ALND: axillary lymph node dissection. aBilateral mastectomy and WLE.
There has been an increasing trend towards ambulatory surgery over the 7 years (
Proportion of surgeries being performed as ambulatory and inpatient procedures from 1 March 2004 to 31 December 2010.
Seventy-five patients (6.2%) who were initially scheduled for ambulatory surgery were managed as inpatients instead. About a third (28 of 75, 37.3%) of these patients had requested to stay longer because family members were not confident of caring for them. Sixteen patients (21.6%) stayed more than 24 hours because of persistent giddiness, nausea, and postural hypotension, which all resolved with conservative treatment within the next 2 days. Details are included in Table
Details of 16 patients with postanaesthesia events who were admitted for longer than 24 hours.
Patient | Age (years) | Preexisting comorbidities | Surgery | Event | Management | LOS (days) |
---|---|---|---|---|---|---|
1 | 68 | Hyperlipidaemia | Mastectomy/AC | Giddiness | Expectant | 2 |
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2 | 47 | Hyperlipidaemia | Mastectomy/AC | Giddiness | Expectant | 2 |
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3 | 41 | Thalassemia minor | Mastectomy/AC | Giddiness | Expectant | 2 |
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4 | 59 | NIL | Mastectomy/AC | Postural hypotension | Fluid challenge | 3 |
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5 | 69 | Hypertension, |
Mastectomy/SLNB | Giddiness | Expectant | 2 |
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6 | 81 | NIL | Mastectomy/SLNB | Giddiness | Expectant | 2 |
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7 | 48 | NIL | Mastectomy/AC | Giddiness | Expectant | 3 |
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8 | 57 | NIL | Mastectomy/AC | Nausea and vomiting | Antiemetics | 2 |
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9 | 71 | Hypertension, hyperlipidaemia, diabetes mellitus | WLE/AC | Postural hypotension | Expectant | 2 |
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10 | 48 | NIL | Mastectomy/SLNB | Giddiness | Expectant | 2 |
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11 | 67 | Hypertension, hyperlipidaemia, diabetes mellitus | Mastectomy/SLNB | Giddiness | Expectant | 2 |
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12 | 79 | Hypertension, hyperlipidaemia, diabetes mellitus | Mastectomy/SLNB | Postural hypotension | Expectant | 2 |
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13 | 71 | Hypertension, hyperlipidaemia, diabetes mellitus | Mastectomy/SLNB | Giddiness | Expectant | 2 |
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14 | 67 | NIL | Mastectomy/SLNB | Giddiness | Expectant | 2 |
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15 | 47 | Hypertension, hyperlipidaemia, diabetes mellitus | Mastectomy/AC | Nausea and vomiting | Antiemetics | 2 |
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16 | 54 | Hypertension, diabetes mellitus | Mastectomy/AC | Giddiness | Expectant | 2 |
AC: axillary clearance; SLNB: sentinel lymph node biopsy; WLE: wide local excision.
Details of 29 patients who required inpatient admission for management of unanticipated perioperative events.
Patient | Age (years) | Preexisting comorbidities | Surgery | Event | Management | LOS (days) |
---|---|---|---|---|---|---|
1 | 59 | Hypertension, |
Mastectomy/AC | Wound bleeding | Wound exploration and haemostasis | 4 |
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2 | 62 | Hypertension, hyperlipidaemia, |
WLE/AC | Desaturation due to OSA and drowsiness postoperatively | CPAP | 6 |
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3 | 66 | Hypertension, hyperlipidaemia, diabetes mellitus, previous transient ischaemic attack | WLE | Uncontrolled blood pressure intraoperatively | Expectant | 4 |
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4 | 42 | Obesity, obstructive sleep apnoea | Mastectomy/SLNB | New onset of atrial fibrillation | Cardiology consult; beta-blockers | 4 |
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5 | 67 | Hypertension, hyperlipidaemia, diabetes mellitus | Mastectomy/SLNB | Wound bleeding | Wound exploration and haemostasis | 4 |
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6 | 62 | Hyperlipidaemia | Mastectomy/AC | High drain output | Expectant | 2 |
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7 | 43 | Hyperthyroidism | WLE/SLNB | Negative pressure pulmonary edema secondary to laryngospasm after extubation | CPAP and diuretics | 5 |
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8 | 58 | Hypertension, hyperlipidaemia | Mastectomy/AC | High drain output | Expectant | 2 |
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9 | 57 | NIL | Mastectomy/AC | Wound pain | Expectant | 2 |
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10 | 51 | NIL | WLE/AC | Atypical chest pain | Expectant | 2 |
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11 | 82 | Hypertension, schizophrenia, |
Mastectomy/AC | Premature ventricular contractions and hypotension intraoperatively | Expectant | 4 |
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12 | 61 | NIL | Mastectomy/AC | Low oxygen saturation postoperatively | Expectant | 4 |
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13 | 78 | Hypertension, |
Mastectomy/SLNB | Acute urinary retention | Indwelling urinary catheter | 5 |
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14 | 44 | NIL | WLE/SLNB | Atypical chest pain | Expectant | 1 |
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15 | 55 | NIL | WLE/SLNB | Intraoperative hypotension secondary to blue dye allergy | Expectant | 1 |
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16 | 60 | NIL | Mastectomy/AC | Wound bleeding | Wound exploration and haemostasis | 2 |
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17 | 61 | History of atypical chest pain | WLE/SLNB | Atypical chest pain | Expectant | 2 |
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18 | 60 | Hypertension, hyperlipidaemia, |
Mastectomy/SLNB | High drain output | Expectant | 4 |
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19 | 42 | Mitral valve prolapse | Mastectomy/SLNB and laparoscopic myomectomy | Wound (abdominal) pain | Expectant | 2 |
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20 | 65 | Hypertension, hyperlipidaemia | Mastectomy/SLNB | High drain output | Expectant | 4 |
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21 | 83 | Hypertension, hyperlipidaemia | Mastectomy/AC | Wound pain | Expectant | 2 |
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22 | 67 | NIL | WLE/SLNB | Intraoperative hypotension secondary to blue dye allergy | Expectant | 1 |
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23 | 49 | Asthma | Mastectomy/AC | Wound bleeding | Expectant | 1 |
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24 | 60 | NIL | Mastectomy/SLNB | Coffee ground aspirate intraoperatively | Proton pump inhibitors | 4 |
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25 | 81 | Hypertension, hyperlipidaemia, diabetes mellitus | Mastectomy/SLNB | Acute urinary retention | Indwelling urinary catheter | 7 |
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26 | 65 | Hepatitis B carrier | Mastectomy/AC | High drain output | Expectant | 2 |
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27 | 79 | Diabetes mellitus, ischaemic heart disease | Mastectomy/AC | Mild congestive cardiac failure | Diuretics | 6 |
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28 | 62 | Hypertension | Mastectomy/SLNB and implant insertion | Cerebrovascular event | Antiplatelet therapy, neurorehabilitation | 22 |
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29 | 43 | NIL | Mastectomy/AC | Wound bleeding | Wound exploration and haemostasis | 3 |
AC: axillary clearance; SLNB: sentinel lymph node biopsy; WLE: wide local excision; CPAP: continuous positive airway pressure.
One patient in the ambulatory surgery group developed a major postoperative complication. This patient had undergone mastectomy and insertion of implant as an ambulatory procedure and developed an acute cerebral infarct in the immediate postoperative period. She had no predisposing factors other than hypertension, which had been well-controlled prior to the surgery. Surgery had also been uneventful. Antiplatelet therapy was started and she was subsequently transferred to a neurology rehabilitation unit where she made a full functional recovery. Sixty-two patients (3.6%) were readmitted within 30 days of surgery, 37 (59.6%) of whom had undergone ambulatory surgery (Table
Details of surgical outcomes in patients who had undergone ambulatory surgery and inpatient surgery (
Characteristics | Ambulatory surgery |
Inpatient surgery |
|
---|---|---|---|
Number of readmissions within 30 days | 37 | 25 | 0.07 |
Median length of stay following readmission (days) | 3 (1–27) | 4 (1–17) | 0.07 |
Complications | 0.69 | ||
Wound hematoma or bleeding | 15 | 7 | |
Wound infection | 13 | 9 | |
Wound dehiscence | 0 | 4 | |
Wound pain | 3 | 0 | |
Drain complicationsa | 0 | 5 | |
Othersb | 6 | 0 | |
Number of reoperations | 10 | 5 | 0.77 |
Wound exploration and haemostasis | 8 | 1 | |
Wound debridement | 2 | 1 | |
Secondary suture of wound | 0 | 3 |
aHigh drain output, drain dislodgement. bSyncope in 3 patients, lower limb deep venous thrombosis in 1 patient, diarrhoea in 1 patient, and hyperkalemia in 1 patient.
Hospital stays after breast cancer surgery were shortened after it became apparent that early discharge, even with the surgical drains
Our institute was one of the first in Singapore to actively push for breast cancer surgery to be done as an ambulatory procedure. Since the first implementation of the AS23 service in 2004, more than 70% of all breast cancer surgeries are now being performed as ambulatory procedures in our institute. Ambulatory breast cancer surgery is now considered the norm, rather than the exception. Only 6% of those initially scheduled for ambulatory surgery were not discharged as planned; even so, most stayed only for an additional 2 days. Most of our patients had adequate home support, and only 2% of patients opted for inpatient admission because of social reasons. Similar to other published reports, we have observed that patient safety was not compromised by early discharge [
Psychological benefit and improved patient outcomes have been said to be among the main advantages of ambulatory surgery [
Yet another major benefit of ambulatory surgery is the significant cost savings resulting from shorter hospital stays [
Our study has shown that ambulatory breast cancer surgery can be successfully implemented in an Asian population. Patient acceptance is high while postoperative complication and readmission rates are low. An integrated workflow involving the surgeons, anaesthetists, and breast care nurses is fundamental to the success of ambulatory surgery. Such a workflow minimises the occurrence of adverse events through proper patient selection and ensures continuity of care upon discharge.
The authors declare that there is no conflict of interests regarding the publication of this paper.