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Am Fam Physician. 2003;67(7):1599-1600

The issue of the length of postmastectomy and other breast-surgery hospitalization has become controversial and highly politicized. One result has been the extensive incorporation of patient perspectives into the development of treatment algorithms. By 1999, more than 98 percent of patients undergoing lumpectomy axillary dissection or sampling, or mastectomy without reconstruction, were requesting to be discharged from the recovery room rather than having an overnight hospital stay. High rates of safe early discharge were obtained in specialist centers using standardized protocols. Dooley studied this approach in a freestanding ambulatory surgery center in a midwestern city.

Dooley studied 87 patients who underwent various surgeries for breast cancer (including lumpectomy with axillary dissection or sampling and various forms of mastectomy) from March 2001 through October 2001. Of the 23 patients who underwent mastectomy, five had bilateral surgeries, and 64 patients (74 percent) underwent breast-conserving surgical procedures. The age range was 38 to 84 years (mean, 59 years). All patients were discharged less than 2.5 hours postoperatively, except one patient who elected to remain in the hospital overnight. All patients were assessed on the evening of the surgery and the next morning by a specialist nurse, and telephone support was available. Complications of surgery included four episodes of nausea or vomiting within 24 hours of discharge, two seromas following drain removal, and one wound infection. No patients required readmission to hospital following discharge.

These results were compared with similar cases at the same hospital during the year 2000. The age and insurance distribution of the patients were identical between the two years. Before the opening of the ambulatory surgery center, the average length of hospital stay was 1.6 days, but breast conservation was performed in only 59 percent of cases. Six percent of cases had wound infections and 2 percent required readmission. The author calculated an 85.4 percent reduction in hospital charges in 2001 compared with 2000.

The author concludes that almost all surgery for breast cancer can be done successfully without hospital admission. Ambulatory surgery is preferred by most patients and is associated with a significant reduction in perioperative complications and hospital costs, without additional morbidity or mortality. Decisions about length of stay following breast cancer surgery should be based on clinical and quality-of-care considerations, and the use of ambulatory surgery requires extensive planning and provision of support services in the community.

editor's note: Patients continue to be shocked by the prospect of having a significant surgery without hospital admission. Family physicians can play a key role in emphasizing the advantages of not being admitted to the hospital and in preparing families and community agencies to assist with postoperative care. If advantages of ambulatory surgery are not explained to patients, they may go to surgery angry, and this may result in poor outcomes. Family medicine can play another crucial role in the movement to increase the use of ambulatory surgery. Our academic research units are ideally positioned to evaluate outcomes and make recommendations about “best practices.” As shown by the discussion following this and other articles in surgical journals, surgeons are fearful that results will be used to drive practice toward day surgeries for financial rather than quality reasons. Researchers from family practice not only have greater “neutrality” in this area, we also are concerned about the long-term and multiple ramifications of surgery. We could bring greater perspective and more complete assessments to this area. It is time to do joint research projects with our colleagues to establish the very best practices for our patients.—a.d.w.

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