After day-case septoplasty, day case thyroidectomy, now day case CSF leak repair – has the pendulum moved too far? The authors put forward a convincing case for what, only 10 years ago, would have sounded like a provocation. They quote in their paper an impressive statistic: according to National Health Statistics Reports on ambulatory surgery published in 2006, an estimated 600,000 sinonasal procedures were performed on an outpatient basis every year. Repair of small skull base defects (smaller than 1cm2) is a straightforward procedure, with high success rates, that normally takes less than an hour and is not associated with significant trauma. The authors collected their data from 2004 to 2014 and included 89 cases, with one surgeon accounting for the vast majority of patients. About half the patients underwent repair as day case surgery, and they were almost evenly divided between iatrogenic, traumatic and spontaneous leaks, with the majority including the ethmoid area, and one fourth the sphenoid area.
Patients treated as day cases included small defects (less than 1cm2), not including the frontal sinus, not requiring flaps or complex repair techniques. One patient from the ambulatory group was seen at the emergency department for preseptal swelling but was not re-admitted. Using the Royal College of Surgeons criteria for ambulatory procedures, the study population certainly fulfills the less than 3% readmission rate requirement for day case surgery.
One must keep in mind the risk of pneumocephalus, meningitis and infection, however, many of these complications could occur in the late postoperative period, and would not have been avoided in a two or even three-day admission. Obviously, it is important to select the patients well: as in thyroid surgery, one would not treat a patient with a huge obstructive goiter as day case, a large and complex repair in a patient with multiple problems is a very different beast to a 2-3mm defect of the lateral lamella.