Tobacco smoking is one of the most significant public health problems worldwide. The adverse effects of smoking on health are well known.1 According to the World Health Organization (WHO), the annual death toll could rise to more than eight million by 2030, unless urgent action is taken against smoking.2

In Hong Kong, 11.1% of the population aged 15 years or above are daily smokers. Men are the high-risk group and have a 22% prevalence of being smokers, which is much higher than in women (4%).3 The situation is particularly alarming, as the smoking population is becoming younger.3 Smoking contributes a large public health and medical burden to society.

The Hong Kong SAR Government has implemented numerous policies and enacted legislation on many occasions to combat tobacco smoking. Such action has entailed raising tobacco tax, making amendments to the existing Smoking (Public Health) Ordinance to prohibit smoking in public places, restricting the sale of tobacco products and tobacco advertising. While strategies such as taxation and prohibition of advertising are proven to be effective, one effective strategy that should not be ignored is “smoking cessation advice” (SCA) delivered by health care professionals.

Smoking tobacco has been identified as an important cause of various oral diseases and pathologies. It is one of the most important factors predisposing to pre-cancerous lesions and cancer of the oral cavity, the reported pooled cancer risk being 3.4-fold higher than in non-smokers.4 It also increases the risk of periodontal diseases,5 complications after extractions,6 and increased rates of implant failures.7 Cross-sectional studies show that smokers have more tooth loss.8 Other easily recognised effects include staining of teeth,9 dental restorations, and prosthesis10 as well as alteration of taste perception11 and halitosis.12 All these have detrimental effects on the quality of life of smokers because of reduced chewing efficiency, poor aesthetics, and poor self-esteem.13

The benefits of smoking cessation are substantial. Evidence shows that smoking counselling given by dental professions can be effective and comparable to that offered by other primary care professionals.14 15 16 Around a quarter of the population have regular dental checkups and 53% have their teeth checked every 1 or 2 years.17 In their daily practice, dental professionals have access to a large patient population, including smokers. Besides, the detrimental effects of smoking on the oral cavity can be readily demonstrated directly and thus easily appreciated by patients; this acts as a strong motivator to quit smoking.16 Moreover, dental treatments entailing multiple visits provide good opportunities to motivate, reinforce, and support smoking cessation. Thus, dental professionals are in an excellent position for delivering advice and counselling to smokers. Notably, counselling by dentists has been reported to achieve an 8.6% cessation rate after 1 year, and over 16% when also coupled with nicotine replacement therapies.18 Despite these observations, delivery of SCA by dentists remains less than satisfactory.19 20 21 22 According to the literature, the reported barriers to such activity include lack of time, resources, remuneration, training, and fear of damaging dentist-patient rapport.23

In Hong Kong, a study conducted in 2006 showed that more than half of all medical doctors did not have adequate knowledge (53%) or favourable attitudes (55%) towards smoking cessation.24 Slightly over 40% lacked confidence in delivery of SCA. Although 77% of them obtained information on the smoking status of their patients, only 29% advised them to quit smoking, reflecting a low involvement of medical doctors in the promotion of smoking cessation.24

Local published data on the dentists’ attitudes, practices, and barriers to delivering SCA to patients are limited, except for one study by Lu et al.25 The rationale of the present study was to collect data from local dentists, and compare local results with those gleaned from international studies.

The objectives of the present study were: (1) to assess the attitudes of dentists towards SCA; (2) to investigate the current practice of dentists in respect of SCA; (3) to examine the perceived barriers to offering SCA; and (4) to seek possible relationships between the characteristics of dentists and their SCA activity.

A 17-item structured, self-administered and validated questionnaire developed by Stacey et al26 in 2006 in the UK was adopted as the survey instrument. The questionnaire consisted of three main parts: (1) smoking cessation views and activities of the dental team; (2) perceived barriers to giving SCA; and (3) perception of the importance of the smoking cessation role of the dental team and general medical practitioners. It was pilot-tested with a small convenience sample (n=20) of dentists.

The target population consisted of 2026 general dentists registered with the Hong Kong Dental Council, whose correspondence addresses are available on a website27 that is open to the general public. The inclusion criterion was any dentist who was currently having a dental practice in Hong Kong with a valid address at the time of this survey. A systematic sample (every 6th dentists on the list) was drawn from the 2026 registered general dentists in Hong Kong, so as to yield the desired sample size. A sample size of 324 subjects was calculated as needed based on a 5% margin of error (type I error), and 95% confidence level, assuming 50% response after distribution. Thus, 330 questionnaires were mailed in January 2012 with stamped self-addressed reply envelopes. Other means of reply allowed were by fax or by online completion of the questionnaires via a designated website. Another follow-up round of 330 questionnaires was sent to these dentists again 3 weeks after the first mailing.

A pilot study was carried out with a convenience sample (n=20) to ensure the face validity of the questionnaire. Test-retest reliability test was also performed using these 20 subjects who were asked to complete the questionnaire a second time (2 weeks later). The questionnaire was viewed by three experts in dental public health to ensure its suitability for the present study.

All data were analysed with the Statistical Package for the Social Sciences (Windows version 19.0; SPSS Inc, Chicago [IL], US). Frequency distributions were generated to illustrate the demographic data, their attitudes, practices, and perceived barriers in SCA. To examine any relationships between demographic variables and outcomes, unconditional logistic regression analysis was performed with each demographic variable and the outcome variables (attitudes, practices, perceived barriers). Multiple logistic regression was then performed for variables that yielded a P value of <0.25 in the individual analysis. The final model contained those statistically significant variables, using a stepwise-forward Wald logistic regression. The significance level was set at 0.05.

From the 330 selected dentists, 223 questionnaires were returned (163 by mail, 39 by fax, 21 online), of which five were incomplete. Thus, 218 questionnaires were valid for analysis, yielding a response rate of 66%. Alarmingly, less than one fourth of the dentists had received training in SCA. Only 16% of them had received such training during their undergraduate training and only 12% during postgraduate training. Moreover, only approximately 60% of the dentists claimed that they knew the contact of relevant supporting agencies for SCA. Table 1 shows the background of these dentists.

Nearly 97% of the dentists claimed that they would enquire about their patients’ smoking status, yet only around half of them would always do so as a routine (Fig 1). About 97% would enquire about smoking status whenever a patient presented with oral diseases related to smoking (eg periodontal disease and leukoplakia). The percentage of routine enquiries about smoking status when patients presented with oral white lesion (a symptom of oral pre-cancer) was slightly higher (73%) than those presented with periodontal disease (66%).

For dentists who would not routinely enquire about the smoking status, around half (53%) would always do so when patients presented with an oral white lesion, and around 40% would do so when the latter presented with periodontal disease.

For dentists who would always enquire about smoking status, 95% claimed they actually offered SCA. The majority of the dental practices (93%) entailed SCA offered by the dentists themselves, only 16% had dental nurses/hygienists who offered such advice and only 3% had practice managers/receptionists who did so.

After adjustments and exclusion of non-significant variables in the unconditional logistic regressions, only three variables were retained in the final model and were found to be statistically significant. These were the type of practice, receipt of training in SCA, and age. Government dentists, those who had received training in SCA, and those aged over 40 years were more likely to always enquire about their patients’ smoking status (outcome variable of the model, P<0.05; Table 2).

Trained dentists were more likely to always enquire about smoking when patients presented with periodontal disease than non-trained dentists, the respective odds ratio (OR) and 95% confidence interval (CI) being 3.3 and 1.5-7.2. Government dentists were also more likely to enquire about smoking when patients presented with a white oral lesion (OR=2.9; 95% CI, 1.4-6.1).

Similar results prevailed with respect to actually offering SCA to patients. Government dentists offered such advice more often than non-government dentists according to the logistic regression analysis (OR=8.3; 95% CI, 1.1-64.4).

Moreover, government dentists were more likely to know how to contact supporting agencies (OR=2.3; 95% CI, 1.1-4.6) than non-government counterparts, and trained dentists were more likely to know how to contact supporting agencies (OR=14.3; 95% CI, 4.2-48.5) than those non-trained.

A high proportion (89%) of dentists agreed or strongly agreed that the dental team has an important role in delivering SCA to patients; the percentage who agreed or strongly agreed that medical doctors had an important role was slightly higher (93%).

Trained dentists were 8.5 times more likely to think that it was imperative for dental teams to offer SCA (P<0.05). Almost all (98%) of those who received training thought that dentists should offer SCA, which was more than that for those who did not have such training (86%; P=0.014).

When dentists were asked who should offer SCA in the team, most (approximately 90%) claimed that they should be responsible, whilst 41% thought that nurses should also be involved, and 47% felt that hygienists too should be involved. However, only 16% of such personnel were actively involved in offering SCA; the percentages were even lower for receptionists (3%) and practice managers (1%).

Among the potential barriers listed in the questionnaire, the most important one identified by the dentists was the “possibility of losing patients” (31%), followed by the “lack of training” (25%) and the “unlikely to be successful” (14%). On the other hand, the “lack of time”, the “lack of fee”, and the “not perceived as my role” were not regarded as important (Fig 2).

This study gathered information on the current attitudes, practices, and perceived barriers among dentists in delivering SCA to Hong Kong patients, which could have implications for the development of training programmes and provide directions for future research.

The present study showed that Hong Kong dentists generally had positive attitudes and knowledge about SCA, and recognised the adverse effects of smoking on oral health, as reflected by the high percentages for enquiry about a patient’s smoking status. Moreover, nearly 90% expressed positive attitudes towards SCA, in that they agreed it had an important role to play.

Government dentists and dentists who received training were significantly more likely (approximately 3 times) to routinely enquire about a patient’s smoking status than other dentists. Trained dentists were also approximately 14 times more likely to know how to contact local supporting agencies, and more than 8 times as likely to offer SCA to the patients. They also perceived their role in offering SCA as very important and were more actively involved than other team members in its delivery. These results were similar to those for Hong Kong medical doctors,24 as well as findings of other international and local studies.20 21 22 25

This study reflects the importance of training and guidelines, although these were not widely available. Only a small proportion (16%) of dentists received training in SCA during their undergraduate studies. Notably, for local students the limited practical training in essential techniques for delivering SCA to patients was similar to the situation in the United States and Europe.28 29 Research has shown that to increase the effectiveness of SCA, education is needed to expand both didactic knowledge and clinical competencies to help patients quit smoking.30 Evidence also suggests that training should be provided early and continued throughout subsequent courses.31 Inclusion of both theoretical and practical training (counselling skills, problem-solving strategies) should be considered in future undergraduate curricula. Moreover, continuing professional education programmes focusing on hands-on SCA techniques could help dentists acquire better knowledge and more up-to-date techniques. According to the results, the continuing education programmes should be directed towards younger and non-government dentists.

The Department of Health has guidelines on SCA for the government dental officers, which includes annual updating of the patient’s smoking status, provision of SCA, and obtaining patient consent for referral to Tobacco Control Office when needed. This may be one reason government dentists were more likely to enquire about a patient’s smoking status, offer SCA, and confirm the importance of relevant guidelines. As in other countries, many dentists are not familiar with guidelines like the “5A approach”.32 Evidence suggests that dentists familiar with guidelines are more likely to engage in SCA.33 Local information and guidelines on SCA are mostly unclear, as they were not being designed specifically for dentists and may not be readily accessible to them.34 Not surprisingly, only approximately 60% of the dentists knew how to contact supporting agencies. Thus, clear, evidence-based, and easily accessible guidelines designed for the dental profession should be developed to facilitate the effective delivery of SCA by dental professionals.

Recently, a WHO Collaborating Centre for Smoking Cessation and Treatment of Tobacco Dependence was set up by Department of Health. It aims to provide evidence-based smoking cessation training for health care personnel. It also aims to develop, test, and evaluate models of smoking cessation to support WHO’s initiatives on assistance in the dissemination of relevant information on smoking cessation. Hopefully therefore, the dental profession will have more opportunities to receive training in SCA in the near future.35

Despite their apparently positive attitudes to SCA, only around half of the dentists always enquired about each patient’s smoking status and, if indicated, offered SCA. These findings are consistent with those from Australia36 and for Hong Kong medical doctors.24 The difference in the beliefs and the actual practice of dentists suggest barriers to implementation. In the present study, “lack of training”, “possibility of losing patients”, and “unlikely to be successful” were regarded as important barriers by the dentists, and were similar to those reported in the UK26 and Malaysia.20 They suggest that dentists lack confidence in delivering SCA and reinforce the importance of adequate training. Dentists worry that by offering SCA, they might damage relationships with their patients. However, in reality, research indicates that over half of the patients expect their dentists to discuss issues related to smoking.37 Also, such discussion could cultivate rapport between the dentists and the patients. Thus, actually delivering SCA could be very cost-effective in terms of gaining patient trust. To encourage involvement of dentists in delivering SCA, efforts should be directed at reducing the above-mentioned barriers (provision of adequate training, informing the dentists about current evidence, reducing their worries about damaging relationships with patients).

In this study, over 40% of the dentists expressed that other personnel in their teams (nurses, hygienists) should be involved in delivering SCA, though the percentages were lower than those in the UK.26 Thus, dentists generally recognised the importance of the team approach to delivering SCA, and the literature indicates that such team members (including administrative staff) are in a good position to do so.18 38 This is especially true for the hygienists, who are responsible for managing periodontal diseases that are smoking-related and require multiple visits, and therefore offer excellent opportunities to deliver SCA.39 40

The team approach should be encouraged, and as team leader, the dentist has overall responsibility and should actively involve other staff.41 In order to increase the effectiveness, training of the entire dental office team could be considered.42 The proportion of local dentists who thought practice managers and receptionists should be involved was low compared to that reported from the UK.26 Variations in dental clinic organisation in different countries may be part of the reason; for example, locally it is not common to involve dental practice managers in patient care.

As mentioned previously, various aspects of our results were generally comparable to those of other studies. The response rate in the present study was just under 70%, which was higher than 60% reported from the UK,26 and 55% reported from Malaysia,20 as well as 19% reported for Hong Kong medical doctors24 and 50% in another study on Hong Kong dentists.25 Our higher questionnaire response rate could be because the questions were simple, straightforward, and not time-consuming. Notably, the locally developed questionnaire used by Lu et al25 (on Hong Kong dentists) gathered more detailed information than we did.

The relatively low response rate in our study may limit the generalisability of the results, and our sample size was less than ideal. A full population survey should be conducted if resources and time permit. The tendency of respondents to provide positive, favourable responses may be a source of bias, resulting in an over-optimistic estimate of SCA implementation. The characteristics of the non-respondents were not known due to the anonymous nature of the questionnaire. The questionnaire was comparatively simple, and did not address specific aspects of knowledge on SCA, nor any specific aspects of advice offered to patients. This limited the scope of information being collected. Due to time and resource limitations, other important personnel, such as nurses and hygienists, were not surveyed.

A qualitative design could be considered to gain a deeper understanding on the beliefs and barriers to SCA with respect to the dental professions. Thereafter an updated questionnaire could be designed and validated, specifically for the local setting. This could entail specific questions on the knowledge of dentists regarding SCA and the specific activities they and their teams undertake. Further research could also focus on evaluating the effectiveness of different smoking cessation training programmes and practical approaches to SCA.

The present research showed that dentists in Hong Kong generally have positive attitudes towards their role in delivering SCA to patients. However, barriers like the relative lack of training and guidelines, the lack of confidence, and fear of damaging relationships with patients may prevent them from delivering the relevant advice. Local guidelines specifically designed for the dental profession should be developed and relevant resources made readily accessible. More importantly, adequate practical training programmes should be included in both the undergraduate curriculum and continuing education activities, especially for the private and younger dentists.

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19. Allard RH. Tobacco and oral health: attitudes and opinions of European dentists; a report of the EU working group on tobacco and oral health. Int Dent J 2000;50:99-102. CrossRef

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21. Uti OG, Sofola OO. Smoking cessation counseling in dentistry: attitudes of Nigerian dentists and dental students. J Dent Educ 2010;75:406-12.

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24. Abdullah AS, Rahman AS, Suen CW, et al. Investigation of Hong Kong doctors' current knowledge, beliefs, attitudes, confidence and practices: implications for the treatment of tobacco dependency. J Chin Med Assoc 2006;69:461-71. CrossRef

25. Lu HX, Wong MC, Chan KF, et al. Perspectives of the dentists on smoking cessation in Hong Kong. Hong Kong Dent J 2011;8:79-86.

26. Stacey F, Heasman PA, Heasman L, Hepburn S, McCracken GI, Preshaw PM. Smoking cessation as a dental intervention—views of the profession. Br Dent J 2006;201:109-13. CrossRef

27. The Hong Kong Dental Council. Lists of Registered Dentists in Hong Kong, September 2011. DCHK website: http://www.dchk.org.hk/docs/List_of_Registered_Dentists_Local.pdf. Accessed 2 Jan 2012.

28. Geller AC, Powers CA. Teaching smoking cessation in U.S. medical schools: a long way to go. Virtual Mentor 2007;9:21-5. CrossRef

29. Raupach T, Shahab L, Baetzing S, et al. Medical students lack basic knowledge about smoking: findings from two European medical schools. Nicotine Tob Res 2009;11:92-8. CrossRef

30. Ramseier CA, Christen A, McGowan J, et al. Tobacco use prevention and cessation in dental and dental hygiene undergraduate education. Oral Health Prev Dent 2006;4:49-60.

31. Brown RL, Pfeifer JM, Gjerde CL, Seibert CS, Haq CL. Teaching patient-centered tobacco intervention to first-year medical students. J Gen Intern Med 2004;19:534-9. CrossRef

32. Succar CT, Hardigan PC, Fleisher JM, Godel JH. Survey of tobacco control among Florida dentists. J Community Health 2011;36:211-8. CrossRef

33. Hu S, Pallonen U, McAlister AL, et al. Knowing how to help tobacco users. Dentists' familiarity and compliance with the clinical practice guideline. J Am Dent Assoc 2006;137:170-9. CrossRef

34. Tobacco Control Office, Department of Health, Hong Kong. Health promotion-tobacco control resources centre. Available from: http//www.tco.gov.hk/English/health/health_tcrc.html. Accessed 1 May 2012.

35. Hong Kong Council on Smoking and Health. News update—First WHO collaborating centre for smoking cessation officially launched in Hong Kong. COSH Website: http://smokefree.hk/en/content/web.do?page=news20120410. Accessed 4 May 2012.

36. Trotter L, Worcester P. Training for dentists in smoking cessation intervention. Aust Dent J 2003;48:183-9. CrossRef

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38. Pizzo G, Piscopo MR, Pizzo I, Giuliana G. Smoking cessation counselling and dental team [in Italian]. Ann Ig 2006;18:155-70.

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Ultrasound-guided percutaneous biopsy is a well-established means for diagnosis of focal or diffuse disease in solid organs. It is generally safe and confers minimal risk of complications. However, it is contra-indicated in patients with bleeding tendencies, which means that histological diagnosis may be lacking and sometimes life-saving treatment cannot be commenced. Plugging of the biopsy tract is a promising technique to decrease the risk of post-biopsy haemorrhage, for which Gelfoam is the most commonly used agent. In this article, we share our experience in performing this procedure using Gelfoam slurry followed by Gelfoam torpedo in patients at high risk of post-procedure haemorrhage in our institution.

The Department of Radiology and Organ Imaging, United Christian Hospital, is the main radiology training centre of the Kowloon East Cluster, Hong Kong. Apart from diagnostic imaging, we provide both emergency and elective interventional radiology services. In the form of a retrospective study approved by our local ethics committee, since 2005, it has been our standard practice to plug the biopsy tract in all patients considered at risk of haemorrhage after having ultrasound-guided percutaneous biopsy of a solid organ. Our departmental registry recorded all the cases receiving plugged percutaneous biopsy (PPB) of solid organs performed from 1 January 2005 to 30 September 2012. There was no reported refusal of the procedure by any patient. Demographic data, indication for the biopsy and for plugging of the biopsy tract, details of the biopsy technique, biopsy results, and any episodes of post-biopsy haemorrhage treated by transfusion or any other type of intervention were reviewed for each patient. Relevant details are listed in Table 1.

All PPBs were performed under strict aseptic conditions with instruments as shown in Figure 1. A biopsy path avoiding critical structures and major vessels was selected under ultrasound guidance. The length of the biopsy path starting from the organ capsule to the target region was measured (Fig 2a). A strip of Gelfoam of the same length and with a width of approximately 2 mm was cut from a sheet of Gelfoam. Before being cut, the sheet of Gelfoam was compressed manually to expel all air bubbles. A Gelfoam torpedo was formed by rolling the strip of Gelfoam into a rod-like structure (Fig 2b). The remaining Gelfoam sheet was then cut into tiny pledgets of around 2 mm x 2 mm in size. A syringe filled with Gelfoam pledgets and another syringe filled with saline were both connected to a 3-way stopcock. Macerating the suspension with two syringes and a 3-way stopcock allowed further decreases in size of the pledgets into a slurry (Fig 2c). After the Gelfoam torpedo and slurry were ready, the puncture site was injected with local anaesthetic (5-10 mL of 1-2% lignocaine) and a small skin incision was created. Patients were then instructed to hold their breath while a coaxial introducer needle (17G or 19G, CareFusion; Waukegan [IL], US) was advanced to the target region. The stylet of the coaxial introducer needle was removed, with the outer sheath held firmly in place. A Temno biopsy needle (18G or 20G, CareFusion) was then inserted through the sheath under ultrasound guidance. Biopsy specimens were obtained in a standard manner. After removal of the Temno needle between passes, the stylet of the coaxial introducer needle was reinserted into the sheath to decrease the chance of haemorrhage. After adequate specimens were obtained by inspection, 1 to 2 mL of Gelfoam slurry was injected into the sheath of the coaxial introducer needle (Fig 3). The Gelfoam torpedo was then placed at the hub of the sheath of the coaxial introducer needle (Fig 4a) and pushed by the stylet until the echogenic tip of the stylet was advanced to the organ capsule (Fig 4b). The outer sheath was then withdrawn while keeping the stylet still (Fig 4c), so that the Gelfoam torpedo could be deployed along it and therefore sealing the biopsy tract. Finally, the entire coaxial introducer needle was removed.

During a 7-year period, we performed 11 cases of plugged percutaneous solid organ biopsy in 11 patients, all of whom were considered at high risk of post-biopsy bleeding due to the reasons listed in Table 1. The mean patient age was 58 (standard deviation [SD], 14) years. Three patients were male and eight were female. The target organ was the liver in 10 cases and the spleen in one. The indications for biopsy were to achieve a diagnosis of a focal mass in five cases, and characterisation of diffuse hepatic diseases in six (Table 1). The number of needle passes ranged from one to four, with a mean of 2.5 (SD, 0.9). In all cases, the combination of a coaxial introducer needle and Temno needle (both by CareFusion) were used. The combination of a 17G coaxial introducer needle and 18G Temno needle was used in eight biopsies, while the combination of a 19G coaxial introducer needle and 20G Temno needle was used thrice. All the biopsies were technically successful in obtaining adequate specimens for a histological diagnosis. None of the patients experienced post-biopsy haemorrhage treated by transfusion or any other form of intervention.

Ultrasound-guided percutaneous solid organ biopsy is a well-established means of diagnosing focal or diffuse disease in solid organs. In general, it is safe and confers minimal risk of complications. Major and minor complication (mainly bleeding) rates of 0.8% and 2-3.8%, respectively, have been reported.1 2 Many factors increase the risk of post-biopsy haemorrhage, which can be divided into lesional, technical, and patient-related. Lesional factors consist of peripheral subcapsular location, close proximity to major vessels, hypervascularity, and hypervascular biopsy sites (such as the spleen). Technical factors include increased numbers of needle passes, large needle sizes, use of cutting needles, blind biopsies, and less-experienced operators.3 Patient factors include coagulopathy, platelet dysfunction or thrombocytopenia, medications (eg antiplatelet agents and anticoagulants), chronic liver disease, haematological malignancy, presence of moderate-to- severe ascites, and uncooperative patients.2 4 5 Some studies showed that peripheral blood coagulation indices have a poor correlation with liver bleeding time following laparoscopic biopsy, which might be caused by low regional platelet counts, clotting factor deficiencies in the liver parenchyma, and the lack of mechanical compression of the biopsy tract by inelastic tissue (eg cirrhotic liver).6 Therefore operators should always be prepared for the possibility of significant post-biopsy haemorrhage, even in patients with normal clotting profiles and platelet counts.

Obviously, the main contra-indication to image-guided percutaneous solid organ biopsy is a bleeding diathesis.2 However, histological diagnosis is critical and even lifesaving, by means of achieving correct treatment. In the past, transjugular liver biopsy had been advocated in patients with bleeding diathesis, massive ascites, and poor respiratory control.7 8 However, this has multiple disadvantages. In particular, it is not feasible for liver lesions far from the major hepatic veins. Moreover, it is technically demanding and associated with a high rate of insufficient specimen retrieval for satisfactory histological examination (11.2-29%).7 9 10 11 12 It can also give rise to complications at the puncture site (jugular vein) and induce arrhythmias during right atrial passage. Haemoperitoneum is possible if the liver capsule is perforated, which can sometimes be fatal.

Plugged percutaneous biopsy is an alternative to transjugular liver biopsy in patients at high risk of bleeding.2 8 13 It was first described by Riley et al in 1984.13 In plugged biopsy, the tract is embolised (plugged) after the percutaneous biopsy, thus decreasing the risk of haemorrhage. Multiple studies on PPB have demonstrated at least a 95% success rate in obtaining adequate specimens for histological diagnoses. It is also a safe procedure with a complication rate of less than 2% (Table 27 8 9 14 15 16). It has the obvious advantages of being direct and can be used to biopsy focal hepatic lesions away from major hepatic veins and in other organs. Also, a larger biopsy needle can be used, which increases the chance of obtaining adequate specimens. Finally, it does not involve the vascular system or passage through the right atrium and thus the relevant complications can be avoided.

The most commonly used embolic agent is Gelfoam, which is an absorbable compressed gelatin sponge prepared from purified porcine skin.3 7 It is capable of absorbing up to 45 times its weight of whole blood, and induces haemostasis by speeding up thrombus formation and providing structural support for the clot. Gelfoam is a temporary embolic agent, which is usually completely absorbed within a few days or weeks, depending on the amount used, the degree of saturation with blood, and the application site. It is widely used in tract plugging as it is relatively inexpensive and readily available. It is easy to use and can be prepared in different forms, depending on the site of application. In our centre, Gelfoam was prepared in the form of torpedo and slurry. The Gelfoam torpedo was made from tight rolling of a small strip and used at the site of active bleeding. Due to their larger size, Gelfoam torpedoes can remain at the site of deployment instead of being flushed away by blood. The drawback of the torpedo is that distal embolisation cannot be achieved. In contrast, Gelfoam slurry is suitable for distal embolisation. It can be prepared by mixing tiny Gelfoam pledgets with contrast or saline. Further decrease in size of the pledgets can be created by macerating the suspension with two syringes and a 3-way stopcock. The syringe should be held nose up as Gelfoam floats in fluid. The disadvantage of slurry is that it is difficult to deploy at sites of active bleeding, as the suspension can be flushed away by blood. In our centre, we injected Gelfoam slurry first for distal embolisation and then filled up the rest of the biopsy tract with a torpedo. To the best of our knowledge, plugging of the biopsy tract using a combination of Gelfoam slurry followed by Gelfoam torpedo is a new technique that has not been previously described. Gelfoam is safe to use most of the time, although there is a minute risk of non-targeted embolisation of the biliary or vascular systems and of becoming a nidus for microbial growth.3

Apart from plugging of the biopsy tract, there are other measures to decrease the risk of bleeding in patients undergoing solid organ biopsy. First, as appropriate, we should try to correct any coagulopathy by administration of fresh frozen plasma, platelets, coagulation factors, and vitamin K, whilst also withholding antiplatelet or anticoagulant medications if at all feasible. Although not related to the bleeding risk, red cell or whole blood transfusion should be given before the biopsy to significantly anaemic patients. Next, careful planning of the method of biopsy is important. A safe biopsy path not traversing vessels or critical structures should be sought. Leaving adequate distance of normal parenchyma from the organ capsule and the biopsy site can also help mechanical compression of the biopsy tract by virtue of tissue elasticity, after the needle is removed. We have to strike a balance between the tissue yield and the use of smaller needles. The use of a coaxial system allows multiple needle passes with just a single puncture. Reducing ascites, if present with diuretics or paracentesis, can also decrease the risk of haemorrhage.

One limitation of our study was the small sample size. Second, it was a retrospective observational study without a control group. A large-scale prospective randomised controlled study may be ideal to validate the efficacy and safety of PPB. We share our experience in this small-scale study to raise the awareness of this procedure (especially for those not specialised in interventional radiology), as it shows that PPB is a simple and safe method with a high technical success rate that can help prevent post-biopsy haemorrhage.

Plugging of the biopsy tract with Gelfoam slurry followed by a Gelfoam torpedo is a direct, simple, safe, and effective means of preventing haemorrhage in patients at high risk of post-biopsy haemorrhage.

1. Hatfield MK, Beres RA, Sane SS, Zaleski GX. Percutaneous imaging-guided solid organ core needle biopsy: coaxial versus non coaxial method. AJR Am J Roentgenol 2008;190:413-7. CrossRef

2. Albeniz Arbizu E, Lopez San Roman A, Garcia Gonzalez M, et al. Fibrin-glue sealed liver biopsy in patients with a liver transplantation or in liver transplantation waiting list: preliminary results. Transplant Proc 2003;35:1911-2. CrossRef

3. Azar N, Delman T, Nakamoto D. Transcutaneous management of bleeding after solid organ biopsy what the radiologist needs to know and use. US Radiology 2011;3:53-6.

4. Chuah SY. Liver biopsy-past, present and future. Singapore Med J 1996;37:86-90.

5. Sherlock S, Dick R, Van Leeuwen DJ. Liver biopsy today. The Royal Free Hospital Experience. J Hepatol 1984;1:75-85. CrossRef

6. Ewe K. Bleeding after liver biopsy does not correlate with indices of peripheral coagulation. Dig Dis Sci 1981;26:388-93. CrossRef

7. Zins M, Vilgrain V, Gayno S, et al. US-guided percutaneous liver biopsy with plugging of the needle track: a prospective study in 72 high-risk patients. Radiology 1992;184:841-3.

8. Atar E, Ben Ari Z, Bachar GN, et al. A comparison of transjugular and plugged-percutaneous liver biopsy in patients with contraindications to ordinary percutaneous liver biopsy and an "in-house" protocol for selecting the procedure of choice. Cardiovasc Intervent Radiol 2010;33:560-4. CrossRef

9. Kamphuisen PW, Wiersma TG, Mulder CJ, de Vries RA. Plugged-percutaneous liver biopsy in patients with impaired coagulation and ascites. Pathophysiol Haemost Thromb 2002;32:190-3. CrossRef

10. Lebrec D, Goldfarb G, Degott C, Rueff B, Benhamou JP. Transvenous liver biopsy: an experience based on 1000 hepatic tissue samplings with this procedure. Gastroenterology 1982;83:338-40.

11. Velt PM, Choy OG, Shimkin PM, Link RJ. Transjugular liver biopsy in high-risk patients with hepatic disease. Radiology 1984;153:91-3.

12. Wolska-Krawczyk M, Krawczyk M, Katoh M, et al. Liver fibrosis: how many samples in transjugular liver biopsy are sufficient? Histological vs. clinical value. Abdom Imaging 2013;38:461-4. CrossRef

13. Riley SA, Ellis WR, Irving HC, Lintott DJ, Axon AT, Losowsky MS. Percutaneous liver biopsy with plugging of needle track: a safe method for use in patients with impaired coagulation. Lancet 1984;2:436. CrossRef

14. Tobin MV, Gilmore IT. Plugged liver biopsy in patients with impaired coagulation. Dig Dis Sci 1989;34:13-5. CrossRef

15. Sawyerr AM, McCormick PA, Tennyson GS, et al. A comparison of transjugular and plugged-percutaneous liver biopsy in patients with impaired coagulation. J Hepatol 1993;17:81-5. CrossRef

16. Smith TP, McDermott VG, Ayoub DM, Suhocki PV, Stackhouse DJ. Percutaneous transhepatic liver biopsy with tract embolization. Radiology 1996;198:769-74.

Lymphedema is the accumulation of tissue fluid in the interstitial spaces, resulting from anatomical or functional lymphatic obstruction or defective lymphatic drainage.1 Local data about the prevalence of this condition are not available, but it is estimated to affect 2 to 3 million inhabitants in the US.2 Lymphoscintigraphy has emerged and become the standard investigation in the evaluation of lymphedematous extremities. We reviewed our experience in the use of lymphoscintigraphy for this purpose in a single regional hospital.

We retrospectively identified all the cases with suspected lower limb lymphedema referred for lymphoscintigraphy from 1998 to 2011. Case records and imaging studies were reviewed.

Studies conducted from 1998 to 2007 were performed with a single detector system (Picker Prism 1000; Picker International, Cleveland [OH], US). Studies performed after 2007 were performed with a single photon emission computed tomography–computed tomography imaging system (Siemens Symbia T6; TruePoint SPECT CT, Siemens Medical Solutions, Illinois, US). The interdigital web space between the first and second digits on the patient’s lower limbs was anaesthetised with local anaesthetic cream, and subsequently 0.5 mCi of Technetium-99m filtered sulphur colloid (through 0.22 micron filter) was injected into the preanaesthetised interdigital web spaces, creating a wheal. About 1 to 2 minutes after the injection, patients were encouraged to exercise their toes. Two-phase dynamic images were obtained at 5 minutes (from toes to knee) and 10 minutes (from knee to groin). Anterior whole-body scans were obtained at 15, 30, 45, and 60 minutes. Delayed 4-hour and 24-hour whole-body scans were obtained whenever deemed necessary.

There were 24 patients with suspected lymphedema of lower extremities who had undergone lymphoscintigraphy. The patients were aged 14 to 83 (mean, 58) years; 13 were males and 11 were females. Apart from mild pain during injection, all patients tolerated the examination well without any serious complication.

A predictable sequence should be seen in patients with normal lymphatic anatomy and function. In the lower limb, there should be symmetrical migration of radionuclide through discrete lymph vessels (3-5 per calf and 1-2 per thigh). Ilioinguinal nodes should be visualised within 1 hour. Typically, 1 to 3 popliteal nodes and 2 to 10 ilioinguinal nodes are seen. Figure 1 shows a normal lymphoscintigraphic examination of the lower limbs.

Abnormal lymphoscintigraphy scans manifest a wide range of findings, including interruption of lymphatic flow, collateral lymph vessels, dermal backflow, reduced number of lymph nodes, dilated lymphatics, delayed or non-visualisation of lymph nodes and even the lymphatic systems.

There were eight patients confirmed to be positive for lymphedema. These included one with lymphangiectasia (Fig 2), five with lymphatic obstruction (Fig 3), and two with lymphatic leakage (Fig 4). The Table summarises the lymphoscintigraphic findings and follow-up data on these eight cases.

Lymphedema of the extremities is typically a chronic disease, which is often misdiagnosed and results in significant functional impairment, and may give rise to reduced coordination and mobility.3 Therefore, prompt and accurate diagnosis of the condition is important.

Decades ago, lymphangiography had been used to investigate lymphatic disorders, but it was a time-consuming investigation involving direct cannulation of lymph vessels. Moreover, complications such as infections, hypersensitivity, oil embolism, and lymphatic obstruction were reported.4 Lymphoscintigraphy has replaced lymphangiography and become the investigation of choice. Its advantages include being non-invasive, free from adverse effects, and low radiation exposure to patients. Furthermore, it can be repeated and can even be used to follow-up after treatment response.5 The reported sensitivity and specificity of lymphoscintigraphy is approximately 66 to 100% and 83.5 to 99%, respectively.6

Lymphedema can usually be diagnosed clinically. The differential diagnosis of suspected lower-extremity lymphedema includes obesity, chronic venous insufficiency, Milroy’s disease,7 and systemic diseases (eg hypoalbuminaemia). Lymphoscintigraphy enables confirmation of the diagnosis in unclear cases, assessing the risk of developing lymphedema,8 predicting the outcome of therapy,9 and assessing the results of lymphedema treatment.10 11 12 13

Lymphoscintigraphy can usually identify the approximate anatomical site of lymphatic obstruction adequately. However, when greater anatomical details are warranted, cross-sectional imaging techniques like computed tomography and magnetic resonance imaging can be used to supplement the findings.14 This point was well illustrated in this study.

Lymphoscintigraphy aids the diagnosis of underlying lymphatic disorders and hence, guides subsequent treatment, which have proven to be effective in the management of lymphedema.15 16 17 18 19 Conservative treatment includes physical therapy, drug therapy, and psychosocial rehabilitation.14 Operative treatment includes microsurgery, liposuction, and surgical resection.14 The treatment choice depends on the cause of lymphedema, disease severity, functional impairment, and availability of local expertise.

Lymphoscintigraphy is a safe and effective investigation for suspected lymphatic disorders. Our local experience supports its use in the investigation of lower-extremity lymphedema in our locality.

1. Ter SE, Alavi A, Kim CK, Merli G. Lymphoscintigraphy. A reliable test for the diagnosis of lymphedema. Clin Nucl Med 1993;18:646-54. CrossRef

2. Rockson SG, Rivera KK. Estimating the population burden of lymphedema. Ann N Y Acad Sci 2008;1131:147-54. CrossRef

3. Szuba A, Shin WS, Strauss HW, Rockson S. The third circulation: radionuclide lymphoscintigraphy in the evaluation of lymphedema. J Nucl Med 2003;44:43-57.

4. Van Rensburgl. Lymphangiography—its technique and value. S Afr Med J 1965;39:271-7.

5. Williams WH, Witte CL, Witte MH, McNeill GC. Radionuclide lymphangioscintigraphy in the evaluation of peripheral lymphedema. Clin Nucl Med 2000;25:451-64. CrossRef

6. Bourgeois P. Critical analysis of the literature on lymphoscintigraphic investigations of limb edemas. Eur J Lymphology Relat Probl 1996;6:1-9.

7. James WD, Berger TG, Elston DM, Odom RB, editors. Andrews' diseases of the skin: clinical dermatology. Philadelphia: Saunders Elsevier; 2006: 849.

8. Bourgeois P, Leduc O, Leduc A. Imaging in the management and prevention of posttherapeutic upper limb edema. Cancer 1998;83(12 Suppl American):2805-13.

9. Szuba A, Strauss W, Sirsikar SP, Rockson SG. Quantitative radionuclide lymphoscintigraphy predicts outcome of manual lymphatic therapy in breast cancer–related lymphedema of the upper extremity. Nucl Med Commun 2002;23:1171-5. CrossRef

10. Campisi C. Lymphoedema: modern diagnostic and therapeutic aspects. Int Angiol 1999;18:14-24.

11. Ho LC, Lai MF, Yeates M, Fernandez V. Microlymphatic bypass in obstructive lymphedema. Br J Plast Surg 1988;41:475-84. CrossRef

12. Brorson H, Svensson H, Norrgren K, Thorsson O. Liposuction reduces arm lymphedema without significantly altering the already impaired lymph transport. Lymphology 1998;31:156-72.

13. Hwang JH, Kwon JY, Lee KW, et al. Changes in lymphatic function after complex physical therapy for lymphedema. Lymphology 1999;32:15-21.

14. International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema. 2009 Consensus Document of the International Society of Lymphology. Lymphology 2009;42:51-60.

15. McNeely ML, Peddle CJ, Yurick JL, Dayes IS, Mackey JR. Conservative and dietary interventions for cancer-related lymphedema: a systematic review and meta-analysis. Cancer 2011;117:1136-48. CrossRef

16. Badger CM, Peacock JL, Mortimer PS. A randomized, controlled, parallel-group clinical trial comparing multilayer bandaging followed by hosiery versus hosiery alone in the treatment of patients with lymphedema of the limb. Cancer 2000;88:2832-7. CrossRef

17. Miller TA, Wyatt LE, Rudkin GH. Staged skin and subcutaneous excision for lymphedema: a favorable report of long-term results. Plast Reconstr Surg 1998;102:1486-98; discussion 1499-501. CrossRef

18. Yamamoto Y, Sugihara T. Microsurgical lymphaticovenous implantation for treatment of chronic lymphedema. Plast Reconstr Surg 1998;101:157-61. CrossRef

19. Matarasso A, Hutchinson OH. Liposuction. JAMA 2001;285:266-8. CrossRef

Day surgery is defined as a process in which a patient undergoes surgery and stays in the hospital for less than 24 hours.1 As an innovative form of medical practice, it is growing increasingly popular globally.2 3 4 For example, around 70% to 80% of North American patients expressed a preference for day surgery.5 In Scotland, among all operations the percentage involving day surgery increased 570% from 1981 to 1995.6 Advances in surgical technology continue to render day surgery more acceptable and suitable for minimally invasive or minor operations compared with traditional surgery, thus expanding its scope. In the past, almost all surgical patients had to stay in hospital until they were capable of caring for themselves and became ambulant, and they returned to hospital for removal of sutures. Under such circumstances, even for wound healing, patients had to stay in hospital for 21 days, which generated great social and economic pressure that patients and their families had to endure. Comparatively, many patients find day surgery to be more ‘economical and reliable’.7 Day surgery can provide not only economic, but also social advantages to patients. These include shorter hospital stays, avoiding the drawbacks of a hospital environment (cross-infection and less inconvenience to family members).8 Day surgery also benefits hospitals by increasing the quantity of successful operations, while maintaining efficient use of resources.

Many patients nevertheless worry about the uncertainties of day surgery. In addition to the uncertainty inherent in the operation itself, the more rapid day surgery model creates unique challenges for postoperative care. Many patients worry about the uncertainty of their postoperative recoveries.9 Some choose continuous rest in hospital post-surgery, thinking it better to recover under the direct supervision of doctors, which tend to counter day surgery preferences.10 For patients, these uncertainties make day surgery a controversial medical choice, despite its many advantages.11

Consequently, further exploration of patient perceptions about day surgery becomes crucial to accomplish long-term improvements and the promotion of such practice, which is particularly important where day surgery is in its infancy, such as in China. There was no day surgery in China until 2005, when hospitals in Chengdu, Shanghai, Tianjin, and elsewhere began to experiment with the concept to address the rising demand for surgery. Hospitals and doctors therefore have strong motivation to appreciate patients’ perceptions of day surgery, wherever it is a fairly new medical service.

Therefore, the aim of this study was to investigate patients’ perceptions of day surgery—specifically with regard to convenience; social, functional and economic attributes; risk perceptions; and overall satisfaction.

The study was conducted using a questionnaire survey in the West China Hospital, Sichuan Province, China. This hospital was founded in 1892, and is one of the country’s leading general hospitals. It is affiliated to Sichuan University, which has been selected as a national clinical and education base by the Ministry of Health, China. It has 7800 employees and 38 clinical departments providing complete medical services covering all clinical areas. Being the most highly regarded hospital in southwestern China, it copes with an ever-increasing demand for surgery, for which reason the Centre for Day Surgery was created.

This survey study was reviewed and approved by West China Hospital in advance, and involved interviews of all 225 patients admitted to the Centre in December 2011. In all, questionnaires were directly distributed to 200 patients post-surgery and collected on-site after completion by the adult patients themselves or the family members of patients younger than 16 years old. In addition, telephone survey was conducted for another 25 patients who had left hospital at once after the surgery. The telephone survey questionnaires were conducted verbally and completed by the researcher. Informed consent was obtained from all patients and/or carers before the questionnaire was used.

The questionnaire comprised four parts. The first collected background information including the patient’s gender, age, residence location, and surgery type. The second explored each patient’s perceptions about day surgery, including: (1) convenience (defined as shorter in-patient and treatment duration); (2) social value, in terms of reducing its impact on the lives of family members; (3) functional value (receipt of safer and more effective treatment); and (4) economic value, defined as saving in expenses by patient and carers (from loss of earnings and travel by patient and carers). The third part evaluated the patient’s perceptions of day surgery, in terms of: (1) risk of postoperative complications and adverse events, not amenable to timely treatment after returning home; (2) uncertainty about the risks of the rehabilitation process (defined as insufficient medical knowledge about rehabilitation in the absence of medical care); and (3) psychological risk, described in terms of insufficient psychological preparation for recovery in the absence of medical care. The fourth part explored the patient’s satisfaction with day surgery, including the clinical service, attitude of staff, hospital surgery environment, operating skills, operation results, and communication with the patient. In the last three parts, the patients were asked to choose “Yes” or “No” answers.

We used the Statistical Package for the Social Sciences (Windows version 19.0; SPSS Inc, Chicago [IL], US) for the statistical analysis. All the continuous variables were presented as means and standard deviations (SDs). Categorical variables were presented as frequencies and percentages. Fisher’s exact test was applied to compare the different value perceptions according to surgery types. A two-tailed P value of <0.05 was considered statistically significant.

From the 225 questionnaires, those with incomplete answers were removed. Finally 153 valid questionnaires were obtained, giving a completion rate of 68%. The background information about these 153 patients (70 males and 83 females) is summarised in Table 1. The mean age of the patients was 39 (SD, 20) years. In all, 67% of the patients came from Chengdu City and the others were from other cities in Sichuan Province. More than half of the patients underwent general surgery; 63% of them already knew about day surgery to some extent before hospitalisation for their surgery.

As shown in Table 2, the convenience value related to shorter in-patient stays and treatment duration was the most emphasised (87%). The social value of reducing the influence of surgery on the lives of the patients and their family members was chosen by 60% of the respondents. Comparatively, the functional value for patients receiving safer and more effective treatment and the greater economic value (reducing expenditure on surgery) was chosen by 50% and 43% of the respondents, respectively.

Table 2 also shows the numbers of patients having “Yes” or “No” responses for each type of surgery and for different perception categories. It illustrates that respondents undergoing different types of day surgery had significantly varied perceptions about its convenience, but there were no significant differences in terms of social, functional, or economic perceptions.

Regarding patient perceptions about the risks of day surgery, most (75%) worried that they would not receive timely treatment if they were to experience a sudden postoperative complication or adverse event after discharge. About half of the respondents were concerned about rehabilitation knowledge that was inherent in the absence of medical professionals to provide specific advice during recovery. This shortfall of medical knowledge could inhibit and lengthen the recovery period. In contrast, only 27% of the respondents considered there was significant psychological risk from day surgery (Table 3). There was no significant difference among the different surgery types with respect to risk perceptions.

Table 4 reveals that the respondents were generally satisfied with day surgery. More than 95% were satisfied with the clinic service process, service attitude of the staff, the hospital surgery environment, operating skills and the results. Fewer respondents (84%) expressed satisfaction with the communication processes surrounding day surgery, but there was no significant difference for this parameter for the different surgery types.

Our study indicates that day surgery (a new type of medical service in China) is being applied to patients of various ages, as shown by the wide distribution of patient age-groups. Minimally invasive operations, particularly general and gynaecological surgeries, were the main types. Day surgery was embraced not only by patients from that city but also those from other cities. This implies patients’ appreciation for efficiency of day surgery.

The efficiency that day surgery delivered to patients was considerable convenience, which was highly valued. Patients think day surgery can save them from having to spend time in hospital, and decrease interruptions to their normal lives. Patients who underwent ear, nose and throat surgery, eye surgery, and gynaecological surgery placed significant emphasis on the convenience of day surgery. Moreover, the social value was emphasised, in that day surgery required less additional care by family members. Patients paid much less attention to functional and economic aspects, which suggests that while patients were confident about the quality of day surgery, its monetary burden was not a major determinant for them. Convenience for patients and their families was the main reason they choose day surgery, which implies that hospital should promote and emphasise this aspect.

Although our study acknowledges the value of day surgery, it nevertheless reveals that patients are conscious of and concerned about its potential risks. Risk of postoperative complications and adverse events posed a particular concern, more so than lack of rehabilitation knowledge and any psychological risks. Because patients must be discharged soon after surgery, they worry about unexpected postoperative complications or adverse events, where they might not be able to receive timely appropriate treatment, unlike the situation for in-patient recovery. In addition, the patients were concerned about whether they would experience smooth rehabilitation at home, without recourse to professional medical and psychological consultation opportunities with doctors or nurses.

Patient satisfaction is an important indicator for assessing improvements in medical service.12 The patients in this study generally exhibited high degree of satisfaction with day surgery, which is consistent with findings in the literature.13 While most were satisfied with the clinical service process, service attitude, the hospital surgery environment, and operating skills and results, some expressed dissatisfaction with the levels of communication. They complained that hospital staff lacked requisite communication skills to put patients and their family members at ease, resulting in pre- and post-surgery anxiety. Despite time constraints, in the context of day surgery, sufficient communication and interaction between patients and hospital staff is very important.

Both patients and health care workers very likely have concerns and uncertainties regarding the change from usual in-patient surgery to day surgery. Therefore, it is important to provide education to health care workers as well as the public to enhance their understanding of day surgery as a new medical service. Specifically, hospitals should enhance communications between doctors and day surgery patients, pre- and post-surgery, to increase understanding of what it involves, so as to decrease their concerns about risks and facilitate recovery. Specific training and reference materials about possible post-surgery complications and other problems could be provided to patients and their family members. Hospitals can also establish telephone consulting services to patients who have undergone day surgery to deal with enquiries about the recovery process. Moreover, specific mechanisms should be established to address possible recovery accidents, providing patients with rapid access to in-patient medical treatment rather than ordinary out-patient services.

Regarding the limitations of this study, it focused only on patients who had undergone day surgery in December 2011, which may only reflect information about day surgery during its development stages. Nevertheless, patients’ perceptions of day surgery remain a potential topic for further investigation. Additional research in more hospitals could provide a more comprehensive understanding of day surgery as a new medical practice. We studied day surgery patients from West China Hospital, but given that day surgery practice may be significantly diversified, replication of this study elsewhere could provide more diverse insights. Second, future study could investigate doctors’ perceptions of day surgery. As key operators of the day surgery model, they are crucial to its success and their opinions and suggestions have not been systematically addressed in the literature. Future studies could target this gap to enrich the understanding of day surgery from both sides (doctors and patients). Third, comparative studies addressing patients who refuse day surgery are also necessary. These types of initiatives could provide more useful information about how to improve the practice of day surgery so as to increase patient acceptance and outcomes.

This study showed that the majority of patients studied accepted day surgery as an innovative medical service that offers significant convenience and social value. Main patient concerns were postoperative complications and adverse events and the lack of adequate communication with doctors and nurses about their surgery and recovery process. More convenient and comprehensive design of day surgery programmes may help to promote day surgery for more patients.

This research is supported by the key special project of Central University basic scientific research expenses (Philosophy and Social Sciences) of Sichuan University (No.skqy201208) “Hospital outpatient service quality evaluation and optimization strategy based on the patients’ satisfaction” and the key project of NSFC “Resource dispatching and optimizing research in medical service (No.71131006)”.

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3. Markovic M, Bandyopadhyay M, Manderson L, et al. Day surgery in Australia: qualitative research report. J Sociol 2004;40:74-84. CrossRef

4. Ojo EO. Day case surgery and developing countries: a review. Niger J Clin Pract 2010;13:459-66.

5. Jenkins K, Grady D, Wong J, Correa R, Armanious S, Chung F. Post-operative recovery: day surgery patients' preferences. Br J Anaesth 2001;86:272-4. CrossRef

6. Bain J, Kelly H, Snadden D, Staines H. Day surgery in Scotland: patient satisfaction and outcomes. Qual Health Care 1999;8:86-91. CrossRef

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8. Bittmann S, Ulus H. Parent satisfaction with paediatric day-surgery: a questionnaire-based study. Ambul Surg 2004;11:3-5. CrossRef

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10. Lee YC, Chen PP, Yap J, Yeo P, Chu C. Attitudes towards day-case surgery in Hong Kong Chinese patients. Hong Kong Med J 2007;13:298-303.

11. Alexander-Williams J. Arguments for day case surgery. Practitioner 1996;240:152-60.

12. Attree M. Patients' and relatives' experiences and perspectives of 'Good' and 'Not so Good' quality care. J Adv Nurs 2001;33:456-66. CrossRef

13. Lemos P, Pinto A, Morais G, et al. Patient satisfaction following day surgery. J Clin Anesth 2009;21:200-5. CrossRef