Outpatient surgery is defined as surgical procedures and/or explorations programmed and performed under technical conditions that imperatively require the safety of an operating room, under anesthesia of variable mode and followed by post-operative monitoring allowing, without increased risk, the discharge of the patient on the same day. Outpatient surgery is therefore a scheduled surgery [1]. Outpatient management of medical and surgical procedures could be the standard of tomorrow, when 50% to 75% of these interventions will be performed according to this modality. An increasing number of interventions must already be performed on an ambulatory basis (knee arthroscopy, inguinal hernia cure, etc.) [2].

This method of care is considered to be beneficial in terms of the organization of the care system, the quality of care, patient satisfaction and it is a source of reduction in the cost of care. But it must be carried out under special organizational conditions allowing the patient to benefit from an intervention without additional risk and to be discharged the same day [3]. The duration of outpatient stay is less than 12 hours according the French medical literature and 24 hours according to the Anglo-Saxons [4].

In 2009, a large international survey concluded that it already concerned 83% of patients who underwent surgery in the USA, 74% in Denmark, 69% in Sweden, 53% in Great Britain, 53% in Holland, 50% in Norway, 49% in Portugal, 43% in Germany and 35% in France [5]. In 2017, a study conducted in France had found that it concerned 55.9% and projected to reach 70% in 2022 [6].

In Africa, studies on ambulatory anesthesia are scarce. Nevertheless, let us cite that of Khamouna in Morocco which reported the realities and prospects of this practice [7] and in the Democratic Republic of Congo (DRC), Luty AN et al. described the clinical profile of tonsillectomy indications in Lubumbashi and found that it was performed on an outpatient basis in 19% [8]. Ambulatory anesthesia is performed in the Democratic Republic of Congo but we do not have epidemiological data. Hence this study is carried out with the goal of making a state of play when it comes to anesthesia for outpatient medical and surgical procedures in the city of Kinshasa.

We collected data from 971 patients who underwent anesthesia in seven medical facilities in the city of Kinshasa province. Among these patients, 394 had received outpatient anesthesia and were the subject of this study, while 577 did not meet our inclusion criteria because they were subject to conventional hospitalization. Hence the frequency of ambulatory anesthesia has been estimated at 40.5%.

Our sample was 394 patients larger than that of Khamouna [7] in Morocco which had 100 patients in a single-center study. The frequency of ambulatory anesthesia in our series is 40.5%, lower than in the last French study that reported a frequency of 55.9% [6]. Note that our study concerned only a few medical facilities in the city of Kinshasa and the distribution of this practice is disparate.

Ambulatory anesthesia seems to be used much more in young women (58.6%). Patients under the age of 20 only represented 12.4%, while Khamouna [7] found that 68% were under 15 years old. The mean age was 39.3 ± 16.5 years. The youngest patient was one year old and the oldest was 82 years old, because apart from prematurity there are no age limits for outpatient anesthesia [9].

Graduate instruction level patients were in the majority in 59.2%, as it takes a certain level of understanding to understand and follow the instructions for this anesthesia. The majority of our patients (89.9%) took less than an hour to reach medical facilities as per SFAR recommendations [9].

Explorations represented 55.1% of the indications followed by OB-GYN procedures, unlike Khamouna [7] who noted a predominance of ENT indications in 38%. It seems that, in our community, the teams are still afraid of performing a lot of outpatient surgeries not only because of the level of understanding of the patients, but also of the traffic jams that can delay a fast return of the patient to the hospital in the event of complications.

Our study noted that 75.1% of the patients were classified ASA I. The ASA II and III patients represented 23.4% and 1.5% respectively. These results corroborate the formalized expert recommendations of the 2010 French Society of Resuscitation (SFAR) [9] which establish that ASA I, ASA II and ASA III (stable) patients are eligible for outpatient anesthetic treatment. Khamouna’s study [7] did not register ASA III patients because they were not included.

Written recommendations were given to only one patient out of the 394 (i.e. 0.3%), this is explained by the fact of our oral tradition probably, the operators in this modality of care were limited to verbal instructions while the 2010 formalized recommendations from the experts of the French Society and Resuscitation (SFAR) [9] of require the mandatory submission of an information document (instructions) after oral information. However, there is no such legislation in the Democratic Republic of the Congo.

In this study, the proportion of patients who benefited from the pre-anesthetic Consultation (PAC) was 57.8%, the patients who were not consulted by an anesthesiologist prior to the procedure were those who were assessed on the day of the procedure. This reality deviates from the 2010 formalized recommendations of the French Society of Resuscitation (SFAR) experts [9], which require patients to be consulted by an anesthesiologist at least 48 hours earlier to allow them to make necessary arrangements (on pre-operative fasting, on habits, explanations on the different anesthetic protocols…).

Pre-anesthetic fasting was effective in 96.7% of patients. Other authors such as Warner MA in 1999 [10] and Pandit SK in 2000 [11] as well as the recommendations of the ASA [10] [11] insist on this preoperative fast to avoid both inhalations and the disadvantages of prolonged fasting. The average duration of intervention was one hour and in most cases, the intervention lasted about one hour and thirty minutes, i.e. 98.2% of cases according to the 2010 formalized recommendations of SFAR experts [9].

Narcosis was the most widely used type of anesthesia (82.4%) because it is best suited to short lasting procedures. Propofol has been the most widely used narcotic because of its good kinetics as other authors had suggested [12] [13]. Suxamethonium was the most used curare in our study (13.2%). It is used to facilitate tracheal intubation but exposes the patient to postoperative myalgia related to fasciculation (in 5% to 10% of cases especially if the rise and ambulation are early, which is the rule in outpatient settings). In our study, it was used without this adverse effect. Although Lemmens [14] has established since 1998, that the morphinics to be preferred on an outpatient basis are remifentanil, alfentanil and sufentanil because of their rapid elimination, fentanyl was used in 14.5% in our series because of its availability on the market so morphinics less prone to residual effects are rare on the local market.

In this study, eleven patients had complications (3.2%): desaturation, hypotension, bradycardia and bradypnea. In a Matthew meta-analysis [12], the mean rates of airwayevents (partial or complete obstruction, apnea and hypoxia) and haemodynamic events (low blood pressure, arrhythmia, tachycardia, bradycardia) were 1.44%. Our complication rate exceeds Matthew’s because he had only worked on sedations.

Almost all patients were accompanied as recommended [9]. The majority of patients were almost not assessed before being discharged, only 3 patients out of the 394 i.e. 0.8% were assessed by the Chung score. An attitude that deviates from the principles of outpatient anesthetic care. As a matter of fact, it is the lack of a document proving this evaluation that is missing and not the consultation itself. The proportion of patients who benefited from thromboembolic prevention was 0.5%. Here we must qualify the fact that our series had no major interventions. But this is one of the advantages offered by this mode of care [15]. The average length of stay was 11.9 ± 6.4 hours and most patients had stayed more than 12 hours (67.3%), this result corroborates the conception of Anglo-Saxon countries on outpatient anesthetic care (<24 hours) [4].

In this study, only ASA II class [ORa: 3.3% CI 1.1 - 9.7) p = 0.023] appeared to be the determinant of complications. This result is different from Ansell’s observation in 1998 [16] who retrospectively assessed the outcome of patients following outpatient surgery. Among the 30,000 outpatients managed on an outpatient basis between 1998 and 2002, 3.3% were classified as ASA III. Compared with an ASA I or II control group, matched in age, sex, type and year of intervention, the incidence of postoperative complications was similar in both groups. Similarly, the percentage of unplanned hospitalization was comparable (2.9% and 1.9% for ASA III and ASA I or II patients respectively) [16]. However, the under-representation of ASA III patients in our study should be noted.

Limitations of the study:

- This study does not allow a direct comparison of the advantages (benefits) of ambulatory anesthesia to conventional hospitalization.

- The non-follow-up of patients who have benefited from ambulatory anesthesia after their discharge from hospital.

Ambulatory anesthesia is a reality in the city of Kinshasa; however, it is still underdeveloped with different frequencies depending on the hospital.

Half of outpatient anesthesia is indicated for explorations (gastroscopy, colonoscopy, laparoscopy, etc.). But it is also worth noting some essentially minor interventions. Almost all patients are classified as ASA I and these procedures are most often performed by senior doctors. Propofol is the most widely used narcotic. Complications, although rare, are related to class ASA II.

There is clearly interest in broadening the indications to make it a priority axis for the development of surgery, anesthesia and a source of health savings, as in Western countries. An effort should also be made to comply with the recommendations of learned societies.

- Tsangu Joseph designed, collected, interpreted, wrote the manuscript;

- Longo-Mbenza Benjamain coordinated the writing of the article;

- Mfulani Gibency carried out the statistical analyses;

- Mbombo Wilfrid and the others corrected the manuscript.

The authors declare no conflicts of interest regarding the publication of this paper.

Tsangu Phuati, J., Mboloko Esimo, J., Tshimpi Wola, A., Longo-Mbenza, B., Bulabula Isokuma, M., Mokassa Bakumobatane, L., Amisi Bibonge, E., Mbombo Dibwe, W., Mukuna Miteo, P., Kobo Utumpu, P., Mawalala Malengele, H., Mfulani, G. and Barhayiga Nsimire, B. (2022) State of Play of Anesthesia for Outpatient Medical and Surgical Procedures in the City of Kinshasa. Open Journal of Anesthesiology, 12, 77-90. https://doi.org/10.4236/ojanes.2022.122007