Special Populations in Ambulatory Surgery: Oncologic, Lactating, Transgender and Gender Diverse, and Suicidal Ideation

PatientsProvision of surgical care to oncologic populations in ambulatory settings involves leveraging several factors including the procedural risk, patient functional status, comorbidity burden, and availability of workflows aimed at reducing common postoperative complications, such as pain, nausea, and bleeding.1 Potential benefits of ambulatory surgery like efficiency, cost, and patient satisfaction, have led to gradual migration of procedures to ASCs, 2 from large procedures in low-risk patients with early-stage cancer (e.g., mastectomy) to minor procedures in patients with metastatic cancer for palliation and improving quality of life (e.g., pleural drainage catheter insertion).Disseminated cancer is a known risk factor for elevated morbidity and readmission among high-risk general surgery patients undergoing ambulatory procedures.3,4 Oncologic patients may require repeated outpatient surgery and interventional radiology procedures for diagnosis, treatment, and possibly palliation with one study reporting that 26% of patients required multiple procedures at their oncologic ASC.5,6 There are limited studies examining adverse postoperative outcomes related to anesthesia for study populations specifically composed of cancer patients undergoing ambulatory surgery.Simon et al. reported a low incidence of anesthesia-related adverse postoperative outcomes in a large sample size of cancer patients suggesting that carefully selected cancer patients can undergo anesthesia for same-day surgery without significant added risk. 5 Cancer and Comorbidity Burden: Cancer patients are likely to be older, frail, and have chronic conditions related to cancer and cancer treatment (e.g., malnutrition, chronic lymphedema, chronic pain).At the time of diagnosis, comorbid conditions are known to be prevalent in cancer patient populations.7 The coexistence of cancer and comorbidity is known to affect cancer care delivery, including time to diagnosis, treatment choice and delivery, and cancer treatment outcomes.For example, cancer patients with comorbidities, such as cardiovascular disease, obesity and metabolic disease, and musculoskeletal conditions, are generally less likely to receive curative treatment than those without comorbidity.8 Examining these specific aspects of disease severity and general physical status is particularly important when considering ambulatory surgery in this medically complex population.Common consequences of cancer, including weight loss, anemia, cancer-associated thrombosis, and chemotherapy-related toxicities, contribute to a patient's general physical status.9 Cancer severity, functional status, and frailty should be distinguished from comorbidity.8,10,11 Comorbidity, functional status, and frailty can affect perioperative outcomes independently and it is important to evaluate each one of them to establish anesthesia safety for ambulatory surgery.Anesthesiologists can lead the way in establishing clinical workflows at ASCs to meet these challenges to patient selection in the oncologic surgical population. 1Oncologic Treatment and Anesthesia: Chemotherapy, Immunotherapy, Radiotherapy: Chemotherapy-induced organ toxicity is an important consideration due to toxic side effects impacting multiple organ systems, including cardiac, pulmonary, renal, hepatic, lymphatic, and immunological functions.These toxicities can directly impact perioperative management and increase perioperative complications.12,13 Several chemotherapeutic drugs are associated with cardiovascular toxicities, including Simon et al.