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Laparoscopic Day Surgery: The Laparoscopic Day Surgery: The American ExperienceAmerican Experience
Alfons Pomp, MD, FACSAlfons Pomp, MD, FACS
Weill Medical College of Cornell Weill Medical College of Cornell UniversityUniversity
Ambulatory/Day SurgeryAmbulatory/Day Surgery
Same day discharge (< 23 hour stay) Physician office, ambulatory surgical centers
(ASC) and hospital based outpatient 1990’s American Hospital Insurance Programs
looked at risk/benefit of the economics Standard of care…safe outcomes?
Nonetheless 60-70% operations are performed as outpatient procedures
Weill Cornell NYP HospitalWeill Cornell NYP Hospital
11,741
5,9355,292
100
11,935
6,444
5,499
802
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
Ambulatory (+2%) Admit Day (+9%) Inpatient (+4%) Outpatient (+702%)
2004 2005
Mandate: The American Mandate: The American ExperienceExperience
Ambulatory Surgery (hernia/cholecystectomy) Reflux surgery Bariatrics
-Banding
-Gastric bypass Surgery of increasing complexity in more fragile
patients
What is the riskWhat is the riskof having an operationof having an operation
No one really knows
Netherlands (Arbous et al 2001) 800,000 pts 8.8/10,000 mortality (1.4 due to anesthesia)
USA (Fleisher et al 2004) 564,267 Medicare procedures; 7 day mortality rates 4.1/10,000;
Operative RisksOperative Risks data taken from inpatient procedures
Associated with patient factorsAssociated with anesthesiaAssociated with the surgical procedureAssociated with doing the procedure as
ambulatory/day surgery
Patient Factors: AgePatient Factors: Age
Age (>65 years)
adverse intra-op events/not post-op events
hypertension: intra-op cardiovascular events
unanticipated readmission ratesAge (85 years)
co-morbidity, hospitalization < 6 months
Patient Factors Patient Factors
Hyper-reactive airway disease
(asthma, COPD, smoking)Coronary artery disease(IHD, MI, CHF,BP)ObesityObstructive sleep apneaDiabetes
DiabetesDiabetes
80% type II/ 80% are obese: associated with increase in unplanned admissions
Poor control associated with increased rate of surgical complications
DiabetesDiabetes
Understand disease/ measure BS at homeTreatment of hypoglycemiaNo recurrent admission with complications
related to diabetesHb1Ac >8 unsuitable > 9 not any elective
surgeryMetformin associated with lactic acidosis
American Society of American Society of Anesthesia (ASA) ClassAnesthesia (ASA) Class
Class 1 Healthy patient, no medical problems Class 2 Mild systemic disease Class 3 Severe systemic disease, but not incapacitating Class 4 Severe systemic disease that is a constant threat to life Class 5 Moribund, not expected to live 24 hours irrespective of operation An e is added to designate an emergency operation.
AnesthesiaAnesthesia analgesia/amnesia/paralysis
Anxiety Pain afferent, inflammation Consciousness Autonomic stimulation Memory Movement
PONVPONV(Post-anesthesia nausea/vomiting)(Post-anesthesia nausea/vomiting)
Common cause of unplanned admissions
Risk factors
intra-peritoneal gas
bowel manipulation
female gender
history of motion sickness
opiates
PONV PreventionPONV Prevention
Pre-induction anti-emeticsShort term induction anestheticsVolatile anesthetics (sevoflurane)Short acting muscle relaxantsAnalgesia
portals, intra-peritoneal spray
NSAIDS/ketorolac
Post-anesthesia Discharge Post-anesthesia Discharge Scoring SystemScoring System
Vital signsActivity levelNausea and vomitingPainSurgical care
Are ambulatory risks higher Are ambulatory risks higher than inpatient?than inpatient?
5-8% of procedures are performed in MD’s office w/o federal regulations, moderate rates of “readmission”
ASC have lowest adverse outcomeHighest rates of readmission and deaths are
surgeries performed as outpatient in hospital setting
Ambulatory Surgery Risk Ambulatory Surgery Risk FactorsFactors
ASA class Advanced age (> 85 years)Inpatient admission historySurgical procedure complexity (time)
Medical causes account for less than 20% of admissions
Ambulatory Surgery Risk Ambulatory Surgery Risk FactorsFactors
Hyper-reactive airway disease (smoking)Coronary artery disease (functional)DiabetesObesityObstructive sleep apnea
Ambulatory SurgeryAmbulatory Surgery
90 minutes/6 hour recovery time
Reflux operations -Nissen
Bariatric operations-Banding90 minutes/23 hour discharge time
Bariatric operations-LRYGBP
Day Case Laparoscopic Day Case Laparoscopic Nissen FundoplicationNissen Fundoplication
Patient selectionAnesthesia protocolsDischarge rates and timePostoperative complications/re-admissions
Ng et al ANZ J Surg 2005
Nissen FundoplicationNissen Fundoplication
ASA grade I-II (patient bias selection)30 minute drive from the hospitalObesityAsthmaAge
Nissen FundoplicationNissen Fundoplication
Pre-emptive analgesiaAnti-emeticsPropofol as induction, variable maintenanceLocal anesthesia in the wounds
Post-operative reviews
Nissen FundoplicationNissen Fundoplication
> 90% discharge rate most studies 6-7 hrs
cardiovascular stability
clear fluids
adequate pain control
able to ambulate
Nissen FundoplicationNissen Fundoplication
1-11% re-admission rate
dysphagia/inability to tolerate fluid
comparable to hospitalized patients86% patients have resolution of symptoms1.5-3 days US $2500-3400/case
Bariatric ExplosionBariatric Explosion
Epidemic of obesity Laparoscopic approach Publicity / media Patient demand
Schirmer, B. Watts, S.H. Laparoscopic Bariatric Surgery Surg Endosc 2003
Bariatric Surgery-USABariatric Surgery-USA
1994-1999 10-15,000/year 2000 22,000 2001 48,000 2002 75,000 2003 105,000 2004 140,000 (450,000 lap cholecystectomies)
Schirmer B., Watts S.H., Surg Endosc 2003
Surgery for ObesitySurgery for Obesity
WLS today– Restriction– Malabsorption
4 operations
- Lap band– Sleeve gastrectomy– Gastric bypass– Duodenal Switch
Surgical Procedures:Surgical Procedures:Laparoscopic Adjustable Gastric Laparoscopic Adjustable Gastric
BandingBanding
Inflatable gastric band just distal to G-E junction
Purely restrictive procedure
“Reversible” Technically “simple”
Gastric BandingGastric Banding
343 patients 4/2003-1/2005 Contra-indications cardiac co-morbidity pulmonary co-morbidity poorly controlled diabetes ( + all > 60) anticoagulation impaired mobility
Watkins B. M. et al Obesity Surgery 2005
Gastric bandingGastric banding
4.5 –13.5kg pre-op weight lossDVT prophylaxisAnesthesia
scopolamine/IV rantidine/ondansetron
local bupivacaine/ketorolac/dexamethasone
liquid hydrocodone/acetaminophen
Gastric bandingGastric banding
305 females/38 males 43.5 years/BMI 44.5OR 53 minutes8.2 % paid by insurance company10 complications
5 occlusions treated medically
colon perforation
3 transfers to hospital
Gastric bypassGastric bypass
2000 patients LRYGBP 10/2001-12/2004Average BMI 49 Female to male ratio 7:1OR times 54-115 minutes average1669 (84%) discharged within 23 hours
McCarty T.M. et al Annals of Surgery 2005
Gastric bypassGastric bypass
Early complications (<30 days)
stricture , bleeding, leaks, PE
(0.8%,0.3%,0.2%,0.1%)Late complications
internal hernias, stricture, G-G fistula
(2.5%,1.3%,0.2%)2 mortalities: hemorrhage /sepsis
Gastric bypassGastric bypass
Predictive of discharge
surgeon experience (>50 cases)
patient age (<56)
BMI <60
weight < 400 lbs (180 kg)
co-morbidities < 4
intra-operative steroid bolus
Gastric bypassGastric bypass
Lessons learned
KEEP RATE OF COMPLICATIONS LOW
Circular stapler 25mm/ Linear Stapler
Staple buttress
Internal hernias less with ante-colic approach
Intra-operative steroids
Gastric bypassGastric bypass
National Hospital Discharge Survey 10% complication rate LOS 7 daysVariability: open procedure, clinical care
pathways to reduce pain, nausea, narcotic requirements and complications
Livingston E.H. Am J Surg 2004
Laparoscopic Day surgery for Laparoscopic Day surgery for Liver ResectionLiver Resection
17 patients, no conversions 2002-2004Anterior and medial segments of the liverTissuelink, GIA stapler, intra-op U/S11 patients averaged 14 hours stay
5 segmentectomies
OP time 174 minutes
Decreased pain and wound related morbidity
Short hospital stay in appropriate patients
(lower ASA scores)
Learn P. et al J Gastrointestinal Surgery 2006
Successful dischargeSuccessful discharge meticulous surgery, low complication rate
Post-operative pain and nausea
Pre-operative analgesia
Anti-emetics
Standardized anesthesia protocols
short acting agents
Successful DischargeSuccessful Discharge
Information prior to the procedureWritten instructions on dischargeHome contact
monitor progress, reassure
detect early problemsSelf referral to surgical team-minimal delay
ConclusionsConclusions
Attractive to the surgeon
reduce waiting times
decreases cancellations due to bed shortage
COST-EFFECTIVEAttractive to the patient?
PONV, pain, anxiety (help) addressed
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