Fast-track surgery
Report of a Center
Fast track surgery
A new method of application of
preexisting procedures in pre-intra
and post surgical phase pre-written
and carried out in a multi-disciplinary
way in order to obtain a rapid
recovery after operation.
Organisational steps for fast track surgey
• Develop a plan or critical pattway
• Outline specifics of pre-operative preparatio
• Develop anaesthesia and analgesia programmes
• Minimise stress of operatio
• Adjust post-operative care according to evidence-
based studies
• Develop post-oprative nursing care programmes
• Determine patient follow-up
• Develop a patient information programme
• Document results, tabulate problems and patient
satisfaction
• Revise and improve programme
Fast-track surgery
Optimized surgery
Enhanced recovery
Fast-track rehabilitation
Fast-track surgery
• lap. cholecystectomy: > 80% day surg.
• fundoplicatio: > 90% day surg.
• splenectomy: day surg.
• colon (open and lap.): 2 - 4 g.
• mastectomy: 90% day surg.
• lap. surrenalectomy: day surg.
• parathiroydectomy: 90% ambulatoriale
• thiroydectomy: day surg.
• lung: 1 – 5 g.
Fast-track surgery
Personal experience
• Day surgery/One day surgery
- hernie
- laparoceli (diam 40 years
• Rx chest > 60 years
• Electrolyte-azoto-creatinina > 60 years
• Glicemia > 60 years
• Urine: only specific indication
Fast-track surgery
Thyroidectomy
Fast-track surgery
Thyroidectomy
'Same-day' thyroid surgery. Results
after 805 thyroidectomies in a fast-
track program
Ortega J, Cassinello N, Lledó S.
Fast-track surgery
Thyroidectomy
Outpatient and short-stay thyroid
surgery.
Lo Gerfo P, Gates R, Gazetas P.
Department of Surgery, Columbia University, Columbia Presbyterian
Medical Center, New York, New York 10032.
Fast-track surgery
Thyiroidectomy
…conclusions:
• Specialized centre
• Lobectomy or sub-total
• No total thyroidectomy
• No ASA 3
Fast-track surgery
Thyroidectomy
DISCHARGE sec. U.E.C.
• In selected patients: I° day (day
surgery criteria)
• Other patients: II°-III° day
• No Day Hospital.
Fast-track surgery
Personal experience
• Thyiroydectomy
- Admittance day of operatio
- Clyster befor surgery
- Free nutritional intake until midnight
- Free oral fluid intake
- Drains: I°-II°day
- Discharge: II°-III° day
Fast-track surgery
Breast surgery
William Stewart Halsted
1852 - 1922
Surgeon-in-chief Johns Hopkins Hospital
1890-1922
Fast-track surgery
Personal experience.
• Brest surgery:
- Free oral intake
- Admittance day of operation
- Mobilization: I° day
- Drains: I°-V° day
- Discharge: I°-V° day
Fast-track surgery
Colon surgery
Fast-track surgery
Colon
The “Coast trial” is an important multicentric
randomized and controlled trial that shows an
hospital stay significantly decreased after
laparoscopic surgery (5 days) respect to open
surgery (6 days)
N.Engl.J.Med,2004
Annals of Surgery Vol. 241, N. 3, March 2005
Randomized & Blinded Controlled Trials
FUNCIONAL RECOVERY AFTER OPEN VS LAPAROSCOPIC COLONIC RESECTION
LINDA BASSE…HENRIK KEHLET
…Conclusion: functional recovery after colonic
resection is rapid with multimodal rehabilitation
regimen and WITHOUT DIFFERENCES
BETWEEN OPEN AND LAPAROSCOPIC
RESECTION…
Basse L et al. – Dis Colon Rectum 2004; 47: 271-8
“Colonic surgery with accelerated rehabilitation or conventional care”
•Post-op. stay: II°-III° day
•Readmission: 20%
Wolfgang Schwenk – TATM 2007; 9: 43-44
“Editorial: principles of fast-track rehabilitation in
elective colonic surgery”
Morbility
Traditional Care 20-35%
Fast-track Rehabilitation < 10%
Fast-track surgery
Personal experience
• Colon
- Free nutritional oral intake until midnitht
- Free oral fluid intake
- Clyster 12h and 2h before surgery
- Naso-gastric tube: II°-III° day
- Urinary catheter: I°-II° day
- Mobilization: I° day
- Oral nutritional intake: II°-III° day
- Drains: V°-VIII° day
- Discharge: V°-VIII° day
Fast-track surgery
Gastric surgery
Biology of intestinal anastomosys
1° PHASE (24-48 h postop.)
Early acute infiammation
The anatomosis is garanted by the
solidity of the stapler/stiches on
preexisting collagene
Biology of intestinal anastomosys:
2° PHASE (III°-IV° postop. day)
Proliferation
Fibroblast proliferation
on anastomotic site
Production of “good” collagen
Biology of intestinal anastomosys
3° PHASE (V°-VI° post-op. day)
Rimodellamento
Decrease of macrophagyes and
fibroblast density
Plasticity of collagene
N-G tube and gastric surgery
No difference in
Wu CC 2002 terms of:
Yoo CH 1994
Lee JH 2002
•Morbility
Doglietto 2004
•Mortality
•Post-op. stay
Gastic surgery
Personal experience
• Free nutritional oral intake until midnight
• Clyster 12h and 2h before surgery
• Naso-gastric tube: II°-III° day
• Urinary catheter: II° day
• Drains: IV°-VII° day
• Oral nutritional intake: IV°-VI° day
• Mobilization: I° day
• Discharge: VI°-VIII° day
Fast-track surgery
Personal experience
• Lung surgery:
pneumothorax: II°-III° day
- VATS
wedge-resection: II°-III° day
- TAC-guidate needle biopsy: ambulat.
- Lobectomy: VII° day
- Pneumonectomy: IX°-X° day
La Fast-track surgery demands a motivated team:
- Anaesthesist
- Surgeon
- Dietician
- Physiologist
- Nursing staff
- Home/Ambulatory care
The results of Fast track rehabilitation are
based on the charitable continuity on the
territoryal care and a complete ambulatoriale
attendance.
The suspicion is that the expense saved in
hospital comes used on the territoy
Grazie !