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The Physiology of Minimally Invasive Surgery

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The Physiology of Minimally Invasive Surgery Powered By Docstoc
					Laparoscopic Day Surgery: The
    American Experience




          Alfons Pomp, MD, FACS
          Weill Medical College of Cornell
                    University
CHUM Hotel-Dieu Montreal
     Ambulatory/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 Hospital
14,000

           11,74111,935
12,000


10,000


 8,000
                                      6,444
                              5,935
 6,000                                                 5,292 5,499


 4,000


 2,000
                                                                                 802
                                                                           100
    0
         Ambulatory (+2%)   Admit Day (+9%)          Inpatient (+4%)   Outpatient (+702%)

                                              2004   2005
     Mandate: The American
          Experience

 Ambulatory Surgery (hernia/cholecystectomy)
 Reflux surgery
 Bariatrics
    -Banding
    -Gastric bypass
 Surgery of increasing complexity in more fragile
  patients
          What is the risk
      of 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 Risks
    data taken from inpatient procedures

 Associated with patient factors
 Associated with anesthesia
 Associated with the surgical procedure
 Associated with doing the procedure as
  ambulatory/day surgery
       Patient Factors: Age
 Age (>65 years)
adverse intra-op events/not post-op events
hypertension: intra-op cardiovascular events
unanticipated readmission rates
 Age (85 years)
co-morbidity, hospitalization < 6 months
          Patient Factors
 Hyper-reactive airway disease
  (asthma, COPD, smoking)
 Coronary artery disease(IHD, MI, CHF,BP)
 Obesity
 Obstructive sleep apnea
 Diabetes
                Diabetes
 80% type II/ 80% are obese: associated with
  increase in unplanned admissions
 Poor control associated with increased rate
  of surgical complications
                 Diabetes
 Understand disease/ measure BS at home
 Treatment of hypoglycemia
 No recurrent admission with complications
  related to diabetes
 Hb1Ac >8 unsuitable > 9 not any elective
  surgery
 Metformin associated with lactic acidosis
       American Society of
     Anesthesia (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.
                 Anesthesia
            analgesia/amnesia/paralysis

   Anxiety
   Pain afferent, inflammation
   Consciousness
   Autonomic stimulation
   Memory
   Movement
             PONV
(Post-anesthesia nausea/vomiting)
  Common cause of unplanned admissions
  Risk factors
     intra-peritoneal gas
     bowel manipulation
     female gender
     history of motion sickness
     opiates
         PONV Prevention
 Pre-induction anti-emetics
 Short term induction anesthetics
 Volatile anesthetics (sevoflurane)
 Short acting muscle relaxants
 Analgesia
    portals, intra-peritoneal spray
    NSAIDS/ketorolac
    Post-anesthesia Discharge
         Scoring System
 Vital signs
 Activity level
 Nausea and vomiting
 Pain
 Surgical care
    Are ambulatory risks higher
         than inpatient?
 5-8% of procedures are performed in MD’s
  office w/o federal regulations, moderate
  rates of “readmission”
 ASC have lowest adverse outcome
 Highest rates of readmission and deaths are
  surgeries performed as outpatient in hospital
  setting
    Ambulatory Surgery Risk
           Factors
 ASA class
 Advanced age (> 85 years)
 Inpatient admission history
 Surgical procedure complexity (time)


Medical causes account for less than 20% of
 admissions
    Ambulatory Surgery Risk
           Factors

 Hyper-reactive airway disease (smoking)
 Coronary artery disease (functional)
 Diabetes
 Obesity
 Obstructive sleep apnea
       Ambulatory Surgery
 90 minutes/6 hour recovery time
     Reflux operations -Nissen
     Bariatric operations-Banding
 90 minutes/23 hour discharge time
     Bariatric operations-LRYGBP
    Day Case Laparoscopic
     Nissen Fundoplication

 Patient selection
 Anesthesia protocols
 Discharge rates and time
 Postoperative complications/re-admissions




Ng et al ANZ J Surg 2005
      Nissen Fundoplication

 ASA grade I-II (patient bias selection)
 30 minute drive from the hospital
 Obesity
 Asthma
 Age
        Nissen Fundoplication
 Pre-emptive analgesia
 Anti-emetics
 Propofol as induction, variable maintenance
 Local anesthesia in the wounds


   Post-operative reviews
        Nissen Fundoplication
   > 90% discharge rate most studies 6-7 hrs
     cardiovascular stability
     clear fluids
     adequate pain control
     able to ambulate
      Nissen Fundoplication
 1-11% re-admission rate
      dysphagia/inability to tolerate fluid
      comparable to hospitalized patients
 86% patients have resolution of symptoms
 1.5-3 days US $2500-3400/case
          Bariatric Explosion
 Epidemic of obesity
 Laparoscopic approach
 Publicity / media
 Patient demand




Schirmer, B. Watts, S.H. Laparoscopic Bariatric
  Surgery Surg Endosc 2003
    Bariatric 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 Obesity

   WLS today
    – Restriction
    – Malabsorption




                          4 operations
                            - Lap band
                           – Sleeve gastrectomy
                           – Gastric bypass
                           – Duodenal Switch
               Surgical Procedures:
     Laparoscopic Adjustable Gastric
               Banding
 Inflatable gastric band
  just distal to G-E
  junction
 Purely restrictive
  procedure
 “Reversible”
 Technically “simple”
            Gastric 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 banding
 4.5 –13.5kg pre-op weight loss
 DVT prophylaxis
 Anesthesia
 scopolamine/IV rantidine/ondansetron
 local bupivacaine/ketorolac/dexamethasone
 liquid hydrocodone/acetaminophen
          Gastric banding
 305 females/38 males 43.5 years/BMI 44.5
 OR 53 minutes
 8.2 % paid by insurance company
 10 complications
    5 occlusions treated medically
    colon perforation
    3 transfers to hospital
Roux-en-Y Gastric Bypass


   15-30 cc
    Pouch

                  100-150 cm
                  Roux limb
           Gastric bypass
 2000 patients LRYGBP 10/2001-12/2004
 Average BMI 49
 Female to male ratio 7:1
 OR times 54-115 minutes average
 1669 (84%) discharged within 23 hours


McCarty T.M. et al Annals of Surgery 2005
            Gastric 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 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 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 bypass
National Hospital Discharge Survey
  10% complication rate
  LOS 7 days
Variability: open procedure, clinical care
 pathways to reduce pain, nausea, narcotic
 requirements and complications

Livingston E.H. Am J Surg 2004
Laparoscopic Day surgery for
      Liver Resection
 17 patients, no conversions 2002-2004
 Anterior and medial segments of the liver
 Tissuelink, GIA stapler, intra-op U/S
 11 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 discharge
meticulous surgery, low complication rate

Post-operative pain and nausea
Pre-operative analgesia
Anti-emetics
Standardized anesthesia protocols
  short acting agents
      Successful Discharge
 Information prior to the procedure
 Written instructions on discharge
 Home contact
    monitor progress, reassure
    detect early problems
 Self referral to surgical team-minimal delay
             Conclusions
 Attractive to the surgeon
  reduce waiting times
  decreases cancellations due to bed shortage
  COST-EFFECTIVE
 Attractive to the patient?
  PONV, pain, anxiety (help) addressed
Un grazie
(di cuore)


     Alfons Pomp, MD, FACS

				
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posted:9/27/2011
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