Fast-track surgeryReport of a Center

Fast track surgeryFast track surgery

A new method of application of A new method of application of preexisting procedures in pre-intra preexisting procedures in pre-intra

and post surgical phase pre-and post surgical phase pre-written and carried out in a multi-written and carried out in a multi-disciplinary way in order to obtain disciplinary way in order to obtain a rapid recovery after operation.a rapid recovery after operation.

Organisational steps for fast track surgeyOrganisational steps for fast track surgey

• Develop a plan or critical pattwayDevelop a plan or critical pattway• Outline specifics of pre-operative preparatioOutline specifics of pre-operative preparatio• Develop anaesthesia and analgesia programmesDevelop anaesthesia and analgesia programmes• Minimise stress of operatioMinimise stress of operatio• Adjust post-operative care according to evidence-Adjust post-operative care according to evidence-

based studiesbased studies• Develop post-oprative nursing care programmesDevelop post-oprative nursing care programmes• Determine patient follow-upDetermine patient follow-up• Develop a patient information programmeDevelop a patient information programme• Document results, tabulate problems and patient Document results, tabulate problems and patient

satisfactionsatisfaction• Revise and improve programmeRevise and improve programme

Fast-track surgeryFast-track surgeryOptimized surgery

Enhanced recovery

Fast-track rehabilitationFast-track rehabilitation

Fast-track surgeryFast-track surgery

• lap. cholecystectomy: > 80% day surg.lap. cholecystectomy: > 80% day surg.

• fundoplicatio: > 90% day surg.fundoplicatio: > 90% day surg.

• splenectomy: day surg.splenectomy: day surg.

• colon (open and lap.): 2 - 4 g.colon (open and lap.): 2 - 4 g.

• mastectomy: 90% day surg.mastectomy: 90% day surg.

• lap. surrenalectomy: day surg.lap. surrenalectomy: day surg.

• parathiroydectomy: 90% ambulatorialeparathiroydectomy: 90% ambulatoriale

• thiroydectomy: day surg.thiroydectomy: day surg.

• lung: 1 – 5 g.lung: 1 – 5 g.

Fast-track surgeryFast-track surgeryPersonal experiencePersonal experience

• Day surgery/One day surgeryDay surgery/One day surgery

- hernie- hernie

- laparoceli (diam< 3 cm)- laparoceli (diam< 3 cm)

- hemorrhoids- hemorrhoids

- thoracentesis- thoracentesis

Fast-track surgery

Cholecystectomy

Ambulatory CholecystectomyAmbulatory Cholecystectomy

ForrestForrest U.S.AU.S.A 20012001 117117 Adm 23%Adm 23%

Readm Readm 1.5%1.5%

SkattumSkattum NorvegiaNorvegia 20042004 10601060 Adm 9.9%Adm 9.9%

Readm Readm 6.6%6.6%

LledoLledo SpagnaSpagna 20062006 448448 Adm Adm 10.1%10.1%

Ream 1.2%Ream 1.2%

TopalTopal BelgioBelgio 20072007 107107 Adm 7%Adm 7%

Readm Readm 4.3%4.3%

Fast-track surgeryFast-track surgeryPersonal experiencePersonal experience

• CholecystectomyCholecystectomy - medical history!- medical history!

- - admittance day of operationadmittance day of operation

- early mobilization: I°day- early mobilization: I°day - drain: II°day- drain: II°day - discharge: II°-III° day- discharge: II°-III° day

Pre-operative examinations

• Hemocromo – PT- PTT

• ECG > 40 years

• Rx chest > 60 years

• Electrolyte-azoto-creatinina > 60 years

• Glicemia > 60 years

• Urine: only specific indication

Fast-track surgery

Thyroidectomy

Fast-track surgeryFast-track surgeryThyroidectomyThyroidectomy

'Same-day' thyroid surgery. 'Same-day' thyroid surgery. Results after 805 Results after 805 thyroidectomies in a fast-track thyroidectomies in a fast-track programprogram

Ortega JOrtega J, , Cassinello NCassinello N, , Lledó SLledó S..

Fast-track surgeryFast-track surgeryThyroidectomyThyroidectomy

Outpatient and short-stay Outpatient and short-stay thyroid surgery.thyroid surgery.

Lo Gerfo PLo Gerfo P, , Gates RGates R, , Gazetas PGazetas P..

Department of Surgery, Columbia University, Columbia Department of Surgery, Columbia University, Columbia Presbyterian Medical Center, New York, New York 10032.Presbyterian Medical Center, New York, New York 10032.

Fast-track surgeryThyiroidectomy

…conclusions:

• Specialized centre

• Lobectomy or sub-total

• No total thyroidectomy

• No ASA 3

Fast-track surgeryFast-track surgeryThyroidectomyThyroidectomy

DISCHARGE sec. U.E.C.DISCHARGE sec. U.E.C.

• In selected patients: I° day (day In selected patients: I° day (day surgery criteria) surgery criteria)

• Other patients: II°-III° dayOther patients: II°-III° day

• No Day Hospital.No Day Hospital.

Fast-track surgeryFast-track surgeryPersonal experiencePersonal experience

• ThyiroydectomyThyiroydectomy

- - Admittance day of operatioAdmittance day of operatio - Clyster befor surgery- Clyster befor surgery - Free nutritional intake until midnight- Free nutritional intake until midnight - Free oral fluid intake- Free oral fluid intake - Drains: I°-II°day- Drains: I°-II°day - Discharge: II°-III° day- Discharge: II°-III° day

Fast-track surgery

Breast surgery

William Stewart HalstedWilliam Stewart Halsted 1852 - 19221852 - 1922

Surgeon-in-chief Johns Hopkins HospitalSurgeon-in-chief Johns Hopkins Hospital1890-19221890-1922

Fast-track surgeryPersonal 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 surgeryFast-track surgeryColonColon

The “Coast trial” is an important The “Coast trial” is an important multicentric randomized and controlled multicentric randomized and controlled

trial that shows an hospital stay trial that shows an hospital stay significantly decreased after laparoscopic significantly decreased after laparoscopic

surgery (5 days) respect to open surgery (6 surgery (5 days) respect to open surgery (6 days)days)

N.Engl.J.Med,2004N.Engl.J.Med,2004

Annals of Surgery Vol. 241, N. 3, March 2005Randomized & Blinded Controlled Trials

FUNCIONAL RECOVERY AFTER OPEN VS LAPAROSCOPIC COLONIC RESECTIONLINDA BASSE…HENRIK KEHLET

Annals of Surgery Vol. 241, N. 3, March 2005Randomized & Blinded Controlled Trials

FUNCIONAL RECOVERY AFTER OPEN VS LAPAROSCOPIC COLONIC RESECTIONLINDA BASSE…HENRIK KEHLET

……Conclusion: functional recovery after Conclusion: functional recovery after colonic resection is rapid with colonic resection is rapid with

multimodal rehabilitation regimen and multimodal rehabilitation regimen and WITHOUT DIFFERENCES BETWEEN OPEN WITHOUT DIFFERENCES BETWEEN OPEN

AND LAPAROSCOPIC RESECTION…AND LAPAROSCOPIC RESECTION…

……Conclusion: functional recovery after Conclusion: functional recovery after colonic resection is rapid with colonic resection is rapid with

multimodal rehabilitation regimen and multimodal rehabilitation regimen and WITHOUT DIFFERENCES BETWEEN OPEN WITHOUT DIFFERENCES BETWEEN OPEN

AND LAPAROSCOPIC RESECTION…AND LAPAROSCOPIC RESECTION…

Basse L et al. – Dis Colon Rectum 2004Dis Colon Rectum 2004; 47: 271-8“Colonic surgery with accelerated rehabilitation or conventional care”

•Post-op. stay: II°-III° dayPost-op. stay: II°-III° day

•Readmission: 20%Readmission: 20%

Morbility

Traditional Care 20-35%

Fast-track Rehabilitation < 10%

Wolfgang Schwenk – TATM 2007; 9: 43-44“Editorial: principles of fast-track

rehabilitation in elective colonic surgery”

Fast-track surgeryFast-track surgeryPersonal experiencePersonal experience

• ColonColon

- Free nutritional oral intake until midnitht- Free nutritional oral intake until midnitht - Free oral fluid intake- Free oral fluid intake - Clyster 12h and 2h before surgery- Clyster 12h and 2h before surgery - Naso-gastric tube: II°-III° day- Naso-gastric tube: II°-III° day - Urinary catheter: I°-II° day- Urinary catheter: I°-II° day - Mobilization: I° day- Mobilization: I° day - Oral nutritional intake: II°-III° day- Oral nutritional intake: II°-III° day - Drains: V°-VIII° day- Drains: V°-VIII° day - Discharge: V°-VIII° day- Discharge: V°-VIII° day

Fast-track surgery

Gastric surgery

Biology of intestinal anastomosys

1° PHASE (24-48 h postop.)1° PHASE (24-48 h postop.)Early acute infiammationEarly acute infiammation

The anatomosis is garanted by the solidity of the stapler/stiches on preexisting collagene

Biology of intestinal anastomosys:Biology of intestinal anastomosys:

2° PHASE (III°-IV° postop. day)2° PHASE (III°-IV° postop. day)ProliferationProliferation

Fibroblast proliferationFibroblast proliferationon anastomotic siteon anastomotic siteProduction of “good” collagenProduction of “good” collagen

Biology of intestinal anastomosysBiology of intestinal anastomosys

3° PHASE (V°-VI° post-op. day) 3° PHASE (V°-VI° post-op. day) RimodellamentoRimodellamento

Decrease of macrophagyes and Decrease of macrophagyes and fibroblast densityfibroblast densityPlasticity of collagenePlasticity of collagene

Wu CC 2002Wu CC 2002

Yoo CH 1994Yoo CH 1994

Lee JH 2002Lee JH 2002

Doglietto 2004 Doglietto 2004

No difference in terms of:

•Morbility

•Mortality

•Post-op. stay

N-G tube and gastric N-G tube and gastric surgerysurgery

Gastic surgeryGastic surgeryPersonal experiencePersonal experience

• Free nutritional oral intake until midnightFree nutritional oral intake until midnight

• Clyster 12h and 2h before surgeryClyster 12h and 2h before surgery

• Naso-gastric tube: II°-III° dayNaso-gastric tube: II°-III° day

• Urinary catheter: II° dayUrinary catheter: II° day

• Drains: IV°-VII° dayDrains: IV°-VII° day

• Oral nutritional intake: IV°-VI° dayOral nutritional intake: IV°-VI° day

• Mobilization: I° dayMobilization: I° day

• Discharge: VI°-VIII° dayDischarge: VI°-VIII° day

Fast-track surgeryFast-track surgeryPersonal experiencePersonal experience

• Lung surgery:Lung surgery:

pneumothorax: II°-III° day pneumothorax: II°-III° day

- VATS- VATS

wedge-resection: II°-III° daywedge-resection: II°-III° day

- TAC-guidate needle biopsy: ambulat.- TAC-guidate needle biopsy: ambulat.

- Lobectomy: VII° day- Lobectomy: VII° day

- Pneumonectomy: IX°-X° day- Pneumonectomy: IX°-X° day

La Fast-track surgery demands a motivated team:La Fast-track surgery demands a motivated team:

- Anaesthesist- Anaesthesist - Surgeon - Surgeon - Dietician - Dietician - Physiologist - Physiologist - Nursing staff - Nursing staff - Home/Ambulatory care - Home/Ambulatory care

The results of Fast track rehabilitation are The results of Fast track rehabilitation are based on the charitable continuity on the based on the charitable continuity on the territoryal care and a complete territoryal care and a complete ambulatoriale attendance.ambulatoriale attendance.

The suspicion is that the expense saved in The suspicion is that the expense saved in hospital comes used on the territoyhospital comes used on the territoy

Grazie !Grazie !