Alfons Pomp, MD, FACS Weill Medical College of Cornell University
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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
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CHUM Hotel-Dieu MontrealCHUM Hotel-Dieu Montreal
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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
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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
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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
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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;
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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
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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
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Patient Factors Patient Factors
Hyper-reactive airway disease
(asthma, COPD, smoking)Coronary artery disease(IHD, MI, CHF,BP)ObesityObstructive sleep apneaDiabetes
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DiabetesDiabetes
80% type II/ 80% are obese: associated with increase in unplanned admissions
Poor control associated with increased rate of surgical complications
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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
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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.
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AnesthesiaAnesthesia analgesia/amnesia/paralysis
Anxiety Pain afferent, inflammation Consciousness Autonomic stimulation Memory Movement
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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
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PONV PreventionPONV Prevention
Pre-induction anti-emeticsShort term induction anestheticsVolatile anesthetics (sevoflurane)Short acting muscle relaxantsAnalgesia
portals, intra-peritoneal spray
NSAIDS/ketorolac
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Post-anesthesia Discharge Post-anesthesia Discharge Scoring SystemScoring System
Vital signsActivity levelNausea and vomitingPainSurgical care
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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
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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
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Ambulatory Surgery Risk Ambulatory Surgery Risk FactorsFactors
Hyper-reactive airway disease (smoking)Coronary artery disease (functional)DiabetesObesityObstructive sleep apnea
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Ambulatory SurgeryAmbulatory Surgery
90 minutes/6 hour recovery time
Reflux operations -Nissen
Bariatric operations-Banding90 minutes/23 hour discharge time
Bariatric operations-LRYGBP
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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
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Nissen FundoplicationNissen Fundoplication
ASA grade I-II (patient bias selection)30 minute drive from the hospitalObesityAsthmaAge
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Nissen FundoplicationNissen Fundoplication
Pre-emptive analgesiaAnti-emeticsPropofol as induction, variable maintenanceLocal anesthesia in the wounds
Post-operative reviews
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Nissen FundoplicationNissen Fundoplication
> 90% discharge rate most studies 6-7 hrs
cardiovascular stability
clear fluids
adequate pain control
able to ambulate
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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
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Bariatric ExplosionBariatric Explosion
Epidemic of obesity Laparoscopic approach Publicity / media Patient demand
Schirmer, B. Watts, S.H. Laparoscopic Bariatric Surgery Surg Endosc 2003
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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
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Surgery for ObesitySurgery for Obesity
WLS today– Restriction– Malabsorption
4 operations
- Lap band– Sleeve gastrectomy– Gastric bypass– Duodenal Switch
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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”
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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
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Gastric bandingGastric banding
4.5 –13.5kg pre-op weight lossDVT prophylaxisAnesthesia
scopolamine/IV rantidine/ondansetron
local bupivacaine/ketorolac/dexamethasone
liquid hydrocodone/acetaminophen
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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
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15-30 cc15-30 ccPouchPouch
100-150 cmRoux limb
Roux-en-Y Gastric Bypass
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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
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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
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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
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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
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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
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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
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Decreased pain and wound related morbidity
Short hospital stay in appropriate patients
(lower ASA scores)
Learn P. et al J Gastrointestinal Surgery 2006
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Successful dischargeSuccessful discharge meticulous surgery, low complication rate
Post-operative pain and nausea
Pre-operative analgesia
Anti-emetics
Standardized anesthesia protocols
short acting agents
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Successful DischargeSuccessful Discharge
Information prior to the procedureWritten instructions on dischargeHome contact
monitor progress, reassure
detect early problemsSelf referral to surgical team-minimal delay
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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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Un grazieUn grazie(di cuore)(di cuore)Un grazieUn grazie(di cuore)(di cuore)
Alfons Pomp, MD, FACSAlfons Pomp, MD, FACS