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

CHUM Hotel-Dieu MontrealCHUM Hotel-Dieu Montreal

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

15-30 cc15-30 ccPouchPouch

100-150 cmRoux limb

Roux-en-Y Gastric Bypass

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

Un grazieUn grazie(di cuore)(di cuore)Un grazieUn grazie(di cuore)(di cuore)

Alfons Pomp, MD, FACSAlfons Pomp, MD, FACS