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Alfons Pomp, MD, FACS Weill Medical College of Cornell University

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

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Alfons Pomp, MD, FACS Weill Medical College of Cornell University

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  1. Laparoscopic Day Surgery: The American Experience Alfons Pomp, MD, FACS Weill Medical College of Cornell University

  2. CHUM Hotel-Dieu Montreal

  3. 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

  4. Weill Cornell NYP Hospital

  5. Mandate: The American Experience • Ambulatory Surgery (hernia/cholecystectomy) • Reflux surgery • Bariatrics -Banding -Gastric bypass • Surgery of increasing complexity in more fragile patients

  6. What is the riskof 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;

  7. 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

  8. 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

  9. Patient Factors • Hyper-reactive airway disease (asthma, COPD, smoking) • Coronary artery disease(IHD, MI, CHF,BP) • Obesity • Obstructive sleep apnea • Diabetes

  10. Diabetes • 80% type II/ 80% are obese: associated with increase in unplanned admissions • Poor control associated with increased rate of surgical complications

  11. 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

  12. 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.

  13. Anesthesia analgesia/amnesia/paralysis • Anxiety • Pain afferent, inflammation • Consciousness • Autonomic stimulation • Memory • Movement

  14. PONV(Post-anesthesia nausea/vomiting) Common cause of unplanned admissions Risk factors intra-peritoneal gas bowel manipulation female gender history of motion sickness opiates

  15. PONV Prevention • Pre-induction anti-emetics • Short term induction anesthetics • Volatile anesthetics (sevoflurane) • Short acting muscle relaxants • Analgesia portals, intra-peritoneal spray NSAIDS/ketorolac

  16. Post-anesthesia Discharge Scoring System • Vital signs • Activity level • Nausea and vomiting • Pain • Surgical care

  17. 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

  18. 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

  19. Ambulatory Surgery Risk Factors • Hyper-reactive airway disease (smoking) • Coronary artery disease (functional) • Diabetes • Obesity • Obstructive sleep apnea

  20. Ambulatory Surgery • 90 minutes/6 hour recovery time Reflux operations -Nissen Bariatric operations-Banding • 90 minutes/23 hour discharge time Bariatric operations-LRYGBP

  21. Day Case Laparoscopic Nissen Fundoplication • Patient selection • Anesthesia protocols • Discharge rates and time • Postoperative complications/re-admissions Ng et al ANZ J Surg 2005

  22. Nissen Fundoplication • ASA grade I-II (patient bias selection) • 30 minute drive from the hospital • Obesity • Asthma • Age

  23. Nissen Fundoplication • Pre-emptive analgesia • Anti-emetics • Propofol as induction, variable maintenance • Local anesthesia in the wounds • Post-operative reviews

  24. Nissen Fundoplication • > 90% discharge rate most studies 6-7 hrs cardiovascular stability clear fluids adequate pain control able to ambulate

  25. 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

  26. Bariatric Explosion • Epidemic of obesity • Laparoscopic approach • Publicity / media • Patient demand Schirmer, B. Watts, S.H. Laparoscopic Bariatric Surgery Surg Endosc 2003

  27. 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

  28. WLS today Restriction Malabsorption 4 operations - Lap band Sleeve gastrectomy Gastric bypass Duodenal Switch Surgery for Obesity

  29. Surgical Procedures:Laparoscopic Adjustable Gastric Banding • Inflatable gastric band just distal to G-E junction • Purely restrictive procedure • “Reversible” • Technically “simple”

  30. 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

  31. Gastric banding • 4.5 –13.5kg pre-op weight loss • DVT prophylaxis • Anesthesia scopolamine/IV rantidine/ondansetron local bupivacaine/ketorolac/dexamethasone liquid hydrocodone/acetaminophen

  32. 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

  33. Roux-en-Y Gastric Bypass 15-30 cc Pouch 100-150 cm Roux limb

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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

  39. 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

  40. Decreased pain and wound related morbidity • Short hospital stay in appropriate patients (lower ASA scores) Learn P. et al J Gastrointestinal Surgery 2006

  41. Successful discharge meticulous surgery, low complication rate Post-operative pain and nausea Pre-operative analgesia Anti-emetics Standardized anesthesia protocols short acting agents

  42. 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

  43. 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

  44. Un grazie(di cuore) Alfons Pomp, MD, FACS

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