Fast track surgery

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Fast-track surgeryReport of a Center
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Fast track surgery

• A new method of application of preexisting
  procedures in pre-intra and post surgical phase
  pre-written and carried out in a
  multi-disciplinary way in order to obtain a rapid
  recovery after operation.

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Organisational steps for fast track surgey

• Develop a plan or critical pattway
• Outline specifics of pre-operative preparatio
• Develop anaesthesia and analgesia programmes
• Minimise stress of operatio
• Adjust post-operative care according to
  evidence-based studies
• Develop post-oprative nursing care programmes
• Determine patient follow-up
• Develop a patient information programme
• Document results, tabulate problems and patient
  satisfaction
• Revise and improve programme

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Fast-track surgeryOptimized surgeryEnhanced
recovery Fast-track rehabilitation
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Fast-track surgery

• lap. cholecystectomy gt 80 day surg.
• fundoplicatio gt 90 day surg.
• splenectomy day surg.
• colon (open and lap.) 2 - 4 g.
• mastectomy 90 day surg.
• lap. surrenalectomy day surg.
• parathiroydectomy 90 ambulatoriale
• thiroydectomy day surg.
• lung 1 5 g.

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Fast-track surgeryPersonal experience

• Day surgery/One day surgery
• - hernie
• - laparoceli (diamlt 3 cm)
• - hemorrhoids
• - thoracentesis

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Fast-track surgery

• Cholecystectomy

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Ambulatory Cholecystectomy
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Fast-track surgeryPersonal experience

• Cholecystectomy
• - medical history!
• - admittance day of operation
• - early mobilization Iday
• - drain IIday
• - discharge II-III day

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Pre-operative examinations

• Hemocromo PT- PTT
• ECG gt 40 years
• Rx chest gt 60 years
• Electrolyte-azoto-creatinina gt 60 years
• Glicemia gt 60 years
• Urine only specific indication

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Fast-track surgery

• Thyroidectomy

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Fast-track surgeryThyroidectomy

• 'Same-day' thyroid surgery. Results after 805
  thyroidectomies in a fast-track program
• Ortega J, Cassinello N, Lledó S.

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Fast-track surgeryThyroidectomy

• Outpatient and short-stay thyroid surgery.
• Lo Gerfo P, Gates R, Gazetas P.
• Department of Surgery, Columbia University,
  Columbia Presbyterian Medical Center, New York,
  New York 10032.

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Fast-track surgeryThyiroidectomy

• conclusions
• Specialized centre
• Lobectomy or sub-total
• No total thyroidectomy
• No ASA 3

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Fast-track surgeryThyroidectomy

• DISCHARGE sec. U.E.C.
• In selected patients I day (day surgery
  criteria)
• Other patients II-III day
• No Day Hospital.

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Fast-track surgeryPersonal experience

• Thyiroydectomy
• - Admittance day of operatio
• - Clyster befor surgery
• - Free nutritional intake until midnight
• - Free oral fluid intake
• - Drains I-IIday
• - Discharge II-III day

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Fast-track surgery

• Breast surgery

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William Stewart Halsted 1852 -
1922 Surgeon-in-chief Johns Hopkins
Hospital1890-1922
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Fast-track surgeryPersonal experience.

• Brest surgery
• - Free oral intake
• - Admittance day of
  operation
• - Mobilization I day
• - Drains I-V day
• - Discharge I-V day

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Fast-track surgery

• Colon surgery

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Fast-track surgeryColon

• The Coast trial is an important multicentric
  randomized and controlled trial that shows an
  hospital stay significantly decreased after
  laparoscopic surgery (5 days) respect to open
  surgery (6 days)
• 
  N.Engl.J.Med,2004

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Annals of Surgery Vol. 241, N. 3, March
2005 Randomized Blinded Controlled
Trials FUNCIONAL RECOVERY AFTER OPEN VS
LAPAROSCOPIC COLONIC RESECTION LINDA BASSEHENRIK
KEHLET
Conclusion functional recovery after colonic
resection is rapid with multimodal rehabilitation
regimen and WITHOUT DIFFERENCES BETWEEN OPEN AND
LAPAROSCOPIC RESECTION
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Basse L et al. Dis Colon Rectum 2004 47
271-8 Colonic surgery with accelerated
rehabilitation or conventional care

• Post-op. stay II-III day
• Readmission 20

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Wolfgang Schwenk TATM 2007 9
43-44Editorial principles of fast-track
rehabilitation in elective colonic surgery

• 
  Morbility
• Traditional Care 20-35
• Fast-track Rehabilitation lt 10

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Fast-track surgeryPersonal experience

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

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Fast-track surgery

• Gastric surgery

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• Biology of intestinal anastomosys
• 1 PHASE (24-48 h postop.)
• Early acute infiammation
• The anatomosis is garanted by the solidity of
  the stapler/stiches on preexisting collagene

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Biology of intestinal anastomosys2 PHASE
(III-IV postop. day)ProliferationFibroblast
proliferationon anastomotic siteProduction of
good collagen
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Biology of intestinal anastomosys3 PHASE
(V-VI post-op. day) RimodellamentoDecrease
of macrophagyes and fibroblast densityPlasticity
of collagene
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N-G tube and gastric surgery
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Gastic surgeryPersonal experience

• Free nutritional oral intake until midnight
• Clyster 12h and 2h before surgery
• Naso-gastric tube II-III day
• Urinary catheter II day
• Drains IV-VII day
• Oral nutritional intake IV-VI day
• Mobilization I day
• Discharge VI-VIII day

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Fast-track surgeryPersonal experience

• Lung surgery
• pneumothorax II-III
  day
• - VATS
• wedge-resection
  II-III day
• - TAC-guidate needle biopsy ambulat.
• - Lobectomy VII day
• - Pneumonectomy IX-X day

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La Fast-track surgery demands a motivated team
- Anaesthesist - Surgeon
- Dietician - Physiologist - Nursing
staff - Home/Ambulatory care
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The results of Fast track rehabilitation are
based on the charitable continuity on the
territoryal care and a complete ambulatoriale
attendance.The suspicion is that the expense
saved in hospital comes used on the territoy
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Grazie !