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American Experience
Ambulatory/Day Surgery
Same
Surgery (hernia/cholecystectomy)
Reflux surgery
Bariatrics
-Banding
-Gastric bypass
Surgery of increasing complexity in more fragile
patients
Operative Risks
data taken from inpatient procedures
Associated
(>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
Patient Factors
Hyper-reactive
airway disease
(asthma, COPD, smoking)
Coronary artery disease(IHD, MI, CHF,BP)
Obesity
Obstructive sleep apnea
Diabetes
Diabetes
80%
Diabetes
Understand
American Society of
Anesthesia (ASA) Class
Class
Anesthesia
analgesia/amnesia/paralysis
Anxiety
Pain
afferent, inflammation
Consciousness
Autonomic stimulation
Memory
Movement
PONV
(Post-anesthesia nausea/vomiting)
Common cause of unplanned admissions
Risk factors
intra-peritoneal gas
bowel manipulation
female gender
history of motion sickness
opiates
PONV Prevention
Pre-induction
anti-emetics
Short term induction anesthetics
Volatile anesthetics (sevoflurane)
Short acting muscle relaxants
Analgesia
portals, intra-peritoneal spray
NSAIDS/ketorolac
Post-anesthesia Discharge
Scoring System
Vital
signs
Activity level
Nausea and vomiting
Pain
Surgical care
Ambulatory Surgery
90
selection
Anesthesia protocols
Discharge rates and time
Postoperative complications/re-admissions
Nissen Fundoplication
ASA grade
Nissen Fundoplication
Pre-emptive
analgesia
Anti-emetics
Propofol as induction, variable maintenance
Local anesthesia in the wounds
Post-operative
reviews
Nissen Fundoplication
>
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
Bariatric Explosion
Epidemic
of obesity
Laparoscopic approach
Publicity / media
Patient demand
Bariatric Surgery-USA
1994-1999
2000
2001
2002
2003
2004
10-15,000/year
22,000
48,000
75,000
105,000
140,000
(450,000 lap cholecystectomies)
today
Restriction
Malabsorption
operations
- Lap band
Sleeve gastrectomy
Gastric bypass
Duodenal Switch
Surgical Procedures:
gastric band
just distal to G-E
junction
Purely restrictive
procedure
Reversible
Technically simple
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
Gastric banding
4.5
Gastric banding
305
Gastric bypass
2000
Gastric bypass
Early
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
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
Gastric bypass
National
Decreased
morbidity
Short hospital stay in appropriate patients
(lower ASA scores)
Learn P. et al J Gastrointestinal Surgery 2006
Successful discharge
Successful Discharge
Information
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
Un grazie
(di cuore)