2. Fast-track surgery Report of a Center

3. 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.

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

5. Fast-track surgery Fast-track rehabilitation Fast-track surgery Optimized surgery Enhanced recovery Fast-track rehabilitation

6. Fast-track surgery Fast-track surgery lap. cholecystectomy: > 80% day surg. lap. cholecystectomy: > 80% day surg. fundoplicatio: > 90% day surg. fundoplicatio: > 90% day surg. splenectomy: day surg. splenectomy: day surg. colon (open and lap.): 2 - 4 g. colon (open and lap.): 2 - 4 g. mastectomy: 90% day surg. mastectomy: 90% day surg. lap. surrenalectomy: day surg. lap. surrenalectomy: day surg. parathiroydectomy: 90% ambulatoriale parathiroydectomy: 90% ambulatoriale thiroydectomy: day surg. thiroydectomy: day surg. lung: 1 – 5 g. lung: 1 – 5 g.

7. Fast-track surgery Personal experience Day surgery/One day surgery Day surgery/One day surgery - hernie - hernie - laparoceli (diam< 3 cm) - laparoceli (diam< 3 cm) - hemorrhoids - hemorrhoids - thoracentesis - thoracentesis

8. Fast-track surgery Cholecystectomy

10. Ambulatory Cholecystectomy Forrest U.S.A U.S.A 2001 2001 117 117 Adm 23% Readm 1.5% Skattum Norvegia Norvegia 2004 2004 1060 1060 Adm 9.9% Readm 6.6% Lledo Spagna Spagna 2006 2006 448 448 Adm 10.1% Ream 1.2% Topal Belgio Belgio 2007 2007 107 107 Adm 7% Readm 4.3%

11. Fast-track surgery Personal experience Cholecystectomy Cholecystectomy - medical history! - medical history! - admittance day of operation - admittance day of operation - early mobilization: I°day - early mobilization: I°day - drain: II°day - drain: II°day - discharge: II°-III° day - discharge: II°-III° day

12. Pre-operative examinations Hemocromo – PT- PTT ECG > 40 years Rx chest > 60 years Electrolyte-azoto-creatinina > 60 years Glicemia > 60 years Urine: only specific indication

13. Fast-track surgery Thyroidectomy

16. Fast-track surgery Thyroidectomy 'Same-day' thyroid surgery. Results after 805 thyroidectomies in a fast- track program Ortega JOrtega J, Cassinello N, Lledó S. Cassinello NLledó S Ortega JCassinello NLledó S

17. Fast-track surgery Thyroidectomy Outpatient and short-stay thyroid surgery. Outpatient and short-stay thyroid surgery. Lo Gerfo P, Gates R, Gazetas P. Lo Gerfo P, Gates R, Gazetas P. Lo Gerfo PGates RGazetas P Lo Gerfo PGates RGazetas P Department of Surgery, Columbia University, Columbia Presbyterian Medical Center, New York, New York 10032. Department of Surgery, Columbia University, Columbia Presbyterian Medical Center, New York, New York 10032.

18. Fast-track surgery Thyiroidectomy …conclusions: Specialized centre Lobectomy or sub-total No total thyroidectomy No ASA 3

19. Fast-track surgery Thyroidectomy DISCHARGE sec. U.E.C. In selected patients: I° day (day surgery criteria) In selected patients: I° day (day surgery criteria) Other patients: II°-III° day Other patients: II°-III° day No Day Hospital. No Day Hospital.

20. Fast-track surgery Personal experience Thyiroydectomy Thyiroydectomy - Admittance day of operatio - Admittance day of operatio - Clyster befor surgery - Clyster befor surgery - Free nutritional intake until midnight - Free nutritional intake until midnight - Free oral fluid intake - Free oral fluid intake - Drains: I°-II°day - Drains: I°-II°day - Discharge: II°-III° day - Discharge: II°-III° day

21. Fast-track surgery Breast surgery

22. William Stewart Halsted 1852 - 1922 1852 - 1922 Surgeon-in-chief Johns Hopkins Hospital 1890-1922

26. Fast-track surgery Personal experience. Brest surgery: - Free oral intake - Admittance day of operation - Mobilization: I° day - Drains: I°-V° day - Discharge: I°-V° day

27. Fast-track surgery Colon surgery

28. Fast-track surgery Colon 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 N.Engl.J.Med,2004

29. Annals of Surgery Vol. 241, N. 3, March 2005 Randomized & Blinded Controlled Trials FUNCIONAL RECOVERY AFTER OPEN VS LAPAROSCOPIC COLONIC RESECTION LINDA BASSE…HENRIK KEHLET Annals of Surgery Vol. 241, N. 3, March 2005 Randomized & Blinded Controlled Trials FUNCIONAL RECOVERY AFTER OPEN VS LAPAROSCOPIC COLONIC RESECTION LINDA BASSE…HENRIK KEHLET …Conclusion: functional recovery after colonic resection is rapid with multimodal rehabilitation regimen and WITHOUT DIFFERENCES BETWEEN OPEN AND LAPAROSCOPIC RESECTION…

30. Dis Colon Rectum 2004 Basse L et al. – Dis Colon Rectum 2004; 47: 271-8 “Colonic surgery with accelerated rehabilitation or conventional care” Post-op. stay: II°-III° dayPost-op. stay: II°-III° day Readmission: 20%Readmission: 20%

31. Morbility Traditional Care 20-35% Fast-track Rehabilitation < 10% Wolfgang Schwenk – TATM 2007; 9: 43-44 “Editorial: principles of fast-track rehabilitation in elective colonic surgery”

32. Fast-track surgery Personal experience Colon Colon - Free nutritional oral intake until midnitht - Free nutritional oral intake until midnitht - Free oral fluid intake - Free oral fluid intake - Clyster 12h and 2h before surgery - Clyster 12h and 2h before surgery - Naso-gastric tube: II°-III° day - Naso-gastric tube: II°-III° day - Urinary catheter: I°-II° day - Urinary catheter: I°-II° day - Mobilization: I° day - Mobilization: I° day - Oral nutritional intake: II°-III° day - Oral nutritional intake: II°-III° day - Drains: V°-VIII° day - Drains: V°-VIII° day - Discharge: V°-VIII° day - Discharge: V°-VIII° day

33. Fast-track surgery Gastric surgery

34. 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

35. Biology of intestinal anastomosys: 2° PHASE (III°-IV° postop. day) Proliferation Fibroblast proliferation on anastomotic site Production of “good” collagen

36. Biology of intestinal anastomosys 3° PHASE (V°-VI° post-op. day) Rimodellamento Decrease of macrophagyes and fibroblast density Plasticity of collagene

37. Wu CC 2002 Yoo CH 1994 Lee JH 2002 Doglietto 2004 No difference in terms of: Morbility Mortality Post-op. stay N-G tube and gastric surgery N-G tube and gastric surgery

38. Gastic surgery Personal experience Free nutritional oral intake until midnight Free nutritional oral intake until midnight Clyster 12h and 2h before surgery Clyster 12h and 2h before surgery Naso-gastric tube: II°-III° day Naso-gastric tube: II°-III° day Urinary catheter: II° day Urinary catheter: II° day Drains: IV°-VII° day Drains: IV°-VII° day Oral nutritional intake: IV°-VI° day Oral nutritional intake: IV°-VI° day Mobilization: I° day Mobilization: I° day Discharge: VI°-VIII° day Discharge: VI°-VIII° day

39. Fast-track surgery Personal experience Lung surgery: Lung surgery: pneumothorax: II°-III° day pneumothorax: II°-III° day - VATS - VATS wedge-resection: II°-III° day wedge-resection: II°-III° day - TAC-guidate needle biopsy: ambulat. - TAC-guidate needle biopsy: ambulat. - Lobectomy: VII° day - Lobectomy: VII° day - Pneumonectomy: IX°-X° day - Pneumonectomy: IX°-X° day

40. La Fast-track surgery demands a motivated team: - Anaesthesist - Surgeon - Dietician - Physiologist - Nursing staff - Home/Ambulatory care La Fast-track surgery demands a motivated team: - Anaesthesist - Surgeon - Dietician - Physiologist - Nursing staff - Home/Ambulatory care

41. 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

42. Grazie !