Fast Track: Definition - Journée des Centres Spécialisés de l`Obésité

LA REHABILITATION RAPIDE EN
CHIRURGIE DE L’OBESITE
Elie CHOUILLARD
Department of General & Minimally Invasive Surgery
Poissy/Saint-Germain-en-Laye(FRANCE)
For The Intercontinental Society of Natural, Orifice, Endoscopic, and Laparoscopic Surgery (i-NOELS)
[email protected]
Introduction
 Chirurgie,
traitement de référence
pour l’obésité pathologique.
 2000-2015: Innovations techniques
anesthésiques visant à accélérer le
rétablissement, sans compromettre
la sécurité
 ⬇ durée de séjour 300 % en 20 ans.
[email protected]
Fast Track: Definition
A fast-track pathway indicates a
multidisciplinary strategy to enhance
postoperative recovery and decrease
morbidity by reducing surgical stress and
its consequences (stress-free surgery)
Slim K. Fast-track surgery: the next revolution in surgical care
following laparoscopy. Colorectal Dis 2011;13:478–480
[email protected]
Fast Track: Definition
A fast-track pathway indicates a
multidisciplinary strategy to enhance
postoperative recovery and decrease
morbidity by reducing surgical stress and
its consequences (stress-free surgery)
Slim K. Fast-track surgery: the next revolution in surgical care
following laparoscopy. Colorectal Dis 2011;13:478–480
[email protected]
Fast Track: Definition
A fast-track pathway indicates a
multidisciplinary strategy to enhance
postoperative recovery and decrease
morbidity by reducing surgical stress and
its consequences (stress-free surgery)
Slim K. Fast-track surgery: the next revolution in surgical care
following laparoscopy. Colorectal Dis 2011;13:478–480
[email protected]
Fast Track: Definition
A fast-track pathway indicates a
multidisciplinary strategy to enhance
postoperative recovery and decrease
morbidity by reducing surgical stress and
its consequences (stress-free surgery)
Slim K. Fast-track surgery: the next revolution in surgical care
following laparoscopy. Colorectal Dis 2011;13:478–480
[email protected]
Fast Track: Definition
A fast-track pathway indicates a
multidisciplinary strategy to enhance
postoperative recovery and decrease
morbidity by reducing surgical stress and
its consequences (stress-free surgery)
Slim K. Fast-track surgery: the next revolution in surgical care
following laparoscopy. Colorectal Dis 2011;13:478–480
[email protected]
Fast Track: Definition
A fast-track pathway indicates a
multidisciplinary strategy to enhance
postoperative recovery and decrease
morbidity by reducing surgical stress and
its consequences (stress-free surgery)
Slim K. Fast-track surgery: the next revolution in surgical care
following laparoscopy. Colorectal Dis 2011;13:478–480
[email protected]
Fast Track: Definition
A fast-track pathway indicates a
multidisciplinary strategy to enhance
postoperative recovery and decrease
morbidity by reducing surgical stress and
its consequences (stress-free surgery)
Slim K. Fast-track surgery: the next revolution in surgical care
following laparoscopy. Colorectal Dis 2011;13:478–480
[email protected]
Fast Track: Finalité
La durée du séjour hospitalier est
significativement réduite en
comparaison avec la prise en charge
tradiotionnelle
Ansari D, Gianotti L, Schroder J, Andersson R.
Fast-track surgery: procedure-specific aspects and
future direction. Langenbecks Arch Surg 2013;398:29–37
[email protected]
Ultra Fast Track: Définition
❒ Pousser le principe de la réduction
de la durée de séjour au maximum…
❒ Récupération fonctionnelle plus
❒
accelérée et délocalisée
❒ Réduire le séjour hospitalier à sa
plus simple expression: Moins d’une
journée!
Hemmerling TM, Romano G, Terrasini N, Noiseux N.
Anesthesia for off-pump coronary artery bypass surgery. Ann
Card Anaesth. 2013;16(1):28–39
[email protected]
Fast Track in Bariatrics
❒ Application to bariatrics allows favorable
outcomes, equivalent to traditional management
strategies
❒ Implementation of this pathway is based on
the following three elements:
• Features of the surgery
• Particularities of patients
• Optimization of perioperative care
Elliott JA, Patel VM, Kirresh A, et al. Fast-track laparoscopic bariatric surgery: a
systematic review. Updates Surg. 2013;65:85–94.
Wasowicz-Kemps DK, Bliemer B, Boom FA, et al. Laparoscopic gastric banding for morbid obesity: outpatient procedure versus
overnight stay. Surg Endosc 2006;20:1233–1237
[email protected]
Fast Track: Philosophie
Collaboration Multidisciplinaire (Chirurgiens, Anesthésistes,
Paramédicaux, Kinésithérapeute, ….et…SURTOUT LE PATIENT
☞Information du patient
☞Préparation nutritionnelle
☞Protocoles dédiés d’anesthésie
☞Chirurgie de + en + mini-invasive
☞Morbilisation précoce
Lemanu DP, Srinivasa S, Singh PP, et al. Optimizing perioperative care in bariatric surgery patients.
Obes Surg. 2012;22(6):979–990
Raeder J. Bariatric procedures as day/short stay surgery: is it possible and
reasonable? Curr Opin Anaesthesiol 2007;20:508–512
Type de chirurgie
Raeder J. Bariatric procedures as day/short stay surgery: is it possible and reasonable? Curr Opin Anaesthesiol
2007;20:508–512
Joshi GP. The adult patient with morbid obesity and/or sleep apnea syndrome for ambulatory surgery. Presentation at
the American Society of Anesthesiology annual meeting. 2010.
http://www.hnanes.org/modjeditor/uploadfile/20101207224350233.pdf. Accessed May 12, 2013
Sasse KC, Ganser JH, Kozar MD, et al. Outpatient weight loss surgery: initiating a gastric bypass and gastric banding
ambulatory weight losssurgery center. JSLS 2009;13:50–5
[email protected]
What is NOTES?
Natural Orifice Translumenal Endoscopic Surgery:
- Intentional puncture of one of the viscera (e.g., stomach,
rectum, vagina, urinary bladder) to access the abdominal
cavity
- With an endoscope (flexible or stiff)
- To perform an intraabdominal operation
Pearl JP, Ponsky JL: J Gastrointest Surg. 2007
[email protected]
[email protected]
[email protected]
Rationale
Rationale: SILS
[email protected]
Rationale: NOTES
[email protected]
Chirurgie
❒ Banding and Roux-en-Y gastric bypass, most
frequently associated with ultra fast-track
❒ Sleeve Gastrecctomy (France)
❒ Abdominoplasty
❒ Careful patient selection
❒ Experienced surgical, anesthetic, and nursing
❒ Postoperative observation and follow up
❒ Miscellaneous:



Short duration of the surgery
High procedure volume
Proximity to a tertiary level hospital
[email protected]
[email protected]
An exemple of specialized Center






Regional center of excellence (> 750 procedures 2014)
Large Teaching hospital (1000 beds)
Bariatric program since 1976
Multidisciplinary team
Fast-track logistics since 2011
Procedures per day on one OR (8.00-15.45h)



7 LRYGB
8 LSG
5 Revision surgery
[email protected]
Patients selection
❒ IMC, tout sauf un facteur limitant
❒ Comorbidités, facteur limitant +++++++
❒ Apnée du sommeil +++++
❒ Sélection obligatoire
❒ Adhésion du patient, cruciale
[email protected]
Prise en charge périopératoire
❒ Information détaillée et réitérée
❒ Restriction calorique préopératoire et
activité physique oxygénée
❒ Arrêt strict du tabac et de l’alcool > 1 mois
❒ Arrivée entre 6:30 et 8:00
❒ Jeûn préopératoire 2 H pour les liquides et
6 H pour les solides
Prise en charge préopératoire
❒ Charge sucrée (50 mg dans 400 mL 2 H avant
l’intervention): contre la déshydratation
améliore l’insulinorésistance
❒ Prophylaxie anthithrombotique
(pharmacologique & mécanique): patients à
haut risque
❒ Bandes ou chaussettes de cotention + 1 dose
préopérqtoire d’anticoagulants (HBPM)
❒ Antibiothérapie prophylactique
❒ Contrôle de l’acidité gastrique
[email protected]
Intraoperative Management
❒ Anesthetic management is based
on the S.A.F.E. principle (short acting drugs
facilitating fast emergence)
❒ Induction : remifentanil, propofol and
rocuronium, or cisatracurium
❒ Opioids: remifentanil, drug of choice
❒ RSI is important in patients with obesity
with symptomatic GERD, gastroparesis,
emergency surgery, and intestinal obstruction.
[email protected]
Intraoperative Management
❒ Preoxygenation and endotracheal
intubation should be performed in the 25degree, head-up position or the head
elevated laryngoscopy position (HELP)
❒ Use ultrasonography selected patients
❒ Pressure-controlled ventilation with a
PEEP
[email protected]
Other intraoperative measures
❒ Goal-directed fluid therapy (esophageal doppler)
❒ Warming
❒ Avoidance of NG tubes and drains
❒ Postoperative nausea vomiting (PONV)
Prophylaxis
❒ Glucocorticoid administration.
❒ A multimodal and opioid sparing
approach for postoperative analgesia
❒ Wound infiltration
[email protected]
Preoperative measures




LMWH evening before surgery
Elastic stockings
Pneumatic stocking for history of DVT
Urinate before surgery (no CAD& no
bladder-scan)



Single dose IV-Antibiotic prophylaxis
OR-shirt with front closure
Weight/diet check 1 week before surgery
(if incorrect; postpone surgery)
[email protected]
Position & Fixation




Information! No premedication
Let the patient install awake (neuropathy)
HELP
Head
Simple, fast & firm fixation
Elevated
Laryngoscopy
Position
Protocoles dédiés d’anesthésie
Opioïds
Ultiva (30)
Alfentanil (31)
Fentanyl (31)
Sufentanil (31)
partition coefficient
oil/water
~ 20
Hypnotics
partition coefficient
oil/gas
Desflurane (33 )
~ 20
Sevoflurane (33)
~ 45
Isoflurane (33)
~ 90
Halothane (33)
~ 220
~ 130
~ 820
~ 1730
Travailler en parallèle et non en série!
Sets de chirurgie, standardisés
[email protected]
Sets à usage unique!


Save time AND MONEY!
Always the correct equipment
[email protected]
Standardized surgery

Every surgeon uses the same technique

Gastric bypass (linear technique with
mesenterial closure)

Sleeve (dorsal SFG-approach)
Obes Surg 2012;22:320-9
[email protected]
Abdominal wall morbidity
Rivas, Asian J Endosc Surg 2009
[email protected]
End of operation



Surgery & anesthesia finish at the same time
Surgeon leaves OR when the patient is in bed
Surgeon does not leave OR-complex
[email protected]
Cleaning in between?
Only if necessary !
Postoperative measures
❒ Extubated at the end of surgery and
transferred awake to the recovery room
❒ Be able to transfer themselves from the
operating table
❒ 25- to 30-degree head-up position,
monitored and provided with oxygen
❒ In patients with OSA, the duration of the
monitoring should be three hours longer
than non-OSA patients.
[email protected]
Postoperative measures
❒ Early mobilization 3H / respiratory exercises
❒ Drink some tea or water
❒ Fluid oral intake and short walk
❒ Criteria for the discharge:
•
•
•
•
•
•
•
No signs of airway obstruction
Saturation at the reoperative level with room air
Sufficient control of pain
No PONV
Full oral liquid intake
Ability to ambulate
Possibility of a follow up (by telephone and presence)
[email protected]
Conclusions
❒ Le Fast-Track Bariatrique nécessite des
STRUCTURES DÉDIÉES, ainsi que l’implication sans
faille de plusieurs spécialités et du patient.
❒ La chirurgie mini-invasive ainsi que la chirurgie
sans stress et sans douleur SONT POSSIBLES,
permettant une meilleure récupération physiologique.
❒ Si bien pratiqué, avec des patients bien sélectionnés
et très bien informés, ce principe est applicable à LA
MAJORITEÉ des patients.
[email protected]
Merci de votre attention
POISSY-FRANCE