Expanding Outpatient Surgery
Same-day Colon Resection Becoming a Reality
Once the stuff of weeklong hospital stays and significant post-op pain, the colectomy has become a three-day affair thanks to laparoscopy. Virtually all colectomy patients are candidates for the laparoscopic technique; even so, it will take a couple weeks for patients to return to normal, says Garth H. Ballantyne, MD, FACS, FASCRS, the director of minimally invasive surgery at Hackensack University Medical Center in New Jersey. (In 5 percent of cases the surgeon may need to convert to an open procedure, he notes.)

Now, laparoscopy and pain pumps are helping one physician send patients home the same day. Mehran Anvari, MB, BS, PhD, started performing colectomy laparoscopically in 1992 at the Centre for Minimal Access Surgery in Hamilton, Ontario, which he founded. He decided last year to try same-day discharge and held a small trial at the CMAS. With the trial a success, Dr. Anvari began extending the same-day discharge option to all qualified patients.

Candidates for the same-day program should

• be in good shape medically;
• not require special post-op monitoring;
• have good home support; and
• live within an hour of the CMAS.

Age is not an issue; one of the first same-day colectomy patients was 83.

"Pain pumps are the key," says Dr. Anvari. "We've almost eliminated narcotic analgesia, so patients are less nauseous, more alert and ambulatory sooner. Because of this, we can give patients clear fluids just a few hours after surgery and get them up and moving more quickly."

Patients get single-use vacuum-run disposable pumps; the CMAS covers the $110 to $150 price tag. The units are not patient-controlled, so extra pain relief, if needed, comes in the form of extra-strength Tylenol or, rarely, Tylenol No. 2, says Dr. Anvari.

"Patients are sent home, on average, in just under 23 hours," he says. "Two patients have stayed about a day-and-a-half, and seven have gone home in less than 22 hours. Only one has needed to return for admission."

After three days on fluids, patients resume their typical diets. Homecare nurses visit daily for three days to check bowel function and pain status. On the third day, the nurse removes the pain pump, and patients return to normal activity.

- Stephanie Wasek

Combined Meniscus and Cartilage Transplants
Biological Restoration on the Horizon in Knee Surgery
As knee surgery becomes easier to perform over the next decade, orthopedics will move toward combining meniscus and cartilage transplants and away from knee replacements with metal and plastic, says a surgeon on the cutting edge of cartilage restoration. The key, he says, is taking advantage of the body's natural resources.

Kevin Freedman, MD, medical director of the cartilage restoration program at Bryn Mawr Hospital (Pa.), recently performed a meniscus transplantation and cartilage cell transplant on a 25-year-old woman who presented with damage to the articular cartilage surface and a missing meniscus in her left knee.

Before the surgery, Dr. Freedman removed a small piece of cartilage from the woman's damaged knee and sent it to a laboratory in Cambridge, Mass. The sample was grown into new cartilage cells and implanted back into the knee, where the cells are expected to grow into nearly normal articular cartilage with good long-term results.

Meniscus and cartilage transplants, done separately, are not new. Combining them is a specialty of Dr. Freedman's. "It's crucial to have the right patient to consider this type of complex operation," he says, noting the woman he operated on was a young, active adult who has gone multiple years with pain, and who underwent a successful ACL repair. "You have to be sure you're treating an isolated problem to greatly increase your likelihood of success."

The dual procedure can be done outpatient. The patient is expected to be on crutches for four weeks to six weeks, walking without crutches at three months and returning to more normal activities at six months. The cartilage cell transplant will take up to 18 months to fully mature.

- Daniel Cook

Headlines on Deadline
N.Y. to Assess Office-based Surgery The New York State Health Department is reconvening its Committee on Quality Assurance in Office-Based Surgery in response to a recent wave of negligent incidents in the field, state officials say. The office-based cases that have spurred the committee's reconstitution, a spokesman says, involved failures to adequately monitor patients and surgeries that led to injury and death. The committee is expected to address anesthesia use, blood loss and the risks of extensive and multiple cosmetic procedures, a spokesman says. Margaret Alteri, CASC, president of the New York State Association of Ambulatory Surgery Centers, says her group favors the committee's return and is urging the department to boost enforcement of the state health code that prohibits office-based practices from identifying themselves as surgery centers without appropriate licensing.

Underwater Telerobotic Surgery Doctors and scientists taking part in NASA"s 18-day underwater research and training mission next month will put telerobotic surgery to the ultimate test. A doctor controlling remote telerobotic equipment in Ontario, Canada, will direct and perform orthopedic and vascular surgery in an underwater habitat submerged 3.5 miles off the Florida Keys some 1,500 miles away. By using telesurgery in such an isolated environment, researchers hope to improve and adapt the technology for real-world use.

W. Va. Medicaid to Require Prior OK for Outpatient Surgeries As the state moves to make its Medicaid program resemble private healthcare plans, low-income and disabled West Virginians will soon need approval before getting outpatient surgery and other procedures.

Want to see Pending ASC Legislation? You can see whether your state is planning to tax ASCs, cap workers' compensation charges or prohibit physician self-referral, among other things, at www.aaasc.org/state/state advocacy.html, a Web site the American Association of Ambulatory Surgery Centers developed to help ASC leaders monitor the introduction and movement of state legislation.