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EDITORIAL |
Spain
Minimally invasive surgical techniques, and especially thoracoscopic surgery, have been in development since 1990. During that time, many advances have also been made in the field of anesthesia, pain control and perioperative support. This in turn has developed numerous models of major outpatient surgery and surgery termed "fast track", especially in the context of digestive tract surgery, to which an abundance of literature has been dedicated.1 The concept of fast track involves an anesthetic technique, surgery and quick rehabilitation, which allow a minimal hospital stay and quick return to normal activity for the patient. The scientific rationale which includes an earlier recovery of muscle strength, tissue oxygenation, pulmonary function and more adequate nutrition, has resulted in a decrease in general morbidity, especially cardiopulmonary, and quicker postoperative recovery. Fast-track surgery puts together a multidisciplinary team of specialists. The optimum selection of patients for a fast-track program is essential; choosing good candidates and carefully evaluating their comorbidity and level of collaboration is fundamental. Preoperative preparation is very important, and physiotherapy should play a vital role as well as the awareness and education of the patient and his or her family. The anesthesia should be optimal, utilizing one-lung anesthesia, with a good analgesic and pharmacological technique and extubation in the same room as the operation. The surgical technique should be quick, with the use of minimal incisions and rapid removal of drainage tubes. Postoperative follow-up should be exhaustive not only in the hospital but also after discharge, requiring the attentive cooperation of the patient’s family.2
Among minimally invasive surgical techniques for the thorax, video-assisted thoracoscopic surgery (VATS) stands out as the most frequently employed. It developed from advances in video technology applied to the classic technique of thoracoscopy. The beginnings were very promising and its use was intensified, especially in pneumothorax surgery, resection of pulmonary nodes and pulmonary biopsies. From this initial experience, indications for thoracic surgery could be extended to facial, palmar and axilary surgery for essential hyperhydrosis or facial flushing, using sympathectomy.
Over time, pulmonary resection by videothoracoscopy came into use, and although not widely applied at first, it gradually became more common with better results. Indications for VATS have increased to include pleural empyema, mediastinal tumors, myasthenia gravis, and operations on the esophagus and spine. Major outpatient surgery within the context of thoracic surgery has also begun recently. The first outpatient technique was mediastinoscopy for lung cancer staging.3 Then came thoracoscopic sympathectomy for the treatment of hyperhidrosis. Very good results have been reported with the application of fast-track models.4 In a recent article, not only are these previous techniques described but also videothoracoscopic pulmonary biopsy. A 50% substitution index (percentage of patients having outpatient surgery with respect to the total undergoing a surgical process) was achieved in these operations, and optimal results with respect to morbidity.5 Other indications included in programs for major outpatient surgery have been anterior mediastinostomy and rigid bronchoscopy.
Regarding complex surgery, especially pulmonary resection, VATS has considerably reduced postoperative morbidity and helped to reduce patient recovery time and hospital stay.6 Even in groups that did not utilize VATS, an important decrease in postoperative stay was obtained with the use of minimally invasive operations (oblique muscle-sparing minithoracotomy), analgesia and a quick postoperative resumption of physical activity.7 At the same time as these changes in surgical technique were produced, new concepts in the management of support processes were developed, which have helped decrease hospital stay and improve the indications for surgical intervention and outpatient consultation. The introduction of these new concepts has established indications for support, which are valid for fast track. The substitution index and rates of unplanned admittance and readmittance are good indices of major outpatient surgery.8 The classic indices of median preoperative stay, postoperative stay, postoperative morbidity and mortality are applicable to processes with conventional hospitalization.2
Fast-track surgery has increased progressively in the thoracic field, but it still needs improvement; however, we can be optimistic for the immediate future because the majority of minimally invasive surgical processes are well developed, and others are clearly progressing. Nevertheless, it is very important to persuade many surgeons to work in a team, creating multidisciplinary units with anesthesiologists who are dedicated to fast-track processes. They need to be encouraged to create work protocols for this type of surgery, and obtain the cooperation of patients and their families. There are still some little-used indications within this concept, and they should be incorporated into these surgical protocols in the future. Among those that should be included are thoracoscopy for pleural effusion, solitary pulmonary node surgery and small mediastinal lesions.8
The development of the concept of fast-track surgery requires a combination of rapid anesthetic technique, optimal surgical process and close collaboration of patients and their families. It is important to create well-coordinated multidisciplinary teams that can apply these protocols efficiently.
REFERENCES
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