Fast-Track Surgery: Quicker, Cheaper May Also Be Safer

No rushing under the knife
No rushing under the knife
Francesca Sacco

GENEVA — If the term “fast-track surgery” conjures a fast-food restaurant in your mind, then some explanation is in order. The term refers to a protocol that can reduce hospital stays by 30% to 50%, without any higher risk of readmission than ordinary surgery.

In a study published last June in the British Journal of Surgery, a University Hospital of Lausanne team confirmed that a patient who has undergone fast-track colon surgery can go home after three to five days, compared to 10 days with traditional care. And the rate of complications is almost twice as low as a result.

“Rapidity is not a goal in itself,” says Nicolas Demartines, head of the visceral surgery service at the University Hospital of Lausanne and co-author of the study. To avoid being likened with the term fast-food, doctors prefer to talk about “enhanced recovery after surgery.”

“The care is optimized as much as possible in the interest of the patient’s recovery,” Demartines says. The days when a patient had to fast before surgery, then put up with a gastric probe, a vesical probe and, finally, drains — and still wait for his intestines to start functioning again before he could eat normally — are over.

It all started around 1995 in Copenhagen, when Henrik Kehlet, professor at the University Hospital Rigshospitalet, demonstrated that the usual intestinal emptying before surgery was pointless. At the time, patients were required to stop eating at least eight hours before undergoing general anesthesia.

Kehlet proved that a three-hour abstinence is sufficient, and that fluids can be authorized up to two hours before surgery. In fact, it’s even recommended that pre-op patients have a drink high in carbohydrates — the kind that an athlete would have before a competition. “It’s about preparing the body to face important stress,” Demartines explains.

University Hospital Rigshospitalet News Oresund

Kehlet also shot down another medical myth. “For a long time, we thought that after an operation, we had to sort of wait and see and not allow the patient to return to eating too quickly,” says Dr. Antoine Meyer of Fribourg Hospital, where the methodology was introduced in 2012. “We used to fear that it would provoke vomiting and, more importantly, that the stitches would rupture. But it turned out that this belief was groundless.”

“Liquid food can be offered to the patient without any restrictions the same day,” Demartines says. A German team from the University Hospital of Heidelberg even concluded that coffee is a positive intestinal stimulant for patients who have just undergone surgery.

Other fast-track measures

Fast-track surgery also includes several other practical measures — though not all are new — such as clearly informing patients before procedures so that they don’t go into surgery passively, minimal post-operative anesthesia, and warm blankets to help patients maintain body temperature. Finally, during recovery, patients are quickly urged to stand up and walk. Each of these steps was rethought and reexamined so as to favor early recovery.

To put these measures into practice, a multidisciplinary collaboration is necessary, implying, for instance, that a nutritionist, the doctor, the nurses, the anesthesiologist and a physiotherapist work hand in hand.

“The fast-track methodology is not a surgeon’s one-man show,” Demartines insists. “Experience shows that a partial adoption of the recommended measures leads to no benefits compared to traditional care. So we must follow all of them. But that makes it difficult to evaluate the impact of each of these methods.”

More generally, the fast-track methodology joins ambulatory care and minimally invasive surgery as part of the trend toward optimizing health care that has gained traction over the last few decades. For a few years now, it has been possible, for instance, to replace heart valves using a catheter, a long flexible tube that is inserted in the femoral artery and that enables delivery of a prosthetic valve to the heart, where it is implanted remotely. Thanks to that method, very old and weak patients who aren’t strong enough to withstand open-heart surgery can now be treated.

According to Demartines’ calculation, fast-track surgery saves each patient an average of $2,180 per operation. At the University Hospital of Lausanne alone, this represents $385,000 saved since 2011, when it became the first hospital in the country to adopt the method.

Patients who undergo fast-track surgery have shorter stays in the hospital and lower post-operative morbidity rates, says Sandrine Ostermann of the University Hospital of Geneva. This led a team of researchers from Duke University to say during a symposium organized last October in Durham, North Carolina, that this new methodology was “possibly one of the most important advances in surgery” in recent years.

In Switzerland, a dozen small and regional hospitals have followed in the footsteps of university centers. In the United Kingdom, fast-track surgery is now considered standard, and the state assumes a bigger share of the cost than it does with other methods, so as to promote it.

But “despite obvious scientific proof and impressive results, fast-track surgery is implemented only too slowly in clinical practice,” the Swiss journal Forum Médical concludes. At the moment, it’s being used in less than of third of Swiss surgeries, and mostly in digestive procedures, colon cancer operations or appendectomies. More recently, its use is becoming more widespread in urology, gynecology and orthopedics.

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Ecological Angst In India, A Mining Dumpsite As Neighbor

Local villagers in western India have been forced to live with a mining waste site on the edge of town. What happens when you wake up one day and the giant mound of industrial waste has imploded?

The mining dumpsite is situated just outside of the Badi village in the coastal state of Gujarat

Sukanya Shantha

BADI — Last week, when the men and women from the Bharwad community in this small village in western India stepped out for their daily work to herd livestock, they were greeted with a strange sight.

The 20-meter-high small hill that had formed at the open-cast mining dumpsite had suddenly sunk. Unsure of the reason behind the sudden caving-in, they immediately informed other villagers. In no time, word had traveled far, even drawing the attention of environment specialists and activists from outside town.

This mining dumpsite situated less than 500 meters outside of the Badi village in the coastal state of Gujarat has been a matter of serious concern ever since the Gujarat Power Corporation Limited began lignite mining work here in early 2017. The power plant is run by the Power Gujarat State Electricity Corporation Limited, which was previously known as the Bhavnagar Energy Company Ltd.

Vasudev Gohil, a 43-year-old resident of Badi village says that though the dumping site is technically situated outside the village, locals must pass the area on a daily basis.

"We are constantly on tenterhooks and looking for danger signs," he says. Indeed, their state of alert is how the sudden change in the shape of the dumpsite was noticed in the first place.

Can you trust environmental officials?

For someone visiting the place for the first time, the changes may not stand out. "But we have lived all our lives here, we know every little detail of this village. And when a 150-meter-long stretch cave-in by over 25-30 feet, the change can't be overlooked," Gohil adds.

This is not the first time that the dumpsite has worried local residents. Last November, a large part of the flattened part of the dumpsite had developed deep cracks and several flat areas had suddenly got elevated. While the officials had attributed this significant elevation to the high pressure of water in the upper strata of soil in the region, environment experts had pointed to seismic activities. The change is evident even today, nearly a year since it happened.

It could have sunk because of the rain.

After the recent incident, when the villagers raised an alarm and sent a written complaint to the regional Gujarat Pollution Control Board, an official visit to the site was arranged, along with the district administration and the mining department.

The regional pollution board officer Bhavnagar, A.G. Oza, insists the changes "aren't worrisome" and attributes it to the weather.

"The area received heavy rain this time. It is possible that the soil could have sunk in because of the rain," he tells The Wire. The Board, he says, along with the mining department, is now trying to assess if the caving-in had any impact on the ground surface.

"We visited the site as soon as a complaint was made. Samples have already been sent to the laboratory and we will have a clear idea only once the reports are made available," Oza adds.

Women from the Surkha village have to travel several kilometers to find potable water

Sukanya Shantha/The Wire

A questionable claim

That the dumpsite had sunk in was noticeable for at least three days between October 1 and 3, but Rohit Prajapati of an environmental watchdog group Paryavaran Suraksha Samiti, noted that it was not the first time.

"This is the third time in four years that something so strange is happening. It is a disaster in the making and the authorities ought to examine the root cause of the problem," Prajapati says, adding that the department has repeatedly failed to properly address the issue.

He also contests the GPCB's claim that excess rain could lead to something so drastic. "Then why was similar impact not seen on other dumping sites in the region? One cannot arrive at conclusions for geological changes without a deeper study of them," he says. "It can have deadly implications."

Living in pollution

The villagers have also accused the GPCB of overlooking their complaint of water pollution which has rendered a large part of the land, most importantly, the gauchar or grazing land, useless.

"In the absence of a wall or a barrier, the pollutant has freely mixed with the water bodies here and has slowly started polluting both our soil and water," complains 23- year-old Nikul Kantharia.

He says ever since the mining project took off in the region, he, like most other villagers has been forced to take his livestock farther away to graze. "Nothing grows on the grazing land anymore and the grass closer to the dumpsite makes our cattle ill," Kantharia claims.

The mining work should have been stopped long ago

Prajapati and Bharat Jambucha, a well-known environmental activist and proponent of organic farming from the region, both point to blatant violations of environmental laws in the execution of mining work, with at least 12 violations cited by local officials. "But nothing happened after that. Mining work has continued without any hassles," Jambucha says. Among some glaring violations include the absence of a boundary wall around the dumping site and proper disposal of mining effluents.

The mining work has also continued without a most basic requirement – effluent treatment plant and sewage treatment plant at the mining site, Prajapati points out. "The mining work should have been stopped long ago. And the company should have been levied a heavy fine. But no such thing happened," he adds.

In some villages, the groundwater level has depleted over the past few years and villagers attribute it to the mining project. Women from Surkha village travel several kilometers outside for potable water. "This is new. Until five years ago, we had some water in the village and did not have to lug water every day," says Shilaben Kantharia.

The mine has affected the landscape around the villages

Sukanya Shantha/The Wire

Resisting lignite mining

The lignite mining project has a long history of resistance. Agricultural land, along with grazing land were acquired from the cluster of 12 adjoining villages in the coastal Ghogha taluka between 1994 and 1997. The locals estimate that villagers here lost anything between 40-100% of their land to the project. "We were paid a standard Rs 40,000 per bigha," Narendra, a local photographer, says.

The money, Narendra says, felt decent in 1994 but for those who had been dependent on this land, the years to come proved very challenging. "Several villagers have now taken a small patch of land in the neighboring villages on lease and are cultivating cotton and groundnut there," Narendra says.

They were dependent on others' land for work.

Bharat Jambucha says things get further complicated for the communities which were historically landless. "Most families belonging to the Dalit or other marginalized populations in the region never owned any land. They were dependent on others' land for work. Once villagers lost their land to the project, the landless were pushed out of the village," he adds. His organization, Prakrutik Kheti Juth, has been at the forefront, fighting for the rights of the villages affected in the lignite mining project.

In 2017, when the mining project finally took off, villagers from across 12 villages protested. The demonstration was disrupted after police used force and beat many protesters. More than 350 of them were booked for rioting.

The villagers, however, did not give up. Protests and hunger strikes have continued from time to time. A few villagers even sent a letter to the President of India threatening that they would commit suicide if the government did not return their land.

"We let them have our land for over 20 years," says Gohil.

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