Operations | A small day and then they go away

The pandemic was the trigger for an ambulatory shift pushed even further: major operations can now be performed in one day. Were it not for the giant leaps in anesthesia and surgery, waiting lists would be even longer.

Is it serious doctor ? Still, but at the very least you will escape powdered potatoes. Operations for colorectal cancer, mastectomies without general anesthesia, hip or knee replacements: the pandemic has multiplied the procedures that can now be done minimally invasive and in one-day operations. Patients are running away (so to speak) and hospitals, struggling with waiting lists, ask for nothing better.

The diagnosis of colorectal cancer? A very bad memory. The subsequent operation to remove 20 centimeters of intestine? A very small convalescence. The same day, Jasmin Laperle, still drowsy, left the hospital. Five days later, he was eating at the restaurant with his wife. And he couldn’t believe it.

Before 2020, explains the D^r Patrick Charlebois, surgeon, no patient was discharged the same day after such a colonic resection. Neither at the McGill University Health Center (MUHC) nor anywhere in America.

“The pandemic was really the trigger” for an ambulatory shift pushed even further, he says.

Today, “at the MUHC, a quarter of patients requiring colonic resection are deemed eligible for day surgery and 85% of these selected patients leave the hospital the same day”.

In the 1990s, laparoscopies, combined with less cumbersome anesthesia and postoperative care, made a giant leap forward in day surgery.

Then came the pandemic, which also changed everything with regard to breast cancer at Maisonneuve-Rosemont Hospital.

Due to the heavy precautions to be taken against the risk of airborne spread of the virus, only a few women could then be operated on each day.

What if we didn’t use general anesthesia? Without a respirator, there would be less spread of the virus, said the anesthesiologists, who began to use paravertebral blocks to “freeze” the patient locally. By giving her a little sedative “to make her relax”, “because a bit like a colonoscopy, you still prefer not to remember it! “, launches the D^r Lucas Sideris.

The day before the interview, he had operated on seven women with breast cancer, of all ages, during more or less heavy operations.

“None of them had general anesthesia. Five minutes after the end of the operation, the patients are completely awake and they say to us: “Is it already finished?” Yes, Madame, it went well, we answer them. They are not in pain and they want to go home. »

Given the waiting lists and the aging of the population, fortunately the techniques have been refined and have made these one-day operations possible, observes Dr.^r Sideris, “because otherwise, we would need hospitals with 4,000 beds today”.

In orthopaedics, immense progress too

In the 1990s, a hip or knee replacement required 12 days of hospitalization. Until 2015, it still took three or four days, explains for his part the D^r Étienne Belzile, orthopedic surgeon.

In 2019, just before the pandemic, he continues, following the example of an Ottawa hospital, the CHU de Québec began to proceed in the context of a day operation. “At the beginning, we did trials: we operated on people, we kept them in the hospital, but without taking care of them at all. After 50 patients, we saw that it was safe. »

Again, nerve blocks – a kind of epidural – have been used, and lower doses of narcotics are administered.

When the pandemic arrived, everything was in order.

Including patients from as far away as Sept-Îles, who are invited to pick up at the hotel.

“As soon as there is hospitalization, it costs $ 3000, notes the D^r Belzile. More importantly, it’s a missed opportunity for another patient. »

Being calm with loved ones

Even if the hospital stay is expeditious with its “get up and walk!” side. (especially for patients who are off schedule early in the day), day surgery is serious and requires care.

The patient should therefore stay around. Jasmin Laperle and his spouse, who live in Drummondville, had therefore taken care to rent a condo in Montreal for some time.

The review study of one-day colonic resections concludes that only 5% of patients “had to go to the emergency room within 72 hours of the operation” and “that 90% of patients say they are satisfied and would choose this course again”, rejoices the D^r Charlebois.

Significantly, since the spring of 2020, this approach has also saved the hospital $500,000 and, above all, freed up beds for other patients whose operation required hospitalization.

A very precise protocol has been put in place to determine which patients can leave the hospital after a one-day colonic resection. Among the eligibility conditions are in particular the fact of having been operated on by laparoscopy, of being able to tolerate the liquid diet well in the recovery room, of having the pain well controlled by medication taken orally, of having someone at yourself for the first few days and to be able to use a specific application on a smart phone to quickly be in contact with a caregiver, in the event of any complication.

All-round progress

Caroline Chapadeau, an operating room nurse for 17 years, also notes that everything has changed over the years. Patients have far fewer tubes when they wake up, they can increasingly take their medication at home instead of being stuck in the hospital with IVs.

“More waterproof dressings also allow us to avoid staples in a large number of cases,” she observes.

CLSC nurses are involved and visit the patient as needed, but many of them only have to remove the bandage that covers their mini-incisions after a few weeks, without having to call anybody.

The fact remains that “some patients are worried or that their spouses are uncomfortable or afraid of the blood. We have to reassure them, make sure they go home safely with all the necessary information and the phone numbers to contact,” insists Ms.^me Hat.

Can we hope that one-day operations will be carried out for even more pathologies and people? The D^r Sideris in doubt. “We are more at the stage of refining all of this,” he believes.

And the profile of sick people limits other advances. Many people live alone, he points out, and while he does same-day breast surgery with women over 80, the general poor health of some requires caution.

A call to order from the Québec Ombudsman

Long live minimally invasive operations, but everything must be done according to the rules. After receiving information on the quality of perioperative care in day surgery at the Montreal Children’s Hospital, the Québec Ombudsman issued warnings in March 2022.

In more than half of the files analyzed, “monitoring of vital and neurological signs does not correspond to what is expected by the Montreal Children’s Hospital” itself, wrote the Québec Ombudsman.

The report also noted that “only a few clients’ records document vital signs at discharge. A few have no mention of vital signs.”

For two users in particular, it is still written, “the values ​​of vital signs are outside the normal values ​​and the subsequent nursing supervision was insufficient. One of them, a 16-year-old user, was discharged all the same, despite a blood pressure of 90/36, which is a much lower rate than the reference level”.

The Québec Ombudsman therefore demanded that this hospital issue the necessary reminders to its staff.