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Fast Track Colorectal Surgery Fast Track Colorectal Surgery ––A new era ofA new era of perioperativeperioperative carecare
P. P. RittlerRittler, Karl, Karl--WalterWalter JauchJauch,,LMULMU GrosshadernGrosshadern, Munich, Munich
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FAST Track = ERAS(FAST Track = ERAS(Enhanced Recovery Enhanced Recovery After After SurgerySurgery) = Multimodal Rehabilitation) = Multimodal Rehabilitation
Pathophysiological PrinciplePathophysiological PrincipleMinimisationMinimisation of Stress/of Stress/Surgical TraumareactionSurgical Traumareaction
AimAim(Patient (Patient orientedoriented))
ReductionReduction of postoperative of postoperative MorbidityMorbidityEnhanced RecoveryEnhanced Recovery
Shorter LengthShorter Length of Hospital of Hospital StayStay
Economic EffectEconomic Effect
Cost savingsCost savings
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Complications in Colonresection
• Conventional, N=2293 Patients– general Complications: 27%– pulmonary Complicatios: 11%– cardial Complications : 7%– Urinary Tract Infections: 4%
• Laparoscopic, N=1311 Patients– general Complications: 11%– cardiopulmonary Complications: 4%– UTI: 4%
Marusch et al. Surg.Endosc. 2001:116Marusch et al. Chirurg 2002:138
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Surgical Trauma / perioperative Stress Factors
• Anxiousness• Operative procedure• Pain• Hypothermia• Fluid overload• Hypoxemia• Nausea, Vomiting (PONV)• Ileus• Immobilisation• perioperative Fasting• Stress induced catabolism
Ø immun function ↓Ø pulmonary function ↓Ø cardiac distress ↑Ø thrombembolism ↑
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Minimisation of Surgical Trauma
COX-II-Inhibitors
PDAMinimal Invasive Surgery
Oblique Incision
No bowel irrigation
preop. Glucose
Volume restriction
No drainages, tubes
Early enteral nutritionMobilisation
OP-TRAUMA
Rehabilitation
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Periop. Tradition
• Preoperative/Admission– in-hospital
evaluation– e.g.
colonoscopy– 1-2 fasting days
– Bowel lavage
• Operation Day– opiates– Fluid loading– Drainages and
tubes– immobilisation
• 1.-x. POP-Day– nasogastric
tube– nil per mouth– parenteral
nutrition– CV catheter– urinary cath.
Fasted – without glykogen-depots into „sport event“???
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European Survey on Perioperative Care in Colorectal Surgery
• 243 hospitals, 850 patients in 2 weeks
• Bowel preparation 86%(UK) –95%(G)• NG-tube day2 55-95% (day 3: 40-70%)• 1st tolerated liquids day2 10% (day 4: 50%)• Solid food day1 10% (day 5: 25-50%)• LOS (days) 11,2 (I); 11,7(F); 12,2(UK);
14.2(G)
• Williamson, Büchler, Kehlet 2004
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FAST Track = ERAS(FAST Track = ERAS(Enhanced Recovery Enhanced Recovery After After SurgerySurgery) = Multimodal Rehabilitation) = Multimodal Rehabilitation
PreopPreop Smoking and Smoking and alcohol abstinencealcohol abstinenceMalnutrition screening Malnutrition screening and and treatmenttreatmentPatient Patient informationinformationNo No FastingFasting, No , No bowel lavage bowel lavage
PeriopPeriop 1) 1) PreopPreop GlucoseGlucose2) 2) AnAnäästhesiasthesia ((PeriduralPeridural AnaestAnaest.).)3) 3) Volume restrictionVolume restriction4) MIC (?)4) MIC (?)5) 5) NormothermieNormothermie, O, O22
PostopPostop PainPain controlcontrol EpiduralEpidural (T(T88--1212) ) COXCOX--22--Inh.Inh.
MobilisationMobilisationDrainage Drainage Oral Oral NutritionNutrition
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OrthogradeOrthograde BowelBowel LavageLavage
• ± Bowel LavageMetaanalysis - +– Wound infections 7% 6%– Anastomotic insufficiency 3% 6% *– Peritonitis 3% 5%
Wille-Jørgensen et al. Dis Colon Rectum 2003
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PREOPERATIVE GLUKOSE LOADINGPREOPERATIVE GLUKOSE LOADING
--Glycogen depot augmentedGlycogen depot augmented
-- Stress Stress reactionreaction ((catecholaminecatecholamine) ) reducedreducedBolderBolder 19981998
--MetabolicMetabolic stress, stress, insulin resistanceinsulin resistance reduced reduced Nygren, Nygren, ThorellThorell 19991999
--Hunger, Hunger, nauseanausea, , fatiguefatigue, , anxiousnessanxiousness reducedreducedHauselHausel 20012001
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E.R.A.S.: Preoperativ GlucoseSafety
Nygren et al. Ann.Surg. 1995:728
Minutes after ingestionIsot
op-a
ctiv
ity in
the
sto
mac
h [%
]
12090603000
20
40
60
80
100
120*
**
*
*
KH-Sol., n=6
Water, n=6
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E.R.A.S.: Preoperative Carbohydrates Insulin resistance
-60
-50
-40
-30
-20
-10
0
CHE Kolorektal Gelenkersatz
KH-Lsg. Kontrolle
%-A
ltera
tions
vs
. pr
eop.
#
##
Ljungqvist et al. Proc.Nutr.Soc. 2002:329
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Preoperative CarbohydratesHospital Stay
Ljungqvist et al Clin Nutr 1998:65
0.02-1.18 ±0.40All Interventions
0.11-1.25±0.71Hip-Replacement
0.152-2.1 ±1.36Colorectal Surgery
0.065-0.71±0.37Open CHE
pReduction of LOS [Days]CH-Lsg. vs. NPO
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Thoracic Peridural AnästhesiaReduction of Morbidity
• Ileus - 2 Tage
• Pneumonia, respiratory
Insufficiency, Pulm.Embolism - 30-50%
• Myocardial Infarction - 30%
• Transfusion of RBC - 20-30%
• Renal Failure - 30%
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Effect Effect of of salt salt and and water balance water balance on on recovery recovery of of gastrointestinal function after elective colonic gastrointestinal function after elective colonic
resectionresection: a : a randomised controlled trialrandomised controlled trial
Lobo et al, Lancet 2002
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Effects of intravenous fluid restriction on postoperative complications
• Randomised Multicenter Trial 8 Hospitals in DK• Standard n=72 Restrictiv n=69• OP –Day 5388ml 2740ml• Complications 51% 33%• Cardiopulmonary 17 5• Woundhealing 22 11
• Brandstrup et al Ann Surg 2003,641-648
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Colon Colon and and Rectal Anastomoses Rectal Anastomoses do do not Require not Require Routine DrainageRoutine Drainage
Urbach et al, Ann Surg 1999
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Integration of new StandardsA bavarian beer drinker after hemicolectomy
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A Meta-Analysis of Selective Versus Routine Nasogastric Decompression after Elective Laparotomy
• Selective Routine p-value Rel Risk• Patients 1986 1978• Tubes replaced 103 36 0.0001 2.9• Complications 833 1084 0.03 0.76• Pneumonia 53 119 0.0001 0.49• Atelectasis 44 94 0.001 0.46• Fever 108 212 0.02 0.51• Vomiting 201 168 0.11 1.19• Nausea 179 181 0.31 0.98• Oral feeding (postop day) 3,5 4,6 0.04
• Cheatham ML etal, Ann Surg 1995; 469-478
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Anastomotic Insufficiency with Enteral vsParenteral Nutrition
• Author enteral parenteral Odds ratio• Schroeder 0/16 0/16 -• Stewart 1/40 0/40 3.08• Sagar 0/15 1/15 0.31• Hartseil 0/29 1/29 0.32• Reissmann 0/80 1/81 0.33• Watters 1/15 4/16 0.21• Beier-Holgerson 2/30 4/30 0.46• Heslin 3/97 4/98 0.75• Ortiz 2/95 4/95 0.49• Bozzetti 7/159 10/158 0.68• Braga 9/126 11/131 0.84• Pacelli 10/119 14/122 0.71
• All 35/821 54/831 0.66 Schwenk et al, Viszeralchir 2004
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• Complication rate ↓• infections• woundhealing problems• anastomotic dehiscence
• LOS ↓• Loss of muscle mass ↓• Fatigue ↓• Letality ↓• Quality of life ↑
Lewis et al. B.M.J. 2001:773
• Anastomosenheilung ?• Ileus ?
E.R.A.S.: Enhanced enteral nutrition
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IntroductionFast Tract Concept
• Feasibility study (20 patients/group)• Reduction of
– preoperative starvation (2 hrs)– bowel preparation– postoperative i.v. fluids
• Oral carbohydrates (Pre Op®)• Oral protein drink• Epidural anesthesia• Early mobilization
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Fast Track Protocol
Wichmann et al Viszeralchirurgie 2003:329
• präop:– Aufklärung– Tagebuch– reduzierte
Nahrungs-karenz
– Kohlenhy-drat Getränk 4×200 ml + 2 ×200 ml bis 2 Std präop
• intraop:– Schmerzthe-
rapie COX-II-Hemmerund PDA
– Wärme– Querlaparo-
tomie
• postop:– O2
– Schmerzthe-rapie
– Neostigmin– Mobilisation
2 Std.– Tee
– 2×Joghurt
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Fast Track Protocol
Wichmann et al Viszeralchirurgie 2003:329
• Tag 1 postop:– DK, Abd.-
Drainentfernen
– Neostigmin– Mobilisation
8 Std (?)– Tee, LVK (1/3)
– 2-3×Joghurt
• Tag 2 postop:– PDK
entfernen– COX-II-Inh.– Metamizol
b.Bedarf– Neostigmin
s.c. bei Bedarf
– Tee, LVK
• Tag 4 postop:– Entlassung
planen– Patientenge-
spräch
• Tag 5 postop:– Entlassung
• Tag 8 postop:– ambulante
Kontrolle
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IntroductionPatients
Fast Track Conv. Care• Age 58.5±3.4 yrs 64.2±2.4 yrs• Male gender 75% 47%• Malignancy 75% 71%• MIS 13% 65%
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Immunological ResultsE.R.A.S. Pilot Study (n=40)
+ p<0.05 vs. preop.
preop postop 1 postop 3 postop 50
50
100
150
200
250
Fast TrackConv. Care
+
+
+
[pg/
ml]
+
+
IL-6
preop postop 1 postop 3 postop 50
20
40
60
80
Fast TrackConv. Care
*+[%
lym
phoc
ytes
]*
*
*p<0.05 Fast Track vs. Conv. Care; + p<0.05 vs. preop.
T-H-cells
preop postop 1 postop 3 postop 50
1
2
3
4
5
Fast TrackConv. Care
**
* p<0.05 Fast Track vs. Conv. Care
CD4/CD8-Ratio
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Clinical Results
Fast Track Conv. Care• Removal
– epidural catheter: 3.0±0 3.2±0.6– abdominal drain: 1.4±0.4 4.6±1.0 (p=0.001)
• Complete oral feeding: 2.6±0.2 6.0±0.6 (p=0.001)
• Hospital stay: 7.0±0.7 9.2±0.7 (p=0.03)
• Adverse Events 0 18%
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Results of Fast Track Colon Resection
• 64 patients, 63% malignant
• 30 conventional OP, 34 laparoscopic OP
• Oral Nutrition– Tea/Yoghourt postop day 0– Solid food postop day 1
– 1. defecation postop day 2
• Discharge postop day 4
• Readmission N=7 (11%)Schwenk et al. Chirurg 2004:508
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Results of Fast Track Colon Resection
• Complications– local N=5 (8%)
• Anastomotic insufficiency N=2 (3%)
• Ileus N=1 (2%)
– general N=5 (8%)• Urinary tract infection N=2 (3%)
• Pneumonia N=0
– Letality N=1 (2%)
Schwenk et al. Chirurg 2004:508
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Fast Track in Open vs Lap. Resection
• Open Laparoscopic
– Age 76 75– Defecation day 2 day 2– LOS 3,8 3,9 days– Complications 8/60 6/60
– Basse et al Ann Surg 2004 in press
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Fast Track -Perspectives
• Implementation as Standard in Colorectal Surgery• Evaluation in Pankreatic, Liver-, Gastric-Resection• Study on preop Glucose, Bowel Lavage on Volume
Regulation and Bowel Motility
• Economic Evaluation• Psychological Evaluation• Multimodal Treatment and Fast Track
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Thanks for Your AttentionThanks for Your Attention
Invitation to Visit Surgical Invitation to Visit Surgical Department , LMUDepartment , LMU GrosshadernGrosshadern, ,
MunichMunich
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