Chirurgia del Colon in Week Surgery?
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1 Chirurgia del Colon in Week Surgery? dr. V. Fiscon dr. G. Portale Chir. Generale, Cittadella -PD- ULSS 6 Euganea
2 E il colon??? Kraft K et al., J C Visc 2013
3 Discharge early Colon in week surgery
4 Readiness for Hospital Discharge Following Colorectal Surgery Criteria Endpoints Tolerance of oral intake Patient able to tolerate 1 meal Patient drinks liquids actively Recovery of lower GI function Patient passed flatus Pain control (w oral analgesia) Patient is able to mobilize (sit up and walk) without pain (<4 in a scale 0-10) Ability to perform self-care Clinical examination/lab tests --- no evidence of complications Patient is able to perform activities of daily living (go to toilet, dress, shower, etc) T, blood pressure, pulse normal Hb stable Pt able to empty the bladder Fiore JF et al., W J Surg 2013
5 ASCRS and SAGES Carmichael JC et al., DCR 2017
6 Carmichael JC et al., DCR 2017
7 Clinical Practice Guidelines for ERAS: ASCRS & SAGES Peri-operative Carmichael JC et al., DCR 2017
8 Clinical Practice Guidelines for ERAS: ASCRS & SAGES Post-operative Carmichael JC et al., DCR 2017
9 Eight Years of Experience with ERAS in Patients with Colon Cancer: Impact of Measures to Improve Adherence Medical Center Alkmaar, Holland; 816 colon cancer patients ERAS Protocol introduced Implementation measures Specialized nurse Teaching sessions x surg. ward personnel Years Adherence (%) 73% 66% 63% 82% Bakker N et al., Surgery 2015
10 Eight Years of Experience with ERAS in Patients with Colon Cancer: Impact of Measures to Improve Adherence Bakker N et al., Surgery 2015
11 Eight Years of Experience with ERAS in Patients with Colon Cancer: Impact of Measures to Improve Adherence The strongest predictors for a shorter duration of stay: 1. No nasogastric tube 2. Early mobilization 3. Early oral nutrition 4. Early removal of epidural catheter 5. Early removal of urinary catheter 6. Non-opioid oral analgesia Bakker N et al., Surgery 2015
12 Post-discharge Follow-Up Using Text Messaging Within an Enhanced Recovery Program After Colorectal Surgery 111 patients, 4 hospitals; colorectal surgery with ERAS (Nov 2014-Sept 2015) Text message (days 1-3-5) of 4 questions on: PAIN BOWEL MOVEMENTS TEMPERATURE PHLEBITIS Responses <12 min (median); 90% of pts answered all questions 48 alerts: - 60% pain ( 4/10) - 40% no response (patients contacted by phone) 3 re-hospitalizations (2.7%), 2 re-operations (1.8%: 1 leak, 1 fascial dehiscence) Carrier G et al., J Visc Surg 2016
13 Is Expedited Early Discharge Following Elective Surgery for Colorectal Cancer Safe? 2012 ACS-NSQIP dataset: elective CR cancer surgery Post-operative discharge: expedited early (day 1 or 2, group A) vs. standard early (day 3 or 4, group B) 305 (group A) vs (group B) pts Adverse events: Readmissions: 2% vs. 2.6% (p=0.87) 5.6% vs. 6.2% (p=0.9) Yuen A et al., Surg Endosc 2016
14 Risk of 30-day adverse event Risk of 30-day readmission Yuen A et al., Surg Endosc 2016
15 Discharge Within 24 to 72 Hours of CR Surgery is Associated with Low Readmission Rates When Using Enhanced Recovery Pathways? 806 major elective CR procedures (single surgeon) 609 laparoscopic, 197 open (64 months) Discharge: 29% <48 hrs (38% lap, 8% open) 50% <72 hrs (62% lap, 19% open) 8.9% of all patients were readmitted (7.2% lap, 14.2% open) Lawrence JK et al., JACS 2013
16 Outpatient Colectomy within an Enhanced Recovery Program 5 patients (4M:1F), mean age 64 yrs - Rectosigmoid juction cancer (1) - Sigmoid diverticulitis (3) - Volvulus (1) Dysuria (1), incisional hematoma (1) Stay <12 hrs Gignoux B et al., Med Oncol 2016
17 January 2012-September 2015; Colon 150 pts --- Rectum 82 pts - LOS C=4 days; R=5 days - Readmission 7.3% (C) vs. 6.1% (R) - Protocol compliance 86.9% (C) vs. 82.6% (C) Pedziwiatr M et al., Med Oncol 2016
18 Casistica interventi al colon retto 2014 Chirurgia Cittadella 130 INTERVENTI AL COLON 101 INTERVENTI AL COLON IN ELEZIONE LAPAROSCOPICI 1 CONVERSIONE LAPAROTOMICA 65 PER PATOLOGIA MALIGNA 43 EMICOLECTOMIA SINISTRA 31 EMICOLECTOMIA DESTRA 22 RESEZIONI DI RETTO 3 RESEZIONI DI ANSA SPLENICA 1 HARTMANN 1 MILES
19 Giornate di degenza
20 Come colpire il bersaglio? Pazienti sottoposti ad emicolectomia sinistra: giorni di degenza giorni degenza Numero pazienti: 43 Età media: 58.2 Pazienti dimessi entro 7 gg: 23 (53.4%) Tempo operatorio (mediana):2h Days to flatus (media): 3.19 Days to feci (media): 4.17 Morbidity: 6 (13.9%) Reinterventi: 1 (2.3%) Mortality: 0
21 CONCLUSIONS For a safe/effective colo (rectal?) discharge early program 1. Implement ERAS protocol and laparoscopic procedure 2. Get involved all the staff 3. Use post-discharge home assistance or surveillance for patients 4. Organisation /Intensity of care
22 CONCLUSIONS For a safe/effective colo (rectal?) week surgery program 1. Organisation /Intensity of care
23 CONCLUSIONS For a safe/effective colo (rectal?) week surgery program 1. Organisation /Intensity of care SECONDO ME NO!
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