Fast Track Colorectal Surgery A new era of perioperative care P. Rittler,, Karl-Walter Jauch, LMU Grosshadern,, Munich
FAST Track = ERAS(Enhanced Enhanced Recovery After Surgery) ) = Multimodal Rehabilitation Pathophysiological Principle Minimisation of Stress/Surgical Surgical Traumareaction Aim(Patient oriented) Reduction of postoperative Morbidity Enhanced Recovery Shorter Length of Hospital Stay Economic Effect Cost savings
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. 2001:116 Marusch et al. Chirurg 2002:138
Surgical Trauma / perioperative Stress Factors Anxiousness Operative procedure Pain Hypothermia Fluid overload Hypoxemia Nausea, Vomiting (PONV) Ileus Immobilisation perioperative Fasting Stress induced catabolism immun function pulmonary function cardiac distress thrombembolism
Minimisation of Surgical Trauma No bowel irrigation preop. Glucose Minimal Invasive Surgery Oblique Incision No drainages, tubes OP-TRAUMA Rehabilitation PDA COX-II-Inhibitors Early enteral nutrition Mobilisation Volume restriction
Periop. Tradition Preoperative/Ad mission 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???
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
FAST Track = ERAS(Enhanced Enhanced Recovery After Surgery) ) = Multimodal Rehabilitation Preop Smoking and alcohol abstinence Malnutrition screening and treatment Patient information No Fasting,, No bowel lavage Periop 1) Preop Glucose 2) Anästhesia (Peridural Anaest.) 3) Volume restriction 4) MIC (?) 5) Normothermie,, O 2 Postop Pain control Mobilisation Drainage Oral Nutrition Epidural (T COX-2-Inh. (T 8-12 )
Orthograde Bowel Lavage ±Bowel Lavage Metaanalysis - + Wound infections 7% 6% Anastomotic insufficiency 3% 6% * Peritonitis 3% 5% Wille-Jørgensenet al. Dis Colon Rectum 2003
PREOPERATIVE GLUKOSE LOADING -Glycogen depot augmented - Stress reaction (catecholamine) reduced -Metabolic stress, insulin resistance reduced -Hunger, nausea, fatigue, anxiousness reduced Bolder 1998 Nygren, Thorell 1999 Hausel 2001
E.R.A.S.: Preoperativ Glucose Isotop-activity in the stomach [%] 120 * 100 * 80 60 40 20 0 0 Safety KH-Sol., n=6 Water, n=6 * * * 30 60 90 Minutes after ingestion 120 Nygren et al. Ann.Surg. 1995:728
E.R.A.S.: Preoperative Carbohydrates Insulin resistance 0 %-Alterations vs. preop. -10-20 -30-40 -50-60 # # # CHE Kolorektal Gelenkersatz KH-Lsg. Kontrolle Ljungqvist et al. Proc.Nutr.Soc. 2002:329
Preoperative Carbohydrates Hospital Stay CH-Lsg. vs. NPO Open CHE Hip-Replacement Colorectal Surgery All Interventions Reduction of LOS [Days] -0.71±0.37-1.25±0.71-2.1 ±1.36-1.18 ±0.40 p 0.065 0.11 0.152 0.02 Ljungqvist et al Clin Nutr 1998:65
Thoracic Peridural Anästhesia Reduction of Morbidity Ileus Pneumonia, respiratory -2 Tage Insufficiency, Pulm.Embolism - 30-50% Myocardial Infarction -30% Transfusion of RBC -20-30% Renal Failure -30%
Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: : a randomised controlled trial Lobo et al, Lancet 2002
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
Colon and Rectal Anastomoses do not Require Routine Drainage Urbach et al, Ann Surg 1999
Integration of new Standards A bavarian beer drinker after hemicolectomy
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 Surg1995; 469-478
Anastomotic Insufficiency withenteral vs Parenteral 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
E.R.A.S.: Enhanced enteral nutrition Complication rate LOS infections woundhealing problems anastomotic dehiscence Loss of muscle mass Fatigue Letality Quality of life Lewis et al. B.M.J. 2001:773 Anastomosenheilung? Ileus?
Introduction Fast 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
Fast Track Protocol präop: Aufklärung Tagebuch reduzierte Nahrungskarenz Kohlenhydrat Getränk 4 200 ml + 2 200 ml bis 2 Std präop intraop: Schmerzthe- rapiecox- II-Hemmer und PDA Wärme Querlaparotomie postop: O 2 Schmerztherapie Neostigmin Mobilisation 2 Std. Tee 2 Joghurt Wichmann et al Viszeralchirurgie 2003:329
Fast Track Protocol Tag 1 postop: DK, Abd.- Drain entfernen 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 Patientengespräch Tag 5 postop: Entlassung Tag 8 postop: ambulante Kontrolle Wichmann et al Viszeralchirurgie 2003:329
Introduction Patients 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%
Immunological Results E.R.A.S. Pilot Study (n=40) IL-6 T-H-cells CD4/CD8-Ratio 250 5 Fast Track Conv. Care 80 200 4 [pg/ml] 150 + + [% lymphocytes] 60 40 *+ * * 3 * * 100 2 50 + + + 20 Fast Track Conv. Care 1 Fast Track Conv. Care 0 preop postop 1 postop 3 postop 5 0 preop postop 1 postop 3 postop 5 0 preop postop 1 postop 3 postop 5 + p<0.05 vs. preop. *p<0.05 Fast Track vs. Conv. Care; + p<0.05 vs. preop. * p<0.05 Fast Track vs. Conv. Care
Clinical Results Removal Fast Track Conv. Care 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%
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 Dischargepostop day 4 Readmission N=7 (11%) Schwenk et al. Chirurg 2004:508
Results of Fast Track Colon Resection Complications local N=5 (8%) Anastomotic insufficiency N=2 (3%) Ileus N=1 (2%) general N=5 (8%) UrinarytractinfectionN=2 (3%) Pneumonia N=0 Letality N=1 (2%) Schwenk et al. Chirurg 2004:508
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
Fast Track -Perspectives Implementationas Standard in ColorectalSurgery Evaluation in Pankreatic, Liver-, Gastric-Resection Studyon preop Glucose, Bowel Lavageon Volume Regulation and Bowel Motility EconomicEvaluation Psychological Evaluation Multimodal Treatment and Fast Track
Thanks for Your Attention Invitation to Visit Surgical Department, LMU Grosshadern, Munich