Fast Track Colorectal Surgery – A new era of perioperative ... · Fast Track Colorectal Surgery...

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



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



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 ↑



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



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“???



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(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



OrthogradeOrthograde BowelBowel LavageLavage

• ± Bowel LavageMetaanalysis - +– Wound infections 7% 6%– Anastomotic insufficiency 3% 6% *– Peritonitis 3% 5%

Wille-Jørgensen et al. Dis Colon Rectum 2003



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



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



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



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



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%



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



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 Colon and and Rectal Anastomoses Rectal Anastomoses do do not Require not Require Routine DrainageRoutine Drainage

Urbach et al, Ann Surg 1999



Integration of new StandardsA 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 Surg 1995; 469-478



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



• 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



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



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



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



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%



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


20

40

60

80


*+[%

lym

phoc

ytes

]*

*

*p<0.05 Fast Track vs. Conv. Care; + p<0.05 vs. preop.

T-H-cells


1

2

3

4

5


**

* p<0.05 Fast Track vs. Conv. Care

CD4/CD8-Ratio



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%



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



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



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

• 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



Thanks for Your AttentionThanks for Your Attention

Invitation to Visit Surgical Invitation to Visit Surgical Department , LMUDepartment , LMU GrosshadernGrosshadern, ,

MunichMunich



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