PERCORSO DELLA CHIRURGIA COLO-RETTALE fileITALIA - DEGENZA POST-OP COLON LAPARO. F. Borghi...

F. Borghi

PERCORSO DELLA CHIRURGIA

COLO-RETTALE

2010: PROCESSO DI ACCREDITAMENTO REGIONALE DEI TUMORI

COLO-RETTALI.

BACKGROUND

F. Borghi

2009: REVISIONE LETTERATURA PER STESURA PDTA

F. Borghi

BACKGROUND:

PIEMONTE - VOLUME TM COLON

F. Borghi

BACKGROUND:

CUNEO - VOLUME TM COLON

F. Borghi

BACKGROUND:

PIEMONTE - VOLUME TM COLON LAPARO

F. Borghi

BACKGROUND:

CUNEO - VOLUME TM COLON LAPARO

F. Borghi

BACKGROUND:

ITALIA - DEGENZA POST-OP COLON LAPARO

F. Borghi

VARIABILITA’ PER REGIONE

DEGENZA POST-OP COLON IN LAPAROSCOPIA

F. Borghi

BACKGROUND:

PIEMONTE - DEGENZA POST-OP COLON LAPARO

In 1999, Kehlet published the first important paper reporting median LOS of

2 days following colonic resections, using Fast Track protocol.

Kehlet H, Mogensen T. Hospital stay of 2 days after open sigmoidectomy with a multimodal

rehabilitation programme. Br J Surg 1999;86:227–30.

BACKGROUND:

LITERATURE DATA

F. Borghi

Kehlet H. Br J Anaesth 1997;78:606–17.

“Fast track surgery" (or ERAS) is a concept, first described by Kehlet in 1990's

that employs a multimodal peri-operative care pathway with the aim of

attenuating the stress response and accelerating recovery.

F. Borghi

FAST TRACK SURGERY or ERAS:

DEFINITION

ELEMENTS INFLUENCING

POST-OPERATIVE RECOVERY

F. Borghi

In 2001 the Enhanced Recovery After Surgery Study Group was

created to develop the Kehlet protocol and to create international surgical

units use the same peri-operative protocol.

Enhanced Recovery After Surgery: The Future of Improving Surgical Care

Varadhan KK et al. Crit Care Clin 26 (2010) 527–547

BACKGROUND:

ERAS STUDY GROUP

F. Borghi

An evidence-based consensus protocol for perioperative care in patients

undergoing colonic surgery was drafted by the ERAS Group in 2005

Fearon et al. Clinical Nutrition (2005) 24, 466–477

BACKGROUND:

WHY FAST-TRACK?

F. Borghi

Gustaffson et al. World J Surg 2013 DOI 10.1007/s00268-012-1772-0

F. Borghi

BACKGROUND:

WHY FAST-TRACK?

The consensus protocol was updated in 2009

F. Borghi

BACKGROUND:

WHY FAST-TRACK?

Lsaan K et al. Arch Surg. 2009;144(10):961-969

FAST TRACK SURGERY EVIDENCE:

APPROPRIATENESS

Author Year Trial Pt ( FT vs TRAD) LOS Mortality Morbidity

Anderson 2003 RCT 25 (14 vs 11)

3 vs 7

p=0.002 0 vs 9% p=n.s.

28.5% vs

45,5% p=n.s.

Delaney 2003 RCT 64 (31 vs 33)5,2 vs 5,8

p=0.12*/

22% vs 30%

p=n.s.

Gatt 2005 RCT 39 (19 vs 20)5 vs 7.5

p=0.0270 vs 5.3% p=n.s.

25,3 vs 55,7

p=0.076

Khoo 2007 RCT 70 (35 vs 35)5 vs 7

p<0.0010 vs 5.7% p=n.s. 26% vs 46%

Ionescu 2009 RCT 96 (48 vs 48)6,4 vs 9,1

p=0.001/

12,5 vs 22,9

p=n.s.

Serclova 2009 RCT 103 (51 vs 52)7 vs 10

p<0.001/

21,6 vs 48,1

p=0.003

Muller 2009 RCT 156 (76 vs 75)5 vs 9

p<0.0001

1.3% vs 1.3%

p=n.s.

17% vs 37%

p=0.006


APPROPRIATENESS

F. Borghi

Author Year Trial Pt (FT vs TRAD) Lap/Open LOS Morbidity % Mortality %

Bradshaw 1998 CCT 72 (36 vs 36) Open 4,9 vs 6 8,3% vs 11,4% /

Stephen 2003 CCT 138 (86 vs 52) Open 3,7 vs 6,6* 12% vs 25% /

Raue 2004 CCT 52 (23 vs 29) Lap 4 vs 7* 17,4% vs 24,7% 0 vs 0

Basse 2004 CCT 260 (130 vs 130) Open 2 vs 8* 25.4% vs 55.4%* 4.6% vs 3%

Jakobsen 2004 CCT 40 (20 vs 20) Open 2 vs 8* / /

Jakobsen 2006 CCT 160 (80 vs 80) Open 4,2 vs 8,3 / /

Polle 2007 CCT 107 (55 vs 52) Open/Lap CR 4 vs 6* 27.3% vs 30.8% 0 vs 0

Wichmann 2007 CCT 40 (20 vs 20) Open 6,7 vs 9,7 / /

Kariv 2007 CCT 194 (97 vs 97) Open / / 0 vs 0

Hill 2008 CCT 100 (50 vs 50) Lap/Open 4 vs 6,5 54 vs 66 0 vs 4

Zargar 2008 CCT 52 (26 vs 26) Open 4 vs 6.5* 54% vs 66% 0 vs 4%

Maessen 2008 CCT 173 (121 vs 52) Open colon 2vs1 delay* Wound infect FT /

Nygren 2009 CCT 168 (99 vs 69) Open CR 2 vs 5* 18% vs 37%* 0

Teeuwen 2009 CCT 183 (61 vs 122) Open CR 6 vs 9* 14.8% vs 33.6%* 0 vs 1.6%

Walter 2010 CCT 600 (200 vs 400) Lap/Open 6 vs 9* p<0.001 n.s.


APPROPRIATENESS

Author Year RCT (pts) CCT (pts) LOS Morbidity Readmission

Wind 2006 3 (64 vs 64) 3 (191 vs 195)−1·56 (−2·61,

−0·50) p=0.004

0·54 (0·42,

0·69) p<0.001

1·17 (0·73,

1·86) p=0.52

Gouvas 2009 4 (99 vs 101) 7 (447 vs 416)-2.46 (-3.43,-

1.48) p<0.00001

0.56 (0.45,

0.69) p<0.00001

1.37 (0.97,

1.92) p=0.07

Eskicioglu 2009 4 (198) / /0.61 (0.42,

0.88) p=0.009

0.67 (0.20,

2.19) p=0.50

Walter 2009 2 (33 vs 31)* 2 (153 vs 159)-3.64 (-4.98, -

2.29) p<0.0001

0.63 (0.39,

1.02) p=0.06*

/

Varadhan 2010 6 (226 vs 226) /-2.51(-3.54, -

1.47) p<0.00001

0.53 (0.41,

0.69) p<0.00001

0.80 (0.32,

1.98) p=0.62


APPROPRIATENESS

F. Borghi

Metanalysis 2006-2010

Primary analyses ERAS versus conventional, outcome: Major Complications.

Primary analyses ERAS versus conventional, outcome: All complications


APPROPRIATENESS

F. Borghi

La creazione di percorsi clinici costituisce la soluzione ideale per

standardizzare il trattamento pre, intra e post-operatorio dei pazienti e per

ridurre i costi (diretti e indiretti).

King PM, et al. Colorectal Dis 2006; 8(6):506–513


COSTS

F. Borghi

Lemanu et al.. Colorectal Dis

2013


COSTS

F. Borghi

A recent systematic review to assess cost effectiveness of enhanced recovery

after surgery programmes in colorectal surgery shows that FT is cost

effective (deficiencies regarding the reporting of data).

Lemanu et al. A systematic review to assess cost effectiveness of enhanced recovery after surgery

programmes in colorectal surgery. Colorectal Dis 2013


COSTS

F. Borghi

Khan S et al. Colorectal Disease 2010 ; 12: 1175–1182

There is no evidence that ERAS adversely affect QoL or patient

satisfaction. Certain aspects of such as pain and fatigue may improve with

ERAS. Further research is required.


QoL

F. Borghi

We have enough evidence to conclude that the FT methodology

concept provides major benefits to colonic surgery.

The issue is no longer whether Fast-Track colonic surgery is

better than standard care, but how to improve the approach and

its implementation.

Kehlet. Nat. Rev. Gastroenterol. Hepatol (2011). 8, 539–540

FAST-TRACK SURGERY:

From WHY to HOW

F. Borghi

Kehlet. Nat. Rev. Gastroenterol. Hepatol (2011). 8, 539–540

Despite some examples of FT program implemented outside expert

centres, there is a real gap between evidence based medicine and daily

practice: “the knowing-doing gap’’.

FAST-TRACK SURGERY:

From WHY to HOW

F. Borghi

Surgery 2010; 147:219-26

The first Italian trial in FT program.

FAST-TRACK SURGERY:

From WHY to HOW

F. Borghi

Surgeons, nurses, anesthesiologists motivation

(multidisciplinary team)

Preconceptions (patients and

clinicians)

Complexity of the program

Different resourses in different centres

Changement in the organization

FAST-TRACK SURGERY:

OBSTACLES

F. Borghi

FAST-TRACK SURGERY:

PERCHE’ AUDIT?

- Letteratura specifica convincente

- Outcomes lavori scientifici di centri accreditati difformi

- Prevedibile miglioramento qualità assistenza

- Messa in discussione abitudini consolidate

- Modello clinico e manageriale

-Racchiude appropriatezza, efficacia, efficienza e qualità tecnica

F. Borghi

H. Kehlet and DW. Wilmore. Evidence-Based Surgical Care and the Evolution of Fast-Track Surgery.

Ann Surg 2008; 248: 189-198.

F. Borghi

FAST-TRACK SURGERY:

HOW?

Dietician

General

Practitioner

Nurse

Anesthesiologist

Surgeon

Physiotherapist

Patient

FAST-TRACK SURGERY:

HOW?

F. Borghi

Direzione sanitaria

Dott. F. BorghiDott. L. Pellegrino

Dott. D. DonatiDott.ssa MC.Giuffrida

Dott. M. MeineriDott.ssa A. MerloDott. G. Coletta

Inf. P. A. CirioInf. P. M. VialeInf. P. M. PeanoInf. P. F. Ferrero

Dott.ssa MC. Da Pont

Dietician

General

Practitioner

Nurse

Anesthesiologist

Surgeon

Physiotherapist

Patient

FAST-TRACK SURGERY:

HOW?

F. Borghi

Direzione Sanitaria

(consenziente)

H. Kehlet and DW. Wilmore. Evidence-Based Surgical Care and the Evolution of Fast-Track Surgery.

Ann Surg 2008; 248: 189-198.

F. Borghi

FAST-TRACK SURGERY:

HOW?

St. Luc’s University Hospital Brussels – Belgium

Department of Abdominal Surgery and Transplantation

Colorectal Surgery Unit (Prof. Alex Kartheuser)

ASO S. Croce e Carle Cuneo - Italy

Dipartimento chirurgico

SC Chirurgia Generale (Direttore: Dr. F. Borghi)


VISITING CENTER WITH EXPERIENCE

F. Borghi


WRITING PROTOCOL

F. Borghi

... FOR ANESTHESIA AND ANALGESIA

... FOR NURSING

F. Borghi

... FOR NURSING

F. Borghi

... INCLUDING THE ITEMS

F. Borghi

Inclusion criteria Exclusion criteria

Suitable family environment Unsuitable family environment

Elective surgery Urgent surgical procedure

Benign or malignant disease Neuro-psichiatric disorder

Laparoscopy or Laparotomy Major Ansiety

Colon disease Rectal disease

ASA score I, II, III IBD (?)

ASA score IV

INCLUSION AND EXCLUSION CRITERIA

… AT THE BEGINNING

F. Borghi

1. Pain control with oral pain killers

2. Resuming of oral feeding

3. Recovery of intestinal function (gas)

4. Willing of the patient to come back home

DISCHARGE CRITERIA

…AT THE BEGINNING

F. Borghi


DATA COLLECTION

F. Borghi

Intervento

DimissioneContatto telefonico

Visita pre-operatoria

J0 J3 J4-J20 -J1

Ricovero

Posiz.CPD

CHO

No MBP

Chirurgo, Anestesista,

Infermiere e Dietologo

J2 J7 J30

Visita ambulatoriale

Pre-ospedaliera Fase ospedaliera Fase Post-ospedaliera

J1

Rimozione CPD

CHO

Stop ev

Ripresa alimentazione

Mobilizzazione

Rimozione CV

Deambulazione

J5

Visita dal MMG

J6

MMG

Restrizione ev

O2 terapia

Stop O2 terapia

Emocr elettr creat

CoagulEsami preoperatori

Esame istologico

Incremento alimentazione


CARE PLAIN

F. Borghi


-J20



Pre-ospedaliera

Esami preoperatori

- Inclusion in FT program and program

explication

- Brochure


PRE-HOSPITAL CARE PLAIN

F. Borghi


-J20



Pre-ospedaliera

Esami preoperatori


explication

- Brochure

- Optimization of pre-operative status

- PONV

- Explication of analgesia (epidural

analgesia)



F. Borghi


-J20



Pre-ospedaliera

Esami preoperatori


explication

- Brochure

- Optimization of pre-operative status

- PONV

- Explication of analgesia (epidural

analgesia)

- Counselling in case of stoma creation

(rectal surgery with TME)

- Diet and maltodestrin (3h before

surgery)

- LMWH

- In case of >10% weight loss



F. Borghi

Intervento

Dimissione


J0 J3-J20 -J1

Ricovero

Posiz.CPD

CHO

No MBP



J2

Pre-ospedaliera Fase ospedaliera

J1

Rimozione CPD

CHO

Stop ev


Mobilizzazione

Rimozione CV

Deambulazione

MMG

Restrizione ev

O2 terapia

Stop O2 terapia

Emocr elettr creat



Hospitalization POD 0:

-Mon and when not 1° in list

-LMWH: 8 PM at home

-Maltodextrin: at home

-Acceptance: 7 AM

-CPD POD 0

Hospitalization POD -1:

-Tue-Wed when 1° in list

-Acceptance: 1 PM POD -1

-CPD: POD -1

-LMWH: 6h after CPD placement

-Maltodextrin: in surgical department

at 5 AM


HOSPITAL CARE PLAIN

F. Borghi

Intervento

Dimissione

Contatto telefonico chirurgo o infermiera


J0 J3 J4-J20 -J1

Ricovero

Posiz.CPD

CHO

No MBP



J2 J7 J30

Visita ambulatoriale

Pre-ospedaliera Fase ospedaliera Fase Post-ospedaliera

J1

Rimozione CPD

CHO

Stop ev


Mobilizzazione

Rimozione CV

Deambulazione

J5

Visita dal MMG

J6

MMG

Restrizione ev

O2 terapia

Stop O2 terapia

Emocr elettr creat


Esame istologico



POST- HOSPITAL CARE PLAIN

F. Borghi

FAST-TRACK SURGERY:

HOW?

FAST-TRACK SURGERY:

HOW?

F. Borghi

F. Borghi

Post-HospitalPre-Hospital Intra-Hospital

FAST-TRACK SURGERY:

AUDIT

F. Borghi

Feroci F et al. Int J Colorectal Dis Sept. 2012

Improved adherence to the standardized multimodal ERAS protocol is

significantly associated with improved clinical outcomes, indicating a dose-

response relationship.

Gustafsson UO et al. Arch Surg 2011 May;146(5):571-577.

Stein SL. Semin Colon Rectal Surg 2010; 21:180-183

F. Borghi

FAST-TRACK SURGERY:

AUDIT FOR COMPLIANCE

Passive elements (delivered to the patient without their direct contribution)

Active elements (the participation of the patient is required)

Preadmission counselling Carbohydrate loading

Avoidance of MBP (except TME cases) Urinary catheter removed day1 or 3TME

Avoidance of long acting sedative GI stimulation (laxatives)

Thoracic epidural Oral analgesia alone day 3

PONV prophylaxis IV fluids discontinued on day 1

Laparoscopic surgery Solid food taken on day 1

Avoidance of NG tube «Mobilization»

Intra-operative patient warming

Intra-operative fluid guidance

Avoidance of abdominal drains (colon)

Compliance with the passive elements (93,5%) is higher than active elements

(53,6%). Poor compliance with active elements is associated with major

morbidity and may be a surrogate marker of early complications.

Cthorn et al. Int J Colorectal Dis 2016 DOI 10.1007/s00384-016-

2588-4F. Borghi

FAST-TRACK SURGERY:


Avoiding overload of ev fluids and oral intake of calories on the day of operation

are predictors of improved 5-year survival. A third independent predictor for

improved long-term survival is low C-reactive protein levels

Gustafsson et al World J Surg 2016 DOI 10.1007/s00268-016-3460-y

FAST-TRACK SURGERY:


F. Borghi

• Personal collection data

• Multicentric collection data

• Literature analysis / congress/

referral centre

• Protocol modifications

AUDIT…

F. Borghi



• Literature analysis / congress/

referral centre


AUDIT…

F. Borghi

N° pazienti

(tot 150)

Dindo-Clavien 3a 2 (1,3%)

Posizionamento di drenaggio radiologico (%) 2 (1,3%)

Dindo-Clavien 3b 8 (5.3%)

Deiscenze anastomotiche (%) 3 (2%)

Lesioni coliche iatrogene (%) 2 (1,3%)

Peritoniti post-operatorie (%) 3 (2%)

Dindo-Clavien 4 1 (0,7%)

ARDS (%) 1 (0,7%)

Mortalità (Dindo-Clavien 5) 0%


PRELIMINARY DATA

F. Borghi

L-Group

(64 pts)

R-Group

(41 pts)

Dindo-Clavien 1-2 16

(25,0%)6 (14,6%)

Dindo Clavien 3a 0 2 (4,9%)

Dindo Clavien 3b 1 (1,6%) 3 (7,3%)

Dindo Clavien 4-5 0 0

L-Group: emicolectomia sinistra LAPR-Group: emicolectomia destra lap

Posters presentation at the 1° ERAS Congress, Cannes, October 2012


PRELIMINARY DATA

F. Borghi

N° pazienti

(tot 150)

Degenza post-operatoria mediana (giorni) 3 giorni [range, 2-35]

Degenza post-operatoria media ± DS (giorni) 4.4 ± 3.5 giorni

Degenza post operatoria mediana LAP 3 giorni [range, 2-18]

Degenza post operatoria mediana OPEN 4,5 giorni [range, 3-35]

Degenza post operatoria mediana CPD 3 giorni [range, 2-35]

Degenza post operatoria mediana non CPD 4 giorni [range, 3-14]


PRELIMINARY DATA

F. Borghi


PRELIMINARY DATA

F. Borghi

3%

49%

27%

21%

DPO 2 giorni

DPO 3 gg

DPO 4 gg

DPO > 4 gg

79% dei pazienti dimessi entro la IV giornata post-operatoria

N° patients

(tot 150)

Pazienti dimessi entro le 72h po 85 (56,7%)

Pazienti dimessi dopo le 72h po 65 (43,3%)

Complicanze intra-ospedaliere 34 (22,7%)

Complicanze maggiori 10 (6,7%)

Complicanze minori/osservazione clinica 24 (16%)

Ritardo nella riabilitazione 15 (10%)

Problemi nell’applicazione del protocollo 16 (10,7%)

1° poster prize at the 12° International meeting on coloproctology, Turin, March 2012


PRELIMINARY DATA

F. Borghi


• Multicentric collection data???

• Literature analysis / congress /

referral centre (>50 visiting surgeons)


AUDIT…

F. Borghi

Author Year Pts RCT (FT vs no FT) Pts CCT (FT vs no FT)

Wind 2006 3 (64 vs 64) 3 (191 vs 195)

Gouvas 2009 4 (99 vs 101) 7 (447 vs 416)

Eskicioglu 2009 4 (198) /

Walter 2009 2 (33 vs 31) 2 (153 vs 159)

Varadhan 2010 6 (226 vs 226) /

Spanjersberg 2011 4 (119 vs 118) /

Adamina 2011 6 (226 vs 226) /

Lv 2012 7 (419 vs 433) /

Lemanu 2013 (costs) 2 5

Zhuang 2013 13 (1910) /

Greco 2013 16 (1181 vs 1195) /

Shao 2014 13 (9+4*) (1962) /

Li 2014 6 (323 vs 332) /

Zhao 2014 5 (696 vs 621) 5

Wang 2014 24 (2093 vs 1272) /

Spanjerberg 2015 3 (520 pts) 5 (422 pts)

Implementation of FT program in colorectal surgery:

reduction in LOS, post operative morbidity and cost.

F. Borghi

FAST TRACK SURGERY EVOLVING DATA:

META-ANALYSIS

ERAS pathway significantly reduced overall morbidity (15.1 % in the ERAS

group vs 24.6 % in the control group)

Greco M et al. World J Surg 2013 DOI 10.1007/s00268-013-2416-8

F. Borghi


OVERALL COMPLICATIONS

A significant reduction in nonsurgical complications was found in the ERAS

group (3.0 %) versus the control group (7.5 %)


F. Borghi


NON SURGICAL COMPLICATIONS


F. Borghi


POST-OPERATIVE STAY

In metanalysis mean LOS is 5.8 days in the ERAS group and 8.0 days in the

control group (p<0.001).


EVOLVING APPROPRIATENESS

World J Surg. 2013 Feb;37(2) F. Borghi



• Literature analysis / congress


AUDIT…

F. Borghi

Inclusion criteria Exclusion criteria

Elective surgery Urgent surgical procedure

Benign or malignant disease

Laparoscopy or Laparotomy

IBD

Colonic disease

Rectal disease (PME and TME)

ASA score I, II, III, IV

EVOLVING… INCLUSION AND EXCLUSION

CRITERIA

F. Borghi

1. Pain control with oral pain killers

2. Resuming of oral feeding

3. Recovery of intestinal function (gas)

4. Willing of the patient to come back home

4. Stoma management and correct output (in TME)

EVOLVING… DISCHARGE CRITERIA

F. Borghi

Item Colon Rectum

Preoperative CounselingYes (surgeon,

anesthesiologist)Yes (idem + nurse)

Preoperative Optimisation Yes Yes

MBP No Yes

CHO and no fasting Yes Yes

Preanaesthesia No long-acting sedation No long-acting sedation

Hospitalization J0 (J-1) J0 (J-1)

Analgesia Peridural Peridural

PONV Yes Yes

Nasogastric tube No No

Anaesthesia management Blended Blended

Laparoscopic approach Laparoscopic/Open Robotic/Open

Resection-site drainage No Yes

Immediate postoperative diet Yes Yes

Removal of urinary catheter J1 J2 (3)

656 pazienti

Patients (M:F) 383/273

Age (mean) 68,6 [25-91 anni]

BMI (Kg/m^2) 25.3 ± 4.7 Kg/m2

Benign disease (%) 47 (7,5%)

Cancer or polyp (%) 607 (92,5%)


PERSONAL EXPERIENCE (2010 – 03/2016)

F. Borghi


PATIENTS DATA

F. Borghi


ASA SCORE

F. Borghi

110 RAR + PME72 RAR + TME


SURGICAL PROCEDURE

F. Borghi

656 patients

MIS procedures (lap + rob) 439 (67%)

Laparotomic procedures 217 (33%)

Conversion rate (%) 28 (4,3%)

Median operative time (min) 194


OPERATIVE DATA

F. Borghi

656 patients

Peridural catheter positioning (%) 584 (89%)

Problems related to PDA (%) 6.4%

PDA displacement 4,5%

Ipothension related to PDA 1,9%

PDA removing (median) II day


PERIDURAL

F. Borghi

J0 J1 J2 J3

Posizione seduta (min) 14 258 278 397

Deambulazione (min) ---- 178 168 289

Totale (min) 14 436 446 686

Data recorded for 60 patients


PATIENT MOBILIZATION

F. Borghi

656 patients

Minor complications (Dindo-Clavien 1-2) 216 (32,9%)

Major complications (Dindo-Clavien 3-4) 35 (5,3%)

Mortality (Dindo-Clavien 5) (30 days) 1 (0,1%)

Post-operative complications in literature: 4 – 47%

(bias: different classification of complications)


COMPLICATIONS

F. Borghi

4,3% re-intervention


COMPLICATIONS

F. Borghi

In LAFA Trial the median POS in lap+FT group was 5 (4–7) days;

open+FT 6 (4.5–10) days.

656 patients

Median post operative stay (days) 4 days [range, 2-35]

Mean post-operative stay ±DS (days) 5,6 ± 4,1 days

Median post-operative stay in LAP 4 days [range, 2-18]

p<0,05Median post-operative stay in OPEN 7 days [range, 3-35]


LOS

F. Borghi

65% patients are discharged within V post-operative day


LOS

F. Borghi

INTERA CASISTICA (316 CASI)

PRIMI 100 CASI SELEZIONATI

3 days

4 days

> 4 days

4 days

> 4 days

3 days

Median LOS 4 days Median LOS 3 days

4 days

> 4 days

3 days


LOS

F. Borghi


VARIATION IN INCLUSION CRITERIA

F. Borghi

656 patients

Median post operative stay (days) 4 days [range, 2-35]

Median post-operative stay in colon 4 days

Median post-operative stay in RAR 5 days

Median post-operative stay in RAR + TME 6 days

K. Anderin et al. / EJSO 41 (2015) 724e730

The presence of diverting stoma in patients undergoing RAR within an ERAS

setting is associated with a delayed postoperative recovery .


VARIATION IN INCLUSION CRITERIA

F. Borghi

Re-admission in FT program in literature: 0 – 25%.

656 patients

Patients without re-admission 639 (97,4%)

Re-admissions (30 days) (%) 17 (2,6%)

Re-intervention after discharge 1 (0,1%)


RE-ADMISSION

F. Borghi

Fonte: www.agenas.it

From 2010 the

FT protocol was

implemented in

our department

ASO SANTA CROCE CUNEO

DEGENZA POST-OP COLON IN LAPAROSCOPIA

F. Borghi

BACKGROUND:

WHY FAST-TRACK?

F. Borghi

F. Borghi

F. Borghi

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