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Alexander Perathoner Univ.-Klinik für Viszeral-, Transplantations- und Thoraxchirurgie

Jahrestagung der Tirolisch-Venezianisch-Lombardischen Chirurgenvereinigung BOZEN, 21. Juni 2008. FAST TRACK Was haben wir in die Routine übernommen? Ein Zentrumsbericht Cosa abbiamo trasportato nella routine? Un resoconto di centro. Alexander Perathoner

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Alexander Perathoner Univ.-Klinik für Viszeral-, Transplantations- und Thoraxchirurgie

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  1. Jahrestagung der Tirolisch-Venezianisch-Lombardischen Chirurgenvereinigung BOZEN, 21. Juni 2008 FAST TRACKWas haben wir in die Routine übernommen? Ein ZentrumsberichtCosa abbiamo trasportato nella routine?Un resoconto di centro Alexander Perathoner Univ.-Klinik für Viszeral-, Transplantations- und Thoraxchirurgie Medizinische Universität Innsbruck

  2. October 2004 INTRODUCTION FAST TRACK colorectal surgery in Innsbruck concept by H. Kehlet (Hvidovre) and W. Schwenk (Berlin) 1 ward (colorectal surgery) Inclusion criteria: all consecutive elective colorectal resections EVALUATION after 1 year (82 patients) outcome + feasibility

  3. 82 Fast Track Patients ----------------------------------------------------------------------------------------------------------------------------------- SEX male 55 %, female 45 % AGE60,5 years (32-90) BMI25,5 kg/m² ASA-Score2,7 INDICATION70 % colorectal cancer 23 % sigmoid diverticulitis 7 % IBD PROCEDURE25 % sigmoid resection 23 % rectal resection 19 % right hemicolectomy 15 % left hemicolectomy 14 % ileocaecal resection 4 % proctocolectomy 47 % laparoscopy

  4. Length of hospital staymean 9 days median 7 days range 3 – 60 days

  5. Complications… Surgical complications 13 % Anastomotic Insufficiency 9 Bleeding 1 Burst abdomen 1 Morbidity 17 % Urinary tract infection 5 Pneumonia 3 Wound infection 3 Subileus (Fast Track stopped) 3 Readmissions 2,4 % Pneumonia 2 Mortality 1,2 %

  6. October 2004 INTRODUCTION FAST TRACK colorectal surgery in Innsbruck concept H. Kehlet (Hvidovre) and W. Schwenk (Berlin) 1 ward (colorectal surgery) Inclusion criteria: all consecutive elective colorectal resections EVALUATION after 1 year (82 patients) outcome + feasibility high patients satisfaction acceptable morbidity decreased length of hospital stay October 2005 FAST TRACK colorectal surgery in Innsbruck ROUTINE

  7. INDICATION all patients with elective resection of colon/rectum CONTRAINDICATIONS emergency surgery inadequate compliance AGE, a relative contraindication forFast Track Surgery? Is it too risky to treat older patients with the Fast Track concept?

  8. INDICATION … younger patients are best suited for fast track surgery … older patients profit most! (adapt Fast Track to age/compliance of older patients)

  9. preoperative phase INFORMATION a crucial factor for the success of the Fast Track treatment (motivate to collaborate) Information about... • ... Purpose of Fast Track elements/measures • e.g. postoperative mobilisation • ... Goal of treatment: • not early discharge • reduction of morbidity • acceleration of convalescence !

  10. Allgemeine Informationen (Fast Track, Narkose, OP-Vorbereitung, postoperative Therapie…) *** Tagebuch (Schmerz, Stuhlgang, Übelkeit...) *** Verhaltenstips nach Entlassung *** Krankheitszeichen *** Kontaktinformationen

  11. preoperative phase BREATHING THERAPY breathing exercises, breathing technique (physiotherapy) FLOW 600 ml, 900 ml, 1200 ml

  12. preoperative phase DIET CONSULTATION DIETICIAN information about preoperative and postoperative diet

  13. MECHANICAL BOWEL PREPARATION NO mechanical bowel preparation • discomfort • alterated electrolytes • hypovolemia • no advantage in randomised controlled trials Contant CM, et al. Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial. Lancet. 2007 Dec 22;370(9605):2112-7. Bretagnol F, et al. Rectal cancer surgery without mechanical bowel preparation. Br J Surg. 2007 Oct;94(10):1266-71. Wille-Jørgensen P, et al. Pre-operative mechanical bowel cleansing or not? an updated metaanalysis. Colorectal Dis. 2005 Jul;7(4):304-10. Review.

  14. MECHANICAL BOWEL PREPARATION but… 2 exceptions: • Enema (70 ml) • rectal resection • sigmoid resection • Laxative(Karlsbader salt, laxative tea…) • protective Loop-Ileostomy (low rectal resection) to evacuate the bowel between ostomy and anastomosis

  15. preoperative phase CARBOLOADING • prevent postoperative postaggression-syndrom = inability to metabolise glucose • 200 ml drink with high content of carbohydrates 2h before surgery • malnutrition: 3 x 1 drink, 5 days before surgery fettfrei milcheiweißfrei 2 h nach Gabe von 200ml entspricht das Restvolumen im Magen dem eines nüchternen Menschen

  16. INNSBRUCK NUTRITION SCORE TOOL Age (years) BMI (kg/m²) Weight loss (last 3 months) (%) Oral nutrition (%) INST > 3 = malnutrition 3 x 1 drink with high content of proteins and carbohydrates at least 5 days before surgery

  17. preoperative phase SOBRIETY • patients are allowed to drink clear drinks until 2 hours before surgery • evening before surgery: fluid diet with carbohydrate drink • Guidelines International Societies of Anaesthesia • no food from midnight • no drinking 2h before surgery • = improvement of patient well-being • = prevention of hypovolemia • = risk of aspiration not increased

  18. SURGERY first operation in the morning (makes postoperative mobilisation and nursing easier)

  19. SURGICAL TECHNIQUE • minimal traumatic surgery(minimize surgical complications, reduce postoperative pain, improve postoperative mobilisation) • avoid drainage (remove drains as soon as possible, day 1) • laparoscopy(intracorporal anastomosis) • laparotomy: transverse incision • right hemicolectomy • ileocaecal resection • (sigmoid resection)

  20. transverse laparotomy, ileocaecal resection (colon cancer)

  21. ANAESTHESIA avoid/reduce opiate = improve mobilisation general anaesthesia peridural anaesthesia

  22. intraoperative phase ANAESTHESIA FLUID THERAPY restrictive normovolemia guideline 10 ml/h/kg cristalloids and colloids Gefahr der Hypervolämie/Hyperhydratation Ödeme (Anastomose!), Ergüsse, resp. Insuffizienz, kardiale Belastung, Elektrolytstörungen, Darmparalyse, Zunahme des intraabd. Drucks, verlängerter stat. Aufenthalt

  23. „Patients are not able to drink enough after the operation“ Day 1 post operationem Oral fluid intake 150 – 3500 ml (mean 1600 ml) >1000 ml 83 % >2000 ml 40 %

  24. „The urinary excretion goes down with restrictive intravenous fluid therapy.“ Day 1 post operationem Urinary excretion 500 – 5100 ml (mean 2350 ml) 34 % furosemid (on demand) 1,5 % K+ < 3mmol 0 % renal insufficiency

  25. fluid management preoperative p.o. liberal intraoperative i.v. restrictive postoperative (day 0,1) i.v. restrictive postoperative p.o. liberal MONITORING Blutdruck, Herzfrequenz, Hautturgor, Atemfrequenz, Sauerstoffsättigung, Schweißsekretion, Harnausscheidung, Hämatokrit, Nierenfunktionsparameter, Elektrolyte, Körpergewicht, Kolloidosmotischer Druck, Durstgefühl, Harnnatrium (< 20 mmol/l = i.v. Therapie) Indication for intravenous therapy: urine sodium < 20 mmol/l

  26. postoperative phase DAY 0 postoperative IMCU; transfer to ward, as soon as possible

  27. postoperative phase DAY 0 • Restrictive administration of i.v. fluid (max. 500 ml) • early prophylaxis/therapy of PONV (Metoclopramid 20 mg i.v., Tropisetron 5 mg i.v.) • Tea (max. 1500 ml) • Mobilisation (get out of the bed, attempt at walking) • Joghurt in the evening (max. 2 portions)

  28. postoperative phase ANALGETIC THERAPY

  29. postoperative phase DAY 1 • Therapy per os • Stimulation of bowel motility • Magnesium (3 x 350 mg) • Metoclopramid 20 mg on demand • Chewing gum (gastrocephal reflex!) • Light food

  30. bowel movement

  31. postoperative phase DAY 2 • remove PDA-catheter, central venous catheter, urinary catheter • removement of urinary catheter about 4 hours after the PDA-catheter postoperative phase DAY 3 • Discussion and information about discharge

  32. DISCHARGE • Discharge with informational booklet for patient and family doctor • Out-patient control on day 10 with inspection of the wound, removement of sutures and information about additional therapies (oncological patients, chemotherapy…)

  33. Leistungsorientierte Krankenhausfinanzierung in Österreich (LKF-Punkte) LKF-Punkte pro Behandlung = Pauschalbehandlung = Pauschalbetrag längerer stat. Aufenthalt bei gleicher Leistung = weniger LKF-Punkte = weniger Geld längerer stat. Aufenthalt bei mehr Leistung (Komplikationen) = mehr LKF-Punkte = mehr Geld short hospital stay = weniger Leistung = weniger LKF-Punkte = less money DISCHARGE • FAST track = EARLY discharge ? • Does every patient want to be discharged as soon as possible ? • Does the hospital want to discharge patients as soon as possible ?

  34. Zentrumsbericht … resoconto • Fast Track concept is feasible and convincing • Patients are satisfied and appreciate the treatment • Low morbidity • Acceleration of convalescence • Extension of Fast Track treatment to whole department • Role of perioperative fluid management? • Optimization of postoperative diet (functional food…) to reduce risk of postoperative ileus and improve well-being? • Information • Definition of exact guidelines

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