PEN Group Nutritional Support – A vision for the future Fast Track approach to recovery after surgery August 2005 John MacFie MD FRCS.

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PEN Group Nutritional Support A vision for the future Fast Track approach to recovery after surgery August 2005 John MacFie MD FRCS Slide 2 Hospital Stay After Colonic Surgery 1990 Days Multimodal Laparoscopic Conventional Slide 3 Fast Track Surgery Kehlet H and Wilmore DW Br J Surg 2005 ; 92 : 3-4 Slide 4 Problems: Observational studies only Other perioperative factors not considered Slide 5 Slide 6 Optimisation Programme: Scabro Preoperative information Hathaway 1986 (n=4018) No bowel preparation Brownson 1992, Burke 1994, Santos 1994, Platell 1998, Miettinen 2000 (n>400) Synbiotics McNaught/Woodcock 2001 (n=129) Preoperative carbohydrates Nygren 1996, Ljungqvist 2001 (n=52) Transverse incision Armstrong 1990 (n=60), Lindgren 2001 (n=53) Slide 7 Optimisation Programme: Scabro Perioperative Oxygen Grief 2000 (n=500) No nasogastric tubes/drains MacFie 1993 (n=148) Epidural analgesia/ no opiates Carli 2001 (n=42), Rodgers 2000 (n=9559) Exercise programme Henricksen 2002 (n=40) Early resumption oral diet Reissman 1995 (n=161), Lewis 2001 (n=837) Slide 8 Preoperative bowel preparation General Anaesthesia Surgeons choice - Incision - Drain - Nasogastric tube Patient controlled analgesia Ward mobilization !Traditional fluid regimen! Conventional treatment : Slide 9 Anderson ADG, Mc Naught CE, MacFie J, et al. Randomized clinical trial of multimodal optimisation and standard perioperative surgical care. BJS 2003; 90: 1497-1504 Patients: right and left hemicolectomy only self caring / independent / on telephone Methods: 10 point optimisation programme Results: optimisation associated with - Lower fatigue scores - Maintained grip strength - Lower pain scores Slide 10 Anderson ADG, Mc Naught CE, MacFie J, et al. Randomized clinical trial of multimodal optimisation and standard perioperative surgical care. BJS 2003; 90: 1497-1504 Length of stay (days) Control Optimisation Group N = 11 14 p = 0.002 Primary outcome: Primary outcome: - Shortened hospital stay (median 3 vs. 7 days) Optimisation is safe Optimisation is safe Probably multifactorial Probably multifactorial Slide 11 Multi modal treatment strategies Problems with PRCTs: Unblinded Selected patients Overwhelming influence of epidurals Slide 12 To assess the effect of a multimodal optimisation package (excluding epidural anaesthesia) on a consecutive series of patients (i.e. unselected) undergoing major colorectal resections ScaBro Multimodal trial 2 Slide 13 Optimisation package Pre-operative Per-operative Post-operative cf previous study : major excisional surgery / all pts had epidurals - Written pre-op information. - Pre-assessment by SpR / Anaesthetist. - Synbiotics. - No bowel prep. - Oral carbohydrate loading & 3h fast. - High inspired O 2 (80%). - Transverse incision. - No drains or post-op NGT. - Early fluid & diet reintroduction. - Structured mobilisation plan. - No opiate analgesics. Slide 14 End points Physiological:Spirometry, grip strength, POSSUM, duration of catheterisation, time to mobilisation. Psychological:Cognitive function scoring, fatigue scoring, pain scoring, analgesic requirements. Gut function:Tolerance to fluids, fluid balance, tolerance to diet, duration of IV fluids. Outcome:Length of stay, complications, need for readmission, GP visits. Slide 15 Design of study 39 consecutive patients needing major colonic surgery 39 consecutive patients needing major colonic surgery RandomisationRandomisation Optimisation group (N = 19) Optimisation group (N = 19) Control group (N = 20) Control group (N = 20) Followed up for 30 days post-op Slide 16 Patients Control groupOptimisation groupP - value Total number2019 Age (years) *67 NS Sex ratio (M : F)14 : 69 : 10NS Body mass index *2724NS ASA *22NS POSSUM score *3228NS * Values are median, NS (not significant) Slide 17 Surgical procedures OperationControl groupOptimisation group R/L hemicolectomy75 Sigmoid colectomy / Hartmanns Anterior resection / Subtotal colectomy912 Panproctocolectomy / Pouch formation22 AP resection20 ControlOptimisationP value POSSUM operative severity *1213NS Malignancy1215NS * Values are median, NS (not significant) Slide 18 Results 1: physiological function ControlOptimisationP value Time out of bed on day 1 (minutes) 81050.047* Duration of catheterisation (hours) 72470.002* Values are median No difference in: - POSSUM scoring - POSSUM scoring - Grip strength - Grip strength - Spirometry - Spirometry - Time to full mobilisation - Time to full mobilisation Slide 19 Results 2: psychological function No difference in: - Cognitive function scoring - Fatigue scoring - Pain scoring - Analgesic requirements Slide 20 Results 3: gut function p = 0.007 N = 20 19 Control Optimisation Group Duration of IV fluids (hours) Duration of IV Fluids Return of Gut Function N = 20 19 Control Optimisation Group Return of Gut Function (hours) p = 0.042 Slide 21 Results 4: length of stay Control Optimisation Length of stay (days) Percentage (%) p = 0.027 N = 20 19 Control Optimisation Group aLength of stay (days) Slide 22 Results 5: morbidity & mortality Control Optimisation P-value Complications 15 9 0.076 GP visits * 0 (0 - 1) 1 (0 - 1) 0.373 Readmissions 4 1 0.169 Deaths 0 1 0.299 * Values are median (interquartile range) Slide 23 so, it appears that: Optimisation decreases: - time to mobilisation. - duration of catheterisation. - dependency on intravenous fluids. - length of hospital stay. Shortened stay had no observed effect on: - morbidity. - need for readmission. - GP visits. - mortality. Slide 24 and that : Multimodal optimisation is safe & overall is superior to conventional care. This cannot be only because of epidural analgesia. ??? WHY Slide 25 Why? reduced cardiovascular & immunological stress reduced insulin resistance reduced post-operative pain reduced catecholamine / cortisol response avoidance fluid overload less use of blood products 1 shorter hospital stay early return to full activity preservation / early return of gut function 1. Kiran RP et al. Arch Surg. 2004 Jan;139(1):39-42. Slide 26 Optimisation package Pre-operative Per-operative Post-operative cf previous study : major excisional surgery / all pts had epidurals - Written pre-op information. - Pre-assessment by SpR / Anaesthetist. - Synbiotics. - No bowel prep. - Oral carbohydrate loading & 3h fast. - High inspired O 2 (80%). - Transverse incision. - No drains or post-op NGT. - Early fluid & diet reintroduction. - Structured mobilisation plan. - No opiate analgesics. Slide 27 Optimisation package Pre-operative Per-operative Post-operative cf previous study : major excisional surgery / all pts had epidurals - Written pre-op information. - Pre-assessment by SpR / Anaesthetist. - Synbiotics. - No bowel prep. - Oral carbohydrate loading & 3h fast. - High inspired O 2 (80%). - Transverse incision. - No drains or post-op NGT. - Early fluid & diet reintroduction. - Structured mobilisation plan. - No opiate analgesics. Slide 28 Meta-analysis: Early enteral feeding vs nil by mouth Lewis SJ et al. 2001 * * Slide 29 Early vs delayed nutrient intake Heyland et al Canadian practice guidelines, JPEN 2003 27;355 8 RCTs (level 2) 8 RCTs (level 2) Early EN associated with trend towards mortality Early EN associated with trend towards mortality (RR 0.52; 95% CI 0.25 1.08, p=.08) Early EN associated with trend towards infections Early EN associated with trend towards infections (RR 0.66; 95% CI 0.36 1.22, p=.19) Slide 30 The Enteral Nutrition Dilemma: >60% of patients fail to meet nutritional requirements. Vs. Gut should be used for feeding when possible. Slide 31 N P Woodcock et al. Nutrition 2001; 17: 1-12 Enteral vs Parenteral Nutrition: a pragmatic study Slide 32 Patients receiving less than 80% of target intake N P Woodcock et al. Nutrition 2001; 17: 1-12 Slide 33 Complications / causes of inadequate intake % incidence of complications N P Woodcock et al. Nutrition 2001; 17: 1-12 P < 0.001 p < 0.001 P = 0.02 p < 0.001 Slide 34 Overall mortality Slide 35 Summary EN is associated with a significantly higher incidence of non- septic morbidity and mortality than TPN EN is associated with a significantly higher incidence of inadequate nutritional intake compared to TPN There is no significant difference between EN and TPN in the incidence of septic morbidity Slide 36 Clinicians are poor are poor at assessing Intestinal function Inadequate gut function is a predictor of poor prognosis poor prognosis Slide 37 Tolerance of enteral nutrition: A prognostic indicator? NS P