The Fast Track Concept in Colo-rectal Surgery A. Tuchmann, P. Razek, C. Kienbacher, P. Patri, K. Pinnisch, Hospital Floridsdorf, Vienna, Austria SMZ Floridsdorf,

The Fast Track Concept in Colo-rectal Surgery

A. Tuchmann, P. Razek, C. Kienbacher, P. Patri, K. Pinnisch,

Hospital Floridsdorf, Vienna, Austria

SMZ Floridsdorf, Vienna, Austria

What is Fast Track Surgery?

synonyms: - accelerated recovery program

- ERAS: enhanced recovery after surgery

Prof Henrik Khelet, Kopenhagen, DK; 1989

Definition: a concept for acceleration of postoperative convalescence by a multimodal rehabilitation program

accelerated convalescence

reduction of overall complications

shorter hospital stay

increased patient comfort

optimal pain relief (EDC)

perioperative fluid restriction

early enteral nutrition

early postoperative mobilization

minimal use of tubes, drains, and catheters

reduce:

stress response

organ dysfunction

Modified W. Schwenk und J.M. Müller: Was ist "Fast-track"-Chirurgie?

Deutsche Medizinische Wochenschrift 2005; 130 (10): 536-540

Pre- and perioperative period• oral and written information about the surgery and postoperative procedure by attending surgeon in our outpatient clinic

• information about epidural catheter (EDC) and epidural analgesia by anaesthesiologist

• admission one day prior to surgery

• preoperative oral bowel preparation (Macrogol 3350), oral intake of clear fluids until 2 hours preoperative

• EDC placement in operating theatre

• postoperative mobilization ~ 5 hrs. after surgery

• free oral intake of fluids; yogurt or 2 protein drinks

• opioids and local anaesthetics through EDC

Postoperative period

day 1: continuous pain management per EDC

removal of urinary bladder catheter

mobilization ≥ 8 hrs

mashed food

metamizole or paracetamole to relieve pain

day 2: normal oral intake

full mobilization

removal of EDC

NSAIDs orally on demand

day 3-5: planned discharge

day 8: checkup in the outpatient clinic, information on histological findings

Patient data

patients conventional care fast trackn 167 142

age 66,6 a (33-91) 65,4 a (36-83)m/f 84 (50%) / 83 (50%) 79 (56%) / 63 (44%)

period 01/2002 - 12/2003 02/2004 - 10/2005

ASA-criteria

0

10

20

30

40

50

60

70

80

90

1 2 3 4

n

conventional care

fast track

Diagnoses

others

8.5%

divitis

24% carcinoma

59%

polyp

8.5%

diagnosis conventional care fast trackcarcinoma 99 68 rectum 28 24 colon 71 44polyp 13 15diverticulitis 40 55bowel reconstruction 10 3bleeding diverticulitis 1M. Crohn 2colitis 2

others

3%

divitis

39%

carcinoma

48%

polyp

10%

conv.care fast-track

Operation technique

open

11%

lap.

89%

conv.care fast-track

lap.

43%

open

57%

diagnosis open lap open lap

total 95 72 16 126carcinoma 73 26 13 55 rectum 20 8 1 23 colon 53 18 12 32polyp 3 10 15diverticulitis 7 33 3 52bowel reconstruction 8 2 3M. Crohn 2 1colitis 2bleeding diverticulitis 1EDC 7 46

conventional care fast track

Results

1

21

19

25

17

11

9

65

2

54

1

3

1 11 1 1 1

6

9

1211

10

14

17

14

78

5

3

1

7

5

1

4

0

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21days

n

fast-track

conventional care

conventional care fast track

postoperative stay 12 (1-97) 6 (2-48)first defecation (days) 3 (1-8) 1 (1-5)oral feeding (days) 4 (1-20) 1 (1-8)

postop. stay 7

66%

Major complications

major complications conventional care fast tracktotal 23 (13.7%) 12 (8.4%)suture line insufficiency 16 (9%) 8 (5%) carcinoma (rectum) 8 5 carcinoma (colon) 4 2 diverticulitis 3 1 bowel reconstruction 1peritonitis 4 3 bowel lesion 1 1 ischemia of colon 2 abscess 1 unknown origin 2intraperitoneal hemorrhage 2 1

therapy conventional care (open/lap) fast track (open/lap)

Hartmann procedure 6 (6/0) 6 (5/1)protective stoma 5 (4/1) 4 (1/3)removal of hemorrhage 2 (1/1) 1 (0/1)splenectomy 1 (1/0)new anastomosis 1 (0/1)drainage 4 (3/1)conservative treatment 2 1

Treatment of major complications

Minor complications

surgical n reoperation n reoperationtotal 24 (14%) 6 12 (8%) 4abscess (subcutaneous) 18 2 7wound rupture (subcutaneous) 1 1 2 2nerve lesion 2 2 1hematoma (subcutaneous) 1 1 1 1enhanced drainage 1 1stenosis (ileostoma) 1 1

general n reoperation n reoperationtotal 50 (30%) 6 (4%)urinary tract infection 13 2pneumonia 13 2myocardial infarction 1bowel paralysis 8 1heart insufficiency 13pulmonary embolism 2colitis due to antibiotics 1

conventional care fast track

Readmissions (Fast-Track)

diagnosis n therapywound rupture 3 revisionperineal abscess 1 incisionlocale peritonitis 1 relaparascopygastrointestinal complaints 5 conservative treatment

total 10 (7%)

Mortality

conventional care fast tracktotal 11 (6,6%) 3 (2,11%)rectum 4 (2,4%) 1 (4,1%)colon 7 (4,2%) 2 (1,7%) suture line insufficiency 4 1 bowel lesion 1 1 peritonitis 1 1 pneumonia 2 heart failure 2 pulmonary embolism 1

A view at surgical tradition and suspected disadvantages

no bowel cleansing……………..anastomotic failure

early oral feeding………………..vomiting / aspiration / pneumonia

anastomotic failure

no drainage……………………….retention, insufficiency

no parenteral fluids………………thrombosis, renal failure

enforced mobilization……………fatigue, exhaustion

Fast track and open surgery:complications

anastomotic failure 1abscess (subcutaneous) 1bowel paralysis 1myocardial infarction 1

mortality 0

total open surgeries: n = 16

total complications: n = 4

Summary IThe fast track concept is

1. feasible at

- Hospital Floridsdorf (hospital of the community of Vienna)

- with non selected patients undergoing

- colorectal surgery (open / lap.)

2. advantages:

- reduction of general complications

- accelerated convalescence

- shorter hospital stay

- patient satisfaction

Summary II

3. unchanged:

- local complications

4. caution:

- readmissions

5. question and hope:

- reduction of costs

- less immunosuppression

- better oncologic results

SMZ Floridsdorf, Vienna, Austria