elective colorectal resection – how to hasten the recovery? dr. lily ng rhtsk
TRANSCRIPT
Elective Colorectal Resection – How to Hasten the Recovery?
Dr. Lily NgRHTSK
Background Elective colorectal resection is comm
on operation in general Surgery Laparoscopic / Laparoscopic-assisted
resection was known to be associated with a faster recovery by reducing pain and post-op ileus
Means to hasten recovery in open resection
Conventional Management No standard protocol Wide variations in
Use of Peri-operative Pain Control Use of Tubes, Drains and Catheters Timing of Feeding Timing of Mobilization
Depends on attending anaesthetist, surgeon, physiotherapist and nursing staff
Means to Hasten Recovery
Use of Perioperative Pain Control Use of Tubes, Drains and Catheters Timing of Feeding Timing of Mobilization
Peri-operative Pain Control Wide variation
Systemic opioid e.g. PCA Epidural anaesthesia
Opioid LA Opioid – LA mixture
Best if provide best pain control, without increasing undesirable side effects or post-op ileus
Effects of Peri-operative Analgesic Technique on Rate of Recovery after Colon Surgery
Liu, Spencer S. MD, et al.Anaesthesiology Vol 83(4), Oct 1995, p757-765
Results – Pain score
P<0.01
Anaesthesiology Vol 83(4), Oct 1995, p757-765
Results – Return of GI function and LOS
Anaesthesiology Vol 83(4), Oct 1995, p757-765
Conclusion
Use of epidural analgesia with bupivacaine or bupivacaine and morphine: Best balance of analgesia and side effects Faster recovery of GI function Shorter time to fulfill discharge criteria
Anaesthesiology Vol 83(4), Oct 1995, p757-765
Means to Hasten Recovery
Use of Perioperative Pain Control Use of Tubes, Drains and Catheters Timing of Feeding Timing of Mobilization
NG Tube Decompression Prophylactic nasogastric decompression aft
er laparotomy was common Underlying reasons:
? Hasten return of bowel function ? Reduce risk of aspiration thus pulmonary com
plications ? Decrease patient discomfort by lessen abdomi
nal distension ? Protect anastomoses and prevent anastomoti
c leakage
Prophylactic nasogastric decompression after abdominal s
urgery [Review]
Nelson, R, et alThe cochrane Database of Systematic Reviews
The Cochrane collaboration Vol (4) 2005
Results - Time to Flatus
The Cochrane collaboration Vol (4) 2005
Results – Complications
The Cochrane collaboration Vol (4) 2005
Pulmonary Complication
Anastomotic Leakage
Conclusion
Routine NG decompression in elective colonic surgery Slower return of GI function No significant difference in terms of pulm
onary complication / anastomotic leakage
Routine NG decompression is not recommended
The Cochrane collaboration Vol (4) 2005
Means to Hasten Recovery
Use of Perioperative Anaesthesia and Analgesia
Use of Tubes, Drains and Catheters Timing of Feeding Timing of Mobilization
Anastomotic Drainage Prophylactic anastomotic drainage was co
mmonly used worldwide Intention to:
Prevent accumulation of fluids in pelvic or peritoneal cavity
Permit early detection of anastomotic dehiscence
Treat or ?prevent anastomotic dehiscence
Can it really improve the outcome?
Prophylactic anastomotic drainage for colorectal surgery [Review] Jesus, EC, et al
ResultsDrain No Drain 95%CI
Mortality 3% 4% 0.39-1.31 Anastomotic dehiscence
Clinical 2% 1% 0.61-3.95 Radiological 3% 4% 0.42-1.61
Wound infection 5% 5% 0.60-1.76 Re-intervention 6% 5% 0.73-2.05 Extra-abdominal Cx 7% 6% 0.66-1.85
The Cochrane Collaboration Vol (4) 2005
Conclusion
No evidence that prophylactic anastomotic drainage in colorectal surgery can decrease mortality or other post-op complications
Prophylactic anastomotic drainage is not recommended
The Cochrane Collaboration Vol (4) 2005
Means to Hasten Recovery
Use of Perioperative Anaesthesia and Analgesia
Use of Tubes, Drains and Catheters Timing of Feeding Timing of Mobilization
Urinary Catheterization To prevent post-op urinary retention
esp. those with epidural anaelgesia Prolong catheterization increase risk
of UTI Optimal duration is unknown Common practice: catheter was kept
at least until epidural analgesia was taken off
Is urinary Drainage Necessary During Continuous Epidural Analgesia After Colonic Resection ? Linda Basse, et al
Patients were put on urinary drainage for 24 hours and epidural analgesia for 48 hours
Results Urinary retention 9% (CI 2%-16%)
Urinary tract infection 4% Voiding complaint at D30 0% (CI 0%-3.6%)
Regional Anesthesia and Pain Medicine Vol 25 No 5, 2000; p498-501
Conclusion
Routine urinary bladder catheterization is not required despite ongoing continuous thoracic epidural analgesia
Regional Anesthesia and Pain Medicine Vol 25 No 5, 2000; p498-501
Means to Hasten Recovery
Use of Perioperative Pain Control Use of Tubes, Drains and Catheters Timing of Feeding Timing of Mobilization
Post-op Enteral Feeding No consensus in the timing of
feeding Two schools of thoughts
NG catheter and fasting until passage of flatus,
No NG tube and allow oral intake soon after operation
Early Oral Feeding After Colorectal Resection: A Randomized Controlled Study Carlo V. Feo, et al
ANZ J. Surg. 2004; 74: 298-301
Conclusion
Patients undergoing elective colorectal resection can be started on oral feeding on the first post-op day
Early post-op oral feeding was safe without increase in post-op complications
ANZ J. Surg. 2004; 74: 298-301
Summary
Means to Hasten Recovery Epidural analgesia provides good pain co
ntrol No routine use of nasogastric tube / anas
tomotic drainage Routine urinary catheterization is not nec
essary despite use of epidural Early enteral feeding is safe
Fast Track Surgery Multimodal rehabilitation program
Pre-operative patient education Newer anaesthetic, analgesic and surgica
l techniques Aggressive post-operative rehabilitation
Early enteral nutrition Early mobilization Minimal use of tubes, drains and catheters
Aim to shorten time to recovery
A clinical pathway to accelerate recovery after colonic resection Linda Basse, et al. A prospective study to test for feasibili
ty of a 48-hour postoperative stay program after colonic resection
Well-defined post-op care program
Continuous thoracic epidural analgesia Enforced early mobilization Early enteral nutrition Planned 48-hour post-op hospital stay
Ann Surg July 2000
Ann Surg July 2000
Results
Ann Surg July 2000
Return of GI Function Length of Hospital Stay
95% patient defecate within 48 hrs
Median LOS: 2 days
Conclusion
Multimodal rehabilitation program may significantly reduce Post-op ileus Post-op hospital stay
Ann Surg July 2000
Randomized clinical trial of multimodal optimization of surgical c
are in patients undergoing
major colonic resection
M. Gatt, et alBJS 2005; 92: 1354-1362
Optimization Package
BJS 2005; 92: 1354-1362
Outcome Measures Physiological Function Psychological Function
Pain Score Gut Function
Time to tolerate diet Clinical Outcome
Length of hospital Stay Complications and death Need for readmission
BJS 2005; 92: 1354-1362
Results
P=0.042
BJS 2005; 92: 1354-1362
Return of GI function
P=0.027
Length of Hospital Stay
Post-op Morbidity / Mortality
BJS 2005; 92: 1354-1362
Conclusion
Use of multimodal opitmization Earlier return of GI function Shorter length of hospital stay No increase in post-op morbidity / mortal
ity
BJS 2005; 92: 1354-1362
Summary Revision of traditional surgical care program
s, Minimal use of tubes, drains, bladder catheter Optimal pain relief with continuous thoracic epi
dural analgesic with LA and opioids, Early enteral nutrition Enforced mobilzation
may enhance recovery after elective colonic resection.
In future, large randomized or multi-center studies, using identical protocols should be conducted
Our Experience at RHTSK Objective: To develop a standardized treat
ment protocol (clinical pathway) in managing patients who undergo elective colorectal resection
All patients undergoing elective colorectal resection with anastomosis during Jun 2005 to Aug 2005 (total 13 patients) were compared with those during Sept 2003 to Aug 2004 (total 37 patients)
Results – No. of Days (median)
0 1 2 3 4 5 6 7 8 9
Epidural Catheter
Urinary Catheter
N-G tube
Sips of Water
Fluid Diet
Normal Diet
Sitting out
Walking Exercise
Post-op length of stay
Day (Median)
~ The End ~