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Colorectal Surgery Retrospective Analysis Colorectal Surgery Retrospective Analysis Presentation Transcript

  • COLORECTAL SURGERY RETROSPECTIVE ANALYSIS ENRIQUE MONCADA. Colo-proctology Unit Dept. of Surgery H. Meixoeiro- CHUVI XVII Colo-proctology Course. Baiona February 2009
  • POSTOPERATIVE STAY IN COLORECTAL SURGERY Europe USA F-T/ERAS
    • ARE WE DOING THE RIGHT THING?
    • IT IS POSSIBLE TO IMPROVE THE DATA STAY WITHOUT ADDING MORBIDITY?
    • DO WE HAVE TOOLS TO IMPROVE EFFICIENCY IN THE HANDLING OF OUR PATIENTS ?
      • Perioperative care in conventional surgery.
      • Evidence-based medicine.
      • Level of implementation of EBM ( evidence based medicine ) in daily practice.
  • PERIOPERATIVE CARE
    • Admittance 24-48 hours prior
    • Mecanical Colon Prep.
    • Preoperative fasting.
    • Vertical incisions.
    • Open access.
    • Postoperative fasting.
    • Late post-op mobilization.
    • Naso-gastric tube
    • Routine drains.
    • Urinary catheter 5 days.
    • Admittance on previous day
    • No MCP.
    • No fasting.
    • Horizontal / oblique incisions
    • Laparoscopic access.
    • No post-op fasting.
    • Early post-op mobilization.
    • No NGT
    • No routine drains.
    • Urinary catheter 1 day.
    CONVENTIONAL EBM
  • Mechanical preparation of the colon
    • Untouchable dogma.
    • Cornerstone of a safe surgery
  • Guenaga KKFG, Matos D, Wille-Jørgensen P Cochrane Database of Systematic Reviews 2009, Issue 1.
    • 4777 patients 2390 CP 2387NCP
    • Dehiscence 4.2% 3.7%
    • Dehiscence CR 2.9% 2.5%
    • Dehiscence LAR 10% 6.6%
    • Wound infection 9.6% 8.3%
  • Guenaga KKFG, Matos D, Wille-Jørgensen P Cochrane Database of Systematic Reviews 2009, Issue 1.
    • “ THERE IS NO STATISTICALLY SIGNIFICANT EVIDENCE THAT PATIENTS BENEFIT FROM MBP”
    • “ THE BELIEF THAT MBP IS NECESSARY BEFORE ELECTIVE COLORECTAL SURGERY SHOULD BE RECONSIDERED ”
  • MECHANICAL PREPARATION OF COLON Spain Roig JV Colorectal Dis 2008 Europe USA F-T/ERAS Kehlet JAmColSurg 2006
  • PREOPERATIVE FASTING
    • Liquid diet the day before. Absolute diet 8hrs. prior to surgery
    Hunger Anxiety Pre-op Stress Catecholamines Increased insulin resistance Post-op Hyperglycemia
  • EBM
    • The intake of carbohydrates the evening before and up to 2 hours before surgery, breaks the night fasting:
    • Postoperative stress, catabolism, endocrine-metabolic response, complications.
    Soop M et al. Br. J Surg 2004
  • VERTICAL INCISIONS
    • Used by the vast majority of surgeons .
    • Fast.
    • Facilitates the location of the stomata .
    • Facilitates a reopening .
  • HORIZONTAL INCISIONS
    • Less pain.
    • Less eviscerations and incisional hernia.
    • Less impairment of respiratory function.
    • Anatomically more physiological.
    Brown SR et al. Transverse verses midline incisions for abdominal surgery. Cochrane Database of Systematic Reviews 2005, Issue 4 .
  • Laparoscopic Access
    • Less pain.
    • Faster recovery of intestinal transit.
    • Less pulmonary morbidity.
    • Better postoperative quality of life.
    • Less postoperative hospital stay.
    Schwenk W et al. Short term benefits for laparoscopic colorectal Resection. Cochrane Database Syst Rev 2005
  • Laparoscopic colorectal surgery UK France Germany Italy Spain USA Kehlet el al. J Am Coll Surg .2006
  • Postoperative Fasting
    • Avoids vomiting due to postoperative ileus .
    • Protects the anastomosis.
    • Absolute diet 4-5 days .
  • Nutrition immediately postoperative
    • Nutrition 6 hours post surgery:
    • - The rate of wound infection.
    • - The rate of anastomosis dehiscence.
    • - Length of stay post-op.
    Lewis el al BMJ 2001
  • Postoperative Nutrition: introduction of liquids. UK France Germany Italy Spain USA F-T/ERAS Kehlet JAm Coll Surg 2006
  • Postoperative Nutrition: First solid food UK France Germany Italy Spain USA F-T/ERAS Kehlet. J Am Coll Surg 2006
  • Postoperative rest
    • - Deep Vein Trombosis ( DVT )
    • - Respiratory complications.
    • Delay on the recovery of the transit.
    • Increases Postoperative fatigue.
    • - Extends the postoperative hospital stay.
  • Postoperative movilization
    • Europe: 53% walk on the 3 rd day Post.Op.
    • USA: 85% the 3 rd day Post.Op.
    • F-T: 90 % Are up on the day of the intervention.
    Kehlet J Am Coll Surg 2006
  • NGT
    • T raditionaly NGT is employed for:
    • Reduction:
    • Postoperatorio ileus.
    • Risk of anastomotic dehiscence .
    • Prevents postoperative vomiting / nausea .
  • Cheatham et al. Ann.Surg 1995. Meta-analysis compares a selective routinary use of NGT on 6850 patients
    • Routine use:
    • significant discomfort.
    • Significant increase on pulmonary complications .
    • Does not increase anastomotic complications .
    • Extends the ileus.
    • Only 6% of the patients required NGT replacement.
    • Increments the length of stay Post Op.
  • NGT in Spain 1996 2006 Roig JV. Cir Esp. 2008
  • Prophylactic drains
    • Inadequate hemostasis.
    • Contamination.
    • Unsatisfactory Anastomosis.
    • Early detection of dehiscences or collections
    • “ Reassures” the surgeon.
  • Karliczec A et al. Drainage or non drainage in elective colorectal anastomosis: a systematic review and meta analysis. Colorectal Dis. 2006
    • 1140 patients.
    • There are no statistical differences in:
    • - Anastomotic dehiscence.
    • - Wound infection.
    • - Rates of readmission
    • - Systematic studies are still needed to evaluate the use of drains in anastomosis below the peritoneal reflection.
  • Drains in Spain Routinary Selective Roig JV. Cir Esp. 2008
  • Foley ( urine )catheter
    • 2/3 of patients with rectal resection suffer urinary dysfunction .
    • There was never any consensus on when the catheter must be withdrawn .
    • The average time of maintenance of the indwelling catheter is 5 days (3-10).
  • Benoist S . Optimal duration of urinary drainage after rectal resection: A randomized controlled trial. Surgery 1999
    • Compares catheterization 5 days vs. 1 day post-rectal surgery
    • A day of probing is recommended on the majority of/ most patients.
    • It is only recommended to prolong the catheter in RAB (< 5cm.), prostate patients and epidural catheter carriers .
  • PERIOPERATIVE CARE
    • Admission 24-48 hours before
    • MCP.
    • Preoperative fasting.
    • Vertical incisions
    • Open access .
    • Postoperative fasting.
    • Late post-op mobilization.
    • NGT.
    • Routine drains.
    • Prolonged urinary catheter
    • Admittance on previous day
    • No MCP.
    • No fasting.
    • Horizontal/oblique incisions
    • Laparoscopic access.
    • No post-op fasting.
    • Early post-op mobilization.
    • No NGT
    • No routine drains.
    • Shortened urinary catheter
    CONVENTIONAL EBM
  • Surgical practice evidence based Ubbink DT Br J Surg 2004
  • ¿MEDICINE BASED ON EVIDENCE?
  •  
  • Eminence-based medicine.
  • Medicine based on vehemence
  • Surgeons are questioning the veracity and accuracy of the publications : “one thing is what has been published and another……”
  • THE NEAR FUTURE
    • Like the Ambulatory Major Surgery (AMS) that at a time was considered a utopian occurrence, is now a reality.
    • The protocols of rapid postoperative recovery (FAST-TRACK) based on the best evidence will be a routine practice in a very near future.
    • Procedure Stay
    • Hernia 1,5-6hrs.
    • Cholecystectomy 80% < 24 hours
    • Colectomy 2-4 days
    • Complex colorectal surgery 3-5 days
    • Adrenalectomy 80% < 24 hours
    • Thyroid and parathyroid 80-90% AMS
    • Anti-Reflux Surgery 98% < 24 hours
    • Esophagectomy 7-8 days
    • Mastectomy 90% < 24 horas
    Kehet H, Wilmore D. Ann Surg 2008
  • Thank You