Colorectal Surgery Retrospective Analysis

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Colorectal Surgery Retrospective Analysis

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

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