Simposium Madrid 051108

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Simposium Madrid 051108

  1. 1. www.ftsurgery.comwww.ftsurgery.com Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
  2. 2. www.ftsurgery.comwww.ftsurgery.com Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
  3. 3. www.ftsurgery.comwww.ftsurgery.com • Optimize the perioperative treatment of the patients with the aim to: reduce morbidity improve recovery after surgery reduce hospital stay reduce health costs Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
  4. 4. www.ftsurgery.comwww.ftsurgery.com Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
  5. 5. www.ftsurgery.comwww.ftsurgery.com Preoperative Intraoperative Postoperative • What changes supposes the management of patients? Information and consent. Adequate nutrition No bowel preparation Beverage intake rich on Carbohydrates pre-op. Avoid drains Avoid NGT Use of de laparoscopic techniques Use of transverse Incisions Epidural Analgesia (Open Surgery). Avoid Hypothermia Use high concentrations of Oxygen Controlled Fluid therapy (“Goal-directed”). CardioQ Early mobilization (same afternoon) Energy intake (same afternoon) Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
  6. 6. www.ftsurgery.comwww.ftsurgery.com • What changes supposes the management of patients? Surgeon Anesthesiologist Nurse Information and consent. Adequate nutrition No bowel preparation Beverage intake rich on Carbohydrates pre-op. Avoid drains Avoid NGT Use of de laparoscopic techniques Use of transverse Incisions Epidural Analgesia (Open Surgery). Avoid Hypothermia Use high concentrations of Oxygen Controlled Fluid therapy (“Goal-directed”). CardioQ Early mobilization (same afternoon) Energy intake (same afternoon) Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
  7. 7. www.ftsurgery.comwww.ftsurgery.com Colorectal Dis. 2008 May 3 "Fast-track"-colonic surgery in Austria and Germany - results from the survey on patterns in current peri-operative practice. T Hasenberg, M Keese, F Längle, B Reibenwein, K Schindler, A Herold, G Beck, S Post, K W Jauch, C Spies, W Schwenk, E Shang Conclusions: Although there is an evident benefit of fast-track management, the survey shows that they are not yet widely used as a routine. Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
  8. 8. www.ftsurgery.comwww.ftsurgery.com • Spanish multicenter group of Fast-Track Objectives: What are our results for traditional surgery? Where are the difficulties of implementing a program of Fast-Track? Evidence of a multi-center group using the same protocol for the patients themselves. Are the results extrapolated to any other centers? Permanent audit of the multi-center group results. To collaborate with other national or international centers. To offer the best available information on fast-track to whom it may concern. Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
  9. 9. www.ftsurgery.comwww.ftsurgery.com MULTI-CENTER STUDY FOR THE INTRODUCTION OF A PROGRAM ON ENHANCED REHABILITATION IN COLORECTAL SURGERY: – Inclusion Criteria: • Patients older than 18 years, scheduled for surgery intervention for right colon, left and / or rectum due to a malignant or benign cause. – Exclusion Criteria: • Emergency surgery. • ASA IV • Patients in need of colostomy or ileostomy. • Diabetic patients • Patients who have not signed informed consent. Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
  10. 10. www.ftsurgery.comwww.ftsurgery.com MULTI-CENTER STUDY FOR THE INTRODUCTION OF A PROGRAM ON ENHANCED REHABILITATION IN COLORECTAL SURGERY: Ethical Aspects: Taking into account that each point of “Fast Track” is a form of treatment fully accepted and supported by the best available scientific evidence. It was not considered necessary by ethics committees and clinical trials to request the approval . However, patients are individually informed orally and in writing on the early rehabilitation program, expecting them to cooperate. Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
  11. 11. www.ftsurgery.comwww.ftsurgery.com Protocol PRE-OPERATIVE - Verbal and written information about the early rehabilitation program and obtain signature for the informed consent. Evaluation of quality of life baseline : SF-36, EuroQoL. - Malnourished patients (>10% weight in < than three months), hyperproteine supplement twice daily, at least the whole week before surgery. DAY -1:  Non preparation of the colon. Two Enemas Casen ® at 20.00 hr.  Normal intake in the morning. Throughout the afternoon, 4 Nutricia Preop ® bricks of 800 ml (100 mg of carbohydrates).  During the afternoon, fluid intake on demand.  A drink rich in carbohydrates at 20.00 hr.  Not to use pre-medication.  Antibiotic prophylaxis as usual.  Prophylaxis of pulmonary embolism as usual. Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
  12. 12. www.ftsurgery.comwww.ftsurgery.com Protocol DAY 0:  Two hours before surgery, intake of drink rich in carbohydrates (Nutricia Preop ®, 2 bricks, 400ml, 50g CHO).  Two hours before Casen ® Enema.  Not to use pre-medication.  Routine Vital Signs surveillance IN THE OPERATING ROOM Surgeons:  Not to use drains.  Avoid gastric nasal tube.  Attempt Laparoscopic intervention. Transverse incision in open surgery.  Infiltrate wounds with Bupivacaine 0,25 % (20 ml). Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
  13. 13. www.ftsurgery.comwww.ftsurgery.com (*)Grocott MP, Mythen MG, Gan TJ. Anesth Analg. 2005;100:1093–1106. (*)Bundgaard-Nielsen M, Holte K, Secher NH, et al. Acta Anaesthesiol Scand. 2007;51:331– 340. Protocol Anesthesiologists: • Epidural analgesia. At T9-T10 Bupivacaine 0,25/0,50% with Sulfentanyl/Fentanyl.  Maintenance: Oxygen/air with FiO2>80%.  Do not use morphine  Analgesia with Paracetamol IV in the operating room, Diclofenac IV, unless contraindication or alteration of the renal function.  Anti-emetics: Ondansetron IV (Zofran) 4 mg. Do not use Dexamethason.(If necessary use Droperidol 0.625 mg or Haloperidol 1 mg).  Monitoring: Routine + esophageal Doppler. Central catheter / arterial catheter if necessary *Goal directed fluid therapy: Optimization according to ejection volume (Stroke Volume) with the esophageal Doppler probe (Reset volume bolus of coloid 250cc depending on the drop in the cardiac output measured by the esophageal Doppler). Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
  14. 14. www.ftsurgery.comwww.ftsurgery.com You'll see, something will happen today day ... Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
  15. 15. www.ftsurgery.comwww.ftsurgery.com Protocolo Postoperative :  High flow oxygen mask for 2 hours. After nasal mask to keep saturation>95%.  In the afternoon mobilize the patient to arm chair (min. 2 hrs)  From 18.00 hr, liquid diet (800-1000cc) + 2 units rich in protein and calories.  Minimum diuresis (500cc first 24 hrs).  Analgesia with 1 gr Paracetamol / 6 hrs + Epidural catheter.  Gluco-saline maintenance. Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA DAY 1: -Liquid diet (min. 2 liters) + 3 energy preps. -Mobilization with armchair 6 hrs. day. -Discontinue fluids IV if tolerated. IV access heparinized. -Maintain epidural pump (if any). -Paracetamol 1 gr / 6 hrs. -Lactulose 1 pack / 12 hrs. -Evaluate criteria for discharge.
  16. 16. www.ftsurgery.comwww.ftsurgery.com Protocolo Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA DAY +2:  Suspend epidural catheter. Start with NSAIDs.  Soft / normal diet.  Mobilization on demand.  Remove bladder catheter.  Evaluate criteria for discharge. DAY +3: - Revision of the patient's general state. - Evaluate criteria for discharge. - Evaluate criteria for discharge and take decision over it. DAY +4 and the following: Similar to Day +3.
  17. 17. www.ftsurgery.comwww.ftsurgery.com • Discharge criteria Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA •Only oral analgesia •Mobilization until preoperative level •Tolerates solid nutrition •Flatulation •Absence of nausea •Wants to go home
  18. 18. www.ftsurgery.comwww.ftsurgery.com
  19. 19. www.ftsurgery.comwww.ftsurgery.com
  20. 20. www.ftsurgery.comwww.ftsurgery.com
  21. 21. www.ftsurgery.comwww.ftsurgery.com
  22. 22. www.ftsurgery.comwww.ftsurgery.com Hospital Do Meixoeiro. Vigo Hospital Fundación de Calahorra Hospital Clínico Universitario. Zaragoza Hospital Mutua de Terrassa. Hospital General Universitario de Valencia Hospital Universitario de Elche Hospital Son Llátzer. Palma de Mallorca Hospital Clínico San Carlos de Madrid Hospital Gregorio Marañón. Madrid Hospital La Paz. Madrid Complejo Hospitalario La Mancha-Centro (A. de San Juan) 1st of April 1st of June Participants Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
  23. 23. www.ftsurgery.comwww.ftsurgery.com Participants Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA 1st of April 5th of November Retrospective study (data Introduction) 0 2 4 6 8 10 12 Junio Julio Agosto Septiembre Octubre 0 2 4 6 8 10 12 Junio Julio Agosto Septiembre Octubre Prospective study (prepared for the study) June July August September October June July August September October
  24. 24. www.ftsurgery.comwww.ftsurgery.com Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA Multi-center study to introduce a program of enhanced rehabilitation in colorectal surgery Preliminary results Average age 69,6 years ± Std. Dev. 13,2 (43 - 89 years). Male 61%. 49 10 45 78 0 5 10 15 20 25 30 35 40 1 Técnica Quirúrgica R.Hemicolectomy L.Hemicolectomy. RAB Sigmoidectomy Open Surgery Minimal Invasive Surgery 69% 31% Way of ApproachSurgical Technique Retrospective study (182 patients)
  25. 25. www.ftsurgery.comwww.ftsurgery.com 0 2 4 6 8 10 12 14 16 Wound Infection Hemorrhage + Transfusion Exitus Íleo Undone Anastomosis Serie1 Retrospective study. Initial results (182 pat.) Complications Postoperative TOTAL: 24,82% Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA Mean Stay: 12,1 days ± Std. Dev. 13,731 (4-78 days)
  26. 26. www.ftsurgery.comwww.ftsurgery.com Retrospective study Initial results (64 pat.) Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA Design of the study: Data is analyzed on the principle of “intention to treat” 1. Meets Inclusion Criteria 2. Doesn’t meet Exclusion Criteria STUDY PATIENT Objectives: 1. Success of the Program 2. Satisfaction of the Patient 3. Complications 4. Mortality 5. Re-operated 6. Hospital stay 7. Re-admission 8. Total length of stay Pre-operatoria information yes / no Preparation intestine yes / no Pre-surgery drink the night before yes / no Sedation yes / no Morning drink yes / no Pre-medication yes / no Epidural anaesthesia yes / no High flow oxygen yes / no Oesophageal Doppler yes / no Thermal blanket yes / no Nasal gastric tube yes / no Drains yes / no Early mobilization yes / no Early oral intake (High calorie drinks) yes / no
  27. 27. www.ftsurgery.comwww.ftsurgery.com Retrospective study. Initial results (64 pat.) (*)Implementation of a Fast-Track Perioperative Care Program: What Are the Difficulties? .Sebastiaan W. Polle, Jan Wind, Jan W. Fuhring, Jan Hofland, Dirk J. Gouma, Willem A. Bemelman. Dig Surg 2007;24:441–449 Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA Pre-operative information 100% 87% Preparation of the intestine 95% 100% Pre-surgery drink the night before 95% 83% Sedation 87% 40% Morning drink 75% 30% Pre-medication 80% 70% Epidural anaesthesia 50% 71% High flow oxygen 70% 67% Oesophageal Doppler 72% Termal blanket 75% 100% Nasal gastric tube 72% Drains 72% Early mobilization 80% 40% Early oral intake ( high calorie drinks ) 56% 13% Mean Age 63,4 years ± Std. Dev. 10,2 (38-89 years). Male 60%. Degree of complianceDegree of compliance 77.1%77.1% 63%63%
  28. 28. www.ftsurgery.comwww.ftsurgery.com Surgical Technique Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA 0 5 10 15 20 25 30 35 40 45 50 % H.Right H.Left A.R. Serie1 44% 47% 9% Open Laparascopic Conversion Open Surgery Minimal Invasive Surgery 69% 31% 49 10 45 78 0 10 20 30 40 1 Surgical Tecnique Right Hemicolect omy Lef t Hemicolect omy RAB Sigmoidectomy Retrospective Retrospective study. Initial results (64 pat.)
  29. 29. www.ftsurgery.comwww.ftsurgery.com Complications Post-operative TOTAL: 14,52% Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZARetrospective study. Initial results (64 pat.) 0 2 4 6 8 10 12 14 16 % Wound infection Exitus Ileo Wound leakage others Serie1 0 2 4 6 8 10 12 14 16 Infección de Herida Hemorragia + Transfusión Exitus Íleo Dehiscencia Anastomosis Serie1
  30. 30. www.ftsurgery.comwww.ftsurgery.com MEAN Length of stay: 5,43 days (3-18 days) Readmission: 3/64 (4.7%) Mean LOS (including readmission): 6,03 (3-37) Estudio Prospectivo. Resultados iniciales (64 pac.) Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA Post Operative Stay 0 20 40 60 80 100 120 3 4 5 6 7 8 9 10 11 12 Days post operative %
  31. 31. www.ftsurgery.comwww.ftsurgery.com Medical complications: Nausea. Vomiting. Ileus… Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA 0 2 4 6 8 10 12 14 16 18 20 % Medical Problems Doesn't want to Traditional Staff Social Problems
  32. 32. www.ftsurgery.comwww.ftsurgery.com Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA Success Program Satisfaction Patient. Complications Mortality Recovery Hospital Stay Re-admission Total Length Stay Difficult to Organize and to establish Difficulty to obtain all parameters. We do not have an analysis yet Seems to decrease significantly Similar Similar Seems to be significantly lower <5% 6 days. Seems significantly lower Retrospective study. Initial results (64 pat.)
  33. 33. www.ftsurgery.comwww.ftsurgery.com

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