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Elective Colorectal Resection – How to Hasten the Recovery?

Elective Colorectal Resection – How to Hasten the Recovery?. Dr. Lily Ng RHTSK. Background. Elective colorectal resection is common operation in general Surgery

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Elective Colorectal Resection – How to Hasten the Recovery?

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  1. Elective Colorectal Resection – How to Hasten the Recovery? Dr. Lily Ng RHTSK

  2. Background • Elective colorectal resection is common 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

  3. 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

  4. Means to Hasten Recovery • Use of Perioperative Pain Control • Use of Tubes, Drains and Catheters • Timing of Feeding • Timing of Mobilization

  5. 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

  6. 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

  7. Results – Pain score Anaesthesiology Vol 83(4), Oct 1995, p757-765 P<0.01

  8. Results –Return of GI function and LOS Anaesthesiology Vol 83(4), Oct 1995, p757-765

  9. Conclusion Anaesthesiology Vol 83(4), Oct 1995, p757-765 • 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

  10. Means to Hasten Recovery • Use of Perioperative Pain Control • Use of Tubes, Drains and Catheters • Timing of Feeding • Timing of Mobilization

  11. NG Tube Decompression • Prophylactic nasogastric decompression after laparotomy was common • Underlying reasons: • ? Hasten return of bowel function • ? Reduce risk of aspiration thus pulmonary complications • ? Decrease patient discomfort by lessen abdominal distension • ? Protect anastomoses and prevent anastomotic leakage

  12. Prophylactic nasogastric decompression after abdominal surgery [Review] Nelson, R, et al The cochrane Database of Systematic Reviews The Cochrane collaboration Vol (4) 2005

  13. Results - Time to Flatus The Cochrane collaboration Vol (4) 2005

  14. Results – Complications Pulmonary Complication Anastomotic Leakage The Cochrane collaboration Vol (4) 2005

  15. Conclusion • Routine NG decompression in elective colonic surgery • Slower return of GI function • No significant difference in terms of pulmonary complication / anastomotic leakage • Routine NG decompression is not recommended The Cochrane collaboration Vol (4) 2005

  16. Means to Hasten Recovery • Use of Perioperative Anaesthesia and Analgesia • Use of Tubes, Drains and Catheters • Timing of Feeding • Timing of Mobilization

  17. Anastomotic Drainage • Prophylactic anastomotic drainage was commonly 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?

  18. Prophylactic anastomotic drainage for colorectal surgery [Review]Jesus, EC, et al Results DrainNo Drain95%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

  19. 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

  20. Means to Hasten Recovery • Use of Perioperative Anaesthesia and Analgesia • Use of Tubes, Drains and Catheters • Timing of Feeding • Timing of Mobilization

  21. 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

  22. 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

  23. 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

  24. Means to Hasten Recovery • Use of Perioperative Pain Control • Use of Tubes, Drains and Catheters • Timing of Feeding • Timing of Mobilization

  25. 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

  26. Early Oral Feeding After Colorectal Resection: A Randomized Controlled Study Carlo V. Feo, et al ANZ J. Surg. 2004; 74: 298-301

  27. 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

  28. Summary • Means to Hasten Recovery • Epidural analgesia provides good pain control • No routine use of nasogastric tube / anastomotic drainage • Routine urinary catheterization is not necessary despite use of epidural • Early enteral feeding is safe

  29. Fast Track Surgery • Multimodal rehabilitation program • Pre-operative patient education • Newer anaesthetic, analgesic and surgical techniques • Aggressive post-operative rehabilitation • Early enteral nutrition • Early mobilization • Minimal use of tubes, drains and catheters • Aim to shorten time to recovery

  30. A clinical pathway to accelerate recovery after colonic resectionLinda Basse, et al. • A prospective study to test for feasibility 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

  31. Ann Surg July 2000

  32. Results Return of GI Function Length of Hospital Stay Median LOS: 2 days 95% patient defecate within 48 hrs Ann Surg July 2000

  33. Conclusion • Multimodal rehabilitation program may significantly reduce • Post-op ileus • Post-op hospital stay Ann Surg July 2000

  34. Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection M. Gatt, et al BJS 2005; 92: 1354-1362

  35. Optimization Package BJS 2005; 92: 1354-1362

  36. 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

  37. Results Length of Hospital Stay Return of GI function P=0.042 P=0.027 BJS 2005; 92: 1354-1362

  38. Post-op Morbidity / Mortality BJS 2005; 92: 1354-1362

  39. Conclusion • Use of multimodal opitmization • Earlier return of GI function • Shorter length of hospital stay • No increase in post-op morbidity / mortality BJS 2005; 92: 1354-1362

  40. Summary • Revision of traditional surgical care programs, • Minimal use of tubes, drains, bladder catheter • Optimal pain relief with continuous thoracic epidural 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

  41. Our Experience at RHTSK • Objective: To develop a standardized treatment 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)

  42. Results – No. of Days (median) Day (Median)

  43. ~ The End ~

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