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Fast-track surgery

”Fast track” - kirurgi Jonas Nygren Kirurgkliniken Ersta Sjukhus Dagkirurgi i Sverige Örebro 11 maj, 2012. Henrik Kehlet 2004. arthroscop. op mastectomy parathyroid op. adrenalectomy cholecystectomy rectal prolapse fundoplication lap/vag hyst. hernia repair. Fast-track surgery.

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Fast-track surgery

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  1. ”Fast track” - kirurgiJonas NygrenKirurgklinikenErsta Sjukhus Dagkirurgi i SverigeÖrebro11 maj, 2012

  2. Henrik Kehlet 2004 arthroscop. opmastectomyparathyroid op.adrenalectomycholecystectomyrectal prolapsefundoplicationlap/vag hyst.hernia repair Fast-track surgery carotid endart.don. nephrectomypulm. resectionopen hysterectomyrad. prostatectomyhip replacement aortic aneurismcolonic resection ambulatory 1 – 2 days 2 – 3 days Kehlet and Wilmore Am J Surg 2002;183:630Kehlet and Dahl Lancet 2003;363:1921

  3. ERAS protocol results in accelerated recovery and shorter hospital stay Multimodal treatment ad modum Henrik Kehlet, Hvidovre, Danmark

  4. ERAS and clinical outcome ?Review of 6 RCTs (n=452) Hospital stay Complications Vardhan, Clin Nutr, 2010

  5. After H Kehlet 2004 Hospital stay after colonic surgery 10 global 8 Basse (2005) Basse (2004) Anderson (2003)DiFronzo (2003)Delaney (2003)Basse (2003)Stephen (2003)Smedh (2001)Di Fronzo (1999)Basse (2000)Kehlet (1999) Möiniche (1995)Liu (1995)Choi (1996)Bradshaw (1998) 6 global Basse (2005) Senagore (2003)Senagore (2002)Senagore (2001)Bardram (2000)Bardram (1995) 4 2 0 TraditionalOpen res Fast track Lap res Fast track Open res TraditionalLap res Early fast track Open res

  6. Fast-track • Lap Colonic resection • n=48 • 2 Complications • 1 Readmission * * * * * Patel G, Am J Surg, 2010, Levy BF, Dis Col Rect, 2009

  7. Modification of ERAS in lap surgery ? • RCT EDA vs Spinal vs PCA, n=91 • Lap colorectal surgery • LOS • EDA (3.7 d) longer than PCA and Spinal (2,8 and 2,7 d) • Spinal • Faster return of bowel function (vs EDA and PCA) • Earlier tolerance of food (vs EDA) • Levy, BJS, 2011

  8. ERAS and Lap colorectal resection • One center (North Bristol, UK), • n=606, 2004-2009 • Primaryanastomosis • ERAS formally after 2008 • Transversusabdominis plane (TAP) or rectussheath block • No EDA or PCA • KAD withdrawn in theatre • 46% dischargedwithin 3 days(Median LOS 4 days) • 2 same day, 70 within 24 hrs, • 116 within 48 hrs, 91 within 72 hrs • Readmission rates 4 %, • Gash KJ, Colorectal Dis, 2012

  9. Early removal of KAD during EDA ? • During thoracic epidural anesthesia • Removal of KAD in the morning after surgery • Or after removal of EDA • RCT, N=205 • No increased need for recatheterization • Transient increase in post-void residual volume (UL Scanning) • Zaouter, Acta Anasth Scand, 2012

  10. What are current practice in colorectal surgery • Previous quite recent surveys • Perioperative traditional care common • Very little adherence with ERAS pathways • Lassen K, BMJ, 2005 • Hanneman P, Acta Anaesth Scand, 2006 • Kehlet H, J Am Coll Surg, 2006 • Roig JV, Colorectal Dis, 2008 • Hausenberg T, Colorectal Dis, 2010

  11. Recent survey in UK, 275 members of ACPGBI (64% response rate) District or University Hospital;ERAS enthusiast Type of surgeon No differenceNo (169) Yes (106) Open (108) Lap (63) • No oral bowel prep. 63 65 64 65 • Preop carbohydrates 43 57* 40 56* • High O2 >80% 38 43 39 38 • No intraperitoneal drain 85 87 82 95* • No nasogastric drain 87 87 80 94* • Fasting <24h postop 86 91 84 94 • Eating day 1 postop 76 87* 71 90* Arsalani-Zadeh R,Int J Surg,2010

  12. 24 german hospitals with fast track rehabilitation • FTCII qualityassurance program group • Totally 2047 patients in data base • 748 patients, opencolonicresection • for cancer • Excellent compliance (70-80%) with ERAS pathway • 24% morbidity, 4% readmissions, 0.4% mortality • Fit for discharge usuallywithin 5 days • Median postop hospital stay9 days • LOS in traditionalcare after colonicsurgery 17 days in Germany • Decreasedreimbursementifdischargedbefore 6 days Braumann C, Dig Surg, 2009

  13. ERAS group / ERAS Society : Started in 2000 Hvidovre Stockholm Tromsö Edinburgh Maastricht Nottingham London Berlin Auckland Örebro Paris Clermont-Ferrand Lausanne Milano Zaragoza, Spain McGill, Montreal Duke UH, Durham, US ……… www.erassociety.org

  14. ERAS Peri-op fluid management Remifentanyl DVT prophylaxis No - premed Epidural Anaesthesia Pre-op councelling No bowel prep Early mobilisation CHO - loading/ no fasting Perioperative Nutrition Incisions Bairhugger No NG tubes Prevention of ileus/ prokinetics Oral analgesics/ NSAID’s Early removal of catheters/drains

  15. New elements should be added to the protocol when there is new evidenceSmoking • RCT n = 117 (Blinded outcome assessment) • Hernia, Cholecystectomy, Hip/knee replacement • 4 weeks before surgery • Postoperative complications • 41% vs. 21% • Smoking abstinent after 1 yr • 33% vs. 15% Lindström D. Ann Surg, 2008. Anaesthesia, 2009

  16. ERAS database Colon Colon

  17. Quality assessmentAn art that requires a nurse ? • Qualityassessment in 108 European medical centers • In 77% of hospitals, complications are tracked by residents or junior staff At the department of Surgery, Zurich University Hospital • Registration by residents supervised by studynurse for 3 months • 80% (164/206) of the complicationswere not recorded by residents • Comorbiditiesincorrectlyassessed in 20% • After a teachingcourse, the auditcontinued for 3 months • 79% (275/347) of the complicationswere not recorded by residents • Conclusion • Recordingoutcome by surgical residents are unreliabledespitetraining Dindo D, Ann Surg, 2010

  18. 2010 Pre/Intra ComplianceColon surgery

  19. Compliance and clinical outcomeERAS progress at Ersta Hospital

  20. 2002-2004 (n = 464) Implementation Audit Outcomes Compliance 2005-2007 (n=489) Reinforcement Audit Outcomes Compliance 953 consecutive patients at Ersta HospitalMajor surgery for colorectal cancer • Between time periods 2002-2004 and 2005-2007 • Similar patient characteristics • Similar surgical procedures • 40-50% pelvic surgery Gustafsson, Arch Surg, 2011

  21. Results Adherence to pre- and perioperative ERAS interventions • Preadm info • Preop CHO • 0-bowel prep • 0-premed. • Aktive heating • EDA • i.v. fluids < 3000 ml d0 • oral fluids > 0 ml d0 • i.v kcal < 200 kcal d0 • oral kcal > 0 ml d0 • Mobil >2h d0 • Nutr.supplements d0 % 70.6% 43.3% p<0.0001 Gustafsson U, Arch Surg, 2011

  22. Results – multivariate analysis * * *P<0.05 Gustafsson U, Arch Surg, 2011

  23. Compliance and outcomesMultivariate analysis of the impact of individual ERAS variables on outcome • Preoperative oral carbohydrate loading • Perioperative fluid volume • Significant, independent predictors for improved clinical outcome Gustafsson U, Arch Surg, 2011

  24. Multivariate analysis of the impact of individual ERAS variables on outcome • Preoperative oral carbohydrate loading • Significantly reduced risk for symptoms • PONV, pain and dizzieness • 450 ml less fluid during surgery • Preoperative bowel preparation • 1000 ml more fluid during surgery (Pasta not recommended ) Gustafsson U, Arch Surg, 2011

  25. Multivariate analysis of the impact of individual ERAS variables on outcome • The probability of complications • Increased with 32% for each litre of additional fluids given during surgery • (p<0.001) Gustafsson U, Arch Surg, 2011

  26. Varadhan K, Proc Nutr Soc, 2010 Standard vs. Liberal vs. Restricted ???

  27. Meta analysis based on amount of fluid given <1.75 l / 24h >2.75 l / 24h Varadhan K, Proc Nutr Soc, 2010

  28. Varadhan K, Proc Nutr Soc, 2010 59% reduced risk for complications 3.4 days reduction in hospital stay

  29. Conclusion • Increased adherence to ERAS-protocol • 25% reduced risk for complications • 50% reduced risk for symptoms delaying discharge • Reduced LOS • Dose-response • Two independent variables for improved outcome • Preoperative carbohydrate loading • Perioperative fluid volume

  30. Summary • To maintain high compliance with ERAS • ERAS data base • Dedicated ERAS coordinator(s) • Continuous • audit • education • motivation • Relaunch efforts • Clinical trials

  31. Acknowledgements • Ersta Hospital ERAS group • Ulf Gustafsson, Anders Thorell • Mattias Soop, Jonatan Hausel, Olle Ljungqvist • ERAS coordinators • Ersta Research Unit • Surgeons • Anaesthesiologists • Nurses and other staff

  32. Enhanced Recovery After Surgery improve outcomes

  33. PERIOPERATIVE Care Eminence or Evidence ? Lassen K et al, BMJ, 2005

  34. Disclosures • None

  35. Similar patient characteristics 953 consecutive patients. Major surgery for colorectal cancer Gustafsson U, Arch Surg, 2011

  36. Similar surgical procedures 953 consecutive patients. Major surgery for colorectal cancer Gustafsson U, Arch Surg, 2011

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