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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

Elective Colorectal Resection – How to Hasten the Recovery?

Dr. Lily Ng

RHTSK


Background
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


Conventional management
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


Means to hasten recovery
Means to Hasten Recovery

  • Use of Perioperative Pain Control

  • Use of Tubes, Drains and Catheters

  • Timing of Feeding

  • Timing of Mobilization


Peri operative pain control
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


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


Results pain score
Results Recovery after Colon Surgery– Pain score

Anaesthesiology Vol 83(4), Oct 1995, p757-765

P<0.01


Results return of gi function and los
Results Recovery after Colon Surgery–Return of GI function and LOS

Anaesthesiology Vol 83(4), Oct 1995, p757-765


Conclusion
Conclusion Recovery after Colon Surgery

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


Means to hasten recovery1
Means to Hasten Recovery Recovery after Colon Surgery

  • Use of Perioperative Pain Control

  • Use of Tubes, Drains and Catheters

  • Timing of Feeding

  • Timing of Mobilization


Ng tube decompression
NG Tube Decompression Recovery after Colon Surgery

  • 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


Prophylactic nasogastric decompression after abdominal surgery [Review]

Nelson, R, et al

The cochrane Database of Systematic Reviews

The Cochrane collaboration Vol (4) 2005


Results time to flatus
Results - Time to Flatus surgery [Review]

The Cochrane collaboration Vol (4) 2005


Results complications
Results surgery [Review]– Complications

Pulmonary Complication

Anastomotic Leakage

The Cochrane collaboration Vol (4) 2005


Conclusion1
Conclusion surgery [Review]

  • 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


Means to hasten recovery2
Means to Hasten Recovery surgery [Review]

  • Use of Perioperative Anaesthesia and Analgesia

  • Use of Tubes, Drains and Catheters

  • Timing of Feeding

  • Timing of Mobilization


Anastomotic drainage
Anastomotic Drainage surgery [Review]

  • 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?


Prophylactic anastomotic drainage for colorectal surgery review j esus ec et al
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


Conclusion2
Conclusion [Review]

  • 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


Means to hasten recovery3
Means to Hasten Recovery [Review]

  • Use of Perioperative Anaesthesia and Analgesia

  • Use of Tubes, Drains and Catheters

  • Timing of Feeding

  • Timing of Mobilization


Urinary catheterization
Urinary Catheterization [Review]

  • 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


Is urinary Drainage Necessary During [Review]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


Conclusion3
Conclusion [Review]

  • 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


Means to hasten recovery4
Means to Hasten Recovery [Review]

  • Use of Perioperative Pain Control

  • Use of Tubes, Drains and Catheters

  • Timing of Feeding

  • Timing of Mobilization


Post op enteral feeding
Post-op Enteral Feeding [Review]

  • 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


Early oral feeding after colorectal resection a randomized controlled study carlo v feo et al
Early Oral Feeding After Colorectal Resection: A Randomized Controlled Study Carlo V. Feo, et al

ANZ J. Surg. 2004; 74: 298-301


Conclusion4
Conclusion Controlled Study

  • 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


Summary
Summary Controlled Study

  • 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


Fast track surgery
Fast Track Surgery Controlled Study

  • 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


A clinical pathway to accelerate recovery after colonic resection linda basse et al
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



Results
Results resection

Return of GI Function

Length of Hospital Stay

Median LOS: 2 days

95% patient defecate within 48 hrs

Ann Surg July 2000


Conclusion5
Conclusion resection

  • Multimodal rehabilitation program may significantly reduce

    • Post-op ileus

    • Post-op hospital stay

Ann Surg July 2000


Randomized clinical trial of multimodal optimization of surgical care in

patients undergoing

major colonic resection

M. Gatt, et al

BJS 2005; 92: 1354-1362


Optimization package
Optimization Package surgical care in

BJS 2005; 92: 1354-1362


Outcome measures
Outcome Measures surgical care in

  • 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


Results1
Results surgical care in

Length of Hospital Stay

Return of GI function

P=0.042

P=0.027

BJS 2005; 92: 1354-1362


Post op morbidity mortality
Post-op Morbidity / Mortality surgical care in

BJS 2005; 92: 1354-1362


Conclusion6
Conclusion surgical care in

  • 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


Summary1
Summary surgical care in

  • 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


Our experience at rhtsk
Our Experience at RHTSK surgical care in

  • 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)


Results no of days median
Results surgical care in – No. of Days (median)

Day (Median)


~ The End ~ surgical care in


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