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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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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
slide6
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 – Pain score

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

P<0.01

results return of gi function and los
Results –Return of GI function and LOS

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

conclusion
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
means to hasten recovery1
Means to Hasten Recovery
  • Use of Perioperative Pain Control
  • Use of Tubes, Drains and Catheters
  • Timing of Feeding
  • Timing of Mobilization
ng tube decompression
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
slide12
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

The Cochrane collaboration Vol (4) 2005

results complications
Results – Complications

Pulmonary Complication

Anastomotic Leakage

The Cochrane collaboration Vol (4) 2005

conclusion1
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

means to hasten recovery2
Means to Hasten Recovery
  • Use of Perioperative Anaesthesia and Analgesia
  • Use of Tubes, Drains and Catheters
  • Timing of Feeding
  • Timing of Mobilization
anastomotic drainage
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?

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
  • 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
  • Use of Perioperative Anaesthesia and Analgesia
  • Use of Tubes, Drains and Catheters
  • Timing of Feeding
  • Timing of Mobilization
urinary catheterization
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
slide22
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

conclusion3
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

means to hasten recovery4
Means to Hasten Recovery
  • 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
  • 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
  • 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
  • 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
  • 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

Return of GI Function

Length of Hospital Stay

Median LOS: 2 days

95% patient defecate within 48 hrs

Ann Surg July 2000

conclusion5
Conclusion
  • Multimodal rehabilitation program may significantly reduce
    • Post-op ileus
    • Post-op hospital stay

Ann Surg July 2000

slide34
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

BJS 2005; 92: 1354-1362

outcome measures
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

results1
Results

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

BJS 2005; 92: 1354-1362

conclusion6
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

summary1
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
our experience at rhtsk
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)