Fast-Track: perioperative care after colorectal surgery in senior patients

Article

Reference

Fast-Track: perioperative care after colorectal surgery in senior patients

OSTERMANN BUCHER, Sandrine, MOREL, Philippe

OSTERMANN BUCHER, Sandrine, MOREL, Philippe. Fast-Track: perioperative care after colorectal surgery in senior patients. Swiss Knife , 2012, no. 4, p. 14-15

Available at:

http://archive-ouverte.unige.ch/unige:28644

Disclaimer: layout of this document may differ from the published version.

1 / 1

14

Focus

Fast-Track: Perioperative Care after Colorectal Surgery in Senior Patients

The concept of multimodal perioperative care (fast-track surgery or enhanced recovery programmes) aims to re- duce perioperative surgical stress after colorectal surgery resulting in lower morbidity and enhanced recovery.

Sandrine Ostermann, sandrine.ostermann@hcuge.ch Philippe Morel, philippe.morel@hcuge.ch

It was initially developed by H. Kehlet et al in the 1990s. The main evi- dence-based 6-7 elements of fast-track (FT) programmes are listed in Table 1. FT led to significant decrease in postoperative morbidity (10- 20% vs. 25-35% with standard care) and reduce length of hospital stay (LOS) from 8-12 to 3-4 days, without increase in readmission rate.

Recently, many randomized trials, meta-analyses and systematic re- views have confirmed its safety and efficacy in reducing morbidity and LOS, but also by improving patient satisfaction as compared to stand- ard care.

Current progress in perioperative care have focused on perioperative fluid management, while accumulating evidence through randomised trials has demonstrated the importance of balanced fluid reanimation (by individua- lized i.v. fluids therapy) which significantly decrease morbidity (cardiopulmo- nary & thromboembolic complications) and reduce postoperative ileus and LOS.

Metabolic stress and insulin resistance following major surgery results in postoperative hyperglycaemia which is associated with increased morbidity and mortality. In non-diabetic patients, avoiding preoperative fastening using oral carbohydrate (CHO) loading until 2-3 hours before surgery substantially reduces postoperative stress and insulin resistance, resulting in a decrea- sed risk of hyperglycaemia postoperatively.

Commercially available CHO-rich (12.5%) solutions contains small carbohydrate polymers to mini- mize the osmotic load and reducing gastric emptying time. In addition to its metabolic effect, preoperative CHO load improves patient well-being.

Moreover, type 2 diabetic patients showed no signs of increasing glucose peak or delayed gastric emptying; suggesting that a CHO drink may be sa- fely administrated 2-3h before anaesthesia without risk of hyperglycaemia or preoperative aspiration.

Evolutions of Fast-Track concept

Although FT surgery has been shown to improve postoperative recovery af- ter colorectal surgery, universal implementation has not yet occurred. Some reasons are that FT programs are often complex; resource demanding and possibly elusive because of the relative contribution of each intervention re- mains uncertain.

A recent prospective study assessed the influence of FT components and protocol compliance on clinical outcomes (morbidity, LOS, postoperative symptoms directly responsible for delayed LOS) after colo- rectal procedures. Adherence to FT protocol increase from 43 to 71% after 1 to 3 years with a significant reduction in postoperative complications.

More interesting is that perioperative i.v fluids restriction and CHO admini-

stration were the two only major independent predictors. For each additional intravenous litre given during day of surgery, postoperative symptoms dela- ying recovery were increased by 16% and morbidity by 32% (in particular cardio-respiratory complications) In patients receiving CHO load, postope- rative symptoms were reduced by 44%, in particular postoperative nausea and vomiting, pain, diarrhoea, and dizziness. Wound dehiscence was also reduced by CHO administration.

Prevalence of malnutrition concern up to 35% of colorectal patients and was identified as an independent factor that directly influences postopera- tive morbidity and mortality.

According to the NRS-2002, (recommended screening by ESPEN: European Society of Parenteral and Enteral Nutrition

), nutritional support should be used to initiate 7 days before surgery in every patient at nutritional risk. (NRS . 3, >70 years old or cancer)

The use of thoracic epidural analgesia (TEA) has been recommended as one of the key element of fast-track surgery.

Recently, others techniques such as abdominal wall block49-50, surgical wound infiltration of local ana- esthetics

or continuous intravenous lidocaïne infusion

have been as- sessed with promising results but deserve further investigations to be propo- sed as a safe alternative for pain control in a FT program.

Fast-Track Surgery in senior patients

With improving life expectancy and baby boomers (born in 1946-1964) ente- ring in their retirement age, senior population (>70 years) represent one of the most rapidly growing parts of Western countries (12-18%) and is attending to double in the next two decades. Moreover, seniors have a high incidence of colorectal pathology and already account for 2/3 of all solids cancers of which 50% are colorectal cancers54. More and more surgeries will therefore be performed in these frail patients. Colorectal surgery in senior patients is frequently associated with higher postoperative morbidity (10%–43%) and mortality (2.5%–11%) rates than in their younger counterparts, primarily due to their pre-existing comorbid conditions and reduced functional reserve.

They also typically experience a prolonged hospital stay (10-15 days), often

require an extended-care or specialized nursing facility at discharge and are

at greater risk for loss of independence after surgery with traditional care.

Only scarce information

is currently available on fast-track perioperative

care in senior patients, as reported in Table 2. These early studies using mul-

timodal rehabilitation reveal therefore encouraging results with significant re-

duction in postoperative morbidity (5 to 28%) resulting in a shorter hospital

stay (3 to 8 days).

swiss knife 2012; 4

15

Focus

Sandrine Ostermann Philippe Morel

As the benefits of faster recovery may be still more pronounced in senior patients, a dedicated fast-track perioperative care program was recently ini- tiated after colorectal surgery in senior patients. This prospective randomized trial was approved by the Geneva University Hospital Ethical Committee and is currently ongoing with 102 seniors included so far (registration number NCT 01646190). The aim of this RCT is to evaluate feasibility of a dedicated senior fast-track program as compared to current standard care after elec- tive colorectal surgery. It will be particularly focused on implementing highest evidence on oral nutrition, individualized optimization of fluid management, analgesic regimen and physical rehabilitation.

Table 2: Background data of fast-track programs evaluation in senior patients

Authors Year Design*, (MIS/open) N Age med Morbidity (%) Mortality (%) LOS (d) Read (%)

Bardram59 2000 PC 39 81 21 5 3 -

(MIS)

DiFronzo60 2003 RC 87 77 15 0 4 -

(open)

Senagore61 2003 PC 183 78 20 1 7 7

(MIS:50%)

Scharfenberg62 2007 PC 74 74 28 1 5 12

(MIS:40%)

Rumstadt63 2009 PC 742 80 27 1 6 -

(MIS:36%)

Wang64 2011 RCT 40 71 5 ? ? -

(MIS)

Pawa65 2012 RC 130 83 26 16 8 9

(MIS:93%)

*Design: PC: prospective cohort; RC retrospective cohort; RCT: randomized controlled trial

Summary

Fast-track surgery is a multimodal, multidisciplinary-team approach to red- uce perioperative surgical stress after colorectal surgery, resulting in lower morbidity and enhanced recovery. As fast-track seems to be the most bene- ficial in senior patients (>70 years), only scarce information is available in this population. Therefore a randomized controlled trial was initiated in our insti- tution comparing a senior dedicated fast-track approach to modern standard care after colorectal surgery.

Table 1: Evidence-based fast-track components:

Preoperative elements:

Patient information (clinical pathway, discharge criteria), organ dysfunc- tion optimization

Preoperative oral nutritional support

No preoperative fasting, oral carbohydrate loading night before & 2-3h before surgery

No mechanical bowel preparation

Thrombo-embolic prophylaxis

Intraoperative elements:

Antimicrobial prophylaxis, single dose 1h before incision

Multimodal analgesia optimisation (epidural, systemic, or regional anal- gesia; short-acting anaesthetics, opioïd-sparing agents)

Use of minimally invasive surgery (MIS) or small incisions

Maintenance of normothermia

Avoidance of intravenous fluid excess

Selective use of abdominal drains

, urinary catheters

Postoperative elements:

No routine use of nasogastric tube

Postoperative nausea & vomiting prevention

Early initiation of oral nutrition

Early active mobilization

16

Focus

References

1. Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 2008; 248: 2: 189-96

2. Kehlet H. Surgery: Fast-track colonic surgery and the ‚knowing-doing‘ gap. Nat Rev Gastroenterol Hepatol. 2011; 8 (10): 539-40

3. Kehlet H, Slim K. The future of fast-track surgery. Br J Surg. 2012; 99 (8): 1025-6.

4. Kehlet H. Fast-track surgery-an update on physiological care principles to enhance recovery. Langenbecks Arch Surg. 2011; 396 (5): 585-90

5. Stottmeier S, Harling H, Wille-Jørgensen P, et al. Pathogenesis of morbidity after fast-track laparoscopic colonic cancer surgery. Colorectal Dis. 2011; 13 (5): 500-5 6. Phillips B, BC, Sacket D, et al. Levels of evidence and grades of recommendations.

Centre for evidence-based medicine; University of Oxford; 2007. http://www.cebm.

net/index.aspx?o51025

7. Lassen K, Soop M, Nygren J, et al. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommen- dations. Arch Surg. 2009; 144 (10): 961-9

8. Basse, L; Hjort J, et al. A clinical pathway to accelerate recovery after colonic resec- tion. Ann Surg 2000; 232: 1; 51-7

9. Weimann A, Braga M, Harsanyi L, et al. ESPEN Guidelines on Enteral Nutrition:

Surgery including organ transplantation. Clin Nutr 2006; 25: 224-44

10. Stratton RJ, Elia M. Encouraging appropriate, evidence-based use of oral nutritional supplements. Proc Nutr Soc. 2010; 69 (4): 477-87

11. Noblett SE, Watson DS, et al. Preoperative oral carbohydrate loading in colorectal surgery: a randomized controlled trial. Colorectal Dis 2006; 8: 563-9

12. Guenaga KF Matos D, et al. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev 2005; 1:CD001544

13. White FP Kehlet H, et al. The role of the anaesthesiologist in fast track surgery: from multimodal analgesia to perioperative medical care. Anesth Analg 2007; 104:1380-96 14. Jorgensen H, Wetterslev J, et al. Epidural local anesthetics versus opioid-based analgesic regimens on postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery. Cochrane Database Syst Rev 2000; 4: CD001893

15. Levy BF, Tilney HS, Dowson HM, Rockall TA. A systematic review of postoperative analgesia following laparoscopic colorectal surgery. Colorectal Dis. 2010; 12 (1):

5-15

16. Carli F, Kehlet H, Baldini G, Steel A, et al. Evidence basis for regional anesthesia in multidisciplinary fast-track surgical care pathways. Reg Anesth Pain Med. 2011; 36 (1): 63-72

17. Marret E, Rolin M, Beaussier M, Bonnet F. Meta-analysis of intravenous lidocaine and postoperative recovery after abdominal surgery. Br J Surg. 2008 Nov; 95 (11):

1331-8

18. Vlug MS, Wind J, Hollmann MW, et al. Laparoscopy in Combination with Fast Track Multimodal Management is the Best Perioperative Strategy in Patients Undergoing Colonic Surgery: A Randomized Clinical Trial (LAFA-study). Ann Surg. 2011; 254 (6):

868-75

19. Van Bree S, Vlug M, Bemelman W, et al. Faster recovery of gastrointestinal transit after laparoscopy and fast-track care in patients undergoing colonic surgery. Gas- troenterology. 2011; 141 (3): 872-80

20. Feroci F, Kröning KC, Lenzi E, et al. Laparoscopy within a fast-track program en- hances the short-term results after elective surgery for resectable colorectal cancer.

Surg Endosc. 2011; 25 (9): 2919-25

21. Basse L, Jakobson DH, Bardram L et al. Functional recovery after open versus laparoscopic colonic resection. A randomized blinded study. Ann Surg 2005; 241, 3: 416-23

22. Frank SM, Fleicher LA, et al. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial. JAMA, 1997;

227:1127-34

23. Srinivasa S, Taylor MH, Sammour T, et al. Oesophageal Doppler-guided fluid ad- ministration in colorectal surgery: critical appraisal of published clinical trials. Acta Anaesthesiol Scand. 2011; 55 (1): 4-13

24. Hübner M, Schäfer M, Demartines N, et al. Impact of restrictive intravenous fluid re- placement and combined epidural analgesia on perioperative volume balance and renal function within a Fast Track program. J Surg Res. 2012; 173 (1): 68-74 25. Abraham-Nordling M, Hjern F, Pollack J, et al. Randomized clinical trial of fluid re-

striction in colorectal surgery. Br J Surg. 2012; 99 (2): 186-91

26. Petrowsky H, Demartines N, et al. Evidence-based value of prophylactic drainage in gastro-intestinal surgery: a systematic review and meta-analyses. Ann Surg 2004;

240: 1074-84

27. Benoist S, Panis Y, Denet C, et al. Optimal duration of urinary drainage after rectal resection: a randomized controlled trial. Surgery. 1999; 125 (2): 135-41

28. Zaouter C, Kaneva P, Carli F. Less urinary tract infection by earlier removal of blad- der catheter in surgical patients receiving thoracic epidural analgesia. Reg Anesth Pain Med. 2009; 34 (6): 542-8

29. Nelson R, Edwards S, et al. Prophylactic nasogastric decompression after abdomi- nal surgery. Cochrane Database Syst Rev 2007; 3:CD004929

30. Bardram L, Funch Jensen P, et al. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilization. Lancet 1995; 345: 763-4 31. Kehlet H, Dahl JB. Anesthesia, surgery, and challenges in postoperative recovery.

Lancet 2003; 362: 1921-8

32. Andersen J, Hjort-Jakobsen D, et al. Readmission rates after a planned hospital stay of 2 versus 3 days in fast track colonic surgery. Br J Surg 2007; 94: 890-3 33. Spanjersberg WR, Reurings J, Keus F, et al. Fast-track surgery versus conventional

recovery strategies for colorectal surgery. Cochrane Database Syst Rev 2011; 16 (2): CD007635

34. Varadhan KK, Lobo DN, Ljungqvist O. Enhanced recovery after surgery: the future of improving surgical care. Crit Care Clin. 2010; 26 (3): 527-47

35. Archibald LH, Ott MJ, Gale CM, et al. Enhanced recovery after colon surgery in a community hospital system. Dis Colon Rectum. 201; 54 (7): 840-5

36. Sailhamer EA, Sokal SM, et al. Environmental impact of accelerated clinical care in a high volume center. Surgery 2007; 142; 3: 343-9

37. Slim K, Fast-track surgery: the next revolution in surgical care following laparosco- py. Colorectal Dis. 2011; 13 (5): 478-80

38. Fischer M, Matsuo K, Gonen M, et al. Relationship between intraoperative fluid administration and perioperative outcome after pancreaticoduodenectomy: results of a prospective randomized trial of acute normovolemic hemodilution compared with standard intraoperative management. Ann Surg. 2010; 252 (6): 952-8 39. Ljungqvist O. Insulin resistance and outcomes in surgery. J Clin Endocrinol Metab.

2010; 95 (9): 4217-9

40. Gustafsson UO, Nygren J, Thorell A, et al. Pre-operative carbohydrate loading may be used in type 2 diabetes patients. Acta Anaesthesiol Scand. 2008; 52 (7): 946-51 41. Wang ZG, Wang Q, Wang WJ, et al. Randomized clinical trial to compare the effects of preoperative oral carbohydrate versus placebo on insulin resistance after colo- rectal surgery. Br J Surg. 2010; 97 (3): 317-27

42. Can MF, Yagci G, Dag B, étal. Preoperative administration of oral carbohydrate-rich solutions: Comparison of glucometabolic responses and tolerability between pati- ents with and without insulin resistance. Nutrition. 2009; 25 (1): 72-7

43. Gustafsson UO, Hausel J, Thorell A, et al. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg.

2011; 146 (5): 571-7

44. Polle SW, Wind J, Fuhring JW, et al. Implementation of a fast-track perioperative care program: what are the difficulties? Dig Surg. 2007; 24 (6): 441-49

45. Kehlet H, Büchler MW, Beart RW Jr, et al. Care after colonic opération_ is it evi- dence-based? Results from a multinational survey in Europe and the United States.

J Am Coll Surg. 2006; 202 (1): 45-54

46. Nygren J, Soop M, Thorell A, et al. An enhanced recovery protocol improves out- come after colorectal resection already during the first year: a single-center expe- rience in 168 consecutive patients. Dis Colon Rectum. 2009; 52 (5): 978-985 47. Schwegler I, von Holzen A, Gutzwiller JP et al. Nutritional risk is a clinical predictor

of postoperative mortality and morbidity in surgery for colorectal cancer. Br J Surg.

2010; 97 (1): 92-7

48. Sorensen J, Kondrup J, Prokopowicz J, et al. EuroOOPS: an international, multi- centre study to implement nutritional risk screening and evaluate clinical outcome.

Clin Nutr. 2008; 27 (3): 340-9

49. Johns N, O‘Neill S, Ventham N, et al. Clinical effectiveness of transversus abdominis plane (TAP) block in abdominal surgery: a systematic review and meta-analysis.

Colorectal Dis. 2012 May 25. Epub ahead of print

50. Abdallah FW, Chan VW, Brull R.Transversus abdominis plane block: a systematic review. Reg Anesth Pain Med. 2012; 37 (2): 193-209

51. Gross ME, Nelson ET, Mone MC, et al. A comparison of postoperative outcomes utilizing a continuous preperitoneal infusion versus epidural for midline laparotomy.

Am J Surg. 2011; 202 (6): 765-9

52. Beaussier M, El‘Ayoubi H, Schiffer E, et al. Continuous preperitoneal infusion of ropivacaine provides effective analgesia and accelerates recovery after colorectal surgery: a randomized, double-blind, placebo-controlled study. Anesthesiology.

2007 Sep; 107 (3): 461-8

53. Wongyingsinn M, Baldini G, Charlebois P, et al. Intravenous lidocaine versus thora- cic epidural analgesia: a randomized controlled trial in patients undergoing laparo- scopic colorectal surgery using an enhanced recovery program. Reg Anesth Pain Med. 2011; 36 (3): 241-8

54. Ostermann S, Bucher P, Gervaz P, et al. Really so far from fast-track colorectal surgery in senior patients ?.Rev Med Suisse. 2009 26; 5: 1676-9

55. Balducci L. Epidemiology of cancer and aging. J. Oncol Manag 2005; 14: 47-50 56. Marusch F, Koch A, Schmidt U, et al. The Impact of the Risk Factor „Age” on the

Early Postoperative Results of Surgery for Colorectal Carcinoma and Its Signifi- cance for Perioperative Management. World J Surg 2005; 29 (8): 1013-21 57. Massarweh N, Legner V, Symons R, et al. Impact of advancing age on abdominal

surgical outcomes. Arch Surg 2009; 144 (12): 1008-14

58. Colorectal Cancer Collaborative Group. Surgery for colorectal cancer in elderly pa- tients: a systemic review. Lancet 2000; 356: 968-74

59. Bardram L. Fuch-Jensen P, et al. Rapid rehabilitation in elderly patients after laparo- scopic colonic resection. Br J Surg 2000 87; 11; 1540-5

60. DiFronzo LA, Yamin N, et al. Benefits of early feeding and early hospital discharge in elderly patients undergoing open colon resection. J Am Coll Surg 2003; 197: 747-52 61. Scharfenberg M, Raue W, et al. „Fast-track” rehabilitation after colonic surgery in

elderly patients- is it feasible? Int J Colorectal Dis 2007; 22: 1469-74

62. Senagore A, Madbouly K, Fazio V, et al. Advantages of laparoscopic colectomy in older patients. Arch Surg 2003; 138: 252-56

63. Rumstadt B, Guenther N, Wendling P, et al. Multimodal perioperative rehabilitation for colonic surgery in the elderly.World J Surg. 2009; 33 (8): 1757-63

64. Wang Q, Suo J, Jiang J, et al. Effectiveness of Fast Track rehabilitation vs. conventi- onal care in Laparoscopic Colorectal Resection for Elderly Patients: A Randomized Trial. Colorectal Dis. 2011 Oct 11. Epub ahead of print

65. Pawa N, Cathcart P, Arulampalam T, et al. Enhanced recovery program following colorectal resection in the elderly patients. World J Surg 2012; 36: 415-23 66. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new

proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240 (2): 205-13