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FAST TRACK SURGERY

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FAST-TRACK SURGERY UNIVERSITA’ E TERRITORIO . LA PREVENZIONE E LA CURA DEI TUMORI” 15/10/2010 Fondachelli Fantina -Messina :

FAST-TRACK SURGERY UNIVERSITA’ E TERRITORIO . LA PREVENZIONE E LA CURA DEI TUMORI” 15/10/2010 Fondachelli Fantina -Messina UNIVERSITY OF MESSINA Department of Surgery, Pathology and Oncology. U.O.C. GENERAL SURGERY A.O.U. "G. MARTINO "MESSINA ANTONIO GIACOMO RIZZO

FAST TRACK SURGERY some of history ....:

FAST TRACK SURGERY some of history .... The term "Fast Track Surgery" is encoded in the late 90's by a Danish surgeon Henrik Kehlet

FAST TRACK ?:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY FAST TRACK ? “ “ Henrik Kehlet et al.: BMJ 2001 Fast track surgery combines various techniques used in the care of patients undergoing elective operations. The methods used include epidural or regional anaes­ thesia, minimally invasive techniques, optimal pain control, and aggressive postoperative rehabilitation, including early enteral (oral) nutrition and ambulation. Per Fast-track Surgery ( Chirurgia scambio o ricambio veloce) si intende la combinazione di varie tecniche usate nell’assistenza di pazienti sottoposti ad interventi chirurgici di elezione. L’obiettivo della “FAST” è di pianificare la rapida dimissione ospedaliera e la precoce ripresa delle normali attività della vita quotidiana.

advantages of FAST TRACK:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY The combination of these approaches reduces the stress response and organ dysfunction and therefore greatly shorten the time required for full recovery. “ “ advantages of FAST TRACK Henrik Kehlet et al.: BMJ 2001

FAST TRACK SURGERY:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY FAST TRACK SURGERY In the preoperative period the Fast - Track Surgery requires careful patient selection to choose from with an accurate control of chemical - clinical and instrumental examinations preparatory intervention and various organ functions.

standardization of Fast-Track Surgery:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY standardization of Fast-Track Surgery 1) detailed information on the procedure and its purpos 2) no bowel preparation; 3) no premedication; 4) use of probiotics before surgery; 5) carbohydrate-rich liquids up to 2 hours before surgery; 6) epidural anesthesia; 7) short-acting anesthetic; 8) high concentration of oxygen in the perioperative period; 9) reduced fluid infusion in the perioperative period (6-8ml/kg/h); 10) minimally invasive surgery; 11) pain control without the use of opioids; 12) non-routine use of drains; 13) non-routine use of nasogastric tube; 14) early removal of the catheter; 15) laxatives and prokinetics; 16) early mobilization; 17) early oral refeeding J. Wind et al: Br J Surg 2006;93:800-809 H. Kehlet. Lancet 2008: 371: 791-793

FAST TRACK SURGERY:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY FAST TRACK SURGERY In the management of intra-operative must be used all the methods suitable for the reduction of surgical stress: minimal invasive surgery techniques of local anesthesia or regional spot maintaining state normothermic use of drugs

FAST TRACK SURGERY:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY FAST TRACK SURGERY Postoperatively are important: pain control the prevention of nausea and vomiting early mobilization nutrition orally the lowest usage possible drainage tubes and catheters

Fast track surgery: indicazioni:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY Fast track surgery: indicazioni Ambulatory or 24 hour surgery Extensive knee and shoulder reconstruction (laparoscopy/endoscopy) ricostruzione ginocchio e spalla Vaginal hysterectomy Gastric fundoplication (laparoscopy/endoscopy) Splenectomy (laparoscopy/endoscopy) Adrenalectomy (laparoscopy/endoscopy) Donor nephrectomy (laparoscopy/endoscopy) Mastectomy Cholecystectomy (laparoscopy/endoscopy) Short stay surgery—1 to 4 days Colectomy Total hip and knee replacement (protesi anca e ginocchio ) Aortic aneurysmectomy Pneumonectomy and lobectomy Radical prostatectomy Peripheral vascular reconstruction Henrik Kehlet et al.: BMJ 2001

FAST-TRACK SURGERY:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY FAST-TRACK SURGERY The Day Surgery is the organizational model which is applied more widely and with greater attention to the technique of Fast-Track Surgery. Requires training of staff and a reorganization of its specification and uses procedures and specially designed courses. The "fast-track surgery" provides: - the active participation of the patient - modification of anesthetic technique - pain management - modification of the behaviors of nursing - modification of the concepts of post-operative medical assitance with so-called "protected resignation" - the patient must be provided with all information (telephone numbers et al.) To be used in case of need

FAST TRACK SURGERY:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY FAST TRACK SURGERY In the Scandinavian countries has established the "fast-track surgery": - Laparoscopic cholecystectomy:> 80% discharged the same day; - Fundoplication:> 90% <23 hr; - Interventions and laparoscopic colorectal open: 2-4 days of hospitalization; - Mastectomy: 90% <1 day; - Laparoscopic adrenalectomy: <1 day; - Parathyroidectomy: 90% on an outpatient basis; - Thyroidectomy: <1 day; - Lung surgery: 1 day, 4-5 days depending on the intervention.

FAST-TRACK SURGERY:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY FAST-TRACK SURGERY

FAST-TRACK SURGERY:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY FAST-TRACK SURGERY

SURGICAL STRESS:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY SURGICAL STRESS Less stress and fewer cardiovascular complications: The pain causes hyperactivity of the sympathetic system with tachycardia, hypertension and increased peripheral vascular resistance. In high-risk patients with coronary insufficiency, increased cardiac work and myocardial oxygen demand may lead to ischemic heart disease, stroke, congestive heart failure. Pulmonary complications cause pain induced by hypoxia and accentuate the problems. A good epidural analgesia during and after major surgery may reduce these effects .

SURGICAL STRESS:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY SURGICAL STRESS Surgical stress is a common feature shared by all surgical patients, which involves changes in the function of various organs. The response to surgical stress is the pathogenic factor of post-operative morbidity with the exception of surgical technique and anesthesia mistakes. After a surgical tissue injury such as neuroendocrine alterations occur due to stimulation of the hypothalamus, which is directly related to pain pathways. These changes called “ STRESS REACTION ", b y secretion feature of catabolic hormones ( Cortisol, glucagon, growth hormone, catecholamines ) and by inhibiting substances such as anabolic Testosterone and insulin .

SURGICAL STRESS:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY SURGICAL STRESS

FATTORI RISCHIO PERIOPERATORI:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY FATTORI RISCHIO PERIOPERATORI

FAST-TRACK SURGERY:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY FAST-TRACK SURGERY The "fast-track surgery" is a fast paced surgery, the acceleration times of the various phases of hospitalization for surgery (preoperatively, intraoperatively, postoperative). The aim is to reduce the time of hospitalization. To understand this new reality we must remember what happened until a few years ago. The most useful is that of cholecystectomy for gallstones; was first planned a stay of 7 days, with time the hospital has been reduced to 4 days then 2 days with laparoscopic surgery (minimally invasive). With the "fast-track surgery", the fast paced, you can program a hospital stay of 1 day foreigner in a hospital 12 hours ( no overnight ).

Colecistectomia laparoscopica in regime di Fast-track:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY Colecistectomia laparoscopica in regime di Fast-track The laparoscopic cholecystectomy surgery accounts for 20% of the surgery department of general surgery in 1 year. A significant slice of the budget of the total budget of the department of general surgery. The cost of a cholecystectomy is also represented by hospitalization, while the operating room has reached a level hardly compressible, the admission can be further compressible by limiting it to 24 hours (overnight).

Laparoscopic cholecystectomy in the Fast Track:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY Laparoscopic cholecystectomy in the Fast Track prior to surgery - Informed consent - No dietary restriction - No bowel preparation - No pre-medication Wind et al: BJS 2006 Holte et al: J Am Coll Surg 2006 Kehlet et al: BJS 2000

Evidence Based Medicine e Fast track:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY Evidence Based Medicine e Fast track Compounding the difficulty of change is the imperative to act according to EBM ( Evidence Based Medicine ) that is, choose the treatment that has proven to be effective bases in which "fast-track surgery" does not exist . There is no evidence of efficacy of the methodology "fast-track surgery", There are no demonstrations of efficacy on outcome of patients operated in "fast-track surgery" compared with those operated normally (we call them operated in the "normal track surgery?"). The economic imperative to reduce the cost of the absurd conditions favor the EBM while the "fast-track surgery". Beyond the apparent contradiction of the opportunity to choose to save it is certain that led to the need to save progress in surgery. Many taboos have fallen surgical environment. The modern general surgeon is completely different from that of the previous generation. The surgeon who does not get updated and adapted to the needs quotas for professional marginalization.

K colorectal cancer treatment in the fast track:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY K colorectal cancer treatment in the fast track No bowel preparation + Probiotics Admission on the day before surgery Waste-free diet for up to 12h before surgery DVT prophylaxis (low molecular weight heparin + stockings) preparation for surgery

K colorectal cancer treatment in the fast track:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY K colorectal cancer treatment in the fast track During the intervention Restriction of fluids Active prevention of hypothermia Epidural analgesy Laparoscopic / minimally invasive No nasogastric tube No drainage Wind et al: BJS 2006 Holte et al: J Am Coll Surg 2006 Kehlet et al: BJS 2000

K colorectal cancer treatment in the fast track:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY K colorectal cancer treatment in the fast track In the post-operative Early mobilization "forced" Early oral nutrition No Morphine Use of laxatives Early removal of urinary catheter Wind et al: BJS 2006 Holte et al: J Am Coll Surg 2006 Kehlet et al: BJS 2000

Trattamento K colon retto in fast track : I “risultati” in letteratura :

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY Kehlet Basse Badram Delaney Schwenk Basse Br J Surg Ann Surg Br J Surg Br J Surg Chirurg Ann Surg 1999 2000 2000 2001 2004 2005 n 16 60 50 60 64 30 30 age 71 (41-91) 74 (33-94) 81 (70-93) 44.5 (13-70) 66 (74-31) 75 (57-90) 75 (58-85) Lap/open open open lap open lap+open open lap anaesthesia PD PD PD PD PD Gastric tube no no no no no no Solid food 24h 24h 24h 24h 24h 24h First stool 48h (93%) 48h (95%) 24h (58%) 48h (66%) 48h 48h Hospital stay 2 (2-6) 3 (2-6) 2.5 (2-9) 4.3 (1-6) 4 (4-5) 2 (2-5) 2 (2-5) Anast. leakage 0 2 2 0 2 1 0 readmission 0 2 2 4 7 8 6 Trattamento K colon retto in fast track : I “risultati” in letteratura

K colorectal cancer treatment in the fast track:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY K colorectal cancer treatment in the fast track Wind et all : BJS 2006

Early oral refeeding:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY Early oral refeeding A diet water can already be predicted from a few hours after colorectal resection Early oral refeeding does not cause alterations in the anastomotic

PowerPoint Presentation:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY reduction of - incidence of infections - length of stay No increase in anastomotic dehiscence Review of 11 studies with a total of 873 patients

Fluid therapy in the Fast-Track:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY Fluid therapy in the Fast-Track K.Holte, H.Kehlet :Am.College of Surgeons, 2006 Lobo DN et al .: Lancet 2002

:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY Anestesia spinale (generale se necessario) Restrizione dei fluidi Profilassi antibiotica short Chirurgia laparoscopica\ mini-invasiva Catetere vescicale (solo in chirurgia maggiore) SNG solo se distensione gastrica e rimozione prima del risveglio STRATEGIA Intervento chirurgico

STRATEGIA :

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY STRATEGIA Precoce mobilizzazione Pompa ad infusione con Meperidina per 48h Monitoraggio VAS ogni 12h ( scala analogica visuale dolore) Rimozione catetere vescicale: 1° g. Profilassi TVP: per 30 gg. Rialimentazione : d. liquida in 1° g. d. solida in 2° g. Dimissione: in 4°- 6° g. Post-operatorio

STRATEGIA:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY STRATEGIA

VANTAGGI:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY VANTAGGI

VANTAGGI:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY VANTAGGI

the strategy La strategia:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY the strategy La strategia Laparoscopic approach systematically in election eventuale programmata di necessità Mini-laparotomy conversione

conversions:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY conversions Conversion Rate 18.8 %

FAST-TRACK SURGERY:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY FAST-TRACK SURGERY

conclusions:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY conclusions Very well tolerated by patients The good pain control (epidural anesthesia) induces early mobilization and oral feeding faster The laparoscopic approach + epidural anesthesia + Early enteral nutrition reduces the time of paralytic ileus in 1-2days The early mobilization reduces respiratory and cardiac complications The surgical complications does not appear to be affected by the Protocol Kehlet et al: BJS 2000 Kehlet et al : Br J Anaest 1997 Wind et al: BJS 2006 Holte et al: J Am Coll Surg 2006

… and then the limits? e allora i limiti ???:

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY … and then the limits? e allora i limiti ??? Few randomized trials Protocols not "homogeneous” " Staffing needs "dedicated" Need help on the Territory Family support and collaboration

Fast track surgery :

ANTONIO GIACOMO RIZZO UNIVERSITY OF MESSINA SICILY Fast track surgery The "Fast Track Surgery" is a fast paced surgery, is the combination of various techniques used in the care of patients undergoing elective surgery. The aim is to reduce hospital length of stay and early resumption of normal activities. This organizational model requires continuous training of personnel and in particular its re-organization and makes use of specific procedures and specific routes. On the other side also includes the full participation and cooperation of the patient. In the preoperative period, one aims to optimize the various organ functions, the management of intra-operative shall take all appropriate methods to reduce the stress of surgery, minimally invasive techniques of regional anesthesia and the use of medications, behavior modification concepts of nursing and medical care postoperatively.

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