Laparoscopy vs fast track

H.Pernthaler, 1.Chirurgie, Bozen

Cleveland Clinic Florida, 1992

Results of fast-track compared with traditional surgery   • Reduced duration of ileus• Improved muscle strength, exercise capacity, or lean body

mass• Improved oral energy and protein intake• Decreased cardiopulmonary morbidity• Reduced hospital stay• No effect on rate of readmissions• Decreased period of postoperative convalescence• Reduced costs

Kehlet, Lancet Volume 371, Issue 9615, 8 March 2008-14 March 2008, Pages 791-793

Evidence-based methods

• Obtain preoperative information on patients and optimise organdysfunction

• Epidural analgesia or non-opioid multimodal analgesia• Avoidance of fluid excess or use of goal-directed therapy• No preoperative bowel clearance• No routine use of drains• No routine use of nasogastric tubes• Early oral feeding and mobilisation• Consider preoperative carbohydrate administration• Well-defined daily care maps or discharge criteria

Kehlet, Lancet Volume 371, Issue 9615, 8 March 2008-14 March 2008, Pages 791-793

TABLE 3. Duration of Surgery, Transfusion, Hospitalization, and Readmissions in 60 Patients Randomized to Open or Laparoscopic Colonic Resection (* = P < 0.05 Between Groups) From:   Basse: Ann Surg, Volume 241(3).March 2005.416-423

Care after colonic operation- ist it evidence based? Results from a multimodal survey in

Europe and the US, Kehlet H, Büchler RW, Beart RW Jr, Billingham RP, Williamson R J Am Coll Surg 2006, 202: 45-54

• 295 hospitals, 1,082 Patients, 2 weeks postop.• Preop. bowel clearance > 85%• nasogastric tube in situ 40% EU 66% US 3-4 pod• liquids after 3-4 days 50% • Postop ileus 45% for 5 days• Discharge mean 10 days EU, 7 days US,

2-5 days fast track trials

Laparoscopic colonic surgery in Denmark 2004-2007

Schulze S, Colorectal Dis 2008 in press

• 1149 procedures without stoma

• 25 departments, 4 departments > 100 procedures

• Median postop d: 4 (mean 7.7)

• Readmission within 30 days: 10.9%

• Mortality: 3.5% postop, 2.6% 30 days

Dickdarmresektionen 2007, 1.Chirurgie, laparoskopisch: 31.7% der potentiellen Indikationen, 0 Konversionen

  Notfall Offen laparoskopisch

Rektum 0 13 2

Abdominoperineal   2 1

Sigma   3 7

Hemikolektomie sx 11 6 3

Hemikolektomie dx 1 17  

Kolektomie 2    

Erweiterte Eingriffe   5  

Res. Mit anderen Eingriffen

  4  

  14 50 13

Conclusions laparoscopy/fast track

• Both laparoscopic colon resection and fast track surgery improve recovery and reduce hospital stay

• Large scale studies are required on potential differences in serious morbidity and mortality

• A protocol is not enough