risiko

kirurgiens risikoelementer

ventetid

kir.

teknik

”svigt”

præop

morbi-

ditet

periop

behand-

ling

kir.

eksper-

tise

• fast-track kirurgi

• ny teknologi

• monitering/ optimering

kræftkirurgi/operationsrisiko

• every operation can be ambulatory ?

• why is the patient in hospital today ?

• what is it that we cannot control ?

improvement of

perioperative outcome?

why is the patient in hospital today ?

• organ dysfunction (”surgical stress”)

• pain

• PONV / ileus

• fluid excess/ hypovolaemia

• immobilisation

• semi-starvation

• traditions (tubes,drains,restrictions,etc.)

• and others

Kehlet & Dahl Lancet 2003; 363: 1921

Kehlet & Wilmore Ann Surg 2008;248:189

Kehlet Langenbecks Arch Surg 2011;396:585

Multimodal approach to control postoperative

pathophysiology and rehabiliation

1997; 78:606-617

H. Kehlet

attenuation

of stress

pain

relief

exerciseoral

nutrition

enhanced recovery and

reduced morbidity

preop

optimisation/

information

Kehlet Langenbecks Arch Surg 2011;396:585

fast-track (2-4 days) vs ”traditional”

(7-10 days) open colonic surgery

• mobilisation

• ileus hosp stay

• oral nutrition

• pulm-, cardiac-, muscle function

• after discharge:

fatigue, need for sleep

need for health support

• ”medical” compliations

Kehlet Lancet 2008;371:791

Varadhan Clin Nutr 2010:29:434

Clin Nutri 2010; 29: 434-440

fast-track vs traditional care - morbidity

mission accomplished or

work in progress ?

laparoscopic

colonic surgery

Kehlet & Kennedy Colorectal Dis 2006;8:514

hospital stay

lap vs open colonic resection

Schwenk Cochrane Library 2005

Noel J Am Coll Surg 2007;204:291

Lourenco Surg Endosc 2008;22:1140

Kehlet Lancet 2008;317:791

0

2

4

6

8

10

lap open fast-track

meta-analyses

days

• integrate fast-track methodology

• pharmacological stress reduction

• focus on high risk and morbidity

• LOS 1-2 days ?

future of

laparoscopic

colonic surgery

Kehlet Nat Rev Gastr Hepatol 2011;8:539

fast-track lap gastric surgery

• n = 32

Roux-en-Y total gastrectomy n=10

Billroth II resection n=22

• median stay 4 days

• no mortality, 2 readmissions (wound

infect/ UTI)

Grantcharov & Kehlet Br J Surg 2010;97:1547

Pain 2011;152:S2-S15single incision lap surgery (SILS)

Surg Endosc 2011;25:1887-1892.

• case control 18 SILS 21 lap

• conclusion ”safe and feasible”

• no benefit in short-term outcome

• LOS 5 days in both groups

Pain 2011;152:S2-S15

natural orifice surgery (NOTES)

Br J Surg 2011;98:710-715.

• case control n = 2 x 34

• NOS less pain

• cosmesis NOS

• LOS 7.9 vs. 8.0 days !!

Pain 2011;152:S2-S15robotkirurgi

xxx

Surg Endosc 2012;26:580-581.

Surg Endosc 2012;26:598-606.

NEJM 2010;363:701-598-606.

Pain 2011;152:S2-S15

robotkirurgi

• the jury is still out

• combine with fast-track

• procedure-specific studies required

(bleeding, nerve injury, diff. anatomy)

• significant cost issues !

Arch Surg 2010;145:1191-92

• learning curve ?

• LOS ?

• complications ?

• umbilical hernia ?

• cosmesis , but…

Br J Anaesth 2011;106:289-91.

• fast-track methodology not implemented

• ”surgical” vs ”medical” morbidity ?

established risk indices, but

Nature Reviews Gast Hepatol 2011;8:539-40

slow uptake in contrast to

available scientific evidence

implementation of

evidence-based surgery

improved

quality/ cost

reduction/

outcome

monitoring

national/

government

region/ state

administration

hospital

administration

chairman/

department

surgeons/ nurses/

anaesthesiologists

• privat initiativ/kirurger samt SST

• > 15 operationer

• organisation

• nationale data

• tidlig outcome (30 dage)

• > 30 publikationer

• stor betydning for specialeplanlægning

• nedlagt primo 2011

”kirurgiprojektet” i SST

Scand J Surg. 2007;96:41-5.

• antal afd.

- esophagus n = 26

- pancreas n = 13

- gastric n= 37

• mortalitet 8-9 %

• 4 afdelinger

• n = 237

• mortalitet (30 dage) 2 %

• morbiditetsproblemer (samarbejde

indledt)

esophagus-cardia-ventrikel cancer

op i DK 2010 (databasen)

nephrectomy in DK 2002 - 2005

(~ 650/ yr)

0

2

4

6

8

10

12

Firoozfard

Ugeskr Læger

2006;168:1526

2002-2005 open fast-track

Firoozfard

Scand J Urol

2003;37:305

hosp stay

days

Ugeskr Læger 2006;168:1537-40.

• n = 32 afd. (stad III)

• n = 5 (2011)

• ingen nationale protokoller

Fagö-Olsen Acta Obstet Gynecol Scand 2011;90:273

evidence-based care maps

meetings - national/ workshops (proc.specific)

web site (www.periopsygepleje.dk)

(www.periopnursing.dk)

perioperative nursing care unit in DK

Kirsten Rud Dorthe Hjort

Jacobsen

Ingrid Egerod

risiko

kirurgiens risikoelementer

ventetid

kir.

teknik

”svigt”

præop

morbi-

ditet

periop

behand-

ling

kir.

eksper-

tise

risiko

kirurgiens risikoelementer

ventetid

kir.

teknik

”svigt”

præop

morbi-

ditet

periop

behand-

ling

kir.

eksper-

tise