Multimodal Perioperative Rehabilitation in Elective Conventional Resection of Colonic Cancer: Results from the German Multicenter Quality Assurance Program ‘Fast-Track Colon II’

Braumann, Chris; Guenther, Nina; Wendling, P; Engemann, R.; Germer, Christoph T.; Probst, W.; Mayer, Hans-P.; Rehnisch, Bernd; Schmid, Michael; Nagel, K.; Schwenk, W.

doi:10.1159/000206149

Cited by 25 publications

(17 citation statements)

References 52 publications

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“…These programmes do not, therefore, appear to place the patient at any extra risk. Our results are similar to previous multicenter studies [27,28] in terms of surgical complications, mortality and readmission rate. The surgical complication rate was 24% compared to the 14.1% reported by Schwenk et al [27] and 20% reported by Braumann et al [28].…”

Section: Discussionsupporting

confidence: 92%

Enhanced recovery in colorectal surgery: a multicentre study

Ramı́rez

Blasco²,

Roig

et al. 2011

BMC Surg

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BackgroundMajor colorectal surgery usually requires a hospital stay of more than 12 days. Inadequate pain management, intestinal dysfunction and immobilisation are the main factors associated with delay in recovery. The present work assesses the short and medium term results achieved by an enhanced recovery program based on previously published protocols.MethodsThis prospective study, performed at 12 Spanish hospitals in 2008 and 2009, involved 300 patients. All patients underwent elective colorectal resection for cancer following an enhanced recovery program. The main elements of this program were: preoperative advice, no colon preparation, provision of carbohydrate-rich drinks one day prior and on the morning of surgery, goal directed fluid administration, body temperature control during surgery, avoiding drainages and nasogastric tubes, early mobilisation, and the taking of oral fluids in the early postoperative period. Perioperative morbidity and mortality data were collected and the length of hospital stay and protocol compliance recorded.ResultsThe median age of the patients was 68 years. Fifty-two % of the patients were women. The distribution of patients by ASA class was: I 10%, II 50% and III 40%. Sixty-four % of interventions were laparoscopic; 15% required conversion to laparotomy. The majority of patients underwent sigmoidectomy or right hemicolectomy. The overall compliance to protocol was approximately 65%, but varied widely in its different components. The median length of postoperative hospital stay was 6 days. Some 3% of patients were readmitted to hospital after discharge; some 7% required repeat surgery during their initial hospitalisation or after readmission. The most common complications were surgical (24%), followed by septic (11%) or other medical complications (10%). Three patients (1%) died during follow-up. Some 31% of patients suffered symptoms that delayed their discharge, the most common being vomiting or nausea (12%), dyspnoea (7%) and fever (5%).ConclusionThe following of this enhanced recovery program posed no risk to patients in terms of morbidity, mortality and shortened the length of their hospital stay. Overall compliance to protocol was 65%. The following of this program was of benefit to patients and reduces costs by shortening the length of hospital stay. The implantation of such programmes is therefore highly recommended.

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Section: Discussionsupporting

confidence: 92%

Enhanced recovery in colorectal surgery: a multicentre study

Ramı́rez

Blasco²,

Roig

et al. 2011

BMC Surg

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“…48 Such programs have been shown to be effective in different surgical populations. [48][49][50] It has also been suggested that rehabilitation programs should be reserved for patients who require postoperative care after the prehabilitation program. 47 If these multidisciplinary prehabilitation and rehabilitation programs are implemented, anesthesiologists should play a prominent role in their management.…”

Section: Future Considerationsmentioning

confidence: 99%

Clinical prediction model to identify vulnerable patients in ambulatory surgery: towards optimal medical decision-making

Mijderwijk

Stolker

Duivenvoorden

et al. 2016

Can J Anesth/J Can Anesth

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Background Ambulatory surgery patients are at risk of adverse psychological outcomes such as anxiety, aggression, fatigue, and depression. We developed and validated a clinical prediction model to identify patients who were vulnerable to these psychological outcome parameters. Methods We prospectively assessed 383 mixed ambulatory surgery patients for psychological vulnerability, defined as the presence of anxiety (state/trait), aggression (state/trait), fatigue, and depression seven days after surgery. Three psychological vulnerability categories were considered-i.e., none, one, or multiple poor scores, defined as a score exceeding one standard deviation above the mean for each single outcome according to normative data. The following determinants were assessed preoperatively: sociodemographic (age, sex, level of education, employment status, marital status, having children, religion, nationality), medical (heart rate and body mass index), and psychological variables (self-esteem and self-efficacy), in addition to anxiety, aggression, fatigue, and depression. A prediction model was constructed using ordinal polytomous logistic regression analysis, and bootstrapping was applied for internal validation. The ordinal c-index (ORC) quantified the discriminative ability of the model, in addition to measures for overall model performance (Nagelkerke's R 2 ). Results In this population, 137 (36%) patients were identified as being psychologically vulnerable after surgery for at least one of the psychological outcomes. The most parsimonious and optimal prediction model combined sociodemographic variables (level of education, having children, and nationality) with psychological variables (trait anxiety, state/trait aggression, fatigue, and depression). Model performance was promising: R 2 = 30% and ORC = 0.76 after correction for optimism.

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“…Despite its convincing results, world-wide adoption for various elements of Fast Track surgery is poor [42]. Still, in a recent report from a German quality assurance program (Fast Track Colon II), compliance for epidural anaesthesia (89%), systemic basic non-opoid analgesia (93%), intraoperative fluid restriction (81%), early oral feeding (73%) and enforced mobilization (84%) was high in a multicenter setting [43].…”

Section: Perioperative Managementmentioning

confidence: 99%

Surgery of colon cancer (conventional open and laparoscopic surgery)

Spatz

Anthuber

2010

Eur Surg

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Zusammenfassung. Grundlagen: Das Kolonkarzinom ist eine der häufigsten Todesursachen in der westlichen Hemisphäre mit ca. 639.000 krebsbezogenen Todesfällen pro Jahr weltweit. Die radikale chirurgische Tumorentfernung ist die entscheidende Behandlungsoption und stellt ein klassisches Betätigungsfeld des Allgemein-und Viszeralchirurgen dar.Methodik: Ziel der vorliegenden Arbeit war mit Hilfe einer Literatursuche in PubMed, DIMDI und EMBASE ergänzt durch eigene klinische Erfahrungen wichtige Arbeiten zur chirurgischen Therapie im Sinne einer aktuellen Ü bersichtsarbeit zusammenzufassen und dabei auch theoretische Grundlagen zu vermitteln.Ergebnisse: Tumorsitz und entsprechende Lymphabflusswege, Respektierung von anatomisch-embryonalen Schichten und arterielle Perfusion an den Absetzungsrändern bestimmen das Resektionsausmaß. Eine an diesen Prinzipien orientierte optimale chirurgische Technik ermöglicht eine niedrige Lokalrezidivrate und wirkt sich positiv auf das Langzeitergebnis aus. Die laparoskopische Technik ist dabei der offenen Technik ebenbü rtig. Auch in der Metastasenchirurgie ermöglicht die R0 Resektion ein Langzeitü berleben fü r ausgewählte Patienten. Durch multimodale Rehabilitation im Sinne eines perioperativen Fast Tack Managements lässt sich das chirurgische Trauma reduzieren und die Rekonvaleszenz beschleunigen.Schlussfolgerungen: Resektabilität und chirurgische Technik sind entscheidend für das Ü berleben von Patienten mit lokalisiertem oder bereits metastasiertem Kolonkarzinom.Schlüsselwörter: Kolonkarzinom, lymphogene Ausbreitung, chirurgische Technik, Ü berleben, perioperatives Management.Summary. Background: Colon cancer is a leading cause of death in western countries and accounts for 639,000 cancer-related deaths worldwide. Surgical tumour clearance is the key treatment option and represents a classic field of action for the general and visceral surgeon.Methods: PubMed, EMBASE and DIMDI were searched for articles referring to state of the art surgical management of colon cancer complemented by our own clinical experience to create an overview of up-todate treatment options and theoretical background knowledge.Results: The extent of bowel and mesenteric resection is dictated by the vascular supply and corresponding lymphatic drainage, careful attention to anatomical-embryological tissue planes and provision of adequate blood supply at the resection margins. Accordingly, optimal surgical clearance results in low local recurrence rates and translates into improved survival. In this context, the open and laparoscopic approaches yield similar results in terms of long-term outcome and oncological radicality. Radical resection of metastases results in long-term survival in selected patients. Fast Track rehabilitation facilitates attenuation of perioperative stress response and enhances recovery.Conclusion: Resectability and surgical technique are pivotal for long-term survival in all stages of colon cancer.

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Multimodal Perioperative Rehabilitation in Elective Conventional Resection of Colonic Cancer: Results from the German Multicenter Quality Assurance Program ‘Fast-Track Colon II’

Cited by 25 publications

References 52 publications

Enhanced recovery in colorectal surgery: a multicentre study

Enhanced recovery in colorectal surgery: a multicentre study

Clinical prediction model to identify vulnerable patients in ambulatory surgery: towards optimal medical decision-making

Surgery of colon cancer (conventional open and laparoscopic surgery)

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