1. Elective Colorectal Resection – How to Hasten the Recovery? Dr. Lily Ng RHTSK

2. Background Elective colorectal resection is common operation in general Surgery Laparoscopic / Laparoscopic-assisted resection was known to be associated with a faster recovery by reducing pain and post-op ileus Means to hasten recovery in open resection

3. Conventional Management No standard protocol Wide variations in Use of Peri-operative Pain Control Use of Tubes, Drains and Catheters Timing of Feeding Timing of Mobilization Depends on attending anaesthetist, surgeon, physiotherapist and nursing staff

4. Means to Hasten Recovery Use of Perioperative Pain Control Use of Tubes, Drains and Catheters Timing of Feeding Timing of Mobilization

5. Peri-operative Pain Control Wide variation Systemic opioid e.g. PCA Epidural anaesthesia Opioid LA Opioid – LA mixture Best if provide best pain control, without increasing undesirable side effects or post-op ileus

6. Effects of Peri-operative Analgesic Technique on Rate of Recovery after Colon Surgery Liu, Spencer S. MD, et al. Anaesthesiology Vol 83(4), Oct 1995, p757-765

7. Results – Pain score P<0.01 Anaesthesiology Vol 83(4), Oct 1995, p757-765

8. Results – Return of GI function and LOS Anaesthesiology Vol 83(4), Oct 1995, p757-765

9. Conclusion Use of epidural analgesia with bupivacaine or bupivacaine and morphine: Best balance of analgesia and side effects Faster recovery of GI function Shorter time to fulfill discharge criteria Anaesthesiology Vol 83(4), Oct 1995, p757-765

10. Means to Hasten Recovery Use of Perioperative Pain Control Use of Tubes, Drains and Catheters Timing of Feeding Timing of Mobilization

11. NG Tube Decompression Prophylactic nasogastric decompression after laparotomy was common Underlying reasons: ? Hasten return of bowel function ? Reduce risk of aspiration thus pulmonary complications ? Decrease patient discomfort by lessen abdominal distension ? Protect anastomoses and prevent anastomotic leakage

12. Prophylactic nasogastric decompression after abdominal surgery [Review] Nelson, R, et al The cochrane Database of Systematic Reviews The Cochrane collaboration Vol (4) 2005

13. Results - Time to Flatus The Cochrane collaboration Vol (4) 2005

14. Results – Complications The Cochrane collaboration Vol (4) 2005 Pulmonary Complication Anastomotic Leakage

15. Conclusion Routine NG decompression in elective colonic surgery Slower return of GI function No significant difference in terms of pulmonary complication / anastomotic leakage Routine NG decompression is not recommended The Cochrane collaboration Vol (4) 2005

16. Means to Hasten Recovery Use of Perioperative Anaesthesia and Analgesia Use of Tubes, Drains and Catheters Timing of Feeding Timing of Mobilization

17. Anastomotic Drainage Prophylactic anastomotic drainage was commonly used worldwide Intention to: Prevent accumulation of fluids in pelvic or peritoneal cavity Permit early detection of anastomotic dehiscence Treat or ?prevent anastomotic dehiscence Can it really improve the outcome?

18. Prophylactic anastomotic drainage for colorectal surgery [Review] Jesus, EC, et al Results DrainNo Drain95%CI Mortality3%4%0.39-1.31 Anastomotic dehiscence Clinical2%1%0.61-3.95 Radiological 3%4%0.42-1.61 Wound infection5%5%0.60-1.76 Re-intervention6%5%0.73-2.05 Extra-abdominal Cx7%6%0.66-1.85 The Cochrane Collaboration Vol (4) 2005

19. Conclusion No evidence that prophylactic anastomotic drainage in colorectal surgery can decrease mortality or other post-op complications Prophylactic anastomotic drainage is not recommended The Cochrane Collaboration Vol (4) 2005

20. Means to Hasten Recovery Use of Perioperative Anaesthesia and Analgesia Use of Tubes, Drains and Catheters Timing of Feeding Timing of Mobilization

21. Urinary Catheterization To prevent post-op urinary retention esp. those with epidural anaelgesia Prolong catheterization increase risk of UTI Optimal duration is unknown Common practice: catheter was kept at least until epidural analgesia was taken off

22. Is urinary Drainage Necessary During Continuous Epidural Analgesia After Colonic Resection ? Linda Basse, et al Patients were put on urinary drainage for 24 hours and epidural analgesia for 48 hours Results Urinary retention 9% (CI 2%-16%) Urinary tract infection 4% Voiding complaint at D30 0% (CI 0%-3.6%) Regional Anesthesia and Pain Medicine Vol 25 No 5, 2000; p498-501

23. Conclusion Routine urinary bladder catheterization is not required despite ongoing continuous thoracic epidural analgesia Regional Anesthesia and Pain Medicine Vol 25 No 5, 2000; p498-501

24. Means to Hasten Recovery Use of Perioperative Pain Control Use of Tubes, Drains and Catheters Timing of Feeding Timing of Mobilization

25. Post-op Enteral Feeding No consensus in the timing of feeding Two schools of thoughts NG catheter and fasting until passage of flatus, No NG tube and allow oral intake soon after operation

26. Early Oral Feeding After Colorectal Resection: A Randomized Controlled Study Carlo V. Feo, et al ANZ J. Surg. 2004; 74: 298-301

27. Conclusion Patients undergoing elective colorectal resection can be started on oral feeding on the first post-op day Early post-op oral feeding was safe without increase in post-op complications ANZ J. Surg. 2004; 74: 298-301

28. Summary Means to Hasten Recovery Epidural analgesia provides good pain control No routine use of nasogastric tube / anastomotic drainage Routine urinary catheterization is not necessary despite use of epidural Early enteral feeding is safe

29. Fast Track Surgery Multimodal rehabilitation program Pre-operative patient education Newer anaesthetic, analgesic and surgical techniques Aggressive post-operative rehabilitation Early enteral nutrition Early mobilization Minimal use of tubes, drains and catheters Aim to shorten time to recovery

30. A clinical pathway to accelerate recovery after colonic resection Linda Basse, et al. A prospective study to test for feasibility of a 48-hour postoperative stay program after colonic resection Well-defined post-op care program Continuous thoracic epidural analgesia Enforced early mobilization Early enteral nutrition Planned 48-hour post-op hospital stay Ann Surg July 2000

32. Results Ann Surg July 2000 Return of GI FunctionLength of Hospital Stay 95% patient defecate within 48 hrs Median LOS: 2 days

33. Conclusion Multimodal rehabilitation program may significantly reduce Post-op ileus Post-op hospital stay Ann Surg July 2000

34. Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection M. Gatt, et al BJS 2005; 92: 1354-1362

35. Optimization Package BJS 2005; 92: 1354-1362

36. Outcome Measures Physiological Function Psychological Function Pain Score Gut Function Time to tolerate diet Clinical Outcome Length of hospital Stay Complications and death Need for readmission BJS 2005; 92: 1354-1362

37. Results P=0.042 BJS 2005; 92: 1354-1362 Return of GI function P=0.027 Length of Hospital Stay

38. Post-op Morbidity / Mortality BJS 2005; 92: 1354-1362

39. Conclusion Use of multimodal opitmization Earlier return of GI function Shorter length of hospital stay No increase in post-op morbidity / mortality BJS 2005; 92: 1354-1362

40. Summary Revision of traditional surgical care programs, Minimal use of tubes, drains, bladder catheter Optimal pain relief with continuous thoracic epidural analgesic with LA and opioids, Early enteral nutrition Enforced mobilzation  may enhance recovery after elective colonic resection. In future, large randomized or multi-center studies, using identical protocols should be conducted

41. Our Experience at RHTSK Objective: To develop a standardized treatment protocol (clinical pathway) in managing patients who undergo elective colorectal resection All patients undergoing elective colorectal resection with anastomosis during Jun 2005 to Aug 2005 (total 13 patients) were compared with those during Sept 2003 to Aug 2004 (total 37 patients)

42. Results – No. of Days (median) Day (Median)

43. ~ The End ~