Spanish Colorectal Surgery Group Studies Fast-Track Protocol

www.ftsurgery.comwww.ftsurgery.com
Division of Coloproctology
SURGERY SERVICE. HCU.ZARAGOZA

• Optimize the perioperative treatment of the
patients with the aim to:
reduce morbidity
improve recovery after surgery
reduce hospital stay
reduce health costs

Preoperative
Intraoperative
Postoperative
• What changes supposes the management of
patients?
Information and consent.
Adequate nutrition
No bowel preparation
Beverage intake rich on Carbohydrates pre-op.
Avoid drains
Avoid NGT
Use of de laparoscopic techniques
Use of transverse Incisions
Epidural Analgesia (Open Surgery).
Avoid Hypothermia
Use high concentrations of Oxygen
Controlled Fluid therapy (“Goal-directed”). CardioQ
Early mobilization (same afternoon)
Energy intake (same afternoon)

• What changes supposes the management of
patients?
Surgeon
Anesthesiologist
Nurse
Information and consent.
Adequate nutrition
No bowel preparation
Beverage intake rich on Carbohydrates pre-op.
Avoid drains
Avoid NGT
Use of de laparoscopic techniques
Use of transverse Incisions
Epidural Analgesia (Open Surgery).
Avoid Hypothermia
Use high concentrations of Oxygen
Controlled Fluid therapy (“Goal-directed”). CardioQ
Early mobilization (same afternoon)
Energy intake (same afternoon)

Colorectal Dis. 2008 May 3
"Fast-track"-colonic surgery in Austria and Germany - results from the survey on patterns in current
peri-operative practice. T Hasenberg, M Keese, F Längle, B Reibenwein, K
Schindler, A Herold, G Beck, S Post, K W Jauch, C Spies, W Schwenk, E Shang
Conclusions: Although there is an evident benefit of fast-track management, the
survey shows that they are not yet widely used as a routine.

• Spanish multicenter group of Fast-Track
Objectives:
What are our results for traditional surgery?
Where are the difficulties of implementing a program of Fast-Track?
Evidence of a multi-center group using the same protocol for the patients
themselves.
Are the results extrapolated to any other centers?
Permanent audit of the multi-center group results.
To collaborate with other national or international centers.
To offer the best available information on fast-track to whom it may concern.

MULTI-CENTER STUDY FOR
THE INTRODUCTION OF A PROGRAM
ON ENHANCED REHABILITATION IN COLORECTAL SURGERY:
– Inclusion Criteria:
• Patients older than 18 years, scheduled for surgery intervention for
right colon, left and / or rectum due to a malignant or benign cause.
– Exclusion Criteria:
• Emergency surgery.
• ASA IV
• Patients in need of colostomy or ileostomy.
• Diabetic patients
• Patients who have not signed informed consent.

MULTI-CENTER STUDY FOR
THE INTRODUCTION OF A PROGRAM
ON ENHANCED REHABILITATION IN COLORECTAL SURGERY:
Ethical Aspects:
Taking into account that each point of “Fast Track” is a form of treatment fully
accepted and supported by the best available scientific evidence. It was not
considered necessary by ethics committees and clinical trials to request the
approval .
However, patients are individually informed orally and in writing on the early
rehabilitation program, expecting them to cooperate.

Protocol
PRE-OPERATIVE
- Verbal and written information about the early rehabilitation program and obtain signature for
the informed consent. Evaluation of quality of life baseline : SF-36, EuroQoL.
- Malnourished patients (>10% weight in < than three months), hyperproteine supplement twice
daily, at least the whole week before surgery.
DAY -1:
 Non preparation of the colon. Two Enemas Casen ® at 20.00 hr.
 Normal intake in the morning. Throughout the afternoon, 4 Nutricia Preop ® bricks of
800 ml (100 mg of carbohydrates).
 During the afternoon, fluid intake on demand.
 A drink rich in carbohydrates at 20.00 hr.
 Not to use pre-medication.
 Antibiotic prophylaxis as usual.
 Prophylaxis of pulmonary embolism as usual.

Protocol
DAY 0:
 Two hours before surgery, intake of drink rich in carbohydrates (Nutricia Preop ®, 2
bricks, 400ml, 50g CHO).
 Two hours before Casen ® Enema.
 Not to use pre-medication.
 Routine Vital Signs surveillance
IN THE OPERATING ROOM
Surgeons:
 Not to use drains.
 Avoid gastric nasal tube.
 Attempt Laparoscopic intervention. Transverse incision in open surgery.
 Infiltrate wounds with Bupivacaine 0,25 % (20 ml).

(*)Grocott MP, Mythen MG, Gan TJ. Anesth Analg. 2005;100:1093–1106.
(*)Bundgaard-Nielsen M, Holte K, Secher NH, et al. Acta Anaesthesiol Scand. 2007;51:331–
340.
Protocol
Anesthesiologists:
• Epidural analgesia. At T9-T10 Bupivacaine 0,25/0,50% with
Sulfentanyl/Fentanyl.
 Maintenance: Oxygen/air with FiO2>80%.
 Do not use morphine
 Analgesia with Paracetamol IV in the operating room, Diclofenac IV, unless
contraindication or alteration of the renal function.
 Anti-emetics: Ondansetron IV (Zofran) 4 mg. Do not use Dexamethason.(If
necessary use Droperidol 0.625 mg or Haloperidol 1 mg).
 Monitoring: Routine + esophageal Doppler. Central catheter / arterial catheter
if necessary
*Goal directed fluid therapy:
Optimization according to ejection volume (Stroke Volume) with the esophageal
Doppler probe (Reset volume bolus of coloid 250cc depending on the drop in
the cardiac output measured by the esophageal Doppler).

You'll see, something
will happen today
day ...

Protocolo
Postoperative :
 High flow oxygen mask for 2 hours. After nasal mask to
keep saturation>95%.
 In the afternoon mobilize the patient to arm chair (min. 2
hrs)
 From 18.00 hr, liquid diet (800-1000cc) + 2 units rich in
protein and calories.
 Minimum diuresis (500cc first 24 hrs).
 Analgesia with 1 gr Paracetamol / 6 hrs + Epidural
catheter.
 Gluco-saline maintenance.
DAY 1:
-Liquid diet (min. 2 liters) + 3 energy preps.
-Mobilization with armchair 6 hrs. day.
-Discontinue fluids IV if tolerated. IV access heparinized.
-Maintain epidural pump (if any).
-Paracetamol 1 gr / 6 hrs.
-Lactulose 1 pack / 12 hrs.
-Evaluate criteria for discharge.

Protocolo
DAY +2:
 Suspend epidural catheter. Start with NSAIDs.
 Soft / normal diet.
 Mobilization on demand.
 Remove bladder catheter.
 Evaluate criteria for discharge.
DAY +3:
- Revision of the patient's general state.
- Evaluate criteria for discharge.
- Evaluate criteria for discharge and take decision over it.
DAY +4 and the following: Similar to Day +3.

• Discharge criteria
•Only oral analgesia
•Mobilization until preoperative
level
•Tolerates solid nutrition
•Flatulation
•Absence of nausea
•Wants to go home

Hospital Do Meixoeiro. Vigo
Hospital Fundación de Calahorra
Hospital Clínico Universitario. Zaragoza
Hospital Mutua de Terrassa.
Hospital General Universitario de Valencia
Hospital Universitario de Elche
Hospital Son Llátzer. Palma de Mallorca
Hospital Clínico San Carlos de Madrid
Hospital Gregorio Marañón. Madrid
Hospital La Paz. Madrid
Complejo Hospitalario La Mancha-Centro (A. de San Juan)
1st
of April 1st
of June
Participants

Participants
1st
of April
5th
of November
Retrospective study (data Introduction)
0
2
4
6
8
10
12
Junio Julio Agosto Septiembre Octubre
0
2
4
6
8
10
12
Junio Julio Agosto Septiembre Octubre
Prospective study (prepared for the study)
June July August September October June July August September October

Multi-center study to introduce a program of enhanced rehabilitation in colorectal
surgery
Preliminary results
Average age 69,6 years ± Std. Dev. 13,2 (43 - 89 years). Male 61%.
49
10
45
78
0
5
10
15
20
25
30
35
40
1
Técnica Quirúrgica
R.Hemicolectomy
L.Hemicolectomy.
RAB
Sigmoidectomy
Open Surgery
Minimal Invasive
Surgery
69%
31%
Way of ApproachSurgical Technique
Retrospective study (182 patients)

0
2
4
6
8
10
12
14
16
Wound
Infection
Hemorrhage
+ Transfusion
Exitus Íleo Undone
Anastomosis
Serie1
Retrospective study. Initial results (182 pat.)
Complications
Postoperative
TOTAL: 24,82%
Mean Stay: 12,1 days ± Std. Dev. 13,731 (4-78 days)

Retrospective study
Initial results (64 pat.)
Design of the study: Data is analyzed on the principle of “intention to treat”
1. Meets Inclusion Criteria
2. Doesn’t meet Exclusion Criteria
STUDY PATIENT
Objectives:
1. Success of the Program
2. Satisfaction of the Patient
3. Complications
4. Mortality
5. Re-operated
6. Hospital stay
7. Re-admission
8. Total length of stay
Pre-operatoria information yes / no
Preparation intestine yes / no
Pre-surgery drink the night before yes / no
Sedation yes / no
Morning drink yes / no
Pre-medication yes / no
Epidural anaesthesia yes / no
High flow oxygen yes / no
Oesophageal Doppler yes / no
Thermal blanket yes / no
Nasal gastric tube yes / no
Drains yes / no
Early mobilization yes / no
Early oral intake (High calorie drinks) yes / no

(*)Implementation of a Fast-Track Perioperative Care Program: What Are the Difficulties? .Sebastiaan W.
Polle, Jan Wind, Jan W. Fuhring, Jan Hofland, Dirk J. Gouma, Willem A. Bemelman. Dig Surg 2007;24:441–449
Pre-operative information 100% 87%
Preparation of the intestine 95% 100%
Pre-surgery drink the night before 95% 83%
Sedation 87% 40%
Morning drink 75% 30%
Pre-medication 80% 70%
Epidural anaesthesia 50% 71%
High flow oxygen 70% 67%
Oesophageal Doppler 72%
Termal blanket 75% 100%
Nasal gastric tube 72%
Drains 72%
Early mobilization 80% 40%
Early oral intake ( high calorie drinks ) 56% 13%
Mean Age 63,4 years ± Std. Dev. 10,2 (38-89 years). Male 60%.
Degree of complianceDegree of compliance 77.1%77.1% 63%63%

Surgical Technique
0
5
10
15
20
25
30
35
40
45
50
%
H.Right H.Left A.R.
Serie1
44%
47%
9%
Open
Laparascopic
Conversion
Open Surgery
Minimal Invasive
Surgery
69%
31%
49
10
45
78
0
10
20
30
40
1
Surgical Tecnique
Right Hemicolect omy
Lef t Hemicolect omy
RAB
Sigmoidectomy
Retrospective

Complications
Post-operative
TOTAL: 14,52%
SURGERY SERVICE. HCU.ZARAGOZARetrospective study. Initial results (64 pat.)
0
2
4
6
8
10
12
14
16
%
Wound
infection
Exitus Ileo Wound
leakage
others
Serie1
0
2
4
6
8
10
12
14
16
Infección de
Herida
Hemorragia +
Transfusión
Exitus Íleo Dehiscencia
Anastomosis
Serie1

MEAN Length of stay: 5,43 days (3-18 days)
Readmission: 3/64 (4.7%)
Mean LOS (including readmission): 6,03 (3-37)
Estudio Prospectivo. Resultados iniciales (64 pac.)
Post Operative Stay
0
20
40
60
80
100
120
3 4 5 6 7 8 9 10 11 12
Days post operative
%

Medical complications: Nausea. Vomiting. Ileus…
0
2
4
6
8
10
12
14
16
18
20
%
Medical Problems Doesn't want to Traditional Staff Social Problems

Success Program
Satisfaction Patient.
Complications
Mortality
Recovery
Hospital Stay
Re-admission
Total Length Stay
Difficult to Organize and to establish
Difficulty to obtain all parameters.
We do not have an analysis yet
Seems to decrease significantly
Similar
Similar
Seems to be significantly lower
<5%
6 days. Seems significantly lower

Spanish Colorectal Surgery Group Studies Fast-Track Protocol

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