eras cambodia

Fast Track Surgery : implications for developping

countries.

Prof. Dr. Y. Van Nieuwenhove

Dpt. Of Gastrointestinal Surgery

University Hospital Ghent, Belgium

Fast-track??

• Enhanced Recovery After Surgery

ERAS

• Enhanced Recovery After Surgery– Multimodal program of perioperative care– Change old habits– Apply new insights– No need for expensive infrastructure– Efficient use of resources

Henrik Kehlet from Danmark

• Lancet 1995: “stress-free” colon resection in 8 patients >70yrs– Laparoscopic approach– Pain control by epidural– Early (day 1) feeding– Early (day 1) mobilisation– Discharge from hospital day 2-3

Open-laparoscopic?

• Basse, Ann Surg 2005– RCT: 30 pts lap / 30 open colectomy– Age 75 (57-90)!!– Pts blinded by abdominal dressing– Hospital stay: L 2 (2-20) vs O 2 (2-5)– 1/3 of patients did not feel type of surgery

Multimodal

• Surgeon, anaesthetist, nurse, patient, family,…

• Elective surgery• to be planned in a clear program

Which patients?

• All patients– More fragile => better effect

• Elective surgery• No extra problems to be expected

THE STEPS TO TAKEEnhanced Recovery After Surgery

Bowel preparation

Slim et al, BJS 2004

Preoperative feeding

• Ljunqvist BJS 2002– Fasted for solids >6hrs before surgery– Clear liquids allowed 2-3h before surgery– Clear carbohydrate liquid can reduce

metabolic stress

Anaesthesiology

• Short acting anaesthetics (propofol, remifentanyl..)

• Epidural catheter (T7-8 / T9-10) with long acting local anaesthetic

• PONV prevention• Paracetamol, NSAIDS as pain control

Laparoscopy or open surgery?

LAFA study, Vlug et al, Ann Surg 2011

Drain-no drain

Petrowsky et al,

Gastric tube?

Verma & Nelson, Cochrane database 2007

PONV

Feeding and mobilisation

Lewis et al, BMJ 2001

Discharge when…

1. Oral feeding is possible

2. Oral pain control is possible

3. No signs of septic complications

4. Patient can walk around

5. Patient is willing to go

Take home message

• ERAS ≠ fast surgery• Breaks with tradition• Better for most patients• Multimodal approach• Cost reducing, efficient use of resources