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Implementation of fast-track preoperative care in a developing country can save on health resources while improving quality of care.
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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