Perioperative Ernährung We make them sick - … · vielmehr auf die Vorbereitung und...

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Perioperative Ernährung

R.Kafka2

"We make them sick"

Unter diesem Gesichtspunkt hat Prof. Khelet vom Hvisdovre Krankenhaus in Kopenhagen viele Dogmen in der perioperativen Behandlung von Patienten hinterfragt und verändert.

FAST TRACK OA.Dr.R.KAFKA-RITSCH 3

"We make them sick"

Zeigen Sie mir einen 80jährigen, der tagtäglich 2 Liter Flüssigkeit trinkt", sagt Prof. Khelet ,"warum belasten wir ihn dann nach einer Operation damit?“Patienten wurden bei geplanten Dickdarmeingriffen bedingt durch Darmspülung und präoperative Nüchternheit bis zu 3 Tage „ausgehungert“.


Fast trackWörtlich übersetzt heißt es ‚schnelle Schiene’. "Fast Track" bedeutet keine neue, bessere Chirurgie, sondern bezieht sich vielmehr auf die Vorbereitung und Nachbehandlung von operierten Patienten

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Fast track Ziel

Das primäre Ziel des FAST TRACK Programms ist jedoch nicht die

Verkürzung der Aufenthaltsdauer, sondern die Vermeidung von

perioperativen Komplikationen und die möglichst rasche Wiederherstellung der

Körperfunktionen

„optimale multimodale Therapie“FAST TRACK OA.Dr.R.KAFKA-RITSCH 6

Fast track Bausteine

Reduzierung von StressOptimale SchmerzbehandlungKörperliche AktivitätErnährungChirurgische Techniken


Fast track

Reduzierung von StressAusführliche Aufklärung des Patienten über Erkrankung, OP und Narkoseart (PDA)Kein präoperatives FastenKeine DarmlavageDurch PDA Blockade viszeraler Afferenzen und Reduzierung von SIRS


Fast track

Optimale SchmerzbehandlungPeridurale Anästhesie mit Pumpe bis zum 2. postoperativen TagLaparoskopische Operation oder alternative Schnittführungen bei konventioneller Operation

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Fast track

Körperliche AktivitätFrühmobilisation bereits am OP Tag mit unterstütztem Gehen und QuerbettsitzenAb 1. OP Tag 2-3x Gehen am Stationsflur und 2-3 x 2h SitzenBettsperre ab dem 3. OP Tag ( nur Mittagsschlaf)


Fast trackPräoperative Ernährung:

Wie ein Sportler sich auf einen Marathon vorbereitet so sollte ein Patient vor einer geplanten Operation ernährt werden

unterernährte Patienten ( Gewichtsverlust 10% des Körpergewichts, oder BMI < 24) sollten 5-7 Tage präoperativ und bevorzugt oral ernährt werden (Immunonutrition)

normal ernährte Patienten sollten bis 2h vor OP mit kohleydratreicher Trinknahrung versorgt werden


Fast track

Intraoperativ:PDA, Blockade der Afferenzen kann SIRS reduzierenflüssigkeits- und opiatsparende Narkose soll die Darmmotilität erhaltentraumasparendes operierenExtubation, Magensonde ex am OP TischDrains vermeidenintraoperative Antioxidantiengabe (Vit C, Vit E)


Fast track Protokollin der elektiven Kolonchirurgie

seit 1. Oktober 2004 Klinische Abteilung für Allgemein- Thorax-und TransplantationsmedizinStation 9 NordAlle Patienten die zur geplanten Dickdarm-resektion aufgenommen werden.

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OP Tagpostoperativ sobald der Patient wach ist Tee trinken bis max 1500ml, am Abend 1 Portion Joghurt6h nach OP Mobilisation mit dem Versuch einige Schritte zu gehen und 2h zu sitzenmax 500ml Infusion postoperativ



1. Postoperativer TagFalls Drain, Drain entfernen1500 ml trinkenPDA, Diclofenac 2x100mg oral, PantolocMagnosolv 2x1 Btl tglKrankenhauskost wird angeboten2-3 x 2h mobilisieren mit GehenLabor: BB, CRP, Crea, Hst, Elyte, Harnnatrium



2. Postoperativer TagZVK entfernenPDA Katheter entfernen, 4h später DK ex1500 ml trinken, KrankenhauskostDiclofenac, Pantoloc, Magnosolv2-3 x 2h mobilisierenbei Bedarf: Crea, Hst, Elyte, Harn-Na



3. Postoperativer TagBettsperre (ins Bett nur zum Mittagsschlaf)Patient soll sich zivil kleidenGespräch mit Patienten über Versorgung zu Hause1500 ml trinken, KrankenhauskostDiclofenac, Pantoloc, MagnosolvLabor:BB, CRP, Crea, Hst, Elyte, Harnnatrium


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Entlassung ab 5.TagAufklärung des PatientenInformationsblatt für Patienten

Patient misst täglich Temperatur und führt Flüssigkeitsbilanz

Informationsblatt für den HausarztKontrolltermin zur Histobesprechung und Nachkontrolle in 1 Woche



Fast track- Patientin 83a

Konventionelle OP wegen kardialem Risiko

erweiterte Hemicolektomie re

2 von 39 Lymphknoten positiv

Stenosesymptomatik, von Gastroenterologie zugewiesen zur OP


Fast track- eigene Erfahrungen

Video Patientin



Entlassungstag: 8 median (3 - 41)weniger Elektrolytentgleisungennicht toleriert: 7Wiederaufnahmen: 2(Pneumonie E d4, WA d5/ Hämatom WA d 10)

PDA Dysfunktion 9

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Entlassungstag

0123456789

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1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41

median

E vorher


Fast TrackGrenzen aus chirurgischer Sicht

.... including´new methods of aggressive reduction of surgicalstress using pharmacological modifiers, such as steroids, a-blockers and anabolic agents.There will be new developments in minimally invasive surgery, liquid management, and anaestheticand analgesic techniques ....... it may even be that most major operations, even in high riskpatients, will prove possible in an ambulatory or semiambulatorysetting

Leading article: Fast-track surgeryH. Kehlet1 and D. W. Wilmore2 January 2005

Keine ?



Der Anästhesist Funktionierende PDAopiatsparende NarkoseFlüssigkeitsmanagementfunktionierende Teamarbeit vom OP über Aufwach bis zur Normalstation


Preoperative fasting.Ljungqvist O, Søreide E.Br J Surg. 2003 Apr;90(4):400-6.Centre of Gastrointestinal Disease, Ersta Hospital, Stockholm, Sweden

.

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Carboloading 1 - PONV

Hausel J, ….. Ljungqvist O.Randomized clinical trial of the effects of oral preoperative carbohydrates onpostoperative nausea and vomiting after laparoscopic cholecystectomy.Br J Surg. 2005 Apr;92(4):415-21.


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Carboloading 2 – insulin resitance

Ljungqvist O.Clin Nutr. 2005 Oct;24(5):815-21.



Präoperative Ernährung2h vor OP kohlenhydratteiches Getränkkeine Darmvorbereitung

Roumen RM, Meta-analysis of randomized clinicaltrials of colorectal surgery with or without mechanicalbowel preparation (Br J Surg 2004; 91: 1125-1130).


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Pre-operative oral carbohydrate loading in colorectal surgery: a randomized controlled trial.

Noblett SE,etal.Department of Colorectal Surgery, Freeman Hospital, High Heaton,Colorectal Dis. 2006 Sep;8(7):563-9

… patients in the carbohydrate group had a median postoperative hospital stay of 7.5 days compared with 13 days in the water group (P > 0.01) and 10 days in the fasted group (P = 0.06). The median time postsurgery to first flatus was 3 days for both the fasted and water groups compared with 1.5 days in the carbohydrate group (P = 0.13).

… first bowel movement occurred on day 3 in the carbohydrate group, day 4 in the fasting group and day 5 in the water group.

… the fasted group showed a significant reduction in postoperative grip strength (P < 0.05) with a median drop of 10% at discharge. Neither the water nor the carbohydrate groups showed significant reductions in muscle strength.

CONCLUSION: … pre-operative administration of oral carbohydrate leads to a significantly reduced postoperative hospital stay, and a trend towards earlier return of gut function when compared with fasting or supplementary water.

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Darmvorbereitung Literatur

Contant CM, et al.Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial.Lancet. 2007 Dec 22;370(9605):2112-7.

Bretagnol F, et al.Rectal cancer surgery without mechanical bowel preparation.Br J Surg. 2007 Oct;94(10):1266-71.

Wille-Jørgensen P, et al.Pre-operative mechanical bowel cleansing or not? an updated metaanalysis.Colorectal Dis. 2005 Jul;7(4):304-10. Review.


Jung B, et al ; Mechanical Bowel Preparation Study Group.Multicentre randomized clinical trial of mechanical bowel preparation in elective

colonic resection.Br J Surg. 2007 Jun;94(6):689-95.

Darmvorbereitung LiteraturContant CM, et alMechanical bowel preparation for elective colorectal surgery: a multicentrerrandomised trialLancet. 2007 Dec 22;370(9605):2112-7..

BJS:CONCLUSION: MBP does not lower the complication rate and can be omitted before elective colonic resection.

LancetINTERPRETATION: We advise that mechanical bowel preparationbefore elective colorectal surgery can safely be abandoned.


Darmvorbereitung LiteraturBretagnol F et al.Rectal cancer surgery without mechanical bowel preparation.Br J Surg. 2007 Oct;94(10):1266-71.

The present study has provided preliminary evidence for the safety of rectalcancer surgery without MBP. It showed no benefit of MBP before anteriorresection, but that omission of bowel preparation might have a positive impact in terms of decreased morbidity and a shorter hospital stay.


Päoperative Ernährungelektive Viszeralchirurgie - Mangelernährung ?

INST (Innsbucker Nutrition Score Tool) 1 2 3 Alter (Jahre) >70 BMI (kg/m2) <18,5 <16 % Gewichtsabnahme in 3 Monaten >5 >10 >15 Nahrungszufuhr in der letzten Woche <75%

bei INST ≥3 + Tumorpat. vor großen viszeralchir. Eingriffen (Ösophagus, Leber, Pancreas, Gefäße)

oral/enteral: 5 Tage vor geplanter OP 3x1 proteinreiche TN bis zum Vorabend der OP (auch ambulant möglich!)periphervenös (oral nicht möglich!): 3 Tage präop. tgl. 1000 ml StructoKabiven + 100 ml Omegaven

Carbo-Loading: bis 2 Stunden vor OP zum Auffüllen der Glykogenspreicher: gesüßten Kaffee oder Tee, Säfte ohne Fruchtfleisch, ev. bis 400 ml ProvideX

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Postoperative Nüchternheit

Speichel ~ 2 LiterGalle 700-1500 mlPancreas 1000-2000ml

Nüchternheit nach colorectaler Chirurgie ?

Ziel - Fast track recovery : keine postoperativen InfusionenEssen ab dem 1. p.o. Tag

Limitation: Narkosenachwirkung, PONV,


Vorteil enteraler Nahrungszufuhr:Durchblutung Darm - Zottennahrung

Moore FA, et al.

Early enteral feeding, compared with parenteral, reduces postoperative septiccomplications.

Ann Surg 1992: 216; 172-83


ostoperative Motilität

SpeichelPDA

SympathekektomieOpiatsparende AN

nichtsteroidale A.

Flüss.sparende AN

Laxans (Magnosolv)

Prokinetika

orale Zufuhr,gastrocephaler Reflex


Does enteral nutrition affect clinical outcome? A systematic review of the randomized trials.

Koretz RL, et al.Am J Gastroenterol. 2007 Feb;102(2):412-29;

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33 of 376 RCT of EN enteral nutrition18 of 150 RCT comparing EN versus PN54 of 418 of VNS were included

No grade 1 evidence was found:

There is reasonable evidence for using VNS in malnourished ... patients.The recommendations to consider EN/VNS in perioperative ... patients are limited by the low quality of the RCTs.


ImmunonutritionImmunmodulatorische Effekte:

Glutaminnicht ess. Aminosäure, zur Erhaltung der mukosalen Darmfunktion

Argininim katabolen Zustand als semi-essentielle Aminosäure

soll die Ausschüttung von anabolen Hormonen wie Somatotropin, Prolactin und Insulin bei Traumapatienten steigern, T-Lymphozyten aktivieren, sowie Phagocytenaktivität und Adhärenz von polymorphkernigen Leukozyten verbessern. ... die Ausschüttung von proinflammatorischen Zytokinen wie TNF-alpha oder IL-6 verringert werden.

Omega3-FettsäurenMembranstabilisierung, Ausschüttung von proinflammatorischen Zytokinen

verringern

Vit C, Vit EAntioxidativ, Radikalenfänger


ImmunonutritionHorie H,Surg Today. 2006;36(12):1063-8.

Favorable effects of preoperative enteral immunonutrition on surgical site infections in patients with colorectal cancer without malnutrition.

... superficial incisional SSI, deep incisional SSI and organ/space SSI in the immunonutrition ( 5 days prior to surgery, n=33) and control groups(n=34) were

0% and 11.8% (4/34; P < 0.05), 0% and 0%, and 0% and 2.9% (1/34),

Preoperative enteral immunonutrition appears to be effective for preventing SSI in patients with colorectal cancer without malnutrition.


Immunonutrition

Takeuchi H, et al.World J Surg. 2007 Nov;31(11):2160-7.Clinical significance of perioperative immunonutrition for patients with esophageal cancer.

Group A: n=20 control enteral standardGroup B: n=6 postoperative immunonutritionGroup C: n=14 perioperative immunonutrition

SSI in group C was significantly lower than that in group A (p = 0.03)SIRS was significantly shorter in group C than in group A (p < 0.05)

Conclusion:... perioperative immune-enhanced formula may be superior to postoperative control enteral formulas in terms of reducing surgical wound infection and postoperative SIRS...

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Early enteral supplementation with key pharmaconutrients improvesSequential Organ Failure Assessment score in critically ill patients withsepsis: Outcome of a randomized, controlled, double-blind trial*Richard J. Beale,Crit Care Med 2008 Vol. 36, No. 1

Objective: To assess the safety and efficacy of an early enteralpharmaconutrition supplement containing glutamine dipeptides, antioxidativevitamins and trace elements, and butyrate in critically ill, septic patients.Design: A prospective, randomized, controlled, double-blind clinical trial.Setting: Adult intensive care unit in a university hospital.Patients: Fifty-five critically ill, septic patients requiring enteral feeding.Interventions: Patients received either an enteral supplement (500 mL of Intestamin, Fresenius Kabi) containing conditionally essential nutrients or a control solution via the nasogastric route for up to 10 days. … additionallyenteral feeding with an immunonutrition formula (experimental group) orstandard formula (control group) initiated within 48 hrs after enrollment.

Conclusions: … early enteral pharmaconutrition with glutamine dipeptides, vitamin C and E, -carotene, selenium, zinc, and butyrate in combination with an immunonutrition formula results in significantly faster recovery of organ function


1: Surg Today. 2009;39(10):855-60. Epub 2009 Sep 27. Links

Optimal dose of preoperative enteral immunonutrition for patients with esophageal cancer.Nakamura M, Iwahashi M, Takifuji K, Nakamori M, Naka T, Ishida K, Ojima T, Iida T, Katsuda M, Hayata K, Yamaue H.Wakayama Medical University, Japan.PURPOSE: A preoperative immunonutrition pharmaceutics diet (IMPACT) significantly reduced the incidence of postoperative infectious complications, but the optimal regimen still remains unclear. We evaluated the optimal dose of a preoperative IMPACT for patients with esophageal carcinoma and the incidence of postoperative complications based on the dose of IMPACT. METHODS: This study design was a prospective nonrandomized study. Twenty patients with thoracic esophageal carcinoma who underwent a right transthoracic subtotal esophagectomy were divided into two groups. These patients were administered immunonutrition of 500 ml/day (IMP500) or 1000 ml/day (IMP1000) for 7 days before the operation. RESULTS: The incidence of postoperative mortality and morbidity was not different between the IMP500 group and the IMP1000 group. No difference was observed in the perioperative changes in inflammatory, immunological and nutritional variables between the two groups. There were no adverse effects in the IMP500 group, but four patients (40%) had diarrhea and four patients (40%) had appetite loss in the IMP1000 group. In the IMP1000 group, only four patients (40%) could take 1000 ml, but others reduced the quantity of IMPACT because of diarrhea and discomfort. CONCLUSION: This study suggests that 500 ml of IMPACT is recommended as an optimal dose for patients with esophageal cancer.


Eur J Gynaecol Oncol. 2009;30(4):418-21. LinksThe role of immunonutrition in gynecologic oncologic surgery.Celik JB, Gezginç K, Ozçelik K, Celik C.Department of Anesthesiology Konya, Turkey.BACKGROUND: This study assesses the effect of immunonutrition onbiochemical and hematological parameters, incidence of infection, postoperative complications, mortality rate and length of hospital stay. MATERIAL AND METHODS: A total of 50 patients operated on for gynecological malignancies were randomly assigned to two groups, each receiving two days preoperative and seven days postoperative enteral nutrition after intestinal movements started. The patients in group 1 were given 1000 kcal/d immun-enhancing enteral nutrition (IEN). The patients in group 2 received 1000 kcal/d standard enteral nutrition. The nutritional (albumin, prealbumin), immunologic (CRP, white blood cell (WBC) count, lymphocyte population) parameters, length of hospital stay (LOS) and clinical outcomes were examined. RESULTS: The two groups did not differ in terms of demographic data, nutritional status, surgical status, mortality rate (p > 0.05). WBC count, lymphocyte population, CRP levels were significantly higher in group 1 compared with group 2 in the postoperative period (p < 0.05). Pulmonary and urinary tract infection rates were similar in both groups (p > 0.05) but wound infection, and LOS rate were significantly lower in group 1 than group 2 (p < 0.05).CONCLUSION: Perioperative immunonutrition proved to be safe and useful in increasing the immunologic response. It may decrease postoperative complications and LOS in patients undergoing surgery for gynecological malignancy.

FAST TRACK OA.Dr.R.KAFKA-RITSCH

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• World J Surg. 2009 Sep;33(9):1815-21. Links

– Attenuation of the systemic inflammatory response and infectiouscomplications after gastrectomy with preoperative oral arginine and omega-3 fatty acids supplemented immunonutrition.

– Okamoto Y, Okano K, Izuishi K, Usuki H, Wakabayashi H, Suzuki Y.– Department of Gastroenterological Surgery,, Kagawa University, Japan. – BACKGROUND: Past trials have shown perioperative immunonutrition to improve the

outcome for patients with gastric cancer. The present study was designed to evaluate the effect of preoperative oral immunonutrition on cellular immunity, the duration of the systemic inflammatory response syndrome (SIRS), and detailed postoperative complications in patients with gastric cancer.

– METHODS: Sixty patients with gastric cancer were randomly assigned to two groups: one group received immune-enhanced formulas supplemented with arginine and omega-3 fatty acids (immune-enhancing diet (ID) group, n = 30); the other received standard formulas (conventional diet (CD) group, n = 30) for 7 days before the operation. These groups were well matched in terms of age, sex, operations, cancer stages, and intraoperative variables. The postoperative outcome was evaluated based on clinical variables, including postoperative infectious complications, noninfectious complications, and SIRS duration. In addition, the perioperative state of cellular immunity was evaluated and compared between the two groups.

– RESULTS: The incidence of postoperative infectious complications in the ID group (6%) was significantly (p < 0.05) lower than that of the CD group (28%). The duration of SIRS in the ID group (0.77 +/- 0.9 days) was significantly (p < 0.05) shorter than that in the CD group (1.34 +/- 1.45 days). The postoperative lymphocyte and CD4(+)T-cell counts significantly decreased (p < 0.05) in both groups. However, the number of CD4(+)T-cells on preoperative day 1 and postoperative day 7 was significantly (p < 0.05) higher in the ID group than in the CD group.

– CONCLUSIONS: Preoperative oral immune-enhanced formulas supplemented with arginine and omega-3 fatty acids enhanced the immune status of the patients, reduced the duration of SIRS, and decreased the incidence of postoperative infectious complications. CD4(+)T-cell immunity likely played an important role in the modulation of the postoperative immune and inflammatory response after gastrectomy.

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FAST TRACK OA.Dr.R.KAFKA-RITSCH

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• World J Gastroenterol. 2009 Jan 28;15(4):467-72. Links

– Effect of preoperative immunonutrition and other nutrition models on cellular immune parameters.

– Gunerhan Y, Koksal N, Sahin UY, Uzun MA, Ekşioglu-Demiralp E.– Department of Surgery, Kafkas University Faculty of Medicine, Pasacayiri

36100, Kars, Turkey. [email protected]– AIM: To evaluate the effects of preoperative immunonutrition and other

nutrition models on the cellular immunity parameters of patients with gastrointestinal tumors before surgical intervention. In addition, effects on postoperative complications were examined. METHODS: Patients with gastrointestinal tumors were randomized into 3 groups. The immunonutrition group received a combination of arginine, fatty acids and nucleotides. The second and third group received normal nutrition and standard enteral nutrition, respectively. Nutrition protocols were administered for 7 d prior to the operation. Nutritional parameters, in particular prealbumin levels and lymphocyte subpopulations (CD4+, CD8+, CD16+/56+, and CD69 cells) were evaluated before and after the nutrition protocols. Groups were compared in terms of postoperative complications and duration of hospital stay. RESULTS: Of the 42 patients who completed the study, 16 received immunonutrition, 13 received normal nutrition and 13 received standard enteral nutrition. prealbumin values were low in every group, but this parameter was improved after the nutritional protocol only in the immunonutrition group (13.64+/-8.83 vs 15.98+/-8.66, P=0.037). Groups were similar in terms of CD4+, CD16+/56, and CD69+ prior to the nutritional protocol; whereas CD8+ was higher in the standard nutrition group compared to the immunonutrition group. After nutritional protocols, none of the groups had an increase in their lymphocyte subpopulations. Also, groups did not differ in terms of postoperative complications and postoperative durations of hospital stay. CONCLUSION: Preoperative immunonutrition provided a significant increase in prealbumin levels, while it did not significantly alter T lymphocyte subpopulation counts, the rate of postoperative complications and the duration of hospital stay.



Anastomosenschutz

Anastomosen werden noch intraoperativ entweder koloskopisch(Kolon) oder gastroskopisch (Gastrektomie) auf Dichtigkeit geprüft, halten daher auch der normalen Peristaltik stand



Mangelnde Diurese - wie lange kann ich warten - dauerhafte Schädigung der Nierenfunktion ?

Harnnatrium –wenn < 20 mmol/l dann zusätzlich i.v. FlüssigkeitNormalwert (10-226 mmol/l)


HARNAUSSCHEIDUNG (Tag 1)

1000 – 3600 mlMittelwert 2354ml≈ Stundenharn 100 ml/h

LASIX (20 mg i.v. bei Bedarf)

8/28 28,5%

S-KREATININ (mg/dl)

präop. 0,91 (0,54 – 1,28)postop. 0,99 (0,64 – 1,8)Anstieg 43%

0

1000

2000

3000

4000

Fast track – ErgebnisseTeilauswertung – Dr.A.Perathoner

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Infusionen

15

86

31

05

101520

1 2 3 4 5

ENTERALE Flüssigkeitszufuhr

> 1000 ml 27/28 97,5 %

> 2000 ml 14/28 50 %

PARENTERALE Flüssigkeitszufuhr (additiv!)

Infusionsvolumen

0

200400

600800

1000

1 2 3 4 5



PONV3/28 10,5 %

Antiemetika2/28 7 %

Magensonde1/28 3,5 %

02468

101214

Tag 1 Tag 2 Tag 3 Tag 4

STUHLGANG


Functional Recovery After Open Versus Laparoscopic Colonic Resection: A Randomized, Blinded Study.

Basse L, Jakobsen DH, Bardram L, Billesbolle P, Lund C, Mogensen T, Rosenberg J, Kehlet H.

From the *Department of Surgical Gastroenterology and daggerDepartment of Anesthesiology, Copenhagen University Hospital, Hvidovre, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark.

März 2005

METHODS:In a randomized, observer-and-patient, blinded trial, 60 patients (median age 75 years) underwent elective laparoscopic or open colonic resection with fast-track rehabilitation and planned discharge after 48 hours. Functionalrecovery was assessed in detail during the first postoperative month.

RESULTS:Median postoperative hospital stay was 2 days in both groups, with early and similar recovery to normal activities as assessed by hours of mobilization per day, computerized monitoring of motor activity assessed, pulmonary function, cardiovascular response to treadmill exercise, pain, sleep quality, fatigue, and return to normal gastrointestinal function. There were no significantdifferences in postoperative morbidity, mortality, or readmissions, although 3 patients died in the open versus nil in the laparoscopic group.

CONCLUSION:Functional recovery after colonic resection is rapid with a multimodal rehabilitation regimen and without differences between open and laparoscopic operation. Further large-scale studies are required on potential differences in serious morbidity and mortality.

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Entlassungstag


Fast trackZusammenfassung

Fast bei allen elektiven Operationen am Gastrointestinaltrakt möglichSenkt krankenhausspezifische KomplikationenWeniger Beeinträchtigung – mehr Komfortschnellere Wiederherstellung der Körperfunktionen


Fast track LimitationenAkutoperationenStenosierender Prozess im DarmKeine PDA möglichKardiales Risiko ev. eingeschränkte MobilisationMangelnde Kooperation

FAST TRACK OA. Dr.R. KAFKA-RITSCH 56

Fast track

Erfordert Zusammenarbeit Chirurgie, Anästhesie und PflegeErfordert bessere Aufklärung von Patient und Hausarzt Fast track kann biologische Prozesse wie die Heilung der Anastomose an sich natürlich nicht beschleunigen. Anastomosendehiszenz kann bis zum 10.Tag auftreten

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FAST TRACK OA. Dr.R. KAFKA-RITSCH 57

Konklusion

Es fehlt einem ja nicht`saußer dem Tumor

Perioperative Ernährung We make them sick - … · vielmehr auf die Vorbereitung und...

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