Int J Colorectal Dis (2006) 21: 547–553 DOI 10.1007/s00384-005-0056-7

W. Schwenk J. Neudecker W. Raue O. Haase J. M. Müller

Accepted: 30 September 2005 Published online: 9 November 2005 # Springer-Verlag 2005

W. Schwenk . J. Neudecker . W. Raue . O. Haase . J. M. Müller Department of General, Visceral, Vascular and Thoracic Surgery, Humboldt University, Charité, Campus Mitte, Berlin, Germany W. Schwenk (*) Universitätsklinik für Allgemein-, Visceral-, Gefäß- und Thoraxchirurgie, Universitäre Medizin Berlin-Charité Campus Mitte, Schumannstrasse 20/21, 10117 Berlin, Germany e-mail: [email protected] Tel.: +30-450-522199 Fax: +30-450-522929

ORIGINA L ARTI CLE

“Fast-track” rehabilitation after rectal cancer resection

Abstract Background and aims: After rectal cancer surgery, postoperative general complications occur in 25–35% of all patients and postoperative hospital stay is 14–21 days. “Fast-track” rehabilitation has been shown to accelerate recovery, reduce general morbidity and decrease hospital stay after elective colonic surgery. Because the feasibility of “fast-track” rehabilitation in patients undergoing rectal cancer surgery has not been demonstrated yet, we demonstrate our initial results of “fast-track” rectal cancer surgery. Patients and methods: Seventy consecutive unselected patients undergoing rectal cancer resection by one surgeon underwent a perioperative “fast-track” rehabilitation. Demographic and operative data, pulmonary function, pain and fatigue, local and general complications and mortality were assessed prospectively. Results and findings: Thirty-six female and 34 male patients aged 65 (34–77) years underwent open (n=31) or laparoscopic (n=39) anterior resection with partial mesorectal exci-

Introduction Perioperative care for patients with rectal cancer is rather “traditional” in Germany and the rest of Europe. Only 4 to 44% of European surgeons provide their patients with early solid feeding after abdominal surgery [1], and only 66% of European physicians utilised epidural analgesia after a major abdominal surgery (D. Benhamou, 2005, personal communication). Postoperative general complications after

sion (PME 27), anterior resection with total mesorectal excision and protective loop ileostomy (TME 29) or abdominoperineal excision with colostomy (APR 14). Overall, pulmonary function returned to >80% of preoperative value on day 2 (1–4) and the first bowel movement occurred on day 1 (0–3) after surgery. The incidence of local and general complications was 27 and 18%, respectively. Postoperative hospital stay was 8 (3–50) days overall, but shorter after PME [5 (3–47)] than TME [10 (5–42)] or APR [9 (5–50)] (p<0.01). Interpretation and conclusion: “Fast-track” rehabilitation was feasible in patients undergoing rectal cancer resection. Local morbidity was not increased, while general morbidity and postoperative hospital stay compared favourably to other series with “traditional” perioperative care. Keywords Rectum carcinoma . Perioperative treatment . Morbidity . Fast-track surgery . Hospital stay

resection of rectal cancer ranges from 27–35% and postoperative hospital stay is as long 14–21 days [2–7]. Perioperative, multimodal “fast-track” rehabilitation programs for elective colonic resections have been shown to enhance postoperative recovery, reduce postoperative morbidity and decrease duration of postoperative hospital stay [8–11]. However, reports on “fast-track” rehabilitation after rectal surgery are rare [12, 13] and the feasibility of a “fasttrack” program for rectal cancer patients has not been

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evaluated yet. After the successful introduction of a multimodal rehabilitation program for elective colonic resection in our department [14], we implemented the same “fasttrack” protocol for patients undergoing resection of rectal cancer. Because the feasibility of “fast-track” rehabilitation in patients undergoing rectal cancer surgery has not been demonstrated yet, we prospectively collected and analysed the data of the first 70 consecutive rectal cancer patients.

Materials and methods All patients undergoing elective resection of rectal cancer between January 2002 and February 2004 by one surgeon (W. S.) were included. There were no patients excluded and all data were assessed prospectively. All tumours were located within 16 cm from the anal verge. The principles of the perioperative “fast-track” rehabilitation program for rectal cancer resection were adopted from Kehlet et al. [10, 15, 16] and are given in Table 1. All patients underwent bowel preparation (Prepacol, Guerbet, Germany; 2 l PEG solution, Klean-Prep, Norgine, Germany) and received “single-shot” antibiotic prophylaxis (1.5 g cefuroxim, Zinacef, Glaxo Wellcome, Germany and 0.5 g metronidazol, Clont, Bayer, Germany) at induction of anaesthesia. All patients had a central venous line, an arterial catheter, a urinary catheter and a nasogastric tube. An epidural catheter placed at the level of Th6–Th8 was recommended to all patients.

Patients with rectal carcinoma located higher than 12 cm above the anal verge (upper rectum) underwent anterior rectal resection with partial mesorectal excision (PME). The mesorectum and rectum were dissected 5 cm below the tumour. These patients received protective ileostomy only when the risk of a postoperative leakage seemed to be increased (i.e. obese men and stapled anastomosis oversewn after intraoperative testing revealed small leak). Patients with carcinoma below 12 cm (middle or lower rectum) underwent total mesorectal excision (TME) with colorectal or coloanal anastomosis and all of these patients received protective loop ileostomy. Patients with tumours less than 2 cm from the anal sphincter underwent abdominoperineal excision (APR) with permanent terminal colostomy. The indication for laparoscopic or conventional surgery was at the surgeon’s discretion. Patients with tumours in the upper rectum were randomised to either laparoscopic or conventional resection. For conventional rectal resection, a wide midline laparotomy from the suprapubic to the infraxyphoidal area was used. Laparoscopic surgery was either performed in a 5 trocar technique as described by Milsom and Böhm [17] or in a laparoscopic-assisted technique using a transverse incision in the lower abdomen for pelvic dissection. The specimens were extracted using a waterseal bag through a minilaparotomy in the left lower quadrant (laparoscopic) or through the lower transverse laparotomy (laparoscopicassisted). All anastomoses were accomplished by the ‘double-stapling’ technique. During APR the specimen

Table 1 Multimodal protocol for anaesthesia, surgery and postoperative rehabilitation for elective “fast-track” rectal cancer surgery Time

Procedure

Preoperative Intraoperative

Informed consent, discuss discharge on postoperative days 5–7 when feasible Non-opioid analgesia after induction of anaesthesia; thoracic combined EDA (LA/opioid, level Th6–Th8); limit intraoperative fluid therapy to 1,500 cc colloid and 1,500 cc crystalloid infusion; in case of hypotension after induction of anesthesia not responding to 500 cc of colloid solution, administer vasopressor, midline laparotomy, 5 trocar laparoscopy or laparoscopic-assisted procedure; extract nasogastric tube at extubation Day of surgery Admit to regular nursing floor via PACU; continuous EDA (LA/opioid); basal i.v. non-opioid analgesia; avoid systemic opioids; limit postop. i.v. fluids to 500 cc; drink 1,500 cc; if orthostatic dysregulation occurs, add 500– 1,000 cc of crystalloids i.v., yoghurt 2×150 g or 2 protein drinks; magnesium citrate 3×300 mg per day until first bowel movement; short walk outside of room, mobilized to chair for 2 h Postoperative day 1 Continuous EDA (LA/opioid); avoid systemic opioids; basal oral non-opioid analgesia; regular hospital food; drink >1,500 cc; if orthostatic dysregulation occurs, add 500–1,000 cc of crystalloids i.v.; mobilized out of bed >8 h, walk outside of room twice; extract intraabdominal drain and urinary catheter Postoperative day 2 Extract EDC and CVL in the morning; basal i.v. non-opioid analgesia; regular hospital food; drink >1,500 cc; if orthostatic dysregulation occurs, add 500–1,000 cc of crystalloids i.v.; fully mobilised From postoperative Continue as on day 2, until patient is discharged day 3 Postoperative day 8 Outpatient clinic; extract skin staples; discuss result of histological examination, plan adjuvant therapy if (if already needed discharged) EDA Epidural analgesia, LA local anaesthetics, PACU post-anaesthesia care unit, EDC epidural catheter, CVL central venous catheter

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Table 2 Epidemiological data of patients, operative technique, concomitant diseases and type of resection in elective “fast-track” rectal cancer surgery. Continuous data are given as median (5th–95th percentile)

Epidemiological data Age (years) BMI (kg m−2) Preoperative FVC (l) Sex (♀/♂) ASA class Type of resection Laparoscopy/conventional Stoma (yes/no) Ileo-/colostomy (of 59 pts.) Concomitant disease [n (%)] Arterial hypertension Cardiac Diabetes Pulmonary Hepatic Renal Anaemia

PME (n=27)

TME (n=29)

APR (n=14)

Total (n=70)

p value

– 65 (43–76) 26.6 (22.8–35.6) 3.6 (1.7–6.0) 15/12 3/15/10/1 – 14/13 6/21 6/0

– 65 (47–77) 25.6 (19.1–43.3) 3.9 (1.9–6.0) 13/16 3/15/10/1 – 19/10 29/0 29/0

– 66 (38–81) 27.5 (16.0–34.6) 3.4 (2.1–5.4) 6/8 1/8/4/1 – 6/8 14/0 0/14

– 65 (43–77) 26.6 (20.0–37.0) 3.6 (1.9–6.0) 34/36 7/38/23/2 – 39/31 59/21 35/14

– n.s. n.s. n.s. n.s. n.s. – n.s.

11 (41) 10 (37) 7 (26) 6 (22) 2 (7) 2 (7) 1 (4)

16 (55) 8 (28) 4 (14) 3 (10) 2 (6) 0 (0) 1 (3)

7 5 4 2 0 0 0

34 (49) 23 (33) 15 (21) 11 (16) 4 (6) 2 (3) 2 (3)

n.s. n.s. n.s. n.s. n.s. n.s. n.s.

(50) (36) (28) (14) (0) (0) (0)

n.s. not significant

was extracted via the perineal wound. The perineal wound was closed after a suction drain had been placed in the subcutaneous tissue. In all patients a 24 Charriere Robinson drain was placed in the presacral space. Because postoperative pneumonia, one of the most common general complications after abdominal surgery, is associated with prolonged suppression of pulmonary function, we assessed forced pulmonary vital capacity on days 1–5 by bedside spirometry (Renaissance Spirometer, Puritan Bennett Hoyer, Germany) with the patient lying in bed and whose upper body was elevated by 45° [18]. At the same time pain at rest (VAS-R) and while coughing (VASC) and fatigue (VAS-F) were assessed using a 100-mm visual analogue scale [19]. Until the second postoperative day, the continuous administration of a fixed combination of opioid and local anaesthetic via thoracic epidural catheter (EDC) in “fast-track” patients was preferred. Additionally, systemic non-opioid analgesic (COX-II inhibitors, metamizol or paracetamol) was given. Systemic application of opioids was avoided. When patients refused or had contraindications against EDC, piritramid was administered on demand, completing the basic medication of non-opioids every 4 to 6 h. In all patients a visual analogue score at rest lower than 35 was aimed at.

using Kruskal–Wallis test [20]. Categorical data were analysed using Fisher’s exact test. p values <0.05 were considered significant. Statistical analysis of all data was performed using SAS 8.0 for Windows XP.

Results Patients Seventy consecutive patients underwent resection of rectal cancer, 27 patients (39%) by PME, 29 patients (41%) by PME

TME

APR

100 90 80 FVC (% of preop.) 70 60 50

Data analysis and statistics Continuous parameters are given as median (5th–95th percentile). Differences between groups were compared

pre

1

2

3

4

5

postoperative day

Fig. 1 Perioperative changes in FVC in elective “fast-track” rectal cancer surgery

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Table 3 Clinical data for gastrointestinal function, duration of postoperative hospital stay and readmission rate after elective “fast-track” rectal cancer surgery. Continuous data are given as median (5th–95th percentile)

Reinsertion of nasogastric tube Tea/yoghurt (postoperative day) Solid food (postoperative day) Intravenous fluids (postoperative day) First bowel movement (postoperative day) Discharged (postoperative day) Readmission within 30 days

PME (n=27)

TME (n=29)

APR (n=14)

Total (n=70)

n

(%)

n

(%)

n

(%)

n

(%)

0 0 1 1 1 5 2

(0) (0–0) (0–2) (0–46) (0–4) (3–47) (7)

8 0 1 4 1 10 2

(29) (0–1) (1–3) (1–18) (0–3) (5–42) (14)

2 0 1 2.5 2 9 7

(7) (0–0) (0–5) (0–49) (1–3) (5–50) (24)

11 0 1 2 1 8 17

(15) (0–1) (0–2) (0–46) (0–3) (3–50) (23)

p value

0.02a n. s. n. s. 0.03a <0.001b <0.001c n. s.

n.s. not significant a TME vs. rest b APR vs. rest c PME vs. rest

TME and 14 (20%) by APR. The epidemiological data of patients, operative technique, concomitant diseases and ASA classification are shown in Table 2. In 50 patients (71%) relevant comorbidity was diagnosed and 25 (36%) were ASA class III or IV. Thirty-one patients (44%) underwent conventional surgery while 39 patients (56%) were operated on laparoscopically. PME, TME or APR was not associated with a higher frequency of the laparoscopic approach. TME took a longer time [270 (170–370) min] than APR [218 (150–440) min] or PME [190 (115–290) min] (p<0.001). Operative time was longer after laparoscopic procedures [265 (150–370) min] than conventional surgery [180 (115–310) min] (p<0.001). In 12 (17%) patients (PME 21%, TME 23%, APR 10%; p=0.3), thoracic epidural analgesia (thPDA) was not utilised because of patient’s refusal, contraindications or technical problems during puncture of the epidural space.

PME (coughing)

TME (coughing)

APR (coughing)

PME (at rest)

TME (at rest)

APR (at rest)

Pulmonary and gastrointestinal function Preoperative pulmonary function was comparable in all groups (Table 1). Overall, patients had reached 80% of the preoperative pulmonary function on the second postoperative day (Fig. 1). Normal gastrointestinal function was achieved early in all groups, but TME patients took a little longer to tolerate solid oral feeding (p=0.05) than the other patients and reinsertion of the nasogastric tube was more common among them (p=0.02) (Table 3). However, because of the lack of colonic passage of stool, TME patients with ileostomy had a slightly shorter interval of bowel movement than the others and therefore had it first than the other patients (p<0.01) (Table 3). No differences in return of normal gastrointestinal function were detected in patients with or without thPDA (insertion of nasogastric tube p=0.7; first bowel movement p=0.1; oral liquids p=0.9; solid food p=0.2; duration of i.v. fluids, p=0.5).

PME

100

100

75

75

VAS-pain 50

VAS fatigue 50

25

25

0

0

TME

APR

* *p<0.05

pre

1

2

3

4

5

postoperative day

Fig. 2 Perioperative pain at rest and while coughing in elective “fast-track” rectal cancer surgery

pre

1

2

3

4

5

postoperative day

Fig. 3 Perioperative fatigue in elective “fast-track” rectal cancer surgery (*p<0.05 PME vs. TME/APR)

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Table 4 Local and general morbidity and mortality after elective “fast-track” rectal cancer surgery

Surgical complications Patients Incidents Subcutaneous wound infection Anastomotic leakage Peritonitis Ileus (conservative treatment) Small bowel lesion Transfusions required General complications Patients Incidents Cardiac Pulmonary Renal Urinary tract Neurological/psychiatric Catheter related Mortality

PME (n=27)

TME (n=29)

APR (n=14)

Total (n=70)

n

n

n

n

– 5 – 3 3 2 2 0 2 – 5 – 4 4 3 1 2 1 1

(%) – (18) – (11) (11) (7) (7) (0) (7) – (19) – (15) (15) (11) (4) (7) (4) (4)

– 10 – 3 2 2 6 0 4 – 7 – 4 3 1 1 4 0 1

Pain and fatigue Postoperatively, all VAS-R scores were low and no differences in VAS-R or VAS-C were observed among the three groups (Fig. 2). VAS-F was high on the first postoperative day in all groups, but patients undergoing PME recovered faster than APR and TME patients and did feel significantly less fatigued on day 3 after surgery (Fig. 3). Morbidity, mortality, postoperative hospital stay and readmission rate Local complications were diagnosed in 19 (27%) patients without any significant difference between the groups or with regard to the operative access (minimal invasive vs. conventional). Infection of the perineal wound after primary closure occurred in three (21%) patients undergoing APR. Anastomotic leakage occurred in five patients (9% of all anastomoses) and was treated by CT drainage in two cases and reoperation in three (Table 4). General complications were observed in 12 (17%) of all patients and the incidence increased from 0% (APR) over 19% (PME) to 24% (ANT-TME) (p=0.14) (Table 4). General morbidity was only 8% in patients without surgical complications, but increased to 42% in patients with local complications (p<0.001). One patient with rectal cancer and multiple liver metastases had an anastomotic leakage after PME. Despite reoperation and control of the septic

(%) – (34) – (10) (7) (7) (20) (0) (11) – (24) – (14) (10) (3) (3) (13) (0) (3)

– 4 – 3 0 0 1 1 0 – 0 – 0 0 0 0 0 0 0

(%) – (29) – (21) (0) (0) (7) (3) (0) – (0) – (0) (0) (0) (0) (0) (0) (0)

– 19 – 9 5 4 9 1 6 – 12 – 8 7 3 2 2 1 2

(%) – (27) – (13) (9) (6) (13) (1) (9) – (17) – (11) (10) (4) (3) (3) (1) (3)

focus by Hartmann’s resection, the patient died of liver failure. The overall mortality was 1.4%. The median postoperative hospital stay was 8 (3–47) days. Postoperative hospital stay was significantly shorter after PME (Table 3). Within 30 days after surgery, 11 patients (16%) were readmitted to our hospital (Table 3). A subcutaneous wound infection caused the only readmission after PME. After APR, both readmissions were due to infection of the perineal wound. Three of seven readmissions after TME were related to ileostomy (two with high output and exsiccosis and one with local enterostomy problem). Other reasons for readmission were one case each of hematochezia, subcutaneous wound infection, intraabdominal abscess (requiring CT drainage) and suspected but not confirmed anastomotic leakage. No readmissions occurred because of cardiovascular, pulmonary or any other general complications.

Discussion This prospective trial demonstrates that a perioperative multimodal “fast-track” rehabilitation program is feasible in patients undergoing resection of rectal cancer. Pulmonary as well as gastrointestinal function was restored rapidly and postoperative pain was well controlled after laparoscopic and conventional rectal resection. Surgical morbidity was not increased while general morbidity (total 17%, patients without local morbidity 8%) compare favourably to the incidence of 27–35% from other series

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utilising “traditional” perioperative care [4, 6, 7, 21]. Despite unchanged criteria for hospital discharge, “fasttrack” rectal cancer patients were discharged after 9 days, compared to 14–20 days in other German series with “traditional” perioperative care [2, 7, 21]. While several reports about successful “fast-track”-colonic surgery have been published [8, 10, 11, 22, 23], experience with “fast-track” rehabilitation after rectal surgery is still small. Basse et al. [12] reported the Hvidovre-experience of 27 consecutive patients in a median age of 55 years undergoing conventional “fast-track” Hartmann reversal. In these patients postoperative ileus resolved within 2 days, median postoperative stay was 3 days and the readmission rate was 7%. Delaney et al. [13] described the results of 48 patients from Cleveland Clinic in Ohio undergoing major abdominal and pelvic colorectal surgery. Most of their patients (77%) underwent surgery for inflammatory bowel disease and only 11 patients were treated for carcinoma. Their patients were younger (median age 44 years) The postoperative hospital stay in this series was 3.5 to 4.6 days. Four patients (7%) were readmitted within 30 days for reasons not related to the “fast-track” program. Compared to the data from Basse et al. [12] and Delaney et al. [13], our patients were all treated for rectal cancer. They were much older (median age 65 years), 72% had relevant concomitant disease and 63% required TME or APR for cancer of the middle or lower rectum. Although the number of “fast-track” rectal cancer patients reported from our institution is small, distinct differences in the postoperative course after “fast-track” PME, TME and APR were noticed. Patients with PME showed a postoperative course similar to our patients undergoing “fast-track”-colonic resection [14] as well as those published by Basse et al. [12] for Hartmann reversal [12]. After APR, general recovery was fast, general complications did not occur at all and infections of the

perineal wound after primary closure were the main reason for prolonged hospital stay (18.5 days after infection vs. 8 days with primary healing; p<0.05). Following TME recovery of pulmonary and gastrointestinal tract function was also rapid, but the further course was more complex because postoperative hospital stay was dependent on the incidence of surgical complications (8 days without local morbidity vs. 15.5 days with; p<0.001). The incidence of surgical complications “fast-track”-TME (35%) was comparable to other series with a more “traditional” approach to perioperative care (22–36%) [7]. Incidence of anastomotic leakage after TME was not increased in our series (9%) compared to other reports (8–13%) and mortality was also comparable to reports of TME under “traditional” care [2–4, 6, 7, 24, 25]. Postoperative stay after “Fast-track”PME was only 5 days in our series, less than half compared to Marusch et al. [2] (17 days) after resection of cancer in the upper rectum with “traditional” care. Furthermore, the incidence of general complications was only 17% after “fast-track” surgery compared to 27– 35% in those with traditional care [2, 3, 7]. Although postoperative hospital stay is not only influenced by patient recovery but also reflects surgical traditions, discharge after 9 to 10 days after “fast-track” APR or TME indicates an accelerated reconvalescence when compared to 14–20 days in “traditional” care programs [2, 7]. In summary, multimodal perioperative treatment restores physiological parameters within 2–3 days after rectal cancer surgery in most of the patients. Local morbidity was not increased, general morbidity was low and postoperative hospital stay decreased to 5 days after PME and 9–10 days after TME and APR. This prospective observational study demonstrates that “fast-track” rehabilitation after elective resection of rectal cancer is effective and safe in patients admitted for cancer resection despite any concomitant disease or high ASA classification.

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