Rehabilitación multimodal en cirugía electiva colorrectal: evaluación de la curva de aprendizaje con 300 pacientes / Multimodal (fast-track) rehabilitation in elective colorectal surgery: Evaluation of the learning curve with 300 patients

Introducción: El objetivo es evaluar la influencia del aprendizaje en la aplicación de un programa de rehabilitación multimodal (RHMM) sobre el cumplimiento del protocolo y la recuperación de los pacientes intervenidos de cirugía electiva colorrectal. Material y métodos: Estudio prospectivo comparativo de 3 cohortes consecutivas de 100 pacientes (P1, P2 y P3) intervenidos de cirugía de colon o recto. En todos los casos se aplicó el mismo protocolo de RHMM. Se ha analizado el cumplimiento del protocolo, tolerancia a la dieta y deambulación. También se han comparado los porcentajes de alta hospitalaria precoz. Resultados: El cumplimiento mejoró progresivamente alcanzando la significación estadística entre P1 y P3: el inicio de la dieta el día 1 del postoperatorio fue de 52 vs. 86% (p=0,0001) y la retirada de sueros fue de 21 vs. 40% (p=0,005). Esta diferencia se mantuvo durante los días 2 y 3. La tolerancia a la dieta en el día 1 (P1: 34 vs. P3: 66%; p=0,0001) y la deambulación en el día 2 (P1: 41 vs. P3: 68%; p=0,0002) también fueron mayores en el tercer periodo. No encontramos diferencias en la morbilidad entre los 3 períodos. El porcentaje de altas hospitalarias en el día 3 (P1: 1 vs. P3: 15%; p=0,0003), día 4 (P1: 12 vs. P3: 32%; p=0,001) y día 5 (P1: 30 vs. P3: 50%; p=0,002) fue mayor en el tercer periodo. Conclusiones: El cumplimiento del protocolo y los resultados de la aplicación de un programa de RHMM mejoran significativamente con la mayor experiencia de los profesionales implicados (AU)

Introduction: The aim of this paper is to assess the learning curve on compliance to the application of a multimodal rehabilitation program (MMRP) protocol and patient recovery after elective colorectal surgery. Material and methods: comparative prospective study of 3 consecutive cohorts of 100 patients (P1, P2 and P3) who had colonic or rectal surgery. The same MMRP protocol was applied in all cases. Compliance to the protocol, tolerance to the diet and walking have been analysed. The percentages of early hospital discharges have also been compared. Results: Compliance gradually improved, reaching statistical significance between P1 and P3. Starting the diet on day 1 post-surgery was 52% vs 86% (p=0.0001) and the removal of drips was 21% vs 40% (p=0.005). This difference remained during days 2 and 3. Tolerance to the diet on day 1 (P1: 34% vs. P3: 66%;p=0.0001) and walking on day 2 (P1: 41% vs. P3: 68%; p=0.0002) were also better in the third period. No differences in morbidity were found between the three periods. The percentage of hospital discharges on day 3 P1: 1% vs. P3: 15%; p=0.0003), day 4 (P1: 12% vs. P3: 32%; p=0.001) and day 5 (P1: 30% vs. P3: 50%; p=0.002) was higher in the third period. Conclusions: The compliance to the protocol and the results of applying the MMRP improved significantly with the greater experience of the professionals involved (AU)

[Multimodal (fast-track) rehabilitation in elective colorectal surgery: evaluation of the learning curve with 300 patients]. / Rehabilitación multimodal en cirugía electiva colorrectal: evaluación de la curva de aprendizaje con 300 pacientes.

INTRODUCTION: The aim of this paper is to assess the learning curve on compliance to the application of a multimodal rehabilitation program (MMRP) protocol and patient recovery after elective colorectal surgery. MATERIAL AND METHODS: A comparative prospective study of 3 consecutive cohorts of 100 patients (P1, P2 and P3) who had colonic or rectal surgery. The same MMRP protocol was applied in all cases. Compliance to the protocol, tolerance to the diet and walking have been analysed. The percentages of early hospital discharges have also been compared. RESULTS: Compliance gradually improved, reaching statistical significance between P1 and P3. Starting the diet on day 1 post-surgery was 52% vs 86% (p=0.0001) and the removal of drips was 21% vs 40% (p=0.005). This difference remained during days 2 and 3. Tolerance to the diet on day 1 (P1: 34% vs. P3: 66%; p=0.0001) and walking on day 2 (P1: 41% vs. P3: 68%; p=0.0002) were also better in the third period. No differences in morbidity were found between the three periods. The percentage of hospital discharges on day 3 P1: 1% vs. P3: 15%; p=0.0003), day 4 (P1: 12% vs. P3: 32%; p=0.001) and day 5 (P1: 30% vs. P3: 50%; p=0.002) was higher in the third period. CONCLUSIONS: The compliance to the protocol and the results of applying the MMRP improved significantly with the greater experience of the professionals involved.

[Multimodal rehabilitation programme in elective colorectal surgery. Development of a clinical pathway and preliminary results]. / Rehabilitación multimodal en cirugía colorrectal electiva. Elaboración de una vía clínica y resultados iniciales.

INTRODUCTION: Multimodal rehabilitation programmes enhance recovery and may reduce the postoperative complication rate and hospital stay after elective colorectal surgery. PATIENTS AND METHOD: A clinical pathway of multimodal rehabilitation in elective colorectal surgery was developed. After implementation, 90 consecutive patients received multimodal rehabilitation care from April to December 2006. Outcomes were compared with a control group of 134 patients receiving conventional care during 2005, just before the implementation of the new protocol. Demographics, surgical risk and type of surgery were similar in both groups. RESULTS: With a clinical pathway of multimodal rehabilitation, on postoperative day 1 mobilization was accomplished in 68% of patients, early feeding in 52%, diet was well tolerated in 33% and intravenous fluids were stopped in 21% of patients. On postoperative day 5 predetermined discharge criteria were fulfilled in 82% of patients, although only 55% were discharged by postoperative day 6. Adherence to antibiotic prophylaxis protocol was better in the multimodal rehabilitation group (90% vs 41%; p < 0.001). Postoperative wound infection was lower in the multimodal rehabilitation group (13.3% vs 19.4%) with no statistical significance. Median hospital stay was significantly lower in the multimodal rehabilitation group (8.8 days vs 11.9 days; p = 0.03) with a mean of 6 days vs 9 days respectively. CONCLUSIONS: A clinical pathway of multimodal rehabilitation in elective colorectal surgery reduces hospital stay without increasing morbidity rates.

Rehabilitación multimodal en cirugía colorrectal electiva. Elaboración de una vía clínica y resultados iniciales / Multimodal rehabilitation programme in elective colorectal surgery. Development of a clinical pathway and preliminary results

Introducción. Los programas de rehabilitación multimodal(RHMM) optimizan los cuidados perioperatorios, pueden reducir las complicaciones y acortan la estancia hospitalaria. Pacientes y método. Elaboración de una vía clínica de cirugía colorrectal electiva basada en un programa de RHMM. Entre abril y diciembre de 2006 se ha incluido a 90 pacientes consecutivos tratados con el protocolo de RHMM. Los resultados se comparan con los de un grupo control de 134 pacientes intervenidos durante el año 2005 antes de su implantación. Las características demográficas, el riesgo quirúrgico y el tipo de intervención fueron similares en ambos grupos. Resultados. Con el programa de RHMM se consiguió, el primer día del postoperatorio, la movilización del 68% de los pacientes, el inicio de dieta en el 52%,la tolerancia a ésta en el 33% y se retiró la sueroterapia al 21% de los pacientes. En el quinto día del postoperatorio el 82% de los pacientes cumplían criterios de alta, aunque sólo se había dado de alta al 55%el sexto día del postoperatorio. El cumplimiento de la profilaxis antibiótica fue mejor en el grupo de RHMM(el 90 frente al 41%; p < 0,001). Las complicaciones infecciosas postoperatorias fueron menores en el grupo RHMM (el 13,3 frente al 19,4%), aunque no alcanzó la significación estadística. La media de estancia postoperatoria fue significativamente más corta en el grupo RHMM (8,8 ± 6,6 días frente a 11,9 ± 13,1días; p = 0,03), con una mediana de 6 y 9 días, respectivamente. Conclusiones. Una vía clínica de RHMM en cirugía colorrectal electiva acorta la estancia hospitalaria sin incrementar la morbilidad (AU)

Introduction. Multimodal rehabilitation programmes enhance recovery and may reduce the postoperative complication rate and hospital stay after elective colorectal surgery. Patients and method. A clinical pathway of multimodal rehabilitation in elective colorectal surgery was developed. After implementation, 90 consecutive patients received multimodal rehabilitation care from April to December 2006. Outcomes were compared with a control group of 134 patients receiving conventional care during 2005, just before the implementation of the new protocol. Demographics, surgical risk and type of surgery were similar in both groups. Results. With a clinical pathway of multimodal rehabilitation, on postoperative day 1 mobilization was accomplished in 68% of patients, early feeding in 52%, diet was well tolerated in 33% and intravenous fluids were stopped in 21% of patients. On postoperative day 5 predetermined discharge criteria were fulfilled in 82% of patients, although only 55% were discharged by postoperative day 6. Adherence to antibiotic prophylaxis protocol was better in the multimodal rehabilitation group (90% vs 41%; p < 0.001). Postoperative wound infection was lower in the multimodal rehabilitation group (13.3% vs 19.4%) with no statistical significance. Median hospital stay was significantly lower in the multimodal rehabilitation group (8.8 days vs 11.9 days; p = 0.03) with a mean of 6 days vs 9 days respectively. Conclusions. A clinical pathway of multimodal rehabilitation in elective colorectal surgery reduces hospital stay without increasing morbidity rates (AU)