Abstract
Bowel cancer is a leading cause of cancer-related death in the UK. For many years, treatment of this condition was largely unchanged and involved radical surgery, using long midline incisions and typically requiring a lengthy stay in hospital. In the last few years, there has been a quiet revolution in how patients undergoing surgery for this condition are managed. In this article, we provide an overview on how the introduction of laparoscopic surgery allied with enhanced recovery programmes has resulted in less post-operative pain, earlier return to normal activity and earlier discharge from hospital. We also discuss the increasing role of community health care professionals, and GPs in particular, in supporting these patients both before and after their time in hospital.
The GP curriculum and colorectal surgery
This article is relevant to
It provides the GP with an insight into the modern management of patients with colorectal cancer It demonstrates the patient-centred approach within enhanced recovery programmes (ERPs), empowering patients to play an active role within their own recovery It shows the holistic approach to modern surgical practice, with physical, social and psychological factors taken into consideration Facilitates effective communication with the patient and carer(s) about the disease and its treatment options The ability to define and apply evidence-based care in patients with cancer
Laparoscopic colorectal surgery
The first laparoscopic colorectal resections were performed in the 1990's. Although patient recovery was quicker, with a shorter hospital stay and earlier return to normal activities, the new techniques struggled for acceptance compared with other new key hole operations, such as laparoscopic cholecystectomy. Reasons for this initial reluctance included limitations in instrument technology, long learning curves for the surgeon and early reports of metastases at the port sites. The cases were also expensive, with lengthy operating times.
However, gradually, studies emerged demonstrating that in experienced hands, laparoscopic surgery was in fact safe and feasible. A succession of randomized -controlled trials, including the Medical Research Council's Conventional versus Laparoscopic-Assisted Surgery In patients with Colorectal Cancer (MRC CLASSICC) trial, the American Clinical Outcomes of Surgical Therapy (COST) trial and the European Colon carcinoma Laparoscopic or Open Resection (COLOR) trial, eventually caught the attention of the National Institute for Health and Clinical Excellence (NICE). In 2006, NICE published guidelines recognizing the laparoscopic approach as a suitable alternative in colorectal cancer surgery, with the caveat that it should be performed only by appropriately trained individuals. Gradually, instruments became cheaper and as expertise increased, operating times have reduced making laparoscopic resections more cost effective.
Implications for primary care
The introduction of laparoscopic colorectal surgery has also resulted in changes that will have implications for primary care. GPs and their patients need to be assured that the colorectal surgeon to whom they are referring will be able to offer safe laparoscopic surgery. Funded by the Department of Health, the National Laparoscopic Training Programme (‘LAPCO’) ensures that surgeons receive the training required to perform these challenging operations. LAPCO subjects registered surgeons to a robust training process, which includes supervised operating, mentoring, completion of structured assessment forms, individual learning curves plotted for each surgeon and video assessments. Surgeons are ‘signed-off’ after completion of this process, and also, after two LAPCO, trainers have independently approved their operating ability.
It is also feasible that patients will initially seek the counsel of their GPs when determining whether to undergo open or laparoscopic surgery. In our view, this debate no longer has merit as laparoscopic surgery should now be the default option for most patients. There is no doubt that the laparoscopic approach offers a much less painful option, a shorter stay in hospital and, on current evidence, no increased risk of major complications, such as anastomotic leaks. Longer term outcomes, in terms of tumour recurrence and survival, are also comparable, although it is fair to say that this picture is not yet complete. For these reasons, current NICE guidelines require that all suitable patients are offered laparoscopic surgery.
Enhanced recovery programmes
Historically, colorectal surgeons have tended to perform cancer resections on a cleansed bowel, necessitating the pre-operative administration of a purgative, with the patient often fasted for 6 hours or more. Patients would typically arrive for major abdominal surgery in a dehydrated and catabolic state. They would then have their operation through a long midline incision, under a general and epidural anaesthetic. Post-operatively, the emphasis was on a phased introduction of diet over 3–4 days, starting with sips of water and building to a ‘light-diet’ consisting of soup and ice cream, thereby further depriving the patient of nutrition at a time when it is most needed. Pain from the incision, controlled by prolonged use of epidural anaesthesia administered by a syringe driver on the ward, resulted in reduced post-operative mobility and contributed to a prolonged hospital stay.
It was a Danish surgeon, Prof. Henrik Kehlet, who challenged these traditional methods, pioneering the concept of an ERP. Over the last 5 years, use of ERP in colorectal surgery has become widespread and is now considered normal practice nationally. By providing education and support for patients during their surgical journey, the ERP, or ‘fast track surgery’, addresses the psychological stress, as well as minimizing the surgical stress response, with the ultimate aim to speed up a patient's post-operative recovery. Although the ERP has been applied to specialties ranging from orthopaedics to urology, its main application at present is colorectal surgery.
Our ERP follows a standard protocol, use of which is now commonplace in most laparoscopic colorectal units nationally. It can broadly be divided into three stages: pre-operative, intra-operative and post-operative.
Pre-operative stage
The pre-operative stage focuses on patient preparation, both physiological and psychological. The emotional buildup to the operation cannot be under-estimated because patient compliance with a strict ERP regime is of paramount importance. Patients must know that if all goes well, they may be out of hospital even within a day or 2 days of the operation. Physiological preparation and optimization are often challenging, particularly with an ageing population. The essence of the approach is to identify higher risk patients with cardiopulmonary exercise testing and to ensure correctable parameters such as haemoglobin, glycaemic control and blood pressure are adequately addressed. A particular feature of ERP is ‘carbohydrate loading’, whereby patients are given a carbohydrate-rich meal in the hours leading to the operation, thereby undergoing surgery in a fed and nutritionally optimized state.
Intra-operative stage
The critical aspect of the intra-operative stage is the use of laparoscopic surgery. This minimizes surgical trauma and stress and lays a foundation for reduced pain in the postoperative stage. Also important is the choice of anaesthetic. Avoiding epidural and favouring instead shorter acting regional anaesthesia, such as spinal or rectus sheath blocks, facilitates earlier urinary catheter removal, reduced opioid load and earlier mobilization. Additional key factors are ‘goal-directed’ fluid therapy, which focuses on judicious fluid therapy tailored to the individual and use of pneumatic compression deep vein thrombosis (DVT) prophylactic stockings.
Post-operative stage
Early mobilization is critical and a rapid return to normal activity is the key as this reduces the risk of DVT and promotes pulmonary and gut function. Importantly, it also encourages patients to take responsibility for their recovery. Simple oral analgesia, such as non-steroidal anti-inflammatory drugs and/or paracetamol, is usually sufficient, and avoiding opioids not only facilitates mobilization but also reduces the incidence of postoperative ileus.
A normal diet is quickly re-established, with a focus on ‘early enteral feeding’. In fact, the only determinant as to when to start feeding is the sedative effect of the anaesthetic; patients may eat on the day of surgery if sufficiently awake. Traditionally, practice was to rest the bowel post-operatively based on the assumption that early feeding would result in an increased risk of anastomotic leaks. However, evidence now suggests that there is no clear advantage in with-holding diet post-operatively. In fact, a meta-analysis of 11 randomized control trials actually demonstrated a reduction in complications when using early enteral feeding (Lewis, Egger, sylvester, & Thomas, 2001).
There is a steadily growing accumulation of evidence nationally that ERP is not only well-tolerated but also results in greater patient satisfaction scores using standardized questionnaires. Certainly, our recent prospective audit of 71 consecutive patients outlining the Poole National Health Service (NHS) Foundation Trust experience with ERP, with data collected over a 12 month period, is in keeping with the positive results reported by other units. We found that by the end of the first post-operative day, 96% of patients were mobilizing, 92% were tolerating a normal diet and 68% had passed flatus. By the third post-operative day, only 9% scored their pain between 6 and 10 and 38% scored zero. Seventy-nine per cent were discharged from hospital within 3 days of surgery, and all were discharged by day 9.
The impact of ERP on primary care
Our audit showed that 95% of patients felt that they were discharged at an appropriate time following their operation, and all patients reported feeling appropriately supported following discharge with knowledge of who to contact if they had any concerns. However, it is quite likely that ERP and the consequent earlier discharge of patients will have an effect on Primary Care, and there is no doubt that the support of community-based health care professionals, and GPs in particular, will be an on going key to the success of ERP.
As patients go home sooner, inevitably, some will seek the support and advice of their GPs soon after discharge for a variety of reasons, ranging from prescriptions for simple analgesics to late presentations of complications, such as anastomotic leaks and wound infections. It is important that GPs local to a unit with an active ERP have an understanding of the process and also a means of communicating directly with the surgical team should problems arise. It is important that colorectal surgeons and GPs meet regularly at a local level to discuss how the ERP is running, and results both in the hospital and in the community are continually audited. This way, re-admissions can be kept to a minimum.
An additional factor, which is now catching wider attention, is the reduced cost of care that ERP has the potential to offer. Earlier discharge of patients is already proving attractive to hospital managers, who see an opportunity to minimize length-of-stay and thereby increase capacity. But a shorter stay in hospital will also prove more cost-effective for the commissioning bodies that fund the treatment.
Conclusions
It is not an over-statement to say that we are entering a new era in the surgical treatment of colorectal cancer. Principles that were enshrined for decades by generations of surgeons have, in the space of a few years, been turned on their head. Laparoscopic surgery has already revolutionized the treatment of gallstones and now a similar revolution is occurring in the treatment of bowel cancer. This fact, together with the use of ERP, means that it is now quite feasible for patients to be considered for discharge within 24 hours of major abdomino-pelvic surgery. Primary care physicians will continue to play a critical role in not only the diagnosis but also the ongoing management of colorectal cancer, more of which will now take place in the community. Finally, as commissioners of colorectal services, it is important that GPs fully appreciate what is offered locally, from the training of the surgeons to their approach to inpatient care.
Key points
Minimally invasive surgery has resulted in some of the most exciting changes in colorectal surgery in recent times NICE guidelines now recommend all patients diagnosed with colorectal cancer should be offered a laparoscopic approach There is an emphasis on training surgeons to performing laparoscopic surgery. The Department of Health has addressed this with the National Laparoscopic Training Programme ERP and their use in laparoscopic colorectal surgery have significantly reduced length-of-stay following major cancer resections ERP will have an impact on primary care as some patients may require additional support in the community; the support of GPs will be critical ERP has positive cost implications, both for hospital management as they seek to maximize bed capacity but also for commissioning bodies that will fund the treatment
Footnotes
Acknowledgements
J. Bromilow, Consultant Anaesthetist, Poole, Aiysha Qureshi and Usama Qureshi.