Evidence for optimal perioperative care in colorectal surgery is abundant.
The specific measures that can be used routinely include no bowel preparation, and epidural anaesthesia/analgesia continued for 1 to 2 days postoperatively.
Other measures include no nasogastric decompression tube postoperatively, intravenous fluid/saline restriction, and free oral intake from postoperative day 1.
Dr Lassen and colleagues designed a survey to characterise perioperative practice in colorectal cancer surgery.
|Epidural analgesia in general wards exceed 90% in Scandinavia versus 11% in Scotland|
|British Medical Journal|
The researchers conducted the survey in 5 northern European countries including Scotland, the Netherlands, Denmark, Sweden, and Norway in 2003.
The research team mailed a questionnaire to the head surgeons of all digestive surgical centres belonging to the Enhanced Recovery After Surgery Group in the 5 countries.
The team presented a hypothetical case of elective laparotomy with colonic resection for cancer in an otherwise healthy 70 year old man.
The research team asked the respondents to answer according to the practice most widely used in their department at that time.
The researchers reported a response rate of 76% from 200 centers.
The team found that oral bowel preparation was still the rule in all countries.
The nasogastric decompression tube was widely used postoperatively only in the Netherlands.
The team noted that "Nil by mouth" was hardly used in Scandinavia but was common in the Netherlands and Scotland.
By postoperative day 1, the team observed that patients ate at will in 85% of Danish units and in almost half of units in Norway, the Netherlands, and Sweden.
The researchers also noted that in Scotland, only a quarter of units allowed free eating on day 1.
The use of epidural analgesia in general wards exceeded 90% in Scandinavia compared with 11% in Scotland.
The team reported that intravenous fluids were used unrestrictedly and in almost half the Dutch centres nasogastric tubes were left in place for 2 days or more.
The researchers noted that about 25% of Dutch centres did not allow patients to eat solid food at will until bowel movements occurred, and many did not allow fluids.
Of centres where nasogastric tubes were removed early, a third still prescribed nil by mouth for at least a day.
In Scotland, patients with epidural anaesthesia/analgesia were not being nursed outside of high dependency units and nil by mouth was used more widely, withholding fluids and solids.
Dr Lassen's team concludes, “The large evidence base for perioperative care aims to alleviate postoperative catabolism and organ dysfunction.”
“However, surgical patients remain exposed to unnecessary starvation, suboptimal stress reduction, and fluid overload.”
“Perioperative routines in colonic cancer surgery differ widely in northern Europe and deviate considerably from the best available evidence.”