Colon-rectum

Fondazione Poliambulanza is a notorious centre of excellence for colorectal surgery, performing about 200 resections annually.In the treatment of malignant tumors, in particular colon cancers (for example left, right and total colectomy) and rectal ones (such as anterior resections and abdominealperineal resection) the best approach is laparoscopy surgery. However, in recent years, depending on the location of the cancer two other approaches have been improved (transanal approach and intersphinteric resection for low rectal cancer).

Patients are treated with other essential requirements:

• A dedicated multidisciplinary team (consisting of various Colorectal surgeons, an oncologist, a radiation oncologists, an interventional radiologist and an anatomopathologist).
• A fast track programme.
• A dedicated enterostomy ambulatory for temporary or definitive ileo-stomies treatment and pelvic floor rehabilitation.
   

Agenas’ data give evidence of the excellent outcomes of Fondazione Poliambulanza’s Colon-rectal Surgery Department. 

• Transanal minimally invasive surgery (TAMIS): it is an innovative technique for the resection of a selected group of low rectal cancers performed without damaging the anal sphincter. 

• In Poliambulanza’s General Surgery Department operations in laparoscopy are made with the 3D technology, a new procedure available into very few hospitals. One of the disadvantages linked to the traditional laparascopy is a restricted visions during the operation as well as the difficulty in handling the instruments. On the contrary, using the 3D technology means going beyond such fators and towards a new surgical approach which merges a three.dimensional view with mini invasive techniques.

• Keywhole colorectal resections: they are reserved for advanced tumors requiring a joint removal of more organs (for example bladder, urethra,duodenum) at the same time. In case of a rectal tumor at an advanced stage, a plastic surgeon takes part during the resection so as to rebuild patient’s damaged perineum.

FAST TRACK SCHEDULE FOR COLON-RECTUM

The fast-track program, result of international experience gained from the early 90's, is aimed at improving, in terms of safety and comfort,  the intra- and postoperative course of patients undergoing  colorectal surgery. The resulting faster recovery allows to reduce the days of hospitalization, thus anticipating the return to normal rhythms of life.

WHAT TO KNOW AND TO ORGANIZE  

Duration of hospitalization

• The discharge will occur on the fourth postoperative day, unless any complications arise.  
• It’s proven that the homecoming allows a faster recovery.

Plan the homecoming

• When you are discharged from the hospital, you can move and       eat autonomously. However, for some time you might need to be     helped for personal hygiene (baths or showers), commissions, housekeeping, taking care of pets. It’s therefore necessary to have reference figures (relatives or friends) who can assist you in carrying out these activities. 

 
Abstaining from smoking is strongly recommended for at least three weeks prior to surgery. Such measure considerably reduces respiratory complications. It’s not advisable to resume the vice once you return home. 
 

PRE-HOSPITALIZATION
Before the surgery you undergo a series of visits and examinations aimed at providing useful information to assess the state of health and to better define the care plan.

Interview with the surgeon

• This section explains in detail the Fast-track program and defines the surgical strategy.
• The patient will be given all the answers to the questions he wants to ask.

Anesthesiological visit

• During the visit, patient’s health state is thoroughly investigated.  For this purpose, the patient is required to bring all medical records relevant to current or previous pathologies (heart, circulatory, lung diseases, diabetes, etc.) and previous surgical procedures. 
• It’s fundamental to report ongoing drug therapies, possible allergies and previous anesthesiological complications. 
• We’ll explain the anesthesiological techniques usually implemented and the modalities with which the pain is expected to be treated.

Interventions office

• It provides information about the documentation to be issued in order to formalize the hospitalization ( hospitalization proposal by the general practitioner, health booklet, fiscal code, etc.) and instructions for patient’s arrangements such as: the diet to be taken during the days prior to the hospitalization, the physical activity to be  practiced, the categorical prohibition of smoking and drinking alcohol, the purchase of antithrombotic elastic stockings. 

ARRIVAL at the hospital 
The patient is welcomed into the ward by a physician tracing the stages of the Fast-track path and providing further clarifications if required by the patient itself.
It’s useful to know that: 

• No tubes or catheters (gastric nose probes, bladder catheters) are inserted before anesthesia induction except for the peridural catheter (see below).
• Many of these catheters will be removed before awakening.
• No bowel preparation is performed.
• No long preoperative fasting is required and it’s allowed to drink light non-alcoholic liquids up to a few hours before the surgery. 
• Depilation (if necessary) is carried out by the ward staff.

SURGICAL INTERVENTION
Day of intervention 

• At a fixed time, the patient is taken to the surgery room and received by the anaesthesiological team consisting of an anesthesiologist and a dedicated nurse. 
• A hollow needle is inserted into the vein and the peridural catheter to be used for monitoring the postoperative paini is positioned. 
• Anesthesia is then induced according to a pharmacological protocol carefully studied in order to achieve a rapid awakening, optimal pain control, quick recovery of intestinal motility to avoid postoperative nausea or vomiting.
• Once left the surgery room, the patient is expected to stay in an awakening room (about 2 hours) during which he/she is assisted until full awakening and achievement of vital functions stability. 
•  At the end of observation period in the recovery room, the patient is transferred to the ward,  where, in order to improve the healing process of the surgical wound, oxygen will be administered by means of a facial mask or nasal cannula to be maintained for a few hours. 
• The nasogastric tube will already be removed.
•  As soon as health conditions allow it  (generally after 2 hours from the return to the room) the patient is helped to take up the sitting position  and strongly encouraged to keep it as long as possible.

The rational aspect of the early mobilization lies in the fact that it reduces the risk of: 

• Respiratory diseases (such as infections).
• Formation of blood clots in leg vessels (thrombosis).
• Onset of postoperative lobe (stop of bowel motility involving a series of disorders such as swelling, nausea, vomiting and slowing down of the healing process. 

Abdominal surgery and the administration of opioid medications may cause the onset of the sluggish ileum contrasted instead by the active movement (such as walking) and chewing chewing gum.  
Generally, two hours after the return to the room, in the absence of nausea or vomiting (in principle) it's allowed to drink light liquids.
 

First postoperative day and following days

• The bladder catheter is removed, thus reducing the risk of urinary infections and making it easier patient’s mobilization. 
• The patient can eat solid food. 
• The patient is helped to walk progressively longer and longer, according to a precise rehabilitation program, of which the progress is reported in a “Mobilization Diary”,  which is compiled by the patient himself. 
• Respiratory exercises are regularly performed with the support of physiotherapists. 
• It’s worth mentioning that it is normal to feel tired, nervous, hungry or without appetite.  It’s therefore important to rest properly after every walk, drink and eat depending on health conditions.  In any case it’s important to consider the movement and nutrition as fundamental parts of healing process. 
• In particular, the patient can eat whenever he’s hungry without making any efforts if he has no appetite. Otherwise, it is essential to take every meal sitting even for simple snacks. 
• In the presence of nausea or feeling of swelling while eating,   it’s adviceable to report it to the healthcare staff and suspend. 
• Chewing helps bowel motility; that’s why the patient is suggested to use chewing gum already from the surgery day, as soon as he’s able to do it and chew three tablets for at least 5 minutes, 3 times a day.  

POSTOPERATIVE PAIN
A peculiar attention is given to pain control by using most effective methods that have a low incidence of side effects such as nausea, vomiting and ileum. 

For this purpose, there is a poor use of opioid medications (considered excellent to reduce the pain, but affected by the abovementioned side effects).

A good pain control: 

• Reduces the stress and speeds up the recovery.
• Promotes proper breathing and expectoration.
• Enables a better mobility.
• Helps sleeping.

Peridural analgesia is preferred by using a tubing (peridural catheter) inserted through a needle in the vertebral canal through which local anesthetics are injected.  This type of analgesia is generally maintained for three days, after that intravenous or oral medications are administered. 

In the event that the peridural catheter positioning is not possible or contraindicated, intravenous or oral are then administered. 
The effectiveness of analgesia is checked many times a day by asking the patient to express a score on a scale from 0 to 10 in which: 
0 = total absence of pain    10 = unbearable pain
Generally, the pain reported as level 4 or higher is treated to be reduced to optimal levels.
 

HOSPITAL DISCHARGE
As a rule, discharge occurs on the fourth postoperative day, but only if the patient:
• Has no nausea or vomiting.
• Is able to drink or eat.
• Urinates spontaneously.
• Emits gases (it’s not necessary to defecate).
• Is able to walk and get out of bed by himself.