Surgery for IBD and FAP

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The rehabilitation process takes into account surgical intervention and its technical aspects, as well as the probable quality of life of the patient after therapeutic treatment. Whenever possible, the rehabilitation process will begin before surgery by informing and educating the patient about the therapeutic strategy to be adopted. After surgery, all efforts will concentrate on maintaining and/or recovering the patient's autonomy and functionality.

On this subject, attention will be paid to both the recovery of basic functions, that is to say, those linked to vegetative life (such as correct breathing, blood circulation and the tegumentary function) and to functions related to social life. The main objectives are to:

- improve overall functionality.

- Reduce or to keep in check all postoperative symptoms and/or complications.

- Reduce the level of disability.

- Promote rehabilitation to social and working life.

- Help the patient become aware of the disability and actual functionality and to support that new awareness.

Diagnostic evaluation and planning an appropriate therapeutic intervention are needed in order to realise these objectives.

Among the existing colic surgery protocols, one that certainly deserves to be mentioned is the protocol developed by Kehlet and his Danish team [2]: with their concept of "accelerated rehabilitation", they developed a series of perioperative treatments that allow speedy recovery and an early dismissal. This treatment concept preserves bodily organ functions and avoids the usual postoperative deterioration in pulmonary function, body composition and cardiovascular response to exercise [3]. (See Table 1 for a comparison of this protocol with the Conventional Care and Multimodal Rehabilitation programmes.) The multimodal rehabilitation programme, with epidural analgesia, early oral nutrition and mobilisation, besides application after open colonic surgery for noninflammatory bowel disease, is also used after ileocolic resections for Crohn's disease [4]. Andersen and Kehlet, at the end of this prospective, nonrandomized study, observed that open ileocolic resections for Crohn's disease combined with fast-track multimodal rehabilitation with continuos epidural analgesia and enforced early oral feeding and mobilisation enhanced recovery and decreased median hospital stay to 3 days with a low morbidity and readmission rate. Moreover, they suggested that "prospective studies using multimodal

Table 1. Protocol for anaesthesia, surgery and rehabilitation programme after colonic resection with conventional care (group 1) and multimodal rehabilitation (group 2) [3]

Group 1

Group 2

Anaesthesia

Premedication: oral diazepam 10 mg

Epidural catheter: T8-T10

Carbocaine 2% (4+4) ml with epinephrine

Carbocaine 2% 4 ml with epinephrine hourly General anesthesia: Fentanyl 0.1 mg Thiomebumal 3-5 mg/kg Rocuronium O2-N2O-sevoflurane Dextran 70 (Macrodex) 500 ml Saline 3,000 ml (max)

Surgery

Postoperatively

Median laparotomy

Continuous epidural analgesia (3 days): Bupivacaine 0.25% 4 ml and morphine 0.2 mg/h Breakthrough pain: morphine IM or IV After removal of epidural catheter:

morphine 10 mg orally No standard care program: fluid, food, mobilization and discharge depending on the attending surgeon Postoperative nasogastric tube depending on surgeon who performed the operation Physiotherapy: breathing exercise 10 min per day during the first 2 postoperative days and only on working days

Premedication: none Epidural catheter

Right hemicolectomy: T6-T7 Sigmoid resection: T9-T10 Test: lidocaine 2% 3 ml with epinephrine Bupivacaine 0.5% (6+6) ml Bupivacaine 0.25% 5 ml 2 h intraoperatively Morphine 2 mg if <70 years Morphine 1 mg >70 years General anaesthesia:

Remifentanil 1 mg/kg/min Propofol 2-4 mg/kg/h Cicatriceum 0.15 mg/kg Hydroxyethyl starch (HAES) 500 ml Saline 1500 ml (max) Ondansetron 4 mg Ketorolac 30 mg

Bupivacaine 0.25% 20 ml (incision)

Transverse or curved incision

Continuous epidural analgesia (2 days):

Bupivacaine 0.25% 4 ml and morphine 0.2 mg/h Breakthrough pain: ibuprofen 600 mg orally Bupivacaine 0.125% 6 ml epidurally Morphine 10 mg orally (last choice) Food, protein drink 60-80 g protein per day and mobilization from the day of surgery following a well-defined nursing care programme Day of surgery start: acetaminophen (slow release) 2 g/12 hourly Cisapride 20 mg/12 hourly

1st postoperative day: remove bladder catheter in the morning

2nd postoperative day: remove epidural catheter in the morning; discharge after lunch rehabilitation are indicated to evaluate the role of laparoscopic assisted vs open resection for ileo-colic Crohn's disease".

development of a program of topical intervention. - Evaluation and treatment of possible surgical or internal complications.

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