Réhabilitation rapide après chirurgie des sarcomes des ... · EJS 1995 !! Généralités "...
Transcript of Réhabilitation rapide après chirurgie des sarcomes des ... · EJS 1995 !! Généralités "...
Audrey MICHOT , E. STOECKLE
Réhabilitation rapide après chirurgie des sarcomes
des tissus mous
Introduction
Réhabilitation rapide = « fast track » ! Convalescence post op
Objectifs : ! Autonomie ! Morbi-mortalité
! Durée d’hospitalisation
H.Kehlet en 1995 Moiniche et Kehlet. EJS 1995
Généralités
" C h i r u r g i e V i s c é r a l e , U r o l o g i q u e e t Gynécologique Basse et al. Dis Colon Rectum 2004 Gralla et al. World J Urol 2007 Carter. ISRN Surg 2012
" Chirurgie Cardio-thoracique Das-Neves-Pereira. EJCTS 2009 " Chirurgie Orthopédique Husted et al. Acta orthop 2008
" Chirurgie des Sarcomes des tissus mous
Protocole ERAS
Généralités
Adapted from Erassociety
Etude rétrospective descriptive monocentrique
Critères d’évaluation : - morbidité - fonction - contrôle local
Objectif : évaluation de l’impact de la mise en place d’un protocole de réhabilitation rapide dans la chirurgie des sarcomes des tissus mous
Etude
Protocole Classique vs « Fast track »
701 patients pris en charge à l’institut Bergonié Recueil des caractéristiques des patients et tumeurs prise en charge carcinologique et chirurgicale suites opératoires et devenir Protocole Classique de 1989 à 2007 : réhabilitation standard = 445 patients Protocole « Fast-track » de 2008 à 2012 = 256 patients
information analgésie multimodale chirurgie atraumatique absence de drainage pansement compressif mobilisation précoce (kiné)
Matériel et méthodes
Résultats Caractéristiques des patients
Standard
period
ERAS period Total P
n (%) n (%) n (%)
Effective 445 256 701
Median age (years, SD) 55 (±17) 58 (±18) 56 (±17) 0.06
Sex
Female 213 (48) 117 (46) 330 (47) 0.6
Male 232 (52) 139 (54) 371 (53)
ASA score
1 229 (51) 99 (39) 328 (47)
2 178 (40) 128 (50) 306 (44) 0.005
3 38 (9) 29 (11) 67 (9)
OMS score
100 171 (38) 182 (71) 353 (50)
90 147 (33) 36 (14) 183 (26) <0.001
≤ 80 127 (29) 38 (15) 165 (24)
Standard
period
ERAS period Total P
n (%) n (%) n (%)
Effective 445 256 701
Median age (years, SD) 55 (±17) 58 (±18) 56 (±17) 0.06
Sex
Female 213 (48) 117 (46) 330 (47) 0.6
Male 232 (52) 139 (54) 371 (53)
ASA score
1 229 (51) 99 (39) 328 (47)
2 178 (40) 128 (50) 306 (44) 0.005
3 38 (9) 29 (11) 67 (9)
OMS score
100 171 (38) 182 (71) 353 (50)
90 147 (33) 36 (14) 183 (26) <0.001
≤ 80 127 (29) 38 (15) 165 (24)
Standard
period
ERAS period Total P
n (%) n (%) n (%)
Effective 445 256 701
Median age (years, SD) 55 (±17) 58 (±18) 56 (±17) 0.06
Sex
Female 213 (48) 117 (46) 330 (47) 0.6
Male 232 (52) 139 (54) 371 (53)
ASA score
1 229 (51) 99 (39) 328 (47)
2 178 (40) 128 (50) 306 (44) 0.005
3 38 (9) 29 (11) 67 (9)
OMS score
100 171 (38) 182 (71) 353 (50)
90 147 (33) 36 (14) 183 (26) <0.001
≤ 80 127 (29) 38 (15) 165 (24)
Caractéristiques tumorales Résultats
Localization
Shoulder
girdle
29 (7) 17 (7) 46 (7) 0.9
Upper limb 46 (10) 29 (11) 75 (11)
Trunk 73 (16) 40 (16) 113 (16)
Pelvic girdle 76 (17) 50 (19) 126 (18)
Lower limb 221 (50) 120 (47) 341 (49)
Size in mm (range) 80 (8-600) 65 (10-480) 80 (8-600) 0.001
Local extension
Bone, Vessels, Nerves 125 (28) 45 (18) 170 (24) 0.002
Skin 173 (39) 129 (50) 302 (43) 0.003
Deep tumor 365 (82) 180 (70) 545 (78) <0.001
Multifocality (n) 93 (21) 37 (14) 130 (1) 0.03
Localization
Shoulder
girdle
29 (7) 17 (7) 46 (7) 0.9
Upper limb 46 (10) 29 (11) 75 (11)
Trunk 73 (16) 40 (16) 113 (16)
Pelvic girdle 76 (17) 50 (19) 126 (18)
Lower limb 221 (50) 120 (47) 341 (49)
Size in mm (range) 80 (8-600) 65 (10-480) 80 (8-600) 0.001
Local extension
Bone, Vessels, Nerves 125 (28) 45 (18) 170 (24) 0.002
Skin 173 (39) 129 (50) 302 (43) 0.003
Deep tumor 365 (82) 180 (70) 545 (78) <0.001
Multifocality (n) 93 (21) 37 (14) 130 (1) 0.03
Localization
Shoulder
girdle
29 (7) 17 (7) 46 (7) 0.9
Upper limb 46 (10) 29 (11) 75 (11)
Trunk 73 (16) 40 (16) 113 (16)
Pelvic girdle 76 (17) 50 (19) 126 (18)
Lower limb 221 (50) 120 (47) 341 (49)
Size in mm (range) 80 (8-600) 65 (10-480) 80 (8-600) 0.001
Local extension
Bone, Vessels, Nerves 125 (28) 45 (18) 170 (24) 0.002
Skin 173 (39) 129 (50) 302 (43) 0.003
Deep tumor 365 (82) 180 (70) 545 (78) <0.001
Multifocality (n) 93 (21) 37 (14) 130 (1) 0.03
Caractéristiques tumorales Résultats
Histological subtypes
Undifferentiated sarcoma 112 (25) 78 (30) 190 (27) 0.2
Muscular sarcoma(LMS + RMS) 81 (18) 43 (17) 124 (18)
Myxoid LPS 47 (111) 20 (8) 67 (10)
Others LPS 72 (16) 53 (21) 125 (18)
Synovialosarcoma 38 (9) 11 (4) 49 (7)
DFSP 19 (4) 11 (4) 30 (4)
Others 76 (17) 40 (16) 116 (16)
Grade
1 110 (25) 70 (28) 180 (26) 0.040
2 123 (28) 86 (35) 209 (31)
3 202 (46) 90 (37) 292 (43)
Histological subtypes
Undifferentiated sarcoma 112 (25) 78 (30) 190 (27) 0.2
Muscular sarcoma(LMS + RMS) 81 (18) 43 (17) 124 (18)
Myxoid LPS 47 (111) 20 (8) 67 (10)
Others LPS 72 (16) 53 (21) 125 (18)
Synovialosarcoma 38 (9) 11 (4) 49 (7)
DFSP 19 (4) 11 (4) 30 (4)
Others 76 (17) 40 (16) 116 (16)
Grade
1 110 (25) 70 (28) 180 (26) 0.040
2 123 (28) 86 (35) 209 (31)
3 202 (46) 90 (37) 292 (43)
Prise en charge carcinologique Résultats
Standard Period ERAS period Total P
n (%) n (%) n (%)
Effective 445 256 701
Initial management <0.001
Core needle biopsy 75 (17) 85 (33) 160 (23)
Surgical biopsy 72 (16) 19 (7) 91 (13)
Resection at IB* 33 (7) 17 (7) 50 (7)
Outside resection 265 (60) 135 (53) 400 (57)
Prise en charge chirurgicale Résultats
Surgery
Moment of surgery
First 338 (76) 192 (75) 530 (76) 0.8
Second 107 (24) 64 (25) 171 (24)
Number of surgeries
1 164 (37) 119 (46) 283 (40) 0.01
≥2 281 (63) 137 (53) 418 (60)
Tumor rupture 30 (7) 23 (9) 53 (8) 0.3
Resection quality
R0 316 (71) 177 (69) 493 (70) 0.6
R1 126 (28) 79 (31) 205 (29)
R2 3 (1) 0 (0) 3 (1)
Radiotherapy
Prior history of
radiotherapy
18 (4) 8 (3) 26 (4) 0.5
Radiotherapy 339 (76) 149 (58) 488 (70) <0.001
Total dose (Gy) 50 (11-70) 50 (42-65) 50 (11-70)
Chemotherapy 206 (46) 89 (35) 295 (42) 0.003
Neo-adjuvant 105 (24) 70 (27) 175 (25) NS‡
Surgery
Moment of surgery
First 338 (76) 192 (75) 530 (76) 0.8
Second 107 (24) 64 (25) 171 (24)
Number of surgeries
1 164 (37) 119 (46) 283 (40) 0.01
≥2 281 (63) 137 (53) 418 (60)
Tumor rupture 30 (7) 23 (9) 53 (8) 0.3
Resection quality
R0 316 (71) 177 (69) 493 (70) 0.6
R1 126 (28) 79 (31) 205 (29)
R2 3 (1) 0 (0) 3 (1)
Radiotherapy
Prior history of
radiotherapy
18 (4) 8 (3) 26 (4) 0.5
Radiotherapy 339 (76) 149 (58) 488 (70) <0.001
Total dose (Gy) 50 (11-70) 50 (42-65) 50 (11-70)
Chemotherapy 206 (46) 89 (35) 295 (42) 0.003
Neo-adjuvant 105 (24) 70 (27) 175 (25) NS‡
Surgery
Moment of surgery
First 338 (76) 192 (75) 530 (76) 0.8
Second 107 (24) 64 (25) 171 (24)
Number of surgeries
1 164 (37) 119 (46) 283 (40) 0.01
≥2 281 (63) 137 (53) 418 (60)
Tumor rupture 30 (7) 23 (9) 53 (8) 0.3
Resection quality
R0 316 (71) 177 (69) 493 (70) 0.6
R1 126 (28) 79 (31) 205 (29)
R2 3 (1) 0 (0) 3 (1)
Radiotherapy
Prior history of
radiotherapy
18 (4) 8 (3) 26 (4) 0.5
Radiotherapy 339 (76) 149 (58) 488 (70) <0.001
Total dose (Gy) 50 (11-70) 50 (42-65) 50 (11-70)
Chemotherapy 206 (46) 89 (35) 295 (42) 0.003
Neo-adjuvant 105 (24) 70 (27) 175 (25) NS‡
Résultats Prise en charge chirurgicale
Standard period ERAS period Total P
n (%) n (%) n (%)
Effective 445 256 701
Reconstructive surgery
67 (15) 18 (7.5) 85 (12) NS
Drainage
319 (72)
35 (14)
354 (50)
<0.001
Wrapping
74 (17)
171 (67)
245 (35)
<0.001
Length of stay
9 (6-13)
3 (2-5)
6 (3-11)
<0.001
Readmission 19 (4) 9 (4) 28 (4) 0.6
Standard period ERAS period Total P
n (%) n (%) n (%)
Effective 445 256 701
Reconstructive surgery
67 (15) 18 (7.5) 85 (12) NS
Drainage
319 (72)
35 (14)
354 (50)
<0.001
Wrapping
74 (17)
171 (67)
245 (35)
<0.001
Length of stay
9 (6-13)
3 (2-5)
6 (3-11)
<0.001
Readmission 19 (4) 9 (4) 28 (4) 0.6
Standard period ERAS period Total P
n (%) n (%) n (%)
Effective 445 256 701
Reconstructive surgery
67 (15) 18 (7.5) 85 (12) NS
Drainage
319 (72)
35 (14)
354 (50)
<0.001
Wrapping
74 (17)
171 (67)
245 (35)
<0.001
Length of stay
9 (6-13)
3 (2-5)
6 (3-11)
<0.001
Readmission 19 (4) 9 (4) 28 (4) 0.6
Standard period ERAS period Total P
n (%) n (%) n (%)
Effective 445 256 701
Reconstructive surgery
67 (15) 18 (7.5) 85 (12) NS
Drainage
319 (72)
35 (14)
354 (50)
<0.001
Wrapping
74 (17)
171 (67)
245 (35)
<0.001
Length of stay
9 (6-13)
3 (2-5)
6 (3-11)
<0.001
Readmission 19 (4) 9 (4) 28 (4) 0.6
Résultats Evaluation de la morbi-mortalité postopératoire
Complications 171 (38) 87 (34) 258 (37) 0.2
Major 38 (9) 13 (5) 51 (7) 0.09
Minor 133 (30) 74 (29) 207 (30) 0.2
Seroma formation 88 (20) 54 (21) 142 (20) 0.7
Wound dehiscence 83 (19) 38 (15) 121 (17) 0.2
Infection/Abscess 35 (8) 12 (5) 47 (7) 0.1
Hematoma/Bleeding 23 (5) 9 (4) 32 (5) 0.3
Phlebitis 6 (1) 2 (1) 8 (1) 0.7
Others 19 (4) 4 (2) 23 (3) 0.05
Patients with ≥ 2
complications
67 (15) 29 (11) 96 (14) NS
Wound-related complications 148 (33) 81 (32) 229 (33) 0.6
Medical complications 23 (5) 6 (2) 29 (4) 0.07
Function
Excellent + Good 409 (93) 244 (97) 653 (95) 0.04
Fair + Poor + Incapacity 30 (7) 8 (3) 38. (5)
Complications 171 (38) 87 (34) 258 (37) 0.2
Major 38 (9) 13 (5) 51 (7) 0.09
Minor 133 (30) 74 (29) 207 (30) 0.2
Seroma formation 88 (20) 54 (21) 142 (20) 0.7
Wound dehiscence 83 (19) 38 (15) 121 (17) 0.2
Infection/Abscess 35 (8) 12 (5) 47 (7) 0.1
Hematoma/Bleeding 23 (5) 9 (4) 32 (5) 0.3
Phlebitis 6 (1) 2 (1) 8 (1) 0.7
Others 19 (4) 4 (2) 23 (3) 0.05
Patients with ≥ 2
complications
67 (15) 29 (11) 96 (14) NS
Wound-related complications 148 (33) 81 (32) 229 (33) 0.6
Medical complications 23 (5) 6 (2) 29 (4) 0.07
Function
Excellent + Good 409 (93) 244 (97) 653 (95) 0.04
Fair + Poor + Incapacity 30 (7) 8 (3) 38. (5)
Complications 171 (38) 87 (34) 258 (37) 0.2
Major 38 (9) 13 (5) 51 (7) 0.09
Minor 133 (30) 74 (29) 207 (30) 0.2
Seroma formation 88 (20) 54 (21) 142 (20) 0.7
Wound dehiscence 83 (19) 38 (15) 121 (17) 0.2
Infection/Abscess 35 (8) 12 (5) 47 (7) 0.1
Hematoma/Bleeding 23 (5) 9 (4) 32 (5) 0.3
Phlebitis 6 (1) 2 (1) 8 (1) 0.7
Others 19 (4) 4 (2) 23 (3) 0.05
Patients with ≥ 2
complications
67 (15) 29 (11) 96 (14) NS
Wound-related complications 148 (33) 81 (32) 229 (33) 0.6
Medical complications 23 (5) 6 (2) 29 (4) 0.07
Function
Excellent + Good 409 (93) 244 (97) 653 (95) 0.04
Fair + Poor + Incapacity 30 (7) 8 (3) 38. (5)
Complications 171 (38) 87 (34) 258 (37) 0.2
Major 38 (9) 13 (5) 51 (7) 0.09
Minor 133 (30) 74 (29) 207 (30) 0.2
Seroma formation 88 (20) 54 (21) 142 (20) 0.7
Wound dehiscence 83 (19) 38 (15) 121 (17) 0.2
Infection/Abscess 35 (8) 12 (5) 47 (7) 0.1
Hematoma/Bleeding 23 (5) 9 (4) 32 (5) 0.3
Phlebitis 6 (1) 2 (1) 8 (1) 0.7
Others 19 (4) 4 (2) 23 (3) 0.05
Patients with ≥ 2
complications
67 (15) 29 (11) 96 (14) NS
Wound-related complications 148 (33) 81 (32) 229 (33) 0.6
Medical complications 23 (5) 6 (2) 29 (4) 0.07
Function
Excellent + Good 409 (93) 244 (97) 653 (95) 0.04
Fair + Poor + Incapacity 30 (7) 8 (3) 38. (5)
Durée d’hospitalisation
Figure 2 : Répartition de la durée d’hospitalisation en fonction des périodes
Résultats
(jour
s)
Protocole Fast-Track
" Diminution de la durée d’hospitalisation
" Stabilité du taux de réadmission
" Stabilité des complications
" Diminution du taux de séquelles
" Comparaison à la littérature :
Viscéral, Gynécologique et Urologique
Cardio-thoracique
Orthopédie
Discussion
Limites : Etude rétrospective Comparabilité des deux populations Evaluation fonctionnelle Forces : Première étude sur le « fast track » après chirurgie des sarcomes des tissus mous Grande série de 701 patients Tendance forte à modifier les pratiques
Discussion
Conclusion
Merci de votre attention