Multimodale Rehabilitation beim Rektumkarzinom

Zusammenfassung

Zahlreiche Traditionen in der perioperativen Versorgung sind nicht durch Studien abgesichert und werden zunehmend infrage gestellt. Hierzu zählen die Dauer der präoperativen Nüchternheit, der operative Zugang und der postoperative Kostaufbau. Die multimodale Rehabilitation und chirurgische „fast track” Programme überprüfen diese klinischen Traditionen kritisch. Zur multimodalen Rehabilitation bzw. „fast track” Chirurgie beim Rektumkarzinom liegen bislang noch keine prospektiven Studien vor. Durch Modifikationen der Vorbereitung auf die Operation sowie des peri- und postoperativen Managements lassen sich jedoch positive Effekte auf das subjektive Wohlbefinden, die immunologische Kompetenz und die Rekonvaleszenz der Patienten mit Rektumkarzinom erwarten. Eckpunkte der multimodalen Rehabilitation sind kurze präoperative Nüchternheit, Schmerztherapie mit thorakaler Periduralanästhesie und COX-II-Inhibitoren, Querlaparotomie bzw. Laparoskopie, frühzeitige Mobilisation noch am Tag der Operation und frühzeitiger postoperativer Kostaufbau mit proteinreicher Ernährung. Ob auch onkologische Vorteile aus dem Einsatz der multimodalen Rehabilitation resultieren, muss im Rahmen von prospektiv randomisierten Langzeitstudien überprüft werden.

Abstract

A number of traditions within perioperative patient care have not been evaluated within clinical studies and are being questioned. Among these, lengths of preoperative n.p.o. diet, surgical approach and postoperative return to normal diet are of special interest to surgeons. Multimodal rehabilitation and surgical “fast track” programs are currently evaluating the mentioned clinical traditions. Until now no prospective clinical studies on multimodal rehabilitation and “fast track” surgery in patients with rectal cancer have been performed. Nonetheless, modifications of preparation for surgery as well as of the peri- and postoperative management will provide positive effects on patient well-being, immunological competence and recovery after surgery for rectal cancer. Major issues of multimodal rehabilitation are short preoperative fasting periods, pain therapy including thoracic peridural anesthesia and COX-II-inhibitors, transverse laparotomy or laparoskopy, early mobilization on the day of surgery as well as early post-operative return to normal protein-rich diet. Whether or not oncologic advantages may also be provided by the introduction of multimodal rehabilitation remains to be determined within prospective randomized clinical studies.

Schlüsselwörter

Rektumkarzinom - Multimodale Rehabilitation - Fast Track Chirurgie - präoperative Nüchternheit - Insulinresistenz - Immunfunktion

Key words

Rectal cancer - multimodal rehabilitation - fast track surgery - preoperative diet - insulin resistance - immune function

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