Hintergrund, Notwendigkeit und Methodik der S3-Leitlinie „Perioperatives Management bei gastrointestinalen Tumoren (POMGAT)“

Zusammenfassung

Malignome zählen insbesondere im höheren Alter zu den häufigsten Erkrankungen und sind in Deutschland für 25% aller Todesfälle verantwortlich. Insbesondere bei Karzinomen des Gastrointestinaltraktes ist eine Heilung oft nur durch eine ausgedehnte Operation mit signifikanter Morbidität erreichbar. Vor etwa 25 Jahren wurde erstmalig das multimodale, perioperative Fast-Track-Konzept (FT-Konzept) zur Reduktion von postoperativen Komplikationen vorgestellt und in den folgenden Jahren um weitere Bausteine erweitert. Mittlerweile gibt es Hinweise, dass bei einer Umsetzung bzw. Adhärenz der Schlüsselbausteine von über 70% neben einer Reduktion der Komplikationsrate und einer verkürzten Krankenhausverweildauer ein verbessertes onkologisches Outcome möglich sein könnte. Trotz des hohen Bekanntheitsgrades und der nachgewiesenen Vorteile des FT-Konzeptes ist die Implementierung und Aufrechterhaltung der Maßnahmen schwierig und resultiert in einer Adhärenz von nur 20 – 40%. Dies hat viele Gründe: Neben einer fehlenden interdisziplinären und interprofessionellen Kooperation sowie dem hohen zeitlichen und logistischen Aufwand bei der Implementierung und Aufrechterhaltung werden häufig limitierte personelle Ressourcen als ursächlich aufgeführt. Wir haben diese Aspekte zum Anlass genommen und mit der Ausarbeitung einer S3-Leitlinie für die perioperative Behandlung zur beschleunigten Genesung von Patienten mit gastrointestinalen Tumoren begonnen. Durch die Erstellung einer im formalen Prozess konsentierten und evidenzbasierten, multidisziplinären Leitlinie wird eine Möglichkeit eröffnet, die aufgeführten Probleme durch eine Optimierung und Standardisierung der interdisziplinären Versorgung zu lösen, was insbesondere in einem Setting mit vielen verschiedenen Fachdisziplinen und deren unterschiedlichen Interessen wichtig ist. Weiterhin wird angestrebt, durch die Standardisierung der perioperativen Prozesse den zeitlichen und logistischen Aufwand zu reduzieren. Die Darstellung der Evidenz ermöglicht es, den personellen Mehraufwand gegenüber Krankenhausträgern und Krankenkassen transparenter zu gestalten und so auch besser zu begründen. Zusätzlich erlauben es die im Rahmen der Leitlinie generierten evidenzbasierten Qualitätsindikatoren, perioperative Standards in die Zertifizierungssysteme einzubeziehen und so die Qualität der perioperativen Medizin zu messen und zu überprüfen.

Abstract

Malignancies are among the most common diseases, especially in old age, and are responsible for 25% of all deaths in Germany. Especially carcinomas of the gastrointestinal tract can be cured in most cases only through extensive surgery with significant morbidity. About 25 years ago, the multimodal, perioperative Fast Track (FT) concept for reducing postoperative complications was introduced and additional elements were added in the following years. Meanwhile, there is growing evidence that adherence to the key elements of more than 70% leads to reduction in postoperative adverse events as well as a shorter hospital stay and could be associated with an improved oncological outcome. Despite the high level of awareness and the proven advantages of the FT concept, the implementation and maintenance of the measures is difficult and results in an adherence of only 20 – 40%. There are many reasons for this: In addition to a lack of interdisciplinary and interprofessional cooperation and the time consuming and extended logistical efforts, limited human resources are often listed as one of the main causes. We took these aspects as an opportunity and started to develop a S3 guideline for perioperative treatment to accelerate the recovery of patients with gastrointestinal malignancies. By creating a consensus- and evidence-based, multidisciplinary guideline, many of the problems listed above could probably be solved by optimising and standardising interdisciplinary care, which is particularly important in a setting with many different disciplines and their competing interests. Furthermore, the standardisation of the perioperative procedures will reduce the time and logistical effort. The presentation of the evidence allows increased transparency and justifies the additional personnel expenditure on hospital medicine and health insurance companies. In addition, the evidence-based quality indicators generated during the development of the guideline make it possible to include perioperative standards in certification systems and thus to measure and check the quality of perioperative care.

Schlüsselwörter

Fast Track - perioperative Medizin - Leitlinie - gastrointestinale Tumoren - AWMF - evidenzbasiert

Key words

Fast Track Surgery - perioperative care - guideline - gastrointestinal tumours - AWMF - evidence-based

Publikationsverlauf

Artikel online veröffentlicht:
21. Juni 2021

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