Enhancing recovery after GI Surgery
Mr Neil J SmithConsultant General & Colorectal Surgeon
Surrey & Sussex Healthcare NHS Trust & Spire Gatwick Park Hospital
Enhancing Recovery after GI surgery
Topics for discussion
The Enhanced Recovery Programme (ERP) What is ERP & why is it important? What does ERP mean for Primary Care?
Enhancing standards in colorectal surgery Quality & Safety Laparoscopic colorectal surgery Treatment of haemorrhoids
The Enhanced Recovery Programme
Enhancing Recovery after GI surgery
Introduction to Enhanced Recovery Enhance (vb) (tr) to intensify or increase in
quality, value, power, etc.; improve; augment
In practice, usually equated and quantified in terms of time/speed: Length of Stay
Hot topic for NHS managers Can be applied to colorectal, urology, gynae and
musculosketal surgery
Enhancing Recovery after GI surgery
What is Enhanced Recovery?
Minimise stress responses during & after surgery
Optimise pre-op condition Optimise peri-operative
care Optimise post-op
rehabilitation
Time
Function
Traditional care
Enhanced Recovery
Enhancing Recovery after GI surgery
Days
Length of stay after colonic resection
Enhancing Recovery after GI surgery
Factors influencing patient recovery
Pre-op informationOptimised organ functionNo nutritional defectsNo alcohol pre-opStop smoking pre-opNeuraxial blockadeMinimally invasive surgeryNormothermiaNausea preventionIleus preventionEarly feedingGood oxygenationGood sleepOpioid sparingEvidence-based post-op care
Anxiety, fearPre-op organ dysfunctionSurgical stress responseHypothermiaNausea, vomitingIleusSemi-starvationHypoxaemiaPoor sleepDrains & tubesCatheters
Accelerated recovery
Delayed recovery
Enhancing Recovery after GI surgery
Enhanced Recovery in practice
Referral from Primary Care
Pre-Operative
Admission
Operative
Post-Operative
Follow-up
•Optimising pre-operative health state eg anaemia, renal function, smoking
•Managing co-morbidities eg Diabetes, hypertension, obesity
Enhancing Recovery after GI surgery
Enhanced Recovery in practice
Referral from Primary Care
Pre-Operative
Admission
Operative
Post-Operative
Follow-up
•Optimising pre-operative haemoglobin levels
•Managing pre-existing co-morbidities eg Diabetes
•Discharge on planned day
•Therapy input (stoma / physio / dietician)
•24hr telephone follow-up
•Audit & outcome measures
•Planned mobilisation
•Rapid hydration & nourishment
•Appropriate iv therapy
•No wound drains
•No NGT (bowel surgery)
•Catheters removed early
•Regular oral analgesia
•Avoid opiates
•Day of surgery admission
•Reduced starvation / CHO load
•Optimise fluid hydration
•No pre-med/bowel prep
•Minimally invasive surgery
•Transverse incisions
•Avoid nasogastric tubes
•Use of LA/ Regional analgesia with sedation
•Epidural (thoracic)
•Optimised fluid therapy
•Optimised health / medical conditions
•Informed decision-making
•Pre-operative health & risk assessment
•Patient well-informed / expectations managed
•Stoma training
•Discharge planning (EDD)
Enhancing Recovery after GI surgery
What does ER mean for primary care? ER begins & ends with primary care Optimising comorbidities Providing coordinated post-discharge care
(potential for presentation of late complications post-discharge)
Enhancing Recovery after GI surgery
What else does ER mean for primary care? ‘Traditional’ models of care that GPs saw
during their hospital training no longer apply No oral bowel prep, early feeding post-op Day of surgery admission, etc
Managing patient expectations is critical Patients will stay as long as they expect to stay Reassurance & information
Enhancing Standards in Colorectal Surgery
Enhancing Recovery after GI surgery
Multidisciplinary Team decision-making Weekly MDT discussion
Quality imaging & pathology
Prompt treatment
High quality surgery Safe resection margins = low rates of local recurrence
Accountability & clinical governance
Quality & Safety
Enhancing Recovery after GI surgery
First described in early 1990s, but slow uptake in UK
Since 2003, exponential increase in proportion of
‘keyhole’ resections. In 2009 26% of colonic cancer resections in UK
No compromise on oncological safety
Laparoscopic colorectal surgery
Enhancing Recovery after GI surgery
Laparoscopic colorectal surgery
Colonic tumours & inflammatory bowel disease very suitable
Faster recovery times, smaller wounds, less pain
Earlier discharge from hospital
Treatment of Haemorrhoids
Enhancing Recovery after GI surgery
Primary care Grades I-IV
Colorectal OPD Grades I-III
Surgical management Grades II (severe)-III
Grades III (large)-IV
Haemorrhoid protocol
Stapled haemorrhoidopexyHaemorrhoid artery ligation
Conventional haemorrhoidectomy
Rubber band ligation(phenol injection)
Dietary modification / softeners(topical creams)
Enhancing Recovery after GI surgery
QuickTime™ and a decompressor
are needed to see this picture.
Procedure for Prolapse and Haemorrhoids (PPH) described by Longo in 1998
Designed as a less painful alternative to conventional haemorrhoidectomy
Advantages1: less post-op pain, shorter operating time, shorter hospital stay, shorter convalescence
Disadvantages: higher rate of prolapse requiring intervention
1Burch et al. Colorectal Disease 2009 11(3) 233-244
Stapled Haemorrhoidectomy
Enhancing Recovery after GI surgery
Before After
Stapled Haemorrhoidectomy (2)
Enhancing Recovery after GI surgery
QuickTime™ and a decompressor
are needed to see this picture.
Haemorrhoidal artery ligation (HAL) Doppler-Guided disruption of haemorrhoidal
vasculature Short-medium term treatment alternative to
PPH High patient satisfaction ?Role
Enhancing Recovery after GI surgery
Summary
Patient treatment & experience enhanced by Consistent, safe, evidence-based surgical practice Application of Enhanced Recovery principles Utilisation of new technology Team-based working
Any questions?