Transcript Enhancing recovery after GI Surgery
Enhancing recovery after GI Surgery
Mr Neil J Smith
Consultant General & Colorectal Surgeon
Surrey & Sussex Healthcare NHS Trust & Spire Gatwick Park Hospital
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 Enhancing Recovery after GI surgery
The Enhanced Recovery Programme
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 Function Time Traditional care Enhanced Recovery Enhancing Recovery after GI surgery
Length of stay after colonic resection Days Enhancing Recovery after GI surgery
Factors influencing patient recovery
Accelerated recovery
Pre-op information Optimised organ function No nutritional defects No alcohol pre-op Stop smoking pre-op Neuraxial blockade Minimally invasive surgery Normothermia Nausea prevention Ileus prevention Early feeding Good oxygenation Good sleep Opioid sparing Evidence-based post-op care
Delayed recovery
Enhancing Recovery after GI surgery
Enhanced Recovery in practice
Referral from Primary Care
Pre Operative •Optimising pre-operative health state eg anaemia, renal function, smoking •Managing co-morbidities eg Diabetes, hypertension, obesity Admission Operative Post Operative Follow-up Enhancing Recovery after GI surgery
Enhanced Recovery in practice Referral from Primary Care •Optimising pre-operative haemoglobin levels •Day of surgery admission •Planned mobilisation •Rapid hydration & nourishment •Managing pre-existing co morbidities eg Diabetes •Reduced starvation / CHO load •Appropriate iv therapy •No wound drains Pre Operative •Optimise fluid hydration •No NGT (bowel surgery) •No pre-med/bowel prep •Catheters removed early •Regular oral analgesia •Avoid opiates •Optimised health / medical conditions •Informed decision making •Pre-operative health & risk assessment •Patient well-informed / expectations managed •Stoma training •Discharge planning (EDD) Admission •Minimally invasive surgery •Transverse incisions •Avoid nasogastric tubes •Use of LA/ Regional analgesia with sedation •Epidural (thoracic) •Optimised fluid therapy Operative •Audit & outcome measures Follow-up 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 Recovery after GI surgery
Enhancing Standards in Colorectal Surgery
Quality & Safety 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 Enhancing Recovery after GI surgery
Laparoscopic colorectal 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 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 Enhancing Recovery after GI surgery
Treatment of Haemorrhoids
Haemorrhoid protocol Primary care Grades I-IV Dietary modification / softeners (topical creams) Colorectal OPD Grades I-III Rubber band ligation (phenol injection) Surgical management Grades II (severe)-III Grades III (large)-IV Stapled haemorrhoidopexy Haemorrhoid artery ligation Conventional haemorrhoidectomy Enhancing Recovery after GI surgery
Stapled Haemorrhoidectomy Procedure for Prolapse and Haemorrhoids (PPH) described by Longo in 1998 Designed as a less painful alternative to conventional haemorrhoidectomy Advantages 1 : less post-op pain, shorter operating time, shorter hospital stay, shorter convalescence Disadvantages: higher rate of prolapse requiring intervention QuickTime™ and a decompressor are needed to see this picture.
1 Burch et al. Colorectal Disease 2009 11(3) 233-244 Enhancing Recovery after GI surgery
Stapled Haemorrhoidectomy (2) Before After Enhancing Recovery after GI surgery
Haemorrhoidal artery ligation (HAL) Doppler-Guided disruption of haemorrhoidal vasculature Short-medium term treatment alternative to PPH High patient satisfaction ?Role
QuickTime™ and a decompressor are needed to see this picture.
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 Enhancing Recovery after GI surgery