Fast Track Surgery (ERAS) Surgeons Perspective

1. Fast Track Surgery(ERAS)Surgeons Perspective Dr. Vidhyachandra Gandhi DNB (GI surgery), DNB (Gen Surgery), FSGE Gastrointestinal &HPB Surgeon Pune

2. Why is the patient in hospital today ?

3. Concept of stress in surgery • Stimulation of HPA axis - glucocorticoids • Stimulation of sympathetic nervous system - catecholamines

4. ` Focus ….. • Decrease physiological stress • Decrease psychological stress • Decrease organ dysfunction

6. Components

7. FTS – Does not include • FTS and early discharge • One track surgery – no rigid “one size fits all” protocol • Cost containment

8. Pre op strategies Patient Education realistic information counseling

9. Pre op strategies Reduce Fasting Traditional 6 hrs fasting not required long fasting – increase gastric volume & decrease Ph Carbohydrate rich drink prior to elective surgery - conflicting data

10. Pre op Carbohydrate loading ….. • Early recovery from surgery and shorter length of hospital stay  • Decreases insulin resistance with reduced risk of hyperglycemia in the perioperative period  • Reduction in thirst, headache and hunger sensation • Reduces postoperative nausea and vomiting  • Enhances return of bowel function • Improves postoperative food intake  • Maximizes glycogen reserve to support glucose production through surgery, decreases protein breakdown and improves muscle strength 

11. Pre op strategies Mechanical bowel Preparation • Routine use not recommended • Rectal surgeries and lap surgery Improve pre op nutrition Avoid smoking

12. Minimal invasive surgery FTS = MIS Synergistic Complimentary

13. Drains – Early removal • Avoid placement • Detect blood, bile and anastomotic leak – no evidence • Hampers mobilization - cut and bag • Increases SSI, increase pain Catheters – early removal • discomfort , urosepsis Nasogastric tubes – early removal

14. ERAS EARLY FEEDING

15. Myth and Facts • Basal digestive enzyme output is around 5-6 litres • Even if nothing is taken by mouth so much fluid will go across the anastomosis. • “Protection” by keeping NPO is a wrong premise

16. Enteral Feeds • Per oral • Nasogastric • Nasojejunal • Feeding Jejunostomy

17. Early Enteral feeds • Wound healing • Better anastomotic healing • Reduces septic complications • Faster return of GI function • Reduces surgical stress • Early discharge • Decreases cost • Patient satisfaction

18. Some patient reactions.. “I threw up most of the night . . . and then they put up a drip to maintain the fluid balance, but they quickly took it down again . . presumably from the understanding that I should pull myself together and get some liquids down me. So I had to force myself to drink”.

19. Middle Path After your operation you can Eat and Drink whatever appeals to you But we Don’t advise resuming a normal diet or eating a lot of solid food during the first 2-3 Days.

20. Early Ambulation – Day 0/1 • Reduce muscle loss • Improve pulmonary function • Improve tissue oxygenation • Avoid venous stasis GOOD ANALGESIA

21. Implementation - FTS

22. Indian scene • Public sector • Private sector • Insurance sector

23. Barriers to Implementation • Lack of awareness • Difficult to accept • More emphasis on surgical technique – MIS • Lack of support, lack of interest

24. Barriers to Implementation • Complications viewed as failure • Cultural beliefs

25. Limitations • Low compliance and adherence to protocol • Applicability in elderly pts • Only colorectal surgery – not true

28. Length of stay was significantly decreased in ERAS patients in both all studies and the randomized trial subgroup (P < 0.001 for both).

29. Time to flatus – shorter in ERAS Readmission rate – no difference Hospital cost – decreased in ERAS

30. Significant decrease in pulmonary , urinary tract and SSI

32. How do I do ? Lower GI Surgery (Colorectal & Small Bowel) POD1 • Remove ryles tube • All liquids as tolerated. • Supplemental I.V fluids to maintain urine output • Increase liquids in evening , if tolerated well • Ambulation . • Encourage Incentive spirometry every 2 hours for 5 minutes. • Epidural analgesia ,with Diclofenac as rescue analgesic. • Intravenous ondansetron 4mg for any postoperative nausea or vomiting. • Removal of urinary catheter for all who underwent colonic resections and anterior resection.

33. How do I do ? Lower GI Surgery (Colorectal & Small Bowel) POD 2 • Assess tolerance to the previous evening’s feed- Nausea, vomiting, abdominal distention, abdominal cramps and any episode of fever • If patient is comfortable and clinical assessment is satisfactory (no abdominal distention/ fever), then allow patient’s usual daily food intake. • Ambulation to be actively encouraged as the previous day. • Incentive spirometry • Remove epidural catheter. • Oral analgesia • Rescue analgesia if required • Cut and bag the drains if placed • Wound Inspection and dressing change.

34. How do I do ? Lower GI Surgery (Colorectal & Small Bowel) POD 3 • Remove urinary catheter for those who underwent low anterior resections. • Assess tolerance to feeds the previous day. • Continue allowing usual diet. • Continue ambulation. • Continue incentive spirometry. • Continue analgesia with T. Diclofenac POD 4/5 Discharged

35. How do I do ? Upper GI Surgery (Gastrectomy) • Nasogastric tube removal on postoperative day 1. • Allow to drink water on postoperative day 1. • Clear liquid diet on POD2. • Solid diet on demand anytime after POD 4. • Drain removal on POD 5.

36. How do I do ? Upper GI Surgery (Esophagectomy) Jejunostomy feeds day 1 and increase subsequently Ambulation day 1 Remove ryles tube day 3 Remove neck drain day 3 Remove Foleys day 3 Gastrograffin swallow day 5 and start orally

37. How do I do ? Whipples Jejunostomy feeds day 1 and increase subsequently Ambulation day 1 Remove ryles tube day 2 Orals on day 3 and increase subsequently Remove Foleys day 3 Abdominal drains - cut and bag / removed later depending on output

38. Benefits • Early discharge • Streamlining in surgical care • Better QOL • Reduce morbidity • Improved institutional efficiency

39. Email : drgandhivv@gmail.com