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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?
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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
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
Function Time What is Enhanced Recovery? • Minimise stress responses during & after surgery • Optimise pre-op condition • Optimise peri-operative care • Optimise post-op rehabilitation 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 Anxiety, fear Pre-op organ dysfunction Surgical stress response Hypothermia Nausea, vomiting Ileus Semi-starvation Hypoxaemia Poor sleep Drains & tubes Catheters Delayed recovery Enhancing Recovery after GI surgery
Enhanced Recovery in practice Referral from Primary Care • Optimising pre-operative health state eg anaemia, renal function, smoking • Managing co-morbidities eg Diabetes, hypertension, obesity Pre-Operative Admission Operative Post-Operative Follow-up Enhancing Recovery after GI surgery
Enhanced Recovery in practice • Optimising pre-operative haemoglobin levels • Managing pre-existing co-morbidities eg Diabetes • 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 Referral from Primary Care Pre-Operative Admission • Optimised health / medical conditions • Informed decision-making • Pre-operative health & risk assessment • Patient well-informed / expectations managed • Stoma training • Discharge planning (EDD) • Discharge on planned day • Therapy input (stoma / physio / dietician) • 24hr telephone follow-up Operative • Minimally invasive surgery • Transverse incisions • Avoid nasogastric tubes • Use of LA/ Regional analgesia with sedation • Epidural (thoracic) • Optimised fluid therapy Post-Operative Follow-up • Audit & outcome measures 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
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
Primary care Grades I-IV Colorectal OPD Grades I-III Surgical management Grades II (severe)-III Grades III (large)-IV Haemorrhoid protocol Dietary modification / softeners (topical creams) Rubber band ligation (phenol injection) 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 • 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 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 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