Bowel preparation and fasting

Dr Marco Carnelli

Drssa Malandrino Chiara

Dipartimento Materno-infantile e pediatrico USC Ostetricia Ginecologia

Direttore Prof. Luigi Frigerio

Optimizing risks and benefits

Pre-operative management

Infectious risk Legal risk

Risk of postoperative complications

Anesthesiological risk

Adequate preparation

Pre-operative management

Fasting

Bowel preparation

Shower

Personal hygiene

Trichotomy

Premedication for anesthesia

Antibiotic prophylaxis

Antithrombotic prophylaxis

Pre-operative surgery preparation

Warner MA, Warner ME, Weber JG. Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology 1993;78:56-62.

PREOPERATIVE FASTING

NPO (Nihil per os) after MIDNIGHT

“NPO after midnight” has been used in order to

avoid AB INGESTIS PNEUMONIA

(incidence 1:10.000 patients)

Today some studies have not found any scientific support to continue using NPO

Green CR, Pandit SK, Schork MA. Preoperative fasting time: is the traditional policy changing?

Results of a national survey. Anesthesia & Analgesia 1996;83:123-8.

PREOPERATIVE FASTING

NPO (Nihil per os) after MIDNIGHT

In use for many years

Easy to manage Ease in

modifying the operating schedule

PREOPERATIVE FASTING

NPO (Nihil per os) after MIDNIGHT

• Sense of hunger and thirst

• Dehydration • Hypovolemia • Severe hypoglycemia

and insulin resistance • Irritability • Epileptic seizures • Bad compliance

(Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev 2003:CD004423)

In use for many years

Easy to manage Ease in

modifying the operating schedule

PREOPERATIVE FASTING

NPO (Nihil per os) after MIDNIGHT

• Sense of hunger and thirst

• Dehydration • Hypovolemia • Severe hypoglycemia

and insulin resistance

• Irritability • Epileptic seizures • Bad compliance

(Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev 2003:CD004423)

Surgical stress, fasting, pain, and immobilization all result in hyperglycemia and insulin resistance which has been associated with complications following major abdominal surgery, cardiac surgery, and in the ICU setting

Jackson RS, Amdur RL, White JC, Macsata RA. Hyperglycemia is associated with increased risk of morbidity and mortality after

colectomy for cancer. J Am Coll Surg 2012;214:68–80. Sato H, Carvalho G, Sato T, Lattermann R, Matsukawa T, Schricker T. The association of preoperative glycemic control, intraoperative

insulin sensitivity, and outcomes after cardiac surgery. J Clin Endocrinol Metab 2010;95:4338–44.

PREOPERATIVE FASTING

Effects and clinical outcome

PREOPERATIVE FASTING

Effects and clinical outcome

Direct correlation between insulin resistance and hospital stay

PREOPERATIVE FASTING

Effects and clinical outcome

PREOPERATIVE FASTING

Effects and clinical outcome

NPO (Nihil per os)

after MIDNIGHT IS ALWAYS A GOOD

IDEA

Bowel preparation

Prosthetic surgery

Critical diagnostic examinations: a. Angiography b. Endoscopy

Colon-rectal surgery

Surgery with probable contamination: a. Abdominal surgery b. Gynecology c. Urology

1. Decrease the risk of post-operative infecious complications

2. Decrease the post-operative respiratory dysfunction

BUT… It does not seem to reduce the risk of anastomosis leakage

Bowel preparation: Why?

1. Decrease the risk of post-operative infecious complications

2. Decrease the post-operative respiratory dysfunction

BUT… It does not seem to reduce the risk of anastomosis leakage

Bowel preparation: Why? Mechanical bowel preparation

(MBP) solid faeces, which may increase the risk of intra-operative spillage of contaminant

Not only does MBP cause metabolic and electrolyte imbalance, dehydration, abdominal pain/bloating and fatique, but it may actually have detrimental effects on surgical outcome.

Beloosesky Y, et al. Electrolyte disorders following oral sodium phosphate administration for bowel cleansing in elderly patients.

Arch Intern Med 2003 Frizelle FA, Colls BM. Hyponatremia and seizures after bowel

preparation: report of three cases. Dis Colon Rectum 2005 Bucher P, et al. Mechanical bowel preparation for elective

colorectal surgery: a meta-analysis. Arch Surg 2004 Mahajna A,, et al. Bowel preparation is associated with spillage of

bowel contents in colorectal surgery. Dis Colon Rectum 2005

Contant CM, et al. Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial. Lancet 2007

Miettinen RP, et al. Bowel preparation with oral polyethylene glycol electrolyte solution vs. no preparation in elective open colorectal surgery: prospective, randomized study. Dis Colon Rectum 2000; Zmora O, et al. Colon and rectal surgery without mechanical bowel preparation: a randomized prospective trial. Ann Surg 2003

Slim K, et al. Updated Systematic Review and Meta-Analysis of Randomized Clinical Trials on the Role of Mechanical Bowel Preparation Before Colorectal Surgery. Ann Surg 2009

Role Of Mechanical Bowel Preparation

Multiple RCTs and meta-analyses have been published over the last decade suggesting that it is safe to abandon MBP

No difference in anastamotic leakage, septic complications, fascial dehiscence or mortality between the groups.

Meta-analysis and review of the literature demonstrated that any kind of MBP can safely be omitted before colonic surgery

• A systematic review of 18 randomized clinical trials (5805 patients) found no statistically significant evidence that patients benefit from either bowel preparation or rectal enemas

• The infection and anastomotic leak rates in patients with a bowel preparation was 9.6% and 4.4%, respectively, compared to 8.5% and 4.5% for those without

The authors concluded that in colonic surgery, bowel cleansing may be safely omitted

K.F. Guenaga, D. Matos, P.Wille-Jorgensen, Mechanical bowel preparation for elective colorectal surgery, Cochrane Database Syst. Rev. (2011)

Role Of Mechanical Bowel Preparation

Bowel preparation

NOT ALL SURGICAL PROCEDURES AND NOT ALL PATIENTS REQUIRE MECHANICAL BOWEL PREPARATION

Noooo! That is for tea !

ERAS - Enhanced Recovery After Surgery

U.O. Gustafsson, M.J. Scott,W. Schwenk, N. Demartines, D. Roulin, N. Francis, et al., Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations, World J. Surg. 37 (2) (2012) 259–284.

M. Greco, G. Capretti, L. Beretta,M. Gemma, N. Pecorelli,M. Braga, Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials,World J. Surg. 38 (6) (2014) 1531–1541

Group of procedures and interventions to:

1. reduce post-operative hospitalization

2. reduce surgical complications

3. speed patient recovery 4. reduce healthcare costs

Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, et al. Enhanced recovery

after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005;24:466–77.

ERAS - Enhanced Recovery After Surgery

Lassen K, Soop M, Nygren J, et al; Enhanced Recovery After Surgery (ERAS) Group. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg. 2009; 144(10):961-969.

Wilmore DW, Kehlet H. Management of patients in fast track surgery. BMJ. 2001;322 (7284): 473-6. Maessen J, Dejong CH, Hausel J, et al. A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg. 2007;

94(2): 224-231.

ERAS: Key Aspects of Protocols about

Bowel preparation and fasting

In patients without conditions associated with delayed gastric emptying, the intake of clear fluids until 2 h before the induction of anesthesia as well as a 6 h fast for solid food is now recommended.

I. Smith, et Al. Eur. J. Anaesthesiol. 28 (8) (2011) 556–569

Physiology of gastric emptying

Alexander NG, Smith G. Gastroesophageal reflux and aspiration of gastric contents in anesthetic practice. Anesthesia & Analgesia 2001;93:494-513.

Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Systematic Revue 2003;

The somministration of clear liquid up to 2-3 hours before surgery does not increase the risk of complications.

Brady M.C 2003 – Cochrane Review

Preoperative carbohydrates improve wellbeing and reduce nausea and vomiting

J. Hausel et Al, Br. J. Surg. 92 (4) (Apr 2005) 415–421

Carbohydrate loading before surgery has been advocated to achieve a metabolically fed state: oral carbohydrate recudes post-operative insulin resistence (50%), improves pre-operative wellbeing, and should be used routinely (insufficient data is available for diabetic patients). M.D. Smith et AL, Cochrane Database Syst. Rev. (8) (2014).

.

Preoperative intravenous infusion of 10–20% glucose solution with insulin and potassium

Iso-osmolar carbohydrate drink (maltodestrine) that is completely emptied from the stomach within 90 minutes from administration (800 ml evening before surgery; 400 ml 2/3 hours before surgery)

Perioperative Nutrition

Mechanical Bowel Preparation (MBP)

Postoperative Nutrition

Prevention of Prolonged Postoperative Ileus

ERAS Protocols

Assessment and treatment of poor nutrition

Melnyk M. et AL. Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J 2011;5(5): 342-8

ERAS Protocols

Assessment and treatment of poor nutrition

Melnyk M. et AL. Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J 2011;5(5): 342-8

The routine use of mechanical bowel preparation before minimally invasive gynecologic surgery has not been shown to improve intraoperative visualization, bowel handling, or ease of performing the procedure.

7 studies examined the role of enhanced recovery in the setting of gynecologic oncology surgery

Include strategies to: • better prepare patients for surgery • attenuate the stress response of surgery • to hasten recovery

Lu D,Wang X, Shi G. Perioperative enhanced recovery programmes for gynaecological cancer patients. Cochrane Database Syst Rev 2012

Postoperative stay ↓ No difference in

readmission or complication rates

Morbidity and mortality were no different

Reduction in hospital cost

Improvement in “autonomy,” “physical complaints ” “postoperative pain” “patient satisfaction”

http://www.italianperioperativeprogram.it/

ERAS PROTOCOL

ERAS Protocols: Limits

Take Home Message

The adoption of ERAS Protocols has been implemented in

various specialities including Gynecology.

The implementation of the ERAS Procedures has allowed the improvement of clinical practice, outcome and resource management (Health economic benefits)

Althought several RCT and reviews suggest significant

benefits, there are still considerable difficulties in the daily introduction of these evidence-based guidelines

Thank you

Dr Marco Carnelli

Dipartimento Materno-infantile e pediatrico USC Ostetricia Ginecologia

Direttore Prof. Luigi Frigerio