Enhancing recovery after GI Surgery Mr Neil J Smith Consultant General & Colorectal Surgeon Surrey &...

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


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


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


Days

Length of stay after colonic resection


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


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


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)


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)


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


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


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


Laparoscopic colorectal surgery

Colonic tumours & inflammatory bowel disease very suitable

Faster recovery times, smaller wounds, less pain

Earlier discharge from hospital

Treatment of Haemorrhoids


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)


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


Before After

Stapled Haemorrhoidectomy (2)


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


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?

Enhancing recovery after GI Surgery Mr Neil J Smith Consultant General & Colorectal Surgeon Surrey &...

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