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Enhanced recovery in intestinal surgery
INTESTINAL SURGERY e I
Enhanced recovery in intestinal surgery
the support of consultant anaesthetists for advice and assessment of high-risk patients. The clinic allows assessment of a patient’s general fitness, medical comorbidities, drug history and the optimization of pre-existing conditions. Simple investigations such as full blood count and renal function, ECG, CXR, stress test or simple 6-minute walk test can be carried out as required. Nowadays for major resectional surgery, many units carry out objective evaluation of functional capacity with more sophisticated tests such as cardiopulmonary exercise testing (CPET) or myocardial perfusion scanning. This provides a more objective assessment of operative risks to determine a patient’s suitability to proceed to surgery and enables the planning for post-operative critical care facility when necessary.3 Good pre-operative planning helps facilitate same-day admission and avoids unnecessary cancellations. It also provides an opportunity for the assessment of social circumstances to aid discharge planning and social risk factors such as smoking and alcohol, which are linked to increased post-operative complications such as bleeding, wound infection and cardiopulmonary dysfunction.
Hoey C Koh Alan F Horgan
Abstract Enhanced recovery after surgery (ERAS) programmes utilise a multimodal and multidisciplinary approach to surgical care. The aim of ERAS is to reduce the surgical stress response, maintain physiological function and metabolic homeostasis and expedite patients’ recovery to their baseline status. With its success in colorectal practice, ERAS is increasingly adopted in other surgical specialities. A good ERAS programme involves integrated pre-operative, intra-operative and post-operative evidence-based practice. Successful ERAS programme translates to a standardized patient care pathway, improved clinical outcomes and shorter hospital stay, all of which will help facilitate the increasing demand on healthcare and bed pressure. Its principles and many components are transferable to other surgical specialities including acute surgical services and medical specialities to improve patient care and recovery and will soon become the standard of care for the majority of hospital inpatients.
Pre-operative education Apart from pre-assessment of fitness for surgery, patients in an ERAS programme will also receive pre-operative education with information regarding the surgery, anaesthetic procedures, anticipated post-operative recovery and the journey from admission to discharge. Such pre-operative education helps alleviate anxiety and encourages patients’ participation in their recovery process. For bariatric surgery, pre-operative information has been shown to improve patient’s compliance and reduce anxiety and stress postoperatively. For patients undergoing in colorectal surgery, preoperative stoma education is important as it helps mentally and physically prepare the patients in their expectation and management of their stoma and has been shown to reduce hospital stay.
Keywords ERAS; fast-track surgery
Enhanced recovery after surgery (ERAS) programmes utilise a multimodal and multidisciplinary approach to surgical care. ERAS programmes involves integrated pre-operative, intra-operative and post-operative evidence-based practice. The aim of ERAS is to reduce the surgical stress response, maintain physiological function and metabolic homoeostasis and expedite patients’ recovery to their baseline status. The concept of ERAS was first introduced in 1990s in colonic surgery by Henrik Kehlet to reduce postoperative complications and length of hospital stay.1 ERAS is now widely practice despite the initial apprehension and slow uptake, with studies repeatedly showing that it is safe and shortens hospital stay.2 With its success in colorectal practice, ERAS is increasingly adopted in upper GI surgery and pancreatic surgery, as well as in non-GI specialities such as orthopaedics and urology.
Smoking and alcohol cessation Smoking is associated with increased risk of post-operative wound sepsis, pulmonary complications and venous thromboembolism. Cessation for at least 4 weeks leading up to surgery should be greatly encouraged as it has been shown to reduce post-operative complications.4 Alcohol misusers are also at two- to threefold increased risk of post-operative pulmonary complication, wound infection, wound breakdown and increased length of hospital stay. Abstinence has been shown to improve outcome and should be recommended for at least 4 weeks.5
Pre-operative preparation Pre-operative assessment Once the shared decision has been made to proceed with major surgery, patients should undergo pre-operative assessment to assess fitness for surgery. Nowadays this is done at dedicated pre-operative assessment clinics which are often nurse-led with
Pre-operative nutrition The practice of prolonged fasting period is no longer recommended. Patients are allowed solids (6 hours) and clear fluids (2 hours) prior to induction of anaesthesia. Pre-operative fasting will inhibit insulin secretion and promote release of catabolic hormones. The provision of oral carbohydrate drinks up to 2 hours prior to surgery has been shown to reduce post-operative insulin resistance, reduce protein breakdown, improve muscle strength and shorten hospital stay. Pre-operative supplementary nutrition should be considered for patients who had unintentional pre-operative weight loss or those who are significantly malnourished. Unintentional weight loss,
Hoey C Koh MSc FRCS Glasgow is a Colorectal Fellow in the Department of Colorectal Surgery at the Freeman Hospital, Newcastle upon Tyne, UK. Conflicts of interest: none declared. Alan F Horgan MD FRCS (Gen) is a Consultant Surgeon in the Department of Colorectal Surgery at the Freeman Hospital, Newcastle upon Tyne, UK. Conflicts of interest: none declared.
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1
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Koh HC, Horgan AF, Enhanced recovery in intestinal surgery, Surgery (2017), http://dx.doi.org/10.1016/ j.mpsur.2017.01.005
INTESTINAL SURGERY e I
prevention of post-operative nausea and vomiting (PONV). This may help to reduce patient’s stress response and the release of catabolic hormones thereby reducing the incidence of insulin resistance, hyperglycaemia and the consequences of wound and cardiovascular complications.
especially loss of muscle mass, is associated an increased risk of post-operative cardiovascular complications, increased length of stay and increased mortality following colorectal surgery.6 Preoperative nutritional support may need to be considered in patients with significant weight loss. Similar consideration should be given to patients with upper GI or hepato-pancreato-biliary malignancy where the disease process often causes malnutrition for mechanical or functional reasons. Dietician input is recommended and in severe cases it may be beneficial to consider a period of enteric or even parenteral feeding if time allows.
Antimicrobial prophylaxis Antibiotic prophylaxis reduces post-operative wound infection by 20e30% following colorectal surgery. Either systemic or oral antibiotic prophylaxis has a positive effect in reducing postoperative wound infection, although the effect of oral antibiotic prophylaxis is inferior to systemic antibiotic prophylaxis. Combined oral and systemic antibiotic prophylaxis on the other hand is more effective than either route on its own. Combination of systemic antibiotic with oral antibiotic prophylaxis reduces surgical wound infections from 12% to 4.5% and more studies are emerging to show good evidence on the benefits of oral antibiotics prophylaxis in reducing surgical wound infections.8 Such studies were, however, performed in conjunction with mechanical bowel preparation. In an era where the practice of mechanical bowel preparation is increasingly discouraged, further studies are required to establish the benefit of oral antibiotic prophylaxis without mechanical bowel preparation. Studies on patients undergoing gastrectomy and oesophagectomy where mechanical bowel preparation was not given have shown positive effects in the reduction of infection rates.8 Systemic antibiotic prophylaxis is strongly recommended to reduce the risk of surgical site infection. The antibiotics used should have antimicrobial actions against both aerobic and anaerobic pathogens and they should be based on local antibiotic policy and local resistance pattern. Combination of antibiotics is more effective than single-antibiotic regime and should be given within the hour prior to incision, repeated 3 hours later in prolonged cases or in cases where there had been significant intraoperative blood loss. Prolonged use of systemic antibiotics for more than 24e48 hours post-operatively is not required and such practice predisposes to the development of Clostridium difficile infection.9
Pre-operative mechanical bowel preparation Mechanical bowel preparation has no impact in reducing anastomotic leak rates or septic complications. It has the potential to cause greater morbidity such as intravascular depletion or electrolyte disturbances, increased length of stay, and is often poorly tolerated by patients.5 Mechanical bowel preparation is therefore no longer recommended in colorectal surgery, apart from in specific conditions such as the need for on-table colonoscopy to identify small lesions or bleeding points. Many surgeons continue to use mechanical bowel preparation prior to rectal surgery where the weight of evidence is not as strong. Thromboprophylaxis Surgical patients are at increased risks of post-operative venous thromboembolism due to the need for hospitalization, anaesthesia, and a period of immobilization during and following surgery. The risks are greater in the older age group, underlying malignancy, prolonged abdominal or pelvic surgery, and in patients with complications such as sepsis, acute kidney injury, or bleeding with need for blood transfusion.7 When undergoing major surgery, patients should have both mechanical and chemical thromboprophylaxis. Patients should be fitted with embolic stockings or pneumatic compression device especially in prolonged surgery and pelvic surgery. Prophylactic dosage of unfractionated or low-molecular-weight heparin should be given to all patients. For patients who are intolerant of heparin, fondaparinux or aspirin could be used as an alternative. For patients who are at higher risk of bleeding, chemical thromboprophylaxis should only be omitted if the risk of bleeding outweighs the risk of thromboembolism. In such cases, it may be necessary to consider insertion of a caval filter. Thromboprophylaxis is traditionally given whilst patients remain in hospital. The length of stay is however often shorter with ERAS programme leading to suggestion that it should be given for 7e10 days in these patients or extended to 28 days postoperatively in patients with underlying cancer, morbid obesity, or prolonged abdominopelvic surgery.5
Post-operative nausea and vomiting (PONV) PONV affects 25% of surgical patients, and is associated with delayed commencement of oral intake, recovery of gut function and subsequent hospital discharge. Risk factors for PONV include female gender, non-smokers, those with history of PONV or motion sickness, major abdominal surgery and the use of volatile anaesthetic agents or parenteral opiates. A multimodal approach combining non-pharmacological and pharmacological techniques to prevent PONV is recommended. Preventative measures include minimizing the usage of opiates and volatile anaesthetic agents, minimizing pre-operative fasting, the practice of carbohydrate loading and improved hydration in patients prior to surgery. There are four main pharmacological subtypes of antiemetics e cholinergic, dopaminergic, serotonergic and histaminergic. Two or more antiemetics of different subtypes should be used in combination to improve the potency of the antiemetic effect. Dexamethasone has been shown to have a positive effect in the prevention or management of PONV, although its use should be cautioned in diabetic patients, elderly patients and patients with
Intra-operative strategies Anaesthesia The use of rapid short-acting anaesthetic agents (e.g. desflurane), short-acting opioids (e.g. remifentanil) and muscle relaxants have helped to facilitate more rapid awakening and reduce the need for prolonged period of post-operative recovery and monitoring. The use of regional anaesthesia (e.g. epidural or spinal opioids) is helpful in the management of post-operative pain and the
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2
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Koh HC, Horgan AF, Enhanced recovery in intestinal surgery, Surgery (2017), http://dx.doi.org/10.1016/ j.mpsur.2017.01.005
INTESTINAL SURGERY e I
gastrectomy and oesophagectomy have been shown to be safe with the perceived advantage of less complications in terms of intra-operative blood loss, pulmonary complications and shorter intensive care and hospital admission. The evidence in upper GI cancer surgery is, however, not strong and the operation is often more prolonged due to the complexity and technical demand of minimally invasive surgery with concerns regarding the longterm oncological outcomes.13,14
mental health issues due to its risks of hyperglycaemia and psychiatric disturbance.10 In cases of established PONV, the treatment should be multimodal and other subtypes of antiemetic that have not used as a prophylactic measure in that particular patient should be utilised.4 Fluid management Liberal or excessive administration of fluid has a detrimental effect on cardiorespiratory function and tissue healing, which then contributes to an increased in complications and hospital stay. Goal-directed fluid therapy is associated with lower rates of post-operative infectious and cardiorespiratory complications, lower incidence of PONV, less gut oedema which allows a quicker return of bowel function. Goal-directed intra-operative fluid administration based on cardiac output has been shown to be beneficial in multiple randomized controlled trials. The most common method of cardiac output monitoring is the oesophageal Doppler, although other methods such as LidCoÒ or PICCOÒ which rely on invasive arterial pressure monitoring are available.11 Excessive fluid therapy in the post-operative period should also be avoided. Intravenous fluids should be ceased as soon as patient is taking sufficient oral intake and intravenous normal saline should not be used routinely. Epidural-induced hypotension is often an issue among patients with a functioning epidural. In such situations, provided that the patient is normovolaemic, the management of hypotension should be with vasopressors and not with excessive fluid therapy.
Nasogastric tube insertion Routine nasogastric intubation has been shown to increase the risks of post-operative fever, atelectasis and pneumonia.4 Nasogastric intubation does not prevent post-operative ileus but in fact increases the risk with a delay in passage of flatus. It is therefore recommended to remove nasogastric tube prior to the patient waking up from general anaesthesia. Similar recommendation applies to upper GI and pancreatic surgery as prophylactic nasogastric decompression does not improve outcome even among patients who would subsequently develop delayed gastric emptying post-operatively. Peritoneal cavity drainage Following pancreatic surgery, drains are often routinely used due to concerns regarding the development of intra-abdominal collections secondary to leakage form the pancreatic ducts. Early removal of drains in patients who are at low risk of fistulation (drain fluid of amylase <5000 U/litre) on day 3 post-operation is recommended to help reduce risks of pancreatic fistula. Prolonged drainage has not been shown to be of any advantage in the detection or management of anastomotic leaks.14 Similarly in other GI subspecialities, prophylactic drainage does not offer any protection against intraabdominal sepsis or anastomotic leak, nor does it allow earlier detection of anastomotic leak.15 In some situation drains have the potential to cause complications such as drain site infection, pain or bleeding, false reassurance due to a blocked drain or a poorly functioning drain, small bowel or omental evisceration, injury to bowel or adjacent structures, entero-cutaneous fistula formation or bowel obstruction. Despite the lack of evidence supporting prophylactic drain insertion, surgical drains remain an important adjunct in certain circumstances. Prophylactic drain insertion can be considered when there is a need to monitor for potential postoperative bleeding, where a high drain output can help identify bleeding at the early post-operative period.
Thermoregulation Hypothermia predisposes to coagulopathy, impaired immunity and an increased surgical stress response. Maintaining normothermia is therefore important to reduce complications such as bleeding, wound infection and cardiac events.4 Simple measures include the intra-operative use of forced-air warming blanket, heating mattress or warmed intravenous fluids. It is equally important to monitor patient’s temperature to avoid overwarming and hyperpyrexia. Surgery Laparoscopic surgery is the preferred approach in patients undergoing bariatric surgery. The cost and technical complexity associated with the laparoscopic approach are compensated by fewer post-operative complications such as pain issue, blood loss, wound complications (infection, dehiscence, or hernia), quicker recovery and shorter hospital stay.12 In colonic surgery, minimally invasive surgery is an increasingly widely accepted approach. Laparoscopic surgery is associated with a reduced inflammatory response, improved cardiorespiratory function, earlier return of gut function and shorter length of hospital stay without compromising oncological outcomes. The benefits, however, have not been replicated as strongly in pelvic/rectal surgery although it is widely accepted for the colonic component to be performed laparoscopically.5 The long-term outcomes of newer minimally invasive techniques such as robotic surgery or transanal rectal excision are still awaited. Similarly for upper GI surgery, minimally invasive
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Post-operative strategies Early nutrition and mobilization are key components of the postoperative phase of enhanced recovery programmes. Nutritional care Prolonged post-operative fasting is no longer a recommended practice. In colorectal surgery, early feeding has been shown to reduce the risk of post-operative infection and length of hospital stay, without an increased risk of anastomotic dehiscence. Early feeding together with pre-operative carbohydrate drinks and regional analgesia have been shown to minimize insulin resistance and improve blood sugar control.6 Traditional concerns regarding an increased risk of vomiting and/or anastomotic dehiscence with early feeding have proven not to be the case and
3
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Please cite this article in press as: Koh HC, Horgan AF, Enhanced recovery in intestinal surgery, Surgery (2017), http://dx.doi.org/10.1016/ j.mpsur.2017.01.005
INTESTINAL SURGERY e I
results. Alvimopan (an opioid receptor antagonist) has been shown to facilitate gastrointestinal recovery with a reduction in post-operative ileus and shorter hospital stay. Interestingly the use of chewing gum has been shown to have a positive effect on the duration of post-operative ileus.4
post-operative vomiting can be minimized with the use of a prophylactic multimodal regime of antiemetic therapy. Early feeding has also been shown to be safe in upper GI and pancreatic surgery, although patients are advised to increase oral intake cautiously as tolerated.13,14 Enteral feeding may need to be considered in patients who are malnourished or in certain patients with delayed gastric emptying, whereby naso-jejunal feeding can be considered. Parenteral nutrition is not recommended unless there is prolonged gut dysfunction, for example in cases of prolonged ileus provided that any underlying precipitation factor has been dealt with.
The team The success of any ERAS programme is a direct reflection of the composition and functionality of the enhanced recovery team. Representatives of all those involved in the care of the patient throughout their hospital stay and beyond should be involved from the time of conception of any ERAS programme. The team should include specialist nurses, ward nursing staff, anaesthetics, dieticians, physiotherapists, pharmacy staff, management pain management, pre-assessment, medical staff and, where possible, representatives of patients and general practice. Input from each should result in a well-organized and compliant programme with the flexibility to develop based on audit and feedback from patients and staff.
Early mobilization Early mobilization helps reduce pulmonary complications as well as preventing muscle atrophy and insulin resistance due to immobilization. Patients should be encouraged to mobilize as soon as possible with exercise plans from post-operative day 1 onwards, with trial of voiding on day 1 or 2 and cessation of intravenous fluids on day 1 or as soon as they are tolerating oral fluid intake. Failure to mobilize is a common cause of deviation from the ERAS programme with resultant prolongation of hospital stay. This can be exacerbated by a variety of factors such as poor pain control, indwelling urinary catheter or peritoneal drain, continued intravenous fluid infusion, poor patient motivation and lack of staff encouragement.
Conclusion ERAS programmes are undoubtedly of benefit to patients throughout their operative journey and post-operative recovery. This translates to a standardized patient care pathway, improved clinical outcomes and shorter hospital stay, all of which facilitate the increasing demand on healthcare and bed pressure. Its principles and many components are transferable to other surgical specialities including acute surgical services and medical specialities to improve patient care and recovery and will soon become the standard of care for the majority of hospital inpatients. A
Post-operative analgesia Good pain management is a key component to ensure early mobilization. A good analgesic regimen should provide adequate pain relief and allow early mobilisation without causing complications such as drowsiness, respiratory compromise, or nausea and vomiting with a consequent delay in the return of oral intake and gut function. Opiates should be avoided if possible due to their effect on slowing of gut function. A multimodal regimen with paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) is often all that is needed once patients have overcome the immediate postoperative period. Other opioid-sparing methods are available, for example transverse abdominis plane (TAP) block, intravenous lidocaine, or thoracic epidurals. Epidural analgesia is however increasingly abandoned in the context of laparoscopic surgery although it still is seen to have a role in open surgery. The use of combined local anaesthetic and a short-acting opiate allows for good analgesic effect while minimizing the risks of motor blockage and sympathetic blockade which may cause epiduralinduced hypotension. Benefits of a functioning epidural analgesia include reduced risk of PONV, earlier return of gut function and reduced insulin resistance.4
REFERENCES 1 Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78: 606e17. 2 Lourenco T, Murray A, Grant A, McKinley A, Krukowski Z, Vale L. Laparoscopic surgery for colorectal cancer: safe and effective? e A systematic review. Surg Endosc 2008; 22: 1146e60. 3 Snowden C, Prentis J, Anderson H, et al. Submaximal cardiopulmonary exercise testing predicts complications and hospital length of stay in patients undergoing major elective surgery. Ann Surg 2010; 251: 535e41. 4 Feldheiser A, Aziz O, Baldini G, Cox B, Fearon K. Enhanced recovery after surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand 2016; 60: 289e334. 5 Gustafsson U, Scott M, Schwenk W, Demartines N, Roulin D. Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS) society recommendations. World J Surg 2013; 37: k259e284. 6 Scott M, Baldini G, Fearon K, Feldheiser A, Feldman L, Gan T. Enhanced recovery after surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations. Acta Anaesthesiol Scand 2015; 59: 1212e31. 7 Gould M, Garcia D, Wren S, Karanicolas P, Arcelus J. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 144(2_suppl): e227Se77.
Prevention of post-operative ileus Post-operative ileus is a common cause of delayed discharge following abdominal surgery. Different components of the ERAS programme as discussed earlier, namely early nutrition, goaldirected fluid therapy to prevent fluid overload and gut oedema, avoiding prophylactic or unnecessary nasogastric tube decompression, and laparoscopic surgery, are carried out with the aim of reducing the risk of post-operative ileus. Other pharmacological measures such as prokinetic agents, magnesium oxide and bisacodyl have been looked at with mixed
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Please cite this article in press as: Koh HC, Horgan AF, Enhanced recovery in intestinal surgery, Surgery (2017), http://dx.doi.org/10.1016/ j.mpsur.2017.01.005
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8 Roos D, Dijksman L, Tijssen J, Gouma D, Gerhards M, Oudemans-van Straaten H. Systematic review of perioperative selective decontamination of the digestive tract in elective gastrointestinal surgery. Br J Surg 2013; 100(2): 1579e88. 9 Nelson R, Gladman E, Barbateskovic M. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst Rev 2014; 9. Issue 5. Art. No.:CD001181. 10 Kakodkar P. Routine use of dexamethasone for postoperative nausea and vomiting: the case for. Anaesthesia 2013; 68: 889e91. 11 Mehta Y, Arora D. Newer methods of cardiac output monitoring. World J Cardiol 2014; 6: 1022e9. 12 Thorell A, MacCormick A, Awad S, Reynolds N, Roulin D. Guidelines for perioperative care in bariatric surgery: enhanced
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recovery after surgery (ERAS) society recommendations. World J Surg 2016; 40: 2065e83. €fer M, Mariette C, Braga M. 13 Mortensen K, Nilsson M, Slim K, Scha Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERASÒ) Society recommendations. Br J Surg 2014; 101(10): 1209e29. 14 Lassen K, Coolsen M, Slim K, Carli F, de Aguilar-Nascimento J, €fer M. Guidelines for perioperative care for panScha creaticoduodenectomy: Enhanced Recovery After Surgery (ERASÒ) society recommendations. World J Surg 2013; 37(2): 240e58. 15 Jesus E, Karliczek A, Matos D, Castro A, Atallah A. Prophylactic anastomotic drainage for colorectal surgery. Cochrane Database Syst Rev 2004. Issue 4. Art. No.:CD002100.
5
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Koh HC, Horgan AF, Enhanced recovery in intestinal surgery, Surgery (2017), http://dx.doi.org/10.1016/ j.mpsur.2017.01.005
Enhanced recovery in intestinal surgery
the support of consultant anaesthetists for advice and assessment of high-risk patients. The clinic allows assessment of a patient’s general fitness, medical comorbidities, drug history and the optimization of pre-existing conditions. Simple investigations such as full blood count and renal function, ECG, CXR, stress test or simple 6-minute walk test can be carried out as required. Nowadays for major resectional surgery, many units carry out objective evaluation of functional capacity with more sophisticated tests such as cardiopulmonary exercise testing (CPET) or myocardial perfusion scanning. This provides a more objective assessment of operative risks to determine a patient’s suitability to proceed to surgery and enables the planning for post-operative critical care facility when necessary.3 Good pre-operative planning helps facilitate same-day admission and avoids unnecessary cancellations. It also provides an opportunity for the assessment of social circumstances to aid discharge planning and social risk factors such as smoking and alcohol, which are linked to increased post-operative complications such as bleeding, wound infection and cardiopulmonary dysfunction.
Hoey C Koh Alan F Horgan
Abstract Enhanced recovery after surgery (ERAS) programmes utilise a multimodal and multidisciplinary approach to surgical care. The aim of ERAS is to reduce the surgical stress response, maintain physiological function and metabolic homeostasis and expedite patients’ recovery to their baseline status. With its success in colorectal practice, ERAS is increasingly adopted in other surgical specialities. A good ERAS programme involves integrated pre-operative, intra-operative and post-operative evidence-based practice. Successful ERAS programme translates to a standardized patient care pathway, improved clinical outcomes and shorter hospital stay, all of which will help facilitate the increasing demand on healthcare and bed pressure. Its principles and many components are transferable to other surgical specialities including acute surgical services and medical specialities to improve patient care and recovery and will soon become the standard of care for the majority of hospital inpatients.
Pre-operative education Apart from pre-assessment of fitness for surgery, patients in an ERAS programme will also receive pre-operative education with information regarding the surgery, anaesthetic procedures, anticipated post-operative recovery and the journey from admission to discharge. Such pre-operative education helps alleviate anxiety and encourages patients’ participation in their recovery process. For bariatric surgery, pre-operative information has been shown to improve patient’s compliance and reduce anxiety and stress postoperatively. For patients undergoing in colorectal surgery, preoperative stoma education is important as it helps mentally and physically prepare the patients in their expectation and management of their stoma and has been shown to reduce hospital stay.
Keywords ERAS; fast-track surgery
Enhanced recovery after surgery (ERAS) programmes utilise a multimodal and multidisciplinary approach to surgical care. ERAS programmes involves integrated pre-operative, intra-operative and post-operative evidence-based practice. The aim of ERAS is to reduce the surgical stress response, maintain physiological function and metabolic homoeostasis and expedite patients’ recovery to their baseline status. The concept of ERAS was first introduced in 1990s in colonic surgery by Henrik Kehlet to reduce postoperative complications and length of hospital stay.1 ERAS is now widely practice despite the initial apprehension and slow uptake, with studies repeatedly showing that it is safe and shortens hospital stay.2 With its success in colorectal practice, ERAS is increasingly adopted in upper GI surgery and pancreatic surgery, as well as in non-GI specialities such as orthopaedics and urology.
Smoking and alcohol cessation Smoking is associated with increased risk of post-operative wound sepsis, pulmonary complications and venous thromboembolism. Cessation for at least 4 weeks leading up to surgery should be greatly encouraged as it has been shown to reduce post-operative complications.4 Alcohol misusers are also at two- to threefold increased risk of post-operative pulmonary complication, wound infection, wound breakdown and increased length of hospital stay. Abstinence has been shown to improve outcome and should be recommended for at least 4 weeks.5
Pre-operative preparation Pre-operative assessment Once the shared decision has been made to proceed with major surgery, patients should undergo pre-operative assessment to assess fitness for surgery. Nowadays this is done at dedicated pre-operative assessment clinics which are often nurse-led with
Pre-operative nutrition The practice of prolonged fasting period is no longer recommended. Patients are allowed solids (6 hours) and clear fluids (2 hours) prior to induction of anaesthesia. Pre-operative fasting will inhibit insulin secretion and promote release of catabolic hormones. The provision of oral carbohydrate drinks up to 2 hours prior to surgery has been shown to reduce post-operative insulin resistance, reduce protein breakdown, improve muscle strength and shorten hospital stay. Pre-operative supplementary nutrition should be considered for patients who had unintentional pre-operative weight loss or those who are significantly malnourished. Unintentional weight loss,
Hoey C Koh MSc FRCS Glasgow is a Colorectal Fellow in the Department of Colorectal Surgery at the Freeman Hospital, Newcastle upon Tyne, UK. Conflicts of interest: none declared. Alan F Horgan MD FRCS (Gen) is a Consultant Surgeon in the Department of Colorectal Surgery at the Freeman Hospital, Newcastle upon Tyne, UK. Conflicts of interest: none declared.
SURGERY --:-
1
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Koh HC, Horgan AF, Enhanced recovery in intestinal surgery, Surgery (2017), http://dx.doi.org/10.1016/ j.mpsur.2017.01.005
INTESTINAL SURGERY e I
prevention of post-operative nausea and vomiting (PONV). This may help to reduce patient’s stress response and the release of catabolic hormones thereby reducing the incidence of insulin resistance, hyperglycaemia and the consequences of wound and cardiovascular complications.
especially loss of muscle mass, is associated an increased risk of post-operative cardiovascular complications, increased length of stay and increased mortality following colorectal surgery.6 Preoperative nutritional support may need to be considered in patients with significant weight loss. Similar consideration should be given to patients with upper GI or hepato-pancreato-biliary malignancy where the disease process often causes malnutrition for mechanical or functional reasons. Dietician input is recommended and in severe cases it may be beneficial to consider a period of enteric or even parenteral feeding if time allows.
Antimicrobial prophylaxis Antibiotic prophylaxis reduces post-operative wound infection by 20e30% following colorectal surgery. Either systemic or oral antibiotic prophylaxis has a positive effect in reducing postoperative wound infection, although the effect of oral antibiotic prophylaxis is inferior to systemic antibiotic prophylaxis. Combined oral and systemic antibiotic prophylaxis on the other hand is more effective than either route on its own. Combination of systemic antibiotic with oral antibiotic prophylaxis reduces surgical wound infections from 12% to 4.5% and more studies are emerging to show good evidence on the benefits of oral antibiotics prophylaxis in reducing surgical wound infections.8 Such studies were, however, performed in conjunction with mechanical bowel preparation. In an era where the practice of mechanical bowel preparation is increasingly discouraged, further studies are required to establish the benefit of oral antibiotic prophylaxis without mechanical bowel preparation. Studies on patients undergoing gastrectomy and oesophagectomy where mechanical bowel preparation was not given have shown positive effects in the reduction of infection rates.8 Systemic antibiotic prophylaxis is strongly recommended to reduce the risk of surgical site infection. The antibiotics used should have antimicrobial actions against both aerobic and anaerobic pathogens and they should be based on local antibiotic policy and local resistance pattern. Combination of antibiotics is more effective than single-antibiotic regime and should be given within the hour prior to incision, repeated 3 hours later in prolonged cases or in cases where there had been significant intraoperative blood loss. Prolonged use of systemic antibiotics for more than 24e48 hours post-operatively is not required and such practice predisposes to the development of Clostridium difficile infection.9
Pre-operative mechanical bowel preparation Mechanical bowel preparation has no impact in reducing anastomotic leak rates or septic complications. It has the potential to cause greater morbidity such as intravascular depletion or electrolyte disturbances, increased length of stay, and is often poorly tolerated by patients.5 Mechanical bowel preparation is therefore no longer recommended in colorectal surgery, apart from in specific conditions such as the need for on-table colonoscopy to identify small lesions or bleeding points. Many surgeons continue to use mechanical bowel preparation prior to rectal surgery where the weight of evidence is not as strong. Thromboprophylaxis Surgical patients are at increased risks of post-operative venous thromboembolism due to the need for hospitalization, anaesthesia, and a period of immobilization during and following surgery. The risks are greater in the older age group, underlying malignancy, prolonged abdominal or pelvic surgery, and in patients with complications such as sepsis, acute kidney injury, or bleeding with need for blood transfusion.7 When undergoing major surgery, patients should have both mechanical and chemical thromboprophylaxis. Patients should be fitted with embolic stockings or pneumatic compression device especially in prolonged surgery and pelvic surgery. Prophylactic dosage of unfractionated or low-molecular-weight heparin should be given to all patients. For patients who are intolerant of heparin, fondaparinux or aspirin could be used as an alternative. For patients who are at higher risk of bleeding, chemical thromboprophylaxis should only be omitted if the risk of bleeding outweighs the risk of thromboembolism. In such cases, it may be necessary to consider insertion of a caval filter. Thromboprophylaxis is traditionally given whilst patients remain in hospital. The length of stay is however often shorter with ERAS programme leading to suggestion that it should be given for 7e10 days in these patients or extended to 28 days postoperatively in patients with underlying cancer, morbid obesity, or prolonged abdominopelvic surgery.5
Post-operative nausea and vomiting (PONV) PONV affects 25% of surgical patients, and is associated with delayed commencement of oral intake, recovery of gut function and subsequent hospital discharge. Risk factors for PONV include female gender, non-smokers, those with history of PONV or motion sickness, major abdominal surgery and the use of volatile anaesthetic agents or parenteral opiates. A multimodal approach combining non-pharmacological and pharmacological techniques to prevent PONV is recommended. Preventative measures include minimizing the usage of opiates and volatile anaesthetic agents, minimizing pre-operative fasting, the practice of carbohydrate loading and improved hydration in patients prior to surgery. There are four main pharmacological subtypes of antiemetics e cholinergic, dopaminergic, serotonergic and histaminergic. Two or more antiemetics of different subtypes should be used in combination to improve the potency of the antiemetic effect. Dexamethasone has been shown to have a positive effect in the prevention or management of PONV, although its use should be cautioned in diabetic patients, elderly patients and patients with
Intra-operative strategies Anaesthesia The use of rapid short-acting anaesthetic agents (e.g. desflurane), short-acting opioids (e.g. remifentanil) and muscle relaxants have helped to facilitate more rapid awakening and reduce the need for prolonged period of post-operative recovery and monitoring. The use of regional anaesthesia (e.g. epidural or spinal opioids) is helpful in the management of post-operative pain and the
SURGERY --:-
2
Ó 2017 Published by Elsevier Ltd.
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gastrectomy and oesophagectomy have been shown to be safe with the perceived advantage of less complications in terms of intra-operative blood loss, pulmonary complications and shorter intensive care and hospital admission. The evidence in upper GI cancer surgery is, however, not strong and the operation is often more prolonged due to the complexity and technical demand of minimally invasive surgery with concerns regarding the longterm oncological outcomes.13,14
mental health issues due to its risks of hyperglycaemia and psychiatric disturbance.10 In cases of established PONV, the treatment should be multimodal and other subtypes of antiemetic that have not used as a prophylactic measure in that particular patient should be utilised.4 Fluid management Liberal or excessive administration of fluid has a detrimental effect on cardiorespiratory function and tissue healing, which then contributes to an increased in complications and hospital stay. Goal-directed fluid therapy is associated with lower rates of post-operative infectious and cardiorespiratory complications, lower incidence of PONV, less gut oedema which allows a quicker return of bowel function. Goal-directed intra-operative fluid administration based on cardiac output has been shown to be beneficial in multiple randomized controlled trials. The most common method of cardiac output monitoring is the oesophageal Doppler, although other methods such as LidCoÒ or PICCOÒ which rely on invasive arterial pressure monitoring are available.11 Excessive fluid therapy in the post-operative period should also be avoided. Intravenous fluids should be ceased as soon as patient is taking sufficient oral intake and intravenous normal saline should not be used routinely. Epidural-induced hypotension is often an issue among patients with a functioning epidural. In such situations, provided that the patient is normovolaemic, the management of hypotension should be with vasopressors and not with excessive fluid therapy.
Nasogastric tube insertion Routine nasogastric intubation has been shown to increase the risks of post-operative fever, atelectasis and pneumonia.4 Nasogastric intubation does not prevent post-operative ileus but in fact increases the risk with a delay in passage of flatus. It is therefore recommended to remove nasogastric tube prior to the patient waking up from general anaesthesia. Similar recommendation applies to upper GI and pancreatic surgery as prophylactic nasogastric decompression does not improve outcome even among patients who would subsequently develop delayed gastric emptying post-operatively. Peritoneal cavity drainage Following pancreatic surgery, drains are often routinely used due to concerns regarding the development of intra-abdominal collections secondary to leakage form the pancreatic ducts. Early removal of drains in patients who are at low risk of fistulation (drain fluid of amylase <5000 U/litre) on day 3 post-operation is recommended to help reduce risks of pancreatic fistula. Prolonged drainage has not been shown to be of any advantage in the detection or management of anastomotic leaks.14 Similarly in other GI subspecialities, prophylactic drainage does not offer any protection against intraabdominal sepsis or anastomotic leak, nor does it allow earlier detection of anastomotic leak.15 In some situation drains have the potential to cause complications such as drain site infection, pain or bleeding, false reassurance due to a blocked drain or a poorly functioning drain, small bowel or omental evisceration, injury to bowel or adjacent structures, entero-cutaneous fistula formation or bowel obstruction. Despite the lack of evidence supporting prophylactic drain insertion, surgical drains remain an important adjunct in certain circumstances. Prophylactic drain insertion can be considered when there is a need to monitor for potential postoperative bleeding, where a high drain output can help identify bleeding at the early post-operative period.
Thermoregulation Hypothermia predisposes to coagulopathy, impaired immunity and an increased surgical stress response. Maintaining normothermia is therefore important to reduce complications such as bleeding, wound infection and cardiac events.4 Simple measures include the intra-operative use of forced-air warming blanket, heating mattress or warmed intravenous fluids. It is equally important to monitor patient’s temperature to avoid overwarming and hyperpyrexia. Surgery Laparoscopic surgery is the preferred approach in patients undergoing bariatric surgery. The cost and technical complexity associated with the laparoscopic approach are compensated by fewer post-operative complications such as pain issue, blood loss, wound complications (infection, dehiscence, or hernia), quicker recovery and shorter hospital stay.12 In colonic surgery, minimally invasive surgery is an increasingly widely accepted approach. Laparoscopic surgery is associated with a reduced inflammatory response, improved cardiorespiratory function, earlier return of gut function and shorter length of hospital stay without compromising oncological outcomes. The benefits, however, have not been replicated as strongly in pelvic/rectal surgery although it is widely accepted for the colonic component to be performed laparoscopically.5 The long-term outcomes of newer minimally invasive techniques such as robotic surgery or transanal rectal excision are still awaited. Similarly for upper GI surgery, minimally invasive
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Post-operative strategies Early nutrition and mobilization are key components of the postoperative phase of enhanced recovery programmes. Nutritional care Prolonged post-operative fasting is no longer a recommended practice. In colorectal surgery, early feeding has been shown to reduce the risk of post-operative infection and length of hospital stay, without an increased risk of anastomotic dehiscence. Early feeding together with pre-operative carbohydrate drinks and regional analgesia have been shown to minimize insulin resistance and improve blood sugar control.6 Traditional concerns regarding an increased risk of vomiting and/or anastomotic dehiscence with early feeding have proven not to be the case and
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results. Alvimopan (an opioid receptor antagonist) has been shown to facilitate gastrointestinal recovery with a reduction in post-operative ileus and shorter hospital stay. Interestingly the use of chewing gum has been shown to have a positive effect on the duration of post-operative ileus.4
post-operative vomiting can be minimized with the use of a prophylactic multimodal regime of antiemetic therapy. Early feeding has also been shown to be safe in upper GI and pancreatic surgery, although patients are advised to increase oral intake cautiously as tolerated.13,14 Enteral feeding may need to be considered in patients who are malnourished or in certain patients with delayed gastric emptying, whereby naso-jejunal feeding can be considered. Parenteral nutrition is not recommended unless there is prolonged gut dysfunction, for example in cases of prolonged ileus provided that any underlying precipitation factor has been dealt with.
The team The success of any ERAS programme is a direct reflection of the composition and functionality of the enhanced recovery team. Representatives of all those involved in the care of the patient throughout their hospital stay and beyond should be involved from the time of conception of any ERAS programme. The team should include specialist nurses, ward nursing staff, anaesthetics, dieticians, physiotherapists, pharmacy staff, management pain management, pre-assessment, medical staff and, where possible, representatives of patients and general practice. Input from each should result in a well-organized and compliant programme with the flexibility to develop based on audit and feedback from patients and staff.
Early mobilization Early mobilization helps reduce pulmonary complications as well as preventing muscle atrophy and insulin resistance due to immobilization. Patients should be encouraged to mobilize as soon as possible with exercise plans from post-operative day 1 onwards, with trial of voiding on day 1 or 2 and cessation of intravenous fluids on day 1 or as soon as they are tolerating oral fluid intake. Failure to mobilize is a common cause of deviation from the ERAS programme with resultant prolongation of hospital stay. This can be exacerbated by a variety of factors such as poor pain control, indwelling urinary catheter or peritoneal drain, continued intravenous fluid infusion, poor patient motivation and lack of staff encouragement.
Conclusion ERAS programmes are undoubtedly of benefit to patients throughout their operative journey and post-operative recovery. This translates to a standardized patient care pathway, improved clinical outcomes and shorter hospital stay, all of which facilitate the increasing demand on healthcare and bed pressure. Its principles and many components are transferable to other surgical specialities including acute surgical services and medical specialities to improve patient care and recovery and will soon become the standard of care for the majority of hospital inpatients. A
Post-operative analgesia Good pain management is a key component to ensure early mobilization. A good analgesic regimen should provide adequate pain relief and allow early mobilisation without causing complications such as drowsiness, respiratory compromise, or nausea and vomiting with a consequent delay in the return of oral intake and gut function. Opiates should be avoided if possible due to their effect on slowing of gut function. A multimodal regimen with paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) is often all that is needed once patients have overcome the immediate postoperative period. Other opioid-sparing methods are available, for example transverse abdominis plane (TAP) block, intravenous lidocaine, or thoracic epidurals. Epidural analgesia is however increasingly abandoned in the context of laparoscopic surgery although it still is seen to have a role in open surgery. The use of combined local anaesthetic and a short-acting opiate allows for good analgesic effect while minimizing the risks of motor blockage and sympathetic blockade which may cause epiduralinduced hypotension. Benefits of a functioning epidural analgesia include reduced risk of PONV, earlier return of gut function and reduced insulin resistance.4
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Prevention of post-operative ileus Post-operative ileus is a common cause of delayed discharge following abdominal surgery. Different components of the ERAS programme as discussed earlier, namely early nutrition, goaldirected fluid therapy to prevent fluid overload and gut oedema, avoiding prophylactic or unnecessary nasogastric tube decompression, and laparoscopic surgery, are carried out with the aim of reducing the risk of post-operative ileus. Other pharmacological measures such as prokinetic agents, magnesium oxide and bisacodyl have been looked at with mixed
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