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Enhanced recovery after colorectal surgery.

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PREOPERATIVE ASSESSMENT

Enhanced recovery after colorectal surgery: an update on current practice Dhivya Subramaniam

Alan F Horgan

AbstractThe concept of ‘enhanced recovery’ after surgery gained traction in the 1990s and has continued to evolve over the last three decades. It incorporates a host of evidence-based interventions into the patient care pathway and aims to eliminate those practices that were based in tradition and slowed the patient’s recovery. The pathway is designed to involve the patient and the wider surgical team along with primary care and support services. Enhanced recovery pathways have been emerging for a wide range of surgical subspecialties and the principles are applicable to all non day-case surgical interventions. Enhanced re-

covery after surgery pathways can be divided for simplicity into preop- erative, intraoperative and postoperative care and some of the important elements are described in this article along with the support- ing evidence.

Keywords Enhanced recovery; perioperative care

Introduction

‘Enhanced recovery after surgery’ (ERAS) programmes are now

considered to be standard practice after colorectal surgery and

are fast becoming the norm for all major surgical procedures in

any of the surgical specialties. Programmes differ in certain re-

spects depending on the specialty and geographical location but

have certain common themes, the basic principles of which are

the involvement of the patient and family in decision-making

preoperatively and the involvement of the wider hospital team

in formulation and execution of a complete patient pathway of

care which is evidence-based, leading to a quicker recovery for

the patient with less chance of physiological derangement at any

stage of the perioperative period.

Preoperative practice

Patient educationEducation of the patient and family regarding the nature of their

illness, the decisions which need to be made, the options avail-

able and their consequences and the nature of the perioperative

Dhivya Subramaniam BMedSci BMBS is a Trainee in 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 35:2 98

pathway are all integral parts of an effective enhanced recovery

programme. Written information leaflets are useful and

commonly available to inform patients about their illness and

treatment options. It is essential that patients about to undergo

any form of major surgery are given contact details for the

appropriate nurse specialist in case they have any further ques-

tions prior to their surgery and further consultation should be

encouraged in the event of confusion or concern.

Assessment and optimization of comorbiditiesAll patients undergoing major surgery are now routinely seen at

an anaesthetic preoperative assessment clinic. In addition to

providing patient information these clinics are essential in order

to assess and optimize any coexisting medical comorbidities, and

to stratify the patient so that the appropriate level of post-

operative care can be arranged in advance. Stratification is now

generally performed by exposing the patient to a physically

‘stressful’ environment (usually on a cycle or treadmill), in order

that the physiological response of the patient can be assessed.

The anaerobic threshold (AT) is the point at which the patient

moves from aerobic to anaerobic metabolism and gives a good

indication of how the patient will respond to major surgery. The

VO2Max is another good indicator of this and represents the

maximum amount of oxygen that the patient can utilize in a

minute per kilogram of body weight. This is covered in more

detail elsewhere in this issue.

Curtailed fasting and carbohydrate loadingThe traditional practice of overnight fasting to prevent risk of

aspiration during anaesthetic induction is now considered

obsolete. Prolonged fasting is associated with poorer post-

operative outcomes due to increased insulin resistance and risk

of hypovolaemia. The standard practice at present is a fasting

period of 6 hours for solids and 2 hours for clear liquids prior to

surgery and does not increase the risk of aspiration at induction.

Perioperative carbohydrate intake has been shown to

decrease postoperative insulin resistance, minimize post-

operative protein and nitrogen loss from catabolism and preserve

lean body mass. Clinically, this is manifested by a faster recovery

period and shorter duration of stay in hospital.1 A clear oral fluid

containing a high concentration of complex carbohydrate (typi-

cally 12.5% maltodextrin) should be given to all patients the

night before and 2 hours prior to surgery as part of the ERAS

pathway. This is considered safe in patients with uncomplicated

type 2 diabetes mellitus but large-scale studies of its safety in

patients with gastroparesis is currently lacking.

Selective bowel preparationUse of mechanical bowel preparation has been linked to signifi-

cant fluid and electrolyte shifts and prolonged postoperative

ileus. At present, it is not routinely recommended in enhanced

recovery pathways for colorectal surgery. A recent meta-analysis

showed that the use of bowel preparation did not prevent against

anastomotic leak and had comparable mortality, reoperation rate

and incidence of wound infections with patients who had no

bowel preparation or rectal enema alone.2 There may, however,

be specific indications for the use of mechanical bowel prepara-

tion in cases of low rectal anastomoses with a proximal diverting

stoma. A 2010 randomized controlled trial demonstrated

� 2016 Published by Elsevier Ltd.http://dx.doi.org/10.1016/j.mpsur.2016.11.012

PREOPERATIVE ASSESSMENT

significantly increased postoperative morbidity in patients with a

diverting stoma who did not receive mechanical bowel prepara-

tion, with a trend towards a higher risk of anastomotic leak in

this group.3 Further studies will be necessary to evaluate the full

significance of these findings.

Intraoperative practice

Surgical techniqueThe use of minimally invasive techniques is strongly advocated

where possible in elective colorectal surgery and is at least as

safe as the open approach with comparable long-term oncolog-

ical outcomes.4 The benefits of laparoscopic and laparoscopic-

assisted colorectal resections are well-documented and lead to

a shorter duration of inpatient stay.5 The stress response to

surgery is minimized due to the considerably smaller degree of

trauma to the abdominal wall. Postoperative recovery is signifi-

cantly accelerated due to decreased pain and opiate requirement

which in turn prevents respiratory complications and facilitates

earlier mobilization. Minimally invasive surgery is also associ-

ated with earlier return of gut function postoperatively.

Other minimally invasive techniques such as robotic-assisted

colorectal resection, single-incision laparoscopic surgery (SILS)

and natural orifice transluminal endoscopic surgery (NOTES) pro-

cedures have been attempted with some success, but there is

currently little evidence towarrant theiruseoutsideof a trial setting.

Where open surgery is performed, a recent systematic review

suggests that transverse incisions appear to be associated with

less pain and postoperative opiate use compared to midline

laparotomy incisions.6 However, the same study showed no

difference in length of inpatient stay and rate of pulmonary

complications between both groups.

Maintenance of normothermiaIntraoperative hypothermia is a common phenomenon that oc-

curs secondary to anaesthesia and heat loss from the abdominal

cavity. Hypothermia interferes with homoeostasis and is associ-

ated with multiple adverse outcomes including wound infection,

cardiac events, bleeding and coagulopathy. Close monitoring of

core temperature and prevention of hypothermia using active

warming devices is strongly recommended at present.

Inspired oxygen concentrationThe use of high inspired oxygen concentration (HIOC) is a sub-

ject open to debate. It has been proposed that HIOC minimizes

the risk of surgical site infection, particularly in patients under-

going colorectal surgery.7 However current literature on the

subject contains significant heterogeneity and it is recommended

that the FiO2 be titrated to produce normal blood gas levels to

protect against the potential risks of hyperoxia.

Perioperative fluid managementOptimal fluid balance is a crucial component of the ERAS pathway.

Preoperatively this is minimized by selective use of bowel prep-

aration, curtailed fasting allowing intake of clear fluids up to 2

hours before surgery and administration of an oral carbohydrate

preload. Both fluid depletion and overload have been shown to

increase postoperative morbidity. Fluid overload and electrolyte

imbalance have been shown to increase bowel oedema and affect

anastomotic integrity. Intraoperative fluid administration should

SURGERY 35:2 99

be guided by real-time cardiac output monitoring with oesopha-

geal Doppler studies. This is termed goal-directed fluid therapy

and has been shown to reduce postoperative morbidity and

duration of hospital stay.8 There is no consensus on the type of

fluid that should be administered and there appears to be little

difference in outcomes between colloids and crystalloids. Where

hypotension occurs secondary to epidural analgesia in the nor-

movolaemic patient, judicious use of vasoconstrictor drugs is

recommended rather than liberal fluid administration.

Tubes, catheters and drainsThe presence of tubes and drains is a significant impediment to

early mobilization and themselves are associated with various

complications. Routine use of prophylactic nasogastric tubes is

not recommended following elective colorectal surgery as there

is strong evidence linking it to respiratory morbidity and delayed

gut motility.9 Placement of pelvic drains has not been shown to

decrease rates of anastomotic leaks and confer no additional

benefit; as such, routine use of these is also discouraged. Urinary

catheters are associated with urinary tract infections and their

early removal (ideally on postoperative day 1) is recommended,

unless there is a specific clinical indication for the contrary.

Postoperative practice

Early mobilizationProlonged postoperative bed rest has now been linked to

increased incidence of venous thromboembolism (VTE), pro-

longed insulin resistance, muscle loss from catabolism and res-

piratory complications such as atelectasis and pneumonia.

Current ERAS protocols typically encourage mobilization as

soon as 4 hours postoperatively. Typically, patients are encour-

aged to spend 2 hours out of bed on the day of surgery and 6

hours daily thereafter until discharge.

Postoperative analgesiaSystemic analgesia: effective pain relief remains a cornerstone

of every ERAS programme. It enables early mobilization and

prevents complications such as respiratory infections and venous

thromboembolism. Opiate analgesia is associated with significant

morbidity (respiratory depression, drowsiness, decreased

mobility, PONV and delayed gut function) and should be avoided

where possible. A multimodal analgesic regime typically

comprising paracetamol and non-steroidal anti-inflammatory

drugs (NSAIDs) is extremely effective at achieving sufficient pain

relief especially in combination with the regional/local analgesia

described below. There have been some weak associations be-

tween the use of NSAIDs and COX-2 inhibitors with increased

risk of anastomotic leak, but a subsequent meta-analysis showed

no significant increase in leak rates in patients receiving post-

operative NSAIDs in the first 48 hours after surgery.10

Recently, systemic administration of intravenous magnesium,

or local anaesthetic (such as lidocaine) has increasingly been

used and is shown to decrease systemic opiate requirements.

Currently, the precise details of administration that achieves the

best analgesic effect remains undefined.

Regional/local analgesia: thoracic epidural analgesia (TEA) re-

mains the gold standard in patients undergoing open colorectal

� 2016 Published by Elsevier Ltd.http://dx.doi.org/10.1016/j.mpsur.2016.11.012

PREOPERATIVE ASSESSMENT

resection. Neuraxial blockade has been shown to mitigate the

surgical stress response and postoperative insulin resistance.

TEA has also been linked to earlier return of gut function, lower

incidence or cardiorespiratory complications and decreased

mortality. These benefits were not observed in patients under-

going laparoscopic resections and TEA has also been linked with

postoperative hypotension and urinary retention.

Laparoscopic-assisted resections are associated with signifi-

cantly less pain and there has been a shift towards the use of

intrathecal opiates in conjunction with transverses abdominis

plane (TAP) blocks over the lower abdominal incision in these

patients. There is good evidence demonstrating the efficacy of a

single-shot TAP block in the first 24 hours of surgery11 but cur-

rent evidence surrounding the use of continuous TAP infusion of

local anaesthetic is ambiguous.12

Postoperative nutritionEarly postoperative feeding does not increase the risk of post-

operative anastomotic leak and is associated with decreased

incidence of postoperative infections and length of hospital stay.13

Most of the evidence surrounding early postoperative oral feeding

has been obtained from traditional postoperative care pathways

rather than in a dedicated ERAS setting. However, early oral/

enteral nutrition should be attemptedwherever possible following

colorectal surgery as it decreases postoperative insulin resistance

by limiting the surgical stress response and preserves gut barrier

function, both of which improve tissue healing. Most ERAS

guidelines typically recommend drinking in the immediate post-

operative period and intake of solids approximately 4 hours post-

surgery. Meta-analyses have indicated an increased risk of post-

operative vomiting with early oral feeding e therefore, it is

important that the patient receives adequate anti-emetic cover in

the early postoperative period.

There is weak evidence in support of the use of oral nutri-

tional supplements (ONS), including immunonutrition, which

contains specific combinations of amino acids, nucleotides and

omega-3 fatty acids that help boost immune function. However

the effect of these supplements is most marked in malnourished

patients and there is currently no ERAS-specific evidence in

support of ONS. A 2016 meta-analysis on immunonutrition in

upper gastrointestinal surgery showed a decreased risk of wound

infection and length of hospital stay in the intervention group,

but no difference in other infective complications.14

Postoperative ileusPatients undergoing bowel surgery are at increased risk of devel-

oping postoperative ileus. It is a major impeding factor of early

mobilization, predisposes to aspiration and is associated with

extended hospital stay and increased hospital costs. Risk factors

for developing postoperative ileus include old age, long duration

of surgery, fluid and electrolyte imbalance, intra-abdominal sepsis

and postoperative placement of nasogastric tubes.

Current practices associated with a lower incidence of post-

operative ileus include the use of minimally invasive surgical

techniques, mid-thoracic epidural analgesia, early oral/enteral

nutrition and goal-directed fluid therapy. There is weak evidence

to suggest that the use of laxatives and chewing gum may play a

role in prevention of ileus. However, a Cochrane review found

that the use of prokinetic agents had no significant effect in

SURGERY 35:2 100

stimulating gut motility.15 Interestingly, recent evidence has also

shown that early postoperative mobilization does not directly

stimulate gastrointestinal motility; although it does confer an

overall beneficial effect on postoperative recovery.

Conclusion

Enhanced recovery after colorectal surgery is a cost-effective,

evidence-based means of optimizing the whole of the perioper-

ative pathway of patient care. Individual elements are each

important but are ineffective without the involvement of the

patient and the whole team that will be caring for the patient,

including, where possible, primary care. The addition of an

‘enhanced recovery facilitator’ to the team is highly desirable,

particularly when starting such a programme as a means of

provision of information, bringing together the patient and the

whole of the care team, and auditing such pathways to inform

the team on a regular basis so that changes can be made where

necessary to provide the optimum patient experience and surgi-

cal outcome. A

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