Enhancing recovery after GI Surgery

1. Enhancing recovery after GI Surgery Mr Neil J Smith Consultant General & Colorectal Surgeon Surrey & Sussex Healthcare NHS Trust & Spire Gatwick Park Hospital

2. 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

3. The Enhanced Recovery Programme

4. 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

5. 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

6. Length of stay after colonic resection Days Enhancing Recovery after GI surgery

7. 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

8. 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

9. 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

10. 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

11. 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

12. Enhancing Standards in Colorectal Surgery

13. 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

14. 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

15. 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

16. Treatment of Haemorrhoids

17. 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

18. 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

19. Stapled Haemorrhoidectomy (2) Before After Enhancing Recovery after GI surgery

20. 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

21. 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

22. Any questions?