Surgeons Perspective Dr Vidhyachandra Gandhi DNB GI surgery DNB Gen Surgery FSGE Gastrointestinal ampHPB Surgeon Pune Why is the patient in hospital today Concept of stress in surgery ID: 780441
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Fast Track Surgery(ERAS)Surgeons Perspective
Dr.
Vidhyachandra
Gandhi
DNB (GI surgery), DNB (Gen Surgery), FSGE
Gastrointestinal &HPB
Surgeon
Pune
Slide2Why is the patient in hospital today ?
Slide3Concept of stress in surgeryStimulation of HPA axis - glucocorticoids
Stimulation of sympathetic nervous system - catecholamines
Slide4`Decrease physiological stress
Decrease psychological stress
Decrease organ dysfunction
Focus …..
Slide5Slide6Components
Slide7FTS – Does not includeFTS and early discharge
One track surgery
– no rigid “one size fits all” protocol
Cost containment
Slide8Pre op strategies
Patient Education
realistic information
counseling
Slide9Pre op strategies
Reduce Fasting
Traditional 6 hrs fasting not required
long fasting – increase gastric volume & decrease Ph
Carbohydrate rich drink prior to elective surgery
- conflicting data
Slide10Pre op Carbohydrate loading …..Early recovery from surgery and shorter length of hospital stay
Decreases insulin resistance with reduced risk of hyperglycemia in the perioperative period
Reduction in thirst, headache and hunger sensation
Reduces postoperative nausea and vomiting
Enhances return of bowel function
Improves postoperative food intake
Maximizes glycogen reserve to support glucose production through surgery, decreases protein breakdown and improves muscle strength
Pre op strategies
Mechanical bowel Preparation
Routine use not recommended
Rectal surgeries and lap surgery
Improve pre op nutrition
Avoid smoking
Minimal invasive surgery
FTS = MIS
Synergistic
Complimentary
Slide13Drains – Early removal
Avoid placement
Detect blood, bile and anastomotic leak – no evidence
Hampers mobilization - cut and bag
Increases SSI, increase pain
Catheters – early removal
discomfort , urosepsis
Nasogastric tubes – early removal
ERAS
EARLY FEEDING
Slide15Myth and Facts
Basal digestive enzyme output is around 5-6 litres
Even if nothing is taken by mouth so much fluid will go across the anastomosis.
“Protection” by keeping NPO is a wrong premise
Slide16Enteral Feeds
Per oral
Nasogastric
Nasojejunal
Feeding Jejunostomy
Slide17Early Enteral feeds Wound healing
Better anastomotic healing
Reduces septic complications
Faster return of GI function
Reduces surgical stress
Early discharge
Decreases cost
Patient satisfaction
Slide18Some patient reactions..
“I threw up most of the night . . . and then they put up a drip to maintain the fluid balance, but they quickly took it down again . . presumably from the understanding that I should pull myself together and get some liquids down me. So I had to force myself to drink”.
Slide19Middle Path
After your operation you can Eat and Drink whatever appeals to you
But we Don’t advise resuming a normal diet or eating a lot of solid food during the first 2-3 Days.
Slide20Early Ambulation – Day 0/1Reduce muscle loss
Improve pulmonary function
Improve tissue oxygenation
Avoid venous stasis
GOOD ANALGESIA
Slide21Implementation - FTS
Slide22Indian scene
Public sector
Private sector
Insurance sector
Slide23Barriers to ImplementationLack of awareness
Difficult to accept
More emphasis on surgical technique – MIS
Lack of support, lack of interest
Slide24Barriers to ImplementationComplications viewed as failure
Cultural beliefs
Slide25Limitations
Low compliance and adherence to protocol
Applicability in elderly pts
Only colorectal surgery – not true
Slide26Slide27Slide28Length of stay was significantly decreased in ERAS patients in
both all studies and the randomized trial subgroup (P < 0.001 for both).
Slide29Hospital cost – decreased in ERAS
Time to flatus – shorter in ERAS
Readmission rate – no difference
Slide30Significant decrease in pulmonary , urinary tract and SSI
Slide31Slide32How do I do ?
Lower GI Surgery (Colorectal & Small Bowel)
POD1
Remove ryles tube
All liquids as tolerated.
Supplemental I.V fluids to maintain urine output
Increase liquids in evening , if tolerated well
Ambulation .
Encourage Incentive spirometry every 2 hours for 5 minutes.
Epidural analgesia ,with Diclofenac as rescue analgesic.
Intravenous ondansetron 4mg for any postoperative nausea or vomiting.
Removal of urinary catheter for all who underwent colonic resections and anterior resection.
Slide33How do I do ? Lower GI Surgery (Colorectal & Small Bowel)
POD 2
Assess tolerance to the previous evening’s feed- Nausea, vomiting, abdominal distention, abdominal cramps and any episode of fever
If patient is comfortable and clinical assessment is satisfactory (no abdominal distention/ fever), then allow patient’s usual daily food intake.
Ambulation to be actively encouraged as the previous day.
Incentive spirometry
Remove epidural catheter.
Oral analgesia
Rescue analgesia if required
Cut and bag the drains if placed
Wound Inspection and dressing change.
Slide34How do I do ?
Lower GI Surgery (Colorectal & Small Bowel)
POD 3
Remove urinary catheter for those who underwent low anterior resections.
Assess tolerance to feeds the previous day.
Continue allowing usual diet.
Continue ambulation.
Continue incentive spirometry.
Continue analgesia with T. Diclofenac
POD 4/5
Discharged
Slide35How do I do ? Upper GI Surgery (Gastrectomy)
Nasogastric tube removal on postoperative day 1.
Allow to drink water on postoperative day 1.
Clear liquid diet on POD2.
Solid diet on demand anytime after POD 4.
Drain removal on POD 5.
Slide36How do I do ? Upper GI Surgery (Esophagectomy)
Jejunostomy feeds day 1 and increase subsequently
Ambulation day 1
Remove ryles tube day 3
Remove neck drain day 3
Remove Foleys day 3
Gastrograffin swallow day 5 and start orally
Slide37How do I do ? Whipples
Jejunostomy feeds day 1 and increase subsequently
Ambulation day 1
Remove ryles tube day 2
Orals on day 3 and increase subsequently
Remove Foleys day 3
Abdominal drains - cut and bag / removed later depending on output
Slide38BenefitsEarly discharge
Streamlining in surgical care
Better QOL
Reduce morbidity
Improved institutional efficiency
Slide39Email : drgandhivv@gmail.com