Journal club Clinical practice guidelines for enhanced recovery after colon and rectal surgery American Society of Colon and Rectal Surgeons Society of American Gastrointestinal and Endoscopic Surgeons Diseases of the colon & Rectum Volume 60:8 (2017) Hind Zaidan Dr. Amro Slem August 2017

Previous evidence: up to January 2012 prior to this guideline introduction How do we improve peri-operative care for patients undergoing major colon and rectal surgery? Previous evidence: up to January 2012 prior to this guideline American Society of Colon and Rectal Surgeons (ASCRS) Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Current best quality care for enhanced recovery after colon and rectal surgery Purpose: Provide information aiding in decision making rather than dictating

The problem Colorectal surgery is associated with Long length of stay (Open 8 days, Lap 5 days) High cost Rate of surgical Site infection (up to 20%) Post operative Nausea and Vomiting (up to 80%) High readmission rates (35.4%) What is Enhanced Recovery Program Cochrane (2011) review: reduction of overall complications and LOS when compared to conventional peri-operative management Goals of ERP Free of pain Improved wound healing Free of nausea Early hospital discharge Early return of bowel function

Evidence base Guidelines built following a standardised algorithm Existing guidelines Formulation of key questions Systematic review of literature Selection and appraisal of quality of evidence Development of clear recommendations MEDLINE PubMed EMBASE Cochrane Database of Collected Reviews Total of 12,483 citations 764 articles selected for extensive review 2 independent reviewers

American College of Chest Physicians

categories (1,2,3): Number of sub-guidelines PRE-OPERATIVE INTERVENTIONS PERI-OPERATIVE INTERVENTIONS POST-OPERATIVE INTERVENTIONS Pre-admission Counselling (2) Surgical Site infection(1) Patient Mobilisation (1) Preadmission Nutrition & Bowel Prep (3) Pain Control (2) Ileus Prevention (3) Preadmission Optimization (1) Perioperative Nausea & vomiting (2) Postoperative Fluid management (1) Preadmission Orders (1) Intraoperative Fluid Management (3) Urinary Catheters (2) Surgical Approach (2) (1,2,3): Number of sub-guidelines

Pre-operative

Pre-admission counselling 1. A preoperative discussion of milestones and discharge criteria should typically be performed with the patient before surgery. GRADE 1C 2. Ileostomy education, marking, and counseling on dehydration avoidance should be included in the preoperative setting. GRADE 1B

Pre-admission nutrition & bowel prep 1. A clear liquid diet may be continued <2 hours before general anesthesia. GRADE 1A 2. Carbohydrate loading should be encouraged before surgery in nondiabetic patients. GRADE 2B 3. Mechanical bowel preparation plus oral antibiotic bowel preparation before colorectal surgery is the preferred preparation and is associated with reduced complication rates.

Pre-admission OPTIMISATION 1. Prehabilitation before elective surgery may be considered for patients undergoing elective colorectal surgery with multiple comorbidities or significant deconditioning. GRADE 2B

Pre-admission ORDERS 1. Preset orders should be used as a part of the enhanced care pathway. GRADE 2C

Peri-operative

SURGICAL SITE INFECTION 1. A bundle of measures should be in place to reduce surgical site infection. GRADE 1B

PAIN CONTROL 1. A multimodal, opioid-sparing, pain management plan should be used and implemented before the induction of anaesthesia. GRADE 1A 2. Thoracic epidural analgesia is recommended for open colorectal surgery, but not for outine use in laparoscopic colorectal surgery. GRADE 1B

Perioperative nausea & vomiting 1. Antiemetic prophylaxis should be guided by preoperative screening for risk factors for postoperative nausea/vomiting. GRADE 2B 2. Preemptive, multimodal antiemetic prophylaxis should be used in all at-risk patients to reduce PONV. GRADE 1A

Intraoperative fluid management 1. Maintenance infusion of crystalloids should be tailored to avoid excess fluid administration and volume overload. GRADE 1B 2. Balanced chloride-restricted crystalloid solutions should be used as maintenance infusion in patients undergoing colorectal surgery. GRADE 1C 3. In high-risk patients and in patients undergoing major colorectal surgery associated with significant intravascular losses, the use of goal-directed fluid therapy is recommended.

Surgical approach 1. A minimally invasive surgical approach should be used whenever the expertise is available and appropriate. GRADE 1A 2. The routine use of intra-abdominal drains and nasogastric tubes for colorectal surgery should be avoided. GRADE 1B

Post-operative

Patient mobilisation 1. Early and progressive patient mobilization is associated with shorter length of stay. GRADE 1C

Ileus prevention 1. Patients should be offered a regular diet immediately after elective colorectal surgery. GRADE 1B 2. Sham feeding (ie, chewing sugar-free gum for ≥10 minutes 3 to 4 times per day) after colorectal surgery is safe, results in small improvements in GI recovery, and may be associated with a reduction in the length of hospital stay. Alvimopan is recommended to hasten recovery after open colorectal surgery, although its use in minimally invasive surgery remains less clear.

Post operative fluid management 1. Intravenous fluids should be discontinued in the early postoperative period after recovery room discharge. GRADE 1B

Urinary catheters 1. Urinary catheters should be removed within 24 hours of elective colonic or upper rectal resection when not involving a vesicular fistula, irrespective of TEA use. GRADE 1B 2. Urinary catheters should be removed within 48 hours of midrectal/lower rectal resections.

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