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

2. Enhancing Recovery after GI surgery
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. What is Enhanced Recovery?
Minimise stress responses during & after surgery
Optimise pre-op condition
Optimise peri-operative care
Optimise post-op rehabilitation
Time
Function
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
Day of surgery admission
Reduced starvation / CHO load
Optimise fluid hydration
No pre-med/bowel prep
Planned mobilisation
Rapid hydration & nourishment
Appropriate iv therapy
No wound drains
No NGT (bowel surgery)
Catheters removed early
Regular oral analgesia
Avoid opiates
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. Enhancing Recovery after GI surgery
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 % 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. Enhancing Recovery after GI surgery
Haemorrhoid protocol
Primary care
Grades I-IV
Colorectal OPD
Grades I-III
Surgical management
Grades II (severe)-III
Grades III (large)-IV
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 (3)
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. Enhancing Recovery after GI surgery
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?