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AAGBI Enhanced Recovery Seminar April 2010

AAGBI Enhanced Recovery Seminar April 2010

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07/02/2012

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Anaesthesia, Goal Directed Therapy andEnhanced Recovery for Colorectal Surgery
Thursday 22 April 2010
Organisers: Dr Mike Scott & Dr William Fawcett, Guildford 
Programme:Introduction & overview – A national perspective
 Ann Driver, Director, NHS Improvement,Dr Martin Kuper, National Advisor, ERPP 
Overview of enhanced recovery in open and laparoscopic colorectal surgery
Dr Mike Scott, Guildford 
Fluid management for open and laparoscopic colorectal surgery
Dr Howard Wakeling, Worthing 
Analgesia for open and laparoscopic surgery
Dr William Fawcett, Guildford 
Focus on laparoscopic colorectal procedures: Improving the perioperative care pathway
Dr Patrick Morgan, Redhill 
Implementing enhanced recovery in your unit
Dr Roger Kipling, Yeovil 
 
AAGBI
 
Meeting
 
22
nd
 
April
 
2010
 
Overview
 
of 
 
Enhanced
 
Recovery
 
in
 
Colorectal
 
Surgery
 
Dr
 
Mike
 
Scott
 
Royal
 
Surrey
 
County
 
NHS
 
Foundation
 
Trust,
 
Guildford
 
Enhanced
 
Recovery
 
(ER)
 
is
 
now
 
established
 
as
 
a
 
modality
 
that
 
can
 
be
 
used
 
to
 
reduce
 
the
 
length
 
of 
 
stay
 
and
 
morbidity
 
after
 
major
 
surgery.
 
It
 
was
 
established
 
by
 
Kehlet
 
and
 
colleagues
 
as
 
part
 
of 
 
the
 
ERAS
 
(Enhanced
 
Recovery
 
After
 
Surgery)
 
group
 
in
 
Scandinavia
 
and
 
is
 
being
 
adopted
 
and
 
implemented
 
across
 
the
 
UK
 
by
 
the
 
Department
 
of 
 
Health.
 
It
 
is
 
based
 
around
 
17
 
points
 
of 
 
care
 
to
 
minimise
 
intervention
 
and
 
return
 
the
 
patients
 
back
 
to
 
independence
 
and
 
mobility
 
with
 
increasing
 
oral
 
diet.
 
Some
 
UK
 
centres
 
,
 
including
 
ours,
 
have
 
used
 
it
 
for
 
the
 
last
 
4
 
years
 
with
 
increasing
 
success.
 
Laparoscopic
 
Colorectal
 
surgery
 
is
 
ideally
 
suited
 
for
 
ER
 
as
 
patients
 
can
 
eat
 
and
 
drink
 
after
 
surgery
 
and
 
the
 
SIRS
 
response
 
is
 
also
 
a
 
lot
 
more
 
limited
 
compared
 
to
 
upper
 
GI
 
Surgery.
 
We
 
have
 
simplified
 
the
 
approach
 
to
 
Enhanced
 
Recovery
 
by
 
delivering
 
most
 
of 
 
the
 
ER
 
components
 
by
 
protocol
 
but
 
taking
 
out
 
the
 
fluid/oxygen
 
delivery
 
and
 
analgesic
 
components.
 
We
 
feel
 
these
 
are
 
the
 
most
 
important
 
individual
 
components
 
to
 
achieve
 
a
 
successful
 
outcome
 
apart
 
from
 
the
 
surgery
 
itself 
 
and
 
are
 
delivered
 
by
 
the
 
anaesthetist.
 
Simplified Enhanced Recovery in LaparoscopicColorectal Surgery–TrimodalModel
EnhancedRecoveryProtocolIndividualisedFluid TherapyEffectiveAnalgesiaEarlyMobilityEarly GutFunctionModulationof stressresponse
Scott Fawcett Levy Rockall
Simplified Enhanced Recovery in LaparoscopicColorectal Surgery–TrimodalModel
Early MobilityEarly GutFunctionModulation ofstress responseDecreasedComplicationsHealingDecreasedLength ofStay
Scott Fawcett Levy Rockall
 
These
 
components
 
combined
 
with
 
early
 
mobility
 
lead
 
to
 
early
 
feeding
 
and
 
gut
 
function.
 
This
 
in
 
turn
 
helps
 
to
 
modulate
 
the
 
stress
 
response
 
and
 
promotes
 
healing.
 
Reduced
 
complications
 
and
 
secondary
 
infection
 
lead
 
to
 
a
 
decreased
 
length
 
of 
 
stay.
 
 
Analgesia
 
There
 
has
 
been
 
much
 
controversy
 
over
 
the
 
optimal
 
analgesic
 
modality
 
in
 
laparoscopic
 
colorectal
 
surgery.
 
Most
 
groups
 
accepted
 
the
 
concept
 
that
 
Epidural
 
Analgesia
 
which
 
was
 
a
 
proven
 
benefit
 
in
 
open
 
surgery
 
would
 
be
 
transferrable
 
to
 
laparoscopic
 
surgery.
 
We
 
have
 
not
 
found
 
this
 
so.
 
Short
 
duration
 
of 
 
inpatient
 
stay
 
has
 
been
 
successful
 
by
 
groups
 
using
 
morphine.
 
Our
 
carefully
 
practised
 
use
 
of 
 
spinal
 
analgesia
 
combined
 
with
 
general
 
anaesthesia
 
has
 
lead
 
to
 
a
 
reproducible
 
23
 
hour
 
stay.
 
Our
 
experience
 
with
 
epidurals
 
in
 
an
 
RCT
 
with
 
Oesophageal
 
Doppler
 
guided
 
fluids
 
has
 
shown
 
patients
 
with
 
epidurals
 
are
 
more
 
immobile,
 
receive
 
more
 
fluid
 
and
 
have
 
a
 
longer
 
time
 
to
 
bowel
 
function
 
and
 
hospital
 
discharge.
 
Fluids
 
and
 
Oxygen
 
Delivery
 
Laparoscopic
 
surgery
 
is
 
not
 
without
 
its
 
own
 
problems.
 
Complex
 
surgery,
 
length
 
of 
 
surgery
 
and
 
bleeding
 
can
 
all
 
lead
 
to
 
increased
 
length
 
of 
 
stay.
 
We
 
believe
 
individualised
 
fluid
 
therapy
 
using
 
Oesophageal
 
Doppler
 
(OD)
 
is
 
one
 
of 
 
the
 
most
 
important
 
strategies
 
to
 
be
 
adopted
 
by
 
anaesthetist
 
as
 
well
 
using
 
modern
 
anaesthetic
 
techniques.
 
Our
 
haemodynamic
 
studies
 
have
 
shown
 
a
 
reduction
 
in
 
oxygen
 
delivery
 
during
 
laparoscopic
 
surgery
 
due
 
to
 
increased
 
aortic
 
afterload
 
which
 
we
 
believe
 
is
 
detrimental
 
in
 
certain
 
patient
 
groups
 
such
 
as
 
the
 
elderly
 
and
 
those
 
with
 
co
 
morbidity.
 
This
 
can
 
be
 
exaggerated
 
further
 
by
 
the
 
steep
 
head
 
down
 
position
 
common
 
in
 
a
 
lot
 
of 
 
laparoscopic
 
colorectal
 
procedures.
 
Unless
 
OD
 
is
 
used
 
in
 
these
 
groups
 
and
 
oxygen
 
delivery
 
optimised
 
during
 
and
 
at
 
the
 
end
 
of 
 
the
 
procedure
 
some
 
of 
 
the
 
benefits
 
of 
 
having
 
minimally
 
invasive
 
surgery
 
are
 
negated
 
by
 
an
 
oxygen
 
deficit
 
and
 
splanchnic
 
hypoperfusion.
 
Outcome
 
Short
 
inpatients
 
stays
 
utilising
 
ER
 
and
 
minimally
 
invasive
 
surgery
 
has
 
been
 
shown
 
to
 
be
 
safe
 
with
 
good
 
patient
 
satisfaction.
 
With
 
patient
 
selection
 
and
 
optimal
 
care
 
23
 
hour
 
stay
 
is
 
achievable.
 
Two
 
to
 
four
 
days
 
is
 
more
 
usual
 
for
 
our
 
patients,
 
particularly
 
those
 
who
 
are
 
elderly
 
or
 
with
 
co
morbidities.
 
Our
 
patient
 
follow
 
up
 
outcome
 
has
 
demonstrated
 
an
 
improved
 
5
 
year
 
mortality
 
when
 
compared
 
to
 
national
 
figures
 
by
 
upto
 
30%
 
for
 
an
 
equivalent
 
Duke’s
 
stage
 
cancer.
 
It
 
is
 
unclear
 
exactly
 
why
 
there
 
is
 
this
 
benefit
 
but
 
If 
 
this
 
improvement
 
in
 
outcome
 
is
 
substantiated
 
then
 
perioperative
 
care
 
using
 
enhanced
 
recovery
 
and
 
minimally
 
enhanced
 
surgery
 
should
 
be
 
now
 
viewed
 
as
 
an
 
important
 
treatment
 
strategy
 
in
 
cancer.
 
Key
 
References
 
for
 
Fast
 
track
 
Colorectal
 
Surgery
1
7
 
1.
 
Delaney
 
CP.
 
Outcome
 
of 
 
discharge
 
within
 
24
 
to
 
72
 
hours
 
after
 
laparoscopic
 
colorectal
 
surgery.
 
Dis
 
Colon
 
Rectum
 
2008;
51
(2):
 
181
185.
 
2.
 
Kehlet
 
H.
 
Randomized
 
controlled
 
trial
 
to
 
examine
 
the
 
influence
 
of 
 
thoracic
 
epidural
 
analgesia
 
on
 
postoperative
 
ileus
 
after
 
laparoscopic
 
sigmoid
 
resection.
 
Br 
 
 J
 
Surg
 
2000;
87
(3):
 
379.
 
3.
 
Kehlet
 
H.
 
Postoperative
 
ileus
‐‐
an
 
update
 
on
 
preventive
 
techniques.
 
Nat 
 
Clin
 
Pract 
 
Gastroenterol 
 
Hepatol 
 
2008;
5
(10):
 
552
558.
 
4.
 
Lassen
 
K,
 
Soop
 
M,
 
Nygren
 
J,
 
Cox
 
PB,
 
Hendry
 
PO,
 
Spies
 
C,
 
von
 
Meyenfeldt
 
MF,
 
Fearon
 
KC,
 
Revhaug
 
A,
 
Norderval
 
S,
 
Ljungqvist
 
O,
 
Lobo
 
DN,
 
Dejong
 
CH.
 
Consensus
 
review
 
of 
 
optimal
 
perioperative
 
care
 
in
 
colorectal
 
surgery:
 
Enhanced
 
Recovery
 
After
 
Surgery
 
(ERAS)
 
Group
 
recommendations.
 
 Arch
 
Surg
 
2009;
144
(10):
 
961
969.
 
5.
 
Levy
 
BF,
 
Scott
 
MJ,
 
Fawcett
 
WJ,
 
Rockall
 
TA.
 
23
hour
stay
 
laparoscopic
 
colectomy.
 
Dis
 
Colon
 
Rectum
 
2009;
52
(7):
 
1239
1243.
 
6.
 
Noblett
 
SE,
 
Snowden
 
CP,
 
Shenton
 
BK,
 
Horgan
 
AF.
 
Randomized
 
clinical
 
trial
 
assessing
 
the
 
effect
 
of 
 
Doppler
optimized
 
fluid
 
management
 
on
 
outcome
 
after
 
elective
 
colorectal
 
resection.
 
Br 
 
 J
 
Surg
 
2006;
93
(9):
 
1069
1076.
 
7.
 
Wakeling
 
HG,
 
McFall
 
MR,
 
Jenkins
 
CS,
 
Woods
 
WG,
 
Miles
 
WF,
 
Barclay
 
GR,
 
Fleming
 
SC.
 
Intraoperative
 
oesophageal
 
Doppler
 
guided
 
fluid
 
management
 
shortens
 
postoperative
 
hospital
 
stay
 
after
 
major
 
bowel
 
surgery.
 
Br 
 
 J
 
 Anaesth
 
2005;
95
(5):
 
634
642.
 
8.
 
http://www.18weeks.nhs.uk/content.aspx?path=/achieve
and
sustain/Transforming
and
improving/enhanced
recovery/
 
9.
 
Levy
 
B,
 
Dowson
 
H,
 
Scott
 
M,
 
Stoneham
 
J,
 
Fawcett
 
W,
 
Zuleika
 
M,
 
Rockall
 
T.
 
Trans
oesopageal
 
Doppler
 
assessment
 
of 
 
the
 
haemodynamic
 
changes
 
occurring
 
during
 
laparoscopic
 
colorectal
 
surgery.
 
BJS
 
2008;
 
95
(S3):57
 

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