1-4 METS Standard light home activities

Walk around the house

Walk 1-2 blocks on level ground at 3-5 km/h

5-9 METS Climb a flight of stairs, walk up a hill

Walk on level ground at >6 km/h
Run a short distance
Moderate activities (golf, dancing, mountain
walk)

>10 METS Strenuous sports (swimming, tennis, bicycle)

Heavy professional work

METS =metabolic equivalents of oxygen consumption

ASA class

ASA
Classification
ASA I A normal healthy Healthy, non-smoking, no or
patient. minimal alcohol use
ASA II A patient with mild Mild diseases only without
systemic disease substantive functional
limitations.
Current smoker, social alcohol
drinker, pregnancy, obesity
(30<BMI<40), well-controlled
DM/HTN, mild lung disease
ASA III A patient with severe Substantive functional
systemic disease limitations; One or more
moderate to
severe diseases. Poorly
controlled DM or HTN, COPD,
morbid
obesity (BMI 240), active
hepatitis, alcohol dependence
or abuse,
implanted pacemaker, moderate
reduction of ejection fraction,
ESRD undergoing regularly
scheduled dialysis, history (3
months) of Mi, CVA, TIA, or
CAD/stents.
ASA IV A patient with severe Recent (<3 months) MI, CVA,
systemic disease that TIA or CAD/stents, ongoing
is a constant threat to cardiac
life ischemia or severe valve
dysfunction, severe reduction of
ejection fraction, shock, sepsis,
DIC, ARD or ESRD not
undergoing regularly scheduled
dialysis
ASA V A moribund patient who is not Ruptured abdominal/thoracic
expected to survive without the aneurysm, massive trauma,
operation who is not expected to
intracranial bleed with mass
effect, ischemic bowel in the
face of significant cardiac
pathology or multiple
organ/system dysfunction
ASA VI A declared brain-dead
patient whose organs.
are being removed for
 donor purposes

Oesophagectomy

PreOp

How do you reduce penperatre mortality & morbidity

Manpunts directly related are

Nutrition

Respiratay complications

Infection

cardiac issues

Nutrition for healing, withstand infection.

dietary hx

assess BMI

nutrional refael

high protein diet, micronutrients, calantes, hydration,

Infections - mostly orpharyngeal organism

proper oral, gum, pharyngeal hygiene

dental reffrall

bruching,mouth wash

Cleaning gums
On examinatoas what to look for

Palor

Micro nutriton defiency

Oral herine-gum

Ocelema

Hydratorm

Tx existing Rsd.

2. step stroking

Respiratay complications

Lung capacity reduced

3. CXR, lung function - reserve & FEV1 reduction has direct corelation with mortality

4. Can increase lung volumes

breathing excercise(chest physiotherapy ) treatment of existing RS disease

moentre spirometry CPET-to access

walking

stop smoking

* Lung capacity has direct co-relation, for mortality

After factors
Assess Cardiac function

DVT prophylaxis

After comabid mx optimira drugs.

 Explain the condition and Tx options to pt and relatives
Oncology referral
 Nutritional assessment
o Anthropometric assessment
o Biochemical assessment
 Nutritional supplement
o High protein diet, high calorie diet.
o Fe, vit B₁2,
 Anaesthetic referral
 Grouping & DT 2 units of blood
 Chest physiotherapy
 Steam inhalation
 Hb level-if anaemic blood Transfusion 2 days prior to Sx to achieve 10g/dl
 Pre-op Ix-FBC, BU/SE, S.creatinine, S.protein, PT/INR, ECG, CXR, 2D echo, Lung function tests
 Breathing exercise (Insentive spirometer)
 If abnormality in PT/INR correct with Vit K & FFP
 Overnight fasting
 Graduated compression stockings or DVT prophylaxis

Icu booking
Send the patient with BHT, DVT stockings + prophylactic antibiotics to the theatre

Nutrition
Clinical assessment of Micronutrient deficiencies?
 BMI for Macronutrient deficiency

Body Region Signs Possible Deficiencies

Skin Petechiae Vitamins A, C
Purpura Vitamins C, K
Pigmentation Niacin
Edema Protein, vitamin B1
Pallor Folic acid, iron, biotin,
Decubitus vitamins B12, B6
Seborrheic dermatitis Protein, energy
Unhealed wounds Vitamin B6, biotin,
zinc, essential fatty
acids
Vitamin C, protein,
zinc
Nails Pallor or white Iron, protein, vitamin
coloring B12
Clubbing, spoon-
shape, or transverse
ridging/banding;
excessive dryness,
darkness in nails,
curved nail ends
Head/Hair Dull/lackluster; Protein and energy,
banding/sparse; biotin, copper,
alopecia; essential
depigmentation of fatty acid
hair; scaly/flaky scalp
Eyes Pallor conjunctiva Vitamin B12, folic acid,
Night vision iron
impairment Vitamin A
Photophobia Zinc
Oral cavity Glossitis Vitamins B2, B6, B12,
Gingivitis niacin, iron, folic acid
Fissures, stomatitis. Vitamin C
Cheilosis Vitamin B2, iron,
Pale tongue protein
Atrophied papillae Niacin, vitamins B2,
B6, protein
Iron, vitamin B12
Vitamin B2, niacin,
iron
Nervous system Mental confusion Vitamins B1, B2, B12,
Depression, lethargy water
Weakness, leg Biotin, folic acid,
paralysis vitamin C
Peripheral neuropathy Vitamins B1, B6, B12,
Ataxia pantothenic acid
Hyporeflexia Vitamins B2, B6, B12
Muscle cramps Vitamin B12
Fatigue Vitamin B1
Vitamin B6, calcium,
magnesium
Energy, biotin,
magnesium, iron
16 Preoperative Nutrition Assessment-1
1. Medical & Nutritional History
Medical history includes acute or chronic disease, medication,
surgeries, & other therapies (i.e., chemotherapeutics,
immunosuppressive)
Nutrition History includes recent changes in appetite or
weight, activity level, use of diet.
Subject Global Assessment (SGA)

17 Preoperative Nutrition Assessment-2

2. Physical examination
Logical assessment from head to toe
3. Anthropometric parameters
% of IBW = Actual weight x 100/Ideal body weight
Triceps Skinfold Thickness (TSF) for assessing fat reserve. It is decreased when fat stores are depleted.
Midarm muscle circumference (MAC) to assess the degree of somatic protein depletion. TSF and Mid
Arm
Circumference are no more recommended as an accurate measurement.
Creatinine Height Index (CHI) to assess somatic protein stores.
Serum Protein Determination to assess the degree of visceral protein depletion, e.g. Albumin,
Transferring,
Prealbumin.
Measure Total Lymphocyte Count (TLC) to assess Immune function becomes impaired
4. Lab assessment

18 Fat, Anthropometric parameters

Assessment of body fat
Triceps Skinfold Thickness (TSF) for
assessing fat reserve. It is decreased when
fat stores are depleted.

19 Protein (Somatic Protein)

Assessment of the fat-free muscle mass (Somatic Protein) depletion
Mid-upper-arm circumference (MAC)
TSF and MAC are no more
recommended as an accurate measurement
MUST tool
 The MUST tool

(i) BMI (kg/m3)

0 =>20.0

1 = 18.5-2.0

2=<18.5

*If height, weight or weight loss cannot be established, use documented or recalled values (if considered
reliable). When measured or recalled height cannot be obtained, use knee height as a surrogate
measure.

If neither can be calculated, obtain an overall impression of malnutrition risk (low, medium, high) using
the following:

(1) Clinical impression (very thin, thin, average, overweight);

(2) (iia) Clothes and/or jewellery have become loose fitting:
(3) (lib) History of decreased food intake, loss of appetite or dysphagia up to 3-6 months;
(4) (c) Disease (underlying cause) and psychosocial/physical disabilities likely to cause weight loss.
↑ Involves treatment of underlying condition, and help with food choice and eating when
necessary (also applies to other categories).
Figure 19.2 The malnutrition uni- versal screening tool (MUST) for adults (adapted from Elia M
(ed.). The MUST Report. Development and use of the 'malnutrition uni- versal screening tool'
(MUST) for adults. A report by the Malnutrition Advisory Group of the British Asso- ciation for
Parenteral and Enteral Nutrition. Report No. 152, 2003, ISBN 1 899467 70X).
PostOp

Principles of post-operative management in this patient?

o ● Principles as for any major surgery

o ● ICU management is required
o ● Observation and monitoring of vital parameters
o ● Monitor drains including IC tubes, NG
o ● Analgesics – via epidural catheter
o ● NBM
o ● Fluid management – Basic principles
o ● Pulmonary care – Proper chest physiotherapy
o ● DVT prophylaxis
o ● Monitor for complications – Are as for any major surgery but monitor for
specific complications.

Complications related to the anastomosis Respiratory complications

o ● Damage to the recurrent laryngeal nerve Tracheo bronchial injury

o ● Pneumonia Pleural effusion Chylothorax
o ● GI care

NBM

o ● About 2nd day commence feeding via the feeding jejunostomy tube
o ● 5-7th postoperative day after intact anastomosis confirmed commence
oral feeds Start with clear fluids and then move on to semi solids and solids
o ● Small volume frequent meals (6 – 8 times per day)
o ● Confirmation of intact anastomosis by water soluble contrast study
o ● Advice on discharge and follow up

Complications and mx
Post of complications

High risk of aspiration

1. Loss of LOS function

2. No reservoir

3. damage to RLN-Vocal Cords

4. sensory fibres to pharynx Cough reflex lost

5. Pyloric sphincter contracted - vagus N. damaged

Need to do swollowing assessment speech therapist before entoral feeding

or else NJ tube

2 Rict of arythmias Vagus in damage.

A anastomote leak highest leale rate. (14%)

due to failure of healing

Decrease blood supply of stomach - many vessels divided & pulled up

A. tension.

9. nutrition - Check pre-albumisa

vocal cord paralysis

Late-strictures

pyloric stenosis

(Vagus N) X , GB stasis - gallstones

Disease - local recurrence

Is there a place for adjust Tx?

Yes ( not much as for rectal CA)

To local recurrence
Pre op work up before gastrectomy

 Explain the condition and Tx options to pt and relatives

 Oncology referral
 Nutritional assessment
o Anthropometric assessment
o Biochemical assessment

 Nutritional supplement
o High protein diet, high calorie diet
o Fe, vit B12,
 Anaesthetic referral
 Hb level-if anaemic blood Transfusion 2 days prior to Sx to achieve 10g/dl
 Pre-op Ix - FBC, BU/SE, S.creatinine, S.protein, PT/INR, ECG, CXR, 2D echo, Lung function tests
 Grouping & DT 2 units of blood
 Chest physiotherapy
 Steam inhalation
 Breathing exercise(Insentive spirometer)
 If abnormality in PT/INR correct with Vit K & FFP
 Overnight fasting
 Graduated compression stockings or DVT prophylaxis

Icu booking

Send the patient with BHT, DVT stockings + prophylactic antibiotics to the theater

Post Op Mx

Post-op

 Monitoring - PR, RR, UOP, Bleeding, temperature

 Pain relief - epidural analgesia or SC morphine 5mg IV fluid
 Metronidazole 500mg 8/H & cefuroxime 750mg 8/H
 Steam inhalation
 Chest physiotherapy
 Jejunostomy feeding from 2nd post-op day
 Gastrographin study from 10th post-op day to see the anastomotic healing
 If no leaking start oral fluids little by little

Advices after gastrectomy

o Take small frequent meals with large amount of water

o Meals should be consistent with high protein, high in vitamins

o Nutritional supplements should be taken

Post gastrectomy Complications

Complications after gastrectomy

Immediate

General immediate

Mnemonic: PROBS

P Primary hemorrhage/Pain

R Reactive hemorrhage

O Oliguria - acute urinary retention

S Shock/Sepsis

Early

Mnemonic: ABCDE

A Analgesia- or Anesthetic-related nausea + vomiting

B Breakdown of wound or anastomotic dehicence - Gastric fistula, duodenal fistula, peritonitis, intra-
abdominal abscess, seroma, heamatoma

C Confusion-acute

D DVT leading possibly to PE

E Elevated temperature – pyrexia

late

Mnemonic: RIB

R Recurrence of malignancy

I Incisional hernia

B Bowel obstruction

Postgastrectomy complications

Malabsorption

 Pathophysiology
o Lack of chyme stimulation + pancreatic enzyme levels → protein and carbohydrate
maldigestion → fat-soluble vitamin deficiency and weight loss
o Loss of parietal cells/absent intrinsic factor production vitamin B deficiency pernicious
anemia
o Critical reduction of the absorptive surface→↓ time for chyme absorption→↓ iron
absorption iron deficiency anemia •
 Management
 Diet modifications
 o Increased protein intake
o Supplementation of medium-chain triglycerides
o Low carbohydrate diet
 Supplementation of pancreatic enzymes and deficient nutrients (eg, vitamin B, iron, fat-soluble
vitamins)
Small intestinal bacterial overgrowth (SIBO)
• Definition: a pathologically increased growth of bacteria in the small intestine
• Etiology
Anatomic causes
o Short bowel syndrome
o Blind loop syndrome: bacterial overgrowth in the bypassed intestinal segment (blind loop)
that occurs as a result of gastrectomy
o Small bowel diverticulosis
o Inflammatory bowel disease
Motility disorders
o Irritable bowel syndrome
o Diabetes mellitus
o Scleroderma
Pathophysiology: all resulting from bacterial overgrowth Absorption of vitamin B fat-soluble
vitamins, zinc, and iron
↑ Production of folate
↑ Deconjugation of the bile acids
 Clinical features
o Diarrhea, steatorrhea
o Abdominal discomfort, flatulence
o Weight loss, malabsorption
 Diagnostics
o Jejunal aspirate cultures collected during endoscopy
o Positive lactulose breath test
 Management
o Antibiotic therapy
o Parenteral supplementation of vitamins and proteins
o In some cases, surgical treatment
Efferent loop syndrome
•Definition: kinking or anastomotic narrowing of the efferent loop that causes emesis and/or a
feeling of fullness
• Management
o Acute abdomen requires immediate surgical treatment.
o In uncomplicated cases: watch and wait
Afferent loop syndrome
• Definition
o Biliary and pancreatic obstruction due to stenosis, kinking, or incorrect anastomosis of the
afferent loop
o Chyme enters the afferent loop instead of the efferent loop and causes loss of appetite, a
feeling of fullness, and billous vomiting with subsequent relief of nausea.
• Management surgical treatment

Dumping syndrome
 Definition rapid gastric emptying as a result of defective gastric reservoir function, impaired pyloric
emptying mechanisms, or anomalous postsurgery gastric motor function

Early dumping
Pathophysiology: dysfunctional or bypassed pyloric sphincter rapid emptying of undiluted
hyperosmolar chyme into the small intestine fluid shift to the intestinal lumen small bowel
distention→ vagal stimulation increased intestinal motility
Clinical features
o Occur within 15-30 minutes after meal ingestion
o Include nausea, vomiting, diarrhea, and cramps
o Vasomotor symptoms such as sweating, flushing, and palpitations
Management
o Dietary modifications: small meals that include a combination of complex carbohydrates and
foods rich in protein and fat
o 30-60 min of rest in the supine position after meals
o Beta blockers may be helpful to ease tachycardia arising from hypovolemia
Late dumping
Pathophysiology dysfunctional pyloric sphincter rapid emptying of glucose-containing chime into the
small intestine quick reabsorption of glucose hyperglycemia excessive release of insulin hypoglycemia
and release of catecholamines
Clinical features
o Occur hours after meal ingestion
o Include signs of hypoglycemia leg, hunger, tremor, lightheadedness)
o Gl discomfort
Management
o Dietary modifications
o Second-line treatment: octreotide
o Third-line treatment surgery
Suspect late dumping syndrome in a patient with previous gastric surgery and hypoglycemia
Remnant gastric cancer 575859)
 Definition: the development of carcinoma in the remnant stomach after gastrectomy,
regardless of the initial gastric condition or its duration
 Pathophysiology: Studies suggest that duodenogastric reflux, chronic irritation due to billary
or pancreatic secretions, and the denervation of gastric mucosa after surgery result in
chronic inflammation of the remnant mucosa.
 Management total gastrectomy with Roux-en-Y anastomosis and radical lymph node
dissection
Colon Sx
 ERAS protocol for colorectal surgery
Department of Surgery University of Kelaniya
Prehabilitation
 Correction of nutrition-
o High protein diet
o Vitamns Zn, C
o Adequate Hb?/ supplementation
 Structured exercise programme
 Chest physiotherapy with incentive spirometer
(If Hb<79% require transfusion, If Hb>9% no transfusion, Between 7 - 99% - individual assessment)
1. Preoperative Care

1.1 Preoperative Information and Counseling

 All patients should be made aware of what they can anticipate in the perioperative period as
well as what is expected of them in their recovery process
 For patients who do not have postoperative complications and have no other comorbidities
or issues which would affect length of stay, the target for the duration of stay for those
having colon operations is 5 days and for rectal operations (anastomosis below the
peritoneal reflection) is 5 days
 Patients should receive information on approximate length of stay; preoperative fasting and
carbohydrate loading; pain control; early ambulation; postoperative feeding/ileus; time of
catheter removal; and gum chewing
 Patients should also receive information on smoking cessation
 Patients should be instructed to bring 2 packages of chewing gum to the hospital
1.2 Fasting Duration
 For patients who are undergoing elective colorectal surgery and a significant delay in gastric
emptying is not suspected
 Patients should be allowed to eat solid foods according to bowel preparation/^ hours fasting
for solids if no bowel preperation if not bowel and continue clear liquids until 2 hours before
surgery or until they leave for the hospital. Intravenous fluid if bowel prep is given -
Hartman's/ Sterofundin overnight
 Patients should be encouraged to drink a suitable carbohydrate (Glucose 50g in clear juice)
rich drink, up to 800 mL at bedtime the night before surgery and 200 mL until 2 to 3 hours
before surgery or until they leave for the hospital

 Omit ACEI/AT blockers on the day of surgery

 Omit oral hypoglycaemics from the time of fasting

 Start SI-2U 4 hourly above if CBS 200mg/dl

1.3 Mechanical Bowel Preparation

 These recommendations include the following:

 Low fiber diet in the preceding 3 days
 3 sachets of Kleen prep - 1 Kleen enema in the morning
 Oral antibiotics
o Flagyl 1 g at 7 pm
o Rifampicin 400mg at 11 pm/ Ciprofloxacin 500 mg BD for 24hrs

2. Intraoperative Care
2.1 Surgical Site Infection Prevention
 Bowel prep - gut steralisation
 Shower - soap and water
 Prophylactic antibiotics (metranidazol & co-amoxyclav/ cefuroxime)- 4 hourly repeat
doses
2.2 Thromboprophylaxis
 Mechanical prophylaxis for all
 Calf pumps during surgery (when available)
 Post operative - Enoxaparin after risk assessment 40mg s/c nocte
2.3 Intraoperative Fluid Management
 Intraoperative fluid management should be goal directed based on the available
parameters. These parameters include but not limited to: electrocardiogram, heart
rate, blood pressure, and urine output. In some circumstance where monitors to
measure cardiac output and stroke volume are available, fluid therapy should be
titrated to optimize cardiac performance or stroke volume
 Perioperative hemodynamics should be considered relative to baseline values rather
than absolute values that need to be
 maintained. Allowable changes in hemodynamics should be individualized to each
patient, but changes in heart rate and blood pressure of 20% from baseline is most
often acceptable (Level of evidence: Moderate-High)
 When hypovolemia is suspected, a fluid challenge of either crystalloid or colloid (200
250 ml) should be tested. The response should be reassessed using the available
hemodynamic parameters. The fluid challenge may be repeated based on a positive
response e.g. a 10% increase in stroke volume or an increase in blood pressure.
Clinical response to fluid challenge may be monitored by change in heart rate,
measurement/estimation of the pulse pressure variation, and blood pressure before
and after receiving the fluid challenge. Fluid challenge should be repeated until
there is no further increase in stroke volume and/or improvement in the clinical
parameters (Level of evidence: Moderate-Low)
 Intraoperative crystalloid administration should consist of a balanced salt solution
(either Ringer's Lactate or Plasmalyte) (Level of evidence: Moderate-Low)
 The rate of intraoperative fluid for maintenance should not be more than 1-2
ml/kg/hr. If CO monitoring is available - maintainence fluid is not required; manage
with boluses. The use of an infusion pump may be considered to reduce the risk of
fluid overload (Level of evidence: Low)
 The administration of fluid for purposes other than optimization of the intravascular
fluid volume should be avoided. For example, the administration of crystalloid as a
carrier for drug administration can be reduced by using an injection port as close to
the patient as possible to avoid the need to flush in drugs with large amounts of
crystalloid (Level of evidence: Moderate-Low)
 For patients who have had a mechanical bowel preparation, this fluid deficit could
be replaced using crystalloid up to 500ml. Response to fluid challenge should be
considered in determining the dose of crystalloids (Level of evidence: Low)
 Crystalloid can be used to replace minor blood loss. Acute blood loss during surgery
can be replaced with crystalloids or colloids. Colloids should be considered for
situations requiring a rapid replacement of intravascular volume (Level of evidence:
Moderate- Low)
 Acute blood loss during the surgery can be replaced with the use of colloids on a
ratio of 1:1 (Level of evidence: Moderate-Low)
 Use of normal saline should be reserved for patients who are
 hyponatremic or hypochloremic (for example, those where there is drainage of large
volumes of gastric fluid or pre-existing derangements from diuretic use)
 Avoidance of Prophylactic Abdominal Drains - Drains removed 24-48 hours.
 The use of prophylactic abdominal drains should be avoided as much as possible
following elective colorectal surgery
 Avoidance of Prophylactic Nasogastric Tubes - Prophylactic use of nasogastric tubes
for decompression should be avoided.
Postoperative Care

3.1 Mobilisation

§ Early Mobilisation - Patients who undergo elective colorectal surgery

should be encouraged to participate in early mobilization

§ Patients should dangle their legs on the day of surgery

§ Patients should eat all of their meals in a chair

§ Patients should ambulate every 4 to 6 hours each day while they are

awake until discharge (Level of evidence: Moderate)

Incentive spirometry and chest physiotherapy for all

3.2 Postoperative Fluid Management

§ Patients who do not have adequate oral intake should receive not more

than 75 mL/hr of 2/31/

3 with 20 mEq potassium/day, or a similar rate

using a balanced salt solution if electrolyte replacement is required.

The routine use of saline is to be discouraged (Level of evidence:

ModerateLow)

§ Postoperatively, volume status should be assessed before fluid

boluses are given. Boluses should not be given because of low urine

output or low blood pressure alone. Instead, the blood pressure,

heart rate, urine output and mental status of patients should all be

considered. In addition, the preoperative blood pressure should be

considered when making decisions about the postoperative volume

Status

Post operative antibiotics for 3 doses – unless instructed

3.3 Early Enteral Feeding

§ Patients should be offered sips of clear fluid 2 hours postoperatively

provided they are awake, alert and capable of swallowing (Level of

evidence: ModerateLow)

D1 – liquid diet: clear fluids (resource whey protein)

D2 – Jelly /Youghurt/ cream cracker

D3 – soft diet – egg/ fish/ toast

§ Use of Chewing Gum to Reduce Postoperative Ileus –

The use of chewing gum should be encouraged starting on postoperative

day 1. Each patient should chew one stick of gum, for at least 5 minutes, ≥

3 times per day (Level of evidence: ModerateHigh)

3.4 Optimal Duration of Urinary Drainage

All patients undergoing surgery with a low colorectal anastomosis or

coloanal anastomosis (≤6 cm the anal verge) should have their urinary

catheter removed within 72 hours after the surgery – if there is no need to

continue monitoring

For patients undergoing some colon resections, it may be appropriate to

not insert a urinary catheter. If patients do require a urinary catheter it

should be removed within 24 hours after the surgery

The above recommendations apply to patients with or without an epidural

catheter at the time of removal

The above recommendations do not apply if a catheter is needed for

monitoring purposes

3.5 Perioperative Pain Management (refer to BPIGS Guideline # 6)

Epidural removal – 72 hours (time with enoxaparin)

PCM/ GABAPENTINE/CELECOXIB

IV – Morphine (PCA)/ Fentanyl – as required

Pre-op

1. Breaking bad news

2. Informed written consent

3. Electrolyte and fluid balance to prevent hepato-renal syndrome

 IV fluid and adequate hydration

 Maintain fluid balance chart → Maintain UOP 100cc/hour

4. Correction of coagulopathy IV Vit K 10mg/day for 3 days→ Check PT/INR after 3 days →→ If no
increase Give FFP

5. Prophylactic Antibiotics (To prevent hepato-renal syndrome)

 IV cefuroxime 750mg
 IV Metronidazole 500mg

6. Correction of serum protein

7. Oral lactulose 20ml/bd to prevent endotoxin absorption (If constipation)

8. Anaesthetic referral

9. Grouping & DT- Reserve 3 packs of blood

10. Chest physiotherapy - Insentive spirometer

11. Steam inhalation

12. Reserve an ICU bed

Assess the fitness for surgery

 ECG
 CXR
 2D Echo
 S. Creatinine
 BU/SE
 LFT
 FBS

IN CASE OF DELAY OF SUGERY OR AS PALLIATION, SYMPTOMATIC RELIEF BY ERCP & STENTING HAS TO
BE DONE

 10 French gauge needle (ERCP needle) & self expanding metal stent

Post-op

 ICU care
 Monitor PR, BP, RR. Temperature, UOP
  IV fluids - N. Saline, 5% dextrose, KCL if hypokalemia develops
 Pain relief - Epidural analgesia (Light bupivacaine)
 Antibiotics

o Cefuroxime 750mg IV 8H

o Metronidazole 500mg 8H

 Feeding
o No jejunostomy feeding till bowel sounds appear
o Then start jujunostomy feeding from the 2nd day
 After 10 days do gastrographin study to exclude anatomotic leakage. If no leakage start oral sips
of fluid. Then increase gradually.
 Post op chest physiotherapy, steam inhalation
 Sutures are removed on the 10th post-op day.
 Follow up the patient at clinic with histology report.
 Oncology referral

Complications and octreotide

Complications

 Delayed gastric emptying/gastroparesis (most common)

 Pancreaticojejunostomy anastomotic leak/pancreatic ductal disruption leakage of pancreatic
secretions into the abdominal cavity which leads to:
o Hyperchloremic acidosis
o Pancreatic fistula
o Pancreatic pseudocyst
o Pancreatic ascites
 Hepaticojejunostomy anastomotic leak biliary peritonitis
 Exocrine pancreatic insufficiency4
 Endocrine pancreatic insufficiency (diabetes mellitus) and lifelong dependence on insulin
 Small bowel obstruction: herniation, volvulus, anastomotic stricture
 Intraabdominal abscess or sepsis
 Gastrointestinal hemorrhage
 If the duodenum is resected: iron deficiency anemia

Suspect a pancreaticojejunostomy anastomotic leak in a patient with hyperchloremic acidosis (loss of

bicarbonate) and high levels of amylase in abdominal secretions.

Complications

 Fevers occurring after postoperative days 3 to 4 demand careful evaluation.

 Potential sources of fever include those common to all major abdominal surgery: pneumonia,
deep venous thrombosis, central line sepsis, urinary tract infection, and wound infection.
 Patients who undergo pancreaticojejunostomy are at risk for the development of intraabdominal
abscess as a result of leakage from the pancreatic anastomosis.
 Because leaks from either the biliary or gastric anastomoses are very uncommon,
intraabdominal sepsis is considered to be due to a pancreatic anastomotic leak until proven
otherwise.
 Pancreaticojejunostomy anastomotic leaks generally close once adequate drainage is
established.
 Octreotide and antibiotics are utilized when treating established pancreatic anastomotic leaks
that have required percutaneous drainage.
 Complications
 Postoperative gastrointestinal or drain tract bleeding should prompt immediate evaluation with
arteriography.
 While uncommon, an arterial-enteric fistula occasionally occurs in the postoperative setting
(rarely before postoperative day 10).
 The most common cause is a pancreatic anastomotic leak with surrounding inflammation and
infection resulting in blowout of the GDA stump
 Gastrointestinal or drain tract bleeding represents a true emergency; the only patients likely to
survive are those in whom the diagnosis is made immediately.
 The hepatic artery may be embolized or potentially stented if possible.
 Surgical control of hemorrhage from the stump of the GDA is exceedingly difficult in a
postoperative pancreaticoduodenectomy patient and carries a higher mortality than that
associated with hepatic artery embolization.

TURP
The preop evaluation generally includes a history and physical as well as baseline electrolytes,
CBC, PSA, a post-void residual determination, and urinalysis, which are reasonable preoperative
tests prior to urologic surgery. Coagulation studies are no longer considered necessary unless
there is a history of unexplained or unusual bleeding. Renal imaging studies and urodynamics
are also unnecessary in most cases.

The 2021 American Urological Association Guidelines on Management of Benign Prostatic

Hyperplasia recommends the consideration of an evaluation of prostate size and shape before
any surgery. This may be done by cystoscopy, transrectal ultrasonography, computed
tomography (CT), or magnetic resonance imaging (MRI).[10] Uroflowmetry and post-void
residual determinations are also recommended. Peak flow rates of <10 mL/sec are highly
suggestive of bladder outflow obstruction. [16] Pressure-flow studies are suggested if there is
diagnostic uncertainty.[10] The finding of an intravesical lobular extension, such as a ball-valving
median lobe, is highly suggestive of the likely failure of medical BPH therapy.

Two weeks of finasteride therapy, a 5 alpha-reductase inhibitor, has been shown to reduce
microvascular density and intraoperative blood loss; therefore, it is recommended, especially in
larger prostates, prior to TURP.[17]

Preoperative antibiotics are recommended 1 hour before the expected start of surgery.[18]
Patients with indwelling catheters should receive extended antibiotic coverage based on urine
culture results.[19][20]

Due to the high risk of increased bleeding, venous thromboembolism prophylaxis is generally not
recommended in TURP, except for early ambulation.[21][22]

Postoperative Care
After transurethral prostate surgery, patients are typically admitted at least overnight. The
continuous bladder irrigation is titrated to a "light pink" or "pink lemonade" color. If possible, the
irrigation is stopped early the next morning to determine if it is clear enough for either a voiding
trial or discharge. If significant hematuria remains, then the irrigation needs to be continued,
and the hospital stay may need to be extended. Most patients go home with the Foley catheter
and instructions to "take it easy" for the next few days. A stool softener is often recommended to
avoid straining and Valsalva, which can increase prostatic bleeding.

Most patients will return to the clinic or office about one week after the surgery for catheter
removal and a voiding trial. Pathology results can also be reviewed with the patient at that time.
Finasteride is usually continued for an additional 2 to 4 weeks to help with hemostasis and
minimize hematuria. Anticoagulation is typically resumed 24 hours after all visual bleeding has
stopped. Some experts will recommend using 2 to 4 weeks of a low-dose antibiotic such as
trimethoprim-sulfa or nitrofurantoin as prophylaxis immediately after Foley catheter removal
based on the premise that there will be necrotic or devascularized prostatic tissue fragments
remaining in the prostatic fossa which could become infected. This appears reasonable, at least
in higher-risk patients.
There is minimal pain after surgery. Pelvic floor and Kegel exercises may help restore continence
quicker and are generally recommended. Full urinary control, continence, and hemostasis may
take 4 to 6 weeks after the procedure to fully normalize.

Vascular Surgery

Angioplasty
Preparation of pt for angioplasty

 Informed written consent

 Pre procedural Ix - most important renal function
 Preparation
 Proper hydration of the pt
 Administration of NAC in pts with impaired renal function
 Administration of steroids in pts with a high risk of developing contrast allergies
What are the complications of arterial surgery?
Early complications:
 Complications due to generalized atherosclerosis
o Acute myocardial ischaemia
o Stroke
o Renal failure
o Intestinal ischaemia
 Bleeding
 Thrombosis of reconstructed vessels or the graft
 Infection
Late complications:
 Complications due to generalized atherosclerosis
o Acute myocardial ischaemia
o Stroke
 Graft infection
 Graft failure
 False aneurysm formation

Mastectomy

Pre-operative preparation for mastectomy

 Informed written consent
 Pre-op Staging
 ECG, urine sugar, FBS, FBC(Hb & platelet), PT/INR, S.creatinine
 CXR & USS of the abdomen including the liver
 Previous biopsy report - FNAC or true cut biopsy
 Side of the mastectomy should be noted and pt's wrist label should be labeled correctly
 Reservation of cross matched blood 2 units?
 Advice the pt to have a bath on the day prior to the Sx and shave the axilla on the same
side
 BHT with the relevant ix should be sent to the theatre with the pt
 Keep fasting for 6 hrs
 Steam inhalation
 Pre op antibiotics - Cefuroxime (At induction)
Mastectomy

Pre-operative preparation for mastectomy

 ● Informed written consent

 ● Pre‐op Staging
 ● ECG, urine sugar, FBS, FBC(Hb & platelet), PT/INR, S.creatinine
 ● CXR & USS of the abdomen including the liver
 ● Previous biopsy report – FNAC or true cut biopsy
 ● Side of the mastectomy should be noted and pt’s wrist label should be labeled correctly
 ● Reservation of cross matched blood 2 units?
 ● Advice the pt to have a bath on the day prior to the Sx and shave the axilla on the same
side
 ● BHT with the relevant ix should be sent to the theatre with the pt
 ● Keep fasting for 6 hrs
 ● Steam inhalation
 ● Pre op antibiotics – Cefuroxime (At induction)
Post-operative Mx

 ● Keep the pt supine on bed with the arms by the side of the pt
 ● Administer adequate post op. analgesia – SC Morphine 5 mg
 ● Watch for bleeding & the functioning of the surgical site drain
 ● Monitor pulse, BP & RR
 ● IV fluids until oral is started
 ● Start oral fluids in 2hrs once the peristalsis has returned
 ● 2 more doses of Cefuroxime at 6hrs & 12 hrs from the time of the op.
 ● Steam inhalation
 ● Limb & chest physiotherapy
 ● Make the pt sit the next day
 ● Early ambulation
 ● A shower the following day
 ● Remove the drain when the drain is reducing & when the daily output is < 25ml
 ● [important properties of a surgical drain – closed drainage system, with a patent tube,
draining due to negative pressure]
 ● Suture removal after 7‐10 days
 ● Review the pt in the clinic with the histopathology report
 ● Refer the pt to oncologist to decide on adjuvant therapy
Complications of mastectomy and axillary clearance

1. Due to mastectomy

Immediate
  ● Nerve damage - long thoracic, intercostobrachial, thoracodorsal
 ● Bleeding
 ● Haematoma
Erly
 ● Seroma
 ● Wound infection & suppuration ( after 3‐4 days)
 ● Breast cellulitis
 ● Don’t mention pain

Late

 ● Flap necrosis ( rare, but specific for mastectomy)

 ● Keloid
 ● Hypertrophic scar

2. Due to axillary clearance

 ● Lymphedema of the ipsilateral upper limb – high risk erysipelas & cellulitis
o o Mx – limb elevation, massaging, compression garment, prophylactic
penicillin therapy for cellulitis
 ● Frozen shoulder
 ● Axillary vein thrombosis
 ● Neuropraxia – resolve spontaneously in about 6/12
 a) Long thoracic nerve – serratus anterior (easily damaged at
axilla during level 2 clearance)
Ask the pt press the straightened hands against the wall firmly & observe the pt from the back for any
winging of the scapula.
b) Thoracodorsal nerve – latissimus dorsi (vascular pedicle)

c) Intercostobrachial nerve – axillary sensation (not too serious if damaged)

Ask the pt to press his hands firmly on the bed while the arms are on either side of the

body & observe from the back for the contraction of the muscles.

Axillary radiotherapy same efficacy as clearance and 50% less SE

Patient Advise

 ● Encourage proper physiotherapy especially after axillary clearance

 ● Protect arm because can develop lymphedema and infection
 ● Not to lift heavy weights
 ● If any swelling noted come, see doctor