ERAS From SKF

Enhanced Recovery Pathway for Abdominal Wall Reconstruction

1. Preoperative Optimization

• Weight Loss Counseling:
  • Goals set with the patient.
  • Referrals to weight loss programs or bariatric surgery if necessary.
  • BMI Cutoff: BMI of 45 is now the upper limit for elective repairs due to increased postoperative wound complications in this cohort.
• Diabetes Management:
  • Required HbA1c < 7.5 before surgery scheduling.
• Smoking Cessation:
  • Minimum of 4 weeks cessation, verified by serum cotinine at the preanesthesia testing (PAT) appointment.
• Nutritional Optimization:
  • Arginine and omega-3 rich supplementation (IMPACT Advanced Recovery, Nestle) shakes, three times daily for 5 days preoperatively.
• Screening for Obstructive Sleep Apnea (OSA) and MRSA.

2. Perioperative Measures

• Medications:
  • Subcutaneous heparin injections for DVT prevention.
  • First-generation cephalosporin (vancomycin added if positive for MRSA).
  • Gabapentin and Alvimopan for pain and gastrointestinal function support.

3. Postoperative Pathway

• Multimodal Pain Control:
  • Includes acetaminophen, gabapentin, NSAIDs, and minimization of narcotics.
• Enhanced Gastrointestinal Recovery:
  • Limited use of nasogastric tubes.
  • Daily Alvimopan and early advancement of diet.

Outcomes & Benefits

• Quicker Return of Bowel Function and faster transition to a regular diet.
• Shortened Hospital Stay:
  • Reduced from 6.1 days to an average of 4 days.
• Lower 90-Day Readmission Rate.
• Integration of a Nurse Practitioner:
  • Improved preoperative education, easier clinic access, and earlier intervention for complications.

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Evidence-Based Decision Making in Colon and Rectal Surgery

Enhanced Recovery Pathways (ERPs)

• ERPs have gained prominence for improving post-surgical recovery by streamlining care and minimizing complications.
• Key Elements of ERPs (supported by evidence):
  • Preoperative counseling: Educating patients about the surgery and expected recovery improves outcomes (Grade B).
  • No preoperative fasting: Minimizing fasting reduces complications (Grade A).
  • Avoidance of mechanical bowel preparation: Studies suggest bowel prep is not necessary for all patients and can increase complications (Grade A).
  • Opioid-sparing analgesia: Focus on balanced analgesia with minimal opioid use (Grade A).
  • No nasogastric tubes: Routine nasogastric tubes do not improve outcomes and may delay recovery (Grade A).
  • Fluid restrictions and normothermia: Managing fluids and maintaining body temperature during surgery improve recovery (Grade A).
  • Early feeding and mobilization: Resuming oral intake and encouraging movement soon after surgery reduces hospital stay and improves recovery (Grade A).

Mechanical Bowel Preparation

• Historically common in colorectal surgery, but its routine use has been questioned.
  • Multiple RCTs have shown no significant benefit and potentially higher rates of complications like anastomotic leaks.
  • However, newer evidence indicates combining mechanical bowel prep with oral antibiotics significantly reduces surgical site infections and anastomotic leaks.
  • Recent studies (2012–2015) suggest this combination leads to fewer infections, ileus, and shorter hospital stays.

Antibiotic Prophylaxis

• Proven to reduce postoperative wound infections significantly.
  • Prophylactic antibiotics should be administered within 60 minutes before surgical incision (Grade A).
  • Studies support the use of both aerobic and anaerobic coverage for optimal results.
  • Intraoperative redosing may be necessary for longer surgeries or significant blood loss.
  • There is no added benefit of continuing antibiotics beyond 24 hours post-surgery.

Postoperative Oral Intake

• Traditional practice of delaying oral intake until bowel function returns has little scientific support.
  • Early resumption of oral intake is safe and can reduce hospital stay by approximately one day.
  • Meta-analyses confirm that early feeding does not increase complications such as nausea or anastomotic dehiscence.

Mu-Opioid Receptor Antagonists

• Alvimopan, an FDA-approved drug, blocks opioid receptors in the gut and reduces the paralytic effects of opioids.
  • Studies have shown that it accelerates gastrointestinal recovery and shortens hospital stay.
  • Despite its benefits, widespread use is limited due to cost, though studies suggest it can reduce overall hospital costs by shortening stays and preventing complications like ileus.

Postoperative Analgesia

• IV opioids are effective but prolong ileus and delay bowel recovery.
  • Epidural analgesia provides better pain relief and reduces ileus duration but has not consistently shown to shorten hospital stay in enhanced recovery pathways.
  • Thoracic epidurals are recommended for open colorectal surgeries (Grade A), but evidence for laparoscopic surgery is less robust.

Venous Thromboembolic (VTE) Prophylaxis

• VTE is a common complication after colorectal surgery, even with in-hospital prophylaxis.
  • Guidelines strongly recommend in-hospital use of low-molecular-weight heparin (LMWH) or low-dose unfractionated heparin and intermittent pneumatic compression devices.
  • Extended prophylaxis (4 weeks) is advised for high-risk patients, especially those with cancer. Studies have shown significant reductions in VTE rates with extended prophylaxis.

This structured approach to colorectal surgery, integrating ERPs, selective use of bowel preparation, antibiotic prophylaxis, early postoperative feeding, and thromboembolic prevention, ensures reduced morbidity, shorter hospital stays, and enhanced recovery for patients.

Table 181.1 Components of a Standard Enhanced Recovery Pathway for Colorectal Surgery and the corresponding Level of Evidence for each component:

1. Preoperative Counseling: Grade B
2. Preoperative Feeding (minimization of fasting): Grade A
3. Synbiotics: Not discussed in consensus review
4. No Bowel Preparation: Grade A
5. No Premedication: Grade A
6. Fluid Restriction: Grade A
7. Perioperative High O₂ Concentrations: Not discussed in consensus review
8. Active Prevention of Hypothermia: Grade A
9. Epidural Analgesia: Grade A
10. Minimally Invasive/Transverse Incisions: Grade B
11. No Routine Use of Nasogastric Tubes: Grade A
12. No Use of Drains Above Peritoneal Reflection: Grade A
13. Enforced Postoperative Mobilization: Grade B
14. Enforced Early Postoperative Feeding: Grade A
15. Balanced Analgesia (Multimodal, Low/No Opioids): Grade A
16. Standard Laxatives and Antiemetics: Grade B
17. Early Removal of Urinary Catheter: Not discussed in consensus review

Key Notes:

• Grade A: Based on high-quality randomized controlled trials (RCTs) or meta-analyses.
• Grade B: Based on well-conducted clinical studies with lower evidence levels.

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Reducing the Risk of Infection in Elective and Emergent Colectomy Patients

Introduction

Colorectal surgery has a higher risk of postoperative infections compared to other surgical specialties, particularly surgical site infections (SSIs), which occur in 5% to 30% of cases. Patients are also susceptible to respiratory, urinary tract, line-related infections, and Clostridium difficile infections. Implementing perioperative measures can significantly reduce these risks and improve patient outcomes.

Surgical Site Infections (SSIs)

• Definition: SSIs are infections related to an operative procedure occurring at or near the surgical incision within 30 days post-operation or within a year if prosthetic material is implanted.
• Classification:
  • Superficial Incisional SSI: Involves only skin or subcutaneous tissue.
  • Deep Incisional SSI: Involves muscle and fascia layers.
  • Organ/Space SSI: Involves any part of the anatomy opened or manipulated during surgery other than the incision.
• Impact: SSIs lead to significant morbidity, mortality, prolonged hospital stays, increased healthcare costs, and may require readmission or reoperation.

Pathogenesis and Microbiology

• Primary Source: The patient's own colonic flora is the main source of SSIs, with the colon containing a high density of bacteria (>10¹² bacteria per gram).
• Common Organisms:
  • Gram-negative bacteria: Escherichia coli.
  • Anaerobic bacteria: Bacteroides fragilis.
  • Others: Klebsiella pneumoniae, Enterococcus species, Pseudomonas aeruginosa, Serratia, and Acinetobacter species.
• Skin Flora Contribution: Less than 20% of SSIs are due to skin flora like Staphylococcus aureus.
• Host Factors: Immunodeficiency, chronic conditions (e.g., diabetes, liver or kidney disease), and cancer can impair the body's ability to fight infections.

Preoperative Measures to Prevent SSIs

1. Nutritional Optimization:
   • Malnutrition Risk: Up to 50% of colorectal patients are malnourished.
   • Impact: Malnutrition is associated with increased postoperative morbidity.
   • Action: Assess and improve nutritional status before surgery.
2. Control of Active Infections:
   • Recommendation: Postpone elective surgery until any active infections are resolved to reduce SSI risk.
3. Smoking Cessation:
   • Impact of Smoking: Impairs wound healing due to vasoconstriction and tissue hypoxia.
   • Recommendation: Cease smoking at least 4 weeks prior to surgery.
4. Minimizing Preoperative Hospitalization:
   • Risk: Longer hospital stays increase exposure to resistant bacteria.
   • Recommendation: Limit preoperative hospital stay when possible.
5. Preoperative Skin Cleansing:
   • Effectiveness: Routine antiseptic showering has not shown significant SSI reduction.
   • Current Practice: Still commonly included in enhanced recovery protocols.
6. Bowel Preparation:
   • Historical Perspective: Combined mechanical bowel preparation (MBP) and oral antibiotics were initially standard, then fell out of favor.
   • Current Evidence: Supports using MBP with oral antibiotics to reduce SSIs.
   • Recommendation: Implement MBP with oral antibiotics before elective colorectal surgery.

Intraoperative Measures to Prevent SSIs

1. Antibiotic Prophylaxis:
   • Timing: Administer intravenous antibiotics within 60 minutes before incision.
   • Selection: Use antibiotics effective against both aerobic and anaerobic bacteria.
   • Redosing: May be necessary for prolonged surgeries or significant blood loss.
2. Hair Removal:
   • Method: Use clippers or depilatory agents if hair removal is necessary; avoid shaving.
3. Skin Antisepsis:
   • Agents: Chlorhexidine-alcohol solutions are preferred over povidone-iodine.
   • Benefit: Chlorhexidine is not inactivated by blood or serum.
4. Surgical Technique:
   • Principles: Gentle tissue handling, adequate hemostasis, and minimizing tissue trauma.
   • Minimally Invasive Surgery: Associated with reduced SSI rates; consider when feasible.
5. Wound Protectors and Irrigation:
   • Wound Protectors: May reduce contamination and lower SSI rates.
   • Intraoperative Wound Irrigation: Using antibiotic solutions can decrease bacterial load.
6. Optimizing Oxygenation and Temperature:
   • Oxygen Delivery: High inspired oxygen concentrations intraoperatively may reduce SSIs.
   • Normothermia: Maintaining normal body temperature supports immune function.

Postoperative Measures to Prevent SSIs

1. Glycemic Control:
   • Impact of Hyperglycemia: Impairs immune response and increases SSI risk.
   • Recommendation: Monitor and control blood glucose levels postoperatively.
2. Wound Care:
   • Dressings: Can be removed after 24 hours if the wound is dry and sealed.
   • Negative Pressure Therapy: May benefit high-risk patients to prevent SSIs.

Reducing the Risk of Other Infections

1. Urinary Tract Infections (UTIs):
   • Incidence: Occur in over 4% of colorectal surgery patients.
   • Risk Factors: Female sex, open procedures, rectal surgery, advanced age, comorbidities.
   • Prevention:
     • Early Catheter Removal: Preferably on postoperative day 1 for colectomy patients.
     • Sterile Technique: Ensure catheter insertion is performed under sterile conditions.
2. Respiratory Tract Infections:
   • Incidence: Pneumonia occurs in about 6% of patients post-surgery.
   • Prevention Strategies:
     • Smoking Cessation: Encouraged preoperatively.
     • Early Mobilization: Promotes lung function and reduces infection risk.
     • Pulmonary Care: Use incentive spirometry and encourage deep breathing exercises.
3. Clostridium difficile Infection:
   • Risk Factors: Antibiotic use, proton pump inhibitors, hospitalization, older age.
   • Diagnosis: Stool PCR testing for toxins.
   • Treatment:
     • Mild Cases: Oral metronidazole.
     • Severe Cases: Oral vancomycin or fidaxomicin.
     • Severe Complications: May require surgical intervention like total abdominal colectomy.

Conclusion

Preventing infections in colectomy patients requires a comprehensive, multidisciplinary approach involving preoperative optimization, adherence to intraoperative best practices, and vigilant postoperative care. By implementing evidence-based strategies—such as appropriate antibiotic prophylaxis, effective bowel preparation, meticulous surgical technique, and proactive postoperative management—healthcare providers can significantly reduce the incidence of SSIs and other infections, leading to improved patient outcomes and reduced healthcare costs.