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40
D. G. Bakes and L. R. Sands
Table 5.2 Duke activity status index
Can you Weight
1. Take care of yourself:
eating, dressing, bathing or
using the toilet?
2. Walk indoors, such as
around your house?
3. Walk a block or two on
level ground?
4. Climb a ight of stairs
or walk up a hill?
5. Run a short distance? 8.00
6. Do light work around
the house like dusting or
washing dishes?
7. Do moderate work
around the house like
vacuuming, sweeping
oors, or carrying in
groceries?
8. Do heavy work around
the house like scrubbing
oors or lifting or moving
heavy furniture?
9. Do yard work like
raking leaves, weeding, or
pushing a power mower?
10. Have sexual relations? 5.25
11. Participate in moderate
recreational activities like
golf, bowling, dancing,
doubles tennis, or throwing
a baseball or football?
12. Participate in strenuous
sports like swimming,
singles tennis, football,
basketball, or skiing?
Total score: DASI scoring: Positive
2.75
1.75
2.75
5.50
2.70
3.50
8.00
4.50
6.00
7.50
responses are summed to
get a total score, which
ranges from 0 to 58.2.
Higher scores indicate
higher functional
capacity and lower
incidence of MACE.
(apoB). The activity index has greater relevance predicting major adverse cardiac events
after surgery than biomarkers. However, there
are studies suggestive that higher serum levels of natriuretic peptides, particularly BNP
and N-terminal-pro-BNP, which are secreted
by myocardium into the circulation in
response to ischemia and stretching of the
heart wall are signicant markers of cardiovascular risk and complications after noncardiac surgery. High sensitivity cardiac
troponin may also be an indicator of increased
risk of postoperative myocardial infarction
and mortality.
Other tests that may provide additional
preoperative cardiac assessment include resting echocardiograms, cardiac stress tests and
CPET. The echocardiogram has not been
shown to offer any advantage of reducing
postoperative cardiac events over the basic
clinical exam and overall patient assessment.
Routine exercise stress testing is predictive of
a good outcome if the patient can achieve
more than 7 METS on the examination. In
addition, areas of reversible ischemia are
associated with increased cardiac risk. CPET
has also been used as an objective measure of
cardiac and pulmonary tness in some centers but there is a lack of evidence to support
routine use of these exams.
More objective parameters in the clinical
evaluation may lead the surgeon to an in
depth cardiac evaluation. These include a
known history of coronary artery disease,
heart failure, arrhythmias, and valvular heart
disease. A myocardial infarction (MI) within
6 months of elective surgery is one of the
most signicant risks of postoperative cardiac
events. As the length of time between the MI
and surgery increases, the risk of a postoperative cardiac event will decrease. Current
guidelines suggest that non-urgent surgery
should be delayed at least 60days after an MI
if no coronary intervention has been performed. Symptomatic patients with valvular
stenosis, particularly aortic stenosis, may also
pose a signicant risk of cardiac events.
Several scoring systems have been developed
to quantify this risk. The American Society of
Anesthesiologists (ASA) Score was devised
in 1963. The ASA score is a subjective
assessment of a patient’s overall health that is
based on ve classes (I to V) (Table5.3).
Emergency surgery (E) is placed after the
Roman numeral if the procedure being done
requires that it be performed emergently.
5 Perioperative Assessment andRisk Stratication
41
Table 5.3 American Society of Anesthesiologists (ASA)
Score
ASA
I Patient is a completely healthy t patient.
II Patient has mild systemic disease.
III Patient has severe systemic disease that is not
incapacitating.
IV Patient has incapacitating disease that is a
constant threat to life.
V A moribund patient who is not expected to
live 24h with or without surgery.
These cases may pose greater risk to the
patient but will not allow a more substantial
preoperative evaluation due to the urgent
nature of the case. Emergent cases should be
done as safely as possible to allow for the best
possible outcome. In these cases, patients
should be given adequate uid resuscitation
prior to surgery as well as proper prophylaxis
with antibiotics and anticoagulation to prevent deep vein thrombosis. The rate of postoperative complications has been closely
related to ASA classication with the more
complicated patients (ASA IV) having a
23-fold rate of complications compared to the
simpler (ASA I) patients. ASA however does
have limitations. It does not account for the
age, weight, sex, anesthesiologist or surgeon
skill, pregnancy, or preoperative resuscitation
of the patient undergoing surgery. In addition,
the words “systemic disease” may not account
for a recent myocardial infarction as it may
instead represent a local disease.
The Revised Cardiac Risk Index (RCRI)
(Table5.4) has been validated as a tool to predict perioperative cardiac complications. This
relatively simple scale may provide some
insight into perioperative cardiac complications. Glance and his colleagues developed
the Surgical Mortality Probability Model
(S-MPM) because many clinicians who use
the Revised Cardiac Risk Index do not
account for the non-cardiac causes that may
account for perioperative mortality. Their
9-point 30-day mortality risk index includes
ASA physical status (I—0 points, II—2
points, III—4 points, IV—5 points, V—6
points), emergent nature of the intended sur-
Table 5.4 Revised cardiac risk index
1. History of ischemic heart disease
2. History of congestive heart failure
3. History of cerebrovascular disease (stroke or
transient ischemic attack)
4. History of diabetes requiring preoperative insulin
use
5. Chronic kidney disease (creatinine >2mg/dl)
6. Undergoing supra-inguinal vascular, intraperitoneal,
or intrathoracic surgery
Risk for cardiac death, nonfatal myocardial infarction,
and nonfatal cardiac arrest:
0 predictors=0.4%, 1 predictor=0.9%, 2
predictors=6.6%, ≥3 predictors=>11%
gery (1 point for emergent surgery), and surgery risk class (low—0 points,
intermediate—1 point, or high—2 points).
Point totals less than 5 were associated with a
mortality of less than 0.5% while scores over
6 were associated with 10% mortality. The
advantage of the S-MPM system is the relative ease of calculation and use along with its
validity.
E. Other Global Patient Assessment Tools
There have been many different patient
assessment systems that have been devised to
assess patient risk prior to surgery. The purpose of these tools is to allow the physician to
provide proper informed consent for the
upcoming surgical procedure, guide clinical
decision making in the preoperative period,
and thereby improve surgical outcomes. The
many systems that are currently in use are
quite varied. While some systems strictly
make use of preoperative values, some use
intraoperative data as well as postoperative
variables that can all affect patient outcomes.
The problem with adding intraoperative and
postoperative variables is that they are of little value to the practicing physician when
they are seeing a patient in the ofce prior to
surgery and trying to provide guidance to the
patient as to what tests or assessments the
patient will require prior to the intended
procedure.
The most common validated tools currently
used for preoperative risk stratication include
ASA-PS (Physical Status) (Table 5.3), the
42
D. G. Bakes and L. R. Sands
Surgical Risk Scale, the Surgical Risk Score,
and the Charlson Comorbidity Index. The
Surgical Risk Scale and the Surgical Risk Score
both include the ASA-PS while they also consider the urgency and the severity of the intended
surgical procedure. Tools that also consider
intraoperative events and postoperative data
include the Physiological and Operative Score
for the enUmeration of Mortality and Morbidity
(POSSUM) and the Portsmouth variation of
POSSUM (P- POSSUM). Another tool, the
Acute Physiology and Chronic Health
Evaluation II (APACHE II) considers a measure
of acute physiology and chronic health when
evaluating patients as it also utilizes the patient’s
physiologic results within the 24 h of critical
care admission. Even more confusing is that
some of these validated scoring systems, use
subjective data such as the interpretation of
chest X-rays, perhaps making the tools less
effective.
The American College of Surgeons
National Surgical Quality Improvement
Program (ACS NSQIP) Surgical Risk
Calculator is an instrument that employs 21
preoperative risk factors. This calculator
allows a Surgeon Adjustment Score that can
be modied by the physician’s clinical
impression. While this scoring system can
predict risk for many different surgical procedures, it can more specically predict the risk
and complications including potential returns
to the OR for 10 different CPT codes for laparotomy. It has not been found to be as predictive in emergent situations.
An Apgar score has also been described
for surgical procedures. This scoring system
measures blood loss, the lowest heart rate and
the lowest mean arterial pressure. It is based
on a 10-point scale as the one used in childbirth for newborns. Scores less than or equal
to 4 are associated with worse outcomes. The
limitation to this scoring system is that it is
only useful as a predictor after surgery and is
not a valid tool to be used for preoperative
risk assessment since its metrics are all based
upon operative events. It too has a limited
role in emergency procedures.
The Estimation of Physiologic Ability and
Surgical Stress (E-PASS) scoring system was
developed to account for patient’s reserve and
surgical stress to calculate a morbidity and
mortality. This system uses two parts to
derive at a comprehensive score. The rst part
uses a preoperative risk scoring system that
accounts for age, the presence or absence of
heart disease, pulmonary disease, diabetes, as
well as a performance status index, while the
second part uses a surgical stress scoring system which is calculated based upon the
amount of blood loss, the patient’s body
weight, the operative time, and the extent of
the skin incision. As the comprehensive score
rises, so does the complication and mortality
rates. The E-Pass, while specically designed
for gastrointestinal surgery, has yet to be validated in large multicenter trials.
In summary, there are many risk stratication scales and scores that have been developed. The physician must decide which
system best suits their practice so that they
can properly inform their patients of the
appropriate risks of surgery and guide them
to the tests required so they may have the best
clinical outcomes.
F. Risk Reduction Strategies
There have been several strategies proposed to help eliminate cardiac risk in those
patients undergoing non-cardiac surgery.
While many of the methods used today consist of medical therapy some have questioned
the benets of undergoing prophylactic coronary artery bypass surgery prior to having
elective major surgery. The CARP trial demonstrated no mortality reduction associated
with the performance of prophylactic coronary artery bypass surgery in patients with
stable coronary artery disease who were to
undergo major elective vascular surgery. In
addition, the DECREASE V trial did not
show any additional reduction in death and
MI undergoing coronary revascularization in
high-risk vascular surgery patients with
extensive stress-induced ischemia especially
if tight heart rate control was also achieved
with beta blockers.
5 Perioperative Assessment andRisk Stratication
43
In patients with bare metal stent placement, dual antiplatelet therapy (DAPT)
should be continued for 4–6 weeks before
non-cardiac surgery. If a drug eluting stent
has been placed, DAPT should be continued
for 6months, or a minimum of 3 months if
the risk of delay exceeds the risk of an ischemic event.
Perioperative beta-blocker usage is associated with a lower incidence of non-fatal MI,
but higher incidence of bradycardia, hypotension, and stroke. The American College of
Cardiology (ACC) recommends that betablockers should be continued in patients taking them chronically. In addition, they suggest
that beta blocker therapy should begin even
one day prior to surgery in patients with cardiac ischemia or more than 3 cardiac risk
indices (see Table5.4).
The benet of statins has also been called
into question. Statins have been shown to stabilize plaques thereby preventing plaque rupture and thus lowering the risk of myocardial
infarction. The American College of
Cardiology recommends that statins be continued in patients chronically taking them and
to begin therapy for patients undergoing vascular surgery and those with other clinical
indications such as diabetes, coronary artery
disease, peripheral arterial disease and hyperlipidemia while undergoing high-risk procedures (see Table5.1).
The decision to use aspirin must be made
on a case-by-case basis weighing the risks of
a cardiovascular event against the risks of
perioperative bleeding. The POISE 2 trial
compared those patients already on aspirin
therapy to those who were aspirin naïve.
There was no benet in terms of reducing MI
or death but those on aspirin had an increased
risk of bleeding with the highest risk seen in
those started earlier on aspirin.
G. Special Considerations
With the incidence of obesity on the rise and
more of these patients requiring surgery, we
must consider certain aspects in the preoperative evaluation specic for this patient population. Once again, a careful history and physical
examination should be performed focusing on
the presence or absence of sleep apnea and the
need for spirometric studies in those with this
condition. An EKG should be obtained if there
are risk factors that mandate this exam. Fasting
blood sugars should also be assessed to rule
out metabolic syndromes.
Immunosuppressed patients are evaluated in the
same manner as those who are immunocompetent. If the patient is taking chronic steroids prior to surgery, then the patient should
be given stress steroid dosing at the time of
the surgery. Fasting blood sugar levels should
also be monitored. While patients taking antiTNF agents do not require additional preoperative testing, they have been associated
with a higher risk of postoperative infectious
complications remote from the surgical site as
well as overall complications and these
patients should be counseled accordingly. If
feasible, stopping anti-TNF 2months prior to
surgery would be ideal to decrease this rate
and improve postoperative outcomes.
Summary
While the majority of the preoperative evaluation
is now undertaken by internists and anesthesiologists in Preoperative Assessment Clinics (PAC), it
remains the responsibility of the attending surgeon
to ensure that the patients are properly counseled
as to the operative risk for patients undergoing
elective non-cardiac surgery. The surgeon needs to
have a good understanding of the multitude of
tests and stratication systems available preoperatively to ensure patient safety for the best possible
outcome. Risk reduction strategies should be considered carefully and implemented whenever possible for patients undergoing surgery.
Suggested Reading
Cohn S.Preoperative evaluation for non-cardiac surgery.
Ann Intern Med. 2016.
Cohn S.The cardiac consult for patients undergoing non-
cardiac surgery. Heart. 2016.
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D. G. Bakes and L. R. Sands
Copeland GP, etal. POSSUM: a scoring system for surgi-
cal audit. Br J Surg. 1991;78:355–60.
Glance LG, et al. The Surgical Mortality Probability
Model: derivation and validation of a simple risk
prediction rule for noncardiac surgery. Ann Surg.
2012;255(4):696–702.
Hltaky MA, etal. A brief self-administered questionnaire
to determine functional capacity (the Duke Activity
Status Index). Am J Cardiol. 1989;64:651–4.
Huddart S, etal. Use of a pathway quality improvement
care bundle to reduce mortality after emergency laparotomy. Br J Surg. 2015;102(1):57–66.
Knaus WA, et al. APACHE—acute physiology and
chronic health evaluation: a physiologically based
classication system. Crit Care Med. 1981;9:591–7.
Lee TH, etal. Derivation and prospective validation of a
simple index for prediction of cardiac risk of major
noncardiac surgery. Circulation. 1999;100:1043–9.
Oka Y, et al. Usefulness of an estimation of physiologic
ability and surgical stress (E-PASS) scoring system to predict the incidence of postoperative complications in gastrointestinal surgery. World J Surg.
2005;29:1029–33.
Whiteley MS, etal. An evaluation of the POSSUM scor-
ing system. Br J Surg. 1996;83:812–5.
Wilson Tang WH, et al. Prognostic value of estimated
functional capacity incremental to cardiac biomarkers
in stable cardiac patients. J Am Heart Assoc. 2014.
Enhanced Recovery Pathways
inColorectal Surgery
SheriefShawki, DavidLiska, andConorP.Delaney
6
Introduction
The traditional model of perioperative patient management relies on surgical, anesthesia, and other
involved teams, providing care in a separate and
individualized manner. The specic care provided
depends on practice preferences of the various individual members of the healthcare teams involved.
Collectively, this created signicant variation in
patient care, which had the potential to lead to worse
patient outcomes and increased health expenditures.
Enhanced recovery pathways (ERPs), are standardized, multidisciplinary approaches to perioperative
care designed to guide health care teams towards
collaborative care, based on a combination of
evidence- based interventions. The goal is to minimize the patient’s physiologic stress response to
surgery and thereby allow for rapid recovery to
baseline function. The different phases of perioperative care, including preoperative optimization,
intraoperative care, and post-operative recovery are
integrated into a single patient-centered pathway,
allowing for decreased variability and costs, and
improved outcomes. In colorectal surgery and in
S. Shawki
Department of Colorectal Surgery, Mayo Clinic,
Rochester, MN, USA
D. Liska · C. P. Delaney (*)
Department of Colorectal Surgery, Digestive Disease
and Surgery Institute, Cleveland Clinic, Cleveland,
OH, USA
e-mail: delanc@ccf.org
many other disciplines, the efciency of patient
care, accelerated recovery, and reduction in length
of stay achieved by ERPs has been shown not to
compromise patient safety or lead to an increase in
readmission rates. An important component of
ERPs, running parallel to these three phases of care,
is an ongoing audit and evaluation of outcomes and
value provided by the pathway. Figure 6.1 illustrates the ow and different components of ERPs as
described below.
A.Preoperative Management
Refer to Algorithm in Fig. 6.1
Patient Education andEngagement
In ERPs the patient is an integral part of the process
and rather than being a passive recipient, is an active
participant in their own recovery process. To manage expectations, education of patients and their
caregivers must start in the preoperative phase and
should include a clear explanation of the perioperative care plan. Besides the traditional explanations
regarding the disease, surgical plan, and risks associated with the surgery, patients should be provided
with information about postoperative expectations,
including daily goals/milestones regarding pain
management, physical activity, and diet. Providing
effective patient education is an acquired skill, and
providing simple yet comprehensive materials is
extremely helpful. The criteria for hospital dis-
© Springer Nature Switzerland AG 2020
S. R. Steele etal. (eds.), Clinical Decision Making in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-65942-8_6
45
46
Fig. 6.1 Algorithm for enhanced recovery pathways for colorectal surgery
S. Shawki et al.
charge should also be explained during this phase as
a way of setting realistic expectations for patients,
emphasizing that their active involvement can
improve outcomes. Establishing a good patienthealthcare team relationship and providing a solid
method of communication can aid in developing
patients’ trust in the process, reduce patient anxiety
and may alleviate unnecessary readmissions.
Evaluation, Optimization, Nutrition
andPrehabilitation
Modern practice of surgery views the patient as a
whole, since other factors, beyond surgical techniques, can often signicantly contribute to
patient outcomes. The principal goal of preoperative optimization is to target patients with preexisting functional compromise in whom
physiologic reserves can be improved to better
withstand the stress of the planned surgery. Social
and behavioral factors that can inuence recovery, such as illicit drug use, tobacco smoking, and
alcohol dependency should also be addressed.
Poor nutritional status leads to increased susceptibility to infection, poor wound healing, and
is associated with worse postoperative outcomes
including increased morbidity and length of stay
(LOS). Therefore, malnutrition should always be
screened for in-patients undergoing colorectal
surgery. Several validated tools can be used to
identify poorly nourished patients preoperatively.
One of which is the patient-generated Subjective
Global Assessment (SGA) which assesses nutritional status based on features of the history and
physical examination and categorizes patients
into well nourished (SGA-A), moderately nourished (SGA-B), and severely malnourished
(SGA-C). Nutritional optimization for 2–3weeks,
preferably via the enteral route, has been shown
to improve outcomes in malnourished patients.
Recent studies have shown that perioperative
intake of nutritional supplements enriched with
arginine and sh oils (“immunonutrition”) can
reduce the incidence of postoperative infectious
complication, especially, in high risk patients. A
recent meta-analysis of 27 randomized controlled
trials assessing the role of immunonutrition in
patients undergoing surgery for gastrointestinal
malignancies found that perioperative enteral
immunonutrition signicantly reduced the incidence of postoperative infectious complications
when compared to with standard enteral nutrition
(RR, 0.46; 95% CI, 0.34–0.62).
The body’s capacity to compensate for the
stress induced by surgery relies on its physio-
6 Enhanced Recovery Pathways inColorectal Surgery
47
logical reserve. Frailty, dened as globally
reduced physiologic reserve, is frequently present in the elderly or other patients who harbor
multisystem impairment, or are functionally
deconditioned at baseline. These patients are at
increased risk for postoperative complications,
and prolonged recovery and LOS. Prehabilitation
is a structured process aiming at increasing
patients’ physiological reserve in anticipation of
an upcoming stressor and thereby reduce postoperative morbidity and accelerate recovery.
There are several different assessments and
indices available to help measure the degree of
frailty for risk stratication. The 11-variable
modied Frailty Index (mFI) is one such tool
that, based on the patient’s baseline functional
status and comorbidities, identies those who
could benet from preoperative prehabilitation.
The mFI assigns a score from 0 to 11, with a
score of 0 signifying the absence of frailty,
whereas a score of 11 equals maximum frailty.
Recent studies demonstrated that about 61% of
postoperative patients with mFI of 0–1 (an
increase in the mFI score implies increased
frailty) spent 1–3 days in the hospital, while
more than 50% of patients with mFI of 3 or
more were hospitalized between 4 and 8days.
Further studies suggest that a 4-week period of
prehabilitation can improve walking capacity in
colorectal cancer patients, with deconditioned
patients making the biggest gains. However,
these functional gains have not yet been shown
to lead to improved perioperative outcomes and
further studies are needed.
Preoperative optimization also extends to
include disease-specic and lifestyle modications in patients with comorbidities such as diabetes mellitus, chronic obstructive lung disease
and congestive heart failure. Occasionally, optimization by a specialist is recommended.
Smoking also imposes risks to postoperative pulmonary status, incisional healing and anastomotic integrity. One study found that patients
who underwent smoking cessation at least
4 weeks prior to surgery had better outcomes
than a reference cohort of patients that did not
participate in cessation programs. Similarly,
increased alcohol consumption (>3ETOH units/
day) been associated with increased complications, and preoperative alcohol cessation may
result in decreased complications.
Additional data is needed to justify the allocation of resources toward creation of a structured program that combines preoperative
exercise training, nutritional support, and optimization of chronic disease processes, although
such a practice appears rational for preoperative
optimization.
Mechanical Bowel Preparation andOral
Antibiotics
The role of mechanical bowel preparation (MBP)
in reducing intra- and post-operative complications in colon and rectal surgery had been an area
of debate with multiple prospective studies showing no difference in outcomes when MBP is used.
However, many of these trials did not include
oral antibiotics. In U.S clinical trials, mechanical
bowel preparation combined with oral antibiotics
has consistently been found to decrease infections rates. Furthermore, with mechanical bowel
preparation intraoperative laparoscopic manipulation of the bowel, specimen extraction through
small incisions, and performing stapled anastomoses is easier and less traumatic. It is therefore
our practice for all colorectal resections to routinely prescribe preoperative mechanical bowel
preparation in combination with oral antibiotics
consisting of neomycin and metronidazole.
Reduction ofPre-operative Fasting
andCarbohydrate Loading
Traditional preoperative preparation included
patient fasting after midnight on the day of surgery,
to reduce the risk of aspiration during the induction
of anesthesia. This resulted in a prolonged period
of time for the patient without hydration or nutrition. Mechanical bowel preparation, with the
resulting diarrhea and uid shifts, can further
increase the risk for dehydration in these patients
that can in turn lead to hypotension upon induction
of anesthesia due to vasodilation. Furthermore,
thirst and hunger, rank among the most common
complaints patients have before surgery. Studies
have shown that the intake of clear uids up to 2h
before surgery does not increase gastric volumes
48
S. Shawki et al.
and the risk for aspiration in patients without
underlying gastroparesis. Therefore, current anesthesia guidelines prohibit solid food intake for 6h
before elective surgery, but encourage clear liquid
intake until 2h before surgery.
Recent studies have evaluated the effect of oral
supplementation with carbohydrate rich drinks
before surgery on the patient’s postoperative metabolic state. Several studies have shown that carbohydrate loading prior to elective surgery, by
administration of a complex carbohydrate- rich
drink (100 mg the evening before surgery and
50g 2–3 h prior to anesthesia), increases insulin
sensitivity. Insulin resistance is a recognized risk
factor for the development of postoperative complications. While physiological data supports the
concept of carbohydrate loading, it is not yet clear
if reducing insulin resistance in turn results in
improved clinical outcomes such as decreased
postoperative complications and LOS.Thus, further investigation is needed to better dene the
role of preoperative carbohydrate loading, and
whether there is any improvement over placebo.
However, irrespective of the proposed benets on
postoperative outcomes, preoperative carbohydrate loading may also decrease anxiety, and
reduce hunger and thirst while waiting for surgery, thereby improving patient satisfaction.
B.Intraoperative Care
Minimally Invasive Colorectal Surgery
While laparoscopic colorectal surgery and ERPs
result in improved outcomes independently, there
is a synergistic effect when both are combined
together resulting in the shortest hospital stay,
averaging 2.6days, with some patients being discharged within 24h. Other benets include faster
regain of bowel motility, earlier tolerance of solid
oral intake and having bowel function. A
Cochrane review of 3RCTs and 6control studies
conrmed the above mentioned outcomes without an increase in patient morbidity. Reduction in
hospital stay and early discharge did not have an
impact on readmission rate. The laparoscopic
approach has also been shown to reduce the risk
of infectious complications. It is now well established that minimally invasive surgery results in
improved perioperative outcomes and accelerated recovery from surgery. Prospective randomized controlled trials have also shown that, in
colon cancer surgery, long term oncologic outcomes are similar between the laparoscopic and
open approach. Due to inconclusive results of
recent trials examining the role of laparoscopy in
rectal cancer, the optimal approach to rectal cancer is still a matter of debate. However, in experienced hands with documented good oncologic
outcomes, the laparoscopic approach in rectal
cancer has also been shown to improve early
postoperative outcomes and accelerate recovery.
Intraoperative Fluid Administration
Perioperative uid homeostasis is inuenced by
surgical stress induced hormonal changes.
Historically, uid resuscitation was based on
often overestimated requirements, which translated into early postoperative weight gain secondary to uid retention and third spacing. In
elective bowel surgery, uid overload of as little
as 3L may result in increased complication rates
and a narrow range uid balance should be the
goal (indicated by minimal weight gain on POD1;
<2.5kg). Restrictive uid resuscitation strategies
have demonstrated a decrease in cardiopulmonary complications and LOS (as few as 2.7days)
without an adverse effect on anastomotic leakage
or surgical-specic complications. Prolonged
fasting and bowel preparation should be considered during resuscitation due to the associated
uid decits. Intra-operatively, identifying
patients’ needs based on indices reecting realtime volume status can assist in tailoring intraoperative uid resuscitation that minimizes uid
overload. Tools such as transesophageal probes,
central venous catheters, and nger probes can
use circulatory parameters as surrogates of realtime volume status to guide volume repletion.
The use of invasive tools should be selective and
6 Enhanced Recovery Pathways inColorectal Surgery
49
the cost of newer non-invasive cardiac output
measuring tools still needs to be justied by evidence demonstrating improved outcomes. The
current state of the literature would suggest that
goal-directed uids tend to improve outcomes
when the control group has neither goal-directed
uids, nor an event related potentials (ERP).
Trials comparing goal-directed uids vs placebo
in patients on enhanced recovery pathways for
intestinal surgery tend to show no improvement
with GDFT.Similarly, postoperatively, the use of
maintenance intravenous uids should be judicious and based on objective indices including,
but not limited to, urinary output, serum creatinine, and blood urea nitrogen.
Analgesia
In ERPs pain control is envisioned as one continuum rather than separate pre-, intra- and postoperative phases. The goal is to achieve adequate
postoperative pain control to accomplish daily
activity milestones such as ambulation and deep
breathing while minimizing the development of
adverse effects, such as nausea, vomiting, ileus,
hypotension, and/or kidney injury, among others. It is often helpful to discuss and review the
proposed postoperative regimen and set appropriate expectations prior to surgery. For better
efcacy, pain control should start during the
perioperative phase. Suppressing nociceptors
prior to surgical pain stimulus has been shown
to reduce postoperative narcotic requirements.
This “preemptive” analgesia includes a spectrum of analgesia ranging from oral medications
starting the day prior to surgery, to neuroaxial
blockade via placement of epidural catheter, or
spinal analgesia prior to the procedure, to local
inltration of surgical sites prior to incision as
in laparoscopic surgery. Non-steroidal antiinammatory drugs (NSAIDs) such as ibuprofen, ketorolac, or celecoxib are administered on
the day of surgery. Acetaminophen and gabapentin are both given in the preoperative stage.
Peripheral nerve blockade using transverse
abdominis muscle plane (TAP) block have
shown to decrease postoperative opioid usage
without many of the side effects associated with
epidural analgesia. It is a technically simple,
easy to learn, low-cost procedure and can easily
be performed under laparoscopic or ultrasound
guidance. In our practice, we have not favored
the use of epidurals, as there is no clear evidence
of them helping in the setting of an enhanced
recovery pathway, and two randomized trials we
have performed and several meta- analyses show
no improvement.
Multimodal pain control regimens should be
tailored towards each patient based on patients’
history of chronic narcotics usage, liver and kidney function, age, and type of surgery.
Venous Thromboembolism Prophylaxis
According to Surgical Care Improvement Project
(SCIP) guidelines pharmacological venous
thromboembolism (VTE) prophylaxis should be
given within 24h of surgery, and it is our practice
to administer 5000units of unfractionated heparin prior to induction, in addition to the use of
sequential compression devices (SCD).
Mechanical and pharmacological VTE prophylaxis is routinely continued postoperatively until
discharge. Early post-operative mobilization has
been shown to dramatically reduce the incidence
of VTEs. Both unfractionated heparin and low
molecular weight heparin (LMWH) can be used
with data showing no signicant difference
between both prophylactic agents. When epidural
catheters are used for analgesia, timing of the
administration of heparin needs to be coordinated
to minimize the risk of bleeding during placement and removal of the catheter. Current guidelines recommend extending postoperative VTE
chemoprophylaxis for up to 4weeks in high risk
individuals such as cancer patients undergoing
major abdominopelvic surgery. Other high risk
conditions that may benet from extended VTE
prophylaxis include morbid obesity, limited
mobility, history of prior VTE or PE, and possibly inammatory bowel disease. Patients going