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previous mesh repairs in the patient undergoing surgery for recurrent incisional hernia, or residual small bowel length in a patient with multiple previous small bowel
resections. In the elective setting, up to date cross-sectional imaging should be
sought as appropriate to delineate the anatomy and previous operative notes obtained
and reviewed if possible. Previous surgical procedures are also an independent predictor of septic complications in patients with Crohn’s. Relevant medications should
be inquired about, specically anticoagulants such as warfarin or the family of
direct oral anticoagulants; antiplatelet agents; systemic corticosteroids, mTOR
inhibitors such as sirolimus, targeted therapies such as bevacizumab, and immunomodulators such as anti-TNF agents; and SGLT2 inhibitors such as dapagliozin.
These may present risks of intraoperative bleeding, wound complications such as
seromas and dehiscence, and perioperative ketoacidosis respectively. Close liaison
with the anesthetic team, and if appropriate, the primary medical team caring for the
patient is best practice to ensure optimal patient outcomes.
Consent andShared Decision Making
Thorough counselling of the patient with regard to the rationale, risks and benets
of surgery is imperative. Their ideas, concerns and expectations regarding the goals
of care and desired long-term outcome to be achieved by surgery should be discussed. This is especially important for procedures being undertaken for a quality of
life indication. Ideally, this consultation should be undertaken in the outpatient setting, so that patient queries and clarications can be explored and addressed outside
of the constraints of a busy elective theatre list. The consent process should also
ideally be undertaken in the outpatient setting, rather than on the morning of surgery.
In the setting of emergency surgery, decision making regarding the goals of care
and anticipated long-term functional outcomes remain paramount. Thorough consideration should be given to the expected effectiveness or futility of surgical interventions, respectively. The next-of-kin and other close family members should be
kept apprised of the plan and the patient’s condition, as the clinical situation and
consequently surgical plan may evolve rapidly. The input of family or next-of-kin
should be sought in instances where this may aid in decision-making, for example
collateral history regarding the patient’s premorbid state and overall condition, presence of frailty and tness for surgery. However, it is important to recall that while
valuable insight may be provided by relatives and family agreement is highly desirable, for those adult patients who lack capacity ultimately decisions regarding
appropriate medical care and management rest with the treating team. Exceptions to
this include where a family member or other named individual has power of attorney with respect to medical care, and appropriately set out advanced care directives.
31 Peri-Operative Care
331
Pre-Operative Scoring Systems
Multiple risk calculators exist which can aid in evaluating a patient’s pre-operative
morbid state and predicting risk of post-operative complications, morbidity and
mortality. They may pertain to the elective or emergency setting. These range from
general, such as the ACS-NSQIP, P-POSSUM (Physiological and Operative Severity
Score for the enumeration of Mortality and Morbidity) and NELA (National
Emergency Laparotomy Audit) scores, to those which may be used to predict the
likelihood of specic post-operative complications, such as the CeDaR score to
predict risk of overall morbidity and hernia recurrence in the setting of incisional
hernia repair [1]. These represent useful adjuncts to clinical assessments, and can
help inform shared decision-making with patients and their relatives when deciding
on the appropriateness or otherwise of surgical interventions.
Prehabilitation
Pre-habilitation, often abbreviated as “prehab”, is an increasingly recognized
approach in the medical eld aimed at optimizing a patient’s physical and psychological state before undergoing surgery. This preoperative strategy is designed to
enhance the individual’s overall health, with the objective of reducing postoperative
complications, accelerating recovery, and improving surgical outcomes. The concept of pre-habilitation is grounded in a multidisciplinary approach that encompasses physical optimisation, nutritional optimisation, psychological support, and
medical management. The rationale, components, and evidence supporting prehabilitation are an integral part of preoperative care in modern medicine.
Rationale forPre-Habilitation
Pre-habilitation is predicated on the understanding that better preoperative health
status is associated with improved postoperative outcomes. Surgery represents a
signicant physiological stressor that can trigger new pathology or exacerbate preexisting disease states in patients, potentially leading to complications and prolonged recovery times. By addressing these vulnerabilities before surgery,
pre-habilitation aims to enhance the patient’s resilience to the stress of surgery,
thereby facilitating a smoother and quicker postoperative recovery.
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L. O’Connell
Components ofPre-Habilitation
Physical Exercise
A core component of pre-habilitation is a tailored exercise program designed to
improve cardiovascular tness, muscle strength, and endurance. Such programs are
often personalized to the patient’s baseline tness level, comorbidities, and the specic demands of the upcoming surgery. Cardiopulmonary exercise testing (typically
abbreviated to CPET or CPEX) is frequently utilized in the elective setting for
assessment and stratication of tness for surgery prior to demanding planned operative interventions. In the UK, it is frequently used in patients planned for major
gastrointestinal, vascular, urological or cardio-thoracic surgical procedures. Use of
CPET assists in providing patients with accurate information regarding their perioperative risk, informs surgical decision-making and helps to plan both perioperative
management and post-operative care. It is a dynamic, non-invasive assessment of
effectiveness of cardiac and pulmonary function at rest and during exertion. Peak
oxygen consumption (VO
are assessed and predict operative tness. The anaerobic threshold indicates the
exertional threshold for an individual at which aerobic metabolism switches to
anaerobic metabolism due to insufcient oxygen delivery to the peripheral tissues.
An anaerobic threshold of less than 11ml/kg/min is the limit currently accepted as
indicative of signicantly increased perioperative risk, although this varies by the
particular type of surgery planned.
), anaerobic threshold (AT) and ventilatory efciency
2max
Nutritional Optimization
Adequate nutrition plays a critical role in preparing the body for surgery and recovery. Nutritional interventions may include oral supplementation to correct caloric
and vitamin deciencies, dietary modications to support immune function and tissue healing, and strategies to optimize body composition. For specic indications
such as bariatric surgery, patients may be placed on a protocolized very low-calorie
(400–800kcal/day) diet in the week preceding surgery, with the goal of achieving
rapid weight loss, primarily by reduction of body fat percentage. This has been
shown to reduce visceral adipose tissue and liver volume, and is associated with
improved surgical outcomes, namely reduced procedure time, reduced estimated
blood loss, and shorter length of stay. Conversely, for patients with cachexia arising
secondary to malignancy, malnutrition, malabsorption or compromised intestinal
function such as may occur in those with obstruction, short gut syndrome or Crohn’s
disease, additional nutritional support may be required in the pre-operative period.
This may range from simple interventions such as high-calorie, high-protein oral
nutritional supplements, to enteral feeding via nasogastric tube, to parenteral feeding. Although serum albumin is a poor marker of nutritional status, it is a good
31 Peri-Operative Care
marker of overall condition and indicative of likelihood of post-operative morbidity.
Pre-operative hypoalbuminaemia is a well described prognostic marker for poorer
outcomes and increased complication rate, including wound complications and,
particularly in the setting of Crohn’s, septic complications.
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Sarcopenia
Sarcopenia is the loss of muscle mass along with muscle strength, most frequently
observed as part of the ageing and frailty process but also often evident in the context of advanced malignancy. It is frequently underdiagnosed, but is gaining recognition as a predictive marker of post-operative outcomes. The presence of
pre-operative Sarcopenia is associated with an increased incidence of late postoperative complications, increased length of stay, increased 30-day mortality and a
signicantly increased rate of re-admission to hospital after major surgery, including gastrointestinal, orthopedic and cardiac surgeries.
Psychological Support
Psychological readiness for surgery is an often-overlooked aspect of pre- habilitation.
Interventions may include stress management techniques, counseling, and education to alleviate anxiety and depression, thereby improving post-operative compliance and outcomes. Direction of patients to patient-centered resources such as
support groups for those with a similar history may be of assistance, especially for
those with chronic conditions. The need for psychological support is especially the
case for complex patients who may have undergone multiple previous surgeries and
prolonged intensive care admission, such as those with abdominal catastrophe,
longstanding open abdomens and enterocutaneous stulas. Psychological support,
assessment and preparation is also critical for those undergoing bariatric surgery
procedures, where long-term success is highly dependent not just upon a satisfactory technical outcome but also sustained patient motivation, compliance and
engagement.
Medical Optimization
This involves managing existing chronic conditions such as diabetes, hypertension,
and respiratory diseases more aggressively to ensure they are well-controlled and
fully optimized at the time of surgery. It may also include smoking cessation programs and alcohol reduction and cessation strategies. If patients are on medications
such as systemic corticosteroids, chemotherapy or targeted immunomodulatory
334
agents such as sirolimus or bevacizamab, every effort should be made to discontinue
these at least six weeks pre-operatively. Steroid use in the perioperative period is
known to increase the risk of wound complications and septic complications such as
anastomotic leak, while sirolimus is known to increase the risk of seroma formation
and wound dehiscence. Bevacizumab, an anti-VEGF monoclonal antibody used in
the setting of neoadjuvant regimens for breast cancer and metastatic colorectal cancer, may similarly increase the risk of wound breakdown and anastomotic leak. For
other medications such as anti-TNF biologic agents which may be used in the setting of inammatory bowel disease and rheumatological disorders, the effect on
post-operative morbidity is as yet unknown.
L. O’Connell
Evidence Supporting Pre-Habilitation
A growing body of research underscores the efcacy of pre-habilitation in various
surgical contexts, including orthopedic, gastrointestinal, vascular, urological and
cardiothoracic surgery. Studies have demonstrated that patients who undergo prehabilitation programs experience shorter hospital stays, reduced postoperative complications, and quicker return to baseline levels of function compared to those who do
not. Furthermore, pre-habilitation has been associated with a signicant reduction
in healthcare costs due to fewer complications, shorter length of stay and
readmissions.
Implementation Challenges andConsiderations
Despite its benets, the implementation of pre-habilitation programs faces several
challenges. These include identifying those patients who are likely to derive the
most benet from prehabilitation programmes, developing and standardizing intervention protocols, and ensuring patient compliance. Additionally, there is a need for
further research to optimize pre-habilitation strategies, especially for the most comorbid patients, and to establish individualized guidelines for the various surgical
procedures.
Conclusion
Pre-habilitation represents a paradigm shift in preoperative care, emphasizing the
proactive optimization of patients’ health before surgery. By adopting a holistic
approach that includes physical, nutritional, psychological, and medical interventions, pre-habilitation seeks to enhance patients’ physical strength and resilience,
thereby improving surgical outcomes and facilitating recovery. As the evidence base
31 Peri-Operative Care
335
for pre-habilitation continues to grow, it is likely that such programs will become an
integral part of standard preoperative care, tailored to the needs of individual patients
and specic surgical procedures.
Reference
1. Fligor J, Lanier ST, Dumanian GA. Current risk stratication systems are not generalizable
across surgical technique in midline ventral hernia repair. Plast Reconstr Surg Glob Open.
2017;5(3):e1206. https://doi.org/10.1097/GOX.0000000000001206.
Chapter 32
Management ofthePatient
inthePost- Operative Setting
LaurenO’Connell
Abstract As in the pre-operative setting, some components of post-operative man-
agement will be specic to the procedure undertaken, but many other elements of
post-operative care are generalizable and relevant to any surgical procedure. The
core considerations include: Management of post-operative pain and provision of
appropriate analgesia, via a suitable mode of delivery, venous thromboembolism
prophylaxis and others.
Keywords Post-operative · Management · Sheet · Examination · Prophylaxis ·
Venous · Thrombosis · Pain
As in the pre-operative setting, some components of post-operative management
will be specic to the procedure undertaken, but many other elements of postoperative care are generalizable and relevant to any surgical procedure. The core
considerations include:
• Management of post-operative pain and provision of appropriate analgesia, via a
suitable mode of delivery.
• Venous thromboembolism prophylaxis—mechanical and pharmacological.
• Early mobilization and physiotherapy input as required.
• Management and timing of removal of drains, indwelling lines (such as central,
arterial) and urinary catheters.
• Delivery of nutrition in the post-operative period. Consideration of the most
appropriate route of feeding (oral, enteral or parenteral) and anticipated interval
until return of gut function.
L. O’Connell (*)
SVUH, Dublin, Ireland
e-mail: laurenoconnell@rcsi.ie
Switzerland AG 2024
A. Farag et al. (eds.), Clinical Surgical Skills Made Easy,
https://doi.org/10.1007/978-3-031-69158-4_32
337© The Author(s), under exclusive license to Springer Nature
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L. O’Connell
Role ofERAS Protocols
Enhanced Recovery after Surgery (ERAS) programs have become widely adopted
over the past two decades. Initiating with use in elective colorectal surgery, they
have now been taken up for a broad spectrum of surgical procedures [1]. Such programs represent a paradigm shift in perioperative care, aiming to optimize patient
outcomes through a multidisciplinary, evidence-based approach. These protocols
focus on reducing the physiological Sequelae and psychological stress of surgery,
with the goal of accelerating recovery, minimizing complications, and shortening
hospital stays. This comprehensive discussion delves into the principles of ERAS,
with a particular focus on its application in bariatric, colorectal, and esophageal
surgeries.
Introduction toERAS
ERAS protocols encompass preoperative, intraoperative, and postoperative strategies designed to maintain homeostasis, enhance pain control, reduce physiological
surgical stress, and facilitate early mobilization and nutrition. The core elements
include patient education, optimization of nutrition, minimizing fasting, use of multimodal analgesia to reduce opioid use, early enteral feeding, early mobilization,
and early removal of drains and catheters. Prescription of pre-operative carbohydrate containing drinks has been shown to ameliorate the endocrine and metabolic
stress response to surgery, as well as reducing the pre-operative discomfort and
distress which may be associated with prolonged fasting. Where possible, avoidance of placement of indwelling drains and nasogastric tubes is preferred, in order
to facilitate early oral intake and mobilization. Recent data from multiple studies
has demonstrated that this approach is safe and does not result in increased patient
morbidity. Use of parenteral nutrition and intravenous uids is minimized, and early
post-operative oral intake is encouraged. Early mobilization is similarly encouraged; this improves respiratory morbidity by increasing oxygenation and reducing
alveolar collapse, thus minimizing the incidence of atelectasis and consequent lower
respiratory tract infections. Early mobilization also has a signicant role to play in
reducing the risk of venous thromboembolism.
ERAS inBariatric Surgery
Bariatric surgery presents unique challenges due to the patient population’s specic
needs, including higher risks of complications due to obesity and metabolic-related
comorbidities. ERAS protocols in bariatric surgery focus on:
32 Management ofthePatient inthePost-Operative Setting
339
Patient education on lifestyle changes post-surgery, nutritional assessments, and
psychological evaluations are crucial. Prehabilitation, including physical exercises
and dietary adjustments, is strongly encouraged in order to enhance postoperative
recovery.
Minimally invasive techniques such as laparoscopic or robotic approaches are
preferred to reduce pain, wound complications, and length of hospital stay.
Intraoperative uid management is optimized as per a goal-directed paradigm to
avoid uid overload and electrolyte imbalances.
Early mobilization is emphasized to reduce the risk of DVT and PE, which is
especially high in the bariatric population, and represents the commonest complication seen in the post-operative period. Twice daily low molecular weight heparin is
administered as a weight based regimen. Intraoperatively, thrombo-embolic deterrent stockings (TEDS) and sequential compression devices (SCDs) are used; use of
TEDs should continue post-operatively. Multimodal pain management strategies,
including the use of non-opioid analgesics, are employed to facilitate early ambulation and reduce pulmonary complications. Early initiation of liquid diets, progressing to solid foods as tolerated over a period of weeks, is recommended to support
nutritional needs and weight loss objectives.
ERAS inColorectal Surgery
ERAS protocols originated for use in the setting of elective colorectal surgery.
Colorectal surgery can signicantly benet from ERAS protocols, given the high
volume and the potential for complications. Key components include:
Pre-operative counseling and stoma education by a stoma nurse (if applicable)
are provided. Combined mechanical bowel preparation with oral antibiotic decontamination is selectively used, typically for left sided rather than right sided resections. This has been shown to result in reduced supercial and deep space wound
infections, reduced septic complications, reduced incidence of post-operative C. difcile infection and reduced anastomotic leak rates. As with other ERAS protocols,
carbohydrate loading with clear carbohydrate pre-operative drinks is permitted up
until 2h prior to the procedure to maintain an anabolic rather than catabolic state,
reduce perioperative insulin resistance and reduce postoperative nausea.
As with bariatric surgery, minimally invasive surgical techniques such as robotic
or laparoscopic approaches are preferred where feasible. Active warming is used to
prevent hypothermia, and again goal-directed uid therapy is employed to maintain
euvolemia while avoiding volume overload. Early removal of catheters and drains is
preferable in order to reduce infection risk and promote mobilization. Indeed, data
from the literature suggests that avoidance of routine intra-abdominal drain placement is safe in the setting of colorectal surgery and enhances early recovery due to
reduction of pain and facilitation of mobilization. While nasogastric tubes may be
utilized Intraoperatively, these may be removed at the conclusion of the surgical
procedure. Early oral feeding within 24h post-surgery is encouraged to stimulate
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L. O’Connell
bowel function and minimize the incidence of post-operative ileus, while use of
parenteral nutrition and intravenous uid delivery is preferentially avoided.
Multimodal analgesia, avoiding excessive use of opioids, facilitates early ambulation. Patient controlled analgesia is frequently employed, allowing opioid delivery
to be tailored to the individual patient’s needs. Avoidance of epidural analgesia or
the use of ‘walking’ epidurals again facilitates early mobilization and minimizes the
likelihood of prolonged connement to the bed, thus reducing the incidence of atelectasis and respiratory infections.
ERAS inEsophageal andGastric Surgery
Esophageal and gastric surgery, given its complexity and the potential for signicant morbidity, requires tailored ERAS protocols. As the etiology of esophageal
malignancy and many other upper gastrointestinal disorders is strongly linked to
alcohol intake and smoking, many of these patients have signicant cardiorespiratory morbidity also related to these risk factors. Many patients will have
weight loss, sarcopenia and cachexia due to dysphagia or from the presence of
advanced malignancy. They may also frequently have undergone neoadjuvant treatment with systemic chemotherapy and/or radiotherapy prior to surgery as part of
their treatment paradigm. Components of esophageal surgery ERAS protocols typically include:
Preoperatively, nutritional optimization is crucial due to the high prevalence of
preoperative malnutrition and cachexia in esophageal and gastric cancer patients.
This may entail supplemental feeding via oral supplements, nasogastric or nasojejunal tube feeding or parenteral nutrition, if feeding via an enteral route is not feasible due to the disease process. Preoperatively, pulmonary function testing and
assessment of structural cardiac health via echocardiography and ECG is performed.
Patients also routinely undergo cardiopulmonary exercise testing as described
above, to assess their capability to withstand operative intervention and predict
post-operative morbidity risks. Physiotherapy and respiratory exercises are recommended to improve postoperative pulmonary function.
Intraoperatively, minimally invasive oesophagectomy (MIE) is increasingly
favored over open procedures. Open thoracotomy which is required for three-stage
esophageal procedures is associated with substantial post-operative pain and thus
carries a signicant risk of respiratory morbidity due to splinting of the diaphragm
and difculty in engaging with physiotherapy. Minimally invasive approaches result
in reduced postoperative pain and thus respiratory complications. Robotic
approaches are favored due to the surgical limitations presented by the xed bony
compartment of the thoracic cavity, although laparoscopic approaches are also in
use and effective. Careful anesthetic management is essential to maintain hemodynamic stability, identify potential complications such as iatrogenic pneumothorax
early and reduce pulmonary morbidity.