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US groups publish enhanced recovery guidelines for colon and rectal surgery

Tue, 07/18/2017 - 14:44
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The combined ASCRS/SAGES panel developed these guidelines and final recommendations to ensure high-quality perioperative patient care

The American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons has published clinical practice guidelines for enhanced recovery after colon and rectal surgery. According to the organisations, these clinical practice guidelines represent a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and a continuation of their dedication to ensuring high-quality perioperative patient care.

“These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines,” the paper states. “It should be recognised that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.”

A 2011 Cochrane review found that enhanced recovery protocols (ERPs) were associated with a reduction in overall complications and length of stay when compared with conventional perioperative patient management. Additional studies have reported that ERPs are also associated with reduced healthcare costs, improved patient satisfaction and improved outcomes regardless of whether patients undergo laparoscopic or open surgery. Nevertheless, such ERPs require a continued audit process in place to guide compliance and to continue to improve quality.

The Clinical Practice Guidelines examined preoperative interventions, perioperative interventions and postoperative interventions, and states that:

For preoperative interventions -

  • A preoperative discussion of milestones and discharge criteria should typically be performed with the patient before surgery (Grade of recommendation: strong recommendation based on low-quality evidence, 1C)
  • Ileostomy education, marking, and counselling on dehydration avoidance should be included in the preoperative setting (Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B)
  • A clear liquid diet may be continued <2 hours before general anaesthesia (Grade of recommendation: strong recommendation based on high-quality evidence, 1A)
  • Carbohydrate loading should be encouraged before surgery in nondiabetic patients (Grade of recommendation: weak recommendation based on moderate quality evidence, 2B)
  • Mechanical bowel preparation plus oral antibiotic bowel preparation before colorectal surgery is the preferred preparation and is associated with reduced complication rates (Grade of recommendation: weak recommendation based on moderate-quality evidence, 2B)
  • Prehabilitation before elective surgery may be considered for patients undergoing elective colorectal surgery with multiple comorbidities or significant deconditioning (Grade of recommendation: weak recommendation based on moderate-quality evidence, 2B)
  • Preset orders should be used as a part of the enhanced care pathway (Grade of recommendation: weak recommendation based on low-quality evidence, 2C)

For perioperative interventions -

  • A bundle of measures should be in place to reduce surgical site infection (Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B)
  • A multimodal, opioid-sparing, pain management plan should be used and implemented before the induction of anaesthesia (Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B)
  • Thoracic epidural analgesia is recommended for open colorectal surgery, but not for routine use in laparoscopic colorectal surgery (Recommendation: strong recommendation based on moderate-quality evidence, 1B)
  • Antiemetic prophylaxis should be guided by preoperative screening for risk factors for postoperative nausea/vomiting (Grade of recommendation: strong recommendation based on moderate-quality evidence, 2B)
  • Pre-emptive, multimodal antiemetic prophylaxis should be used in all at-risk patients to reduce PONV (Grade of recommendation: strong recommendation based on high-quality evidence, 1A)
  • Maintenance infusion of crystalloids should be tailored to avoid excess fluid administration and volume overload (Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B)
  • Balanced chloride-restricted crystalloid solutions should be used as maintenance infusion in patients undergoing colorectal surgery (Grade of recommendation: strong recommendation based on low-quality evidence, 1C)
  • In high-risk patients and in patients undergoing major colorectal surgery associated with significant intravascular losses, the use of goal-directed fluid therapy is recommended (Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B)
  • A minimally invasive surgical approach should be used whenever the expertise is available and appropriate (Grade of recommendation: strong recommendation based on high-quality evidence, 1A)
  • The routine use of intra-abdominal drains and nasogastric tubes for colorectal surgery should be avoided (Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B)

For postoperative interventions -

  • Early and progressive patient mobilization is associated with shorter length of stay (Grade of recommendation: strong recommendation based on low-quality evidence, 1C)
  • Patients should be offered a regular diet immediately after elective colorectal surgery (Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B)
  • Sham feeding (ie, chewing sugar-free gum for ≥10 minutes 3 to 4 times per day) after colorectal surgery is safe, results in small improvements in GI recovery, and may be associated with a reduction in the length of hospital stay (Grade of recommendation: strong recommendation based on high-quality evidence, 1B)
  • Alvimopan is recommended to hasten recovery after open colorectal surgery, although its use in minimally invasive surgery remains less clear (Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B)
  • Intravenous fluids should be discontinued in the early postoperative period after recovery room discharge (Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B)
  • Urinary catheters should be removed within 24 hours of elective colonic or upper rectal resection when not involving a vesicular fistula, irrespective of TEA use (Grade of recommendation: strong recommendation, based on moderate-quality evidence, 1B)
  • Urinary catheters should be removed within 48 hours of midrectal/lower rectal resections (Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B)

The paper, ‘Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons’, was published in the journal Diseases of the Colon and the Rectum.

To access this paper, please click here

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