Enhancing recovery after GI
Surgery
Mr Neil J Smith
Consultant General & Colorectal Surgeon
Surrey & Sussex Healthcare NHS Trust & Spire Gatwick Park Hospital
Topics for discussion
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The Enhanced Recovery Programme (ERP)
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What is ERP & why is it important?
What does ERP mean for Primary Care?
Enhancing standards in colorectal surgery
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Quality & Safety
Laparoscopic colorectal surgery
Treatment of haemorrhoids
Enhancing Recovery after GI surgery
The Enhanced Recovery
Programme
Introduction to Enhanced Recovery

Enhance (vb) (tr) to intensify or increase in
quality, value, power, etc.; improve; augment
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In practice, usually equated and quantified in
terms of time/speed: Length of Stay

Hot topic for NHS managers
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Can be applied to colorectal, urology, gynae and
musculosketal surgery
Enhancing Recovery after GI surgery
What is Enhanced Recovery?
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Minimise stress responses
during & after surgery
Optimise pre-op condition
Optimise peri-operative
care
Optimise post-op
rehabilitation
Function
Time
Traditional care
Enhanced Recovery
Enhancing Recovery after GI surgery
Length of stay after colonic resection
Days
Enhancing Recovery after GI surgery
Factors influencing patient recovery
Accelerated recovery
Pre-op information
Optimised organ function
No nutritional defects
No alcohol pre-op
Stop smoking pre-op
Neuraxial blockade
Minimally invasive surgery
Normothermia
Nausea prevention
Ileus prevention
Early feeding
Good oxygenation
Good sleep
Opioid sparing
Evidence-based post-op care
Delayed recovery
Enhancing Recovery after GI surgery
Enhanced Recovery in practice
Referral from
Primary Care
•Optimising pre-operative health state eg
anaemia, renal function, smoking
PreOperative
•Managing co-morbidities eg Diabetes,
hypertension, obesity
Admission
Operative
PostOperative
Follow-up
Enhancing Recovery after GI surgery
Enhanced Recovery in practice
Referral from
Primary Care
•Optimising pre-operative
haemoglobin levels
•Managing pre-existing comorbidities eg Diabetes
PreOperative
•Optimised health /
medical conditions
•Day of surgery
admission
•Planned mobilisation
•Reduced starvation
/ CHO load
•Appropriate iv therapy
•Optimise fluid
hydration
•No NGT (bowel surgery)
•No pre-med/bowel
prep
•Rapid hydration & nourishment
•No wound drains
•Catheters removed early
•Regular oral analgesia
•Avoid opiates
Admission
•Discharge on
planned day
•Informed decisionmaking
•Pre-operative health
& risk assessment
Operative
•Minimally invasive surgery
•Patient well-informed
/ expectations
managed
•Transverse incisions
•Stoma training
•Use of LA/ Regional
analgesia with sedation
•Discharge planning
(EDD)
•Therapy input
(stoma / physio /
dietician)
PostOperative
•Avoid nasogastric tubes
•Epidural (thoracic)
•Optimised fluid therapy
•Audit & outcome
measures
Enhancing Recovery after GI surgery
•24hr telephone
follow-up
Follow-up
What does ER mean for primary care?
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ER begins & ends with primary care
Optimising comorbidities
Providing coordinated post-discharge care

(potential for presentation of late complications postdischarge)
Enhancing Recovery after GI surgery
What else does ER mean for primary
care?
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‘Traditional’ models of care that GPs saw
during their hospital training no longer apply
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No oral bowel prep, early feeding post-op
Day of surgery admission, etc
Managing patient expectations is critical
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Patients will stay as long as they expect to stay
Reassurance & information
Enhancing Recovery after GI surgery
Enhancing Standards in
Colorectal Surgery
Quality & Safety
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Multidisciplinary Team decision-making
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Weekly MDT discussion
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Quality imaging & pathology
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Prompt treatment
High quality surgery
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Safe resection margins = low rates of local recurrence
Accountability & clinical governance
Enhancing Recovery after GI surgery
Laparoscopic colorectal surgery
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First described in early 1990s, but slow uptake in UK
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Since 2003, exponential increase in proportion of
‘keyhole’ resections.
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In 2009 26% of colonic cancer resections in UK
No compromise on oncological safety
Enhancing Recovery after GI surgery
Laparoscopic colorectal surgery
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Colonic tumours &
inflammatory bowel
disease very suitable
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Faster recovery times,
smaller wounds, less
pain

Earlier discharge from
hospital
Enhancing Recovery after GI surgery
Treatment of Haemorrhoids
Haemorrhoid protocol
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Primary care
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(topical creams)
Colorectal OPD
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Dietary modification / softeners
Grades I-IV
Rubber band ligation
Grades I-III
(phenol injection)
Surgical management
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Grades II (severe)-III
Stapled haemorrhoidopexy
Haemorrhoid artery ligation
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Grades III (large)-IV
Conventional haemorrhoidectomy
Enhancing Recovery after GI surgery
Stapled Haemorrhoidectomy
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Procedure for Prolapse and Haemorrhoids (PPH)
described by Longo in 1998
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Designed as a less painful alternative to conventional
haemorrhoidectomy

Advantages1: less post-op pain, shorter operating time,
shorter hospital stay, shorter convalescence
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Disadvantages: higher rate of prolapse requiring
intervention
QuickTime™ and a
decompressor
are needed to see this picture.
1Burch
et al. Colorectal Disease 2009 11(3) 233-244
Enhancing Recovery after GI surgery
Stapled Haemorrhoidectomy (2)
Before
After
Enhancing Recovery after GI surgery
Haemorrhoidal artery ligation (HAL)
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Doppler-Guided disruption of haemorrhoidal
vasculature
Short-medium term treatment alternative to
PPH
High patient satisfaction
?Role
QuickTime™ and a
decompressor
are needed to see this picture.
Enhancing Recovery after GI surgery
Summary
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Patient treatment & experience enhanced by
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Consistent, safe, evidence-based surgical practice
Application of Enhanced Recovery principles
Utilisation of new technology
Team-based working
Enhancing Recovery after GI surgery
Any questions?