This document discusses various preoperative considerations for patients undergoing surgery, including endoscopic stenting, coagulopathy, hydration, nutrition, and nutritional assessment. It notes that endoscopic stenting preoperatively increases septic complications. For coagulopathy, it recommends vitamin K and fresh frozen plasma to improve coagulation factors. Proper hydration is important to prevent postoperative renal failure, though mannitol provides no benefits. Thorough preoperative and perioperative nutritional assessment and supplementation can be of great value for surgical patients.

1. Preoperative Optimisation Surgical Gastro Clinics

2. Endoscopic Stenting Coagulopathy Hydration Nutrition

3. Endoscopic Stenting Indications ? ?

4. Endoscopic Stenting Anastomotic leak, haemorrhage and renal failure more common in jaundiced. Br J Surg. 1984 May;71(5):371-5. Reverse the pathophysiological disturbances. No evidence of either a positive or adverse effect of preop stent placement. Gastrointest Endosc. 2002 Oct;56(4):529-34.

5. Endoscopic Stenting Cholangitis Intractable Pruritis Intraluminal Irradiation Palliation

6. Endoscopic Stenting…. Preoperatively – Increases septic complications. Arch Surg 1998: 133: 149-54 Heslin etal. Cholangitis & Very poor Nutritional status. Present data doesnot support as a routine

7. Coagulopathy What to do ?

8. Coagulopathy Decreased synthesis & impaired function of Kupffer cells. Endotoxaemia & Low grade DIC.

9. Coagulopathy…. Vitamin K (Coagulation factors II (prothrombin), VII, IX, and X). Infused at a rate not > 1 mg/min. PT improved 2 hours after IV, & normal after 12 to 36 hours. IM/SC route ? preferable. FFP.

10. Hydration Is it Important

11. ARF – 8-10% ( Mortality 70-80% ). Bile acids – Negative inotropic & chronotropic. U/O – 0.5 ml/kg/hr. Mannitol ?? Mannitol did not improve postop renal function, nor did it prove beneficial in preventing renal failure. Water depletion induced by mannitol may indeed prove detrimental. Surgery. 1988 Jan;103(1):39-44.

12. Nutritional Assessment Is it required?

13. Nutritional Assessment Biochemical (Haemoglobin,Albumin, Prealbumin,Transferrin) Anthropometric (Triceps skin-fold thickness, Midarm circcumference) Immunological (Lymphocyte count) Dynamometric (Hand-grip strength) Finger thumb test ( Pinch skin over triceps/biceps) Bodymass - <10% fat Tendon-bone test (Palpable tendon/ Prominent scapula) - >30% protein store loss

14. Nutrition Supplementation???

15. Nutrition…. Enteral/Parenteral??

16. Nutritional Assessment Normal Normal feeding Near normal Severe/moderate Support Oral Possible Yes EN No GIT Normal Yes EN <2 wks NG feeds >2 wks Long tube No PN <2 wks PPN >2 wks CPN Lim EN possible Supplement PN

17. Hypokalemia with inappropriate kaliuria as a part of a non-acidotic generalized proximal tubular dysfunction, which included renal phosphate, uric acid and glucose wasting. Nephron. 2002;92(3):711-2.

18. Conclusion Limited role for preop Endoscopic stenting. Vitamin K & FFP for Coagulopathy. Proper hydration important to prevent Renal failure. Mannitol no use. Pre & perioperative nutritional assessment & replenishment is of immense value.