Early feeding after surgery, including clear liquids and solid foods within 24 hours, provides nutritional benefits without increasing complications compared to traditional practices of withholding food until bowel function resumes. A meta-analysis of 15 studies found early feeding reduced total postoperative complications and length of stay without increasing mortality, anastomotic leaks, or time to flatus. Recommendations are provided for diet advancement tailored to specific surgeries and conditions. Close collaboration with surgical teams is important to standardize practices and provide guidance on appropriate diets.
Using Enhanced Recovery After Surgery (ERAS) to Enhance Postoperative OutcomesWellbe
Speaker: Francesco Carli, MD, MPhil, senior staff anesthesiologist at the McGill University Health Centre
Cost: Complimentary, sponsored by Wellbe
There is strong evidence that many of aspects of surgical care have little evidence, and therefore the Enhanced Recovery After Surgery (ERAS) program has been set up to accelerate the recovery process and decrease the rate of postoperative complications. There is an opportunity to improve outcomes by using team approach and revision of the standard procedures.
Learn about:
– The elements of ERAS protocols
– How to structure the Team approach
– The role of the patient in ERAS
– How to perform an audit of your program
About the Speaker:
Francesco Carli, MD, MPhil, is Professor of Anesthesia at McGill University and Associate Professor in the School of Dietetics and Human Nutrition at McGill University and a senior staff anesthesiologist at the McGill University Health Centre. He is currently an Elected Member of the American Academy of Anesthesia and a Board Member of the Enhanced Recovery After Surgery (ERAS) Society. Dr. Carli completed his medical training and anesthesia training in Turin, Italy, Paris, France, and London, England. He completed a Master’s Degree in surgical metabolism at the University of London, England.
His research interests are: metabolic changes associated with surgery and the impact of perioperative interventions (regional analgesia, nutrition, hormones, exercise) on postoperative recovery; evaluation of functional outcome measures during the surgical recovery process; prehabilitation of surgical patients. He is the author of over 250 peer-review scientific articles and has been a recipient of over 50 peer and non peer-review grants.
Enhanced Recovery after Surgery its relevance - Evidence BasedDeep Goel
Enhanced recovery programs are evidence-based protocols designed to standardize medical care, improve outcomes, and lower health care costs. These protocols include evidence-based techniques to minimize surgical trauma and postoperative pain, reduce complications, improve outcomes, and decrease hospital length of stay, while expediting recovery following elective procedures.Protocols have been developed for colorectal surgery patients to reduce physiological stress and postoperative organ dysfunction through optimization of perioperative care and recovery
A talk by Olle Ljungqvist at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Using Enhanced Recovery After Surgery (ERAS) to Enhance Postoperative OutcomesWellbe
Speaker: Francesco Carli, MD, MPhil, senior staff anesthesiologist at the McGill University Health Centre
Cost: Complimentary, sponsored by Wellbe
There is strong evidence that many of aspects of surgical care have little evidence, and therefore the Enhanced Recovery After Surgery (ERAS) program has been set up to accelerate the recovery process and decrease the rate of postoperative complications. There is an opportunity to improve outcomes by using team approach and revision of the standard procedures.
Learn about:
– The elements of ERAS protocols
– How to structure the Team approach
– The role of the patient in ERAS
– How to perform an audit of your program
About the Speaker:
Francesco Carli, MD, MPhil, is Professor of Anesthesia at McGill University and Associate Professor in the School of Dietetics and Human Nutrition at McGill University and a senior staff anesthesiologist at the McGill University Health Centre. He is currently an Elected Member of the American Academy of Anesthesia and a Board Member of the Enhanced Recovery After Surgery (ERAS) Society. Dr. Carli completed his medical training and anesthesia training in Turin, Italy, Paris, France, and London, England. He completed a Master’s Degree in surgical metabolism at the University of London, England.
His research interests are: metabolic changes associated with surgery and the impact of perioperative interventions (regional analgesia, nutrition, hormones, exercise) on postoperative recovery; evaluation of functional outcome measures during the surgical recovery process; prehabilitation of surgical patients. He is the author of over 250 peer-review scientific articles and has been a recipient of over 50 peer and non peer-review grants.
Enhanced Recovery after Surgery its relevance - Evidence BasedDeep Goel
Enhanced recovery programs are evidence-based protocols designed to standardize medical care, improve outcomes, and lower health care costs. These protocols include evidence-based techniques to minimize surgical trauma and postoperative pain, reduce complications, improve outcomes, and decrease hospital length of stay, while expediting recovery following elective procedures.Protocols have been developed for colorectal surgery patients to reduce physiological stress and postoperative organ dysfunction through optimization of perioperative care and recovery
A talk by Olle Ljungqvist at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Single incision laparoscopic Surgery-SILSrkmishra14
World Laparoscopy Hospital is Pioneer in SILS. Single incision laparoscopic surgery (SILS) under direction of Prof. R.K. Mishra is a new technique that has now been utilized in many centers for minimal access surgery. http://www.laparoscopyhospital.com/single_incision_laparoscopic_surgery.html
Enhanced recovery care pathways: a better journey for patients seven days a week and a better deal for the NHS - presentation from the Health and Care Innovation Expo 2014 - Sue Cottle, Amy Kerr and Neil Betteridge
In Depth review of the Surgical management of esophageal carcinoma including management overview, endoscopic management, Type of surgeries, Open, and minimally invasive, Extent of lymphadenectomy. Literature review of evidence for type of surgery and complications
Oral Surgery in Patients on Anticoagulant TherapyVarun Mittal
Management of patients on Anticoagulant Therapy in Surgical Practice with special emphasis on Oral Surgical Procedures; along with Guidelines drawn from various Text Books and Journals
Single incision laparoscopic Surgery-SILSrkmishra14
World Laparoscopy Hospital is Pioneer in SILS. Single incision laparoscopic surgery (SILS) under direction of Prof. R.K. Mishra is a new technique that has now been utilized in many centers for minimal access surgery. http://www.laparoscopyhospital.com/single_incision_laparoscopic_surgery.html
Enhanced recovery care pathways: a better journey for patients seven days a week and a better deal for the NHS - presentation from the Health and Care Innovation Expo 2014 - Sue Cottle, Amy Kerr and Neil Betteridge
In Depth review of the Surgical management of esophageal carcinoma including management overview, endoscopic management, Type of surgeries, Open, and minimally invasive, Extent of lymphadenectomy. Literature review of evidence for type of surgery and complications
Oral Surgery in Patients on Anticoagulant TherapyVarun Mittal
Management of patients on Anticoagulant Therapy in Surgical Practice with special emphasis on Oral Surgical Procedures; along with Guidelines drawn from various Text Books and Journals
An academic presentation on Dental considerations, interventions and precautions to ensure a safe pregnancy. The presentation deals with physiology, complications and dental considerations for treating a pregnant patient.
This presentation gives a fine description about stoma and ostomy. This contains the details regarding types, complications and the advices that you should give to a patient with a stoma.
Next day discharge following elective caesarean section using Enhanced Recovery Care Pathways.
Ian Wrench (Consultant Anaesthetist)
Andrea Galimberti (Consultant Obstetrician)
Jan Hall (Midwifery Sister – Postnatal ward)
Julie Humphries (Midwifery Sister – Postnatal Ward)
Sheffield Teaching Hospitals NHS Foundation Trust
Presentation from Shaping the Future Direction of Enhanced Recovery Care Pathway Seven Days a Week workshop held in London on 5 December 2013
A presentation by Olle Ljungqvist at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Background: Traditionally, Patients are not given fl uids or food after abdominal surgery until bowel functions returns, as by bowel sounds, passage of flatus or stool, or a feeling of hunger, Early versus Traditional oral hydration have been studied to evaluate prospectively the benefits and safety of early hydration on bowel movement after Cesarean Section.
Aim of the work: To evaluate prospectively the benefits and safety of early hydration on bowel movement after Cesarean Section.
Is there a place for fast track surgery in Caesarean delivery?scanFOAM
A presentation by Ulla Bang at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Maxilla, Mandible & Hyoid Bone & Clinical Correlations by Dr. RIG.pptx
Utilizing ERAS to improve diet advancement post op
1. Utilising ERAS to improve
meal advancement post
operatively.
Nathan Billing-Surgical Dietitian
2. Acknowledgement
Some slides taken from others presentations
found online.
Emma Osland
Carli Schwartz
Other slides from AERAS study group slides
Mattias Soop
3. Overview
Overview of Enhanced recovery programs
Increasing intake after surgery
Key Nutritional components of ERAS
Early Oral Feeding – Identifying issues
Traditional vs Early post operative diet
advancement
Clear Oral fluids versus Free Oral Fluids
Providing guidance to surgical team
Rationalisation of diets available
? Recommended for diet advancement
4. Enhanced Recovery Program
Pioneered by Henrik Kehlet group in Denmark
Identified factors which delay postoperative
recovery
Pain
Gut dysfunction
Immobilization
Combined a series of interventions to reduce
perioperative stress and organ dysfunction1
1. Kehlet H. Multimodal approach to control postoperative pathophysiology and
rehabilitation. Br J Anaesth 1997; 78:606–617.
5. Recovery After Surgery
What are we trying to achieve?
Reduce the surgical stress response and
support basic body functions by 1, 2
– Use of optimised analgesia
– Early mobilisation
– Early return to normal diet
These interventions have been shown to
improve postoperative outcomes 3,4
1. Fearon, et al, Clinical Nutrition 2005; 24: 466–477.
2. Kehlet, Lancet 2008; 371: 791–793.
3. Khoo, et al, Annals of Surgery 2007; 245: 867–872.
4. Wind, et al. British Journal of Surgery 2006; 93: 800–809.
6. Multimodal steps of ERAS protocol
• Optimised health /
medical condition
• Informed decision and
patient education
• Pre operative health &
risk assessment
• Optimised hydration &
nutrition
• Reduced starvation
• Patient information and
expectation managed
• Discharge planning
• No / Reduced bowel
prep (bowel surgery)
• Minimally invasive
surgery
• Use of transverse
incisions
• No nasogastric tubes
(bowel surgery)
• Use of Local
anaesthetic with
sedation
• Epidural management
(inc thoracic)
• Optimised fluid
management
• Planned mobilisation
• Rapid hydration &
nourishment
• Appropriate IV therapy
• No wound drains
• No NG ( bowel surgery)
• Catheters removed early
• Regular oral analgesia –
paracetamol and
NSAIDS
• Avoidance of opiate-
based analgesia where
possible or administered
topically
• Estimated
discharge date as
planned
• Full information
and ongoing
support
• Allied Health
professional
follow up where
required
• Personal follow
up from clinical
team (home calls)
Pre Operative Intra Operative Post Operative Discharge
7. Increasing oral intake after surgery
Day 0 patients receive
Sandwich for day of surgery
2 x supplements post operatively
Day 1 onwards patients receive
progress to standard diet
3 x supplements post operatively
9. Fluid input:
ERAS vs Conventional Care
Teeuwen, et al, J Gastrointestinal Surgery 2010; 14:pp88–95.
61 ERAS patients vs 122 historical matched controls
ERAS total IV fluid intake ≠ > 2 l/24 h
10. Effect of mobilization on oral
intake
0
0.2
0.4
0.6
0.8
1
Intervention Control
Mean Protein intake
Patients in intervention
group encouraged to
active mobilization from
day 1
Control mobilized in
traditional manner
without specific aims
Main part of meals was
eaten while sitting at a
table and not in a bed
0
20
40
60
80
Intervention Control
Mean Energy Intake
Henriksen, et al, Nutrition 2002; 18(3): pp:263–267.
Kj/kg/day
g/kg/day
11. Importance of team approach
Agreement between
anaesthesia and
surgical teams
FTE requirement
importance of ERAS
nurse
Need surgeon buy in
12. ERAS alone is not enough
Influence of compliance
with the separate care
elements on length of stay
on various components on
length of hospital stay
Hazzard ratio above 1
indicates a better chance of
early discharge whereas a
value below 1 indicates a
lower chance.
Maessen, et al, British Journal of Surgery 2007; 94: pp224-231.
15. Traditional Postoperative Diet
Advancement
Traditional practice
NBM prior to surgery
NBM and gastric
decompression until
bowel function resumed
post surgery
Diet progression once
gut working
Clear fluids
free fluids
soft/light diet
full diet
Rationale
Initially adopted to combat
post operative vomiting
and subsequent concerns
Aspiration pneumonia
Increase abdominal
pressure anastomotic
rupture
Also thought to “protect
the anastomosis” by
allowing gut rest and
avoiding food passing the
surgical site
16. Clear Oral Fluids vs
Free Oral Fluids
Aim: To provide a diet
of liquid foods that
require no chewing.
Includes more protein
high in saturated fat
and low in fibre, and
may require vitamin
and mineral
supplementation.
ClearOral Fluids Free Oral fluids
Aim: To replace or
maintain the body’s
water balance and
leave minimum
residue in the
intestinal tract
Meets anaesthesia
fasting guidelines
Inadequate in all
nutrients
17. Early Postoperative Feeding
Early post-op feeding
Clear fluids to 3-4hrs
pre-anaesthetic
Fluids or diet from first
postoperative day
irrespective of
resumption of bowel
function
No NGT post op
Often in the context of
multimodal approach
including
earlier mobilisation,
non-opioid analgesia,
key-hole surgery
Rationale
Gut secretes and reabsorbs
~7L fluid/d irrespective of
oral intake, so “protecting the
anastomosis” is based on a
false premise
Many patients already
malnourished more
postoperative complications
Nausea/vomiting is much
less of a problem with new
anaesthetic agents
Some evidence that early
feeding reduces the body’s
stress response to
surgery/trauma
18. The research …
Increasing numbers of studies investigating this
topic dating from 1978
Tube feeding early liquids early solids
Individual studies do not demonstrate major
adverse outcomes with early feeding
Some suggestion of organisational benefits
May decrease length of hospital stay and cost of
treatment
Reported adverse outcomes
Nausea, vomiting, NG reinsertion (common)
19. Previously conducted meta-analyses
Nutritional issues
• Inclusion of immune-modulating EN products
• Inclusion of studies feeding both proximal and distal to
anastomoses
• Nutrition provided at 24hrs post op may have included clear
fluids little nutritional value
General issues
Appears to contain inconsistencies in inclusion criteria of studies
included
Criteria for this meta-analysis
Early feeding provision of diet (excluding COFS) and enteral
feeding given within 24 hours postoperatively.
Traditional postoperative management = withholding nutrition
provision until bowel function had resumed, as evidenced by
either passage of flatus or bowel motion
20. Early vs Traditional PostOp feeding
• Fifteen studies involving a total of 1240 patients were analysed in meta-
analysis.
• To investigate impact of early feeding vs traditional postoperative feeding and
• Mortality
• Anastamotic Leaks
• Days to passing Flatus
• Length of stay
• Postoperative Complications
22. Results – Anastamotic Leaks
Osland et al, JPENJPare nte r Ente ralNutr 2011 35(4):p 481
23. Results – Days to passing flatus
Osland et al, JPENJPare nte r Ente ralNutr 2011 35(4):p 482
24. Results – Length of Stay
Osland et al, JPENJPare nte r Ente ralNutr 2011 35(4):p 483
25. Results – Postoperative
Complications (Nausea and Vomiting
excluded)
Study
pre 2000
Sagar
Ryan
Schroeder
Binderow
Beier-Holgersen
Carr
Ortiz
Hartsell
Nessim
Stewart
subtotal
post 2000
Han-Geurts
Delaney
Lucha
Zhou
Han-Geurts
subtotal
POOLED
Early
3 of 15
2 of 7
4 of 16
0 of 32
8 of 30
0 of 14
17 of 93
1 of 29
3 of 27
10 of 40
48 of 303
12 of 56
7 of 31
1 of 26
23 of 161
22 of 46
65 of 320
113 of 623
Traditional
5 of 15
7 of 7
7 of 16
0 of 32
19 of 30
4 of 14
18 of 95
1 of 29
4 of 27
12 of 40
77 of 305
13 of 49
10 of 33
1 of 25
70 of 155
20 of 50
114 of 312
191 of 617
OR
0.53
0.03
0.46
1
0.22
0.08
0.96
1
0.75
0.78
0.55
0.76
0.69
0.96
0.21
1.37
0.62
0.55
L
0.08
0
0.07
0.02
0.05
0
0.24
0.07
0.11
0.17
0.34
0.18
0.14
0.07
0.06
0.33
0.26
0.35
U
3.78
0.94
2.91
61.41
1.08
2.06
3.77
13.42
5.01
3.56
0.9
3.27
3.38
12.99
0.74
5.61
1.51
0.87
0.1 2.0 4.0 6.0
favour Early favour Traditional
Osland et al, JPENJPare nte r Ente ralNutr 2011 35(4):p 479
26. Conclusions of Meta-analyisis
No merit in withholding nutrition provided
proximal to the anastomosis until bowel
function is resumed.
Statistically significant reductions in total
complications in the postoperative course with
early feeding.
No negative effect of early feeding was
demonstrated with regard to in hospital
mortality, anastomotic dehiscence, LOS, and
time to recovery of bowel function
27. Recommending Diet Advancement
Advance diet to full liquids followed by solid
foods, depending on patient’s tolerance.
Consider the patient’s disease state and any
complications that may have come about since
surgery.
Liaise closely with surgical teams
Provide guidance of meal choices available in your
kitchen.
Define meal advancement.
Standardize practices.
28. Liasing with Surgical teams
What does “E & D as tolerated” mean?
Review of diet codes available for use
i.e. Light diet vs Low Residue Diet vs Post Op Diet
When to use Modified consistency diets
e.g. Upper GI surgery vs Lower GI surgery
Upper GI surgery could have impact on peristalsis so
may require liquid or pureed meals
?Sham feeding (i.e. Chewing gum)
29. Type of Surgery /
Underlying Condition
Recommended
diet post op
Rationale
Recurrent Small bowel
obstruction
Low residue diet A diet low in fibre to minimise chance of further
obstructions occurring
UpperGI surgery:
•Nissens Fundoplication
•Oesophagectomy
•Ivor Lewis Gastrectomy
Liquid Diet
or
Pureed Diet
or
Low residue diet
As this surgery would have an impact on the
mechanical ability to swallow feed and lead to a
degree of dysphagia. A liquid or pureed diet is
recommended initially to help minimise
difficulties in swallowing
Small bowel resections Liquid Diet
or
Low residue diet
or
Standard diet
As this surgery may result in anastamotic joins
in small intestine low residue foods are
recommended to minimise pressure on these
joins initially.
Colorectal surgery Standard diet
or
High Energy protein
diet
As this surgery involves the lower GI tract, most
food is well digested by the time it reaches the
colon and regardless of the type of food should
be pretty well digested
Cholecystectomy Standard diet
As gut motility or function has not been altered
by surgery no special requirements or surgery
Non Gut surgery
Standard diet As gut motility or function has not been altered
by surgery no special requirements or surgery
Alternative to E+D as tolerated?
30. Tailor made protocols
Specific surgeries /conditions that will have own specialist diet progression
pathway and dietetic input
Bariatric Surgery
•Gastric Bypass (Roux en Y)
•Gastric Sleeve
•Duodenal Switch
Water only
Optifast
Fluid diet
Pureed diet
Patients need to adjust to smaller stomach
volume and advance their diet slowly after
surgery. There is close working with surgeons
and set plans for these patients in place.
Chylous ascites and Chyle leaks Specialist diet with
reduced fat and high
MCT content
Dietary chylomicrons are absorbed in the small
intestines and gradually pass along larger
omental lymphatics. Reducing the intake of fat
has been shown to be beneficial at minimising
Pancreatic surgery orother
fistulas
Potential enteral NJ
feeding and or
IVN/TPN
Stimulation of pancreatic or other GI secretions
may be an issue and may need to be minimised.
Dietitian input is recommended.
As per
Surgeon
31. Questions
References:
Anderson et al. Early enteral nutrition within 24h of colorectal surgery versus later commencement of
feeding for postoperative complications. Cochrane Database Syst Rev, 2006 (4): CD002080.
Franklin, G.A., McClave, S.A., Hurt, R.T., Lowen, C.C., Stout, A.E, et al., 2011. Physician- Delivered
Malnutrition: Why do patients receive nothing by mouth or a clear liquid diet in a university hospital
setting? Journal of Parental and Enteral Nutrition. 35(3):pp337-342.
Hancock, S., Cresci, G., Martindale, R., 2002. The clear Liquid Diet: When is it appropriate? Current
Gastroenterology reports. 4: pp324-331.
Jeffery, K.M., Harkins, B., Cresci, G.A., Martindale, R.G., 1996. The clear liquid diet is no longer a
necessity in the routine postoperative management of surgical patients. The American Surgeon
62(3):167-70.
Kawamura, Y.J., Kuwahara Y., Mizokami K., et al., 2010. Patient’s appetite is a good indicator for
postoperative feeding: a proposal for individualized postoperative feeding after surgery for colon
cancer. Int JColorectal Dis.;25:pp239-243.
Lewis et al. Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: a systematic
review and meta-analysis of controlled trials. BMJ, 2001, 323 (7316) 773-776
Lewis et al. Early enteral nutrition within 24h of intestinal surgery versus later commencement of
feeding: A systematic review and meta-analysis. JGastrointest Surg, July 16 2008
Story, S.K., Chamberlain, R.S,. 2009 A Comprehensive Review of Evidence-Based Strategies to
Prevent and Treat Postoperative Ileus. Digestive Surgery 2009; 26:265–275.
Warren, J., Bhalla, V., Cresci, G., 2011. Postoperative Diet Advancement: Surgical Dogma vs
Evidence based Medicine. Nutrition in Clinical Practice. 26(2): pp115-125.
Editor's Notes
24/07/2012
24/07/2012
Percentage change in body weight in the control and treatment groups on admission to hospital, at inclusion in the study, and then at two weekly intervals for 10 weeks. studied 101 patients: 52 were randomised to the treatment group (TG) and prescribed a 1.5 kcal/ml nutritional supplement; 49 patients were randomised to the control group (CG) and continued with routine nutritional management. 24/07/2012
Sixty-one patients, treated according to the ERAS program, were matched with 122 historical controls who had conventional postoperative care matched cohort study was performed. ERAS intravenous fluid administration aimed at a urine production of at least 0.5 ml/kg and the total fluid intake should not exceed 2 l/24 h. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2793377/ 24/07/2012
40 patients undergoing elective colorectal surgery were randomly allocated to an intervention group receiving comprehensive information on the importance of mobilization, balanced anesthesia, and postoperative analgesia including epidural local anesthetics and enforced postoperative mobilization or a control group receiving anesthesia without epidural local anesthetics, postoperative analgesia with epidural morphine, and mobilization without fixed goals. The ambulation time improved substantially within 22 h in the intervention group versus 3 h in the control group on day 1 ( P = 0.0004) and within 8 h versus 2 h on day 4 ( P = 0.0003). http://www.nutritionjrnl.com/article/S0899-9007(01)00748-1/abstract 24/07/2012
Barriers to early enteral feeding include fear of GI morbidity, anastomotic disruption or leak but have not been proven valid in clinical or experimental trials. A clear liquid diet is the most frequently ordered first postoperative meal regardless of early or delayed administration. Although generally well tolerated, this diet fails to provide adequate nutrients to the postsurgical patient. In contrast, advancement to a regular diet as the initial meal has been shown to be well tolerated and provides significantly more nutrients than a clear liquid diet. This article reviews basic GI physiology, including motility, nutrient absorption, and the changes that occur in regulation and function of the GI tract following surgery, as well as clinical data regarding postoperative GI function and diet advancement. 24/07/2012
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Odds ratios (ORs) for mortality. Values in the left panel are observed counts for early and traditional feeding, ORs, and lower (L) and upper (U) limits of 95% confidence intervals (CIs) for ORs of the outcome variable. In the graph, squares indicate point estimates of treatment effect (ORs for early vs traditional groups), with the size of the squares representing the weight attributed to each study. The horizontal lines represent 95% CIs for ORs of individual studies. The pooled estimate for the mortality rate is the pooled OR, obtained by combining all ORs of the 15 studies using the inverse variance weighted method. The 95% CI for the pooled estimate is represented by the diamond, and the length of the diamond depicts the width of the CI. Values to the left of the vertical line favor early feeding. 24/07/2012
Odds ratios (ORs) for anastomotic leak. Values in the left panel are observed counts for early and traditional feeding, OR, and lower (L) and upper (U) limits of 95% (CIs) for ORs of the outcome variable. In the graph, squares indicate point estimates of treatment effect (ORs for early vs traditional groups), with the size of the squares representing the weight attributed to each study. The horizontal lines represent 95% CIs for ORs of individual studies. The pooled estimate for the anastomotic leak rate is the pooled OR, obtained by combining all ORs of the 13 studies using the inverse-variance weighted method. The 95% CI for the pooled estimate is represented by the diamond, and the length of the diamond depicts the width of the CI. Values to the left of the vertical line favor early feeding. 24/07/2012
Days to passing flatus. Values in the left panel are sample size (N), mean (standard deviation), weighted mean difference (WMD), and lower (L) and upper (U) limits of 95% confidence interval (CI) for mean of the outcome variable. In the graph, squares indicate point estimates of treatment effect (mean difference, ie, mean for early feeding group of patients minus mean for traditional group of patients), with the size of the squares representing the weight attributed to each study. The horizontal lines represent 95% CI for the mean differences of individual studies. The pooled estimate of the days to passing flatus is the WMD. It is obtained by combining all mean differences using the inverse-variance weighted method. The 95% CI for the overall mean based on the pooled estimate is represented by the diamond, and the length of the diamond depicts the width of the CI. Values to the left of the vertical line favor early feeding. 24/07/2012
Length of stay (days). Values in the left panel are sample size (N), mean (standard deviation), weighted mean difference (WMD), and lower (L) and upper (U) limits of 95% confidence interval (CI) for mean of the outcome variable. In the graph, squares indicate point estimates of treatment effect (mean difference, ie, mean for early feeding group of patients minus mean for traditional group of patients), with the size of the squares representing the weight attributed to each study. The horizontal lines represent 95% CI for the mean differences of individual studies. The pooled estimate of the length of stay (days) is the WMD. It is obtained by combining all mean differences using the inverse-variance weighted method. The 95% CI for the overall mean based on the pooled estimate is represented by the diamond, and the length of the diamond depicts the width of the CI. Values to the left of the vertical line favor early feeding. 24/07/2012
Odds ratio (OR) for complications (nausea and vomiting excluded). Values in the left panel are observed counts for early and traditional feeding, OR, and lower (L) and upper (U) limits of 95% confidence intervals (CIs) for ORs of the outcome variable. In the graph, squares indicate point estimates of treatment effect (OR for early vs traditional groups), with the size of the squares representing the weight attributed to each study. The horizontal lines represent 95% CIs for ORs of individual studies. The pooled estimate for the complication rate is the pooled OR, obtained by combining all ORs of the 15 studies using the inverse-variance weighted method. The 95% CI for the pooled estimate is represented by the diamond, and the length of the diamond depicts the width of the CI. Values to the left of the vertical line favor early feeding. 24/07/2012