Colorectal – McGill colorectal pathway

Preoperative Assessment and Optimization

   – Evaluation of medication compliance and control of risk factors: hypertension, diabetes, COPD, smoking, alcohol, asthma, CAD, malnutrition, anemia

   – Psychological preparation for surgery and postoperative recovery: provide written information and e-module link including daily milestones in perioperative pathway (diet and ambulation plan, management of drains) and expectation about duration of hospital stay (3 days for colon, 4 days for rectal)

   – Physical preparation with exercises at home: Aerobic 30 minutes/day, three times per week at moderate intensity; resistance exercises; breathing exercises

   – Full oral mechanical bowel preparation for rectal resections with planned ileostomy. No prep for laparoscopic colectomy. Stoma teaching as needed

   – Nutritional preparation: oral nutritional supplements for patients with diminished oral intake or mild malnutrition

Day of surgery
   – Drink clear fluids with carbohydrates up to 2 hours prior to operation unless risk factors are present (eg, gastroparesis, obstruction, dysphagia, previous difficult intubation, diabetes, pregnancy)

Intraoperative Management

Anesthetic management
   – Allay anxiety with midazolam and good hydration

   – Epidural catheter for open cases inserted at appropriate intervertebral level. Use local anesthetics and test epidural blockade for bilateral spread. Infusion of local anesthetics during surgery. Minimal amount of i.v. opioids throughout surgery. Intrathecal morphine as alternative for laparoscopic surgery

   – Bilateral transversus abdominus plane (TAP) block with ketorolac IV for laparoscopic surgery

   – Prophylactic antiemetics: 1 or more antiemetics based on baseline risk score

   – Antibiotics and DVT prophylaxis

   – Avoid over hydration. IV Ringer’s Lactate @ 3 ml/Kg/h for laparoscopic surgery; 5 ml/Kg/h for open cases. Colloid 1:1 (Voluven) to replace blood loss.

   – Anesthesia protocol: Total intravenous anesthesia (tiva)/desflourane/ sevoflurane. Lidocaine 1.5mg/kg bolus then 2mg/kg/hr for duration of case (in patients without epidural)

   – Maintenance of normothermia (core temperature >36 degrees)

   – Neuromuscular blockade to facilitate laparoscopic exposure at lower pressure pneumoperitoneum (12 mmHg)

   – Maintain glucose below 10 mmol/L (180 mg/dl).

   – Titrate anesthesia according to the bispectral index.

Surgical care
   – Minimize incision size, minimally invasive approach if possible.

   – Accurate hemostasis and removal of debris.

   – Check integrity of anastomosis.

   – No routine nasogastric and abdominal drains.

   – Remove urinary catheter for right hemicolectomy in OR

Postoperative Strategy

Postanesthesia Care Unit
   – Discharge criteria to ward: patient alert, cooperative, pain free, warm, normotensive, able to lift legs, adequate urine output

Day of surgery (postoperative day 0)
   – Out of bed when transferred to ward.

   – Drinking fluids including nutritional supplements. Hold oral intake if abdomen distended or nausea/vomiting

   – Confirm working epidural with VAS for pain at rest, cough and mobilization. Check skin site (repeated in subsequent days)

   – Oral acetaminophen 650mg every 4 hours and Celecoxib 200mg PO BID x 72 hours then reassess

   – Normal Saline to keep vein open (30 ml/h) if has PCA

   – Gum chewing for 30 minutes TID (continue daily)

Postoperative day 1
   – lock IV in am of POD 1.

   – Urinary catheter removed in the morning.

   – Mobilized 4-6 hours.

   – Full oral diet including nutritional supplements

   – Hold oral intake if abdomen distended. Nasogastric tube for persistent nausea and vomiting (repeated in subsequent days)

Postoperative day 2 and later (>48 hours)
   – Full mobilization

   – Full oral diet including nutritional supplements

   – Transition from epidural to oral medication (oxycontin + oxycodone+ acetaminophen + NSAIDs) if epidural stop test successful (repeated in subsequent days if epidural stop test not successful)

Discharge criteria: passing gas or stool, no fever, minimal pain (<4/10), walking unattended, eating.

Postdischarge care
   – Instructions while recovering at home and/or on chemotherapy/radiotherapy: eating normal diet (±supplements), exercise every day, avoid opioids for pain relief, psychological support

   – Clinic visit postop day 14 to check wound and overall recovery. Discuss pathology and further treatment. Plan further follow-up.

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