Nama Dokter : Dr. dr. Warsinggih,SpB-KBD

Alamat Rumah : Perumahan Dosen UNHAS Blok BG. 86, Tamalanrea, Makassar

Spesialis : Bedah Digestif

DATA PRIBADITempat, Tanggal lahir : Mrentul - Kebumen, 21 Pebruari 1962NIP : 19620221 199002 1 002NIDN : Pangkat /Golongan : Pembina Utama Madya / IV c Jenis kelamin : Laki-lakiStatus : Menikah

CURRICULUM VITAE

• LATAR BELAKANG PENDIDIKAN

• Tahun 1974 : SD. Negri I Mrentul - Kebumen

• Tahun 1977 : SMP Bhakti Mulia - Prembun

• Tahun 1981 : SMA Negri II, Ujung Pandang

• Tahun 1989 : Fakultas Kedokteran Umum UNHAS

• Tahun 2002 : Spesialis Bedah FK UNHAS

• Tahun 2007 : Ahli Bedah Konsultan Bedah DIgestif FK UNHAS

• Tahun 2012 : Program S3 Pasca Sarjana FK UNHAS

• PENGALAMAN KERJA

• Kepala Puskesmas Bira KMUP, tahun 1989 - 1996

• Spesialis Bedah Fk UNHAS , tahun 1997 - 2002

• Spesialis Bedah RSU Bantaeng Sulsel, tahun 2002 - 2005

• Pendidikan Bagian Sub Spesialis Bedah Digestif FK UNHAS , tahun 2005 - 2007

• Dokter spesialis bedah RSU Daya, tahun 2007 – 2014

• Staff Divisi Bedah Digestif Departemen Ilmu Bedah FKUH Makassar tahun 2007 – sekarang

• Ketua Departemen Ilmu Bedah FKUH, tahun 2014 – sekarang

• Pengurus PBSI Sul - Sel , tahun 2010 - sekarang

DEPARTMENT OF SURGERYFACULTY OF MEDICINE

HASANUDDIN UNIVERSITYMAKASSAR

DR. dr. WARSINGGIH, Sp.B-KBD

PRESENTED BY

Dogma: Back to the Past….Senior surgeons had strong principles and they wereassumed as a dogma.• Preoperative prolonged fasting, Mechanical bowel

preparation and nasogastric tubes were thought to benecessary to✓ Empty the bowel✓ Prevent intraoperative contamination✓ Prevent early passage of bowel content through an

anastomotic suture line while it is healing.• Drain tube was believed essential in any GIT surgery• Prolonged bed rest were recommended to facilitate

abdominal wall healing.

Evolution of surgical principles brought about the concept of

E R A SThis concept was first described in 1990s by HenrikKehlet, MD, PhD, Surgical Gastroenterologist.

What is ERAS

ERAS stands for Enhanced Recovery After Surgery

also Known as

Fast Track Surgery

ERAS consists of Enhanced Recovery Programs which is amultimodal perioperative care pathway that aims atreducing stress response to surgery and acceleration ofrecovery.

The Aim OF ERAS

• Pain-Free and stress-free operations•Lower rates of orga dysfunction•Reduced morbidity•Enhanced recovery•Reduced need for hospitalitation

ALGORITHM “FAST-TRACK

CONTROLLING THE POSTOPERATIVE PERIOD

Preop. information

Enteral NutritionPain ReliefAttenuation of stress

Mobilisation

IMPROVE OUTCOMEReduced morbidity and accelerated convalescence

Members of ERAS program

• Nurses

• Clinical Nutritions

• Physiotherapists

• Pain team

• Anaesthetists

• Surgeons

• Hospital management

Pre-Admission• Counseling

• Oral Supplements

Pre-Operative• Admission on the day of surgery

• Preoperative fasting and Carbohydrate Loading

• No Mechanical Bowel Preparation

• Prophylaxis: DVT, Antibiotic

• Perioperative opioid sparing analgesiaAnesthesia• Normothermia

• Mid Thoracic Epidural Analgesia

• Avoidance of fluid overload

SurgicalApproach: Laparoscopy/ Short Incision/ Transverse Incision

Avoid Surgical Drains or Nasogastric tubes

Post-Operative• Hydration

• Active, Multimodal and preventive pain control

• Aggressive management of nausea and vomiting

• Early oral feeding and mobilization

• Nutritional support

• Remove urinary catheters and drains

• Discharge criteria

“Fast Track Surgery” Components

Pre-admission

Pre admission counseling:

• A clear explanation of what is to happen during surgery

• Explanation of role of the patient about food intake, oral nutritional

supplements and mobilization after surgery

Pre-Operative

• Preoperative assessment and optimization of organ function seeks to reduce operative risk.

• Alcohol and smoking cessation for a month preoperatively can reduce the incidence of complications, e.g., bleeding, wound infections, and cardiorespiratory complications .

• Bowel preparation leads to patient discomfort, dehydration, and electrolyte imbalance,and is no longer recommended in elective abdominal surgery . However, bowel preparation may have a role in selected patients such as those undergoing rectal resection .

• Modern fasting guidelines recommend that the duration of preoperative fasting should be 2 h for liquids and 6 h for solids .

• Preoperative nutrition and good carbohydrate diet reduces preoperative thirst, hunger and anxiety, and significantly reduce postoperative insulin resistance.

Intra-operative

Intraoperative fluid therapy

•Avoid Na and Fluid overload .

• Goal directed fluid therapy via Oesophageal Doppler(OD) monitoring.

Fluid overload is associated with delayed gut function and increased complication rates.

Maintenance of normothermia is important for preventing sympathetic responses, cardiac arrhythmias, and wound complications.

Tubes and drains

No routine use of drains , nasogastric tube.

Anasthesia

• Epidural, spinal, or peripheral nerve block remains a key element of the

program and has been associated with attenuated endocrine stress response,

increased gut motility, reduced inflammatory response, and optimal pain

relief, but its application must be procedure-specific.

• For lap. colectomy, spinal analgesia or patient-controlled analgesia may

be superior to epidural analgesia within a program .

.

Minimally invasive techniques

Short, Transverse Incision,Laparoscopy reduce in-patient stays, lessen morbidity and lower postoperative pain.

oxygen therapy

Reduce the risk of wound infection and anastomotic complications.

Antimicrobial prophylaxis

Recommended to prevent infectious complications

Anticoagulants

Minimizes thromboembolic events

Post-operative

Encourage Early Postoperative Oral Intake

• Facilitates early return of bowel function,

• Allows stopping of intravenous drips,

• Aids mobilization,

• Leads to faster recovery.

• Reduces postoperative morbidity and is not associated with an increased risk of anastomotic dehiscence

Early remove of nasogastric tube , drains and catheters

Early Bowel Sounds Not an Indicator for Feeding

Stomach

24 hours Small Intestine

4-8 hours

Colon

3-5 days

Adapted from Waldhausen J, et al. Ann Surg 1990;211:777-785

Early mobilization

Bed rest

• ↑ insulin resistance , muscle loss and risk of thromboembolism.

• ↓ muscle strength, pulmonary function and tissue oxygenation .

• The aim is for patients to be out of bed for 2 h on the day of surgery, and for 6 h a day until discharge.

Post operative pain

Using

• NSAIDs

• Epidural and

• local infiltrating anasthesia is better

• Opiates are associated with decreased gut motility and delay recovery

Prevention of Postoperative Nausea and Vomiting

(PONV) and ileus

• PONV is unpleasant, delays gut function, affects mobility and has

metabolic consequences.

• Give prophylactic anti-emetics i.e. Ondansetron during anesthesia

around 30 min before the end of surgery.

• Ileus can be avoided by early ambulation ,laxatives, and electrolyte

balance.

Discharge criteria

• Patients can be discharged when they meet the following criteria:

• Good pain control with oral analgesia

• Taking solid food, no intravenous fluids

• Independently mobile or same level as prior to admission

• All of the above and willing to go home.

Application of fast track surgery

• Colorectal surgery

• Bariatric surgery

• Liver and pancreatic resection

• Breast surgery

• Urological surgery i.e Lap. Prostatectomy

• Orthopedic operations “Hip and knee replacement”

Enhanced Recovery After Surgery

• Saves money

• Saves resources

• Saves time

• With no inreased complication rate