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General Surgery

Below are summaries of our guideline recommendations for quick use by healthcare providers. If you would like to access our guideline recommendations with supporting evidence, please click here.

Enhanced Recovery After Surgery
1.1  Preoperative information and counseling 
  All patients should be made aware of what they can anticipate in the perioperative period as well as what is expected of them in their recovery process
 
  • For patients who do not have postoperative complications and have no other co-morbidities or issues which would affect length of stay, the target for the duration of stay for those having colon operations is 3 days and for rectal operations (anastomosis below the peritoneal reflection) is 4 days
  • Patients should receive information on approximate length of stay; preoperative fasting and carbohydrate loading; pain control; early ambulation; postoperative feeding/ileus; time of catheter removal; gum chewing and smoking cessatio
  • Patients and their families should receive oral information, as well as the patient education booklet
  • The booklet should be given to patients in the surgeon’s office. The surgeon should inform the patient to bring the booklet with them every time they come to the hospital, including their preoperative appointment and the day of their surgery
  • Patients should be instructed to bring 2 packages of gum to the hospital
1.2 Reduced fasting duration
 
  • For patients who are undergoing elective colorectal surgery and a significant delay in gastric emptying is not suspected, patients should be allowed to eat solid foods until 12 midnight and clear liquids until 2 to 3 hours before surgery or until they leave for the hospital 
  • Patients should be encouraged to drink a suitable carbohydrate rich drink, up to 800 mL at bedtime the night before surgery and 400 mL until 2 to 3 hours before surgery or until they leave for the hospital 

Intraoperative Recommendations 

2.1  Intraoperatively, patients should have goal directed fluid management
2.2  The use of prophylactic abdominal drains should be avoided following elective colorectal surgery, except following abdominoperineal resection
2.3 Prophylactic use of nasogastric tubes for decompression should be avoided

Postoperative Recommendations

3.1  Patients who undergo elective colorectal surgery should be encouraged to participate in early mobilization
 
  • Patients should dangle their legs on the day of surgery
  • Patients should eat all of their meals in a chair beginning POD 1
  • Patients should ambulate every 4 to 6 hours each day while they are awake until discharge beginning POD 1
3.2 Postoperative Fluid Management
 
  • Patients who do not have adequate oral intake should receive not more than 75 mL/hr of 2/3-1/3 with 20 mEq potassium/day, or a similar rate using a balanced salt solution if electrolyte replacement is required. The routine use of saline is to be discouraged 
  • Postoperatively, volume status should be assessed before fluid boluses are given. Boluses should not be given because of low urine output or low blood pressure alone. Instead, the blood pressure, heart rate, urine output and mental status of patients should all be considered. In addition, the preoperative blood pressure should be considered when making decisions about the postoperative volume status
3.3 Early Enteral Feeding
 
  • Patients should be offered sips of clear fluid 2 hours postoperatively provided they are awake, alert and capable of swallowing 
  • Patient controlled diet should be encouraged: patients should be offered a regular diet beginning postoperative day 1 and patients should be allowed to decide what and how much they want to consume each day 
  • Patients should be encouraged to bring dry food from home
3.4 The use of chewing gum should be encouraged starting on postoperative day 1. Each patient should chew one stick of gum, for at least 5 minutes, ≥ 3 times per day
3.5 All patients undergoing surgery with a low colorectal anastomosis or coloanal anastomosis (≤6 cm the anal verge) should have their urinary catheter removed within 72 hours after the surgery. For patients undergoing some colon resections, it may be appropriate to not insert a urinary catheter.  If patients do require a urinary catheter it should be removed within 24 hours after the surgery 
 
  • The above recommendations apply to patients with or without an epidural catheter at the time of removal 
  • The above recommendations do not apply if a catheter is needed for monitoring purposes 

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Management of Acute Pancreatitis
1. Diagnosis of Acute Pancreatitis
1.1  Serum lipase should be performed in all patients with a suspected diagnosis of acute pancreatitis. A 3-fold elevation of serum lipase from the upper limit of normal is required to make the diagnosis of acute pancreatitis.
1.2 Ultrasonography should be performed in all patients at baseline to evaluate the biliary tract and in particular to determine if the patient has gall stones and/or a stone in the common bile duct.
1.3 Magnetic resonance cholangiopancreatography(MRCP) is recommended only in patients in whom there is elevation of liver enzymes and in whom the common bile duct is either not visualized adequately or is found to be normal on ultrasound.
1.4 Computed tomography (CT) should be performed selectively when 1) a patient presents with significant abdominal pain and a broad differential diagnosis which includes acute pancreatitis, or 2) in patients with suspected local complications of acute pancreatitis (e.g. peritonitis, signs of shock, suggestive ultrasound findings). CT for assessment of local complications is most useful after 48-72 hours after the onset of symptoms rather than at the time of admission. Unless contraindicated (e.g. renal dysfunction), intravenous contrast should be given in order to assess for pancreatic necrosis once patients are adequately fluid resuscitated and normovolemia restored.

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2. Assessment of Severity

2.1  A serum C reactive protein (CRP) level of 14 286 nmol/L (150 mg/dL) or greater at baseline or in the first 72 hours is suggestive of severe acute pancreatitis, and is predictive of a worse clinical course. Thus, CRP should be performed at admission and daily for the first 72 hours after admission.
2.2 Acute Physiologic Assessment and Chronic Health Evaluation APACHE II Scores should be calculated on admission and daily for the first 72 hours after admission. An APACHE II Score of 8 or higher at baseline or in the first 72 hours is suggestive of severe acute pancreatitis, and is predictive of a worse clinical course.
2.3 Severe acute pancreatitis should be diagnosed if a patient exhibits signs of persistent organ failure for more than 48 hours despite adequate intravenous fluid resuscitation.

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3. Supportive Care

3.1  Supportive care, including resuscitation with isotonic intravenous fluids  (e.g. Ringer’s Lactate solution), pain control, and mobilization should be the mainstay of treatment of patients with mild acute pancreatitis
3.2 Careful consideration of transfer to a monitored unit should be made in patients with 1) Severe acute pancreatitis based on APACHE II Score greater than 8, CRP greater than 14 286 nmol/L (150 mg/L), or organ dysfunction for more than 48 hours despite adequate resuscitation; 2) Evidence of present or evolving organ dysfunction defined as follows:
 
  • Respiratory (PaO2/FiO2 ≤ 300, or respiratory rate > 20 breaths per minute
  • Cardiovascular (hypotension despite aggressive fluid resuscitation [systolic BP <90 mm Hg off of inotropic support or drop of sBP > 40], need for vasopressors [not fluid responsive], or pH <7.3
  • Renal (≥1.5 fold increase in serum creatinine over 7 days, increase of ≥26.5μmol in serum creatinine over 48 hours, urine output <0.5ml/kg/h for ≥6 hours and/orNeed for aggressive, ongoing fluid resuscitation defined as evidence of severe haemoconcentration (Hb > 160, HCT > 0.500)
  • Patients with one or more of the above criteria and a body mass index (BMI) above 30 (or BMI > 25 in Asian populations) should be monitored carefully, with a lower threshold for transfer to a monitored unit given the worse course of disease in the obese patient population.

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4. Nutrition

4.1  Patients who present with mild acute pancreatitis should receive a regular diet on admission. If patients are unable to tolerate an oral diet owing to abdominal pain, nausea, vomiting, or ileus, they may be allowed to self-advance their diet from withholding oral food and fluids (NPO) to a regular diet as tolerated.
4.2 In patients with severe acute pancreatitis, enteral nutrition should be commenced as soon as possible following admission (within 48 hours). A nasojejunal tube is not superior to feeding by nasogastric feeding tube; thus, commencement of feeds should not be delayed for the purpose of placing a nasojejunal feeding tube. Enteral feeding is recommended over parenteral nutrition.

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5. Prophylactic Antibiotics

5.1  Prophylactic antibiotics are not recommended in patients with mild or severe acute pancreatitis

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6. Diagnosis and Management of Local Complications of Acute Pancreatitis

6.1 Repeat CT should be considered with new (or unresolving) evidence of infection (eg: leukocytosis, fever) without a known source, new inability to tolerate oral/enteral feeds, change in haemodynamic status, or evidence of bleeding.
6.2 Patients who have extensive necrotizing acute pancreatitis, who show no clinical signs of improvement following appropriate initial management, or in whom other complications develop should be managed in consultation with, or at institutions with therapeutic endoscopy, interventional radiology, surgical and intensive care expertise in dealing with severe acute pancreatitis.
6.3 Patients with acute peripancreatic fluid collections with no radiological or clinical suspicion of sepsis should be observed, and image-guided fine needle aspiration (FNA) should be avoided due to the risk of introducing infection into a sterile collection.
6.4 When there is radiological or clinical suspicion of infected necrosis in patients with acute necrotic collections (ANCs) or walled-off pancreatic necrosis (WOPN), image-guided FNA with culture should be performed to distinguish infected from sterile necrosis.
6.5 Sterile necrosis based on negative FNA and/or stable clinical picture should be managed non-operatively, and antibiotics are not indicated. The exception is unstable patients in whom sepsis is suspected but no source has been identified: treatment with broad spectrum antibiotics on speculation may be indicated while an appropriate work up (bacterial and fungal cultures, CT) is carried out.
6.6 Antibiotics should be prescribed only in patients with infected necrosis confirmed by FNA or if there is gas within a collection visualized on CT scan. Antimicrobial therapy should be tailored to FNA culture speciation and sensitivities; however, empiric treatment with antibiotics active against the most common pathogens in infected pancreatic necrosis (Escherichia coli, Bacteroides species, Enterobacter species, Klebsiella species and Streptococcus faecalis, as well as other gram positive organisms such as Staphylococcus epidermidis and Staphylococcus aureus) may be considered until final culture results are available.
6.7 In patients with FNA-confirmed infections of ANCs or WOPN, a step-up approach of antibiotics and image-guided drainage, followed by surgical intervention if necessary, is indicated. Surgical consultation should occur early; however, surgical intervention should be delayed until later in the course of disease whenever possible. Minimally invasive image-guided or endoscopic drainage is recommended as first line therapy, and multiple drains may be necessary. Surgery should be considered for cases in whom less invasive approaches fail, but should be delayed long enough to allow demarcation of necrotic pancreatic tissue.
6.8 Pancreatic pseudocysts which are asymptomatic should be managed non-operatively. Intervention is indicated in pseudocysts that are symptomatic, infected, or increasing in size on serial imaging, and should be performed in a high volume centre.

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7. Management of Patients with Acute Gallstone Pancreatitis

7.1 Endoscopic retrograde cholangiopancreatography (ERCP) should be performed early (within 24-48 hours) in patients with acute gallstone pancreatitis associated with bile duct obstruction or cholangitis. In unstable patients with severe acute gallstone pancreatitis and associated bile duct obstruction or cholangitis, placement of a percutaneous transhepatic gallbladder drainage tube should be considered if ERCP is not safely feasible.
7.2 Cholecystectomy should be performed during the index admission in patients who have mild acute pancreatitis and should be delayed until clinical resolution in patients who have severe acute pancreatitis.
7.3 If cholecystectomy is contraindicated in patients because of medical comorbidities, ERCP and sphincterotomy should be considered prior to discharge in patients with acute gall stone pancreatitis.

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Management of Intra-Abdominal Infections
1. Selection of Empiric Antimicrobial Agents
1.1  Patients with mild-to-moderate community-acquired IAI require empiric coverage for enteric gram-negative bacilli and anaerobes. Cefazolin and metronidazole are recommended. In patients with IgE-mediated allergy or other severe reaction to beta-lactams, Gentamicin and metronidazole are recommended.
1.2 Most patients with mild-to-moderate community-acquired IAI do not require coverage of Enterococcus spp. unless other risk factors are present.
1.3 Patients with high severity community-acquired IAI may benefit from broader coverage against gram-negative bacilli. Ceftriaxone and metronidazole are recommended or gentamicin and metronidazole for IgE-mediated allergy or other severe reaction to beta-lactams.  Piperacillin-tazobactam could also be considered.
1.4 Most patients with health care-associated IAI should receive broad spectrum empiric antimicrobial therapy, including coverage for drug-resistant gram-negative bacilli and Enterococcus spp. Piperacillin-tazobactam is recommended for those with high severity disease.  Some patients with mild-moderate severity health care-associated IAI may not require as broad of coverage and thus, ceftriaxone and metronidazole may be appropriate.  In patients with IgE-mediated penicillin allergy or other severe reaction, vancomycin, gentamicin and metronidazole OR vancomycin plus a carbapenem are recommended.
1.5 Patients with health care-associated IAI should receive antifungal therapy if yeast are identified in peritoneal samples.  Fluconazole should be the empiric agent of choice in the majority of patients. Patients with community-acquired IAI likely do not require antifungal therapy.

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2. Timing and Duration of Antimicrobial Therapy

2.1  Antimicrobial therapy should be initiated once cIAI is diagnosed or considered likely.
2.2 Most patients with cIAI require antimicrobial therapy for 3-7 days after source control.
2.3 After source control is complete, antimicrobial therapy should be discontinued when clinical signs of infection have improved, usually 3-7 days after source control. Oral step-down therapy is rarely required, with the exception of patients with perforated appendicitis or perforated diverticulitis, in whom a very short length of stay precludes a thorough assessment of clinical response.  In these patients, a total of a 5-day course (with a transition to oral ceflexin) is reasonable. A prolonged course of antimicrobials (> 7 days) should be avoided unless source control is incomplete.
2.4 Patients with evidence of ongoing infection at 4-7 days should be re-evaluated for source control rather than continuing with a prolonged course of antimicrobials.

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3. Use of Culture and Sensitivity Specimens to Guide Antimicrobial Therapy

3.1  Blood cultures should only be obtained if the diagnosis of IAI is unclear or if there is a high suspicion of bacteremia.
3.2 Peritoneal samples should not be routinely obtained in mild-to-moderate community-acquired IAI.
3.3 Peritoneal samples should be obtained in all patients with health care-associated IAI and high severity community-acquired IAI.
3.4 Peritoneal fluid should be sent to the lab in aerobic and anaerobic blood culture bottles.

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4. Source Control

4.1  All patients with IAI should undergo evaluation for a potentially controllable source of infection.
4.2 Percutaneous drainage is the preferred source control technique for localized abscesses.
4.3 Operative source control should be undertaken for most patients with cIAI not amenable to percutaneous drainage. The principles of the operation should be to drain infected fluid, debride non-viable tissue and control continued contamination by resection of the source organ or by gastrointestinal tract diversion.
4.4 An on-demand re-laparotomy strategy is preferred over planned re-laparotomy or laparostomy (open abdomen) strategies in most cases of cIAI.
4.5 Laparostomy should only be employed for specific indications: intra-abdominal hypertension, mesenteric ischemia, necrotizing abdominal wall infection, or damage-control surgery (with intestinal discontinuity or incomplete source control).
4.6 There is currently insufficient evidence to make a recommendation about primary colonic anastomosis versus stoma in the setting of peritonitis.  Patients with less severe sepsis might be safely managed with primary anastomosis.

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5. Biliary Tract Infections

5.1  All patients with ascending cholangitis should receive antimicrobial therapy.  Patients with acute calculous cholecystitis should receive antimicrobial therapy if there is an increased likelihood of bactibilia (fever, leukocytosis, advanced age, immunosuppression or diabetes) or a suspicion of superimposed infection (adjacent abscess, air in the gallbladder wall or lumen, or suspicion of perforation).
5.2 All patients with acute cholecystitis taken to the operating room should receive antibiotic prophylaxis prior to skin incision.  If the cholecystitis is uncomplicated then no further antibiotics are required after cholecystectomy .  In cases of complicated cholecystitis characterized by either perforation, gangrene, or empyema, the antimicrobial duration should conform to the duration of antimicrobial therapy for cIAI detailed in Section 2, Timing and Duration of Antimicrobial Therapy.
5.3 Patients with biliary infection should receive antibiotics to cover enteric gram-negative organisms. Cefazolin is recommended in mild-to-moderate cases and ceftriaxone and ampicillin in patients meeting criteria for a high severity infection.  Only patients with biliary-enteric anastomoses require anaerobic coverage, such as metronidazole.  For IgE-mediated or other severe reaction to beta-lactams, gentamicin or gentamicin and vancomycin should be used.
5.4 Patients with ascending cholangitis should receive prompt decompression of the common bile duct.  Endoscopic or percutaneous approaches are preferred to open common bile duct exploration whenever feasible.
5.5 Patients with acute calculous cholecystitis should be considered for early laparoscopic cholecystectomy (within 72-96 hours of symptom onset).
5.6 Prophylactic antibiotics should NOT be administered to patients with necrotizing pancreatitis.

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Mechanical Bowel Preparation Strategies
1. All open or laparoscopic procedures (excluding low anterior resections with/without diverting stoma)
  • No dietary restrictions

  • No MBP

  • Fleet enema may be used for patients having a left sided anastomosis where a stapler will be passed per anus

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2. Open or laparoscopic low anterior resections (LAR) with/without diverting stoma

  • No dietary restrictions prior to MBP; clear fluids after MBP completed

  • MBP

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Perioperative Pain Management
1. Preoperative
1.1  A single 1000 mg dose of acetaminophen is recommended to be given preoperatively in open and laparoscopic colorectal surgical procedures (Level of evidence: Low)
1.2 A single 300 mg dose of gabapentin should be given be should be given preoperatively in open and laparoscopic colorectal surgical procedures (Level of evidence: Moderate)

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2. Intraoperative

2.1  Thoracic epidural analgesia (TEA) at level T6-9 with a combination of local anaesthetic and opioid as a continuous infusion should be considered for all patients having open colorectal surgery and for patients having laparoscopic surgery who are at high risk pulmonary morbidity. TEA should be inserted preoperatively (Level of evidence: High)
2.2  Intraoperative lidocaine infusion bolus of 100 mg prior to the incision and then 1-2 mg/kg/hour continuous infusion is recommended for patients having laparoscopic colorectal surgery, or open colorectal surgery cases where a TEA is contraindicated or declined. Intravenous lidocaine can be continued in the PACU where patients can be monitored but should be discontinued before discharge to the ward (Level of evidence: High)

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3. Postoperative

Patients having open or laparoscopic colorectal surgery should receive a multimodal analgesia package of: 

3.1  Acetaminophen 1000 mg given orally every 6 hours for 72-96 hours (Level of evidence: Low)
3.2 Prescription Post-operative celecoxib 400 mg initial dose followed by 200 mg bid for 5 days is recommended in patients having a colorectal resection where NO anastomosis is performed (for example, abdominal perineal resection) and where no contraindications to its use are present. 
 
  • There is inconclusive evidence about an increased risk of anastomotic leaks in patients who receive perioperative NSAIDS. However, there is some evidence linking perioperative NSAID use and anastomotic leak in patients having a colorectal resection. Thus, for patients having a colorectal resection WITH anastomosis, celecoxib (or other NSAIDS) should only be prescribed with the agreement of the surgeon, and following discussion between the surgeon and the pain team/anesthesiologist, concerning the relative risks and benefits of NSAIDS for that particular patient.  (Level of evidence: Moderate)

  And one of the following alternatives:
3.3 Thoracic epidural analgesia (TEA) at level T6-9 with a combination of local anaesthetic and opioid as a continuous infusion should be considered for all patients having open colorectal surgery and for patients having laparoscopic surgery who are at high risk pulmonary morbidity. TEA should be continued postoperatively for 48-72 hours (Level of evidence: High)
3.4 In patients where TEA is contraindicated or declined, IV Patient Controlled Analgesia (PCA) should be given as part of a multimodal analgesia package. Alternately, oral sustained release opioids may be given in addition to or  instead of PCA to increase duration of analgesia and sleep (Level of evidence: Moderate)

Click here for pain mangement flow chart

Contact Us
For more information or to get involved in the Best Practice in Surgery program, please email bestpracticeinsurgery@utoronto.ca 

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