ส่วนที่ 1 ข้อมูลเอกสาร

ส่วนที่ 2 Indications & Procedures

ส่วนที่ 3 Pre-operative (ERAS)

3.1 Patient Preparation

• Pre-op counseling: expectation, pain management, recovery milestones
• Nutritional assessment: pre-albumin, weight loss; optimize if malnourished
• Smoking cessation 4 weeks before if possible
• Alcohol abstinence 4 weeks
• Exercise (prehabilitation): 2-4 weeks
• Carbohydrate loading: 800 ml clear carb drink night before + 400 ml 2 hr before
• No prolonged NPO: clear fluids until 2 hr before

3.2 Bowel Preparation

• Combined MBP + oral antibiotic (Neomycin + Metronidazole) preferred
• Reduces SSI, anastomotic leak

3.3 Stoma Marking (if stoma planned)

• By WOCN/ET nurse pre-op
• Mark in clear area, visible to patient
• Avoid: scars, belt line, skin folds, umbilicus

ส่วนที่ 4 Post-operative

4.1 ERAS Postop Protocol

• Day 0: Clear fluids evening, IV fluid goal-directed (not excess)
• Day 1: Regular diet, out of bed, remove Foley (if no epidural), oral analgesics
• Day 2: Continue ambulation, remove drains (if any), IV to PO meds
• Day 3-4: Discharge planning (criteria met → home)

4.2 Anastomotic Leak Monitoring

Peak incidence: POD 5-7 (some up to 14)

• Tachycardia (often earliest sign)
• Fever > 38.5°C
• Abdominal pain, peritonitis
• Ileus beyond POD 3-4
• Feculent drainage
• Altered mental status (elderly)
• Action: CT with contrast (water-soluble) → surgical exploration

ส่วนที่ 5 Ostomy Care

5.1 Types

5.2 Healthy Stoma Assessment

• Color: Beefy red/pink (dark red/black = ischemia!)
• Moist, shiny
• Protrudes ~1-2 cm
• Peristomal skin intact
• Passing flatus/stool

5.3 Nursing Care

• Measure stoma size at each appliance change (shrinks first 6-8 weeks)
• Appliance change every 3-7 days (or when leaking)
• Empty pouch when 1/3 full
• Skin protection: proper fit, skin barrier
• High-output ileostomy: monitor electrolytes, dehydration

5.4 Complications

• Ischemia/Necrosis (dark color) — surgical emergency
• Retraction — below skin level
• Prolapse — protrudes too much
• Parastomal hernia
• Peristomal skin breakdown
• Obstruction (food blockage)

ส่วนที่ 6 Patient Education

• Appliance change technique (return demonstration)
• Diet: chew well, adequate fluid, identify trigger foods
• Medications: avoid enteric-coated, extended-release (may not absorb)
• Odor control
• Travel: extra supplies, medical letter
• Activity: return to normal 6-8 weeks, no heavy lifting > 10 lbs × 6 weeks
• Emotional support: body image, sexuality
• Support groups (Ostomy Association)
• When to call: no output > 4-6 hr + pain + vomiting (obstruction!)

KPIs

References

• Gustafsson, U.O., et al. (2019). Guidelines for Perioperative Care in Elective Colorectal Surgery: ERAS Society Recommendations 2018. World Journal of Surgery, 43(3).
• ASCRS Clinical Practice Guidelines for Colorectal Cancer Surgery.
• Wound, Ostomy and Continence Nurses Society (WOCN). Stoma Complication Guidelines.

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