Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials

Outcomes reported in randomised trials of surgical prehabilitation: a scoping review

BACKGROUND

Heterogeneity of reported outcomes can impact the certainty of evidence for prehabilitation. The objective of this scoping review was to systematically map outcomes and assessment tools used in trials of surgical prehabilitation.

METHODS

MEDLINE, EMBASE, PsychInfo, Web of Science, CINAHL, and Cochrane were searched in February 2023. Randomised controlled trials of unimodal or multimodal prehabilitation interventions (nutrition, exercise, psychological support) lasting at least 7 days in adults undergoing elective surgery were included. Reported outcomes were classified according to the International Society for Pharmacoeconomics and Outcomes Research framework.

RESULTS

We included 76 trials, mostly focused on abdominal or orthopaedic surgeries. A total of 50 different outcomes were identified, measured using 184 outcome assessment tools. Observer-reported outcomes were collected in 86% of trials (n=65), with hospital length of stay being most common. Performance outcomes were reported in 80% of trials (n=61), most commonly as exercise capacity assessed by cardiopulmonary exercise testing. Clinician-reported outcomes were included in 78% (n=59) of trials and most frequently included postoperative complications with Clavien-Dindo classification. Patient-reported outcomes were reported in 76% (n=58) of trials, with health-related quality of life using the 36- or 12-Item Short Form Survey being most prevalent. Biomarker outcomes were reported in 16% of trials (n=12) most commonly using inflammatory markers assessed with C-reactive protein.

CONCLUSIONS

There is substantial heterogeneity in the reporting of outcomes and assessment tools across surgical prehabilitation trials. Identification of meaningful outcomes, and agreement on appropriate assessment tools, could inform the development of a prehabilitation core outcomes set to harmonise outcome reporting and facilitate meta-analyses.

Feasibility of the ERAS (Enhanced Recovery After Surgery) Protocol in Patients Undergoing Gastrointestinal Cancer Surgeries in a Tertiary Care Hospital-A Prospective Interventional Study

Enhanced Recovery After Surgery (ERAS) protocols have emerged as a promising approach to optimize perioperative care and improve outcomes in various surgical specialties. Despite feasibility studies on ERAS in various surgeries, there remains a paucity of research focusing on gastrointestinal cancer surgeries in the Indian context. The primary objective is to evaluate the compliance rate of the ERAS protocol and secondary objectives include the compliance rate of individual components of the protocol, the complications, the length of hospital stay, and the challenges faced during implementation in patients undergoing gastrointestinal cancer surgeries in our tertiary care cancer center. In this prospective interventional study (CTRI/2022/04/041657; registered on 05/04/2022), we evaluated 50 patients aged 18 to 70 years undergoing surgery for gastrointestinal malignancies and implemented a refined ERAS protocol tailored to our institutional resources and conditions based on standard ERAS society recommendations for gastrointestinal surgeries and specific recommendations for colorectal, pancreatic, and esophageal surgeries.Our study's mean overall compliance rate with the ERAS protocol was 88.54%. We achieved a compliance rate of 91.98%, 81.66%, and 92.00% for pre-operative, intraoperative, and post-operative components respectively. Fourteen (28%) patients experienced complications during the study. The median length of stay was 6.5 days (5.25-8). Challenges were encountered during the preoperative, intraoperative, and postoperative phases. The study highlighted the feasibility of implementing the ERAS protocol in a cancer institute, but specific challenges need to be addressed for its optimal success in gastrointestinal cancer surgeries.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-024-01897-y.

Predictive Factors for Successful Same-Day Discharge After Minimally Invasive Colectomy and Stoma Reversal

BACKGROUND

Same-day discharge after minimally invasive colorectal surgery is a safe, effective practice in specific patients that can enhance the efficiency of enhanced recovery pathways.

OBJECTIVE

To identify predictive factors associated with success or failure of same-day discharge.

DESIGN

Prospective cohort study from January 2020 to March 2023.

SETTINGS

Tertiary colorectal center.

PATIENTS

Adult patients eligible for same-day discharge with remote postdischarge follow-up included those with minimal comorbidities, residing near the hospital, having sufficient home support, and owning a mobile device.

INTERVENTIONS

Patients were discharged on the day of surgery upon meeting specific criteria, including adequate pain control, tolerance of oral intake, independent mobility, urination, and the absence of complications. Successful same-day discharge was defined as discharge on the day of surgery without unplanned visits in the first 72 hours.

MAIN OUTCOME MEASURES

Factors associated with successful or failed same-day discharge after minimally invasive colorectal surgery.

RESULTS

A total of 175 patients (85.3%) were discharged on the day of surgery, with 14 patients (8%) having an unplanned visit within 72 hours. Overall, 161 patients (78.5%) were categorized as same-day discharge success and 44 patients (21.5%) as same-day discharge failure. The same-day discharge failure group had a higher Charlson Comorbidity Index (3.7 vs 2.8, p = 0.03). Mean length of stay (0.8 vs 3.0, p = 0.00), 30-day complications (10% vs 48%, p = 0.00), and readmissions (8% vs 27%, p = 0.00) were higher in the same-day discharge failure group. Regression analysis showed that failed same-day discharge was associated with higher comorbidities (OR 0.79; 95% CI, 0.66-0.95) and prolonged postanesthesia care unit time (OR 0.99; 95% CI, 0.99-0.99). Individuals who received a regional nerve block (OR 4.1; 95% CI, 1.2-14) and those who did not consume postoperative opioids (OR 4.6; 95% CI, 1-21) were more likely to have successful same-day discharge.

LIMITATIONS

Single-center study.

CONCLUSIONS

Our findings indicate that comorbidities and prolonged postanesthesia care unit stays were associated with same-day discharge failure, whereas regional nerve blocks and minimal postoperative opioids were related to success. These factors may inform future research aiming to enhance colorectal surgery recovery protocols. See Video Abstract .

FACTORES PREDICTIVOS PARA UN ALTA EXITOSA EL MISMO DA DESPUS DE UNA COLECTOMA MNIMAMENTE INVASIVA Y REVERSIN DEL ESTOMA

ANTECEDENTES:El alta el mismo día después de una cirugía colorrectal mínimamente invasiva es una práctica segura y eficaz en pacientes específicos que puede mejorar la eficiencia de las vías de recuperación mejoradas.OBJETIVO:Identificar factores predictivos asociados con el éxito o fracaso del alta el mismo día.DISEÑO:Estudio de cohorte prospectivo del 01/2020 al 03/2023.AJUSTES:Centro colorrectal terciario.PACIENTES:Los pacientes adultos elegibles para el alta el mismo día con seguimiento remoto posterior al alta incluyeron aquellos con comorbilidades mínimas, que residían cerca del hospital, tenían suficiente apoyo en el hogar y poseían un dispositivo móvil.INTERVENCIONES:Los pacientes fueron dados de alta el día de la cirugía al cumplir con criterios específicos, incluido un control adecuado del dolor, tolerancia a la ingesta oral, movilidad independiente, micción y ausencia de complicaciones. El alta exitosa el mismo día se definió como el alta el día de la cirugía sin visitas no planificadas en las primeras 72 horas.PRINCIPALES MEDIDAS DE RESULTADO:Factores asociados con el alta exitosa o fallida el mismo día después de una cirugía colorrectal mínimamente invasiva.RESULTADOS:Un total de 175 (85,3%) pacientes fueron dados de alta el día de la cirugía y 14 (8%) pacientes tuvieron una visita no planificada dentro de las 72 horas. En total, 161 (78,5%) pacientes se clasificaron como éxito del alta el mismo día y 44 (21,5%) pacientes como fracaso del alta el mismo día. El grupo de fracaso del alta el mismo día tuvo un índice de comorbilidad de Charlson más alto (3,7, 2,8, p = 0,03). La duración media de la estancia hospitalaria (0,8, 3,0, p = 0,00), las complicaciones a los 30 días (10%, 48%, p = 0,00) y los reingresos (8%, 27%, p = 0,00) fueron mayores en el mismo día grupo de fallo de descarga. El análisis de regresión mostró que el alta fallida el mismo día se asoció con mayores comorbilidades (OR 0,79; IC del 95 %: 0,66; 0,95) y tiempo prolongado en la unidad de cuidados postanestésicos (OR 0,99; IC del 95 %: 0,99; 0,99). Las personas que recibieron un bloqueo nervioso regional (OR 4,1; IC del 95 %: 1,2, 14) y aquellos que no consumieron opioides posoperatorios (OR 4,6, IC del 95 %: 1-21) tuvieron más probabilidades de tener éxito en el mismo día -descarga.LIMITACIONES:Estudio unicéntrico.CONCLUSIONES:Nuestros hallazgos indican que las comorbilidades y las estancias prolongadas en la unidad de cuidados postanestésicos se asociaron con el fracaso del alta el mismo día, mientras que los bloqueos nerviosos regionales y los opioides postoperatorios mínimos se relacionaron con el éxito. Estos factores pueden informar investigaciones futuras destinadas a mejorar los protocolos de recuperación de la cirugía colorrectal. (Traducción-Yesenia Rojas-Khalil ).

Enhanced recovery after surgery from 1997 to 2022: a bibliometric and visual analysis

Enhanced recovery after surgery (ERAS) is a multimodal perioperative management concept, but there is no article to comprehensively review the collaboration and impact of countries, institutions, authors, journals, references, and keywords on ERAS from a bibliometric perspective. This study assessed the evolution of clustering of knowledge structures and identified hot trends and emerging topics. Articles and reviews related to ERAS were retrieved through subject search from the Web of Science Core Collection. We used the following strategy: "TS = Enhanced recovery after surgery" OR "Enhanced Postsurgical Recovery" OR "Postsurgical Recoveries, Enhanced" OR "Postsurgical Recovery, Enhanced" OR "Recovery, Enhanced Postsurgical" OR "Fast track surgery" OR "improve surgical outcome". Bibliometric analyses were conducted on Excel 365, CiteSpace, VOSviewer, and Bibliometrics (R-Tool of R-Studio). Totally 3242 articles and reviews from 1997 to 2022 were included. These publications were mainly from 684 journals in 78 countries, led by the United States and China. Kehlet H published the most papers and had the largest number of co-citations. Analysis of the journals with the most outputs showed that most journals mainly cover Surgery and Oncology. The hottest keyword is "enhanced recovery after surgery". Later appearing topics and keywords indicate that the hotspots and future research trends include ERAS protocols for other types of surgery and improving perioperative status, including "bariatric surgery", "thoracic surgery", and "prehabilitation". This study reviewed the research on ERAS using bibliometric and visualization methods, which can help scholars better understand the dynamic evolution of ERAS and provide directions for future research.

A Risk-Prediction Platform for Acute Kidney Injury and 30-Day Readmission After Colorectal Surgery

INTRODUCTION

Few known risk factors for certain surgical complications are prospectively analyzed to ascertain their influence on outcomes. Health systems can use integrated machine-learning-derived algorithms to provide information regarding patients' risk status in real time and pair this data with interventions to improve outcomes. The purpose of this work was to evaluate whether real-time knowledge of patients' calculated risk status paired with a stratified intervention was associated with a reduction in acute kidney injury and 30-d readmission following colorectal surgery.

METHODS

Unblinded, retrospective study, evaluating the impact of an electronic health record-integrated and autonomous algorithm-based clinical decision support tool (KelaHealth, San Francisco, California) on acute kidney injury and 30-d readmission following colorectal surgery at a single academic medical center between January 1, 2020, and December 31, 2020, relative to a propensity-matched historical cohort (2014-2018) prior to algorithm integration (January 11, 2019).

RESULTS

3617 patients underwent colorectal surgery during the control period and 665 underwent surgery during the treatment period; 1437 historical control patients were matched to 479 risk-based patients for the study. Utilization of the risk-based management platform was associated with a 2.5% decrease in the rate of acute kidney injury (11.3% to 8.8%) and 3.1% decrease in rate of readmissions (12% to 8.9%).

CONCLUSIONS

In this study, we found significant reductions in postoperative acute kidney injury (AKI) and unplanned readmissions after the implementation of an algorithm based clinical decision support tool that risk-stratified populations and offered stratified interventions. This opens up an opportunity for further investigation in translating similar risk platform approaches across surgical specialties.

Can Colorectal Surgery Be Performed as an Outpatient Surgery?

The potential to discharge patients safely within the same day after colorectal surgery has developed over time with concurrent advances in concepts of enhanced recovery pathways, along with minimally invasive techniques available to surgeons. The advent of planned same-day discharges after elective colectomy is made possible by research establishing improved length of stay with minimal morbidity in patients undergoing minimally invasive surgery and especially minimally invasive surgery in the setting of an enhanced recovery after surgery (ERAS) protocol. In tracing the timeline of research and development of knowledge in this setting, the safety of outpatient colorectal surgery can be established.

Meta-Analysis of Enhanced Recovery After Surgery Protocols for the Perioperative Management of Pediatric Colorectal Surgery

OBJECTIVE

This meta-analysis aimed to investigate the effects and safety of enhanced recovery after surgery (ERAS) for the management of pediatric colorectal surgery.

METHODS

We retrieved relevant studies from PubMed, EMBASE, the Cochrane Library, and China National Knowledgement Infrastructure (CNKI) from its inception until 20 May 2022. Meta-analysis was performed using RevMan 5.4, and power analysis was calculated using G∗Power 3.1.

RESULTS

Ten studies involving 1298 patients were included for meta-analysis. Meta-analysis suggested that ERAS protocol significantly lessened intraoperative fluids (mean difference [MD], -3.11; 95% confidence interval, -4.99 to -1.22) and postoperative opioid usage (MD, -0.58; 95% CI, -1.08 to -0.26), shortened time to bowel return (MD, -12.02; 95% CI, -20.03 to -4.02), first enteral nutrition (MD, -20.88; 95% CI, -28.34 to -13.42) and oral intake (MD, -1.40; 95% CI, -1.96 to -0.84), lowered readmission rate in 30 days (relative risk [RR], 0.61, 95% CI, 0.41 to 0.90), shortened length of hospital stay (MD, -1.50; 95% CI, -1.25 to -1.09), and reduced in-hospital costs (MD, -0.26; 95% CI, -0.34 to -0.18); however, there was a comparable rate of postoperative complications between the two groups. Sensitivity analysis significantly changed the result of the readmission rate in 30 days. The statistical power of all outcomes ranged from 26.84% to 99.44%.

CONCLUSIONS

Our findings demonstrate the beneficial role of the ERAS protocol in accelerating rehabilitation, shortening the length of hospital stay, and decreasing in-hospital costs among pediatric patients undergoing colorectal surgery.

LEVELS OF EVIDENCE

LEVEL V.

Enhanced Recovery After Surgery (ERAS) Protocols for Improving Outcomes for Patients Undergoing Major Colorectal Surgery

Enhanced Recovery After Surgery (ERAS) protocols have gained recognition as a perioperative care approach for patients undergoing major colorectal surgery. This systematic review aims to evaluate the effects of ERAS protocols on outcomes in this patient population. A systematic search was conducted in PubMed, Cochrane Library, and Embase databases for studies published between January 2010 and September 2021. Inclusion criteria encompassed studies assessing the impact of ERAS protocols on patients undergoing major colorectal surgery. Data were extracted, and a qualitative synthesis of the included studies was performed. A total of 18 studies met the inclusion criteria. The implementation of ERAS protocols was associated with several positive outcomes. Compared to traditional care, ERAS protocols significantly reduced the length of hospital stay (mean difference [MD]: -1.64 days, 95% confidence interval [CI]: -2.21 to -1.08, p<0.00001), postoperative complications (odds ratio [OR]: 0.57, 95% CI: 0.46 to 0.71, p<0.00001), and readmission rates (OR: 0.57, 95% CI: 0.38 to 0.85, p=0.006). ERAS protocols also led to a shorter time to return of bowel function (MD: -0.74 days, 95% CI: -1.03 to -0.45, p<0.00001), time to first mobilization (MD: -0.55 days, 95% CI: -0.82 to -0.28, p<0.0001), and time to first oral intake (MD: -0.62 days, 95% CI: -0.95 to -0.28, p=0.0003). Additionally, patients reported higher satisfaction levels with the implementation of ERAS protocols (MD: 1.02, 95% CI: 0.19 to 1.86, p=0.02). This systematic review demonstrates that the implementation of ERAS protocols in major colorectal surgery is associated with improved outcomes. ERAS protocols lead to reduced hospital stays, lower postoperative complications, and decreased readmission rates. Furthermore, they facilitate faster recovery of bowel function, mobilization, and oral intake. Patients also express higher satisfaction levels with ERAS implementation. Healthcare providers should consider adopting ERAS protocols to optimize perioperative care in patients undergoing major colorectal surgery.

Same-day discharge (SDD) vs standard enhanced recovery after surgery (ERAS) protocols for major colorectal surgery: a systematic review

BACKGROUND

Enhanced recovery after surgery (ERAS) programs are well-established, resulting in improved outcomes and shorter length of hospital stay (LOS). Same-day discharge (SDD), or "hyper-ERAS", is a natural progression of ERAS. This systematic review aims to compare the safety and efficacy of SDD against conventional ERAS in colorectal surgery.

METHODS

The protocol was prospectively registered in PROSPERO (394793). A systematic search was performed in major databases to identify relevant articles, and a narrative systematic review was performed. Primary outcomes were readmission rates and length of hospital stay (LOS). Secondary outcomes were operative time and blood loss, postoperative pain, morbidity, nausea or vomiting, and patient satisfaction. Risks of bias was assessed using the ROBINS-I tool.

RESULTS

Thirteen studies were included, with five single-arm and eight comparative studies, of which one was a randomised controlled trial. This comprised a total of 38,854 patients (SDD: 1622; ERAS: 37,232). Of the 1622 patients on the SDD pathway, 1590 patients (98%) were successfully discharged within 24 h of surgery. While most studies had an overall low risk of bias, there was considerable variability in inclusion criteria, types of surgery or anaesthesia, and discharge criteria. SDD resulted in a significantly reduced postoperative LOS, without increasing risk of 30-day readmission. Intraoperative blood loss and postoperative morbidity rates were comparable between both groups. Operative duration was shorter in the SDD group. Patient-reported satisfaction was high in the SDD cohort.

CONCLUSION

SDD protocols appear to be safe and feasible in selected patients undergoing major colorectal operations. Randomised controlled trials are necessary to further substantiate these findings.

ERAS programme in a Portuguese tertiary hospital: An audit of the first six months of implementation in elective colorectal surgery

INTRODUCTION AND OBJECTIVES

Enhanced Recovery After Surgery (ERAS) is a multimodal strategy designed to optimize postoperative recovery and reduce morbidity, length of hospital stay, and care costs. The aim of this study was to evaluate compliance and clinical outcomes 6 months of implementation of the program in scheduled colorectal surgery in a tertiary hospital.

MATERIAL AND METHODS

Data from 209 patients who underwent elective colorectal surgery were analysed. The first 102 patients (pre-ERAS group) who underwent surgery between January and May 2018, before the implementation of the program, were compared with the 107 patients treated between May and October 2019, after ERAS implementation. The main outcomes were patient education and counselling, use of intravenous fluids, early mobilization, incidence of postoperative nausea and vomiting, return of bowel function, length of stay, complications, mortality, and overall compliance.

RESULTS

The ERAS program was associated with a significant increase in patient education and counselling (p<0.001) and with a significant reduction in intra- and postoperative IV fluid administration (p=0.007 and p<0.001, respectively) and postoperative nausea or vomiting (17.6% vs 5.0%, p=0.007). Time to recovery of activities of daily living (5.29 vs 2.85 days; p<0.001), time to solid oral intake (6.21 vs 4.35 days; p<0.001), time to first flatus (2.41 vs 1.51 days; p<0.001) and defecation (3.35 vs 1.66 days; p<0.001) decreased with ERAS. There were no statistically significant differences in length of stay, complications, and mortality.

CONCLUSION

This study showed that the ERAS program improved perioperative outcomes and postoperative recovery in patients undergoing colorectal surgery in our hospital.

Enhanced recovery after colorectal surgery is a safe and effective pathway for older patients: a pooling up analysis

PURPOSE

The current study aimed to explore the efficacy and safety of Enhanced Recovery after surgery (ERAS) in older patients undergoing colorectal surgery.

METHODS

Three databases including PubMed, Embase, Medline, and the Cochrane Library were used for searching eligible studies on Jun 8^th,2022. To evaluate the effect of ERAS, we focused on the short-term outcomes including postoperative complications and recovery. Subgroup analysis was also conducted for patients undergoing colorectal cancer (CRC) surgery. All the data processing and analyses were carried out by Stata (V.16.0) software.

RESULTS

Finally, there were fourteen studies involving 5961 patients enrolled in this study. As for surgical outcomes, we found that the older group had more overall complications (OR = 1.41, I² = 36.59%, 95% CI = 1.20 to 1.65, P = 0.00), more obstruction (OR = 1.462, I² = 0.00%, 95% CI = 1.037 to 2.061, P = 0.0304), more respiratory complications (OR = 1.721, I² = 0.00%, 95% CI = 1.177 to 2.515, P = 0.0051), more cardiovascular complications (OR = 3.361, I² = 57.72%, 95% CI = 1.072 to 10.542, P = 0.0377), more urinary complications (OR = 1.639, I² = 37.63%, 95% CI = 1.168 to 2.299, P = 0.0043), less readmission (OR = 0.662, I² = 44.48%, 95% CI = 0.484 to 0.906, P = 0.0100), higher mortality (OR = 0.662, I² = 44.48%, 95% CI = 0.484 to 0.906, P = 0.0100), and longer overall survival (OS) (HR = 1.21, I² = 0.00%, 95% CI = 0.566 to 1.859, P = 0.0002)). Subgroup analysis also found that older CRC patients had a higher risk of overall complications (OR = 1.37, I² = 37.51%, 95% CI = 1.06 to 1.78, P < 0.05).

CONCLUSION

Although ERAS could accelerate postoperative recovery and reduce postoperative complications, older patients who received ERAS still had higher complication incidence than younger patients. Although the proportion of re-hospitalizations was lower and the OS was better, doctors could not rely too much on ERAS. More measures were needed to improve the outcomes of colorectal surgery in older patients.

Real-World Evidence: How Long Do Our Patients Fast?-Results from a Prospective JAGO-NOGGO-Multicenter Analysis on Perioperative Fasting in 924 Patients with Malignant and Benign Gynecological Diseases

BACKGROUND

Despite the key role of optimized fasting in modern perioperative patient management, little current data exist on perioperative fasting intervals in routine clinical practice.

METHODS

In this multicenter prospective study, the length of pre- and postoperative fasting intervals was assessed with the use of a specifically developed questionnaire. Between 15 January 2021 and 31 May 2022, 924 gynecology patients were included, from 13 German gynecology departments.

RESULTS

On average, patients remained fasting for about three times as long as recommended for solid foods (17:02 ± 06:54 h) and about five times as long as recommended for clear fluids (9:21 ± 5:48 h). The average perioperative fasting interval exceeded one day (28:23 ± 14:02 h). Longer fasting intervals were observed before and after oncological or extensive procedures, while shorter preoperative fasting intervals were reported in the participating university hospitals. Smoking, treatment in a non-university hospital, an increased Charlson Comorbidity Index and extensive surgery were significant predictors of longer preoperative fasting from solid foods. In general, prolonged preoperative fasting was tolerated well and quality of patient information was perceived as good.

CONCLUSION

Perioperative fasting intervals were drastically prolonged in this cohort of 924 gynecology patients. Our data indicate the need for better patient education about perioperative fasting.

Enhanced Recovery after Surgery (ERAS) Program for Patients with Peritoneal Surface Malignancies Undergoing Cytoreductive Surgery with or without HIPEC: A Systematic Review and a Meta-Analysis

Enhanced recovery after surgery (ERAS) program refers to a multimodal intervention to reduce the length of stay and postoperative complications; it has been effective in different kinds of major surgery including colorectal, gynaecologic and gastric cancer surgery. Its impact in terms of safety and efficacy in the treatment of peritoneal surface malignancies is still unclear. A systematic review and a meta-analysis were conducted to evaluate the effect of ERAS after cytoreductive surgery with or without HIPEC for peritoneal metastases. MEDLINE, PubMed, EMBASE, Google Scholar and Cochrane Database were searched from January 2010 and December 2021. Single and double-cohort studies about ERAS application in the treatment of peritoneal cancer were considered. Outcomes included the postoperative length of stay (LOS), postoperative morbidity and mortality rates and the early readmission rate. Twenty-four studies involving 5131 patients were considered, 7 about ERAS in cytoreductive surgery (CRS) + HIPEC and 17 about cytoreductive alone; the case histories of two Italian referral centers in the management of peritoneal cancer were included. ERAS adoption reduced the LOS (-3.17, 95% CrI -4.68 to -1.69 in CRS + HIPEC and -1.65, 95% CrI -2.32 to -1.06 in CRS alone in the meta-analysis including 6 and 17 studies respectively. Non negligible lower postoperative morbidity was also in the meta-analysis including the case histories of two Italian referral centers. Implementation of an ERAS protocol may reduce LOS, postoperative complications after CRS with or without HIPEC compared to conventional recovery.

A retrospective analysis of early discharge following minimally invasive colectomy in an enhanced recovery pathway

BACKGROUND

There is increasing evidence to support discharge prior to gastrointestinal recovery following colorectal surgery. Furthermore, many patients are discharged early despite being excluded from an ambulatory colectomy pathway. The objective of this study was to determine the outcomes of patients discharged early following laparoscopic colectomy in an enhanced recovery pathway (ERP).

METHODS

A retrospective review of all adult patients undergoing elective laparoscopic colectomy at a single university-affiliated colorectal referral center (08/2017-06/2021) was performed. Patients were included if they had undergone elective laparoscopic colectomy or ileostomy closure and excluded if they had been enrolled in an ambulatory colectomy pathway. Patients were then divided into three groups: LOS =1 day, LOS 2-3 days, and LOS 4+ days. The main outcomes were 30-day emergency room (ER) visits and readmissions. Reasons for inpatient stay per post-operative day (POD) were also recorded.

RESULTS

A total of 497 patients were included [LOS1 n = 63 (13%), LOS2-3 n = 284 (57%), and LOS4+ n = 150 (30%)]. There were no differences in patient characteristics, diagnosis, or procedure between the groups. Patients were discharged with gastrointestinal recovery (GI-3) in 54% LOS1 vs. 98% LOS2-3 vs. 100% LOS4+ (p<0.001). Shorter procedure duration, transversus abdominus plane block, and lower opioid requirements were associated with shorter LOS (p<0.001). The absence of flatus was the most common reason to keep patients hospitalized: 61% on POD1, 21% on POD2, and 8% on POD3 (p<0.001). There were no differences in 30-day emergency visits, or readmission between the groups. In the LOS1 group, there were no differences in outcomes between patients with full return of bowel function at discharge compared to those without.

CONCLUSION

Discharge on POD1 was not associated with increased emergency department use, complications, or readmissions. Importantly, full return of bowel function at discharge did not affect outcomes. There may be potential to expand eligibility criteria for ambulatory colectomy protocol.

North American multicentre evaluation of a same-day discharge protocol for minimally invasive colorectal surgery using mHealth or telephone remote post-discharge monitoring

BACKGROUND

Same-day discharge (SDD) after colectomy is feasible but requires effective post-discharge remote follow-up. Previous studies have used in-person home visits or a mobile health (mHealth) phone app, but the use of simple telephone calls for remote follow-up has not yet been studied. Therefore, the objective of this study was to compare outcomes after SDD for minimally invasive colectomy using mHealth or telephone remote post-discharge follow-up.

METHODS

A prospective cohort study was undertaken at two university-affiliated colorectal referral institutions from 02/2020 to 05/2021. Adult patients without significant comorbidities undergoing elective minimally invasive colectomy. Patients were discharged on the day of surgery based on set criteria. Post-discharge remote follow-up was performed using a mHealth app at site 1 and scheduled telephone calls at site 2 up to postoperative day (POD) 7. The main outcome for this study was the success rate of SDD, defined as discharge on POD0 without emergency department (ED) visit or readmission within the first 3 days.

RESULTS

A total of 105 patients were recruited (site 1, n = 70; site 2, n = 35). Overall, 75% of patients were discharged on POD0 (site 1 81% vs. site 2 63%, p = 0.038), of which only two patients required an ED visit within the first 3 days, leading to an overall success rate of 73% (site 1 80% vs. site 2 60%, p = 0.029). The incidence of 30-day complications (16% vs. 20%, p = 0.583), ED visits (11% vs. 11%, p = 1.00), and readmissions (9% vs. 14%, p = 0.367) were similar between the two sites. There was only one patient at each study site that went to the ED without instructions through remote follow-up.

CONCLUSIONS

A high proportion of patients planned for SDD were discharged on POD0 with few patients requiring an early unplanned ED visit. These results were similar with an mHealth app or telephone calls for post-discharge remote follow-ups, suggesting that SDD is feasible regardless of the method of post-discharge remote follow-up.

Tolerating clear fluids diet on postoperative day 0 predicts early recovery of gastrointestinal function after laparoscopic colectomy

INTRODUCTION

A high proportion of colorectal surgery patients within an enhanced recovery pathway (ERP) do not experience complications but remain hospitalized mainly waiting for gastrointestinal (GI) recovery. Accurate identification of these patients may allow discharge prior to the return of GI function. Therefore, the objective of this study is to determine if tolerating clear fluid (CF) on postoperative day (POD) 0 was associated with uncomplicated return of GI function after laparoscopic colorectal surgery.

METHODS

Pooled data from three prospective studies from a single specialist colorectal referral center were analyzed (2013-2019). The present study included adult patients that underwent elective laparoscopic colectomy without stoma. Postoperative GI symptoms were collected daily in all three datasets. The main exposure variable, whether CF diet was tolerated on POD0, was defined as patients drinking at least 300 mL of CF without any nausea, anti-emetics, or vomiting (CF+ vs CF-). The main outcome measure was time to GI-3 (tolerating solid diet and passage of gas or stools).

RESULTS

A total of 221 patients were included in this study, including 69% CF+ and 31% CF-. The groups were similar in age, gender, and comorbidities, but the CF- patients were more likely to have surgery for inflammatory bowel disease. CF+ patients had faster time to GI-3 (mean 1.6d (SD 0.7) vs. 2.3d (SD 1.5), p < 0.001). The CF+ group also experienced fewer complications (19% vs. 35%, p = 0.009), shorter mean LOS (mean 3.6d (SD 2.9) vs. 6.2d (SD 9.4), p = 0.002), and were more likely to be discharged by the target LOS (66% vs. 50%, p = 0.024).

CONCLUSION

Toleration of CF on POD0 was associated with faster return of GI function, fewer complications, and shorter LOS. This may be used as a criteria for potential discharge prior to full return of GI function after laparoscopic colectomy within an ERP.

Association between Pre-Operative 25-Hydroxy Vitamin D Deficiency and Surgical Site Infection after Right Hemicolectomy Surgery

Background: Surgical site infection (SSI) is one of the most important and costly complications of surgical operations. The present study hypothesized that vitamin D deficiency is associated with an increased risk of SSI, and this current study investigated this hypothesis. Patients and Methods: A prospective cohort study was performed with adult patients undergoing open right hemicolectomy operation with stapled anastomosis between February 2018 and March 2021 in the surgery ward of Imam Khomeini hospital. A logistic regression test examined and analyzed the connection between serum 25-OH vitamin D levels and post-operative wound infections. Results: This study comprised 315 participants who met the inclusion criteria. Pre-operative serum vitamin D levels were <30 ng/mL in 107 participants (34%) and ≥30 ng/mL in 208 participants (66%). The mean serum vitamin D level was 35.66 ± 13.26 ng/mL among the study population. Increased vitamin D deficiency was linked with elevated odds of surgical wound infection incidence among the patients after surgery (odds ratio [OR], 5.49; 95% confidence interval [CI], 2.06-14.6; p = 0.001). Conclusions: Pre-operative vitamin D level strongly affects post-operative SSI in patients with colon cancer. This study highlighted the importance of conducting further research to determine the possible advantages of vitamin D in preventing incision infection after surgery.

The outcome of enhanced recovery after surgery vs. a traditional pathway in adolescent idiopathic scoliosis surgery: A retrospective comparative study

Objectives

Methods

Results

Conclusions

A steady stream of knowledge: decreased urinary retention after implementation of ERAS protocols in ambulatory minimally invasive inguinal hernia repair

BACKGROUND

Potential complications after inguinal hernia repair include uncontrolled post-operative pain and post-operative urinary retention (POUR). Enhanced Recovery After Surgery (ERAS) protocols aim to mitigate post-operative morbidity. We study the impact of ERAS measures alongside discharge without a narcotic prescription on post-operative pain and POUR after minimally invasive inguinal hernia repair.

METHODS

A retrospective review of a prospectively maintained database identified patients that underwent minimally invasive inguinal hernia repair at a single institution. Intra-operative data included operative time, narcotic usage, non-narcotic adjunct medication, and fluid administration. Primary outcomes included rates of POUR and uncontrolled post-operative pain. Operations performed after 2018 were included in the ERAS cohort. Uncontrolled post-operative pain was defined as needing additional narcotic prescriptions, admission, or ER visits for post-operative pain. POUR was defined as requiring an indwelling urethral catheter at discharge, admission for retention, or returning to the ER for urinary retention.

RESULTS

Between January 2008 and March 2021, 1097 patients who underwent minimally invasive inguinal hernia repair were identified. 91.3% of these procedures were laparoscopic and 8.7% were robotic. Average patient age was 57.4 years, 93% were male. Patients receiving care after initiation of the ERAS protocol were significantly less likely to experience POUR when compared to their prior counterparts (1.4% vs. 4.2% p = 0.01); there was no difference in post-operative pain complications (1.4% vs. 2.9% p = 0.15). Patients who were discharged without a narcotic prescription had 0% incidence of POUR. Significant differences were found between the ERAS and non-ERAS cohort regarding narcotic usage and fluid administration. Age, higher fluid volume, and higher narcotic usage were found to be risk factors for POUR while ERAS, sugammadex, and dexamethasone were found to be protective.

CONCLUSION

Implementation of an ambulatory ERAS protocol can significantly decrease urinary retention and narcotic usage rates after minimally invasive inguinal hernia repair.

The Impact of Surgical Techniques in Patients with Rectal Cancer on Spine Mobility and Abdominal Muscle Strength-A Prospective Study

The aim of this non-randomized study was to evaluate the impact of spine joint mobility and chest mobility on inhalation and exhalation, and to assess the abdominal muscle strength in patients undergoing surgery for colorectal cancer with one of the following methods: anterior resection, laparoscopic anterior resection or abdominoperineal resection. In patients who were successively admitted to the Department of Surgical Oncology at the Oncology Center in Bydgoszcz, the impact of spine joint mobility, muscle strength and chest mobility on inhalation and exhalation wasassessed three times, i.e., at their admission and three and six months after surgery. The analysis included 72 patients (18 undergoing abdominoperineal resection, the APR group; 23 undergoing laparoscopic anterior resection, the LAR group; and 31 undergoing anterior resection, the AR group). The study groups did not differ in terms of age, weight, height, BMIor hospitalization time (p > 0.05). Three months after surgery, reductions in spine joint mobility regarding flexion, extension and lateral flexion, as well asreductions in the strength of the rectus abdominis and oblique muscles, were noted in all study groups (p < 0.05). In comparison between the groups, the lowest values suggesting the greatest reduction in the range of mobility were recorded in the APR group. Surgical treatment and postoperative management in colorectal cancer patients caused a reduction in spine mobility, abdominal muscle strength and chest mobility. The patients who experienced those changes most rapidly and intensively werethose undergoing abdominoperineal resection.

Enhanced Recovery After Surgery Pathway in Kidney Transplantation: The Road Less Traveled

Enhanced recovery after surgery (ERAS) pathway is a multimodal perioperative care pathway designed to achieve early recovery after surgery. ERAS protocols have not yet been well recognized in kidney transplantation. The aim of this study was to investigate the impact of ERAS pathway on early recovery and short-term clinical outcomes of kidney transplant.

"Optimal recovery" after colon cancer surgery in the elderly, a comparative cohort study: Conventional care vs. enhanced recovery vs. prehabilitation

BACKGROUND

Colon cancer in elderly patients is an increasing problem due to its prevalence and progressive aging population. Prehabilitation has experienced a great grown in this field. Whether it is the best standard of care for these patients has not been elucidated yet.

METHODS

A retrospective comparative cohort study of three different standards of care for elderly colon cancer patients (>65 years) was conducted. A four-weeks trimodal prehabilitation program (PP), enhanced recovery program (ERP) and conventional care (CC) were compared. Global complications, major complications (Clavien-Dindo ≥ 3), reinterventions, mortality, readmission and length of stay were measured. Optimal recovery, defined as postoperative course without major complications, no mortality, hospital discharge before the fifth postoperative day and without readmission, was the primary outcome measure. The influence of standard of care in optimal recovery and postoperative outcomes was assessed with univariate and multivariate logistic regression models.

RESULTS

A total of 153 patients were included, 51 in each group. Mean age was 77.9 years. ASA Score distribution was different between groups (ASA III-IV: CC 56.9%, ERP 25.5%, PP 58.9%; p = 0.014). Optimal recovery rate was 55.6% (PP 54.9%, ERP 66.7%, CC 45.1%; p = 0.09). No differences were found in major complications (p = 0.2) nor reinterventions (p = 0.7). Uneventful recovery favors ERP and PP groups (p = 0.046 and p = 0.049 respectively).

CONCLUSIONS

PP and ERP are safe and effective for older colon cancer patients. Fewer overall complications and readmissions happened in ERP and PP patients. Major complications were independent of the standard of care used.

What is related to postoperative outcome of frail status in elective colorectal cancer surgery?

Background

The population affected by colorectal cancer is growing, and there is an increasing need for prevention of functional decline following treatment. We proposed that the Kihon Checklist published by the Japanese Ministry of Health, Labor, and Welfare would be an appropriate means of frailty assessment for prediction of postoperative complications in older patients with colorectal cancer. This prospective cohort study aims to identify the factors influencing postoperative frailty.

Methods

We prospectively enrolled consecutive patients with colorectal cancer and aged ≥ 65 year (N = 500) between May 2017 and December 2018. Eligible patients were assessed with the Kihon Checklist prior to surgery and 30 days after surgery. The main measures were variables related to postoperative change in view of frail status.

Results

According to the Kihon Checklist questionnaire, 164 patients were frail preoperatively and 172 patients were frail postoperatively, whereas 38 patients changed from "nonfrail" before surgery to postoperative "frail." Overall complications were counted in 97 patients (19.4%), and 5 patients died. Performance status ≥ 2, history of laparotomy, open surgery, complication, ostomy creation, and delirium were significantly associated with changing postoperative "frail" (P = .014, P = .023, P = .006, P < .001, P = .023, and P = .024, respectively). In multivariate analysis, independent related factors of changing postoperative "frail" were complication (odds ratio 2.69, 95% confidence interval 1.19–6.09, P = .018) and ostomy creation (odds ratio 2.32, 95% confidence interval 1.01–5.33, P = .047).

Conclusion

The Kihon Checklist questionnaire could identify the factors related to postoperative change of frailty status in older patients with colorectal cancer. This cohort concluded that whether postoperative complication occurred or not was closely associated with perioperative change of frailty status.

•

Our prospective cohort study examined the factor influencing postoperative frailty in older patients with colorectal cancer by Kihon Checklist questionnaire.

•

The importance of this study is that postoperative complication and ostomy creation were significantly associated with postoperative change of frailty status.

[Medical oncological treatment of colorectal cancer in the elderly]

Approximately a quarter of patients undergoing colorectal cancer surgery are over 75 years of age. Their care must therefore be adapted to minimise his functional consequences, which can be more significant in an elderly patient.

Patient, Surgeon, or Hospital: Explaining Variation in Outcomes after Colectomy

BACKGROUND

Complication rates after colectomy remain high. Previous work has failed to establish the relative contribution of patient comorbidities, surgeon performance, and hospital systems in the development of complications after elective colectomy.

STUDY DESIGN

We identified all patients undergoing elective colectomy between 2012 and 2018 at hospitals participating in the Michigan Surgical Quality Collaborative. The primary outcome was development of a postoperative complication. We used risk- and reliability-adjusted generalized linear mixed models to estimate the degree to which variance in patient-, surgeon-, and hospital-level factors contribute to complications.

RESULTS

A total of 15,755 patients were included in the study. The mean hospital-level complication rate was 15.8% (range, 8.7% to 30.2%). The proportion of variance attributable to the patient level was 35.0%, 2.4% was attributable to the surgeon level, and 1.8% was attributable to the hospital level. The predicted probability of complication for the least comorbid patient was 1.5% (CI 0.7-3.1%) at the highest performing hospital with the highest performing surgeon, and 6.6% (CI 3.2-12.2%) at the lowest performing hospital with the lowest performing surgeon. By contrast, the most comorbid patient in the cohort had a 66.3% (CI 39.5-85.6%) or 89.4% (CI 73.7-96.2%) risk of complication.

CONCLUSIONS

This study demonstrated that variance from measured factors at the patient level contributed more than 8-fold more to the development of complications after colectomy compared with variance at the surgeon and hospital level, highlighting the impact of patient comorbidities on postoperative outcomes. These results underscore the importance of initiatives that optimize patient foundational health to improve surgical care.

Rapid rehabilitation effect on complications, wound infection, anastomotic leak, obstruction, and hospital re-admission for gastrointestinal surgery subjects: A meta-analysis

We performed a meta‐analysis to evaluate the effect of rapid rehabilitation on the curative effect of gastrointestinal surgery subjects. A systematic literature search up to October 2021 was done and 31 studies included 4448 subjects with gastrointestinal surgery at the start of the study: 2242 of them were provided with rapid rehabilitation and 2206 were standard care. They were reporting relationships about the effect of rapid rehabilitation on the curative effect of gastrointestinal surgery subjects. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) to assess the effect of rapid rehabilitation on the curative effect of gastrointestinal surgery subjects using the dichotomous method with a random‐ or fixed‐effect model. Rapid rehabilitation had significantly lower complications (OR, 0.62; 95% CI, 0.54‐0.71, P < .001) and wound infection (OR, 0.73; 95% CI, 0.55‐0.98, P = .03) compared with standard care in subjects with gastrointestinal surgery. However, rapid rehabilitation had no significant effect on the anastomotic leak (OR, 0.90; 95% CI, 0.66‐1.22, P = .49), obstruction (OR, 0.92; 95% CI, −0.64 to 1.31, P = .65), and hospital re‐admission (OR, 0.78; 95% CI, 0.57‐1.08, P = .13) compared with standard care in subjects with gastrointestinal surgery. Rapid rehabilitation had significantly lower complications and wound infection, and had no significant effect on the anastomotic leak, obstruction, and hospital re‐admission compared with standard care in subjects with gastrointestinal surgery. Further studies are required to validate these findings.

Does deep neuromuscular blockade provide improved outcomes in low pressure laparoscopic colorectal surgery? A single blinded randomized pilot study

BACKGROUND

Low intra-abdominal pressure during laparoscopic colorectal surgery may improve outcomes and reduce hospital stay, in addition to Enhanced Recovery After Surgery (ERAS) protocols. There is concern that low pressure reduces laparoscopic vision and may increase surgical complications. Deep neuromuscular blockade may abrogate any reduction in vision of low-pressure pneumoperitoneum. However, antagonism of deep neuromuscular blockade at completion of surgery necessitates the use of sugammadex, which is prohibitively expensive, if there are no surgical benefits and warrants further study.

METHODS

A single institution, single blinded randomized controlled pilot study was performed comparing deep to moderate neuromuscular blockade in major laparoscopic colorectal surgery.

RESULTS

Thirty-eight patients were randomized to deep or moderate neuromuscular blockade. There were no statistically significant differences between groups, when comparing key patient demographics, or surgeon satisfaction with view, which required increased pressure or further relaxation demands. The deep blockade group had increased QoR15 scores and a decrease in pain, C-Reactive Protein (CRP) measurements and operating times, although were non-significant. The moderate group had slightly higher incidents of Medical Emergency Team (MET) calls and more severe complications, although were non-significant.

CONCLUSIONS

Low intra-abdominal pressure in laparoscopic colorectal surgery is feasible and allows adequate surgical visualization, regardless of the degree of neuromuscular blockade. Potential benefits of deep neuromuscular blockade may include improved pain and quality of recovery and a possible reduction of complications; however a larger cohort is required to confirm this. Future ERAS protocols may consider deep neuromuscular blockade with low intra-abdominal pressure to further benefit patients.

Insufficient Post-operative Energy Intake Is Associated With Failure of Enhanced Recovery Programs After Laparoscopic Colorectal Cancer Surgery: A Prospective Cohort Study

Background: Although enhanced recovery after surgery (ERAS) has been proven to be beneficial after laparoscopic colorectal surgery, some of the patients may fail to complete the ERAS program during hospitalization. This prospective study aims to evaluate the risk factors associated with ERAS failure after laparoscopic colorectal cancer surgery.

Methods: This is a prospective study from a single tertiary referral hospital. Patients diagnosed with colorectal cancer who met the inclusion criteria were included in this study. Demographic and clinicopathological characteristics were collected. Post-operative activity time and 6-min walking distance (6MWD) were measured. Patients were divided into ERAS failure group and ERAS success according to decreased post-operative activity and 6MWD. Factors associated with ERAS failure were investigated by univariate and multivariate analysis.

Results: A total of 91 patients with colorectal cancer were included. The incidence of ERAS failure is 28.6% among all patients. Patients in ERAS failure group experienced higher rate of post-operative ileus and prolonged hospital stay (p < 0.001). Multivariate analysis revealed that older age (p = 0.006), body mass index ≥25.5 kg/m² (p = 0.037), smoking (p = 0.002), operative time (p = 0.048), and post-operative energy intake <18.5 kcal/kg•d (p = 0.045) were independent risk factors of ERAS failure after laparoscopic colorectal surgery.

Conclusions: Our findings indicated that a proportion of patients may fail the ERAS program after laparoscopic colorectal surgery. We for the first time showed that post-operative energy intake was an independent risk factor for ERAS failure. This may provide evidence for further investigation on precise measurement of nutritional status and selected high-risk patients for enhanced nutrition support.

Effects of the Enhanced Recovery After Surgery (ERAS) Program for Colorectal Cancer Patients Undergoing Laparoscopic Surgery

This study sought to investigate the effects of the enhanced recovery after surgery (ERAS) program on postoperative recovery and nutritional status in patients with colorectal cancer undergoing laparoscopic surgery. A total of 37 patients were included: 19 in the experimental group and 18 in the control group. The experimental group was supplemented with carbohydrate drinks before and after surgery, and the control group was maintained with fasting and water intake in the traditional method. Both care management and nutrition education were implemented for both groups. Patients were evaluated for physical condition, clinical indicators, blood tests, pain, length of stay, nutritional status, and nutrient intake. Use of the ERAS program for the experimental group resulted in shorter length of stay (p = 0.006), less pain (p < 0.001), and a lower rate of malnutrition (p = 0.014) compared with controls. In conclusion, carbohydrate drinks provide great advantages by reducing discomfort, such as pain or thirst, during fasting in patients after colon cancer surgery, helping patients to eat comfortably and actively, minimizing insulin resistance, maintaining nitrogen balance, and reducing infection and anastomosis leakage. For use of ERAS as a standardized program, repeated and expanded research is needed, and a Korean-style ERAS should be prepared by using this approach for various diseases.

Factors Predicting Increased Length of Stay in Abdominal Wall Reconstruction

BACKGROUND

Enhanced recovery after surgery (ERAS) programs have become increasingly popular in general surgery, yet no guidelines exist for an abdominal wall reconstruction (AWR)-specific program. We aimed to evaluate predictors of increased length of stay (LOS) in the AWR population to aid in creating an AWR-specific ERAS protocol.

METHODS

A prospective, single institution hernia center database was queried for all patients undergoing open AWR (1999-2019). Standard statistical methods and linear and logistic regression were used to evaluate for predictors of increased LOS. Groups were compared based on LOS below or above the median LOS of 6 days (IQR = 4-8).

RESULTS

Inclusion criteria were met by 2,505 patients. On average, the high LOS group was older, with higher rates of CAD, COPD, diabetes, obesity, and pre-operative narcotic use (all P < .05). Longer LOS patients had more complex hernias with larger defects, higher rates of mesh infection/fistula, and more often required a component separation (all P < .05). Multivariate analysis identified age (β0.04,SE0.02), BMI (β0.06,SE0.03), hernia defect size (β0.003,SE0.001), active mesh infection or mesh fistula (β1.8,SE0.72), operative time (β0.02,SE0.002), and ASA score >4 (β3.6,SE1.7) as independently associated factors for increased LOS (all P < .05). Logistic regression showed that an increased length of stay trended toward an increased risk of hernia recurrence (P = .06).

CONCLUSIONS

Multiple patient and hernia characteristics are shown to significantly affect LOS, which, in turn, increases the odds of AWR failure. Weight loss, peri-operative geriatric optimization, prehabilitation of comorbidities, and operating room efficiency can enhance recovery and shorten LOS following AWR.

Predictive factors of high comprehensive complication index in colorectal cancer patients using Enhanced Recovery After Surgery protocol: role as a safety net in early discharge

Purpose

This study was performed to evaluate complications using comprehensive complication index (CCI) in colorectal cancer patients with implementation of the Enhanced Recovery After Surgery (ERAS) protocol, and to investigate the predictive factors associated with high morbidity rates. It can be used as a safety net in determining the timing of discharge.

Methods

A total of 335 consecutive patients who underwent elective colorectal cancer surgery between January 2017 and December 2017 at a single tertiary center were enrolled. Postoperative complications were defined as occurring within 30 days after surgery. The predictive factor analysis for the high CCI group was also performed.

Results

In total, 116 patients experienced postoperative complications. Wound-related complications and postoperative ileus were the most common. The mean CCI for overall colorectal cancer surgery was 9.1 ± 16.7. Patients featuring low CCI (<26.2) were 297 (88.7%) and high CCI were 38 (11.3%). In multivariable analysis, obstructive colorectal cancer (odds ratio, 3.278; 95% confidence interval, 1.217–8.829; P = 0.019) and CRP value on postoperative day (POD) 3–4 (odds ratio, 1.152; 95% confidence interval, 1.036–1.280; P < 0.010) were significant predictors for high CCI.

Conclusion

The clinical usefulness of CCI in colorectal cancer patients with the ERAS protocol was verified, and it can be used for surgical quality control. More cautious care is needed and the timing of discharge should be carefully determined for patients with obstructive colorectal cancer or POD 3–4 CRP of ≥6.47 mg/dL.

Perception and implementation status of enhanced recovery after surgery

Background: The enhanced recovery after surgery (ERAS) program that is being implemented in Korea is difficult to investigate because it is not a standardized protocol with a unified content, and it instead differs according to the details for each hospital. Herein, the author would like to introduce and analyze the results of a recently conducted large-scale survey on the current status and perception of the ERAS program in Korea among large domestic hospitals.Current Concepts: Surveys of domestic general surgeons in 2019 and hepatobiliary-pancreatic surgeons in 2020 both showed lower-than-expected response rates of less than 50% in questions related to perception and clinical implementation of the ERAS program. Thus, implementation of ERAS items related to the limited application of preoperative fasting and surgical drain insertion and active nutritional support before and after surgery remains low.Discussion and Conclusion: For surgeons in Korea, the implementation of ERAS programs and perception levels were low. In this regard, it is necessary to improve awareness through systematic education and promotion of the ERAS program, and supplementation of related multidisciplinary professional manpower and financial resources is essential to facilitate practical implementation of ERAS programs in clinical practice.

Empiric nasogastric decompression after pancreaticoduodenectomy is not necessary

BACKGROUND

The aim of the present study was to evaluate the impact of routine NGT decompression after PD on postoperative outcomes in the era of an enhanced recovery after surgery (ERAS) protocol.

MATERIALS AND METHODS

A retrospective review of all patients undergoing PD between January 2015 and October 2017 at our institution was performed comparing routine post-operative NGT decompression versus omission. The incidence of delayed gastric emptying, post-operative pancreatic fistula, hospital length of stay, operative time, 30-day readmission rate as well the time to first oral intake were evaluated.

RESULTS

Out of 149 patients who underwent PD, 65 maintained post-operative NGT decompression while post-operative NGT decompression was omitted in 84 patients. No differences were noted in delayed gastric emptying rates (both p>0.05). The median length of stay (9 days for NGT group versus 8.5 days for no NGT group) and 30-day readmission rates (13.8% versus 15.5%, respectively) were similar (p=0.781). Compared with patients who had routine post-operative NGT placed, those who had omission of a post-operative NGT had a lower need for reinsertion, shorter time to PO intake, and a lower likelihood of extended length of stay.

CONCLUSIONS

In the era of ERAS protocols, we observed no association between routine post-operative NGT decompression after PD and improved postoperative outcomes.

Trajectory of gastrointestinal function after laparoscopic colorectal surgery within an enhanced recovery pathway

BACKGROUND

Early identification of colorectal surgery patients predicted to have uneventful gastrointestinal recovery may allow for early discharge. Our objective was to identify trajectories of gastrointestinal recovery within a colorectal surgery enhanced recovery pathway.

METHODS

Data from 2 prospective studies enrolling adult patients undergoing elective laparoscopic colorectal resection at a specialist colorectal referral center were analyzed (2013-2019). All patients were managed according to a mature enhanced recovery pathway with a 3-day target length of stay. Postoperative gastrointestinal symptoms were collected daily and expressed using the validated I-FEED score. Latent-class growth curve (trajectory) analysis was used to identify different I-FEED trajectories over the first 3 postoperative days.

RESULTS

A total of 192 patients were analyzed. Trajectory analysis identified 3 distinct trajectories: trajectory 1 had no gastrointestinal symptoms (41%); trajectory 2 had mild early symptoms with improvement over time (48%); and trajectory 3 had gastrointestinal symptoms that significantly worsened between postoperative days 1 and 2 (11%). I-FEED score ≤1 on postoperative day 1 predicted trajectory 1. Trajectory 1 had the best clinical outcomes, whereas trajectory 3 had the worst.

CONCLUSION

I-FEED trajectory over postoperative days 1-3 was associated with clinical outcomes and may be used to predict gastrointestinal recovery. Findings from this study may inform clinical decision making regarding early hospital discharge within colorectal enhanced recovery pathways.

Cancer-related fatigue and treatment burden in surgically treated colorectal cancer patients - A cross-sectional study

OBJECTIVE

This cross-sectional study aimed to describe cancer-related fatigue (CRF) in colorectal cancer (CRC) patients who were surgically treated with curative intent, identify subgroups at risk of elevated fatigue levels and explore associations between CRF and treatment burden.

BACKGROUND

CRF is a prominent symptom among cancer patients. In patients treated for CRC, CRF is associated with adjuvant treatments, low quality of life and reduced ability to self-manage.

METHODS

One hundred thirty-four patients with CRC treated at a Norwegian university hospital between 2016-2018 were included. The Schwartz Cancer Fatigue Scale-6 and the Patient Experience with Treatment and Self-management questionnaires were applied for data collection. Statistical analyses included descriptive statistics and non-parametric approaches to analyse correlations and identify differences between groups. The study adhered to STROBE Statement checklist for reporting of cross-sectional studies.

RESULTS

Median fatigue level was 10.0 (range: 7.0-13.0). Physical fatigue was higher than perceptual fatigue, with medians of 6.0 (interquartile range [IQR]: 3.0-13.0) and 4.0 (IQR: 3.0-12.0), respectively. Higher fatigue levels were associated with age <60 years, advanced cancer and adjuvant treatments. Increased CRF was significantly associated with higher treatment burden on seven of the nine dimensions, adjusted for demographic and clinical variables. The association of fatigue and treatment burden was stronger in survivors <60 years, with advanced cancer, 6-12 months since surgery or who had more comorbid conditions.

CONCLUSIONS

This study showed patients at risk of experiencing CRF following CRC treatment. It established proof of associations between CRF and treatment burden and identified subgroups of CRC patients where this association was stronger.

RELEVANCE TO CLINICAL PRACTICE

Screening of CRF in CRC patients can help clinicians provide individualized treatment and care to manage CRF. Clinicians should consider the association between CRF and treatment burden, especially in subgroups of CRF patients.

Enhanced Recovery After Surgery: Are Benefits Demonstrated in International Studies Replicable in Pakistan?

Objectives

To determine the efficacy of enhanced recovery after surgery (ERAS) protocols in terms of frequency of surgical site infection (SSI) and length of hospital stay in patients undergoing colorectal surgeries for colorectal carcinoma.

Study design

Quasi-experimental study.

Setting/Duration of study

Department of Surgery, Shifa International Hospital, Islamabad, from May 7, 2019 to November 6, 2019.

Methodology

A total of 120 patients with colorectal carcinomas who fulfilled that sample selection criteria were studied. After randomization, patients were divided into two equal groups; one group received management under ERAS while the second group received conventional management. All patients were recorded for length of hospital stay and the development of SSIs. Data were analyzed using SPSS 26.0.

Results

The mean age was 42.34 ± 14.45 years, with a male majority, i.e., 72 (60%). The mean duration of in-patient stay was 3.45 ± 1.73 days with ERAS and 8.25 ± 1.58 days with conventional management (p < 0.001). A total of 28 (23.3%) SSIs developed, of which nine (7.5%) SSIs occurred with ERAS, while 19 (15.8%) occurred with traditional management (p = 0.031).

Conclusion

ERAS protocols have been demonstrated to be effective, cheap, and safe. There is a tangible reduction in length of hospital stay and incidence of SSIs which translates into reduced utilization of resources and financial costs. However, strict adherence to the protocol may be necessary to obtain the aforementioned benefits, which may be difficult to do in the face of professional, institutional, and personal inertia. Intensive efforts are required to make these protocols more convenient and attractive to implement, so as to facilitate conversion to this management approach.

The association between preoperative 25-OH vitamin D levels and postoperative complications in patients undergoing colorectal cancer surgery

BACKGROUND

Determining the modifiable risk factors for postoperative complications is particularly significant in patients undergoing colorectal surgery since those are associated with worse long-term outcomes.

METHODS

Consecutive newly diagnosed 104 colorectal cancer patients were prospectively included in this single-center observational study. Preoperative serum 25-OH vitamin D levels were measured and analyzed for infectious and postoperative complications.

RESULTS

Serum 25-OH vitamin D levels were found to be < 20 ng/ml in 74 patients (71.2%) and ≥ 20 ng/ml in 30 patients (28.8%); and the mean serum 25-OH vitamin D level was 15.95 (± 9.08) ng/ml. In patients with surgical site infection and infectious complications, 25-OH vitamin D levels were significantly lower than patients without complications (p = 0.036 and p = 0.026). However, no significant difference was demonstrated in 25-OH vitamin D levels according to overall postoperative complications.

CONCLUSIONS

Our results suggest that vitamin D levels might be a potential risk factor for infectious complications in patients undergoing colorectal cancer surgery.

The application of enhanced recovery after surgery and negative-pressure wound therapy in the perioperative period of elderly patients with colorectal cancer

Objective

To Explore the perioperative application of enhanced recovery after surgery (ERAS) and negative-pressure wound therapy in the elderly patients with colorectal cancer.

Methods

A retrospective clinical data were studied in the patients with colorectal cancer in Department of General Surgery in Shanghai Fourth People,s Hospital (from March, 2017 to March, 2019), One hundred and fifty patients with undergoing radical surgery for colorectal cancer were divided into two groups: ERAS group (n = 76 cases, accepting ERAS management) and Conventional treatment(CT) group (n = 74 cases, accepting traditional treatment), Bleeding in operation, the time of postoperative anal flatus, number of wound dressing changing, time of wound healing, the length of postoperative hospital stay, readmission rate, postoperative complication, were compared between the two groups.

Results

ERAS was associated with less bleeding in operation, less Wound fat liquefaction, less wound dressing changing, less time of wound healing, less time of postoperative anal flatus compare to CT group (P < 0.05); anastomotic fistula, readmission rate is similar in two groups (P > 0.05).

Conclusion

The modified ERAS can be safely applied to the perioperative period of elderly colorectal cancer patients and promote recovery; negative-pressure wound therapy is helpful for wound healing and promoting rehabilitation.

Clinical and Economic Outcomes of Enhanced Recovery Dissemination in Michigan Hospitals

OBJECTIVE

To evaluate real-world effects of enhanced recovery protocol (ERP) dissemination on clinical and economic outcomes after colectomy.

SUMMARY BACKGROUND DATA

Hospitals aiming to accelerate discharge and reduce spending after surgery are increasingly adopting perioperative ERPs. Despite their efficacy in specialty institutions, most studies have lacked adequate control groups and diverse hospital settings and have considered only in-hospital costs. There remain concerns that accelerated discharge might incur unintended consequences.

METHODS

Retrospective, population-based cohort including patients in 72 hospitals in the Michigan Surgical Quality Collaborative clinical registry (N = 13,611) and/or Michigan Value Collaborative claims registry (N = 14,800) who underwent elective colectomy, 2012 to 2018. Marginal effects of ERP on clinical outcomes and risk-adjusted, price-standardized 90-day episode payments were evaluated using mixed-effects models to account for secular trends and hospital performance unrelated to ERP.

RESULTS

In 24 ERP hospitals, patients Post-ERP had significantly shorter length of stay than those Pre-ERP (5.1 vs 6.5 days, P < 0.001), lower incidence of complications (14.6% vs 16.9%, P < 0.001) and readmissions (10.4% vs 11.3%, P = 0.02), and lower episode payments ($28,550 vs $31,192, P < 0.001) and postacute care ($3,384 vs $3,909, P < 0.001). In mixed-effects adjusted analyses, these effects were significantly attenuated-ERP was associated with a marginal length of stay reduction of 0.4 days (95% confidence interval 0.2-0.6 days, P = 0.001), and no significant difference in complications, readmissions, or overall spending.

CONCLUSIONS

ERPs are associated with small reduction in postoperative length of hospitalization after colectomy, without unwanted increases in readmission or postacute care spending. The real-world effects across a variety of hospitals may be smaller than observed in early-adopting specialty centers.

Enhanced Recovery After Surgery for Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Systematic Review and Meta-Analysis

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a promising approach for the management of peritoneal carcinomatosis, but is associated with significant morbidity and prolonged hospital stay. Herein, we review the impact of Enhanced recovery after surgery (ERAS) protocol on length of stay (LOS) and early complications in patients undergoing CRS and HIPEC for peritoneal carcinomatosis.

Methods: PubMed and Embase were searched for studies comparing ERAS protocol with control for CRS + HIPEC. Mean difference (MD) and risk ratios (RR) were calculated for LOS and complications respectively.

Results: Six retrospective studies were included. Meta-analysis indicated statistically significant reduction in LOS with ERAS (MD: −2.82 95% CI: −3.79, −1.85 I² = 29% p < 0.00001). Our results demonstrated significantly reduced risk of Calvien Dindo grade III/IV complications with the use of ERAS protocol as compared to the control group (RR: 0.60 95% CI: 0.41, 0.87 I² = 0% p = 0.007). Pooled analysis of limited studies demonstrated no statistically significant difference in the risk of reoperation (RR: 1.04 95% CI: 0.54, 2.03 I² = 50% p = 0.90) readmission (RR: 0.55 95% CI: 0.21, 1.49 I² = 0% p = 0.24), acute kidney injury (RR: 0.55 95% CI: 0.28, 1.10 I² = 0% p = 0.09) or mortality (RR: 0.62 95% CI: 0.17, 2.26 I² = 0% p = 0.46) between the study groups.

Conclusion: For CRS + HIPEC, ERAS is associated with significantly reduced LOS along with lower incidence of complications. Limited data suggest that use of ERAS protocol is not associated with increased readmission, reoperation, and mortality rates in these patients. There is a need for randomized controlled trials to corroborate the current evidence.

Implementation of an enhanced recovery after surgery program with robotic surgery in high-risk patients obtains optimal results after colorectal resections

Enhanced recovery after surgery programs reduce postoperative complications and length of stay after laparoscopic colorectal surgery, but are still under evaluation after robotic colorectal surgery. To evaluate potential benefits in terms of length of stay and complications of an Enhanced recovery after surgery program in colorectal surgery. A subanalysis was performed to assess what combination of surgical approach and perioperative care had better outcomes. Prospective observational cohort study. 300 consecutive colorectal surgery patients: 150 were prospectively included in the enhanced recovery after Surgery program group and 150 retrospectively in the traditional care group, and subdivided according to the type of surgery, in Hospital Marques de Valdecilla, between 2013 and 2016. Postoperative complications decreased significantly (p = 0.002) from 46 to 28% (traditional care vs program group). The length of stay was decreased by 2 days (p < 0.001). Multivariate analysis indicated similar effect sizes after adjusting for age, gender, Charlson score, and type of surgery. Type of surgery was an independent predictive factor for postoperative complications and length of stay. Compared to open surgery, postoperative complications decreased by 50% (p < 0.001) after robotic surgery and by 40% (p = 0.01) after laparoscopic surgery, while the median length of stay decreased by three days (p < 0.001) after minimally invasive surgery. Enhanced recovery after surgery program and minimally invasive surgery were associated with decreased morbidity and length of stay after colorectal surgery compared to open surgery and traditional care. An enhanced recovery after surgery program with robotic surgery in high-risk patients might be beneficial.

The feasibility of implementing an enhanced recovery programme in patients undergoing pelvic exenteration

BACKGROUND

Pelvic exenteration (PE) is a complex operative procedure, reserved for patients with locally advanced and recurrent pelvic malignancies. PE is associated with a high index of post-operative morbidity. Enhanced Recovery After Surgery (ERAS) programmes have been successful in improving postoperative outcomes, however, its application in PE has not been studied. The aim of our study is to assess the feasibility and short-term impact of ERAS on PE.

METHODS

A dedicated PE ERAS programme was developed reflecting the complexity of differing subtypes of PE. A prospective cohort study was undertaken to evaluate the feasibility of implementing our PE ERAS between 2016 and 2020. The primary endpoint of this study was overall compliance with the ERAS programme.

RESULTS

145 patients were enrolled into our PE ERAS programme, with 86 (56.2%) patients undergoing a soft tissue PE, 27 (17.6%) a vascular PE and 32 (20.9%) a bony PE. The median overall compliance to the PE ERAS programme was 70% (IQR 55.5-88.8). There were no observed differences between overall compliance to the PE ERAS programme between different subtypes of PE (p = 0.60). Patients with higher compliance with the PE ERAS programme had a shorter LoS (p < 0.001), less post-operative morbidity (p < 0.001), reduced severity of Clavien-Dindo grade of morbidity (p < 0.001) and fewer readmissions (p = 0.03).

CONCLUSIONS

The principles of ERAS can be readily applied to patients undergoing PE, with high adherence to the ERAS programme associated with improved clinical outcomes.

Transition from hospital to home after elective colorectal surgery performed in an enhanced recovery program: An integrative review

AIM

This study aimed to investigate the transition from hospital to home after elective colorectal surgery performed in an Enhanced Recovery After Surgery (ERAS) programme.

DESIGN

An integrative review.

METHODS

A search of ten electronic databases was conducted. Data extraction and quality assessment were performed independently by two authors. Data analysis and synthesis were based on Meleis' Transitions Theory (2010).

RESULTS

Forty-two articles were included, and most (N = 27) were of good or very good quality. The researchers identified five categories to document the nature of transition postsurgery, three conditions affecting such transition, eleven indicators informing about the quality of the transition and several nursing interventions. Overall, this review revealed that the transition from hospital to home after ERAS colorectal surgery is complex. A holistic understanding of this phenomenon may help nurses to recognize what they need to do to optimize the in-home recovery of this clientele.

The impact of enhanced recovery program compliance after elective liver surgery: Results from a multicenter prospective national registry

BACKGROUND

The Enhanced Recovery Program after surgery is a multimodal, evidence-based protocol of care developed to minimize the response to surgical stress. Data on the influence of ERP on outcomes, particularly according to the complexity of liver surgery, are lacking.

METHODS

A prospective multicenter cohort of patients undergoing liver surgery and exposed to Enhanced Recovery Program from 2016 to 2020 in France was analyzed. High Enhanced Recovery Program compliance was defined as more than 70% of items (15 out of 21). The outcomes were the rate of complications, length of stay, and functional recovery according to Enhanced Recovery Program compliance.

RESULTS

A total of 297 patients were included in the study, and they had 61.9% overall compliance (median = 13 items, interquartile range 11-15). Complications were observed in 32.2% (n = 95) of cases, and the mean length of hospital stay was 7.28 (±7.15) days overall. A longer duration of liver surgery was associated with an increase in the complication rate, while high compliance was independently associated with a reduced risk of complications in the multivariable analysis.

CONCLUSION

High Enhanced Recovery Program compliance was associated with a lower rate of postoperative complexity.