Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

Effect of long-lasting nutritional prehabilitation on postoperative outcome in elective surgery for IBD

BACKGROUND & AIMS

Preoperative patient care optimisation appears to be crucial for obtaining good surgical outcomes. Enhanced Recovery After Surgery (ERAS) underlines the necessity to recognize and treat malnutrition perioperatively and to prehabilitate with interventions that can modulate the lean body mass before and after surgery. This procedure has been extensively reported in colorectal cancer patients but in Inflammatory Bowel Disease (IBD) it has not yet been clearly evaluated. The aim of this study was to implement the perioperative nutritional items in surgical Crohn's disease (CD) and ulcerative colitis (UC) patients electively operated in an ERAS setting, thus to clarify the impact of a long-lasting prehabilitation program in IBD.

METHODS

Consecutive adult patients (age ≥18) were included as soon as scheduled for elective surgery for CD or UC. The nutritional intervention included personalized dietary counseling and oral nutritional supplements when necessary. Data prospectively recorded in each phase were: FFM, FM, FFMI and phase angle detected with BIVA, weight, BMI, unintended weight loss, DASI, energy and nutritional intake, gastrointestinal symptoms and bowel functions. Nutritional risk was detected according to the NRS 2002 screening tool. The impact of early oral nutrition on postoperative recovery was analysed.

RESULTS

A total of 61 IBD patients (45 CD and 16 UC) were included. Muscle wasting was present at baseline assessment in 28% of cases, significantly associated with the presence of ileostomy (p < 0.011) and of a previous IBD surgery (p < 0.011). During the preoperative phase, there was a significant improvement in weight, BMI, FFM (CD p = 0.035; UC p = 0.017), FFMI (CD ns; UC p = 0.011) and phase angle (CD p = 0.014; UC p = 0.027). During the intra-hospital phase, weight and FFM decreased due to the catabolic effect of surgery, but in the whole perioperative period, both CD and UC patients did not change significantly in terms of body composition. Patients with earlier resumption of oral feeding had a significantly shorter hospital stay and a faster recovery of bowel function with no significant relationship with early postoperative complications.

CONCLUSIONS

Nutritional prehabilitation positively modulated the body composition of IBD patients scheduled for elective surgery and therefore could represent a beneficial strategy to attenuate the impact of the surgical stress response on lean tissue in an ERAS setting. This effect is even more evident in high nutritional risk patients. Early postoperative oral feeding seems feasible and well tolerated in IBD. This approach positively influences the restoration of bowel function and the duration of hospital stay.

What are the risk factors of failure of enhanced recovery after right colectomy? Results of a prospective study on 140 consecutive cases

PURPOSE

Nausea and vomiting is the main cause of failure of enhanced recovery protocol (ERP) after right hemicolectomy.

METHODS

From January 2013 to January 2018, all patients undergoing right hemicolectomy were prospectively included. Patients undergoing emergency surgery, additional complex procedure or temporary stoma, nasogastric tube (NGT) maintenance, or abdominal drainage were excluded. Failure of ERP was defined as nausea/vomiting precluding oral feeding after POD3 and/or the occurrence of postoperative ileus requiring NGT and/or length of stay (LOS) ≥ 8 days except for patients awaiting admission in rehabilitation unit. Risk factors of failure of ERP were identified using univariate and multivariate analysis.

RESULTS

Among 306 patients undergoing right hemicolectomy, 140 fulfilled the inclusion criteria. Postoperative morbidity was 31%, and the mortality rate was nil. The mean postoperative hospital stay was 7 days (range 2-30). Successful ERP was achieved in 83 patients (59%). Causes of failure were major nausea/vomiting precluding oral feeding after POD3 in 36, postoperative ileus requiring NGT in 16 and LOS ≥ 8 days in 36. On multivariate analysis, preoperative anemia (OR 5.2; CI 95%, 1.3-21.1, p = 0.02) and platelet anti-aggregant/anti-coagulant (OR 4.5; CI 95%, 1.7-12.1, p = 0.003) were associated with the risk of failure of ERP.

CONCLUSION

This study shows that anemia and medication with antiplatelet/anticoagulation therapy increase the risk of failure of ERP after right hemicolectomy that translates most of the time by nausea/vomiting and postoperative ileus. The presence of these factors should lead to adapt the strategy to improve outcome rather than be considered as contraindication to ERP.

Transmuscular quadratus lumborum (TQL) block for laparoscopic colorectal surgery: study protocol for a double-blind, prospective randomized placebo-controlled trial

BACKGROUND

Thoracic epidural anesthesia is no longer considered the gold standard for perioperative analgesia in laparoscopic colorectal procedures. In the search for alternatives, the efficacy of the transverse abdominal plane (TAP) block and other abdominal wall blocks such as the transmuscular quadratus lumborum (TQL) block continues to be investigated for postoperative pain management. Most of the initial studies on TAP blocks reported positive effects; however, the amount of studies with negative outcomes is increasing, most probably due to the fact that the majority of abdominal wall blocks fail to mitigate visceral pain. The TQL block could prove attractive in the search for better postoperative pain relief after laparoscopic colorectal surgery. In several cadaveric studies of the TQL, a spread of dye into the thoracic paravertebral space, the intercostal spaces, and even the thoracic sympathetic trunk was reported. Given the advantage of possibly reaching the thoracic paravertebral space, the potential to reach nerves transmitting visceral pain, and the possible coverage of dermatomes T4-L1, we hypothesize that the TQL provides superior postoperative analgesia for laparoscopic colorectal surgery as compared to patient-controlled intravenous analgesia with morphine alone.

METHODS AND DESIGN

In this prospective, randomized, double-blind controlled clinical trial, 150 patients undergoing laparoscopic colorectal surgery will be included. Patients will be randomly allocated to two different analgesic strategies: a bilateral TQL with 30 ml ropivacaine 0.375% each on both sides, administered before induction of anesthesia, plus postoperative patient-controlled intravenous analgesia with morphine (TQL group, n = 75), or a bilateral TQL block with 30 ml saline each on both sides plus postoperative patient-controlled intravenous analgesia with morphine (placebo group, n = 75). Our primary outcome parameter will be the morphine consumption during the first 24 h postsurgery. Secondary endpoints include pain intensity as assessed with the numerical rating scale (NRS) for pain, time to return of intestinal function (defined as the time to first flatus and the time to the first postoperative intake of solid food), time to first mobilization, the incidence of postoperative nausea and vomiting during the first 24 h, length of stay on the post anesthesia care unit (PACU) and in the hospital, the extent of sensory block at two time points (admission to and discharge from the PACU), the doses of morphine IV as requested by the patient from the PCA pump, the total dosage of morphine administered IV, the need for and dose of rescue analgesics (ketamine, clonidine), free plasma ropivacaine levels after induction and at discharge from the PACU, and the incidence of adverse events during treatment (in particular, signs of local anesthetic systemic toxicity (LAST)). Epidural analgesia is no longer the standard of care for postoperative analgesia in laparoscopic colorectal surgery. Until now, the most effective analgesic strategy in these patients especially in an enhanced recovery program is still unknown. Several abdominal wall blocks (TAP, fascia transversalis plane block) are known to have an analgesic effect only on somatic pain. Recognizing the importance of procedure-specific pain management, we aim to investigate whether a transmuscular quadratus lumborum block delivers superior pain control in comparison to patient-controlled intravenous analgesia with morphine alone.

TRIAL REGISTRATION

EudraCT identifier 2019-002304-40. Registered on 17 September 2019.

Bowel surgery for endometriosis: A practical look at short- and long-term complications

Endometriosis involving the bowel requires a thorough evaluation prior to deciding upon surgical treatment. Patient symptoms, treatment goals, extent and location of disease, surgeon experience, and anticipated risks all play a part in the preoperative decision-making process. Short- and long-term complications after bowel surgery for endometriosis are the focus of this article. Unfortunately, the literature to date has inherent limitations that prevent generalizability. Most studies are retrospective or prospective single-center case series. Publication bias is unavoidable with mainly large volume experts sharing their experience. As a result, there is a need for high-quality prospective studies that standardize inclusion criteria and outcome measures among various centers with an aim to present long-term outcomes. In the meantime, care for those with endometriosis involving the bowel requires a thorough preoperative plan to minimize risks and a need for early diagnosis and management of complications unique to bowel surgery.

EVAN-G score in patients undergoing minimally invasive gynecology oncologic surgery in an Enhanced Recovery After Surgery (ERAS) program

INTRODUCTION

Enhanced Recovery After Surgery (ERAS) has been proven to decrease the length of hospital stay without increasing re-admission rates or complications. There are limited data on the satisfaction of patients undergoing minimally invasive surgery for gynecologic malignancy within ERAS programs. The aim of this study was to evaluate patient satisfaction after minimally invasive surgery for gynecologic malignancy within the ERAS program using the 'Evaluation du Vécu de l'Anésthésie Génerale (EVAN-G)' questionnaire.

METHODS

This observational retrospective study was conducted at the Paoli-Calmettes Institute between June 2016 and December 2018. All the included patients underwent minimally invasive surgery for a gynecologic malignancy. EVAN-G, a validated questionnaire, was used to measure peri-operative patient satisfaction. This questionnaire consists of 26 items assessing six elements: attention, privacy, information, pain, discomfort, and waiting time. Each element is assessed via a 5-step numerical scale and then transformed to a 0-100 scale according to the degree of satisfaction. The EVAN-G questionnaire was given to patients before surgery and collected during the post-operative consultation (2-3 weeks after surgery).

RESULTS

A total of 175 patients underwent minimally invasive surgery for gynecologic malignancy within the ERAS program. Of these, 92 patients were included in the study and 83 patients were excluded. The overall patient compliance rate with our ERAS program was 90%. The analysis of the EVAN-G score of all participants showed an overall high level of satisfaction with a mean score of 81.9 (range 41.6-100). Patients with peri-operative complications or having prolonged hospitalization also showed high levels of satisfaction with a mean score of 80.5 (41.6-100) and 83.2(55-100), respectively.

CONCLUSION

In this study we showed a high patient satisfaction with the ERAS program. When comparing length of stay and complications, neither extended length of stay nor development of complications after minimally invasive surgery impacted patient satisfaction.

Enhanced Recovery after Surgery (ERAS) Protocols Expanded over Multiple Service Lines Improves Patient Care and Hospital Cost

Enhanced recovery after surgery (ERAS) may improve patients’ postoperative course. Our center implemented the ERAS protocol for the colorectal service in 2016, and then expanded to multiple service lines over the course of 1.5 years. Our aim was to determine whether broad implementation of ERAS protocols across different service lines could improve patient care. All ERAS patients from 2018 were captured prospectively. For each service line using ERAS, one full year of data preceding ERAS was compared. ERAS service lines included colorectal, gynecology laparoscopic, gynecology open, hepatopancreaticobiliary, urology – nephrectomy and cystectomy, spinal fusion, cardiac surgery—coronary artery bypass grafting. ERAS and pre-ERAS services were compared based on length of stay (LOS), complications, readmission, and mortality rates. In addition, hospital costs were collected during this time frame. ERAS protocols significantly decreased LOS for colorectal, gynecology, and spine. Complications were significantly decreased in colorectal, gynecology, urology, and spine. Readmissions did not significantly increase in any service line except spine. There was no significant change in mortality. ERAS proved to save the hospital 1847 days and cost saving of almost $5 million in 2018. Implementing ERAS broadly improved patient outcomes (LOS, complications, readmission, and mortality) while providing cost savings to the hospital.

The effect of low- versus normal-pressure pneumoperitoneum during laparoscopic colorectal surgery on the early quality of recovery with perioperative care according to the enhanced recovery principles (RECOVER): study protocol for a randomized controlled study

BACKGROUND

There is increasing evidence for the use of lower insufflation pressures during laparoscopic surgery. Deep neuromuscular blockade allows for a safe reduction in intra-abdominal pressure without compromising the quality of the surgical field. While there is considerable evidence to support superior surgical conditions during deep neuromuscular blockade, there is only a limited amount of studies investigating patient outcomes. Moreover, results are not always consistent between studies and vary between different types of laparoscopic surgery. This study will investigate the effect of low-pressure pneumoperitoneum facilitated by deep NMB on quality of recovery after laparoscopic colorectal surgery.

METHODS

The RECOVER study is a multicenter double-blinded randomized controlled trial consisting of 204 patients who will be randomized in a 1:1 fashion to group A, low-pressure pneumoperitoneum (8 mmHg) facilitated by deep neuromuscular blockade (post tetanic count of 1-2), or group B, normal-pressure pneumoperitoneum (12 mmHg) with moderate neuromuscular blockade (train-of-four response of 1-2). The primary outcome is quality of recovery on postoperative day 1, quantified by the Quality of Recovery-40 questionnaire.

DISCUSSION

Few studies have investigated the effect of lower insufflation pressures facilitated by deep neuromuscular blockade on patient outcomes after laparoscopic colorectal procedures. This study will identify whether low pressure pneumoperitoneum and deep neuromuscular blockade will enhance recovery after colorectal laparoscopic surgery and, moreover, if this could be a valuable addition to the Enhanced Recovery After Surgery guidelines.

TRIAL REGISTRATION

EudraCT 2018-001485-42. Registered on April 9, 2018. Clinicaltrials.govNCT03608436. Registered on July 30, 2018.

Fast-track- recovery surgery with a whey-protein-infused carbohydrate-loading drink pre-operatively and early oral feeding post-operatively among surgical gynaecological cancer patients: study protocol of an open-labelled, randomised controlled trial

Introduction

There has been growing evidence on the favourable outcomes of fast-track-recovery (FTR) surgery; to expedite recovery, minimise complications, and reduce the length of hospital stay for surgical patients. However, there is lack of evidence on the effectiveness of FTR in surgical gynaecological cancer (GC) patients. Most of the previous studies did not focus on feeding composition in the FTR surgery protocol. This study aims to determine the effectiveness of FTR feeding with a whey-protein-infused carbohydrate-loading drink pre-operatively and early oral feeding post-operatively on post-operative outcomes among surgical GC patients.

Methods/design

This open-labelled, randomised controlled trial (RCT) will randomly allocate patients into intervention and control groups. Ambulated Malaysian aged over 18 years and scheduled for elective surgery for (suspected) GC, will be included in this study. The intervention group will be given whey-protein-infused carbohydrate-loading drinks on the evening before their operation and 3 h before their operation as well as started on early oral feeding 4 h post-operatively. The control group will be fasted overnight pre-operation and only allowed plain water, and return to a normal diet is allowed when bowel sounds return post-operatively. The primary outcomes of study are length of post-operative hospital stay, length of clear-fluid tolerance, solid-food tolerance and bowel function. Additional outcome measures are changes in nutritional status, biochemical profile and functional status. Data will be analysed on an intention-to-treat basis.

Trial registration

ClinicalTrials.gov, ID: NCT03667755. Retrospectively registered on 12 September 2018;

Protocol version: version 3 dated 27 September 2017.

Evaluation of abdominal exercises after stoma surgery: a descriptive study

Purpose: To evaluate the feasibility of exercises for the abdominal muscles in patients after colostomy or ileostomy formation on the following parameters: muscle activity, pain, discomfort, and difficulty of performing the exercises.Materials and methods: Patients with a new stoma were divided into groups based on time after surgery: Early group, 0-2 weeks (n = 12); Intermediate group, 2-6 weeks (n = 15); and Late group, 6-12 weeks (n = 10). During a single individual test session, participants in each group performed a different set of 10-11 abdominal coordination and strengthening exercises for the abdominal muscles. Activity of the abdominal muscles was measured with electromyography. Pain, discomfort, and difficulty were rated for each exercise.Results: For the Early group, muscle activity reaching a predetermined threshold was measured for half of the participants in a few exercises. In both the Intermediate group and the Late group, muscle activity reaching the onset criteria was measured for all muscles for a high percentage of participants in several exercises. Both strengthening and coordinating exercises were feasible based on low ratings of pain, discomfort, and difficulty.Conclusions: This study identified feasible exercises that activated the abdominal muscles at different time points after stoma formation. The observations can be used as guidance for the choice of exercises in clinical practice and future research.Implications for rehabilitationThe findings of this study can be used in clinical practice as guidance for choice of exercise at different time points after surgery.This study identified useful exercises for activating the abdominal muscles in rehabilitation after stoma surgery from two weeks on.In the first two postoperative weeks, there was limited involvement of the abdominal muscles with the evaluated exercises.Most of the evaluated abdominal exercises were feasible after stoma surgery based on pain, discomfort, and difficulty.

Impact of oral nutritional supplements in post-discharge patients at nutritional risk following colorectal cancer surgery: A randomised clinical trial

BACKGROUND & AIMS

Guidelines on clinical nutrition recommend the use of appropriate nutritional support therapy for surgical cancer patients at risk of malnutrition both during hospital care and following discharge from the hospital. However, previous studies regarding nutritional interventions have mainly focused on patients during their hospital stay; there is limited evidence supporting the recommendation of nutritional interventions for post-discharge patients after cancer surgery, particularly those who underwent gastrointestinal cancer surgery and at high risk of malnutrition. To clearly address this issue, we designed and conducted two independent studies on two different groups of post-discharge patients at nutritional risk after gastrointestinal cancer surgery. The present study aimed to assess the impact of oral nutritional supplements (ONS) in post-discharge patients at nutritional risk following colorectal cancer surgery. Meanwhile, the sister study on the use of ONS in post-discharge patients following gastric cancer surgery will be reported separately.

METHODS

Between January 2017 and June 2019, post-discharge patients following colorectal cancer surgery in our institution were randomised to receive either dietary advice alone (control group) or dietary advice in combination with ONS (ONS group) for three months if they were at nutritional risk based on the tool of Nutritional Risk Screening 2002. The primary endpoints were nutritional outcomes and sarcopenia prevalence. The secondary endpoints were 90-day readmission rate, chemotherapy tolerance, and quality of life (QoL).

RESULTS

Of the 232 eligible patients, 212 (107 in the control group and 105 in the ONS group) completed the trial. Their data were then analyzed. The mean ONS intake was 410 mL every day. By the three-month intervention, the skeletal muscle index in the ONS group was significantly higher than that in the control group (39.75 ± 5.83 vs 38.01 ± 6.18 cm²/m², P = 0.037), but no significant differences between the two groups were noted in weight, weight loss, body mass index, serum albumin and hemoglobin (P > 0.05). In addition, the ONS group had a significantly lower sarcopenia prevalence (28.6% vs 42.1%, P = 0.040). No significant difference between the two groups was found in the 90-day readmission rate (P > 0.05). The number of patients undergoing postoperative chemotherapy in the two groups was similar, but chemotherapy modifications, such as delay, dose reduction, or termination, were significantly reduced in the ONS group (21.2% vs 36.8%, P=0.024). However, ONS had no significant effect on QoL (P > 0.05).

CONCLUSIONS

In post-discharge patients at nutritional risk following colorectal cancer surgery, the use of ONS may reduce skeletal muscle loss and sarcopenia prevalence, as well as improve chemotherapy tolerance, compared with dietary advice alone. These findings underline the importance of ONS treatment in post-discharge patients at nutritional risk following colorectal cancer surgery.

Failure of enhanced recovery after surgery in laparoscopic colorectal surgery: a systematic review

PURPOSE

Enhanced recovery after surgery programs has been applied extensively in laparoscopic colorectal surgery. However, several studies have found that some patients fail from ERAS programs. It is important to identify these patients so that remedial action can be taken in a timely manner. The aim of this study was to perform a systematic review of ERAS failure and related risk factors following laparoscopic colorectal surgery.

METHODS

A literature search of the PubMed, EMBASE, OVID, and Cochrane databases was performed. The search strategy involved terms related to ERAS, failure, and colorectal surgery. The main outcomes were definitions of ERAS failure and related risk factors.

RESULTS

Seven studies including 1463 patients were analyzed. The definition of ERAS failure was mostly associated with a prolonged postoperative length-of-stay (poLOS). Twenty-four kinds of identified risk factors were divided into three parts, the operative part, the pathophysiological part, and the ERAS elements, of which operative factors including more intraoperative blood loss and longer operative duration were the most frequently identified.

CONCLUSIONS

ERAS failure was mostly related to a prolonged poLOS, and operative factors were the most frequently identified risk factors for ERAS failure following laparoscopic colorectal surgery. These findings will help physicians to take remedial action in a timely manner. Nonetheless, high-quality randomized controlled trials following a standardized framework for evaluating ERAS programs are needed in the future.

Safety and efficacy of laxatives after major abdominal surgery: systematic review and meta-analysis

Background

Recovery of gastrointestinal function is often delayed after major abdominal surgery, leading to postoperative ileus (POI). Enhanced recovery protocols recommend laxatives to reduce the duration of POI, but evidence is unclear. This systematic review aimed to assess the safety and efficacy of laxative use after major abdominal surgery.

Methods

Ovid MEDLINE, Embase, Cochrane Library and PubMed databases were searched from inception to May 2019 to identify eligible RCTs focused on elective open or minimally invasive major abdominal surgery. The primary outcome was time taken to passage of stool. Secondary outcomes were time taken to tolerance of diet, time taken to flatus, length of hospital stay, postoperative complications and readmission to hospital.

Results

Five RCTs with a total of 416 patients were included. Laxatives reduced the time to passage of stool (mean difference (MD) −0·83 (95 per cent c.i. −1·39 to −0·26) days; P = 0·004), but there was significant heterogeneity between studies for this outcome measure. There was no difference in time to passage of flatus (MD −0·17 (−0·59 to 0·25) days; P = 0·432), time to tolerance of diet (MD −0·01 (−0·12 to 0·10) days; P = 0·865) or length of hospital stay (MD 0·01(−1·36 to 1·38) days; P = 0·992). There were insufficient data available on postoperative complications for meta‐analysis.

Conclusion

Routine postoperative laxative use after major abdominal surgery may result in earlier passage of stool but does not influence other postoperative recovery parameters. Better data are required for postoperative complications and validated outcome measures.

Twelve-hour fasting compared with expedited oral intake in the initial inpatient management of hyperemesis gravidarum: a randomised trial

OBJECTIVE

To evaluate fasting for 12 hours compared with expedited oral feeding in hospitalised women with hyperemesis gravidarum (HG).

DESIGN

Randomised trial.

SETTING

University Hospital, Malaysia: April 2016-April 2017.

POPULATION

One hundred and sixty women hospitalised for HG.

METHOD

Women were randomised upon admission to fasting for 12 hours or expedited oral feeding. Standard HG care was instituted.

MAIN OUTCOME MEASURE

Primary outcome was satisfaction score with overall treatment at 24 hours (0-10 Visual Numerical Rating Scale VNRS), vomiting episodes within 24 hours and nausea VNRS score at enrolment, and at 8, 16 and 24 hours.

RESULTS

Satisfaction score, median (interquartile range) 8 (5-9) versus 8 (7-9) (P = 0.08) and 24-hour vomiting episodes were 1 (0-4) versus 1 (0-5) (P = 0.24) for 12-hour fasting versus expedited feeding, respectively. Repeated measures analysis of variance of nausea scores over 24 hours showed no difference (P = 0.11) between trial arms. Participants randomised to 12-hour fasting compared with expedited feeding were less likely to prefer their feeding regimen in future hospitalisation (41% versus 65%, P = 0.001), to recommend to a friend (65% versus 84%, P = 0.01; RR 0.8, 95% CI 0.6-0.9) and to adhere to protocol (85% versus 95%, P = 0.04; RR 0.9, 95% CI 0.8-1.0). Symptoms profile, ketonuria status at 24 hours and length of hospital stay were not different.

CONCLUSION

Advisory of 12-hour fasting compared with immediate oral feeding resulted in a non-significant difference in satisfaction score but adherence to protocol and fidelity to and recommendation of immediate oral feeding to a friend were lower. The 24-hour nausea scores and vomiting episodes were similar.

TWEETABLE ABSTRACT

Women hospitalised for hyperemesis gravidarum could feed as soon, as much and as often as can be tolerated compared with initial fasting.

Does C-reactive Protein Have a Predictive Role in the Early Diagnosis of Postoperative Complications After Bariatric Surgery? Systematic Review and Bayesian Meta-analysis

BACKGROUND

Postoperative leak and intra-abdominal infections are common after bariatric surgery with a significant impact on perioperative outcomes, hospital length of stay, and readmission rates. In the era of enhanced recovery programs, with patients being discharged from the hospital 24-36 h after surgery and potentially before developing any complications, an early indicator of postoperative complications may be decisive. The aim of this study was to evaluate the predictive role of the C-reactive protein (CRP) in the early diagnosis of complications in patients undergoing laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

PubMed, Embase, and Web of Science databases were consulted. A systematic review and a fully Bayesian meta-analysis were conducted.

RESULTS

Seven studies met the inclusion criteria for a total of 1401 patients. Overall, 57.7% underwent LSG while 42.3% underwent LRYGB. The pooled prevalence of postoperative complications was 9.8% (95% CI = 5-16%). The estimated pooled CRP cut-off value on postoperative day 1 (POD1) was 6.1 mg/dl with a significant diagnostic accuracy and a pooled area under the curve of 0.92 (95% credible interval (CrI) 0.73-0.98). The positive and negative likelihood ratios were 13.6 (95% CrI 8.40-15.9) and 0.16 (95% CrI 0.04-0.31), respectively.

CONCLUSION

A CRP value lower than the derived cut-off of 6.1 mg/dl on POD1, combined with reassuring clinical signs, could be useful to rule out early postoperative leak and complications after LSG and LRYGB. In the context of enhanced recovery after surgery protocols, the integration of a CRP-based diagnostic algorithm as an additional complementary instrument may be valuable to reduce cost and improve outcomes and patient care.

Urine drainage management in colorectal surgery

INTRODUCTION

Enhanced recovery programs (ERP) is aimed at reducing a patient's surgical stress response, specifically by reducing the duration of catheterization. In cases of colorectal surgery, there is pronounced heterogeneity in urinary catheterization, which is largely explained by fear of acute urinary retention (AUR).

OBJECTIVE

The objective of the work is to report on the current literature on postoperative urinary catheterization following colorectal surgery, particularly with regard to the risk of AUR, and thereby contribute to the standardization of perioperative practices.

RESULTS

In colon surgery without preoperative urinary disorders, catheterization must not exceed 24h. In rectal surgery, catheter removal starting on postoperative D2 seems reasonable in the absence of AUR risk factor (RF). Male sex, past history of lower urinary tract obstruction, abdomino-perineal amputation (APA) and low rectal anastomosis are AUR risk factors that must be taken into account when deciding to withdraw the urinary catheter. While the role of a suprapubic catheter is not clearly defined, it may be of use following APA. The epidural catheter is another AUR risk factor, but it seems possible to withdraw the urinary catheter on postoperative D1, before the epidural catheter, provided that the other risk factors have been taken into full account. Lastly, up until now no satisfactorily conducted study has assessed the prophylactic value of systematic perioperative alpha-blocker treatment in colorectal surgery.

Intravenous fluid therapy in the perioperative and critical care setting: Executive summary of the International Fluid Academy (IFA)

Intravenous fluid administration should be considered as any other pharmacological prescription. There are three main indications: resuscitation, replacement, and maintenance. Moreover, the impact of fluid administration as drug diluent or to preserve catheter patency, i.e., fluid creep, should also be considered. As for antibiotics, intravenous fluid administration should follow the four Ds: drug, dosing, duration, de-escalation. Among crystalloids, balanced solutions limit acid–base alterations and chloride load and should be preferred, as this likely prevents renal dysfunction. Among colloids, albumin, the only available natural colloid, may have beneficial effects. The last decade has seen growing interest in the potential harms related to fluid overloading. In the perioperative setting, appropriate fluid management that maintains adequate organ perfusion while limiting fluid administration should represent the standard of care. Protocols including a restrictive continuous fluid administration alongside bolus administration to achieve hemodynamic targets have been proposed. A similar approach should be considered also for critically ill patients, in whom increased endothelial permeability makes this strategy more relevant. Active de-escalation protocols may be necessary in a later phase. The R.O.S.E. conceptual model (Resuscitation, Optimization, Stabilization, Evacuation) summarizes accurately a dynamic approach to fluid therapy, maximizing benefits and minimizing harms. Even in specific categories of critically ill patients, i.e., with trauma or burns, fluid therapy should be carefully applied, considering the importance of their specific aims; maintaining peripheral oxygen delivery, while avoiding the consequences of fluid overload.

Patient experience of health and care when undergoing colorectal surgery within the ERAS program

Background

Several studies show that the enhanced recovery after surgery (ERAS) program reduces complications postoperatively and leads to faster recovery and shorter hospital stays. However, little is known about patients’ self-reported health in an enhanced recovery context. The aim of this study was firstly to describe patient experiences of health within the concept of ERAS after colorectal (CR) surgery during a hospital stay and within 2 weeks of discharge. Secondly, to explore whether the ASA classification/co-morbidity, sex, and surgical method affect the patient’s experience of health.

Methods

Data were collected through the ERAS-HEALTH questionnaire, including two open-ended questions, and through telephone interviews postoperatively. Qualitative and quantitative analysis was used. Patients undergoing CR surgery (n = 80) were included from October 2016 to June 2018.

Results

The patients had mainly positive experiences of their hospital stay as well as most of them felt comfortable coming home. However, experienced state of health is affected by factors like surgical method and co-morbidity. Improvements were desired concerning information, food/food intake, pain management, and environment. At home, the patients experienced a lack of information about food/food intake and ostomy care. Decreased appetite and difficulties with micturition were also described. The most troublesome symptom was postoperative fatigue (POF). Analysis of the ERAS-HEALTH questionnaire showed that patients with higher co-morbidity and those who underwent open surgery have a significantly worse experience of their health compared with patients who underwent laparoscopy. However, it seems that the surgical method affects postoperative health to a greater extent than co-morbidity.

Conclusions

The patients reported many positive aspects and challenges when being cared for within the ERAS program. However, several improvements are needed to satisfy patient wishes regarding their care both in hospital and at home. Laparoscopic surgery affects patient state of health positively in several respects compared with open surgery.

Evaluation of Enhanced Recovery After Following a Surgical Protocol for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis

Introduction:

Cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy (CRS ± HIPEC) has positive effects on the survival of patients with peritoneal carcinomatosis (PC) due to intra-abdominal tumors. Currently, the available literature on the safety of the Enhanced Recovery After Surgery (ERAS) protocol for PC, which is associated with severe morbidity and mortality, is insufficient.

Aim:

This study aimed to present our results from treating patients using the ERAS protocol for PC that developed due to intra-abdominal tumors.

Material and Methods:

The data of 120 consecutive patients with PC due to different etiologies of abdominal origin and who underwent CRS ± HIPEC were analyzed. The patients were divided into two groups according to whether the ERAS protocol was applied. Information on demographics, length of hospital stay, cost, morbidity, and mortality was statistically compared between groups.

Results:

A total of 102 patients were included in the study. The first 40 patients did not undergo the ERAS protocol, whereas 62 patients did undergo the protocol. The mean length of hospital stay was 10 days in the non-ERAS group and 7 days in the ERAS group. The ERAS group was observed to have earlier mobilization, earlier gas and stool release, lower oral intake, and fewer respiratory problems than the non-ERAS group.

Conclusion:

CRS ± HIPEC has a positive effect on survival. The simultaneous application of the ERAS protocol with the aforementioned procedure has positive effects on intestinal motility and postoperative outcomes. In addition, this protocol may reduce costs by shortening the length of hospital stay.

Who tolerates early enteral feeding after colorectal surgery?

BACKGROUND

Early enteral feeding and avoidance of routine nasogastric tube (NGT) placement have become standard care following colorectal surgery. However, some patients require NGT decompression post-operatively for vomiting or distension.

METHODS

This was a retrospective cohort study of all patients undergoing elective intra-abdominal colorectal surgery at University Hospital, Geelong, from 2014 to 2018. Failure of early feeding was defined by the placement of an NGT post-operatively, beyond the day of surgery.

RESULTS

A total of 754 patients were identified. Of these, 28 were excluded due to protocol violations (NGT was left in situ at the end of the operation), leaving 726 patients that were included in the analysis. Overall, 156/726 (21%) patients failed early feeding. The strongest independent predictor of failure was undergoing a total or subtotal colectomy compared with all other operations (15/28 (54%) failed versus 141/698 (20%); P < 0.001). Laparoscopic surgery was independently associated with a lower risk of failure compared with open surgery (43/278 (15%) versus 113/448 (25%); P = 0.002). Risk of failure was not associated with gender, age, American Society of Anesthesiologists score, indication for procedure, presence of anastomosis or duration of surgery.

CONCLUSION

Laparoscopic surgery is associated with a lower risk of failure of early feeding compared with open surgery. Patients undergoing subtotal or total colectomy have a high rate (54%) of failure. This may assist in selecting appropriate patients for early feeding after colorectal surgery.

A retrospective observational study of enhanced recovery after surgery in older patients undergoing elective colorectal surgery

BACKGROUND

Enhanced recovery programs (ERPs) in colorectal surgery have demonstrated beneficial effects on postoperative complications, return of bowel function, length of stay, and costs, without increasing readmissions or mortality. However, ERPs were not specifically designed for older patients and feasibility in older patients has been questioned.

AIM

The aim of this study was to assess ERP adherence and outcomes in older patients and to identify risk factors for postoperative complications and prolonged length of stay.

METHOD

Retrospective analysis of consecutive patients (≥70 years) undergoing elective colorectal resection in a tertiary referral hospital in 2017.

RESULTS

Ninety-six patients were included. Adherence rates were above 80% in 18 of 21 ERP interventions considered. The lowest adherence rates were noted for preoperative carbohydrate loading and cessation of intravenous fluids. Postoperative complications (Clavien-Dindo ≥2) and prolonged postoperative length of stay (>75th percentile) were observed in 39.6% and 26.3%, respectively. Median length of stay was 7 days. The 30-day mortality, readmission and reoperation rates were 2.1%, 12.6% and 8.3%, respectively. Multivariable analysis indicated that polypharmacy and site of surgery were independent risk factors for postoperative complications, while higher age, American Society of Anesthesiologists class and preoperative radiotherapy were independent risk factors for prolonged postoperative length of stay.

CONCLUSION

ERP adherence in older patients undergoing colorectal resection is high and ERP is therefore considered feasible. Postoperative complications and prolonged postoperative length of stay are common, so at risk patients should be targeted with tailored geriatric interventions.

The Safety and Feasibility of Enhanced Recovery after Surgery in Patients Undergoing Pancreaticoduodenectomy: An Updated Meta-Analysis

Background

Enhanced recovery after surgery (ERAS) is a multimodal, multidisciplinary, evidence-based approach to care for surgical patients and aims at optimizing the perioperative management and outcomes. The ERAS approach was first implemented in colorectal surgery patients; however, the reported applications in pancreatoduodenectomy patients are limited. In recent years, studies on ERAS for patients undergoing pancreaticoduodenectomy have been published. The accumulation of new randomized controlled trials and high-quality case-control studies stimulated us to update the analysis. Our study comprehensively collected data to provide the best evidence summary for the clinic.

Aim

To evaluate the safety and feasibility of enhanced recovery after surgery in the perioperative management of pancreatoduodenectomy patients.

Methods

A systematic literature search of PubMed, Embase, and the Cochrane Library was performed up to July 2019. All randomized controlled trials and case-control studies that applied ERAS for patients undergoing pancreaticoduodenectomy were considered for inclusion in this study. The patients were divided into two groups: patients who received the ERAS perioperative management approach were defined as the ERAS group and patients who received the traditional perioperative management approach were defined as the control group. All statistical analyses were conducted using the Revman5.3 software, and the outcomes were calculated as odds ratios or weighted mean differences with their corresponding 95% confidence intervals. A funnel plot was created to assess publication bias. Subgroup and sensitivity analyses were performed to explore the sources of heterogeneity.

Results

A total of 20 studies involving 3613 patients (1914 patients in the ERAS group vs. 1699 patients in the control group) were included in this study. Among the 20 studies, 4 were randomized controlled trials, and 16 were case-control studies. The overall postoperative complication rate was significantly lower in the ERAS group (OR = 0.62, 95% CI: 0.53-0.74, P < 0.00001) than in the control group. In addition, the minor complication rate (Clavien-Dindo I-II) was also lower in the ERAS group (OR = 0.70, 95% CI: 0.58-0.86, P = 0.0005). The patients in the ERAS group had a lower incidence of delayed gastric emptying (OR = 0.51, 95% CI: 0.42-0.63, P < 0.00001) and shorter length of hospital stay (WMD = -4.27, 95% CI: -4.81~-3.73, P < 0.00001) than in the control group. The rates of pancreatic fistula (regardless of Grade A/B/C), wound infections, abdominal abscesses, readmission, reoperation, and morbidity were not significantly different between the two groups.

Conclusion

The ERAS approach is safe and effective in the perioperative management of patients undergoing pancreaticoduodenectomy and helps to accelerate the postoperative recovery and improve prognosis.

Early urinary catheter removal after rectal surgery: systematic review and meta-analysis

Background

Urinary catheters are placed after rectal surgery to prevent urinary retention, but prolonged use may increase the risk of urinary tract infection (UTI). This review evaluated the non‐inferiority of early urinary catheter removal compared with late removal for acute urinary retention risk after rectal surgery.

Methods

MEDLINE, Embase and the Cochrane Central Register of Controlled Trials were searched from January 1980 to February 2019. RCTs comparing early versus late catheter removal after rectal surgery were eligible. Primary outcomes were acute urinary retention and UTI; the secondary outcome was length of hospital stay. Early catheter removal was defined as removal up to 2 days after surgery, with late removal after postoperative day 2. The non‐inferiority margin from an included trial was used for analysis of change in urinary retention (Δ_NI = 15 per cent). Pooled estimates of risk differences (RDs) were derived from random‐effects models. Risk of bias was assessed using a modified Cochrane risk‐of‐bias tool.

Results

Four trials were included, consisting of 409 patients. There was insufficient evidence to conclude non‐inferiority of early versus late catheter removal for acute urinary retention (RD 9 (90 per cent c.i. −1 to 19) per cent; P_NI = 0·31). Early catheter removal was superior for UTI (RD −11 (95 per cent c.i. −17 to −4) per cent; P = 0·001). Results for length of stay were mixed. There were insufficient data to conduct subgroup analyses.

Conclusion

The existing literature is inconclusive for non‐inferiority of early versus late urinary catheter removal for acute urinary retention. Early catheter removal is superior in terms of reducing the risk of UTI.

Comparison of Changes in Disease-Free and Overall Survival of Resectable Rectal Adenocarcinoma between 2010 and 2015

Background

Management of rectal cancer (RC) has undergone many changes in recent decades. A multidisciplinary approach to this complex disease is essential, ensuring high-quality diagnostic, treatment, and outcomes. We aimed to compare treatment results of RC in a single-centre setting between 2010 and 2015.

Methods

A retrospective comparative study included patients with newly diagnosed and operated resectable RC. Patients' diagnostic and treatment data were analysed. Postoperative morbidity was measured according to the Clavien-Dindo classification. Survival data were received from the Lithuanian Cancer Registry. Continuous variables were expressed as mean and SD. Student t test and one-way ANOVA were used for parametric data and the Mann-Whitney test for non-parametric. A multivariate logistic regression analysis was used to identify independent factors for increased survival. Association between categorical variables was verified using Pearson χ².

Results

The study included 179 patients: 80 from 2010 and 99 from 2015. Mean sample age was 67.1 ± 10.7 years. There was no significant difference regarding age, gender, median ASA (3 in both groups), but mean hospital stay was 2 days shorter (8 vs. 10 days) in 2015 (p = 0.002). There were only 8 patients (4%) admitted to the hospital on an emergency basis. Pelvis MRI and abdominal CT were performed more often in 2015: from 37.5 to 77.8% (p < 0.001) and from 52.5 to 97% in 2015, respectively. Circumferential margin evaluation increased from 13.8 to 36.4% (p = 0.001). Neoadjuvant therapy increased from 20% in 2010 to 44.9% in 2015 (p = 0.01). The overall postoperative Clavien-Dindo complication rate was higher in 2015 (13.8 vs. 20.2%, p = 0.596), but in-hospital mortality was lower (1 vs. 0 patients). Comparison of radiological TNM and pathological TNM with one-way ANOVA showed a significant difference staging between 2010 (p = 0.002) and 2015 (p = 0.001). The 2-year overall survival (OS) increased from 76.3 to 86.9% (p = 0.046) and the median disease-free survival from 27 (range 0-35) months to 28 (range 0-35) months (72.5-83.5%, p = 0.077). Multivariate logistic regression analysis determined that availability and performance of MRI were associated with an increased OS (OR = 1.529, 95% CI 0.916-2.554, p = 0.020).

Conclusions

The expanded quantity of preoperative imaging, an improved radiological staging, and compulsory multidisciplinary team board discussions have led to selective neoadjuvant treatment decision followed by surgery which can positively affect the 2-year OS rate.

Pain management in the orthopaedic trauma patient: Non-opioid solutions

When treating pain in the orthopaedic trauma patient opioids have classically represented the mainstay of treatment. They are relatively inexpensive and modestly effective for basic pain management. However, they are fraught with considerable side effects as well as the very high risk of addiction. Their use in pain management has been implicated in the opioid epidemic. For this reason, as well as their only moderate efficacy, alternative modes of treatment have been sought for both the patient with isolated limb trauma and the patient with poly trauma. We review alternative treatment methods in pain management for those with isolated limb trauma and poly trauma. These methods include topical agents, as well as non steroidal anti-inflammatory medications, acetaminophen, gabapetoids, intravenous agents, varying degrees of local anesthetic infiltration and peripheral nerve blocks, and the newer modality of fascial plane blocks. Often, it is a combination of these analgesic modalities that gives the most optimum treatment for the trauma patient. This also, more frequently than not, must be individually tailored to the patient, as no two patients act the same in this regard. It is therefore of importance that the physician managing such patients's pain be experienced and well-versed in all these treatment modalities. We also provide a basic stepwise algorithm we have found useful in treating those with single extremity or single site trauma versus those patients with poly trauma and resultant multiple sources as pain generators. It is hoped that this breakdown of the different modalities along with a better understanding of each modality's potential benefits and indications will aid the surgeon in providing better care to patients following orthopedic trauma.

Does the Implementation of Enhanced Recovery After Surgery (ERAS) Guidelines Improve Outcomes of Bariatric Surgery? A Propensity Score Analysis in 464 Patients

BACKGROUND

The aim of this study was to investigate whether the implementation of enhanced recovery after surgery (ERAS) guidelines according to Thorell and co. in our tertiary referral bariatric center might improve post-operative outcomes.

METHODS

ERAS program was introduced in our center since January 1, 2017. Retrospective review of a prospectively collected database identified patients who underwent laparoscopic primary and revisional bariatric surgeries from October 2005 to January 2018. Patients exposed to ERAS program ("ERAS group") were matched in a 1:1 ratio with patients exposed to conventional care (control group) using a propensity score based on age, gender, preoperative body mass index (BMI), diabetes mellitus, and the type of procedures. The primary outcome was total hospital length of stay (LOS) and the secondary outcomes included the post-operative complications and readmission rates.

RESULTS

During the study period, 464 patients were included, 232 in each group. Implementation of the ERAS protocol was significantly associated with a reduction of LOS (2.47 ± 1.7 vs 5.39 ± 1.9 days, p < 0.00001). One-third of patients was discharged (77/232, 33%) on the first postoperative day (POD) and more than three quarter of patients on POD 2 (182/232, 77%). At the opposite, no patients of the control group were discharged on POD 2. Overall 30-day and 90-day morbidity and readmission rates were the same in both groups. There was no death in each group.

CONCLUSIONS

This large case-matched study using a propensity score analysis suggests that implementation of ERAS program significantly reduced length of hospital stay without significant increases on overall morbidity, and readmission rates.

What factors determine specimen quality in colon cancer surgery? A cohort study

PURPOSE

Tenets of 'good quality' colon cancer surgery include mesocolic plane dissection to preserve an intact mesocolic fascia/peritoneum, and excision of sufficient mesocolon for adequate lymphadenectomy. However, it remains controversial what clinicopathological factors determine 'good quality' surgery, and whether quality of surgery influences morbidity/mortality. This study documents the quality of colon cancer surgery at a quaternary referral centre and identifies factors that influence quality of surgery and post-operative outcomes.

METHODS

Consecutive patients who underwent resection for colon adenocarcinoma at St. James's University Hospital, Leeds, UK (2015-2017), were included. Primary outcome measures included (i) plane of mesocolic dissection, prospectively assessed; and (ii) tissue morphometry (area of mesentery and vascular pedicle length). Other histopathological data were extracted from a prospective database. Clinical data were obtained from the National Bowel Cancer Audit and individual records.

RESULTS

Four hundred five patients were included (mean 69.6 years). The majority (67.4%) of specimens were mesocolic plane dissections. Median area of mesentery excised was 12,085.4 mm². Median vascular pedicle length was 89.3 mm. Post-operative complication was recorded in one-third of patients. Mesocolic plane excision was associated with open surgery (OR 1.80, 95% CI 1.05-3.09), especially in emergency colectomy. Open resections also had a greater mesentery excised (P = 0.002), but incurred more post-operative complication (OR 2.11, 95% CI 1.12-3.99). Post-operative complication was not associated with plane of excision or tissue morphometry.

CONCLUSION

Majority of resections were 'optimal' mesocolic plane dissections. Open resections yielded better quality specimens, but incurred more morbidity. There is room for improvement in the quality of laparoscopic colon cancer surgery, particularly those performed as emergency.

Combined robotic approach and enhanced recovery after surgery pathway for optimization of costs in patients undergoing proctectomy

Background

Enhanced recovery after surgery (ERAS) pathways are beneficial in proctocolectomy, but their impact on robotic low rectal proctectomy is not fully investigated. This study assessed the impact of an ERAS pathway on the outcomes and cost of robotic (RTME) versus laparoscopic (LTME) total mesorectal excision.

Methods

A retrospective review was performed of patients with rectal cancer in a single French tertiary centre for three yearly periods: 2011, LTME; 2015, RTME; and 2018, RTME with ERAS. Patient characteristics, operative and postoperative data, and costs were compared among the groups.

Results

A total of 220 consecutive proctectomies were analysed (71 LTME, 58 RTME and 91 RTME with ERAS). A prevalence of lower and locally advanced tumours was observed with RTME. The median duration of surgery increased with the introduction of RTME, but became shorter than that for LTME with greater robotic experience (226, 233 and 180 min for 2011, 2015 and 2018 respectively; P < 0·001). The median duration of hospital stay decreased significantly for RTME with ERAS (11, 10 and 8 days respectively; P = 0·011), as did the overall morbidity rate (39, 38 and 16 per cent; P = 0·002). Pathology results, conversion and defunctioning stoma rates remained stable. RTME alone increased the total cost by €2348 compared with LTME. The introduction of ERAS and improved robotic experience decreased costs by €1960, compared with RTME performed in 2015 without ERAS implementation. In patients with no co‐morbidity, costs decreased by €596 for RTME with ERAS versus LTME alone.

Conclusion

ERAS is associated with cost reductions in patients undergoing robotic proctectomy.

The relationship between anaesthetic technique, clinicopathological characteristics and the magnitude of the postoperative systemic inflammatory response in patients undergoing elective surgery for colon cancer

BACKGROUND/AIM

The magnitude of the postoperative systemic inflammatory response (SIR) is now recognised to be associated with both short and long-term outcomes in patients undergoing surgery for colon cancer. During such surgery, it is unclear whether the anaesthetic regimens influence the magnitude of the postoperative SIR, independent of other factors. The aim of the present study was to examine the association between anaesthetic agents, clinicopathological characteristics and the magnitude of the postoperative SIR in patients undergoing elective surgery for colon cancer.

METHODS

Patients with colon cancer who underwent elective open or laparoscopic surgery between 2008 and 2016 (n = 409) were studied at a single center. The relationship between type of anaesthesia, surgical technique; open (n = 241) versus laparoscopic (n = 168) and clinicopathological characteristics was examined by using chi-square testing. The chi-square test was used to determine which anaesthetic group influences the POD 2 CRP for only patients undergoing elective open colon surgery.

RESULTS

The majority of patients were <75 years old, male, normal weight or obese, underwent open surgery and had regional anaesthesia, in particular an epidural approach. There was a significant association between type of anaesthesia and post-operative CRP on day 2 (p <0.001) in patients undergoing open surgery but not laparoscopic surgery. Other factors associated with type of anaesthesia included; year of operation (p <0.01), surgical technique (p <0.001), and preoperative dexamethasone (p <0.01).

CONCLUSION

In patients undergoing surgery for elective colon cancer, the type of anaesthesia varied over time. The type of anaesthesia appears to influence the magnitude of the postoperative SIR on post-operative day 2 in open surgery but not laparoscopic surgery. Future work using prospective study design is required to better define this relationship.

Perioperative management of gastrointestinal surgery in a resource-limited hospital in Niger: Cross-sectional study

Background

Perioperative management in digestive surgery is a challenge in sub-Saharan Africa. Objective: To describe the process and outcomes of perioperative management in gastrointestinal surgery.

Materials and methods

This was a single center cross-sectional study over a 4-month period from June 1 to September 30, 2017, in a Nigerien hospital (West Africa). This study included caregivers and patients operated on gastrointestinal surgery.

Results

We collected data for 56 caregivers and 253 patients underwent gastrointestinal surgery. The average age of caregivers was 38.6 ± 8.7. The median length of professional practice was 9 years. Almost 52% of caregivers (n = 29) did not know the standards of perioperative care. The median age of patients was 24 years, and male gender constituted 70% of cases (n = 177) with a sex ratio of 2.32. Patients came from rural areas in 78.2% (n = 198). Emergency surgery accounted for 60% (n = 152). The most surgical procedure was digestive ostomies performed in 28.9% (n = 73), followed by hernia repair and appendectomy in 24.5% (n = 62) and 13.9% (n = 35) respectively. The postoperative course was complicated in 28.1% (n = 71) among which 13 deaths. In the group of caregivers, the poor practice of perioperative management was associated with poor professional qualification, insufficient equipment, insufficient motivation (p < 0.05). The ASA3&ASA4 score, undernutrition, emergency surgery, poor postoperative monitoring, and poor psychological preparation were associated with complicated postoperative outcomes (p < 0.05).

Conclusion

The inadequacy of the technical platform and the lack of continuous training for healthcare staff represented the main dysfunctions of our hospital. The risk factors for complications found in this study need appropriate perioperative management to improve prognosis in gastrointestinal surgery.

•

Perioperative care in gastrointestinal surgery in a challenge in Sub-Saharan countries.

•

This setting is characterised by the difficulty of geographical access to hospital, lack of equipment.

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Risk factors for complications are multifactorial.

•

This study can be a draft for improvement the quality of care in low resource settings.

Successful implementation of an enhanced recovery after surgery (ERAS) protocol reduces nausea and vomiting after infratentorial craniotomy for tumour resection: a randomized controlled trial

BACKGROUND

Infratentorial craniotomy patients have a high incidence of postoperative nausea and vomiting (PONV). Enhanced Recovery After Surgery (ERAS) protocols have been shown in multiple surgical disciplines to improve outcomes, including reduced PONV. However, very few studies have described the application of ERAS to infratentorial craniotomy. The aim of this study was to examine whether our ERAS protocol for infratentorial craniotomy could improve PONV.

METHODS

We implemented an evidence-based, multimodal ERAS protocol for patients undergoing infratentorial craniotomy. A total of 105 patients who underwent infratentorial craniotomy were randomized into either the ERAS group (n = 50) or the control group (n = 55). Primary outcomes were the incidence of vomiting, nausea score, and use of rescue antiemetic during the first 72 h after surgery. Secondary outcomes included postoperative anxiety level, sleep quality, and complications.

RESULTS

Over the entire 72 h post-craniotomy observation period, the cumulative incidence of vomiting was significantly lower in the ERAS group than in the control group. Meanwhile, the incidence of vomiting was significantly lower in the ERAS group on postoperative days (PODs) 2 and 3. Notably, the proportion of patients with mild nausea (VAS 0-4) was higher in the ERAS group as compared to the control group on PODs 2 or 3. Additionally, the postoperative anxiety level and quality of sleep were significantly better in the ERAS group.

CONCLUSION

Successful implementation of our ERAS protocol in infratentorial craniotomy patients could attenuate postoperative anxiety, improve sleep quality, and reduce the incidence of PONV, without increasing the rate of postoperative complications.

TRIAL REGISTRATION

ChiCTR-INR-16009662, 27 Oct 2016, Clinical study on the development and efficacy evaluation of Enhanced Recovery After Surgery (ERAS) in Neurosurgery.

Perioperative Pain Management Strategies in the Age of an Opioid Epidemic

According to the US Department of Health and Human Services 2016 and 2017 data, an estimated 130 people per day died from opioid-related drug overdoses; 42,249 people died from overdosing on opioids; and 2.1 million people had opioid-use disorder. Health care organizations such as the American Association of Nurse Anesthetists, the Association of periOperative Registered Nurses, the American Society of PeriAnesthesia Nurses, the American Society of Anesthesiologists, the American College of Surgeons, and the American Medical Association have information related to pain management and/or the opioid epidemic on their Web sites. It is imperative for health care providers to be cognizant of, and use low-dose opioid/opioid-free pain management therapies. This article reviews the pain process and outlines low-dose opioid/opioid-free pain management modalities.

Role of intraoperative oliguria in risk stratification for postoperative acute kidney injury in patients undergoing colorectal surgery with an enhanced recovery protocol: A propensity score matching analysis

BACKGROUND

The enhanced recovery after surgery (ERAS) protocol for colorectal cancer resection recommends balanced perioperative fluid therapy. According to recent guidelines, zero-balance fluid therapy is recommended in low-risk patients, and immediate correction of low urine output during surgery is discouraged. However, several reports have indicated an association of intraoperative oliguria with postoperative acute kidney injury (AKI). We investigated the impact of intraoperative oliguria in the colorectal ERAS setting on the incidence of postoperative AKI.

PATIENTS AND METHODS

From January 2017 to August 2019, a total of 453 patients underwent laparoscopic colorectal cancer resection with the ERAS protocol. Among them, 125 patients met the criteria for oliguria and were propensity score (PS) matched to 328 patients without intraoperative oliguria. After PS matching had been performed, 125 patients from each group were selected and the incidences of AKI were compared between the two groups. Postoperative kidney function and surgical outcomes were also evaluated.

RESULTS

The incidence of AKI was significantly higher in the intraoperative oliguria group than in the non-intraoperative oliguria group (26.4% vs. 11.2%, respectively, P = 0.002). Also, the eGFR reduction on postoperative day 0 was significantly greater in the intraoperative oliguria than non-intraoperative oliguria group (-9.02 vs. -1.24 mL/min/1.73 m2 respectively, P < 0.001). In addition, the surgical complication rate was higher in the intraoperative oliguria group than in the non-intraoperative oliguria group (18.4% vs. 9.6%, respectively, P = 0.045).

CONCLUSIONS

Despite the proven benefits of perioperative care with the ERAS protocol, caution is required in patients with intraoperative oliguria to prevent postoperative AKI. Further studies regarding appropriate management of intraoperative oliguria in association with long-term prognosis are needed in the colorectal ERAS setting.

Effect of scheduled intravenous acetaminophen on postoperative nausea and vomiting in patients undergoing laparoscopic gynecologic surgery

PURPOSE

The aim of this study was to assess the effect of scheduled intravenous acetaminophen (SIVA) on the incidence of postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic gynecologic surgery (LGS).

METHODS

This retrospective observational study identified consecutive patients who underwent LGS at our institution from January to November of 2017 and were managed with either our hospital's old protocol (Group H) or a new protocol using SIVA (Group S). Primary outcomes included the incidences of PONV and the amount of additional antiemetic required in the postoperative period. The secondary outcomes included the pain score on postoperative day 1, the requirement for additional analgesic medications, and the length of hospitalization (LOH).

RESULTS

Patients in Group S had significantly lower incidences of PONV from postoperative days 0 to 1 and required significantly less antiemetics or tramadol than those in Group H (P = 0.0085). Patients at a low risk for PONV in Group S had significantly lower incidences of PONV than those in Group H (P = 0.0129). Further, the amount of additional tramadol required was lower in Group S than in Group H (P = 0.0021).

CONCLUSION

Introduction of SIVA into the postoperative pain management protocol of LGS may reduce the incidence of PONV and the amount of adjunctive antiemetic medication required from postoperative days 0 to 1. In patients undergoing LGS, PONV prophylaxis using antiemetics should be prescribed depending on PONV risk profile; however, SIVA prophylaxis can be used in all patients regardless of PONV risk profile.

Efficacy of transversus abdominis plane (TAP) block in colorectal surgery: a systematic review and meta-analysis

BACKGROUND

Multimodal opioid-sparing analgesia is a key component of the enhanced recovery after surgery (ERAS) protocol for postoperative pain management. Transversus abdominis plane (TAP) block has contributed to the implementation of this approach in different kinds of surgical procedures. The aim of this study was to evaluate the efficacy of TAP block and its impact on recovery in colorectal surgery.

METHODS

A comprehensive literature search of the PubMed, Embase, and Scopus databases was conducted. Studies that compared TAP block to a control group (no TAP block or placebo) after colorectal resections were included. The effects of TAP block in patients undergoing colorectal surgery were assessed, including the technical aspects of the procedure. Two measures were used to evaluate the effectiveness of postoperative pain control: a numeric pain rating score at rest and on coughing or movement at 24 h following surgery and the opioid requirement at 24 h. Clinical aspects of recovery were postoperative ileus, surgical site infection, postoperative nausea and vomiting, and length of hospital stay.

RESULTS

Sixteen studies were included in the analysis. Data showed that TAP block is a safe procedure associated with a significant reduction in the pain score at rest [WMD - 0.91 (95% CI - 1.56; - 0.27); p < 0.05] and on coughing or movement [WMD - 0.36 (95% CI - 0.72; - 0.01); p < 0.05] at 24 h after surgery and a significant decrease in morphine consumption in the TAP block group the day after surgery [WMD - 2.07 (95% CI - 2.63; - 1.51); p < 0.001].

CONCLUSIONS

TAP block appears to provide both an effective analgesia and a significant reduction in opioid use on the first postoperative day after colorectal surgery. Its use does not seem to lead to increased postoperative complications.

[Is postoperative acute pain control in colorectal surgery better within an enhanced recovery after surgery program (ERAS)?]

BACKGROUND AND OBJECTIVE

A good acute pain control is necessary to achieve the main objective of Enhanced recovery After Surgery (ERAS) programs and accelerate recovery. The study objective is to evaluate postoperative (PO) acute pain, PO opioid consumption, and its association with functional recovery, after implementing a colorectal surgery ERAS program. An analysis was made as regards drugs adverse effects.

METHODS

Observational cohort study on scheduled colorectal Surgery: one prospective cohort subjected to the ERAS care program, and one retrospective cohort that received traditional non-standardised care. A record was made of mean pain intensity (measured by a visual analogue scale, which classifies pain intensity from 0 to 10, from lower to higher intensity), as well as the amount of opioid consumption on the day of surgery and on the first three postoperative days, and drugs adverse effects. An analysis was made of the association between PO opioid consumption and ERAS program, and between PO opioid consumption and functional recovery.

RESULTS

The study included a total of 410 patients (313 in the ERAS group and 97 in the control group). In the ERAS group, it was observed that the mean visual analogue scale was less than 2, with a smaller amount of PO opioid consumption, on each single day and the accumulated amount of the four days (4 [0-24] vs. 0 [0-4], P<.001). PO opioid consumption was associated with functional recovery (OR 0.97 [95% CI; 0.96-0.99], P=.011). No drugs adverse effects were observed.

CONCLUSIONS

After implementing a colorectal Surgery ERAS program, good pain control was achieved, as well as a reduction in PO opioid consumption, which is associated with functional recovery. No drugs adverse effects were observed.

Routine postoperative intensive care unit admission after colorectal cancer surgery for the elderly patient reduces postoperative morbidity and mortality

AIM

Older colorectal cancer (CRC) patients are at increased risk of postoperative morbidity and mortality. Routine postoperative overnight intensive care unit (ICU) admission might reduce this risk. This study aimed to examine the effect of routine overnight ICU admission after CRC surgery on postoperative adverse outcomes and costs in patients aged 80 years or older.

METHODS

Patients aged 80 years or older who underwent CRC surgery in our centre were included in this observational cohort study. All patients in the period 2014-2017 with routine overnight ICU admission were assigned to the ICU cohort; all patients in the period 2009-2013 were assigned to the non-ICU cohort. Multivariable logistic regression was performed to compare the primary composite end-point (30-day mortality, serious complications and readmission) between the groups. Cost data from the literature were used to perform a cost analysis.

RESULTS

A total of 242 patients were included, 125 in the ICU cohort and 117 in the non-ICU cohort. Routine overnight ICU admission was associated with a reduced risk of the composite end-point (OR 0.44, 95% CI 0.22-0.87, P = 0.02) after adjusting for important confounders. In the ICU cohort 28% of patients experienced ICU events requiring intervention; this was not associated with postoperative morbidity or mortality. The 9% reduction in the incidence of serious complications in the ICU cohort is sufficient to offset the additional costs of routine overnight ICU admission.

CONCLUSION

Routine overnight ICU admission after CRC surgery in patients aged 80 years and older is associated with reduced risk of postoperative mortality and morbidity and seems to be cost-effective.

A global survey of surgeons' preferences and practice with regard to laxative use after elective colorectal surgery

PURPOSE

The role of laxatives after elective colorectal surgery is unclear, resulting in heterogenous guidelines and variability in clinical practice. This study aimed to gauge surgeons' preferences and practice with regard to laxative use following elective colorectal surgery.

METHODS

A short one-minute anonymous web-based questionnaire designed in English and Chinese (Mandarin) using the Research Electronic Data Capture application (REDCap) was distributed to member surgeons of every identifiable international colorectal specialist society via email communication, physical newsletters and social media channels. Frequency of laxative use after elective colorectal surgery, type of laxative used, and, if not used, the reasons for not using laxatives were collected.

RESULTS

A total of 852 surgeons, representing 28 surgical societies completed the survey: 80% were colorectal surgeons and 20% were general surgeons with colorectal interest. Twenty-seven percent of the respondents routinely prescribed laxatives after colorectal surgery. There was wide variation in the type of laxatives used, with magnesium-based laxatives (42%), macrogol (Movicol, 36%) and lactulose (Duphalac, 22%) being the most common. Geographical location was correlated with choice of laxative. Those not routinely using laxatives stated the reasons as being no evidence for benefit (48%), potential of adverse events (24%), more than one reason (21%) and other (7%). The majority (93%) non-users would consider using laxatives if better evidence was available.

CONCLUSION

Most surgeons do not routinely prescribe laxatives after elective colorectal surgery due to lack of evidence. Amongst those surgeons who do use them, there is wide variability in the type of laxatives used.

A two-step surgery and a multidisciplinary approach in a centenarian patient with an acute presentation of right colon cancer

Background

As surgery remains the cornerstone of colorectal cancer (CRC) treatment, the number of older patients presented for colorectal resection is rapidly increasing. Nevertheless, the choice to operate an oldest-old patient still remain challenging and requires a careful assessment of risk to benefit ratio in order to guarantee appropriate surgical strategies and perioperative management.

Case presentation

A centenarian patient, acutely admitted to the emergency department, was diagnosed with an ileus caused by stenosing ascending colon cancer with abnormal distension of the right colon at high risk of perforation. Facing with this complex clinical scenario, a lateral decompressive cecostomy as alternative surgical procedure, was performed in local anesthesia in order to avoid the stressful event of an emergency surgery. Thereafter, the patient was admitted to the surgical ward and followed by a geriatrician who performed a comprehensive geriatric assessment (CGA) and daily clinical evaluations. This integrated plan of care was mainly focused on rehabilitation, nutritional interventions and therapeutic reconciliation, maximizing patient’s clinical conditions and performance status. Then, the second surgical step, the radical colon surgery with curative intent and bowel continuity reestablishment was performed, demonstrating to be feasible and safety also in a very advanced age patient in term of prolonged survival and preservation of an adequate quality of life.

Conclusions

This is the first case-report that illustrates a successful two step surgery for CRC in a centenarian patient thanks to a multidisciplinary based approach, overwhelming the mere concept of chronological age.

Intracorporeal or Extracorporeal Ileocolic Anastomosis After Laparoscopic Right Colectomy: A Double-blinded Randomized Controlled Trial

OBJECTIVES

The aim of the study was to determine whether there are clinically relevant differences in outcomes between laparoscopic right colectomy (LRC) with intracorporeal ileocolic anastomosis (IIA) and LRC with extracorporeal IA (EIA).

BACKGROUND

IIA and EIA are 2 well-established techniques for restoration of bowel continuity after LRC. There are no high-quality studies demonstrating the superiority of one anastomotic technique over the other.

METHODS

This is a double-blinded randomized controlled trial comparing the outcomes of LRC with IIA and LRC with EIA in patients with a benign or malignant right-sided colon neoplasm. Primary endpoint was length of hospital stay (LOS). This trial was registered with ClinicalTrials.gov, number NCT03045107.

RESULTS

A total of 140 patients were randomized and analyzed. Median operative time was comparable in IIA versus EIA group {130 [interquartile range (IQR) 105-195] vs 130 (IQR 110-180) min; P = 0.770} and no intraoperative complications occurred. The quicker recovery of bowel function after IIA than EIA [gas: 2 (IQR 2-3) vs 3 (IQR 2-3) days, P = 0.003; stool: 4 (IQR 3-5) vs 4.5 (IQR 3-5) days, P = 0.032] was not reflected in any advantage in the primary endpoint: median LOS was similar in the 2 groups [6 (IQR 5-7) vs 6 (IQR 5-8) days; P = 0.839]. No significant differences were observed in the number of lymph nodes harvested, length of skin incision, 30-day morbidity (17.1% vs 15.7%, P = 0.823), reoperation rate, and readmission rate between the 2 groups.

CONCLUSIONS

LRC with IIA is associated with earlier recovery of postoperative bowel function than LRC with EIA; however, it does not reflect into a shorter LOS.