Current perioperative practice in rectal surgery in Austria and Germany

Research progress of fast track surgery

The purpose of surgical treatment is to remove the lesions, repair tissue, and reconstruct organ function, but the process will inevitably cause certain degrees of trauma and stress. As a traumatic treatment, surgical treatment can produce a series of pathophysiological changes while achieving the therapeutic effect. Surgical complications are significantly associated with perioperative stress. Therefore, controlling operation-related stress can effectively improve prognosis. In order to reduce the incidence of surgical stress and postoperative complications and promote the rehabilitation of patients as soon as possible, the concept of fast track surgery has been put forward in recent years. It is supported by evidence-based medicine and subverts the traditional concept of surgery, optimizing the multidisciplinary cooperation in the perioperative treatment and rehabilitation process. Moreover, it accelerates the recovery of postoperative patients. Since the concept was put forward, it has been widely applied in European and American countries in the fields of gastroenterology, cardiothoracic surgery, orthopedics, urology, and gynecology. This paper briefly reviews the advances of fast track surgery in recent years.

Current perioperative practice in Canadian vascular surgery

BACKGROUND

The Enhanced Recovery After Surgery (ERAS) Society has set out to improve patient recovery by developing evidence-based perioperative practices. Many institutions and other specialties have begun to apply their principles with great success; however, ERAS principles focus mostly on general surgery, and their applicability to other specialties, such as vascular surgery, is less clear. We sought to investigate the current standard of perioperative care in Canadian vascular surgery by assessing surgeons' perceptions of evidence supporting ERAS practices, identifying barriers to aligning them and identifying aspects of perioperative care that require research specific to vascular surgery before they could be broadly applied.

METHODS

We administered an online survey with 26 questions to all Canadian Society for Vascular Surgery members.

RESULTS

Respondents varied largely in perioperative practice, most notably in the use of nasogastric tubes, Foley catheters and neck drains. Familiarity with supporting evidence was poor. Approximately half (44%) of respondents were not familiar with contrary evidence, while those who were often perceived institutional barriers to change. Finally, one-third (30%) of respondents felt that relevant evidence did not exist to support changing their practice.

CONCLUSION

The variability of perioperative practice in Canadian vascular surgery is likely due to multiple factors, including a lack of specific evidence. Further research in areas of perioperative vascular care where the current standard of practice varies most greatly may help improve recovery after vascular surgery in Canada over simply adopting existing ERAS principles.

Feasibility of Fast-Track Surgery in Elderly Patients with Gastric Cancer

BACKGROUND

The aim of this study was to investigate the role of the fast-track surgery (FTS) program in elderly patients (aged ≥75 years) who underwent open surgery for gastric cancer (GC) in China.

METHODS

A total of 256 patients with GC were randomly assigned to four groups, each of which consisted of 64 cases: the 45-74-year-old age group was subdivided into the FTS-1 group and the conventional care (CC)-1 group, and the 75-89-year-old age group was subdivided into the FTS-2 group and the CC-2 group. All patients underwent open gastrectomy by the same experienced surgical team. We compared the differences between the pairs of groups in different age ranges with respect to the postoperative recovery index, complications, and medical costs.

RESULTS

Compared with the CC-1 group, the FTS-1 group exhibited earlier postoperative flatus, a shorter postoperative hospital stay, lower medical costs, and a decreased incidence of sore throat (P = 0.010, P = 0.000, P = 0.000, and P = 0.019, respectively). Compared with the CC-2 group, the FTS-2 group had more nausea and vomiting, stomach retention, and intestinal obstruction, as well as a higher readmission rate (P = 0.015, P = 0.011, P = 0.041, and P = 0.013, respectively).

CONCLUSION

The application of FTS can significantly speed up postoperative rehabilitation, shorten the hospitalization time, and lower the medical costs for 45-74-year-old GC patients, but this procedure does not show the same benefits for elderly patients. These findings suggest that we should carefully consider whether the FTS program should be applied to elderly patients with GC.

Evidence or eminence in abdominal surgery: Recent improvements in perioperative care

Repeated surveys from Europe, the United States, Australia, and New Zealand have shown that adherence to an evidence-based perioperative care protocol, such as Enhanced Recovery After Surgery (ERAS), has been generally low. It is of great importance to support the implementation of the ERAS protocol as it has been shown to improve outcomes after a number of surgical procedures, including major abdominal surgery. However, despite an increasing awareness of the importance of structured perioperative management, the implementation of this complex protocol has been slow. Barriers to implementation involve both patient- and staff-related factors as well as practice-related issues and resources. To support efficient and successful implementation, further educational and structural measures have to be made on a national or regional level to improve the standard of general health care. Besides postoperative morbidity, biological and physiological variables have been quite commonly reported in previous ERAS studies. Little information, however, has been obtained on cost-effectiveness, long-term outcomes, quality of life and patient-related outcomes, and these issues remain important areas of research for future studies.

A Prospective Single-Institution Evaluation of Current Practices of Early Postoperative Feeding after Elective Intestinal Surgery

Postoperative diet advancement in patients undergoing elective small bowel or colorectal surgery by general surgeons (GSs) and colorectal surgeons (CRSs) was prospectively evaluated. Demographic (age and gender), disease location (small bowel or colorectum), surgical approach (laparoscopic or open), and surgeon characteristics (GS or GRS) were tabulated. Postoperative feeding after surgery on postoperative Day (POD) 1 was assessed. Operations involved the colorectum (n = 43 [72%]) or small bowel (n = 17 [28%]) and were performed using laparoscopy (n = 38 [63%]) or open (n = 22 [37%]) techniques. Operations were performed by GSs (n = 30) or CRSs (n = 30). Early feeding was ordered on POD 1 on 34 patients (57%). The remaining 26 patients (43%) were kept nothing by mouth. Factors associated with early feeding included age younger than 50 years (P 5.004), surgery done by CRSs ( P < 0.0001), operations on the colorectum ( P = 0.04), and laparoscopic surgery ( P = 0.07). Multivariable analysis revealed that age younger than 50 years (odds ratio [OR], 9.5; 95% confidence interval [CI], 1.8 to 52; P = 0.01), surgery done by CRSs (OR, 16.3; 95% CI, 3.4 to 79.6; P = 0.001), and use of laparoscopic surgery (OR, 12; 95% CI, 2.1 to 67; P = 0.007) were associated with early postoperative feeding. Early postoperative feeding does not appear to be applied commonly in clinical practice. Younger patient age, surgery done by CRSs, and laparoscopy are associated with the use of early postoperative feeding after elective intestinal surgery.

Preliminary experience of fast-track surgery combined with laparoscopy-assisted radical distal gastrectomy for gastric cancer

OBJECTIVE

The aim of this study was to evaluate the safety and effectiveness of fast-track surgery combined with laparoscopy-assisted radical distal gastrectomy for gastric cancer.

METHODS

Eighty-eight eligible patients were randomly assigned into four groups: (1) fast-track surgery (FTS) + laparoscopy-assisted radical distal gastrectomy (LADG), treated with LADG and FTS treatment; (2) LADG, treated with LADG and traditional treatment; (3) FTS + open distal grastectomy (ODG), treated with ODG and FTS treatment; and (4) ODG, treated with ODG and traditional treatment. The clinical parameters and serum indicators were compared.

RESULTS

Compared with the ODG group, the other three groups had earlier first flatus and shorter postoperative hospital stay (all P <0.01; all P <0.05), especially in the FTS + LADG group. The level of ALB was higher in the FTS + LADG group than in the LADG group at 4 and 7 days after surgery (P <0.05, P <0.01). The level of CRP in the FTS + LADG group was lower than in the FTS+ODG group at 4 and 7 days after surgery (P <0.05, P <0.05). The FTS + ODG group had lowest medical costs.

CONCLUSION

Combination of FTS and LADG in gastric cancer is safe, feasible, and efficient and can improve nutritional status, lessen postoperative stress, and accelerate postoperative rehabilitation. Compared with FTS + ODG and LADG, its advantages were limited in short-term follow-up.

Length of stay after laparoscopic colonic surgery - an 11-year nationwide Danish survey

AIM

The use of laparoscopic colonic surgery in Denmark was analysed with particular reference to the length of stay.

METHOD

Data were obtained from the Danish National Patient Registry to assess duration of hospital stay after laparoscopic colonic surgery in Denmark within the 11-year period from 2000 to 2010.

RESULTS

There were 4582 laparoscopic colonic resections performed, reaching about 1000 operations/year in the last 2 years (2009-2010). Length of stay decreased from a median of 7 to 4 days, while mean length of stay only decreased from 9 to 7 days.

CONCLUSION

The use of laparoscopic colonic resection has increased in Denmark over the last 11 years and with a concomitant decrease in postoperative length of stay. However, there is a need for further improvement by combining the laparoscopic technique with fast-track recovery.

Enhanced recovery after surgery versus conventional care in colonic and rectal surgery

INTRODUCTION

Enhanced recovery after surgery (ERAS) programmes have been shown to improve outcomes after colonic surgery. However, there is less evidence supporting ERAS in rectal surgery. The aim of this study was to compare outcomes of conventional perioperative care with those of an ERAS pathway including both colonic and rectal surgery patients.

METHODS

Outcomes of patients undergoing elective colorectal surgery at Christchurch Hospital within the ERAS pathway were compared with patients receiving conventional perioperative care over a 2-year period. A retrospective analysis was conducted, including primary and total length of stay (LOS), readmission, complication and mortality rate.

RESULTS

A total of 240 patients undergoing colorectal surgery were included; 160 patients received conventional perioperative care and 80 patients were managed within the ERAS pathway. Primary and total LOS were shorter in the ERAS group (6 versus 7 days, P = 0.0004, 7 versus 10 days, P = 0.0003, respectively). Re-admission and complication rates were not significantly different between the groups. There was one death (in the conventional care group) within 30 days. Patients undergoing rectal surgery within the ERAS pathway did not show any difference in primary LOS, readmission or complication rate although median total LOS was significantly reduced (7 versus 10 days, P = 0.0457).

CONCLUSION

Patients undergoing elective colorectal surgery managed within the ERAS pathway had shorter hospital stays without increased morbidity or mortality. Differences were less pronounced in the rectal surgery subgroup and further research is needed to investigate the use of ERAS pathways for patients undergoing elective rectal surgery.

Mechanical bowel preparation for elective colorectal surgery: updated systematic review and meta-analysis

PURPOSE

Mechanical bowel preparation (MBP) for elective colorectal surgery has been practiced as a clinical routine for many decades. However, earlier randomized clinical trials (RCTs) and meta-analyses suggest that MBP should be abandoned before colorectal surgery because of the futility in reducing postoperative complications and motility. The new published results from three RCTs comparing MBP with no MBP in colorectal surgery in 2010 make the updating of systemic review and meta-analysis necessary. The aim of this study was to estimate efficacy of MBP in prevention of postoperative complications for elective colorectal surgery.

METHOD

A literature search was performed mainly in electronic database including Cochrane Library, EMBASE, and MEDLINE. The inclusion criteria were randomized clinical trials comparing MBP with no MBP before colorectal surgery. Septic complications, reoperation, and death were recorded as primary and secondary outcomes. The meta-analysis was conducted according to the QUOROM statement.

RESULTS

Fourteen RCTs were included in our analysis with a total number of 5,373 patients: 2,682 with MBP and 2,691 without. Comparing with no MBP for elective colorectal surgery, our study showed that MBP had not reduce any postoperative complications when concerning anastomotic leak [odds ratio (OR) 95% confidence interval (CI), 1.08 (0.82-1.43); P = 0.56]; overall SSI [OR 95% CI, 1.26 (0.94-1.68); P = 0.12]; extra-abdominal septic complications [OR 95% CI, 0.98 (0.81-1.18); P = 0.81]; wound infections [OR 95% CI, 1.21 (1.00-1.46); P = 0.05]; reoperation or second intervention rate [OR 95% CI, 1.11 (0.86-1.45); P = 0.42]; and death [OR 95% CI, 0.97(0.63-1.48); P = 0.88].

CONCLUSION

No evidence was noted supporting the use of MBP in patients undergoing elective colorectal surgery. MBP should be omitted in routine clinical practice.

"Fast track surgery" in the north-west of Italy: influence on the orientation of surgical practice

Fast track surgery is a peri-operative management model, including different strategies to improve patients' convalescence, avoid metabolic alterations, reduce complications, and shorten hospital stay. Prerequisite is coordination between different practitioners (surgeon, anaesthetist, nurse, nutritionist, physiotherapist). The purpose of our investigation is to understand the level of fast track surgery application in Piedmont and to evidence analogies and differences among departments. We projected an investigation proposing, to every surgery department in Piedmont, a multiple-choice questionnaire evaluating the level of fast track surgery peri-operative interventions' application. Data analysis was conducted in two points of view: the transversal one with an overview of answer's percentages, the longitudinal one correlating data through Pearson's index (r). We collected answers by 78 % of balloted departments (38 on 49). Transversal analysis, including the evaluation of percentages of each question, shows that intra-operative period is the most influenced by fast track principles, and that only 12 departments of 38 apply complete protocols. Longitudinal analysis, estimating the whole of each department's answers, demonstrates the absence of statistical significance in the correlation between fast track surgery application and territorial (r = 0.18), economic (r = 0.31), or age (r = 0.06) variables. Influence of fast track surgery is significantly present in our territory, even though it is not fully concretized in protocols. The choice of fast track depends on the instruction, the environment and the sensibility of each surgeon. Knowledge of geographic distribution of departments applying this model can be useful to organize common protocols, starting from more experienced hospitals.

"Fast Track" nasogastric decompression of rectal cancer surgery

This study evaluates the application of fast track (FT) nasogastric decompression in patients who underwent anterior resection of rectal cancer. A randomized control trial was performed comparing the group with the fast track treatment (n = 57) and the group with traditional nasogastric decompression (n = 84). Preoperative characteristics and postoperative recovery indices were recorded and analyzed. The results indicate no significant differences in gender (P = 0.614), age (P = 0.653), tumor location (P = 0.113), and TNM stages (P = 0.054) were observed between the 2 groups. The differences in the type of resection, anastomosis, and adoption of protective colostomy were all not significant between the FT and the traditional group. During the first 24 hours after surgery, the volume of nasogastric drainage averaged 197 ml in the FT group and 155 ml in the traditional group (P = 0.197). The initiation of test-meal (P = 0.000), semiliquid diet (P = 0.002), and ordinary diet (P = 0.008) were all significantly shorter in the FT group. Furthermore, compared with the other group, the patients in the FT group enjoyed earlier removal of the abdominal drainage, urinary catheter, and shorter hospital stays (P = 0.000). Based on a correlation test, the duration of nasogastric decompression is related to the time of test-meal and semiliquid diet. The routine usage of nasogastric decompression in rectal surgery is unnecessary. The fast track procedure might help in facilitating postoperative functional and diet recovery, reducing the time of catheterization, and shortening hospital stay.

Comparison of oral polyethylene glycol plus a large volume glycerine enema with a large volume glycerine enema alone in patients undergoing colorectal surgery for malignancy: a randomized clinical trial

AIM

Recent meta-analyses and randomized clinical trials have concluded that mechanical bowel preparation (MBP) before elective colorectal surgery is not associated with a reduction of surgical site infection (SSI). The aim of this randomized clinical trial was to evaluate the impact of preoperative MBP for colon and rectal cancer surgery in comparison with a single glycerine enema.

METHOD

Patients scheduled for radical colorectal resection for malignancy with primary anastomosis were randomized to preoperative MBP (4 l of polyethylene glycol) (group 1, 114 patients) plus a glycerine 5% enema (2 l) or a single glycerine 5% enema (2 l) (group 2, 115 patients). The postoperative incidence of SSI was recorded prospectively. Patients undergoing minimally invasive surgery (laparoscopy or robotic) accounted for 55 and 51 in groups 1 and 2 respectively.

RESULTS

In all, 229 patients were included in the study, 114 in group 1 and 115 in group 2. At least one SSI was reported in 16 (14.0%) group 1 and in 20 (17.8%) group 2 patients (P=0.475). Perioperative mortality was nil. The incidence of SSI was comparable also in the 73 patients who had a low anterior resection (seven of 33 vs eight of 40, P=1.000), and for the 106 patients who underwent a minimally invasive procedure (nine of 55 vs four of 51, P=0.241).

CONCLUSION

A single large-volume glycerine enema is effective bowel preparation before colorectal resection whether performed by an open or minimally invasive technique.

A randomized controlled trial evaluating early versus traditional oral feeding after colorectal surgery

OBJECTIVE

This prospective randomized clinical study was conducted to evaluate the safety and tolerability of early oral feeding after colorectal operations.

METHODS

A total of 199 patients underwent colorectal surgery and were randomly assigned to early feeding (n = 99) or a regular diet (n = 100). Patients' characteristics, diagnoses, surgical procedures, comorbidity, bowel movements, defecation, nasogastric tube reinsertion, time of tolerance of solid diet, complications, and length of hospitalization were assessed.

RESULTS

The two groups were similar in terms of gender, age, diagnosis, surgical procedures, and comorbidity. In the early feeding group, 85.9% of patients tolerated the early feeding schedule. Bowel movements (1.7±0.89 vs. 3.27±1.3), defecation (3.4±0.77 vs. 4.38±1.18) and time of tolerance of solid diet (2.48±0.85 vs. 4.77±1.81) were significantly earlier in the early feeding group. There was no change between the groups in terms of nasogastric tube reinsertion, overall complication or anastomotic leakage. Hospitalization (5.55±2.35 vs. 9.0±6.5) was shorter in the early feeding group.

CONCLUSIONS

The present study indicated that early oral feeding after elective colorectal surgery was not only well tolerated by patients but also affected the postoperative outcomes positively. Early postoperative feeding is safe and leads to the early recovery of gastrointestinal functions.

Knee arthroscopy routines and practice

PURPOSE

Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures, thus consuming huge medical resources. The aim of the present questionnaire survey was to study knee arthroscopy routines and practice.

METHODS

An electronic web-based survey including questions around pre-, per- and postoperative routines for elective knee arthroscopy was send to all orthopaedic units associated to the Swedish Arthroscopic Society (n = 60).

RESULTS

Responses covering 37 centres out of 60 (response rate 62%) were returned. Preoperative radiograph routines varied considerable between centres; conventional radiograph varied between 5 and 100% and preoperative MRI between 5 and 80% of patients. General anaesthesia was the preferred intra-operative technique used in all centres (median 79% of patients), local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10% of cases) and spinal anaesthesia was used in 15 centres (median 5% of cases). Intra-articular local anaesthesia was provided in all but one of centres. Perioperative administration of oral NSAIDs was common (31 out 37), 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID. Analgesic prescription was provided on a regular base in 18 (49%) of centres; an NSAID being the most commonly prescribed. All but one centre provided written information and instruction at discharge. Referral to physiotherapy, prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably.

CONCLUSION

Routines and practice associated to elective knee arthroscopy differed; however, no clear differences in practice were seen between teaching centres, general or local hospitals apart from a lower usage of NSAID for perioperative analgesia. There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee.