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Wishahi M, Kamal NM, Hedaya MS. Enhanced recovery after surgery: Progress in adapted pathways for implementation in standard and emerging surgical settings. World J Clin Cases 2024; 12:5636-5641. [PMID: 39247727 PMCID: PMC11263044 DOI: 10.12998/wjcc.v12.i25.5636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/29/2024] [Accepted: 05/21/2024] [Indexed: 07/12/2024] Open
Abstract
The concept of enhanced recovery after surgery (ERAS) has been practiced for decades and has been implemented in numerous surgical specialties. ERAS is a global surgical quality improvement initiative, and it is an element in the field of perioperative care. ERAS had shown significant clinical outcomes, patient-reported satisfaction, and improvements in medical service cost. ERAS has been developed for specific surgical procedures, but with the fast progress of newly introduced surgical procedures, the original ERAS have been developed and modified. Recently appearing Topics and future research trends encompass ERAS protocols for other types of surgery and the enhancement of perioperative status, including but not limited to pediatric surgery, laparoscopic and robotic assisted surgery, bariatric surgery, thoracic surgery, and renal transplantation. The elements and pathways of ERAS have been developed with the introduction of up-to-date methodologies in the pre-operative, operative, and post-operative pathways. ERAS costs are higher than traditional care, but the patient's clinical outcome and satisfaction are higher. ERAS is in progress in the fields of anesthetic tasks, pediatric surgery, and organ transplantation. Although ERAS has shown significant clinical outcomes, there are needs to modify the protocol for specific cases, hospital facilities, resources, and nurses training on elements of ERAS. Several challenges and limitations exist in the implementation of ERAS that deserve consideration, it includes: Frailty, maximizing nutrition, prehabilitation, treating preoperative anemia, and enhancing ERAS adoption globally are all included.
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Affiliation(s)
- Mohamed Wishahi
- Department of Urology, Theodor Bilharz Research Institute, Cairo 12411, Egypt
| | - Nabawya M Kamal
- Department of Anaesthesia and Surgical Intensive Care, Theodor Bilharz Research Institute, Cairo 12411, Egypt
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Grüter AA, Sijmons JM, Coblijn UK, Toorenvliet BR, Tanis PJ, Tuynman JB. Best Evidence for Each Surgical Step in Minimally Invasive Right Hemicolectomy: A Systematic Review. ANNALS OF SURGERY OPEN 2023; 4:e343. [PMID: 38144490 PMCID: PMC10735091 DOI: 10.1097/as9.0000000000000343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 08/17/2023] [Indexed: 12/26/2023] Open
Abstract
Objective The aim of this study was to systematically review the literature for each surgical step of the minimally invasive right hemicolectomy (MIRH) for non-locally advanced colon cancer, to define the most optimal procedure with the highest level of evidence. Background High variability exists in the way MIRH is performed between surgeons and hospitals, which could affect patients' postoperative and oncological outcomes. Methods A systematic search using PubMed was performed to first identify systematic reviews and meta-analyses, and if there were none then landmark papers and consensus statements were systematically searched for each key step of MIRH. Systematic reviews were assessed using the AMSTAR-2 tool, and selection was based on highest quality followed by year of publication. Results Low (less than 12 mmHg) intra-abdominal pressure (IAP) gives higher mean quality of recovery compared to standard IAP. Complete mesocolic excision (CME) is associated with lowest recurrence and highest 5-year overall survival rates, without worsening short-term outcomes. Routine D3 versus D2 lymphadenectomy showed higher LN yield, but more vascular injuries, and no difference in overall and disease-free survival. Intracorporeal anastomosis is associated with better intra- and postoperative outcomes. The Pfannenstiel incision gives the lowest chance of incisional hernias compared to all other extraction sites. Conclusion According to the best available evidence, the most optimal MIRH for colon cancer without clinically involved D3 nodes entails at least low IAP, CME with D2 lymphadenectomy, an intracorporeal anastomosis and specimen extraction through a Pfannenstiel incision.
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Affiliation(s)
- Alexander A.J. Grüter
- From the Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Julie M.L. Sijmons
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Usha K. Coblijn
- From the Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Pieter J. Tanis
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Jurriaan B. Tuynman
- From the Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Smith BP, Hollis RH, Shao CC, Gleason L, Wood L, McLeod MC, Kay DI, Oates GR, Pisu M, Chu DI. The association of social vulnerability with colorectal enhanced recovery program failure. Surg Open Sci 2023; 13:1-8. [PMID: 37012979 PMCID: PMC10066546 DOI: 10.1016/j.sopen.2023.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/20/2023] [Indexed: 04/05/2023] Open
Abstract
Background Enhanced recovery programs (ERPs) improve outcomes, but over 20 % of patients fail ERP and the contribution of social vulnerability is unknown. This study aimed to characterize the association between social vulnerability and ERP adherence and failure. Methods This was a retrospective cohort study of colorectal surgery patients between 2015 and 2020 utilizing ACS-NSQIP data. Patients who failed ERP (LOS > 6 days) were compared to patients not failing ERP. The CDC's social vulnerability index (SVI) was used to assess social vulnerability. Result 273 of 1191 patients (22.9 %) failed ERP. SVI was a significant predictor of ERP failure (OR 4.6, 95 % CI 1.3-16.8) among those with >70 % ERP component adherence. SVI scores were significantly higher among patients non-adherent with 3 key ERP components: preoperative block (0.58 vs. 0.51, p < 0.01), early diet (0.57 vs. 0.52, p = 0.04) and early foley removal (0.55 vs. 0.50, p < 0.01). Conclusions Higher social vulnerability was associated with non-adherence to 3 key ERP components as well as ERP failure among those who were adherent with >70 % of ERP components. Social vulnerability needs to be recognized, addressed, and included in efforts to further improve ERPs. Key message Social vulnerability is associated with non-adherence to enhanced recovery components and ERP failure among those with high ERP adherence. Social vulnerability needs to be addressed in efforts to improve ERPs.
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Affiliation(s)
- Burkely P. Smith
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Robert H. Hollis
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Connie C. Shao
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Lauren Gleason
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Lauren Wood
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Marshall C. McLeod
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Danielle I. Kay
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Gabriela R. Oates
- University of Alabama at Birmingham, Department of Pediatrics, 1600 7th Ave S, Birmingham, AL 35233, United States of America
| | - Maria Pisu
- University of Alabama at Birmingham, Division of Preventive Medicine and O'Neal Comprehensive Cancer Center, 1808 7th Ave S, Birmingham, AL 35233, United States of America
| | - Daniel I. Chu
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
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Suvi R, Tuukka T, Matti P, Vilma B, Tom S, Alexey S. ERAS failure and major complications in elective colon surgery: common risk factors. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Liu S, Zhang S, Li Z, Li M, Zhang Y, He M, Jin C, Gao C, Gong J. Insufficient Post-operative Energy Intake Is Associated With Failure of Enhanced Recovery Programs After Laparoscopic Colorectal Cancer Surgery: A Prospective Cohort Study. Front Nutr 2022; 8:768067. [PMID: 34993219 PMCID: PMC8724790 DOI: 10.3389/fnut.2021.768067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/11/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Although enhanced recovery after surgery (ERAS) has been proven to be beneficial after laparoscopic colorectal surgery, some of the patients may fail to complete the ERAS program during hospitalization. This prospective study aims to evaluate the risk factors associated with ERAS failure after laparoscopic colorectal cancer surgery. Methods: This is a prospective study from a single tertiary referral hospital. Patients diagnosed with colorectal cancer who met the inclusion criteria were included in this study. Demographic and clinicopathological characteristics were collected. Post-operative activity time and 6-min walking distance (6MWD) were measured. Patients were divided into ERAS failure group and ERAS success according to decreased post-operative activity and 6MWD. Factors associated with ERAS failure were investigated by univariate and multivariate analysis. Results: A total of 91 patients with colorectal cancer were included. The incidence of ERAS failure is 28.6% among all patients. Patients in ERAS failure group experienced higher rate of post-operative ileus and prolonged hospital stay (p < 0.001). Multivariate analysis revealed that older age (p = 0.006), body mass index ≥25.5 kg/m2 (p = 0.037), smoking (p = 0.002), operative time (p = 0.048), and post-operative energy intake <18.5 kcal/kg•d (p = 0.045) were independent risk factors of ERAS failure after laparoscopic colorectal surgery. Conclusions: Our findings indicated that a proportion of patients may fail the ERAS program after laparoscopic colorectal surgery. We for the first time showed that post-operative energy intake was an independent risk factor for ERAS failure. This may provide evidence for further investigation on precise measurement of nutritional status and selected high-risk patients for enhanced nutrition support.
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Affiliation(s)
- Shuang Liu
- Department of Gastrointestinal Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Sheng Zhang
- Department of Gastrointestinal Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Zike Li
- Department of Gastrointestinal Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Meng Li
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yujie Zhang
- Department of Gastrointestinal Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Min He
- Department of Gastrointestinal Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Chengcheng Jin
- Department of Gastrointestinal Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Chun Gao
- Department of Gastrointestinal Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Jianping Gong
- Department of Gastrointestinal Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
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Bellato V, An Y, Cerbo D, Campanelli M, Franceschilli M, Khanna K, Sensi B, Siragusa L, Rossi P, Sica GS. Feasibility and outcomes of ERAS protocol in elective cT4 colorectal cancer patients: results from a single-center retrospective cohort study. World J Surg Oncol 2021; 19:196. [PMID: 34215273 PMCID: PMC8253238 DOI: 10.1186/s12957-021-02282-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/02/2021] [Indexed: 02/06/2023] Open
Abstract
Background Programs of Enhanced Recovery After Surgery reduces morbidity and shorten recovery in patients undergoing colorectal resections for cancer. Patients presenting with more advanced disease such as T4 cancers are frequently excluded from undergoing ERAS programs due to the difficulty in applying established protocols. The primary aim of this investigation was to evaluate the possibility of applying a validated ERAS protocol in patients undergoing colorectal resection for T4 colon and rectal cancer and to evaluate the short-term outcome. Methods Single-center, retrospective cohort study. All patients with a clinical diagnosis of stage T4 colorectal cancer undergoing surgery between November 2016 and January 2020 were treated following the institutional fast track protocol without exclusion. Short-term postoperative outcomes were compared to those of a control group treated with conventional care and that underwent surgical resection for T4 colorectal cancer at the same institution from January 2010 to October 2016. Data from both groups were collected retrospectively from a prospectively maintained database. Results Eighty-two patients were diagnosed with T4 cancer, 49 patients were included in the ERAS cohort and 33 in the historical conventional care cohort. Both, the mean time of tolerance to solid food diet and postoperative length of stay were significantly shorter in the ERAS group than in the control group (3.14 ± 1.76 vs 4.8 ± 1.52; p < 0.0001 and 6.93 ± 3.76 vs 9.50 ± 4.83; p = 0.0084 respectively). No differences in perioperative complications were observed. Conclusions Results from this cohort study from a single-center registry support the thesis that the adoption of the ERAS protocol is effective and applicable in patients with colorectal cancer clinically staged T4, reducing significantly their length of stay and time of tolerance to solid food diet, without affecting surgical postoperative outcomes.
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Affiliation(s)
- Vittoria Bellato
- Minimally Invasive Unit, Department of Surgery, Università "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy.,Department of Colorectal Surgery, St Mark's Academic Hospital, London, UK
| | - Yongbo An
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Daniele Cerbo
- Minimally Invasive Unit, Department of Surgery, Università "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy
| | - Michela Campanelli
- Minimally Invasive Unit, Department of Surgery, Università "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy
| | - Marzia Franceschilli
- Minimally Invasive Unit, Department of Surgery, Università "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy
| | - Krishn Khanna
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Bruno Sensi
- Minimally Invasive Unit, Department of Surgery, Università "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy
| | - Leandro Siragusa
- Minimally Invasive Unit, Department of Surgery, Università "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy
| | - Piero Rossi
- Minimally Invasive Unit, Department of Surgery, Università "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy
| | - Giuseppe S Sica
- Minimally Invasive Unit, Department of Surgery, Università "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy.
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Abstract
INTRODUCTION Perioperative enhanced recovery after surgery (ERAS) concepts or fast-track are supposed to accelerate recovery after surgery, reduce postoperative complications and shorten the hospital stay when compared to traditional perioperative treatment. METHODS Electronic search of the PubMed database to identify systematic reviews with meta-analysis (SR) comparing ERAS and traditional treatment. RESULTS The presented SR investigated 70 randomized controlled studies (RCT) with 12,986 patients and 93 non-RCT (24,335 patients) concerning abdominal, thoracic and vascular as well as orthopedic surgery. The complication rates were decreased under ERAS following colorectal esophageal, liver and pulmonary resections as well as after implantation of hip endoprostheses. Pulmonary complications were reduced after ERAS esophageal, gastric and pulmonary resections. The first bowel movements occurred earlier after ERAS colorectal resections and delayed gastric emptying was less often observed after ERAS pancreatic resection. Following ERAS fast-track esophageal resection, anastomotic leakage was diagnosed less often as well as surgical complications after ERAS pulmonary resection. The ERAS in all studies concerning orthopedic surgery and trials investigating implantation of a hip endoprosthesis or knee endoprosthesis reduced the risk for postoperative blood transfusions. Regardless of the type of surgery, ERAS shortened hospital stay without increasing readmissions. CONCLUSION Numerous clinical trials have confirmed that ERAS reduces postoperative morbidity, shortens hospital stay and accelerates recovery without increasing readmission rates following most surgical operations.
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Slim K, Joris J. Failure of enhanced recovery after surgery: what is it? Colorectal Dis 2020; 22:1830-1831. [PMID: 32810372 DOI: 10.1111/codi.15322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/13/2020] [Indexed: 02/08/2023]
Affiliation(s)
- K Slim
- Department of Digestive Surgery, CHU Clermont-Ferrand, Clermont-Ferrand, France.,Francophone Group for Enhanced Recovery After Surgery, Beaumont, France
| | - J Joris
- Francophone Group for Enhanced Recovery After Surgery, Beaumont, France.,Department of Anaesthesia, University Hospital Liège, Liège, Belgium
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The factors related to failure of Enhanced Recovery after Surgery (ERAS) in colon cancer surgery. Langenbecks Arch Surg 2020; 405:1025-1030. [PMID: 32870334 DOI: 10.1007/s00423-020-01975-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 08/23/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE Enhanced Recovery after Surgery has been proven effective for patients with gastrointestinal cancer. But radical enhanced recovery could also lead to adverse clinical outcomes. Compared with reports on the estimation of successful implementation of enhanced recovery, studies on risk factors of enhanced recovery failure are still lacking. METHODS A retrospective analysis was carried out on 102 patients in ERAS who underwent elective colon cancer surgery. This study included 102 patients with colon cancer between 2015 and 2019, defining enhanced recovery failure as postoperative length of stay over 10 days, stay in ICU over 24 h after surgery, reoperation, death, or unplanned readmission within 30 days after surgery. Univariate and multivariate analyses were performed to explore potential risk factors of failure. RESULTS Aged ≥ 75, open operation, number of drainage tube over 1, re-urethral catheterization, and Clavien-Dindo grade over 2 were associated with ERAS failure, according to univariate analysis. Multivariate analysis showed that age ≥ 75 [OR 7.231; P = 0.009]; open operation (OR 3.599; P = 0.021); and number of drainage tube over 1 (OR 3.202; P = 0.020) were independent risk factors for ERAS failure. CONCLUSIONS We found age ≥ 75, open operation, and number of drainage tube over 1 are independent risk factors associated with ERAS failure after colon cancer surgery.
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