Laparoscopy within a fast-track program enhances the short-term results after elective surgery for resectable colorectal cancer

Predicting Postoperative Length of Stay in Patients Undergoing Laparoscopic Right Hemicolectomy for Colon Cancer: A Machine Learning Approach Using SICE (Società Italiana di Chirurgia Endoscopica) CoDIG Data

The evolution of laparoscopic right hemicolectomy, particularly with complete mesocolic excision (CME) and central vascular ligation (CVL), represents a significant advancement in colon cancer surgery. The CoDIG 1 and CoDIG 2 studies highlighted Italy's progressive approach, providing useful findings for optimizing patient outcomes and procedural efficiency. Within this context, accurately predicting postoperative length of stay (LoS) is crucial for improving resource allocation and patient care, yet its determination through machine learning techniques (MLTs) remains underexplored. This study aimed to harness MLTs to forecast the LoS for patients undergoing right hemicolectomy for colon cancer, using data from the CoDIG 1 (1224 patients) and CoDIG 2 (788 patients) studies. Multiple MLT algorithms, including random forest (RF) and support vector machine (SVM), were trained to predict LoS, with CoDIG 1 data used for internal validation and CoDIG 2 data for external validation. The RF algorithm showed a strong internal validation performance, achieving the best performances and a 0.92 ROC in predicting long-term stays (more than 5 days). External validation using the SVM model demonstrated 75% ROC values. Factors such as fast-track protocols, anastomosis, and drainage emerged as key predictors of LoS. Integrating MLTs into predicting postoperative LOS in colon cancer surgery offers a promising avenue for personalized patient care and improved surgical management. Using intraoperative features in the algorithm enables the profiling of a patient's stay based on the planned intervention. This issue is important for tailoring postoperative care to individual patients and for hospitals to effectively plan and manage long-term stays for more critical procedures.

Robotic-assisted low anterior resection for rectal cancer shows similar clinical efficacy to laparoscopic surgery: A propensity score matched study

BACKGROUND

Rectal cancer ranks as the second leading cause of cancer-related mortality worldwide, necessitating surgical resection as the sole treatment option. Over the years, there has been a growing adoption of minimally invasive surgical techniques such as robotic and laparoscopic approaches. Robotic surgery represents an innovative modality that effectively addresses the limitations associated with traditional laparoscopic techniques. While previous studies have reported favorable perioperative outcomes for robot-assisted radical resection in rectal cancer patients, further evidence regarding its oncological safety is still warranted.

AIM

To conduct a comparative analysis of perioperative and oncological outcomes between robot-assisted and laparoscopic-assisted low anterior resection (LALAR) procedures.

METHODS

The clinical data of 125 patients who underwent robot-assisted low anterior resection (RALAR) and 279 patients who underwent LALAR resection at Shandong Provincial Hospital Affiliated to Shandong First Medical University from December 2019 to November 2022 were retrospectively analyzed. After performing a 1:1 propensity score matching, the patients were divided into two groups: The RALAR group and the LALAR group (111 cases in each group). Subsequently, a comparison was made between the short-term outcomes within 30 d after surgery and the 3-year survival outcomes of these two groups.

RESULTS

Compared to the LALAR group, the RALAR group exhibited a significantly earlier time to first flatus [2 (2-2) d vs 3 (3-3) d, P = 0.000], as well as a shorter time to first fluid diet [4 (3-4) d vs 5 (4-6) d, P = 0.001]. Additionally, the RALAR group demonstrated reduced postoperative indwelling catheter time [2 (1-3) d vs 4 (3-5) d, P = 0.000] and decreased length of hospital stay after surgery [5 (5-7) d vs 7(6-8) d, P = 0.009]. Moreover, there was an observed increase in total cost of hospitalization for the RALAR group compared to the LALAR group [10777 (10780-11850) dollars vs 10550 (8766-11715) dollars, P = 0.012]. No significant differences were found in terms of conversion rate to laparotomy or incidence of postoperative complications between both groups. Furthermore, no significant disparities were noted regarding the 3-year overall survival rate and 3-year disease-free survival rate between both groups.

CONCLUSION

Robotic surgery offers potential advantages in terms of accelerated recovery of gastrointestinal and urologic function compared to LALAR resection, while maintaining similar perioperative and 3-year oncological outcomes.

Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons

The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.

Fast-Track in Minimally Invasive Gynecology: A Randomized Trial Comparing Costs and Clinical Outcomes

Study Objective: Evaluate the effects of a fast-track (FT) protocol on costs and post-operative recovery.

Methods: One hundred and seventy women undergoing total laparoscopic hysterectomy for a benign indication were randomized in a FT protocol or a usual care protocol. A FT protocol included the combination of minimally invasive surgery, analgesia optimization, early oral refeeding and rapid mobilization of patients was compared to a usual care protocol. Primary outcome was costs. Secondary outcomes were length of stay, post-operative morbidity and patient satisfaction.

Main Results: The mean total cost in the FT group was 13,070 ± 4,321 Euros (EUR) per patient, and that in the usual care group was 3.5% higher at 13,527 ± 3,925 EUR (p = 0.49). The FT group had lower inpatient surgical costs but higher total ambulatory costs during the first post-operative month. The mean hospital stay in the FT group was 52.7 ± 26.8 h, and that in the usual care group was 20% higher at 65.8 ± 33.7 h (p = 0.006). Morbidity during the first post-operative month was not significantly different between the two groups. On their day of discharge, the proportion of patients satisfied with pain management was similar in both groups [83% in FT and 78% in the usual care group (p = 0.57)]. Satisfaction with medical follow-up 1 month after surgery was also similar [91% in FT and 88% in the usual care group (p = 0.69)].

Conclusion: Implementation of a FT protocol in laparoscopic hysterectomy for benign indications has minimal non-significant effects on costs but significantly reduces hospital stay without increasing post-operative morbidity nor decreasing patient satisfaction.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT04839263.

Enhanced Recovery After Surgery Programs for Laparoscopic Abdominal Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols or laparoscopic technique has been applied in various surgical procedures. However, the clinical efficacy of combination of the two methods still remains unclear. Thus, our aim was to assess the role of ERAS protocols in laparoscopic abdominal surgery.

METHODS

We performed a systematic literature search in various databases from January 1990 to October 2017. The results were analyzed according to predefined criteria.

RESULTS

In the present meta-analysis, the outcomes of 34 comparative studies (15 randomized controlled studies and 19 non-randomized controlled studies) enrolling 3615 patients (1749 in the ERAS group and 1866 in the control group) were pooled. ERAS group was associated with shorter hospital stay (WMD - 2.37 days; 95% CI - 3.00 to - 1.73; P 0.000) and earlier time to first flatus (WMD - 0.63 days; 95% CI - 0.90 to - 0.36; P 0.000). Meanwhile, lower overall postoperative complication rate (OR 0.62; 95% CI 0.51-0.76; P 0.000) and less hospital cost (WMD 801.52 US dollar; 95% CI - 918.15 to - 684.89; P 0.000) were observed in ERAS group. Similar readmission rate (OR 0.73, 95% CI 0.52-1.03, P 0.070) and perioperative mortality (OR 1.33; 95% CI 0.53-3.34; P 0.549) were found between the two groups.

CONCLUSIONS

ERAS protocol for laparoscopic abdominal surgery is safe and effective. ERAS combined with laparoscopic technique is associated with faster postoperative recovery without increasing readmission rate and perioperative mortality.

Clinical outcomes of laparoscopic-assisted synchronous bowel anastomoses for synchronous colorectal cancer: initial clinical experience

The primary aim of this study was to explore the safety and feasibility of laparoscopic-assisted synchronous bowel anastomoses (LSBA) for synchronous colorectal cancer (SCRC). All patients who underwent LSBA for SCRC were retrospectively reviewed and analyzed for clinical and pathological features, technical feasibility and short-term as well as long-term oncological outcomes. Between July 2008 and January 2012, a series of 11 consecutive SCRC patients underwent LSBA. Six patients underwent laparoscopic-assisted right hemicolectomy and anterior resection. Five patients had laparoscopic-assisted right hemicolectomy and sigmoidectomy. There were no intraoperative complications that required open conversions. Mean operation time was 233 (range, 195–285) minutes, and mean estimated blood loss was 224 (range, 100–300) mL. The postoperative course of the patients was uneventful with the mean return to oral intake was 6.9 (range 5–12) days, and mean length of hospital stay was 12.6 (range 9–17) days. All surgical wounds showed good cosmetic outcome, and the mean incision length was 4.1 (range 3.5-5.0) cm. During a median follow-up period of 76 months, no local tumor recurrences were found. LSBA is a potentially feasible and safe procedure for SCRC when performed by an experienced surgeon. Further large clinical controlled trials are warranted to confirm the findings.

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.

Total mesorectal excision for mid and low rectal cancer: Laparoscopic vs robotic surgery

AIM: To compare the short- and long-term outcomes of laparoscopic and robotic surgery for middle and low rectal cancer.

METHODS: This is a retrospective study on a prospectively collected database containing 111 patients who underwent minimally invasive rectal resection with total mesorectal excision (TME) with curative intent between January 2008 and December 2014 (robot, n = 53; laparoscopy, n = 58). The patients all had a diagnosis of middle and low rectal adenocarcinoma with stage I-III disease. The median follow-up period was 37.4 mo. Perioperative results, morbidity a pathological data were evaluated and compared. The 3-year overall survival and disease-free survival rates were calculated and compared.

RESULTS: Patients were comparable in terms of preoperative and demographic parameters. The median surgery time was 192 min for laparoscopic TME (L-TME) and 342 min for robotic TME (R-TME) (P < 0.001). There were no differences found in the rates of conversion to open surgery and morbidity. The patients who underwent laparoscopic surgery stayed in the hospital two days longer than the robotic group patients (8 d for L-TME and 6 d for R-TME, P < 0.001). The pathologic evaluation showed a higher number of harvested lymph nodes in the robotic group (18 for R-TME, 11 for L-TME, P < 0.001) and a shorter distal resection margin for laparoscopic patients (1.5 cm for L-TME, 2.5 cm for R-TME, P < 0.001). The three-year overall survival and disease-free survival rates were similar between groups.

CONCLUSION: Both L-TME and R-TME achieved acceptable clinical and oncologic outcomes. The robotic technique showed some advantages in rectal surgery that should be validated by further studies.

Meta-analysis of the laparoscopic versus open colorectal surgery within fast track surgery

BACKGROUND

Laparoscopic methods and fast-track surgery (FTS) can enhance recovery and reduce postoperative hospital stay. However, whether laparoscopic surgery can provide short-term benefits within FTS is controversial. Thus, we conducted a meta-analysis of published studies to evaluate the effect of laparoscopic colorectal surgery within FTS.

METHODS

We searched PubMed, EMBASE, Cochrane Library, and Ovid databases for eligible studies. Endpoints were duration of postoperative hospital stay, time to first bowel movement, total postoperative complication rate, readmission rate, mortality within 30 days after surgery, and conversation rate of laparoscopic surgery.

RESULTS

Four randomized controlled trials and six clinical controlled trials (1510 patients) were eligible for analyses. Duration of postoperative hospital stay (weighted mean difference, -1.65 days; p < 0.001), time to first bowel movement (-1.13 days; p < 0.001), total postoperative complication rate (risk ratio [RR], 0.65; p < 0.001), readmission rate (0.46; p < 0.001), and mortality (0.45; p < 0.001) were significantly reduced in the laparoscopic surgery group. Overall conversion rate of laparoscopic surgery was 11.1%. Subgroup analyses based on each FT element demonstrated that studies without the element "prevention of hypothermia," "no bowel preparation," or "no routine use of drains" did not show significant differences between two groups with regard to duration of postoperative hospital stay or total prevalence of postoperative complications.

CONCLUSION

Within FTS, laparoscopic methods can significantly shorten postoperative hospital stay, accelerate postoperative recovery, and enhance safety in colorectal surgery. The FT elements "prevention of hypothermia," "no bowel preparation," and "no routine use of drains" may play important parts in the combined effect of these two methods.

Enhanced Recovery After Surgery (ERAS®) protocol in patients undergoing laparoscopic resection for stage IV colorectal cancer

Background

There is strong evidence for the use of Enhanced Recovery After Surgery (ERAS) protocol with colorectal surgery. However, in most studies on ERAS, patients with stage IV colorectal cancer (CRC) are commonly excluded. It is not certain if the ERAS protocol combined with laparoscopy improves outcomes in this group of patients as well.

The aim of the study is to assess the feasibility of the ERAS protocol implementation in patients operated laparoscopically due to stage IV CRC.

Methods

A prospective analysis of patients undergoing laparoscopic colorectal surgery was performed. Group 1 included patients with stages I–III, and group 2 included patients with stage IV CRC. Demographic, surgical factors, length of stay (LOS), complications, readmissions, ERAS implementation and early postoperative recovery were compared between the groups.

Results

Group 1 included 168 patients, and group 2 included 20 patients. There was no difference in the age, sex, BMI, ASA, cancer localisation or surgical parameters. No statistically significant difference was noted in complications (26.8 vs 20 %, p = 0.51344), LOS (4.7 vs 5.7 days, p = 0.28228) or readmissions (6 vs 10 %, p = 0.48392). The ERAS protocol compliance was 86.3 and 83.0 %, respectively (p = 0.17158).

Conclusions

Implementation of the ERAS protocol and laparoscopic surgery among patients with stage IV CRC is feasible and provides similar short-term clinical outcomes and recovery as with patients with stages I–III.

Single-incision laparoscopic surgery for diverticulitis in overweight patients

AIM

Single-incision laparoscopic surgery (SILS) has been introduced as a new technique for the treatment of various colorectal diseases. Recurrent or complicated diverticulitis of the sigmoid colon is a frequent indication for minimally invasive sigmoid colectomy. The aim of this study was to investigate the impact of obesity on the outcome of SILS sigmoid colectomy.

METHODS

From September 2009 to October 2014, data from 377 patients who had intended SILS sigmoid colectomy for diverticulitis at our institution were collected in a prospective database. The patients were categorized in the following subgroups: group 1 (normal weight, body mass index (BMI) < 25 kg/m(2)), group 2 (overweight, BMI 25-29.9 kg/m(2)), group 3 (obesity, BMI 30-34.9 kg/m(2)), and group 4 (morbid obesity, BMI > 35 kg/m(2)).

RESULTS

The groups were equivalent for sex, age, status of diverticulitis, the presence of acute inflammation in the specimen, and the percentage of teaching operations, but the percentage of patients with accompanying diseases was significantly more frequent in groups 2, 3, and 4 (p = 0.04, 0.008, and 0.018, respectively). As compared to group 1, the conversion rate was significantly increased in groups 2 and 4 (2.3 vs. 9.3% (p = 0.013) and 2.3 vs. 12.5% (p = 0.017), respectively). The duration of surgery, hospitalization, and morbidity did not differ between the four groups.

CONCLUSION

Up to a body mass index of 35 kg/m(2), increased body weight does not significantly reduce the feasibility and outcome of single-incision laparoscopic surgery for diverticulitis.

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.

Laparoscopic Versus Open Colorectal Resection Within Fast Track Programs: An Update Meta-Analysis Based on Randomized Controlled Trials

The objective of the study was to assess the safety and efficacy of laparoscopic colorectal surgery by comparing open operation within fast track (FT) programs. The Cochrane Library, PubMed, Embase and Chinese Biological Medicine Database were searched to identify all available randomized controlled trials (RCTs) comparing laparoscopic with open colorectal resection within FT programs. A total of seven RCTs were finally included, enrolling 714 patients with colorectal cancer: 373 patients underwent laparoscopic surgery and FT programs (laparoscopic/FT group) and 341 patients received open operation and FT programs (open/FT group). Postoperative hospital stay (weighted mean difference (WMD): 0.66; 95% CI: 0.27 - 1.04; P < 0.05), total hospital stay (WMD: 1.46; 95% CI: 0.40 - 2.51; P < 0.05) and overall complications (RR: 1.31; 95% CI: 1.12 - 1.54; P < 0.05) were significantly lower in laparoscopic/FT group than in open/FT group. However, no statistically significant differences on mortality (risk ratio (RR): 2.26; 95% CI: 0.62 - 8.22; P = 0.21), overall surgical complications (RR: 1.19; 95% CI: 0.94 - 1.51; P = 0.15) and readmission rates (RR: 1.33; 95% CI: 0.79 - 2.22; P = 0.28) were found between both groups. The laparoscopic colorectal surgery combined with FT programs shows high-level evidence on shortening postoperative and total hospital stay, reducing overall complications without compromising patients’ safety.

Minimally invasive surgery for inflammatory bowel disease

Surgical management of inflammatory bowel disease is a challenging endeavor given infectious and inflammatory complications, such as fistula, and abscess, complex often postoperative anatomy, including adhesive disease from previous open operations. Patients with Crohn's disease and ulcerative colitis also bring to the table the burden of their chronic illness with anemia, malnutrition, and immunosuppression, all common and contributing independently as risk factors for increased surgical morbidity in this high-risk population. However, to reduce the physical trauma of surgery, technologic advances and worldwide experience with minimally invasive surgery have allowed laparoscopic management of patients to become standard of care, with significant short- and long-term patient benefits compared with the open approach. In this review, we will describe the current state-of the-art for minimally invasive surgery for inflammatory bowel disease and the caveats inherent with this practice in this complex patient population. Also, we will review the applicability of current and future trends in minimally invasive surgical technique, such as laparoscopic "incisionless," single-incision laparoscopic surgery (SILS), robotic-assisted, and other techniques for the patient with inflammatory bowel disease. There can be no doubt that minimally invasive surgery has been proven to decrease the short- and long-term burden of surgery of these chronic illnesses and represents high-value care for both patient and society.

Systematic review and meta-analysis for laparoscopic versus open colon surgery with or without an ERAS programme

BACKGROUND

In recent years, conventional colorectal resection and its aftercare have increasingly become replaced by laparoscopic surgery and enhanced recovery after surgery (ERAS) pathways, respectively.

OBJECTIVE

To ascertain whether combining laparoscopy and ERAS have additional value within colorectal surgery.

METHODS

A systematic review with meta-analysis was performed with two primary research questions; does laparoscopy offer an advantage when all patients receive ERAS perioperative care and does ERAS offer advantages in a laparoscopically operated patient population. All randomised and controlled clinical trials were identified using MEDLINE, EMBASE and Cochrane databases.

RESULTS

Primary search resulted in 319 hits. After inclusion criteria were applied, three RCTs and six CCTs were included in the meta-analysis. For laparoscopically operated patients with/without ERAS, no differences in morbidity were found and postoperative hospital stay favoured ERAS (MD -2.34 [-3.77, -0.91], Z = 3.20, p = 0.001). When comparing laparoscopy and open surgery within ERAS, major morbidity was significantly reduced in the laparoscopic group (OR 0.42 [0.26, 0.66], Z = 3.73, p = 0.006). Other outcome parameters showed no differences. Quality of included studies was considered moderate to poor overall with small sample sizes.

CONCLUSION

When laparoscopy and ERAS are combined, major morbidity and hospital stay are reduced. The reduction in morbidity seems to be due to laparoscopy rather than ERAS, so laparoscopy by itself offers independent advantages beyond ERAS care. Quality of included studies was moderate to poor, so conclusions should be regarded with some reservations.

Demonstrating the benefits of transversus abdominis plane blocks on patient outcomes in laparoscopic colorectal surgery: review of 200 consecutive cases

BACKGROUND

Quality improvement in colorectal surgery (CRS) requires implementation of tools to improve patient and financial outcomes, and assessment of results. Our objective was to evaluate the durability of transversus abdominis plane (TAP) blocks and a standardized enhanced recovery protocol (ERP) on a large series of laparoscopic colorectal resections.

STUDY DESIGN

Two hundred consecutive laparoscopic CRS patients received TAP blocks under laparoscopic guidance at the end of their operation. All were managed with a standardized ERP. Demographic, perioperative, and postoperative outcomes variables were analyzed. The main outcomes measures were length of stay (LOS), readmission, reoperation, morbidity, and mortality rates.

RESULTS

Of 200 cases, 194 were elective and 6 emergent. The main diagnosis was colorectal cancer (45%). The mean patient age was 61.2 years, mean body mass index was 29.2 kg/m(2), and the majority (63%) were American Society of Anesthesiologists (ASA) class III. The main procedure performed was a segmental colectomy (64%). Mean operative time was 181 minutes. Nine cases (4.5%) were converted to open. The median LOS was 2 days (range 1 to 8 days). Twenty-one percent were discharged by postoperative day (POD) 1, 41% by POD 2, and 77% by POD 3. By POD 7, 99% were discharged. Twelve percent (n = 24) had complications, and 6.5% (n = 13) were readmitted. There were 3 unplanned reoperations and no mortalities. Comparing the first and second groups of 100 consecutive patients further tested the consistency of the TAP block benefit. With comparable demographics, there were no significant differences in readmission, complication, or reoperation rates over the entire series.

CONCLUSIONS

Adding TAP blocks to an ERP facilitated shorter LOS with low readmission and reoperation rates when compared to previously published series. The effect appears durable and consistent in a large case series. Transversus abdominis plane blocks may be an efficient, cost-effective method for improving laparoscopic CRS results.

Fast-track surgery in real life: how patient factors influence outcomes and compliance with an enhanced recovery clinical pathway after colorectal surgery

The aim of this prospective cohort study was to identify the patient factors that predict postoperative deviation from each item of a fast-track colorectal surgery protocol (FT) and these factors' influences on postoperative outcomes. A total of 606 patients with colorectal pathology from 2005 to 2011 were analyzed to assess the relationships between patient factors, the outcome variables, and the items of the FT program. The median length of stay was 5 days, and readmission rate was 2.3%. The morbidity rate was 26.7%. Independent predictors of prolonged length of stay were older than 75 years of age, ASA grade 3 and 4, and the presence of an ileostomy. Independent predictors of morbidity were age above 75 years old and ASA grade, whereas age was confirmed as an independent predictor of mortality. Male sex, age above 75 years old, and ASA 3 and 4 were identified as independent predictors of negative compliance to most of the postoperative FT items.

Discharge within 24 to 72 hours of colorectal surgery is associated with low readmission rates when using Enhanced Recovery Pathways

BACKGROUND

Enhanced Recovery Pathways (ERPs) have demonstrated reduced hospital length of stay and improved outcomes after colorectal surgery. Concerns exist about increases in readmission rates. Laparoscopic colorectal surgery with an ERP can permit earlier discharge without compromising safety or increasing readmission rates.

STUDY DESIGN

A review of a prospective database was performed for major elective colorectal procedures by a single surgeon. All patients followed a standardized ERP and discharge criteria. Patients were categorized by approach and day of discharge (DoD) of ≤ 1, ≤ 2, ≤ 3, ≤ 7, and >7 days. Main outcomes measures were length of stay and 30-day readmission rates in each group.

RESULTS

Eight hundred and six cases (609 laparoscopic, 197 open) were identified during a 64-month period. Mean age was similar for the laparoscopic (59.1 years) and open (58.3 years) groups. Mean overall DoD was at 5 days (± 4.8 days); by approach, the mean laparoscopic DoD was at 3.9 days and open DoD was at 8.4 days. Twenty-nine percent were discharged within 48 hours (38% laparoscopic and 8% open) and 50% were discharged within 72 hours (62% laparoscopic and 19% open). Only 8.9% of all patients (n = 72) were readmitted (7.2% laparoscopic, 14.2% open). The cumulative readmission rate for laparoscopic patients in early DoD groups postoperative days 1, 2, and 3 were 0.2%, 1.6%, and 3.4%, respectively.

CONCLUSIONS

Combining laparoscopy with an ERP optimizes patient care in colorectal surgery. The combination permits early discharge; 38% were discharged within 2 days and 62% within 3 days of surgery, with low readmission rates. These results support that early DoD is possible without compromising patient safety or increasing readmission rates. This might be a marker for low readmission rate, and suggests that readmission rate alone might not be an adequate marker of quality.

Fast-track colorectal surgery: protocol adherence influences postoperative outcomes

PURPOSE

This single-center prospective cohort study, conducted outside of a clinical trial, tried to identify the importance of each fast-track surgery procedure and protocol adherence level on clinical outcomes after colorectal surgery.

METHODS

From a prospectively maintained database, 606 patients who underwent elective laparoscopic or open colorectal resection within a well established fast-track surgery (FT) protocol, between 2005 and 2011, were identified. Univariate and multivariate analysis were performed to assess the relationship between each FT procedure with an adherence rate <100 % and the outcome variables (length of stay-LOS, 30-day morbidity and readmission rate). Patients were divided into four adherence level groups to FT procedures-100 %, 85-95 %,70-80 %, and <65 %. Each adherence group was compared with the other groups to evaluate differences in clinical outcome variables.

RESULTS

Group comparisons revealed that higher levels of FT protocol adherence corresponded to significantly improved LOS and morbidity rates. Readmission rates were only significantly different between the full fast-track pathway and the less implemented groups. Multivariate analyses revealed that the fast removal of bladder catheter positively influenced length of stay (p < 0.0001) and 30-day morbidity (p < 0.0001). Laparoscopy surgery, no drain positioning and enforced mobilization improved LOS (p = 0.027, p < 0.0001, p = 0.002, respectively). Early solid feeding improved LOS (p < 0.0001), morbidity (p < 0.0001) and readmission rate (p = 0.011).

CONCLUSION

Postoperative outcomes after colorectal surgery are directly proportional to FT protocol adherence. The early removal of the bladder catheter and early postoperative solid feeding independently influenced the length of hospital stay and 30-day morbidity rates.

Laparoscopic surgery improves postoperative outcomes in high-risk patients with colorectal cancer

BACKGROUND

Patients with significant comorbidities often are denied laparoscopic colorectal resections, because they are thought to be too "high-risk." This study was designed to examine the feasibility and safety of laparoscopic colorectal resections in high-risk colorectal cancer patients and to compare them with a similar cohort of patients undergoing open resections in the same time period.

METHODS

This was a single-center, prospective, cohort study conducted at a high-volume, nonuniversity, tertiary care hospital. From a database of 616 patients submitted to elective colorectal surgery for cancer within a fast-track protocol (January 2005 to November 2011), 188 patients who met at least one minor (age >80 years and body mass index (BMI) >30 m/kg(2)) and one major (cardiac, pulmonary, renal or liver disease, diabetes mellitus) criterion were classified as high-risk. Differences in baseline characteristics, intraoperative outcomes, and short-term (30-day) postoperative outcomes, as well as the pathology findings and the readmission and reoperation rates, were compared between the open and laparoscopic cohorts in both high- and low-risk groups and between high- and low-risk groups.

RESULTS

During the study period, 68 high-risk patients underwent laparoscopic resections and 120 had open surgeries. A shorter length of postoperative stay (6 vs. 9 days, p < 0.0001) and fewer postoperative nonsurgical complications (4 % vs. 19 %, p = 0.003) were observed among the laparoscopic group. Postoperative major (p = 0.774) and minor complications (p = 0.3) and reoperations (p = 0.196) were similar between the two groups, and a significantly lower rate of mortality (1.5 vs. 7.5 %, p = 0.038) was observed in the laparoscopic group than in the open group.

CONCLUSIONS

Laparoscopic colorectal resection can be safely performed on "high-risk" surgical patients with better results than a similar group of high-risk patients undergoing open colon resections.