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Parrales-Mora M, Cremades M, Parés D, García RD, Pardo Aranda F, Zárate Pinedo A, Navinés López J, Espin Alvarez F, Julian-Ibanez JF, Cugat Andorra E. Morbidity and mortality of elderly patients with pancreaticobiliary disease according to age and comprehensive geriatric assessment: A prospective observational study. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:439-447. [PMID: 37741326 DOI: 10.1016/j.gastrohep.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 08/11/2023] [Accepted: 09/15/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND This study was designed to analyze the influence of age and comprehensive geriatric evaluation on clinical results of pancreaticobiliary disease management in elderly patients. METHODS A prospective observational study has been undertaken, including 140 elderly patients (over 75 years) with benign pancreaticobiliary disease. Patients were divided according to age in the following groups: group 1: 75-79 years old; group 2: 80-84 years old; group 3: 85 years and older. They underwent a comprehensive geriatric assessment with different scales: Barthel Index, Pfeiffer Index, Charlson Index, and Fragility scale, at admission and had been follow-up 90 days after hospital discharge to analyze its influence on morbidity and mortality. RESULTS Overall, 140 patients have been included (group 1=51; group 2=43 and group 3=46). Most of them, 52 cases (37.8%), had acute cholecystitis, followed by 29 cases of acute cholangitis (20.2%) and acute pancreatitis with 25 cases (17.9%). Significant differences has been observed on complications in different age groups (p=0.033). Especially in patients with a Barthel Index result ≤60, which suggests that these less functional patients had more severe complications after their treatment (p=0.037). The mortality rate was 7.1% (10 patients). CONCLUSIONS No significant differences were found between age, morbidity and mortality in elderly patients with pancreaticobiliary disease. Comprehensive geriatric scales showed some utility in their association with specific complications.
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Affiliation(s)
- Mauricio Parrales-Mora
- Hepatobiliary and Pancreas Unit, Department of General and Digestive Surgery, Spain; Department of General and Digestive Surgery, School of Medicine, Universitat Autònoma de Barcelona, Spain
| | - Manel Cremades
- Hepatobiliary and Pancreas Unit, Department of General and Digestive Surgery, Spain; Department of General and Digestive Surgery, School of Medicine, Universitat Autònoma de Barcelona, Spain
| | - David Parés
- Department of General and Digestive Surgery, School of Medicine, Universitat Autònoma de Barcelona, Spain.
| | - Rebeca D García
- Department of General and Digestive Surgery, School of Medicine, Universitat Autònoma de Barcelona, Spain
| | - Fernando Pardo Aranda
- Department of General and Digestive Surgery, School of Medicine, Universitat Autònoma de Barcelona, Spain
| | - Alba Zárate Pinedo
- Hepatobiliary and Pancreas Unit, Department of General and Digestive Surgery, Spain; Department of General and Digestive Surgery, School of Medicine, Universitat Autònoma de Barcelona, Spain
| | - Jordi Navinés López
- Hepatobiliary and Pancreas Unit, Department of General and Digestive Surgery, Spain
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Liu B, Luo H, Li B, Yu H, Sun R, Li J, Gao Y, Ding P, Wang X, Xiao W. Distinct clinical characteristics in stage III rectal cancer among different age groups and treatment outcomes after neoadjuvant chemoradiotherapy. Ther Adv Med Oncol 2024; 16:17588359241229434. [PMID: 38347922 PMCID: PMC10860489 DOI: 10.1177/17588359241229434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 01/11/2024] [Indexed: 02/15/2024] Open
Abstract
Background There is a rapidly increasing incidence of early-onset colorectal cancer (EO-CRC) which threatens the survival of young people, while aging also represents a challenging clinical problem. Objectives We aimed to investigate the differences in the clinical characteristics and prognosis in stage III rectal cancer (RC), to help optimize treatment strategies. Design and methods This study included 757 patients with stage III RC, all of whom received neoadjuvant chemoradiotherapy and total mesorectal excision. The whole cohort was categorized as very early onset (VEO, ⩽30 years old), early onset (EO, >30 years old, ⩽50 years old), intermediate onset (IO, >50 years, ⩽70 years), or late onset (LO, >70 years old). Results There were more female VEO patients than males, more mucinous adenocarcinoma, signet-ring cell carcinoma, pre-treatment cT4 stage, and higher pre-treatment serum carbohydrate antigen 19-9 compared with the other three groups. VEO patients had the worst survival with the highest RC-related mortality (34.5%), recurrence (13.8%), and metastasis (51.7%). LO patients had the highest non-RC-related mortality rate (16.6%). The Cox regression model showed VEO was a negative independent prognostic factor for disease-free survival [DFS, hazard ratio (HR): 2.830, 95% confidence interval (CI): 1.633-4.904, p < 0.001], distant metastasis-free survival (DMFS, HR: 2.969, 95% CI: 1.720-5.127, p < 0.001), overall survival (OS, HR: 2.164, 95% CI: 1.102-4.249, p = 0.025), and cancer-specific survival (CSS, HR: 2.321, 95% CI: 1.145-4.705, p = 0.020). LO was a negative independent factor on DFS (HR: 1.800, 95% CI: 1.113-2.911, p = 0.017), DMFS (HR: 1.903, 95% CI: 1.150-3.149, p = 0.012), OS (HR: 2.856, 95% CI: 1.745-4.583, p < 0.001), and CSS (HR: 2.248, 95% CI: 1.282-3.942, p = 0.005). VEO patients had better survival in the total neoadjuvant therapy-like (TNT-like) pattern on DFS (p = 0.039). IO patients receiving TNT-like patterns had better survival on DFS, OS, and CSS (p = 0.006, p = 0.018, p = 0.006, respectively). Conclusion In stage III RC, VEO patients exhibited unique clinicopathological characteristics, with VEO a negative independent prognostic factor for DFS, DMFS, OS, and CSS. VEO and IO patients may benefit from a TNT-like treatment pattern.
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Affiliation(s)
- Baoqiu Liu
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, 651, East Dongfeng Road, Guangzhou 510060, China
- Department of Oncology, The First Affiliated Hospital of Guangdong Pharmaceutical University, 19 Nonglin Xia Road, Yue Xiu, Guangzhou 510080, China
| | - Huilong Luo
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, 651, East Dongfeng Road, Guangzhou 510060, China
| | - Bin Li
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, 651, East Dongfeng Road, Guangzhou 510060, China
| | - Haina Yu
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, 651, East Dongfeng Road, Guangzhou 510060, China
| | - Rui Sun
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, 651, East Dongfeng Road, Guangzhou 510060, China
| | - Jibin Li
- Statistical Discipline, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, 651, East Dongfeng Road, Guangzhou 510060, China
| | - Yuanhong Gao
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, 651, East Dongfeng Road, Guangzhou 510060, China
| | - Peirong Ding
- Department of Colorectal Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, 651, East Dongfeng Road, Guangzhou 510060, China
| | - Xicheng Wang
- Department of Oncology, The First Affiliated Hospital of Guangdong Pharmaceutical University, 19 Nonglin Xia Road, Yuexiu District Guangzhou 510080, China
| | - Weiwei Xiao
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, 651, East Dongfeng Road, Guangzhou 510060, China
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McKechnie T, Tessier L, Archer V, Park L, Cohen D, Levac B, Parpia S, Bhandari M, Dionne J, Eskicioglu C. Enhanced recovery after surgery protocols following emergency intra-abdominal surgery: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2023:10.1007/s00068-023-02387-6. [PMID: 37985500 DOI: 10.1007/s00068-023-02387-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/21/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE The aim of this systematic review and meta-analysis was to evaluate whether Enhanced Recovery After Surgery (ERAS) protocols for patients undergoing emergency intra-abdominal surgery improve postoperative outcomes as compared to conventional care. METHODS MEDLINE, EMBASE, WoS, CENTRAL, and Pubmed were searched from inception to December 2022. Articles were eligible if they were randomized controlled trials (RCT) or non-randomized studies comparing ERAS protocols to conventional care for patients undergoing emergency intra-abdominal surgery. The outcomes included postoperative length of stay (LOS), postoperative morbidity, prolonged postoperative ileus (PPOI), and readmission. An inverse variance random effects meta-analysis was performed. A risk of bias was assessed with Cochrane tools. Certainty of evidence was assessed with GRADE. RESULTS After screening 1018 citations, 20 studies with 1615 patients in ERAS programs and 1933 patients receiving conventional care were included. There was a reduction in postoperative LOS in the ERAS group for patients undergoing upper gastrointestinal (GI) surgery (MD3.35, 95% CI 2.52-4.17, p < 0.00001) and lower GI surgery (MD2.80, 95% CI 2.62-2.99, p < 0.00001). There was a reduction in postoperative morbidity in the ERAS group for patients undergoing upper GI surgery (RR0.56, 95% CI 0.30-1.02, p = 0.06) and lower GI surgery (RR 0.66, 95%CI 0.52-0.85, p = 0.001). In the upper and lower GI subgroup, there were nonsignificant reductions in PPOI in the ERAS groups (RR0.59, 95% CI 0.30-1.17, p = 0.13; RR0.49, 95% CI 0.21-1.14, p = 0.10). There was a nonsignificant increased risk of readmission in the ERAS group (RR1.60, 95% CI 0.57-4.50, p = 0.50). CONCLUSION There is low-to-very-low certainty evidence supporting the use ERAS protocols for patients undergoing emergency intra-abdominal surgery. The currently available data are limited by imprecision.
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Affiliation(s)
- Tyler McKechnie
- Division of General Surgery Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Léa Tessier
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Victoria Archer
- Division of General Surgery Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lily Park
- Division of General Surgery Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Dan Cohen
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Brendan Levac
- Division of General Surgery Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
| | - Sameer Parpia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Mohit Bhandari
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Joanna Dionne
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Cagla Eskicioglu
- Division of General Surgery Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada.
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
- Division of General Surgery, Department of Surgery, St. Joseph Healthcare, Hamilton, ON, Canada.
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Liu XR, Liu XY, Zhang B, Liu F, Li ZW, Yuan C, Wei ZQ, Peng D. Enhanced recovery after colorectal surgery is a safe and effective pathway for older patients: a pooling up analysis. Int J Colorectal Dis 2023; 38:81. [PMID: 36964841 DOI: 10.1007/s00384-023-04377-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2023] [Indexed: 03/26/2023]
Abstract
PURPOSE The current study aimed to explore the efficacy and safety of Enhanced Recovery after surgery (ERAS) in older patients undergoing colorectal surgery. METHODS Three databases including PubMed, Embase, Medline, and the Cochrane Library were used for searching eligible studies on Jun 8th,2022. To evaluate the effect of ERAS, we focused on the short-term outcomes including postoperative complications and recovery. Subgroup analysis was also conducted for patients undergoing colorectal cancer (CRC) surgery. All the data processing and analyses were carried out by Stata (V.16.0) software. RESULTS Finally, there were fourteen studies involving 5961 patients enrolled in this study. As for surgical outcomes, we found that the older group had more overall complications (OR = 1.41, I2 = 36.59%, 95% CI = 1.20 to 1.65, P = 0.00), more obstruction (OR = 1.462, I2 = 0.00%, 95% CI = 1.037 to 2.061, P = 0.0304), more respiratory complications (OR = 1.721, I2 = 0.00%, 95% CI = 1.177 to 2.515, P = 0.0051), more cardiovascular complications (OR = 3.361, I2 = 57.72%, 95% CI = 1.072 to 10.542, P = 0.0377), more urinary complications (OR = 1.639, I2 = 37.63%, 95% CI = 1.168 to 2.299, P = 0.0043), less readmission (OR = 0.662, I2 = 44.48%, 95% CI = 0.484 to 0.906, P = 0.0100), higher mortality (OR = 0.662, I2 = 44.48%, 95% CI = 0.484 to 0.906, P = 0.0100), and longer overall survival (OS) (HR = 1.21, I2 = 0.00%, 95% CI = 0.566 to 1.859, P = 0.0002)). Subgroup analysis also found that older CRC patients had a higher risk of overall complications (OR = 1.37, I2 = 37.51%, 95% CI = 1.06 to 1.78, P < 0.05). CONCLUSION Although ERAS could accelerate postoperative recovery and reduce postoperative complications, older patients who received ERAS still had higher complication incidence than younger patients. Although the proportion of re-hospitalizations was lower and the OS was better, doctors could not rely too much on ERAS. More measures were needed to improve the outcomes of colorectal surgery in older patients.
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Affiliation(s)
- Xu-Rui Liu
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xiao-Yu Liu
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Bin Zhang
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Fei Liu
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Zi-Wei Li
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Chao Yuan
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Zheng-Qiang Wei
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Dong Peng
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Tidadini F, Trilling B, Quesada JL, Foote A, Sage PY, Bonne A, Arvieux C, Faucheron JL. Association between Enhanced Recovery After Surgery (ERAS) protocol, risk factors and 3-year survival after colorectal surgery for cancer in the elderly. Aging Clin Exp Res 2023; 35:167-175. [PMID: 36306111 DOI: 10.1007/s40520-022-02270-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/26/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION As life expectancy is currently growing, more elderly and fragile patients need colorectal resection for cancer. We sought to assess the link between enhanced rehabilitation after surgery (ERAS), risk factors and overall survival at 3 years, in patients aged 65 and over. METHODS Between 2005 and 2017, all patients undergoing colorectal resection for cancer were included. Overall survival at 3 years was compared for patients treated in following ERAS guidelines compared to conventional treatment (pre-ERAS). RESULTS 661 patients were included (ERAS, n = 325; pre-ERAS, n = 336). The 3-year overall survival rate was significantly better regardless of age for ERAS vs pre-ERAS patients (73.1% vs 64.4%; p = 0.016). With overall survival rates of 83.2% vs 73.8%, 65.4% vs 62.8% and 59.6% vs 40% for the age bands 65-74, 75-84 and ≥ 85 years. The analysis of survival at 3 years by a multivariate Cox model identified ERAS as a protective factor with a reduction in the risk of death of 30% (HR = 0.70 [0.50-0.94], p = 0017) independently of other identified risk factors: age bands, ASA score > 2, smoking, atrial fibrillation and abdominal surgery. This result is confirmed by an analysis of the propensity score (HR = 0.67 [0.47-0.97], p = 0.032). CONCLUSIONS Our study shows that ERAS is associated with better 3-year survival in patients undergoing colorectal resection for cancer, independent of risk factors. The practice of ERAS is effective and should be offered to patients aged 65 and over.
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Affiliation(s)
- Fatah Tidadini
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France.,Lyon Center for Innovation in Cancer, EA 3738, Lyon 1 University, Lyon, France
| | - Bertrand Trilling
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France.,University Grenoble Alpes, UMR 5525, CNRS, TIMC-IMAG, Grenoble, France
| | - Jean-Louis Quesada
- Clinical Pharmacology Unit, INSERM CIC1406, Grenoble Alpes University Hospital, Grenoble, France
| | - Alison Foote
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Pierre-Yves Sage
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Aline Bonne
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Catherine Arvieux
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France.,Lyon Center for Innovation in Cancer, EA 3738, Lyon 1 University, Lyon, France
| | - Jean-Luc Faucheron
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France. .,University Grenoble Alpes, UMR 5525, CNRS, TIMC-IMAG, Grenoble, France.
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Saur NM, Davis BR, Montroni I, Shahrokni A, Rostoft S, Russell MM, Mohile SG, Suwanabol PA, Lightner AL, Poylin V, Paquette IM, Feingold DL. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Perioperative Evaluation and Management of Frailty Among Older Adults Undergoing Colorectal Surgery. Dis Colon Rectum 2022; 65:473-488. [PMID: 35001046 DOI: 10.1097/dcr.0000000000002410] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Nicole M Saur
- Department of Surgery, Division of Colon and Rectal Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bradley R Davis
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Isacco Montroni
- Department of Surgery, Ospedale per gli Infermi, Faenza, Italy
| | - Armin Shahrokni
- Department of Medicine/Geriatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Siri Rostoft
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Marcia M Russell
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Supriya G Mohile
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Pasithorn A Suwanabol
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Vitaliy Poylin
- Division of Gastrointestinal and Oncologic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Daniel L Feingold
- Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
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Lee TH, Choo JM, Kim JS, Shin SH, Kim JS, Baek SJ, Kwak JM, Kim J, Kim SH. Characteristics and Outcomes of Colorectal Cancer Surgery by Age in a Tertiary Center in Korea: A Retrospective Review. Ann Coloproctol 2021; 38:244-252. [PMID: 34735759 PMCID: PMC9263304 DOI: 10.3393/ac.2021.00619.0088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/06/2021] [Indexed: 02/07/2023] Open
Abstract
Purpose Colorectal cancer (CRC) occurs in all age groups, and the application of treatment may vary according to age. The study was designed to identify the characteristics of CRC by age. Methods A total of 4,326 patients undergoing primary resection for CRC from September 2006 to July 2019 were reviewed. Patient and tumor characteristics, operative and postoperative data, and oncologic outcome were compared Results Patients aged 60 to 69 years comprised the largest age group (29.7%), followed by those aged 50 to 59 and 70 to 79 (24.5% and 23.9%, respectively). Rectal cancer was common in all age groups, but right-sided colon cancer tended to be more frequent in older patients. In very elderly patients, there were significant numbers of emergency surgeries, and the frequencies of open surgery and permanent stoma were greater. In contrast, total abdominal colectomy or total proctocolectomy was performed frequently in patients in their teens and twenties. The elderly patients showed more advanced tumor stages and postoperative ileus. The incidence of adjuvant treatment was low in elderly patients, who also had shorter follow-up periods. Overall survival was reduced in older patients with stages 0 to 3 CRC (P<0.001), but disease-free survival did not differ by age (P=0.391). Conclusion CRC screening at an earlier age than is currently undertaken may be necessary in Korea. In addition, improved surgical and oncological outcomes can be achieved through active treatment of the growing number of elderly CRC patients.
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Affiliation(s)
- Tae-Hoon Lee
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Jeong Min Choo
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Jeong Sub Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Seon Hui Shin
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Ji-Seon Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Se-Jin Baek
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Jung-Myun Kwak
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Jin Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Seon-Hahn Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
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Podda M, Sylla P, Baiocchi G, Adamina M, Agnoletti V, Agresta F, Ansaloni L, Arezzo A, Avenia N, Biffl W, Biondi A, Bui S, Campanile FC, Carcoforo P, Commisso C, Crucitti A, De'Angelis N, De'Angelis GL, De Filippo M, De Simone B, Di Saverio S, Ercolani G, Fraga GP, Gabrielli F, Gaiani F, Guerrieri M, Guttadauro A, Kluger Y, Leppaniemi AK, Loffredo A, Meschi T, Moore EE, Ortenzi M, Pata F, Parini D, Pisanu A, Poggioli G, Polistena A, Puzziello A, Rondelli F, Sartelli M, Smart N, Sugrue ME, Tejedor P, Vacante M, Coccolini F, Davies J, Catena F. Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project. World J Emerg Surg 2021; 16:35. [PMID: 34215310 PMCID: PMC8254305 DOI: 10.1186/s13017-021-00378-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients. METHODS The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations. CONCLUSIONS The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.
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Affiliation(s)
- Mauro Podda
- Department of Emergency Surgery, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy.
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Gianluca Baiocchi
- ASST Cremona, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Michel Adamina
- Department of Colorectal Surgery, Cantonal Hospital of Winterthur, Winterthur - University of Basel, Basel, Switzerland
| | | | - Ferdinando Agresta
- Department of General Surgery, Vittorio Veneto Hospital, AULSS2 Trevigiana del Veneto, Vittorio Veneto, Italy
| | - Luca Ansaloni
- 1st General Surgery Unit, University of Pavia, Pavia, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Nicola Avenia
- SC Chirurgia Generale e Specialità Chirurgiche Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | - Walter Biffl
- Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA
| | - Antonio Biondi
- Department of General Surgery and Medical - Surgical Specialties, University of Catania, Catania, Italy
| | - Simona Bui
- Department of Medical Oncology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Fabio C Campanile
- Department of Surgery, ASL VT - Ospedale "San Giovanni Decollato - Andosilla", Civita Castellana, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara, University of Ferrara, Ferrara, Italy
| | - Claudia Commisso
- Department of Radiology, University Hospital of Parma, Parma, Italy
| | - Antonio Crucitti
- General and Minimally Invasive Surgery Unit, Cristo Re Hospital and Catholic University, Rome, Italy
| | - Nicola De'Angelis
- Unit of Minimally Invasive and Robotic Digestive Surgery, Regional General Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Gian Luigi De'Angelis
- Department of Medicine and Surgery, Gastroenterology and Endoscopy Unit, University of Parma, Parma, Italy
| | | | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | | | - Giorgio Ercolani
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | | | - Federica Gaiani
- Department of Medicine and Surgery, Gastroenterology and Endoscopy Unit, University of Parma, Parma, Italy
| | | | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ari K Leppaniemi
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Andrea Loffredo
- UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy
| | - Tiziana Meschi
- Department of Medicine and Surgery, University of Parma Geriatric-Rehabilitation Department, Parma University Hospital, Parma, Italy
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, USA
| | | | | | - Dario Parini
- Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Adolfo Pisanu
- Department of Emergency Surgery, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Andrea Polistena
- Dipartimento di Chirurgia Pietro Valdoni Policlinico Umberto I, Sapienza Università degli Studi di Roma, Rome, Italy
| | - Alessandro Puzziello
- UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy
| | - Fabio Rondelli
- SC Chirurgia Generale e Specialità Chirurgiche Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | | | | | - Michael E Sugrue
- Letterkenny University Hospital and CPM sEUBP Interreg Project, Letterkenny, Ireland
| | | | - Marco Vacante
- Department of General Surgery and Medical - Surgical Specialties, University of Catania, Catania, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
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Ruel M, Ramirez Garcia M, Arbour C. Transition from hospital to home after elective colorectal surgery performed in an enhanced recovery program: An integrative review. Nurs Open 2021; 8:1550-1570. [PMID: 34102021 PMCID: PMC8186688 DOI: 10.1002/nop2.730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 09/29/2020] [Accepted: 10/27/2020] [Indexed: 12/14/2022] Open
Abstract
AIM This study aimed to investigate the transition from hospital to home after elective colorectal surgery performed in an Enhanced Recovery After Surgery (ERAS) programme. DESIGN An integrative review. METHODS A search of ten electronic databases was conducted. Data extraction and quality assessment were performed independently by two authors. Data analysis and synthesis were based on Meleis' Transitions Theory (2010). RESULTS Forty-two articles were included, and most (N = 27) were of good or very good quality. The researchers identified five categories to document the nature of transition postsurgery, three conditions affecting such transition, eleven indicators informing about the quality of the transition and several nursing interventions. Overall, this review revealed that the transition from hospital to home after ERAS colorectal surgery is complex. A holistic understanding of this phenomenon may help nurses to recognize what they need to do to optimize the in-home recovery of this clientele.
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Affiliation(s)
| | - Maria‐Pilar Ramirez Garcia
- Faculty of NursingUniversité de MontréalMontréalQCCanada
- Research CenterCentre Hospitalier de l’Université de MontréalMontréalQCCanada
| | - Caroline Arbour
- Faculty of NursingUniversité de MontréalMontréalQCCanada
- Research CenterHôpital du Sacré‐Cœur de MontréalCIUSSS du Nord‐de‐l’Île‐de‐MontréalMontréalQCCanada
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Studniarek A, Borsuk DJ, Marecik SJ, Park JJ, Kochar K. Enhanced Recovery After Surgery Protocols. Does Frailty Play a Role? Am Surg 2020; 87:1054-1061. [PMID: 33295194 DOI: 10.1177/0003134820956357] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The 5-modified frailty index (mFI) is a valid predictor of 30-day mortality after surgery. With the wide implementation of enhanced recovery after surgery (ERAS) protocols in colorectal patients, the predictive power of frailty and its contribution to morbidity and length of stay (LOS) can be underestimated. METHODS We reviewed all colectomy patients undergoing ERAS protocol at a single, tertiary care institution from January 2016-January 2019. The 5-mFI score was calculated based on the presence of 5 comorbidities: Congestive heart failure (CHF), diabetes mellitus, chronic obstructive pulmonary disease, functional status, and hypertension (HTN). Multivariate analysis was used to assess the impact of 5-mFI score on morbidity, emergency department (ED) visits, readmissions, and LOS. RESULTS 360 patients were evaluated including 163 elderly patients. Frailer patients had a higher rate of ED visits (P = .024), readmissions (P = .029), and LOS (P < .001). Patients with CHF had a higher chance of prolonged LOS, whereas patients with HTN had a higher chance of ED. Elderly patients with an mFI score of 3 and 4 were likely to have longer LOS (P = .01, P = .07, respectively). Elderly patients with an mFI score of 4 were 15 times more likely to visit ED and 22 times more likely to be readmitted than patients with an mFI score of 0. DISCUSSION An increase in 5-mFI for elderly patients undergoing colorectal procedures increases ED visits or readmissions, and it correlates to a higher LOS, especially in elderly patients. This instrument should be used in the assessment of frail, elderly patients undergoing colorectal procedures.
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Affiliation(s)
- Adam Studniarek
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA.,Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Daniel J Borsuk
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Slawomir J Marecik
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - John J Park
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Kunal Kochar
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
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11
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Ifrach J, Basu R, Joshi DS, Flanders TM, Ozturk AK, Malhotra NR, Pessoa R, Kallan MJ, Maloney E, Welch WC, Ali ZS. Efficacy of an Enhanced Recovery After Surgery (ERAS) Pathway in Elderly Patients Undergoing Spine and Peripheral Nerve Surgery. Clin Neurol Neurosurg 2020; 197:106115. [DOI: 10.1016/j.clineuro.2020.106115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/25/2020] [Accepted: 07/25/2020] [Indexed: 01/22/2023]
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12
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Chan DKH, Ang JJ, Tan JKH, Chia DKA. Age is an independent risk factor for increased morbidity in elective colorectal cancer surgery despite an ERAS protocol. Langenbecks Arch Surg 2020; 405:673-689. [DOI: 10.1007/s00423-020-01930-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023]
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13
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Minimizing the impact of colorectal surgery in the older patient: The role of enhanced recovery programs in older patients. Eur J Surg Oncol 2020; 46:338-343. [DOI: 10.1016/j.ejso.2019.12.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 09/04/2019] [Accepted: 12/19/2019] [Indexed: 02/07/2023] Open
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14
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Crucitti A, Mazzari A, Tomaiuolo PM, Dionisi P, Diamanti P, Di Flumeri G, Donini LM, Bossola M. Enhanced Recovery After Surgery (ERAS) is safe, feasible and effective in elderly patients undergoing laparoscopic colorectal surgery: results of a prospective single center study. MINERVA CHIR 2020; 75:157-163. [PMID: 32083412 DOI: 10.23736/s0026-4733.20.08275-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND It is still unknown whether ERAS program is safe, feasible and effective in elderly patients undergoing laparoscopic colorectal surgery. In addition, the definition of the "old patient" in terms of age varies across the studies and different age cut-off, such as 65, 70, and 75 years have been used worldwide. METHODS All adult patients undergoing primary, elective colorectal laparoscopic surgery between January 2017 and December 2018 were considered eligible to follow the ERAS protocol according to the Enhanced Recovery After Surgery (ERAS) Society guidelines. Elderly were defined according three different cut-off values: <65 and ≥65 years, <70 and ≥70 years, <75 and ≥75 years. RESULTS One hundred and eight patients were included in the study. Adherence to protocol did not differ significantly between younger and older patients, for most of the items. Thirty-day mortality was absent. The frequency of postoperative complications globally considered and the frequency of the various single complications did not differ significantly between younger and older patients, independently of the cutoff considered to define the older age. Similarly, the frequency of re-intervention and readmission was similar in younger and older patients. Time to flatus and time to stool were similar in young and older patients, independently of the age cut-off used. Time to oral liquid diet was similar in patients with age <65 and ≥65 years while it was moderately longer in patients ≥70 years (1.5±1.1 days;) than in those <70 years (1.1±0.4 days; P=0.030) as well as in patients ≥75 years with respect to the younger ones (1.2±0.5 vs. 1.6±1.2 days; P=0.045). The time to oral solid feeding was similar in young and old patients, independently of the age cut-off used. Time to bladder catheter removal was significantly longer in older patients, independently of the age cut-off used, although the differences do not seem to be clinically relevant. The length of stay was significantly higher in older patients, when the cutoff of 70 years or 75 years was used, but did not differ significantly when the cut-off of 65 years was used. CONCLUSIONS The present study shows that the ERAS protocol is safe, feasible, and effective in elderly patients as in the young ones, undergoing laparoscopic elective colorectal surgery. This suggests that the ERAS program can be applied usefully to elderly patients in the routine clinical practice.
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Affiliation(s)
- Antonio Crucitti
- General and Minimally Invasive Surgery Unit, Cristo Re Hospital, Rome, Italy - .,Institute of General Surgery, Catholic University, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy -
| | - Andrea Mazzari
- General and Minimally Invasive Surgery Unit, Cristo Re Hospital, Rome, Italy
| | | | - Paolo Dionisi
- Department of Anesthesiology, Cristo Re Hospital, Rome, Italy
| | - Paolo Diamanti
- Department of Anesthesiology, Cristo Re Hospital, Rome, Italy
| | - Giada Di Flumeri
- General and Minimally Invasive Surgery Unit, Cristo Re Hospital, Rome, Italy
| | - Lorenzo M Donini
- Food Science and Human Nutrition Research Unit, Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Maurizio Bossola
- Hemodialysis Unit, Institute of Clinical Surgery, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
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Randomized Controlled Trial of Enhanced Recovery Program Dedicated to Elderly Patients After Colorectal Surgery. Dis Colon Rectum 2019; 62:1105-1116. [PMID: 31318772 DOI: 10.1097/dcr.0000000000001442] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Enhanced recovery program is a multimodal, multidisciplinary-team, evidence-based care approach to reduce perioperative surgical stress, decrease morbidity and hospital stay, and improve recovery after surgery. This program may be most beneficial for elderly (≥70 y), but sparse series have investigated this question. OBJECTIVE Feasibility and efficiency of a dedicated enhanced recovery program in the elderly as compared with standard care were studied. DESIGN This was a nonblinded, randomized controlled study. SETTINGS This study was conducted in a single high-volume university hospital. PATIENTS A total of 150 eligible elderly patients undergoing elective colorectal surgery were included. INTERVENTIONS Enhanced recovery after colorectal elective surgery in elderly patients was studied. MAIN OUTCOME MEASURES The primary outcome was 30-day postoperative morbidity. Additional outcomes included hospital stay, readmission, postoperative pain, opioid consumption, independence preservation, and protocol compliance. RESULTS An enhanced recovery program reduces postoperative morbidity according to Clavien-Dindo classification by 47% as compared with standard care (35% vs 65%; p = 0.0003), total number of complications (54 vs 118; p = 0.0003), and infectious complications (13 vs 29; p = 0.001). No anastomotic leak was recorded in the enhanced recovery group versus 5 for the standard group (p = 0.01). The enhanced recovery program resulted in shorter hospital stay (7 vs 12 d; p = 0.003) and better independence preservation (home discharge, 87% vs 67%; p = 0.005). A high protocol compliance of 77.2% could be achieved in this population. According to multivariate analysis, enhanced recovery program was strongly associated with reduced morbidity (OR = 0.23 (95% CI, 0.09-0.57); p = 0.001), less severe complications (OR = 0.36 (95% CI, 0.15-0.84); p = 0.02), and shorter hospital stay (OR = 2.07 (95% CI, 1.33-3.22); p = 0.001). LIMITATIONS Limitations were a single-center recruitment and the impossibility of subject or healthcare professional blinding attributed to the nature of this multimodal program. CONCLUSIONS Enhanced recovery program is safe and improves postoperative recovery in elderly patients with decreased morbidity, shorter hospital stay, and better maintenance of independence. It should therefore be considered as a standard of care for elective colorectal surgery in elderly patients. See Video Abstract at http://links.lww.com/DCR/A981. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT01646190. ENSAYO CONTROLADO ALEATORIZADO DE UN PROGRAMA DE RECUPERACIÓN INTENSIFICADA DEDICADO A PACIENTES DE EDAD AVANZADA DESPUÉS DE CIRUGÍA COLORECTAL: El Programa de Recuperación Intensificada es un enfoque de atención multimodal, multidisciplinaria y basada en evidencia para reducir el estrés quirúrgico perioperatorio, disminuir la morbilidad y la estancia hospitalaria, y mejorar la recuperación después de la cirugía. Este programa puede ser más beneficioso para las personas mayores (≥70 años), pero pocas series han investigado esta pregunta. OBJETIVO Viabilidad y eficiencia del Programa de Recuperación Intensificada dedicado en personas de edad avanzada en comparación con la atención estándar. DISEÑO:: Este fue un estudio controlado, aleatorizado, sin método ciego. ESCENARIO Este estudio se realizó en un único hospital universitario de alto volumen. PACIENTES Un total de 150 pacientes de edad avanzada elegibles sometidos a cirugía colorrectal electiva fueron incluidos. INTERVENCIONES Recuperación Intensificada después de cirugía electiva colorrectal en pacientes de edad avanzada. PRINCIPALES MEDIDAS DE RESULTADO El resultado primario fue la morbilidad postoperatoria a 30 días. Los resultados adicionales incluyeron estancia hospitalaria, reingreso, dolor postoperatorio, consumo de opioides, preservación de la independencia y cumplimiento del protocolo. RESULTADOS El Programa de Recuperación Intensificada reduce la morbilidad postoperatoria según la clasificación de Clavien-Dindo en un 47% en comparación con la atención estándar (35% vs 65%; p = 0.0003), número total de complicaciones (54 vs 118; p = 0.0003) y complicaciones infecciosas (13 vs 29; p = 0.001). No se registró ninguna fuga anastomótica en el grupo de Recuperación Intensificada frente a 5 para el grupo estándar (p = 0.01). El Programa de Recuperación Intensificada dio como resultado una estancia hospitalaria más corta (7 contra 12 días; p = 0.003) y una mejor conservación de la independencia (alta hospitalaria: 87% vs 67%; p = 0.005). Se pudo lograr un alto cumplimiento del protocolo del 77.2% en esta población. De acuerdo con el análisis multivariable, el Programa de Recuperación Intensificada se asoció fuertemente con la reducción de morbilidad (OR = 0.23; IC 95%: 0.09-0.57; p = 0.001), menos complicaciones graves (OR = 0.36; IC 95%: 0.15-0.84; p = 0.02) y estancia hospitalaria más corta (OR = 2.07; IC 95%: 1.33-3.22; p = 0.001). LIMITACIONES Las limitaciones fueron un centro único de reclutamiento y la imposibilidad de que los pacientes o el profesional de la salud tuvieran cegamiento debido a la naturaleza de este programa multimodal. CONCLUSIONES El Programa de recuperación Intensificada es seguro y mejora la recuperación postoperatoria en pacientes de edad avanzada, con menor morbilidad, menor estancia hospitalaria y mejor mantenimiento de la independencia. Por lo tanto, debe considerarse como un estándar de atención para la cirugía colorrectal electiva en pacientes de edad avanzada. Vea el Resumen en video en http://links.lww.com/DCR/A981.
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Fagard K, Wolthuis A, D'Hoore A, Verhaegen M, Tournoy J, Flamaing J, Deschodt M. A systematic review of the intervention components, adherence and outcomes of enhanced recovery programmes in older patients undergoing elective colorectal surgery. BMC Geriatr 2019; 19:157. [PMID: 31170933 PMCID: PMC6555702 DOI: 10.1186/s12877-019-1158-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 05/13/2019] [Indexed: 12/20/2022] Open
Abstract
Background Enhanced recovery programmes (ERPs) aim to attenuate the surgical stress response and accelerate recovery after surgery, but are not specifically designed for older patients. The objective of this study was to review the components, adherence and outcomes of ERPs in older patients (≥65 years) undergoing elective colorectal surgery. Methods Pubmed, Embase and Cinahl were searched between 2000 and 2017 for randomised and non-randomised controlled trials, before-after studies, and observational studies. The methodological quality of the studies was evaluated using the MINORS quality assessment. The review was performed and reported according to the PRISMA guidelines. Results Twenty-one studies, including 3495 ERP patients aged ≥65 years, were identified. The ERPs consisted of a median of 13 intervention components. Adherence rates were reported in 9 studies and were the highest (≥80%) for pre-admission counselling, no bowel preparation, limited pre-operative fasting, antithrombotic and antimicrobial prophylaxis, no nasogastric tube, active warming, and limited intra-operative fluids. The median post-operative length of stay was 6 days. The median post-operative morbidity rate (Clavien-Dindo I-IV) was 23.5% in-hospital and 29.8% at 30 days. The in-hospital post-operative mortality rate was 0% in most studies and amounted to a median of 1.4% at 30 days. The median 30-day readmission rate was 4.9% and the median reoperation rate was 5.0%. Conclusions ERPs in older patients were in accordance with the ERP consensus guidelines. Although the number of intervention components applied increased over time, outcomes in earlier and later studies remained comparable. Adherence rates were under-reported. Future studies should explore adherence and age-related factors, such as frailty profile, that could influence adherence. Trial registration PROSPERO 2018 CRD42018084756. Electronic supplementary material The online version of this article (10.1186/s12877-019-1158-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katleen Fagard
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.
| | - Albert Wolthuis
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Abdominal Surgical Oncology, KU Leuven, Leuven, Belgium
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Abdominal Surgical Oncology, KU Leuven, Leuven, Belgium
| | - Marleen Verhaegen
- Department of Anaesthesia, University Hospitals Leuven, Leuven, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium
| | - Johan Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium
| | - Mieke Deschodt
- Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium.,Institute of Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
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17
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Bhardwaj N. Enhanced recovery after surgery. J Anaesthesiol Clin Pharmacol 2019; 35:S3-S4. [PMID: 31142952 PMCID: PMC6515718 DOI: 10.4103/joacp.joacp_57_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Neerja Bhardwaj
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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18
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Enhanced Recovery Program for Colorectal Surgery: a Focus on Elderly Patients Over 75 Years Old. J Gastrointest Surg 2019; 23:587-594. [PMID: 30187323 DOI: 10.1007/s11605-018-3943-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 08/20/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND An enhanced recovery after surgery (ERAS) protocol can effectively improve perioperative outcomes in surgical patients by reducing complication rates and hospital stay. However, its application in elderly patients has yielded contradictory results. The aim of this study was to evaluate surgical outcomes in a cohort of elderly patients undergoing colorectal resection in our unit before and after the introduction of ERAS. METHODS From 328 patients undergoing colorectal surgery in our unit over a 2-year period (2015-2016), 114 patients ≥ 75 years of age were selected. The patients were categorized according to perioperative treatment as pre-ERAS and ERAS patients (respectively, 53 vs 61 patients), and the groups were compared for statistical purposes. Outcome measures included length of hospital stay, recovery of bowel functions, oral feeding, postoperative complications, and readmissions. Compliance with the ERAS protocol was also measured. RESULTS Groups were homogeneous for all the clinical-surgical variables, with the sole exception of the Charlson index, which was more severe in the ERAS group (p = 0.012). Compared with control patients, ERAS patients reported improved functional recovery (time to first flatus, stool, and oral feeding; p < 0.001). Hospital stay was reduced in ERAS patients overall and by side of resection, excluding rectal procedures. No differences were observed regarding postoperative complications. Of note, an optimal adherence to the protocol was reported, with 79% of items respected. CONCLUSIONS ERAS can be considered safe in elderly patients undergoing colorectal surgery with a high comorbidity index, providing a reduction in hospital stay and improving short-term postoperative outcomes. Finally, the protocol application was feasible, with a high adherence to the items in this subset of patients.
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Lee GC, Hodin RA. Applying Enhanced Recovery Pathways to Unique Patient Populations. Clin Colon Rectal Surg 2019; 32:134-137. [PMID: 30833863 DOI: 10.1055/s-0038-1676479] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Enhanced Recovery after Surgery (ERAS) pathways have become popular in colorectal surgery due to their associated decrease in length of stay (LOS), complications, and readmission rate. However, it is unclear if these pathways are safe, feasible, or effective in unique patient populations such as elderly patients, urgent/emergent surgeries, patients with specific comorbidities, inflammatory bowel disease, or pediatric patients. Enhanced recovery pathways appear safe in elderly patients, associated with decreased complications, though with slightly lower rates of adherence and increased LOS and readmission rates. Modified ERAS pathways have been applied to urgent and emergent surgeries, resulting in decreased morbidity and LOS. There have been no studies that performed subgroup analyses of ERAS pathways in patients with specific comorbidities. Studies investigating patients with inflammatory bowel disease on enhanced recovery pathways are extremely limited, but suggest that they are safe and feasible. Data on ERAS pathways in pediatric patients are still emerging. Therefore, though data are sparse, enhanced recovery pathways appear to be safe in unique patient populations, with similar efficacy in decreasing LOS and complications. There is an urgent need for more studies investigating these specific patient groups to aid perioperative decision making by colorectal surgeons.
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Affiliation(s)
- Grace C Lee
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Richard A Hodin
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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20
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Meddings J, Skolarus TA, Fowler KE, Bernstein SJ, Dimick JB, Mann JD, Saint S. Michigan Appropriate Perioperative (MAP) criteria for urinary catheter use in common general and orthopaedic surgeries: results obtained using the RAND/UCLA Appropriateness Method. BMJ Qual Saf 2019; 28:56-66. [PMID: 30100564 PMCID: PMC6365917 DOI: 10.1136/bmjqs-2018-008025] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 06/12/2018] [Accepted: 06/30/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Indwelling urinary catheters are commonly used for patients undergoing general and orthopaedic surgery. Despite infectious and non-infectious harms of urinary catheters, there is limited guidance available to surgery teams regarding appropriate perioperative catheter use. OBJECTIVE Using the RAND Corporation/University of California Los Angeles (RAND/UCLA) Appropriateness Method, we assessed the appropriateness of indwelling urinary catheter placement and different timings of catheter removal for routine general and orthopaedic surgery procedures. METHODS Two multidisciplinary panels consisting of 13 and 11 members (physicians and nurses) for general and orthopaedic surgery, respectively, reviewed the available literature regarding the impact of different perioperative catheter use strategies. Using a standardised, multiround rating process, the panels independently rated clinical scenarios (91 general surgery, 36 orthopaedic surgery) for urinary catheter placement and postoperative duration of use as appropriate (ie, benefits outweigh risks), inappropriate or of uncertain appropriateness. RESULTS Appropriateness of catheter use varied by procedure, accounting for procedure-specific risks as well as expected procedure time and intravenous fluids. Procedural appropriateness ratings for catheters were summarised for clinical use into three groups: (1) can perform surgery without catheter; (2) use intraoperatively only, ideally remove before leaving the operating room; and (3) use intraoperatively and keep catheter until postoperative days 1-4. Specific recommendations were provided by procedure, with postoperative day 1 being appropriate for catheter removal for first voiding trial for many procedures. CONCLUSION We defined the appropriateness of indwelling urinary catheter use during and after common general and orthopaedic surgical procedures. These ratings may help reduce catheter-associated complications for patients undergoing these procedures.
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Affiliation(s)
- Jennifer Meddings
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Ted A Skolarus
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Karen E Fowler
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Steven J Bernstein
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Justin B Dimick
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jason D Mann
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Sanjay Saint
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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21
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Singh M, Askari R, Stopfkuchen-Evans M. Enhanced Recovery After Surgery: Are the Principles Applicable to Adult and Geriatric Acute Care and Trauma Surgery? Anesthesiol Clin 2018; 37:67-77. [PMID: 30711234 DOI: 10.1016/j.anclin.2018.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The incorporation of enhanced recovery after surgery (ERAS) fundamentals into perioperative medicine has improved the patient care experience and hastened recovery time while reducing hospital costs. Research studies have shown that incorporating ERAS principles in the adult or geriatric acute care surgery populations minimizes time to resumption of preoperative activity and reduces hospital length of stay. ERAS principles are widely applicable to these patient cohorts and may be applicable in trauma patients. Increased physician and nursing education to promote widespread utilization of enhanced recovery protocols will further improve quality of health care administered in the twenty-first century.
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Affiliation(s)
- Mandeep Singh
- Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, Keck Medical Center, University of Southern California, 1450 San Pablo Street, Suite 3600, Los Angeles, CA 90033, USA.
| | - Reza Askari
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Matthias Stopfkuchen-Evans
- Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, CWN L1, Boston, MA 02115, USA
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22
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Gülcü B, Yılmazlar T, Işık Ö, Öztürk E. Colorectal cancer surgery in octogenarians. Turk J Surg 2018; 34:271-275. [PMID: 30248298 DOI: 10.5152/turkjsurg.2018.4018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 01/26/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The incidence of colorectal cancer becomes higher among octogenarians as the life expectancy increases. Whether advanced age is a risk factor for colorectal surgery is a matter of debate. In the present study, the clinical results of octogenarians who underwent colorectal cancer surgery are discussed to find an answer to this question. MATERIAL AND METHODS Data of 63 octogenarians who were operated in a tertiary colorectal surgery department between January 1, 2010 and December 31, 2013 were reviewed retrospectively. Demographic data and preoperative, peroperative, and postoperative parameters were evaluated. RESULTS Overall, 57.2% of the patients were men. The median age was 81 (80-89) years. Cancer was located at the right colon in 17.5%, left colon in 50.8%, and rectum in 31.7%. Eleven patients underwent emergency surgery (17.5%). The most common surgical procedure was low anterior resection in elective (22.2%) and Hartmann's procedure in the emergency setting (9.5%). Stoma creation was more frequent among patients undergoing emergency procedures (42% vs. 6.8%; p=0.0018). Histopathological diagnosis was adenocarcinoma in 90.5% of the patients, and 34.9% of the patients had stage IIIB disease. Surgical morbidity was significantly higher among patients who underwent rectal resection (66% vs. 10.2%; p=0.0124). Medical morbidity was observed in 10 (15.9%) patients. Preoperative blood transfusion was a risk factor for morbidity (83.4% vs. 29.8%; p=0.0170). Length of total hospital stay was 14 (3-39) days. Surgical (p=0.0004) and medical (p=0.0288) morbidity prolonged the length of total hospital stay. The overall mortality rate was 1.6%. CONCLUSION Colorectal surgery may be safely performed in octogenarians with acceptable morbidity and mortality in specialized centers.
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Affiliation(s)
- Barış Gülcü
- Department of General Surgery, Uludag University School of Medicine, Bursa, Turkey
| | - Tuncay Yılmazlar
- Department of General Surgery, Uludag University School of Medicine, Bursa, Turkey
| | - Özgen Işık
- Department of General Surgery, Uludag University School of Medicine, Bursa, Turkey
| | - Ersin Öztürk
- Department of General Surgery, Uludag University School of Medicine, Bursa, Turkey
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23
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Tejedor P, Pastor C, Gonzalez-Ayora S, Ortega-Lopez M, Guadalajara H, Garcia-Olmo D. Short-term outcomes and benefits of ERAS program in elderly patients undergoing colorectal surgery: a case-matched study compared to conventional care. Int J Colorectal Dis 2018; 33:1251-1258. [PMID: 29721734 DOI: 10.1007/s00384-018-3057-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of the study was to evaluate the benefits of implementing Enhanced Recovery After Surgery (ERAS) protocols in elderly patients undergoing elective colorectal surgery. METHODS A retrospective non-randomized cohort study was conducted from September 2012 to December 2016. We included patients ≥ 70 years undergoing elective colorectal surgery. Outcome measures, compliance with interventions, and postoperative complications of patients treated under ERAS were case-matched (based on gender, age, type of surgery, and the presence/absence of a temporal stoma) to a retrospective group of patients ≥ 70 years treated under conventional care. RESULTS A total of 312 patients (156 ERAS vs. 156 non-ERAS) were included in the study. The ERAS group had a significant reduction of grade III/IV Dindo-Clavien's postoperative complications when compared with conventional care. ERAS had a positive effect in reducing anastomotic leakage (14.7% non-ERAS vs. 9%) and postoperative mortality (11.5% non-ERAS vs. 1.9% ERAS; p = 0.001). A reduction of 2 days in length of hospital stay was achieved after implementing ERAS (8 (6.75) vs. 6 (5.25); p < 0.0001), while readmission rates remained unaffected. The average of global compliance (GC) with all ERAS interventions was 42%. GC was significantly lower in patients with permanent/temporary stomas and in patients in whom an open approach was performed. CONCLUSION In our experience, ERAS should be implemented without reservations in elderly patients expecting the same goals and benefits as with other age groups. Barriers in achieving a high compliance rate are common and will require a great effort in patient's education, an intensive perioperative care, and sometimes a change in the surgeons' practice.
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Affiliation(s)
- Patricia Tejedor
- Department of General Surgery, Division of Colorectal Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain.
| | - Carlos Pastor
- Department of General Surgery, Division of Colorectal Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Santiago Gonzalez-Ayora
- Department of General Surgery, Division of Colorectal Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Mario Ortega-Lopez
- Department of General Surgery, Division of Colorectal Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Hector Guadalajara
- Department of General Surgery, Division of Colorectal Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Damian Garcia-Olmo
- Department of General Surgery, Division of Colorectal Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
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Pędziwiatr M, Mavrikis J, Witowski J, Adamos A, Major P, Nowakowski M, Budzyński A. Current status of enhanced recovery after surgery (ERAS) protocol in gastrointestinal surgery. Med Oncol 2018; 35:95. [PMID: 29744679 PMCID: PMC5943369 DOI: 10.1007/s12032-018-1153-0] [Citation(s) in RCA: 170] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 05/03/2018] [Indexed: 02/07/2023]
Abstract
Enhanced Recovery After Surgery (ERAS) is an evidence-based paradigm shift in perioperative care, proven to lower both recovery time and postoperative complication rates. The role of ERAS in several surgical disciplines was reviewed. In colorectal surgery, ERAS protocol is currently well established as the best care. In gastric surgery, 2014 saw an establishment of ERAS protocol for gastrectomies with resulting meta-analysis showing ERAS effectiveness. ERAS has also been shown to be beneficial in liver surgery with many centers starting implementation. The advantages of ERAS in pancreatic surgery have been strongly established, but there is still a need for large-scale, multicenter randomized trials. Barriers to implementation were analyzed, with recent studies concluding that successful implementation requires a multidisciplinary team, a willingness to change and a clear understanding of the protocol. Additionally, the difficulty in accomplishing necessary compliance to all protocol items calls for new implementation strategies. ERAS success in different patient populations was analyzed, and it was found that in the elderly population, ERAS shortened the length of hospitalization and did not lead to a higher risk of postoperative complications or readmissions. ERAS utilization in the emergency setting is possible and effective; however, certain changes to the protocol may need to be adapted. Therefore, further research is needed. There remains insufficient evidence on whether ERAS actually improves patients’ course in the long term. However, since most centers started to implement ERAS protocol less than 5 years ago, more data are expected.
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Affiliation(s)
- Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Krakow, Poland. .,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland.
| | - Judene Mavrikis
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Krakow, Poland
| | - Jan Witowski
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Krakow, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Alexandros Adamos
- Carol Davila University of Medicine and Pharmacy, Sector 1, Strada Dionisie Lupu 37, 030167, Bucharest, Romania
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Krakow, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Michał Nowakowski
- Department of Medical Education, Jagiellonian University Medical College, św. Łazarza 16, 31-530, Krakow, Poland
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Krakow, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
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25
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Wang LH, Zhu RF, Gao C, Wang SL, Shen LZ. Application of enhanced recovery after gastric cancer surgery: An updated meta-analysis. World J Gastroenterol 2018; 24:1562-1578. [PMID: 29662294 PMCID: PMC5897860 DOI: 10.3748/wjg.v24.i14.1562] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/03/2018] [Accepted: 03/06/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To provide an updated assessment of the safety and efficacy of enhanced recovery after surgery (ERAS) protocols in elective gastric cancer (GC) surgery.
METHODS PubMed, Medline, EMBASE, World Health Organization International Trial Register, and Cochrane Library were searched up to June 2017 for all available randomized controlled trials (RCTs) comparing ERAS protocols and standard care (SC) in GC surgery. Thirteen RCTs, with a total of 1092 participants, were analyzed in this study, of whom 545 underwent ERAS protocols and 547 received SC treatment.
RESULTS No significant difference was observed between ERAS and control groups regarding total complications (P = 0.88), mortality (P = 0.50) and reoperation (P = 0.49). The incidence of pulmonary infection was significantly reduced (P = 0.03) following gastrectomy. However, the readmission rate after GC surgery nearly tripled under ERAS (P = 0.009). ERAS protocols significantly decreased the length of postoperative hospital stay (P < 0.00001) and medical costs (P < 0.00001), and accelerated bowel function recovery, as measured by earlier time to the first flatus (P = 0.0004) and the first defecation (P < 0.0001). Moreover, ERAS protocols were associated with a lower level of serum inflammatory response, higher serum albumin, and superior short-term quality of life (QOL).
CONCLUSION Collectively, ERAS results in accelerated convalescence, reduction of surgical stress and medical costs, improved nutritional status, and better QOL for GC patients. However, high-quality multicenter RCTs with large samples and long-term follow-up are needed to more precisely evaluate ERAS in radical gastrectomy.
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Affiliation(s)
- Liu-Hua Wang
- Division of Gastrointestinal Surgery, Department of General Surgery, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
- Department of General Surgery, Yizheng People’s Hospital, Yangzhou 211400, Jiangsu Province, China
| | - Ren-Fei Zhu
- Division of Gastrointestinal Surgery, Department of General Surgery, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Cheng Gao
- Division of Gastrointestinal Surgery, Department of General Surgery, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Shou-Lin Wang
- School of Public Health, Nanjing Medical University, Nanjing 211166, Jiangsu Province, China
| | - Li-Zong Shen
- Division of Gastrointestinal Surgery, Department of General Surgery, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
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26
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Enhanced Recovery Program in High-Risk Patients Undergoing Colorectal Surgery: Results from the PeriOperative Italian Society Registry. World J Surg 2017; 41:860-867. [PMID: 27766398 DOI: 10.1007/s00268-016-3766-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) pathways represent the optimal approach for patients undergoing colorectal surgery. Elderly or low physical status patients have been often excluded from ERAS pathways because considered at high risk. The aim of this study is to assess the adherence to ERAS protocol and its impact on short-term postoperative outcome in patients with different surgical risk undergoing elective colorectal resection. METHODS Prospectively collected data entered in an electronic Italian registry specifically designed for ERAS were reviewed. Patients were divided into four groups according to age (70-year-old cutoff) and preoperative physical status as measured by the ASA grade (I-II vs. III-IV). Adherence to 18 ERAS elements and postoperative outcomes were compared between groups. Regression analysis was used to identify independent factors associated with improved outcomes. RESULTS Eleven Italian hospitals reported data on 706 patients undergoing elective colorectal surgery within an ERAS protocol. Patients with low physical status had reduced adherence to preoperative carbohydrate loading, epidural analgesia, PONV prophylaxis, and early urinary catheter removal. No difference was found between groups for adherence to other perioperative elements. Major complications occurred in 37 (5.2 %) patients without significant differences among groups (p = 0.384). Median (IQR) time to readiness for discharge (TRD) was 4 (3-6) days, length of hospital stay (LOS) was 6 (4-7) days, and both were significantly shorter by only 1 day in the groups of younger patients (p < 0.001). At multivariate analysis, laparoscopy increased adherence to ERAS items and reduced TRD, LOS, and morbidity. A high ASA grade was significantly associated with lower adherence, whereas older age significantly prolonged TRD and LOS. CONCLUSION ERAS pathway can be safely applied in elderly and low physical status patients yielding slight differences in postoperative morbidity and time to recover. Laparoscopy was independently associated with increased adherence to ERAS protocol and improved short-term postoperative outcome.
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27
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Zeng WG, Liu MJ, Zhou ZX, Wang ZJ. Enhanced recovery programme following laparoscopic colorectal resection for elderly patients. ANZ J Surg 2017. [PMID: 28640971 DOI: 10.1111/ans.14074] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The aim of this study was to investigate the feasibility and safety of an enhanced recovery programme (ERP) in patients aged ≥75 years who undergo laparoscopic surgery for colorectal cancer. METHODS Patients were divided into two groups according to perioperative management: the ERP group (Group A, n = 94) and the conventional perioperative care group (Group B, n = 157). The postoperative outcomes were compared between two groups. RESULTS There were no differences in terms of age, gender, American Society of Anesthesiologists score, operative time or blood loss between two groups. Postoperative return of gastrointestinal function was significantly faster in Group A compared to Group B, including time to first flatus (2 versus 3 days, P < 0.001), first stool (3 versus 4 days, P = 0.001) and oral intake (1 versus 4 days, P < 0.001). Group A was associated with lower overall postoperative complication rate (26.6% versus 44.6%, P = 0.004) and general complication rate (14.9% versus 31.2%, P = 0.004). The median postoperative hospital stay was 6 days in Group A and 8 days in Group B (P < 0.001), respectively. CONCLUSIONS ERP following laparoscopic colorectal resection for elderly patients is associated with faster postoperative recovery, shorter postoperative hospital stay and fewer complications compared with conventional perioperative care.
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Affiliation(s)
- Wei Gen Zeng
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Meng Jia Liu
- Department of Ultrasound, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Zhi Xiang Zhou
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Zhen Jun Wang
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Braga M, Beretta L, Pecorelli N, Maspero M, Casiraghi U, Borghi F, Pellegrino L, Bona S, Monzani R, Ferrari G, Radrizzani D, Iuliani R, Bima C, Scatizzi M, Missana G, Guicciardi MA, Muratore A, Crespi M, Bouzari H, Ceretti AP, Ficari F. Enhanced recovery pathway in elderly patients undergoing colorectal surgery: is there an effect of increasing ages? Results from the perioperative Italian Society Registry. Updates Surg 2017. [PMID: 28620897 DOI: 10.1007/s13304-017-0474-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Previous studies reported that enhanced recovery pathway (ERP) is safe in elderly who did not require a specifically tailored protocol. In previous studies, elderly have been considered as a homogeneous cohort and the cut-off value to identify them was different. The aim of the present study is to assess the compliance to ERP and its impact on postoperative outcome in three subgroups of elderly patients with increasing ages. Prospectively collected data entered in an electronic Italian registry specifically designed for ERP were reviewed. 315 elderly patients undergoing elective colorectal resection were divided into three groups. Group 1: 71-75 years (n = 105), Group 2: 76-80 years (n = 117), Group 3: over 80 years (n = 93). Primary endpoints of the study were adherence to ERP and time to readiness for discharge (TRD). Compliance to ERP was similar in the three groups. No difference among groups was found for mortality, overall morbidity, major complications, reoperation rate and readmission rate. Median TRD and length of hospital stay (LOS) were progressively longer with increasing age (p = 0.018 and p = 0.078, respectively). Increasing age did not impact on adherence to ERP and postoperative morbidity, but delayed both TRD and LOS.
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Affiliation(s)
- Marco Braga
- Department of Surgery, San Raffaele Hospital, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy.
| | - Luigi Beretta
- Department of Anesthesiology, San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Nicolò Pecorelli
- Department of Surgery, San Raffaele Hospital, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy
| | - Marianna Maspero
- Department of Surgery, San Raffaele Hospital, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy
| | - Umberto Casiraghi
- Department of Surgery, San Raffaele Hospital, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy
| | | | | | - Stefano Bona
- Department of Surgery, Humanitas Hospital Milan, Milan, Italy
| | - Roberta Monzani
- Department of Anesthesiology, Humanitas Hospital Milan, Milan, Italy
| | | | | | | | - Carlo Bima
- Department of Surgery, Cottolengo Hospital Turin, Turin, Italy
| | | | | | | | | | - Michele Crespi
- Department of Surgery, Luigi Sacco Hospital, Milan, Italy
| | - Hedayat Bouzari
- Department of Surgery, Mauriziano Hospital Turin, Turin, Italy
| | | | - Ferdinando Ficari
- Department of Surgery, Careggi Hospital, University of Florence, Florence, Italy
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29
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Pirrera B, Lucchi A, Gabbianelli C, Alagna V, Martorelli G, Berti P, Panzini I, Fabbri E, Garulli G. E.R.A.S. pathway in colorectal surgery in elderly: Our experience: A retrospective cohort study. Int J Surg 2017; 43:101-106. [PMID: 28483663 DOI: 10.1016/j.ijsu.2017.05.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/29/2017] [Accepted: 05/02/2017] [Indexed: 02/08/2023]
Abstract
AIM Numerous geriatric patients develop colorectal disease. Elderly patients are often considered high-risk surgical candidates. Enhanced recovery after surgery (E.R.A.S.) has been proven to be beneficial for patients. The aim of the study was to evaluate the results of an ERAS protocol in older patients that underwent colorectal surgery compared to younger patients. METHOD In the period between January 2010 to December 2015 a total of 589 patients underwent elective colorectal surgical interventions treated within the E.R.A.S pathway: 211 patients younger than 65 years, 175 patients aged from 66 years to 75 years, and 203 patients older than 75 years. End point of interest were postoperative complications, 90-day mortality, length of hospital stay and readmission within 30 days. RESULTS Significant differences between the three groups were observed for comorbidities (p:0.001); in particular older patients had significantly more diabetes, renal, cardiac, and respiratory diseases, ASA (p < 0.001), presence of malignancy (p < 0.001). However there were not differences between the groups in surgical procedures (p = 0.095), operative time (p = 0.823), anastomotic leakage (p = 0.960), hospital stay (p = 0.081), readmission rate (p = 0.904), 90-days mortality (p = 0.183) and morbidity (p = 0.973) in accordance with Clavien-Dindo classification. Multivariate logistic regression analysis showed that advanced age in E.R.A.S. pathway is not a predictive factor of morbidity, readmission within 30 days and 90-day mortality. CONCLUSION There was no significant difference in morbidity, 90-day mortality, length of stay or readmission rate in patients aged over 75 years compared with younger patients. Old age does not represent a contraindication to the implementation of the E.R.A.S protocol in patients that underwent colorectal surgery. WHAT DOES THIS PAPER ADD TO THE EXISTING LITERATURE?: In the literature there are not many studies that address the impact of older age in the treatment of colorectal disease in an ERAS program. The aging of the population raises new questions in the management of the colorectal surgery in the elderly. ERAS pathway has been proven to be beneficial for patients, which results in a reduction of postoperative morbidity. Compared to what is reported in the literature this study confirms that ERAS program in colorectal surgery can be applied in older patients with no significant difference in morbidity, 90-day mortality, length of stay or readmission rate compared with younger.
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Affiliation(s)
- Basilio Pirrera
- General, Thoracic and Minimally Invasive Surgery, Ceccarini Hospital, Riccione, Italy.
| | - Andrea Lucchi
- General, Thoracic and Minimally Invasive Surgery, Ceccarini Hospital, Riccione, Italy
| | - Carlo Gabbianelli
- General, Thoracic and Minimally Invasive Surgery, Ceccarini Hospital, Riccione, Italy
| | - Vincenzo Alagna
- General, Thoracic and Minimally Invasive Surgery, Ceccarini Hospital, Riccione, Italy
| | - Giacomo Martorelli
- General, Thoracic and Minimally Invasive Surgery, Ceccarini Hospital, Riccione, Italy
| | - Pierluigi Berti
- General, Thoracic and Minimally Invasive Surgery, Ceccarini Hospital, Riccione, Italy
| | - Ilaria Panzini
- General, Thoracic and Minimally Invasive Surgery, Ceccarini Hospital, Riccione, Italy
| | - Elisabetta Fabbri
- General, Thoracic and Minimally Invasive Surgery, Ceccarini Hospital, Riccione, Italy
| | - Gianluca Garulli
- General, Thoracic and Minimally Invasive Surgery, Ceccarini Hospital, Riccione, Italy
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Forsmo HM, Erichsen C, Rasdal A, Körner H, Pfeffer F. Enhanced Recovery After Colorectal Surgery (ERAS) in Elderly Patients Is Feasible and Achieves Similar Results as in Younger Patients. Gerontol Geriatr Med 2017; 3:2333721417706299. [PMID: 28516129 PMCID: PMC5419065 DOI: 10.1177/2333721417706299] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 03/22/2017] [Accepted: 03/27/2017] [Indexed: 12/17/2022] Open
Abstract
Aim: Enhanced recovery after surgery (ERAS) is a multimodal approach that aims to optimize perioperative treatment. Whether elderly patients receiving colorectal surgery can adhere to and benefit from an ERAS approach is uncertain. The aim of this study was to compare patients in different age groups participating in an ERAS program. Method: In this substudy of a randomized controlled trial, we analyzed the interventional ERAS arm of adult patients eligible for laparoscopic or open colorectal resection with regard to the importance of age. Patients were divided into three groups based on age: ≤65 years (n = 79), 66-79 years (n = 56), and ≥80 years (n = 19). The primary end point was total postoperative hospital stay (THS). Secondary end points were postoperative hospital stay, postoperative complications, postoperative C-reactive protein levels, readmission rate, mortality, and patient adherence to the different ERAS elements. All parameters and measuring the adherence to the ERAS protocol were recorded before surgery, on the day of the operation, and daily until discharge. Results: There were no significant differences in length of THS between age groups (≤65 years, median 5 [range 2-47] days; 66-79 years, median 5.5 [range 2-36] days; ≥80 years, median 7 [range 3-50] days; p = .53). All secondary outcomes were similar between age groups. Patient adherence to the ERAS protocol was as good in the elderly as it was in the younger patients. Conclusion: Elderly patients adhered to and benefited from an ERAS program, similar to their younger counterparts.
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Affiliation(s)
| | | | - Anne Rasdal
- Haukeland University Hospital, Bergen, Norway
| | - Hartwig Körner
- University of Bergen, Norway.,Stavanger University Hospital, Norway
| | - Frank Pfeffer
- Haukeland University Hospital, Bergen, Norway.,University of Bergen, Norway
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Zouros E, Liakakos T, Machairas A, Patapis P, Tzerbinis H, Manatakis DK, Papadimitriou-Olivgeris M, Dervenis C. Fast-Track Pancreaticoduodenectomy in the Elderly. Am Surg 2017. [DOI: 10.1177/000313481708300318] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
It remains uncertain whether enhanced recovery after surgery (ERAS) protocols can be safely implemented for elderly patients, especially after highly complex surgery such as pancreaticoduodenectomy (PD). The present study was designed to assess the feasibility and safety of an ERAS protocol in elderly patients undergoing PD. Starting January 2010 to February 2015, we prospectively collected data from 85 consecutive patients who underwent PD with a fast-track program. Data of patients older and younger than 70 years were compared. Endpoints were morbidity, mortality, readmissions, length of stay, and compliance with ERAS elements. Forty-five patients were less than 70 years old and 40 patients were 70 years of age or older. Both mortality (4.4% vs 5%; P = 1.000) and overall morbidity (33.3% vs 37.5%; P = 0.821) did not differ significantly between the groups. Rates of intervention and relaparotomy were similar in both groups. Length of stay (10 vs 11.8 days; P = 0.099) did not differ significantly between the groups, nor did the readmission rates (6.7% vs 5.0%; P = 0.272). There were no differences in compliance with ERAS elements between groups. An ERAS program seems feasible and can be safely implemented for elderly patients undergoing PD.
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Affiliation(s)
- Efstratios Zouros
- Department of Surgery, “Konstantopouleio” General Hospital, Athens, Greece
| | | | | | - Paulos Patapis
- Third Department of Surgery, Attiko University Hospital, Athens, Greece
| | - Helen Tzerbinis
- Department of Surgery, “Konstantopouleio” General Hospital, Athens, Greece
| | | | | | - Christos Dervenis
- Department of Surgery, “Konstantopouleio” General Hospital, Athens, Greece
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Enhanced recovery ERAS for elderly: a safe and beneficial pathway in colorectal surgery. Int J Colorectal Dis 2017; 32:215-221. [PMID: 27770249 DOI: 10.1007/s00384-016-2691-6] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) pathway includes recovery goals requiring active participation of the patients; this may be perceived as "aggressive" care in older patients. The aim of the present study was to assess whether ERAS was feasible and beneficial in older patients. METHODS Since June 2011, all consecutive colorectal patients were included in an ERAS pathway and documented in a dedicated prospective database. This retrospective analysis included 513 patients, 311 younger patients (<70 years) and 202 older patients (≥70 years). Outcomes were adherence to the ERAS pathway, functional recovery, postoperative complications, and hospital stay. RESULTS Older patients had significantly more diabetes, malignancies, cardiac, and respiratory co-morbidities; both groups underwent similar surgical procedures. Overall adherence to the ERAS pathway was in median 78 % in younger and 74 % in older patients (P = 0.86). In older patients, urinary drains were kept longer (P = 0.001), and oral fluid intake was reduced from day 0 to day 3 (P < 0.001). There were no differences in mobilization and intake of nutritional supplements. Postoperative complications were similar for both comparative groups (51.5 vs. 46.6 %, P = 0.32). Median length of stay was 7 days (IQR 5-13) in older patients vs. 6 days (IQR 4-10) in the younger group (P = 0.001). CONCLUSION Adherence to the ERAS pathway was equally high in older patients. Despite more co-morbidities, older patients did not experience more complications. Recovery was similar and hospital stay was only 1 day longer than in younger patients. ERAS pathway is of value for all patients and does not need any adaptation for the elderly.
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[Colorectal cancer in the elderly. Surgical treatment, chemotherapy, and contribution from geriatrics]. Rev Esp Geriatr Gerontol 2017; 52:261-270. [PMID: 28126268 DOI: 10.1016/j.regg.2016.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 12/12/2022]
Abstract
Age is the biggest risk factor for colorectal cancer, with 70% of the cases in patients over 70 years old. For this reason, a review is presented on the surgical treatment and chemotherapy of cancer of colon and rectum in the elderly. A search was performed in PubMed, including words such as elderly, surgery, colorectal cancer, chemotherapy, radiotherapy, and oncogeriatrics, and review articles and originals on treatment of colorectal cancer in the elderly were selected. A narrative form was developed from the latest evidence with the results obtained on the treatment of this pathology. Although the treatment of colorectal cancer is standardised, a prior comprehensive geriatric assessment is required in the case of the elderly, before deciding the type of treatment in order to offer these robust elderly-standardised guidelines for the robust elderly and adapt them for use in fragile patients.
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Kim B, Park S, Park K, Ryoo S. Effects of a surgical ward care protocol following open colon surgery as part of an enhanced recovery after surgery programme. J Clin Nurs 2016; 26:3336-3344. [PMID: 27982488 DOI: 10.1111/jocn.13682] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2016] [Indexed: 12/20/2022]
Abstract
AIMS AND OBJECTIVES To investigate the effects of a standardised care protocol as part of an enhanced recovery after surgery programme on the management of patients who underwent open colon surgery at the University Hospital, South Korea. BACKGROUND Patients who undergo open colon surgery often have concerns about their care as they prepare for hospitalisation. By shortening hospital stay lengths, enhanced recovery after surgery programmes could reduce the number of opportunities for patient education and communication with nurses. Therefore, our surgical team developed an enhanced recovery after surgery programme, applied using a care protocol for patients with colorectal cancer, that spans the entire recovery process. DESIGN A retrospective, comparative study was conducted using a care protocol as part of an enhanced recovery after surgery programme. Comparisons were made before and after the implementation of an enhanced recovery after surgery programme with a care protocol. METHODS Records of 219 patients who underwent open colon surgery were retrospectively audited. The records were grouped according to the care protocol used (enhanced recovery after surgery programme with a care protocol or traditional care programme). The outcomes, including postoperative bowel function recovery, postoperative pain control, recovery time and postoperative complications, were compared between two categories. RESULTS Patients who were managed using the programme with a care protocol had shorter hospital stays, fewer complications, such as postoperative ileus wound infections, and emergency room visits than those who were managed using the traditional care programme. CONCLUSION The findings can be used to facilitate the implementation of an enhanced recovery after surgery programme with a care protocol following open colon surgery. RELEVANCE TO CLINICAL PRACTICE We present a care protocol that enables effective management using consistent and standardised education providing bedside care for patients who undergo open colon surgery. This care protocol empowers long-term patient self-care capacity, which contributes to increasing the effectiveness of clinical nursing care.
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Affiliation(s)
- BoYeoul Kim
- College of Nursing, Eulji University, Daejeon, Korea
| | - SungHee Park
- Department of Nursing, Kyungmin College, Uijeongbu-si, Korea
| | - KyuJoo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - SeungBum Ryoo
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
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Launay-Savary MV, Mathonnet M, Theissen A, Ostermann S, Raynaud-Simon A, Slim K. Are enhanced recovery programs in colorectal surgery feasible and useful in the elderly? A systematic review of the literature. J Visc Surg 2016; 154:29-35. [PMID: 27842907 DOI: 10.1016/j.jviscsurg.2016.09.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Enhanced recovery programs (ERP) are no longer questionable in the management of patients undergoing surgery. However, there is some doubt as to their feasibility and efficacy in the elderly. Our goal was to systematically review the evidence-based literature concerning the feasibility of ERP in elderly patients undergoing colorectal surgery. MATERIAL AND METHODS The PubMed and Cochrane Database for systematic reviews as well as the "grey" literature between 2000 and 2015 were sought. Articles were selected if they compared ERP in elderly patients to ERP in young patients (feasibility) or compared ERP to traditional post-operative management in the elderly (efficacy). RESULTS Sixteen articles were identified according to the inclusion criteria. All showed that an ERP was feasible in the elderly although post-operative morbidity was higher compared to younger patients. Compared to traditional management, ERP was effective since it decreased (as in the young) the overall rate of complications and thus the duration of hospital stay. There were not enough data on the degree of implementation of ERP and the medico-economic aspects to come to any formal conclusions. CONCLUSION This comprehensive systematic review of the literature showed that ERP was feasible and effective in the elderly undergoing colorectal surgery. Protocols should be adapted to the particular aspects of this population. Future research should target pre-operative evaluation and the place of pre-habilitation in geriatric ERP.
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Affiliation(s)
| | - M Mathonnet
- Service de Chirurgie Digestive, Centre Hospitalo-Universitaire Limoges, France
| | - A Theissen
- Service d'Anesthésie-Réanimation, centre Hospitalier Princesse Grace, Monaco
| | - S Ostermann
- Service de Chirurgie Digestive, Clinique de la Colline Hirslanden, Genève, Suisse
| | - A Raynaud-Simon
- Service de Gériatrie, Centre Hospitalo-Universitaire de Bichat, Paris, France
| | - K Slim
- Service de Chirurgie Digestive, Centre Hospitalo-Universitaire Estaing, Clermont-Ferrand, France.
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- 9 allée du Riboulet, Beaumont, France
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Shorter than 24-h hospital stay for sleeve gastrectomy is safe and feasible. Surg Endosc 2016; 30:5596-5600. [DOI: 10.1007/s00464-016-4933-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 04/09/2016] [Indexed: 01/03/2023]
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Poor nutritional status is associated with other geriatric domain impairments and adverse postoperative outcomes in onco-geriatric surgical patients - A multicentre cohort study. Eur J Surg Oncol 2016; 42:1009-17. [PMID: 27157495 DOI: 10.1016/j.ejso.2016.03.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 03/05/2016] [Accepted: 03/08/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Nutritional status (NS), though frequently affected in onco-geriatric patients, is no standard part of a geriatric assessment. The aim of this study was to analyse the association between a preoperatively impaired NS and geriatric domain impairments and adverse postoperative outcomes in onco-geriatric surgical patients. METHODS 309 patients ≥70 years undergoing surgery for solid tumours were prospectively recruited. Nine screening tools were preoperatively administered as part of a geriatric assessment. NS was based on BMI, weight loss and food intake. Odds ratio's (OR) and 95% confidence intervals (95% CI) were estimated using logistic regression analysis. The occurrence of 30-day adverse postoperative outcomes was recorded. RESULTS At a median age of 76 years, 107 patients (34.6%) had an impaired NS. Decreased performance status and depression were associated with an impaired NS, when adjusted for tumour characteristics and comorbidities (ORPS>1 3.46; 95% CI 1.56-7.67. ORGDS>5 2.11; 95% CI 1.05-4.26). An impaired NS was an independent predictor for major complications (OR 3.3; 95% CI 1.6-6.8). Ten out of 11 patients who deceased had an impaired NS. CONCLUSION An impaired NS is prevalent in onco-geriatric patients considered to be fit for surgery. It is associated with decreased performance status and depression. An impaired NS is a predictor for adverse postoperative outcomes. NS should be incorporated in a geriatric assessment.
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Feasibility of Fast-Track Surgery in Elderly Patients with Gastric Cancer. J Gastrointest Surg 2015; 19:1391-8. [PMID: 25943912 DOI: 10.1007/s11605-015-2839-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 04/24/2015] [Indexed: 02/07/2023]
Abstract
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.
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Taupyk Y, Cao X, Zhao Y, Wang C, Wang Q. Fast-track laparoscopic surgery: A better option for treating colorectal cancer than conventional laparoscopic surgery. Oncol Lett 2015; 10:443-448. [PMID: 26171048 DOI: 10.3892/ol.2015.3166] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 04/08/2015] [Indexed: 12/20/2022] Open
Abstract
Fast-track surgery (FTS), a multimodal rehabilitation technique, has been recommended as surgical therapy for colorectal cancer. The objective of the present study was to compare the outcomes of FTS and conventional laparoscopic surgery. This study was a blinded randomized trial. A total of 70 patients with colorectal cancer were divided into two groups and underwent laparoscopic colorectal resection. The FTS group consisted of 31 patients and the control group consisted of 39 patients. Protocols for the treatment of the FTS group included skipping pre-operative mechanical bowel preparation, early restoration of diet and early post-operative ambulation. Outcome measures, length of hospital stay, post-operative surgical stress response [C-reactive protein (CRP)] and post-operative complications were compared between the two groups. The average length of total hospital stay for the FTS and the control groups was 5.9±0.8 and 10.9±1.3 days, respectively (P<0.05), and the length of post-operative hospital stay for the FTS and control group was 4.3±0.8 and 8.0±1.1 days, respectively. (P<0.05) First flatus time for the FTS and control groups was 1.6±0.8 and 2.5±0.9 days, respectively (P<0.05). Defecation time for the FTS and control groups was 2.2±0.7 and 4.5±0.7 days, respectively (P<0.05). The time to restoration of a solid diet also showed a significant difference between the FTS and control groups (1.1±0.3 vs. 3.6±0.9 days; P<0.05). Following surgery, due to post-operative surgical stress, the two groups CRP levels increased significantly, but the levels of the FTS group were lower than those of the conventional control group (P<0.05). There was no difference in post-operative complications between the FTS and control groups. This study confirms that FTS shortens hospital stay and accelerates the recovery of bowel function without increase of post-operative complications. FTS is safe, improves post-operative recovery and is a better option than conventional laparoscopic surgery for treating colorectal cancer patients.
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Affiliation(s)
- Yerlan Taupyk
- Department of Gastric and Colorectal Surgery, First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Xueyuan Cao
- Department of Gastric and Colorectal Surgery, First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Yinquan Zhao
- Department of Gastric and Colorectal Surgery, First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Chao Wang
- Department of Gastric and Colorectal Surgery, First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Quan Wang
- Department of Gastric and Colorectal Surgery, First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
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Coyle D, Joyce KM, Garvin JT, Regan M, McAnena OJ, Neary PM, Joyce MR. Early post-operative removal of urethral catheter in patients undergoing colorectal surgery with epidural analgesia – A prospective pilot clinical study. Int J Surg 2015; 16:94-98. [DOI: 10.1016/j.ijsu.2015.03.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 03/03/2015] [Indexed: 11/16/2022]
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Pędziwiatr M, Pisarska M, Wierdak M, Major P, Rubinkiewicz M, Kisielewski M, Matyja M, Lasek A, Budzyński A. The Use of the Enhanced Recovery After Surgery (ERAS) Protocol in Patients Undergoing Laparoscopic Surgery for Colorectal Cancer – A Comparative Analysis of Patients Aged above 80 and below 55. POLISH JOURNAL OF SURGERY 2015; 87:565-72. [DOI: 10.1515/pjs-2016-0004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Indexed: 11/15/2022]
Abstract
AbstractAge is one of the principal risk factors for colorectal adenocarcinoma. To date, older patients were believed to achieve worse treatment results in comparison with younger patients due to reduced vital capacity. However, papers have emerged in recent years which confirm that the combination of lap-aroscopy and postoperative care based on the ERAS protocol improves treatment results and may be particularly beneficial also for elderly patients.was to compare the outcomes of laparoscopic surgery for colorectal cancer in combination with the ERAS protocol in patients aged above 80 and below 55.. The analysis included patients aged above 80 and below 55 undergoing elective laparoscopic colorectal resection for cancer at the 2Group 1 comprised 34 patients and group 2, 43 patients. No differences were found between both groups in terms of gender, BMI, tumour progression or surgical parameters. Older patients typically had higher ASA scores. No statistically significant differences were found with regard to the length hospital stay following surgery (5.4 vs 7 days, p=0.446481), the occurrence of complications (23.5% vs 37.2%, p=0.14579) or hospital readmissions (2.9% vs 2.4%). The degree of compliance with the ERAS protocol in group 1 and 2 was 85.2% and 83.0%, respectively (p=0.482558). Additionally, recovery parameters such as tolerance of oral nutrition (82.4% vs 72.1%, p=0.28628) and mobilisation (94.1% vs 83.7%, p=0.14510) within 24 hours of surgery did not differ among the groups. However, a smaller proportion of older patients required opioids in comparison with younger patients (26.5% vs 55.8%, p=0.00891).Similar levels of compliance with the ERAS protocol may be achieved among patients aged ≥80 and younger patients. When laparoscopy is combined with the ERAS protocol, age does not seem to be a significant factor that could account for worse utcomes. Therefore, older patients should not be excluded from perioperative care based on ERAS principles.
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Bagnall NM, Malietzis G, Kennedy RH, Athanasiou T, Faiz O, Darzi A. A systematic review of enhanced recovery care after colorectal surgery in elderly patients. Colorectal Dis 2014; 16:947-56. [PMID: 25039965 DOI: 10.1111/codi.12718] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 05/17/2014] [Indexed: 02/06/2023]
Abstract
AIM Enhanced recovery after surgery (ERAS) can decrease complications and reduces hospital stay. Less certain is whether elderly patients can fully adhere to and benefit from ERAS. We aimed to determine the safety, feasibility and efficacy of enhanced recovery after colorectal surgery in patients aged ≥ 65 years old. METHOD A systematic search of Medline, EMBASE and Cochrane was performed to identify (i) studies comparing elderly patients managed with ERAS vs traditional care, (ii) cohort studies of ERAS with results of elderly vs younger patients and (iii) any case series of ERAS in elderly patients. End-points of interest were length of hospital stay, complications, mortality, readmission and re-operation, and ERAS protocol adherence. RESULTS Sixteen studies were included. Two randomized controlled trials demonstrated shorter hospital stay in elderly patients with ERAS compared with elderly patients with non-ERAS (9 vs 13.2 days, P < 0.001; 5.5 vs 7 days, P < 0.0001). Fewer complications occurred with ERAS in both randomized controlled trials (27.4% vs 58.6%, P < 0.0001; 5% vs 21.1%, P = 0.045). The majority of observational studies did not show differences in outcome between elderly and younger patients in terms of hospital stay, morbidity or mortality. Inconsistent findings between cohort studies may reflect the disparities in ERAS protocol definitions or differences in study populations. CONCLUSION ERAS can be safely applied to elderly patients to reduce complications and shorten length of hospital stay. Further studies are required to assess whether elderly patients are able to adhere to, and benefit from, ERAS protocols to the same extent as younger patients.
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Affiliation(s)
- N M Bagnall
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, Paddington, London, UK
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Ugolini G, Ghignone F, Zattoni D, Veronese G, Montroni I. Personalized surgical management of colorectal cancer in elderly population. World J Gastroenterol 2014; 20:3762-3777. [PMID: 24833841 PMCID: PMC3983435 DOI: 10.3748/wjg.v20.i14.3762] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 12/09/2013] [Accepted: 01/05/2014] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) in the elderly is extremely common but only a few clinicians are familiar with the complexity of issues which present in the geriatric population. In this phase of the life cycle, treatment is frequently suboptimal. Despite the fact that, nowadays, older people tend to be healthier than in previous generations, surgical undertreatment is frequently encountered. On the other hand, surgical overtreatment in the vulnerable or frail patient can lead to unacceptable postoperative outcomes with high mortality or persistent disability. Unfortunately, due to the geriatric patient being traditionally excluded from randomized controlled trials for a variety of factors (heterogeneity, frailty, etc.), there is a dearth of evidence-based clinical guidelines for the management of these patients. The objective of this review was to summarize the most relevant clinical studies available in order to assist clinicians in the management of CRC in the elderly. More than in any other patient group, both surgical and non-surgical management strategies should be carefully individualized in the elderly population affected by CRC. Although cure and sphincter preservation are the primary goals, many other variables need to be taken into account, such as maintenance of cognitive status, independence, life expectancy and quality of life.
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Kim B, Ryoo SB, Park KJ, Park SH. Outcomes of Fast-Track Program after Colorectal Cancer Surgery - Comparison with Conventional Method. ASIAN ONCOLOGY NURSING 2014. [DOI: 10.5388/aon.2014.14.4.249] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Boyoul Kim
- Department of Nursing, Seoul National University Hospital, Seoul, Korea
| | - Seung-Bum Ryoo
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sung Hee Park
- Department of Nursing, Kyungmin College, Uijeongbu, Korea
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