ERAS protocol in laparoscopic surgery for colonic versus rectal carcinoma: are there differences in short-term outcomes?

Implementation barriers for Enhanced Recovery After Surgery (ERAS) in rectal cancer surgery: a comparative analysis of compliance with colon cancer surgeries

We aim to analyze differences in compliance between colon and rectal cancer surgeries under Enhanced Recovery After Surgery (ERAS) for colorectal procedures, and to detect implementation barriers for rectal cancer surgeries. Patients who underwent elective rectal cancer surgeries under ERAS were case-matched based on gender, age, and P-POSSUM with an equal number of patients who underwent colonic surgeries. Achievements of ≥ 70% of ERAS items were considered an acceptable level of compliance. A multivariate analysis was carried out to identify independent risk factors for lower compliance. A total of 434 patients were included over a 5-year period. After matching, there were 111 patients in each group. Overall compliance was significantly lower in the rectal surgery group (73% vs 82%, p = 0.001). A good compliance rate differed from 55% in rectal vs 77.5% in colonic procedures (p = 0.000). We identified three independent risk factors for lower compliance rates: open surgical approach, the use of epidural catheter, and the presence of postoperative ileus. Our data showed that rectal cancer surgeries are more exigent to success on ERAS interventions when compared to colonic resections. There is a need to introduce specific modifications on the protocols for colorectal surgeries when applied to these particular procedures.

Effect of the ACY-1 gene on HER2 and TRAIL expression in rectal carcinoma

The incidence of rectal carcinoma (RC) is increasing and the age at onset of the disease is reducing. Therefore, elucidating the pathogenesis of RC is beneficial for early diagnosis and improving the prognosis. Aminoacylase-1 (ACY-1) is abnormally expressed in various malignant tumor tissues. Furthermore, the human epidermal growth factor receptor-2 (HER2) gene is involved in tumor metastasis and invasion, while tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) induces tumor cell apoptosis. The aim of the present study was to investigate the effect of the ACY-1 gene on the expression of HER2 and TRAIL in RC. Cancerous and adjacent tissues from RC patients were collected. ACY-1 expression was analyzed by immunohistochemistry. The rectal cancer cell lines HT29 and SW620, and normal colorectal mucosal epithelial fetal human cells were cultured in vitro. ACY-1 gene and protein expression levels were tested by reverse transcription-quantitative PCR and western blotting. ACY-1 small interfering RNA (siRNA) was transfected into HT29 and SW620 cells. Cell proliferation was detected by thiazolyl blue MTT assay. Caspase-3 activity was assessed using a commercial kit. HER2 and TRAIL expression levels were determined by western blotting. ACY-1 expression was significantly increased in cancer tissue compared with adjacent tissue (P<0.05). ACY-1 expression was elevated in HT29 and SW620 cells compared with normal colorectal mucosal epithelial cells (P<0.05). ACY-1 siRNA transfected into HT29 cells downregulated its expression, inhibited cell proliferation, enhanced caspase-3 activity, reduced HER2 expression and upregulated TRAIL expression (P<0.05). ACY-1 expression was found to be increased in rectal cancer tissue. Therefore, targeting the ACY-1 gene may regulate HER2 and TRAIL expression levels, and may reduce the occurrence and inhibit the development of rectal cancer.

Do older patients (> 80 years) also benefit from ERAS after colorectal resection? A safety and feasibility study

BACKGROUND AND AIMS

The aim of this study was to evaluate the safety and feasibility of a standard Enhanced Recovery After Surgery (ERAS) program following colorectal resection in a geriatric population, aged 80 years and older.

METHODS

In this single-center before-after cohort study all patients aged 80 years and older were included after colorectal resection. Patients were divided in a pre-ERAS and an ERAS group, according to the type of perioperative care. Data were prospectively collected and analysed retrospectively. The primary outcome was short-term complication rate. Secondary outcome parameters were length of stay (LOS), 30-day mortality and readmission rate.

RESULTS

Over 4 years, 219 patients were included. Of those, 151 underwent colonic and 68 rectal resection, following the ERAS protocol perioperatively in 45 and 21 cases. There were no differences in complication rate, 30-day mortality or readmission rate in the pre-ERAS versus ERAS groups. LOS after colonic resection was reduced by 2.5 days in the ERAS group (p = 0.020). Laparoscopy was found to be an independent variable of LOS (p < 0.001, p = 0.009) and complication rate (p = 0.011, p < 0.001) for colonic and rectal surgery respectively.

DISCUSSION

A standard ERAS protocol is safe and feasible in older patients undergoing colorectal resection. Colon resection was related with shorter LOS without increasing morbidity, readmission rate nor 30-day mortality. No adverse outcome after rectal resection was found either. Laparoscopy was associated with lower complication rate and shorter LOS.

CONCLUSION

A laparoscopic approach within an ERAS protocol should be considered for colorectal resection in every patient regardless of age.

Colorectal robotic surgery: INCA's experience

Introduction Minimally invasive surgery has revolutionized surgical management in the treatment of colorectal neoplasms, reducing morbidity and mortality, hospitalization, inactivity time and minimizing cost, as well as providing adequate oncological results when compared to the conventional approach. Robotic surgery, with Da Vinci Platform, emerges as a step ahead for its potentials. The objective of this article is to report the single institutional experience with the use of Da Vinci Platform in robotic colorectal surgeries performed at a reference center in oncological surgery in Brazil.

Materials and methods A retrospective cohort study was conducted based on the prospective database of patients from the institution submitted to robotic surgery for treatment of colorectal cancer from July 2012 to September 2017. Clinical and surgical variables were analyzed as predictors of morbidity and mortality.

Results A total of 117 patients underwent robotic surgery. The complications related to surgery occurred in 33 patients (28%), the most frequent being anastomotic fistula and surgical wound infection, which corresponded to 11% and 3%, respectively. Conversion rate was 1.7%. Median length of stay was 5 days. The only variable associated with increase of complications and death risk was BMI >30, with p-value of 0.038 and 0.027, respectively.

Conclusion Robotic surgery is safe and feasible for approaching colorectal cancer surgeries, presenting satisfactory results regarding length of hospital stay and rate of operative complications, as well as presenting a low rate of conversion. Obesity has been shown to be a risk factor for surgical complication in robotic colorectal surgery.

Clinical application of enhanced recovery after surgery in the treatment of choledocholithiasis by ERCP

This study aims to investigate the effect of applying enhanced recovery after surgery methods (ERAS) in perioperative nursing of choledocholithiasis following endoscopic retrograde cholangiopancreatography (ERCP) for treatment of biliary calculus.Clinical data from 161 patients who underwent ERCP surgery in Wuhan Union Hospital from January 2017 to December 2019 were retrospectively analyzed. A total of 78 patients received perioperative nursing using the ERAS concept (experimental group) and 83 patients received conventional perioperative nursing (control group). Group differences were compared for the time to first postoperative ambulation, exhausting time, time to first defecation and eating, intraoperative blood loss, postoperative complication incidence (pancreatitis, cholangitis, hemorrhage), white blood cell (WBC), and serum amylase (AMS) values at 24 hours, duration of nasobiliary duct indwelling, length of hospital stay, and hospitalization expenses.No significant between-group differences were noted for demographic characteristics (age, sex, BMI, ASA score, and comorbidity) (P > .05). Time to first ambulation, exhausting time, time to defecation and eating, and nasobiliary drainage time were shorter in the experimental group than the control group, and the differences were statistically significant (P < .05). There was no significant between-group difference in postoperative WBC values at 24 hours (P > .05), but the experimental group's AMS values at 24 hours postoperation were significantly lower than those of the controls (154.93 ± 190.01 vs 241.97 ± 482.64, P = .031). Postoperative complications incidence was 9.1% in the experimental group, which was significantly lower than the 20.4% in the control group, and this difference was statistically significant (P = .039). Compared with the control group, nasobiliary drainage time (26.53 ± 7.43 hours vs 37.56 ± 9.91 hours, P < .001), hospital stay (8.32 ± 1.55 days vs 4.56 ± 1.38 days, P < .001), and hospitalization expenses (36800 ± 11900 Yuan vs 28900 ± 6500 Yuan, P = .016) were significantly lower in the experimental group.ERAS is a safe and effective perioperative nursing application in ERCP for treating choledocholithiasis. It can effectively accelerate patients' recovery and reduce the incidence of complications; therefore, it is worthy of being applied and promoted in clinical nursing.

Asociación entre desenlaces clínicos y cumplimiento del protocolo de recuperación mejorada después de la cirugía (ERAS) en procedimientos colorrectales: estudio multicéntrico

Introducción. Los protocolos de recuperación mejorada después de cirugía se han diseñado como una innovación en salud tras demostrarse que la mejora en los dispositivos médicos y la depuración de técnicas alcanzaron la meseta en disminución de complicaciones. Con estas estrategias de la medicina perioperatoria, en cirugía colorrectal se reducen la morbilidad y estancia hospitalaria. El objetivo del estudio fue evaluar si la tasa de adherencia al programa de recuperación mejorada después de la cirugía (ERAS) está asociada con los resultados quirúrgicos. Métodos. Estudio multicéntrico, observacional, retrospectivo de cohorte (2015-2019), en cinco hospitales latinoamericanos certificados por la sociedad ERAS. Se calculó la incidencia de complicaciones quirúrgicas durante el posquirúrgico inmediato (30 días) y la duración de la estancia hospitalaria. Se utilizaron análisis bivariado y regresión logística multivariada para evaluar los factores asociados con la tasa de complicaciones. Resultados. Fueron incluidos en el estudio 648 pacientes en cinco hospitales ERAS, con edad promedio de 61 años y mayor porcentaje de hombres (51 %). El cumplimiento global al protocolo ERAS fue de 75 % y la estancia promedio de 6,2 días (mediana: 4 días). Se tuvo un cumplimiento óptimo del protocolo ERAS (igual o mayor al 80 %) en 23,6 % de los pacientes. Se documentó fuga de la anastomosis en 4 %, complicaciones infecciosas en 8,4 %, íleo en 5,7 %, reingreso en 10,2 % y mortalidad de 1,1 %. El análisis multivariado mostró que los niveles de adherencia óptima al protocolo ERAS reducen significativamente la aparición de complicaciones como fuga de la anastomosis (OR 0,08; IC95% 0,01-0,48; p=0,005) y complicaciones infecciosas (OR 0,17; IC95% 0,03-0,76; p=0,046). Discusión. Los resultados sugieren que un cumplimiento del programa ERAS mayor al 80 % se asocia a menor frecuencia de complicaciones en pacientes con cirugía electiva colorrectal.

Is an enhanced recovery program (ERP) after rectal surgery as feasible as after colonic surgery? A multicentre Francophone study of 870 rectal resections

BACKGROUND

Enhanced recovery program (ERP) is well-established in colorectal surgery. Rectal surgery (RS) is known to be associated with high morbidity and prolonged hospital stay, which might explain why ERPs are less applied in this specific group of patients. The aim of this large-scale study was to assess the feasibility of an ERP in RS compared with colonic surgery.

METHODS

This study was a retrospective analysis of a prospective database including 3740 patients eligible for colorectal resection from February 2014 to January 2017 in 75 European Francophone centres. Patients were divided into two groups (colon group C vs. rectum group R). The main endpoint was compliance with ERP components. A subgroup analysis was performed in patients for whom a defunctioning stoma (DS) was required after RS.

RESULTS

A total of 3740 patients were included. There were 2870 patients in group C and 870 patients in group R. The overall compliance rate for ERPs was 81.71% in group C and 79.09% in group R. Patients were significantly less mobilized within 24 h in group R. Specific recommendations for RS concerning bowel preparation and abdominal drainage were significantly less implemented. Overall morbidity was significantly higher in group R. Mean length of stay (LOS) was significantly shorter in group C. In the sub-group analysis, a DS was significantly associated with fewer compliance with early mobilization and early feeding, leading to significantly longer LOS (group R).

CONCLUSION

ERP is safe and effective in RS, despite the well-known higher morbidity and LOS compared with colonic surgery. DS could be a limiting factor in ERP implementation after RS.

Outcomes of sleeve gastrectomy in patients older than 60 years: a multicenter matched case-control study

INTRODUCTION

The prevalence of obesity is increasing according to the World Health Organization. Furthermore, global aging is increasing, especially in developed countries in Europe. Whether bariatric surgery should be performed in elderly people is still controversial.

AIM

To determine the clinical outcomes of sleeve gastrectomies (SG) in older central European patients. We compared the safety and efficacy of SG in patients older than 60 years with younger patients.

MATERIAL AND METHODS

Eighty-nine patients older than 60 years, who underwent SG, were included in the study. Eighty-nine younger patients (aged 18-40 years) were matched according to body mass index (BMI) and comorbidities. The analyzed data included age, sex, total body weight, BMI, length of hospital stay, 30-day complications and improvement in comorbidities.

RESULTS

There was no significant difference in the complication rate between the 2 age groups (p = 0.59). An improvement in hypertension was observed in 73.1% of older patients and in 69.2% of younger patients (p = 0.67). There was improvement in diabetes mellitus in 40% of older patients and in 31.1% of younger patients (p = 0.25). The ΔBMI after 12, 24 and 36 months was significantly lower in older patients than in younger patients (p = 0.002, p = 0.001; p = 0.043, respectively). Percent excess BMI loss (%EBMIL) after 12, 24, and 60 months was significantly lower in older than in younger patients (p = 0.001, p = 0.001, p = 0.028, respectively).

CONCLUSIONS

Better weight loss is achieved in younger than in older patients, while maintaining a similar effect on the risk of complications and improvement in comorbidities. Therefore, SG is safe and effective in older people.

Compliance with the ERAS Protocol and 3-Year Survival After Laparoscopic Surgery for Non-metastatic Colorectal Cancer

INTRODUCTION

Enhanced recovery after surgery (ERAS) pathways have been proven to enhance postoperative recovery, reduce morbidity, and reduce length of hospital stay after colorectal cancer surgery. However, despite the benefits of the ERAS program on short-term results, little is known about its impact on long-term results.

OBJECTIVE

The aim of the study was to determine the association between adherence to the ERAS protocol and long-term survival after laparoscopic colorectal resection for non-metastatic cancer.

MATERIAL AND METHODOLOGY

Between 2013 and 2016, 350 patients underwent laparoscopic colorectal cancer resection in the 2nd Department of General Surgery, Jagiellonian University Medical College, and were enrolled for further analysis. The relationship between the rate of compliance with the ERAS protocol and 3-year survival was analyzed according to the Kaplan-Meier method with log-rank tests. Patients were divided into two groups according to their degree of adherence to the ERAS interventions: Group 1 (109 patients), < 80% adherence, and Group 2 (241 patients), ≥ 80% adherence. The primary outcome was overall 3-year survival. The secondary outcomes were postoperative complications, length of hospital stay, and recovery parameters.

RESULTS

The groups were similar in terms of demographics and surgical parameters. The median compliance to ERAS interventions was 85.2%. The Cox proportional model showed that AJCC III (HR 3.28, 95% CI 1.61-6.59, p = 0.0021), postoperative complications (HR 2.63, 95% CI 1.19-5.52, p = 0.0161), and compliance with ERAS protocol < 80% (HR 3.38, 95% CI 2.23-5.21, p = 0.0102) were independent predictors for poor prognosis. Additionally, analysis revealed that adherence to the ERAS protocol in Group 2 with ≥ 80% adherence was associated with a significantly shorter length of hospital stay (6 vs. 4 days, p < 0.0001), a lower rate of postoperative complications (44.7% vs. 23.3%, p < 0.0001), and improved functional recovery parameters: tolerance of oral diet (53.4% vs. 81.5%, p < 0.0001) and mobilization (77.7% vs. 96.1%, p < 0.0001) on the first postoperative day.

CONCLUSIONS AND RELEVANCE

This study reports an association between adherence to the ERAS protocol and long-term survival after laparoscopic colorectal resection for non-metastatic cancer. Lower adherence to the protocol, independent from stage of cancer and postoperative complications, was an independent risk factors for poorer survival rates.

Investigating Risk Factors for Complications after Ileostomy Reversal in Low Anterior Rectal Resection Patients: An Observational Study

Introduction: Defunctioning ileostomy has been widely used in patients undergoing low anterior rectal resection to reduce the rate of postoperative leakage. It is still not clear whether interval between primary procedure and ileostomy reversal has an impact on treatment outcomes. Methods: In our prospective observational study we reviewed 164 consecutive cases of patients who underwent total mesorectal excision with primary anastomosis. Univariate and multivariate regression models were used to search for risk factors for prolonged length of stay and complications after defunctioning ileostomy reversal. Receiver operating characteristic curves were utilized to set cut-off points for prolonged length of stay and perioperative morbidity. Results: In total, 132 patients were included in the statistical analysis. The median interval between primary procedure and defunctioning ileostomy reversal was 134 (range: 17-754) days, while median length of stay was 5 days (4-6 interquartile range (IQR)). Prolonged length of stay cut-off was established at 6 days. Regression models revealed that interval between primary surgery and stoma closure as well as complications after primary procedure are risk factors for complications after defunctioning ileostomy reversal. Prolonged length of stay has been found to be related primarily to interval between primary surgery and stoma closure. Conclusions: In our study interval between primary surgery and stoma closure along with complication occurrence after primary procedure are risk factors for perioperative morbidity and prolonged length of stay (LOS) after ileostomy reversal. The effort should be made to minimize the interval to ileostomy reversal. However, randomized studies are necessary to avoid the bias which appears in this observational study and confirm our findings.

Safety and efficacy of enhanced recovery after surgery in elderly patients after therapeutic endoscopic retrograde cholangiopancreatography

Introduction

The number of elderly patients with biliary and pancreatic diseases has increased significantly. The characteristics of biliary and pancreatic diseases in the elderly increase the risk of treatment.

Aim

To study the safety and efficacy of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients with biliary and pancreatic diseases with the concept of enhanced recovery after surgery (ERAS).

Material and methods

Patients receiving ERCP under ERAS were grouped into an elderly group (group A, n = 58, aged 75 years or above) and a young and middle-aged group (group B, n = 202, aged less than 60 years). The clinical parameters before, during and after the operation of the two groups were compared.

Results

Before the operation, the incidences of cholangiocarcinoma and complications, nutritional screening score ≥ 3, ASA degree III and Child-Pugh grade A in group A were significantly higher than those in group B (p < 0.05), while the incidences of nausea and vomiting, abdominal pain, nutritional screening < 3 and ASA grade I in group A were significantly lower than those in group B (p < 0.05). Intraoperatively, the incidence of juxta-ampullary duodenal diverticulum (JAD) in internal or bottom papilla in the elder patients with difficult selective biliary cannulation (DSBC) was significantly higher than that in the young and middle-aged group (p < 0.05). In addition, the continuous ECG monitoring duration and the first exhaust time in group A were significantly longer than those in group B (p < 0.05).

Conclusions

Endoscopic retrograde cholangiopancreatography under ERAS in elderly patients is as safe and effective as in young patients.

Prolonged hospital stay and readmission rate in an enhanced recovery after surgery cohort undergoing colorectal cancer surgery

AIM

The present database study aimed to identify patients with a longer postoperative length of stay (LOS) or patients readmitted and to characterize both groups based on perioperative factors.

METHOD

A retrospective review of the Danish Colorectal Cancer Group database and a local database was performed of all patients undergoing elective resection for colorectal cancer in a 25-month period. The primary outcome was the number of patients with a prolonged hospital stay (LOS ≥ 10 days after the primary operation) and readmissions within 30 days after discharge.

RESULTS

A total of 372 patients with colon resection and 215 patients with rectal resection were included. Patients undergoing colonic resection had a rate of prolonged hospital stay of 10.6% and a readmission rate of 13.7%; prolonged hospital stay was significantly associated with age ≥ 76 years and those who underwent a conversion from a laparoscopic procedure. Patients undergoing rectal cancer resection had a rate of prolonged hospital stay of 17.7% and a readmission rate of 14.0%; Charlson comorbidity score (CCS) ≥ 2, total mesorectal excision (TME) and laparoscopic conversion were significantly associated with prolonged hospital stay, and American Society of Anesthesiologists (ASA) score ≥ 3, TME and a duration of surgery ≥ 300 min were significantly associated with readmission.

CONCLUSION

In patients with colon cancer, older age and conversion to open surgery were associated with prolonged hospital stay. In patients with rectal cancer, CCS ≥ 2, TME and conversion were associated with prolonged hospital stay, and a preoperative ASA score ≥ 3, TME and a duration of surgery ≥ 300 min were associated with readmission.

Early closure of the protective ileostomy after rectal resection should become part of the Enhanced Recovery After Surgery (ERAS) protocol: a randomized, prospective, two-center clinical trial

Introduction

Protective loop ileostomy (PLI) is used to reduce the anastomotic leak rate after resection of the rectum. It is an effective, yet burdensome procedure contradicting the aims of enhanced recovery after surgery (ERAS) by slowing down recovery. Early closure (EC) of the PLI has the potential to change the situation, and it should become part of ERAS.

Aim

To analyze the effectiveness of EC in ERAS patients.

Material and methods

A randomized clinical trial was performed between October the 1^st, 2016 and December the 31^st, 2017. Fifty-eight adult patients (24 females, 34 males, mean age: 55.7 and 56.2) operated on for rectal carcinoma according to the ERAS protocol with PLI were randomly assigned to the late (L) or early (E) closure group (14 days after discharge). Time to start adjuvant chemotherapy, complication rate, and health care costs were analyzed.

Results

There were no significant differences between groups regarding the length of surgery (83.2 ±15.9 vs. 87.1 ±21.7 min, in E and L, respectively), intraoperative blood loss (15.2 ±7.5 vs. 17.3 ±11.1 ml, respectively), median hospital stay, or the time to pass flatus and stool. The difference in the time needed to start the adjuvant treatment (38.7 ±5.7 vs. 33.2 ±5.8 days, p < 0.01), was compensated by the reduction of time living with a stoma (17.2 vs. 299.0 days) and health care costs: (43.68 vs. 698.42 USD).

Conclusions

Early closure is a safe and effective therapeutic approach, improving the recovery. Therefore it should be implemented as part of the ERAS protocol for rectal cancer patients.

A quest for sphincter-saving surgery in ultralow rectal tumours-a single-centre cohort study

INTRODUCTION

Despite the progress in the treatment of colorectal cancer, there is still no optimal strategy for tumours located adjacent to the anal sphincter. This study aims to evaluate oncological and functional results of surgery for rectal cancer in unfavourable locations in proximity to anal sphincters.

MATERIALS AND METHODS

Patients with rectal cancer, which was either initially infiltrating the anal sphincter or located in the close proximity of the sphincter, were included in the study. Patients were submitted to extralevator abdominoperineal resection (APR), intersphincteric resection, or transanal total mesorectal excision (TaTME). Primary outcomes were perioperative data: operative time, blood loss, complications, length of stay (LOS), and 30-day mortality. Secondary outcomes were pathological quality of the specimens and functional outcome 6 months after defunctioning ileostomy closure.

RESULTS

Among patients with cancer adjacent to the anal sphincter, 13 (25%) underwent APR, 14 (27%) patients were submitted to intersphincteric resection, and 25 (48%) patients were treated with the TaTME approach. Operative time was 240 (210-270 IQR) for APR, 212.5 (170-260 IQR) for intersphincteric resection, and 270 (240-330 IQR) for TaTME (p = 0.018). Perioperative morbidity was 31% for APR, 36% for intersphincteric resections, and 12% for the TaTME group (p = 0.181). Complete mesorectal excision was achieved in 92% of specimens in the TaTME group, 93% in intersphincteric resections, and 78% in the APR group (p = 0.72). Median circumferential resection margin in APR was 6 mm (4-7 IQR), in intersphincteric resections 7.5 mm (2.5-10 IQR), and in the TaTME group 4 mm (2.8-8 IQR). All patients after intersphincteric resections developed major low anterior resection syndrome (LARS). Four patients in the TaTME group developed minor LARS, and 21 had major LARS.

CONCLUSION

Sphincter-saving rectal resections are a feasible alternative to APR with good clinical, pathological, and oncological outcomes. Intersphincteric resections and TaTME seem to be equal in terms of clinicopathological results. The functional outcome is yet to be investigated.

TRIAL REGISTRATION

The study was retrospectively registered in Thai Clinical Trials Registry (23-07-2018, ID TCTR20180724001 ).

Risk Factors for Prolonged Length of Hospital Stay and Readmissions After Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-en-Y Gastric Bypass

Background

Laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (LRYGB) are most commonly performed bariatric procedures. Laparoscopic approach and enhanced recovery after surgery (ERAS) protocols managed to decrease length of hospital and morbidity. However, there are patients in whom, despite adherence to the protocol, the length of stay (LOS) remains longer than targeted. This study aimed to assess potential risk factors for prolonged LOS and readmissions.

Methods

The study was a prospective observation with a post-hoc analysis of bariatric patients in a tertiary referral university teaching hospital. Inclusion criteria were undergoing laparoscopic bariatric surgery. Exclusion criteria were occurrence of perioperative complications, prior bariatric procedures, and lack of necessary data. The primary endpoints were the evaluations of risk factors for prolonged LOS and readmissions.

Results

Median LOS was 3 (2–4) days. LOS > 3 days occurred in 145 (29.47%) patients, 79 after LSG (25.82%) and 66 after LRYGB (35.48%; p = 0.008). Factors significantly prolonging LOS were low oral fluid intake, high intravenous volume of fluids administered on POD0, and every additional 50 km distance from habitual residence to bariatric center. The risk of hospital readmission rises with occurrence of intraoperative adverse events and low oral fluid intake on the day of surgery on.

Conclusions

Risk factors for prolonged LOS are low oral fluid intake, high intravenous volume of fluids administered on POD0, and every additional 50 km distance from habitual residence. Risk factors for hospital readmission are intraoperative adverse events and low oral fluid intake on the day of surgery.

Is It Possible to Maintain High Compliance with the Enhanced Recovery after Surgery (ERAS) Protocol?-A Cohort Study of 400 Consecutive Colorectal Cancer Patients

The aim of our study was to evaluate the implementation and degree of adherence to the Enhanced Recovery after Surgery (ERAS) protocol in a group of 400 patients operated laparoscopically for colorectal cancer, and to assess its impact on the short-term results. The prospective study included patients with histologically confirmed colorectal cancer undergoing elective laparoscopic resection from years 2012 to 2017. For the purpose of further analysis, patients were divided into four groups: 100 consecutive patients were in each group. There were no statistically significant differences between groups in demographic parameters. The mean compliance with the ERAS protocol in the entire study group was 84.8%. Median adherence differed between the groups 76.9% vs. 92.3% vs. 84.6% vs. 84.6%, respectively (p < 0.0001). There were statistically significant differences between groups in the tolerance of oral diet (54% vs. 83% vs. 83% vs. 64%) and mobilization (74% vs. 92% vs. 91% vs. 94%) on the first postoperative day. In subsequent groups, time to first flatus decreased (2.5 vs. 2.1 vs. 2.0 vs. 1.7 days, p = 0.0001). There were no statistical differences in the postoperative morbidity rate between groups (p = 0.4649). The median length of hospital stay in groups was 5 vs. 4 vs. 4 vs. 4 days, respectively (p = 0.0025). Maintaining high compliance with the ERAS protocol is possible, despite the slight decrease that occurs within a few years after its implementation. This decrease in compliance does not affect short-term results, which are comparable to those shortly after overcoming the learning curve.

Transanal total mesorectal excision for low rectal cancer: a case-matched study comparing TaTME versus standard laparoscopic TME

Background

Transanal total mesorectal excision (TaTME) is emerging as a novel alternative to laparoscopic total mesorectal excision (LaTME). The aim of this study was to compare clinical and pathological results from these two techniques in patients undergoing rectal resections because of low rectal cancer.

Materials and methods

Thirty-five patients undergoing TaTME were matched with 35 patients operated on using LaTME. Composite primary endpoint (complete TME, negative circumferential resection margin [pCRM], and distal resection margin [pDRM]) was used to assess pathological quality specimens. Secondary outcomes included operative and postoperative parameters (operative time, total blood loss, postoperative morbidity, length of stay, 30-day mortality).

Results

Composite primary endpoint was achieved by 85% of subjects in the TaTME group and 82% of subjects in the LaTME group (P=0.66). Mean pCRM was 1.1±1.29 vs 0.99±0.78 mm (P=0.25). Distal pDRM was 1.57±0.92 and 1.98±1.22 cm (P=0.15). In the TaTME and LaTME groups, respectively, complete mesorectal excision was achieved in 89% and 83% of subjects, while excision was nearly complete for the remaining 11% and 17% (P=0.23).

Conclusion

TaTME appears to be a noninferior alternative to laparoscopic surgery. TaTME allows for quality retrieval of surgical specimens with comparable clinical outcomes with LaTME.

The Safety of Selective Use of Splenic Flexure Mobilization in Sigmoid and Rectal Resections-Systematic Review and Meta-Analysis

Background: According to traditional textbooks on surgery, splenic flexure mobilization is suggested as a mandatory part of open rectal resection. However, its use in minimally invasive access seems to be limited. This stage of the procedure is considered difficult in the laparoscopic approach. The aim of this study was to systematically review literature on flexure mobilization and perform meta-analysis. Methods: A systematic review of the literature was performed using the Medline, Embase and Scopus databases to identify all eligible studies that compared patients undergoing rectal or sigmoid resection with or without splenic flexure mobilization. Inclusion criteria: (1) comparison of groups of patients with and without mobilization and (2) reports on overall morbidity, anastomotic leakage, operative time, length of specimen, number of harvested lymph nodes, or length of hospital stay. The outcomes of interest were: operative time, conversion rate, number of lymph nodes harvested, overall morbidity, mortality, leakage rate, reoperation rate, and length of stay. Results: Initial search yielded 2282 studies. In the end, we included 10 studies in the meta-analysis. Splenic flexure is associated with longer operative time (95% confidence interval (CI) 23.61–41.25; p < 0.001) and higher rate of anastomotic leakage (risk ratios (RR): 1.02; 95% CI 1.10–3.35; p = 0.02), however the length of hospital stay is shorter by 0.42 days. There were no differences in remaining outcomes. Conclusions: Not mobilizing the splenic flexure results in a significantly shorter operative time and a longer length of stay. Further research is required to establish whether flexure mobilization is required in minimally invasive surgery.

Use of inflammatory markers in the early detection of infectious complications after laparoscopic colorectal cancer surgery with the ERAS protocol

Introduction

Thanks to laparoscopy and enhanced recovery protocols (ERAS) it is possible to shorten hospitalization. Therefore, it seems reasonable to search for new early markers of infectious complications in order to select patients who are prone to development of complications.

Aim

To assess the usefulness of serum levels of C-reactive protein, interleukin-6 and procalcitonin as early indicators of infectious complications in patients after laparoscopic colorectal surgery with ERAS.

Material and methods

The prospective analysis included consecutive patients who underwent laparoscopic colorectal cancer resection. The following parameters were included in the analysis: C-reactive protein (CRP), interleukin 6 (IL-6) and procalcitonin measured on postoperative days (PODs) 1, 2, 3. Patients were divided into two groups: uncomplicated (group 1) and complicated (group 2). The difference in levels of the markers and the dynamics of changes observed in both groups were analyzed.

Results

Group 1 comprised 34 patients, and group 2 consisted of 17 patients. A significant increase of both absolute values and delta increments on all postoperative days was noted. ROC curve analysis showed that the best cut-off values indicating an infectious process were: CRP 129 mg/l on POD3 (92% sensitivity/80% specificity), IL-6 of 78 pg/ml on POD2 (91% sensitivity/97% specificity) and PCT 0.24 ng/ml on POD3 (93% sensitivity/68% specificity).

Conclusions

Our study showed that regular measurement of all analyzed markers in the early postoperative days may be beneficial in the detection of postoperative infectious complications. Further studies are needed to fully assess the role of routine biochemical measurements in the postoperative period after laparoscopic surgery with the ERAS protocol.

Laparoscopic Surgery Within an Enhanced Recovery after Surgery (ERAS) Protocol Reduced Postoperative Ileus by Increasing Postoperative Treg Levels in Patients with Right-Side Colon Carcinoma

Background

The aim of this study was to determine the effects of laparoscopic surgery within an ERAS program on outcomes and immunological function in patients with a carcinoma in the right colon.

Material/Methods

Patient data were acquired from a prospectively maintained database, and 176 patients diagnosed with right colon carcinoma with surgery were selected from the database. These patients were divided into a laparoscopic group (Lap group, n=86) and an open operation group (Open group, n=90). All patients received treatment according to a standardized ERAS protocol. We collected data on CRP levels, CD4⁺/CD8⁺ ratios, and Treg values in peripheral blood, baseline and surgical characteristics, postoperative complications, and postoperative ileus (POI).

Results

Circulating CD4⁺/CD8⁺ ratios and Treg values were decreased and CRP levels were increased in both groups after the operation. However, the values in the Lap group patients recovered much more quickly than those of patients in the Open group (P<0.05). Patients undergoing laparoscopic surgery had significantly less preoperative bleeding (P<0.01), reduced ratio of overall POI (mainly early ileus), and shorter postoperative hospital stay (P=0.03). Multivariate logistic regression analysis showed that POD1 Treg value was an independent predicator for postoperative ileus in patients with right colon carcinoma resection.

Conclusions

In patients with a carcinoma in the right colon, laparoscopic surgery within an ERAS protocol leads to better immunity preservation after surgery, and POD1 Treg value may be an independent predicator for postoperative ileus, which could, at least in part, explain the shorter hospital stay after surgery.

Meta-analysis of short- and long-term outcomes after pure laparoscopic versus open liver surgery in hepatocellular carcinoma patients

Background

The advantages of laparoscopy are widely known. Nevertheless, its legitimacy in liver surgery is often questioned because of the uncertain value associated with minimally invasive methods. Our main goal was to compare the outcomes of pure laparoscopic (LLR) and open liver resection (OLR) in patients with hepatocellular carcinoma.

Methods

We searched EMBASE, MEDLINE, Web of Science, and The Cochrane Library databases to find eligible studies. The most recent search was performed on December 1, 2017. Studies were regarded as suitable if they reported morbidity in patients undergoing LLR versus OLR. Extracted data were pooled and subsequently used in a meta-analysis with a random-effects model. Clinical applicability of results was evaluated using predictive intervals. Review was reported following the PRISMA guidelines.

Results

From 2085 articles, forty-three studies (N = 5100 patients) were included in the meta-analysis. Our findings showed that LLR had lower overall morbidity than OLR (15.59% vs. 29.88%, p < 0.001). Moreover, major morbidity was reduced in the LLR group (3.78% vs. 8.69%, p < 0.001). There were no differences between groups in terms of mortality (1.58% vs. 2.96%, p = 0.05) and both 3- and 5-year overall survival (68.97% vs. 68.12%, p = 0.41) and disease-free survival (46.57% vs. 44.84%, p = 0.46).

Conclusions

The meta-analysis showed that LLR is beneficial in terms of overall morbidity and non-procedure-specific complications. That being said, these results are based on non-randomized trials. For these reasons, we are calling for randomization in upcoming studies. Systematic review registration: PROSPERO registration number CRD42018084576.

Electronic supplementary material

The online version of this article (10.1007/s00464-018-6431-6) contains supplementary material, which is available to authorized users.

Defunctioning ileostomy and mechanical bowel preparation may contribute to development of low anterior resection syndrome

INTRODUCTION

Laparoscopic surgery is an approved technique in colorectal cancer treatment. Functional and quality-of-life studies have revealed significant changes in faecal continence.

AIM

To assess the incidence and risk factors of low anterior resection syndrome (LARS) in patients undergoing rectal resections for cancer.

MATERIAL AND METHODS

We enrolled patients undergoing rectal resections in a general surgery department of a university hospital. The primary outcomes were the Jorge-Wexner scale and the LARS score 6 months after the end of treatment. The secondary outcomes were the risk factors for LARS development.

RESULTS

Fifty-six patients were included; 15 (26%) developed major LARS and 10 (18%) had minor LARS at 6 months. In univariate analysis the risk factors were: preoperative radiotherapy (p < 0.001, OR = 11.9, 95% CI: 2.98-47.48); shorter distance of the tumour from the anal verge (p = 0.001, OR = 0.69, 95% CI: 0.55-0.86); bowel preparation (p = 0.01, OR = 6.27, 95% CI: 1.51-26.07); low anterior rectal resection (p = 0.01, OR = 17.07, 95% CI: 1.86-156.83); and protective ileostomy (p = 0.001, OR = 15.97, 95% CI: 4.07-61.92). The risk factors for a higher Jorge-Wexner score in univariate analysis were greater diameter of tumour (p = 0.035), radiotherapy (p = 0.001), shorter distance from the anal verge (p = 0.002), bowel preparation (p = 0.042), low anterior rectal (LAR) (p = 0.01), ileostomy (p = 0.001), perioperative complications (p = 0.032), and readmission within 30 days (p = 0.034). In the multivariate analysis, readmissions and perioperative complications were significant.

CONCLUSIONS

In addition to typically described risk factors, two new ones have been identified. Mechanical bowel preparation and defunctioning ileostomy may also contribute to LARS development. However, due to the limitations of this study our observations require further confirmation in future trials.

Application of enhanced recovery after surgery in patients undergoing radical cystectomy

OBJECTIVE

This study was performed to evaluate the application of enhanced recovery after surgery (ERAS) in patients undergoing radical cystectomy (RC).

METHODS

The clinical data of 192 patients who underwent RC were collected in this retrospective cohort study. Among them, 91 patients who underwent ERAS were allocated to the ERAS group, and the remaining 101 patients who underwent traditional postoperative care procedures were allocated to the non-ERAS group. Perioperative indexes in the two groups were compared. The ERAS components included rehabilitation exercise, carbohydrate fluid loading, cessation of nasogastric tubes, omission of oral bowel preparation, regional local anesthesia, body-warming procedures, reduced drainage use, and early postoperative drinking and eating.

RESULTS

The times from RC to first water intake, first ambulation, first anal exhaust, first defecation, and pelvic drainage tube removal were significantly shorter and the hospitalization costs were significantly lower in the ERAS than non-ERAS group. The intraoperative blood loss volume, blood transfusion rate, readmission rate, and incidence of postoperative complications were also significantly lower in the ERAS than non-ERAS group.

CONCLUSION

ERAS may effectively accelerate patient rehabilitation and reduce the length of stay, incidence of postoperative complications, readmission rates, and hospitalization costs for patients undergoing RC.

Laparoscopic colorectal surgery and Enhanced Recovery After Surgery (ERAS) program: Experience with 200 cases from a single Italian center

There is increasing evidence that minimally invasive techniques associated with Enhanced Recovery After Surgery (ERAS) protocols reduce surgery-related stress and promote faster recovery after major colorectal surgery. As a single tertiary referral center for colorectal surgery, our aim was to analyze the effects of our ERAS protocol on a heterogeneous population undergoing laparoscopic colorectal surgery.Prospectively collected data from 283 patients undergoing laparoscopic colorectal resection at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust, between March 2014 and March 2018 were retrospectively analyzed. Patients' adherence to pre-, intra-, and postoperative ERAS protocol items together with surgical short-term outcomes such as morbidity, mortality, length of hospital stay, and readmission rate was considered.The study protocol was approved by the Ethics Committee of Azienda Ospedaliera Universitaria Integrata di Verona (CRINF-1034 CESC).During the study period, 200 patients met the inclusion criteria and were enrolled in the ERAS protocol. In this series, 34% of patients were aged 70 years or older. Rectal resections represented 26% of all cases, with stoma formation performed in 14.5% of patients. Despite such procedural heterogeneity, good short-term results were obtained: by postoperative day (POD) 2, 58.5% of patients had full return of bowel function, while 63.5% and 88% achieved regular soft diet intake and autonomous walking, respectively. Median (range) length of hospital stay was 5.5 days (2-40) with 71% of patients being discharged by POD 6. No postoperative mortality was recorded, and the rate of major complications was 3.5%. During the study period, 6 patients required redo surgery (3%) and 5 patients required rehospitalization within 30 days (2.5%).This study analyzing the results of the fast-track program in our first 200 cases confirms the feasibility and safety of ERAS protocol application within a heterogeneous population undergoing laparoscopic colonic and rectal resection for benign and malignant diseases.

Patients' opinions on enhanced recovery after surgery perioperative care principles: a questionnaire study

Introduction

The enhanced recovery after surgery (ERAS) protocol relies on patients’ compliance and their awareness of its principles. Patients’ views on ERAS implementation have never been evaluated in Poland before.

Aim

To analyse patients’ opinions about this protocol.

Material and methods

One hundred forty consecutive patients undergoing elective laparoscopic procedures in which ERAS was implemented were asked to join the study. Out of them, 120 fulfilled the trial criteria and were surveyed once before and twice after surgery. A 22-question survey about the patient’s perception of ERAS principles was presented upon admission and on the day of discharge. A telephone follow-up was performed 2 weeks after discharge.

Results

Patients reported the need for being counselled by the anaesthetist/surgeon as the most important element of the protocol. Items such as being free of pain, being free of gastrointestinal symptoms, and being free of catheter were rated more highly preoperatively than on the day of discharge, whereas telephone check-up call, being able to drink and eat early after surgery, avoiding bowel preparation, avoiding preoperative fasting and reducing postoperative intravenous fluids were rated more highly on the day of discharge. Pain was still present in over half of patients two weeks after discharge. Only 4.76% of patients admitted in the telephone survey that they were afraid of early discharge. Shortening of the length of hospital stay thanks to ERAS was widely appreciated among all patients who did not find it necessary to spend a longer time in the hospital.

Conclusions

Polish patients approve the ERAS protocol as modern perioperative care. Patients emphasize the need for preoperative counselling and painless recovery.

Postoperative complications are associated with worse survival after laparoscopic surgery for non-metastatic colorectal cancer - interim analysis of 3-year overall survival

Introduction

Postoperative morbidity after colorectal resections for cancer remains a significant problem. Data on the influence of complications on survival after laparoscopic colorectal resection are still limited.

Aim

To analyze the impact of postoperative complications on long-term survival after radical laparoscopic resection for colorectal cancer.

Material and methods

Two hundred and sixty-five consecutive non-metastatic colorectal cancer patients undergoing laparoscopic colorectal resection for cancer were included in the analysis. The entire study group was divided into two subgroups based on the occurrence of postoperative complications. Group 1 included patients without postoperative morbidity and group 2 included patients with complications. The primary outcome was overall survival.

Results

Median follow-up was 45 (IQR: 34–55) months. Group 1 consisted of 187 (70.5%) patients and group 2 comprised 78 (29.5%) patients. Studied groups were comparable in terms of sex, age, body mass index, ASA class, cancer staging, localization of the tumor and operative time. Patients in group 1 had significantly better overall 3-year survival compared to those with complications (84.9% vs. 69.8%, p = 0.022). Kaplan-Meier curves showed significantly improved survival rates in patients without complications compared with complicated cases. The Cox proportional multivariate model showed that postoperative complications (HR = 2.83; 95% CI: 1.35–5.92; p = 0.0058) and AJCC III (HR = 3.17; 95% CI: 1.52–6.6; p = 0.0021) were independent predictors of worse survival after laparoscopic colorectal cancer surgery.

Conclusions

Our analysis of interim results after 3 years confirms that complications after laparoscopic colorectal cancer surgery have an impact on survival. For this reason, these patients should be carefully monitored after surgery aiming at early detection of recurrence.

Pancreatoduodenectomy for pancreatic head tumors in the elderly - Systematic review and meta-analysis

The age at which patients are undergoing pancreatoduodenectomy is increasing worldwide. The data on the outcome of this surgical procedure in the elderly is constantly expanding. This meta-analysis aims to assess the safety of pancreatoduodenectomy in elderly population, primarily focusing on morbidity and mortality. We searched the Medline, Embase and Cochrane databases to identify eligible studies. The most recent search was performed on 10th April 2017. Inclusion criteria were: (1) comparison of the characteristics and perioperative outcomes of older patients versus younger patients undergoing pancreatoduodenectomy; (2) objective evaluation of mortality or overall morbidity; and (3), publication in English. Exclusion criteria were: (1) a lack of comparative data; (2) a lack of primary outcomes or insufficient data to analyze; (3) a focus on procedures other than pancreatoduodenectomy; or (4), the impossibility of extraction of data specifically concerning pancreatoduodenectomy. Primary outcomes were overall morbidity and mortality. Secondary outcomes analyzed postoperative complications, R0 rate and length of hospital stay. 45 eligible studies were chosen, with a combined total of 21,295 patients. Older patients compared to younger patients had a higher risk of death (2.26% vs. 4.54%; RR: 2.23; 95% CI 1.74-2.87) and a higher complication rate (47.23% vs. 39.35%; RR: 1.17; 95% CI 1.12-1.24). There were no differences in pancreatic fistula occurrence (p = 0.27), bile leakage (p = 0.81), postoperative hemorrhage (p = 0.08), or R0 rate (p = 0.92). Our review confirms, that in the case of pancreatoduodenectomy, advanced age is a risk factor for increased non-surgical morbidity and, by extension, higher mortality.

Is the laparoscopic approach for rectal cancer superior to open surgery? A systematic review and meta-analysis on short-term surgical outcomes

Introduction

Over the past years the incidence of colorectal cancers has increased worldwide. Currently it is the most common gastrointestinal malignancy worldwide. The laparoscopic approach has become the gold standard for surgical treatment. However, a recently published meta-analysis showed no difference in short- and long-term oncological outcomes of laparoscopy for treating rectal cancer.

Aim

To assess current literature on short-term outcomes of rectal cancer treatment using laparoscopic surgery in comparison to the open approach.

Material and methods

We performed a systematic review and meta-analysis according to the PRISMA guidelines. The primary outcomes of interest were morbidity and short-term complications.

Results

We identified 4,328 potential references. In the end we included 13 randomized controlled trials (RCTs). We did not find any significant differences in terms of morbidity, haemorrhage, ureter injury, anastomotic leakage, mortality, intra-abdominal abscess or postoperative ileus. We found significant differences in the rate of surgical site infections, operative time, blood loss, length of hospital stay and time to first bowel movement.

Conclusions

This systematic review based on available RCTs confirms that laparoscopic rectal cancer surgery is associated with short-term outcomes comparable to the open approach. Moreover, in some aspects it provides better results (e.g. functional postoperative recovery, lower rate of surgical site infections (SSIs)). The quality of evidence is high; therefore in our opinion it is very unlikely that future trials will alter these results, and for this reason the laparoscopic approach can be considered the gold standard for the treatment of the majority of patients.

Current status of enhanced recovery after surgery (ERAS) protocol in gastrointestinal surgery

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.

Defunctioning ileostomy reduces leakage rate in rectal cancer surgery - systematic review and meta-analysis

Objectives

The role of a defunctioning ileostomy in every anterior rectal resection with total mesorectal excision (TME) is still controversial. In this study, we aimed to review the current literature to determine the impact of ileostomy creation on postoperative outcomes in patients undergoing anterior rectal resection with TME.

Methods

MEDLINE, Embase and Cochrane Library were searched for eligible studies. We analyzed data up to October 2017. Eligible studies had to compare patients with vs. without a defunctioning ileostomy in rectal cancer surgery and comprise data on anastomotic leakage in both groups. The primary outcome was anastomotic leakage. Secondary outcomes included the complication rate, mortality, reoperation rate, length of hospital stay and 30-day readmission.

Results

Initial search yielded 1,966 articles. Thorough evaluation resulted in 13 eligible articles which were analyzed. Leakage rate (RR = 0.43, 95% CI 0.28-0.67) and the number of reoperations (RR = 0.62, 95% CI 0.40-0.94) were significantly lower in the defunctioning stoma group. Morbidity was significantly higher in the stoma group (RR = 1.32, 95% CI 1.05–1.65). Analysis of mortality, length of hospital stay and readmission rate did not show any significant differences.

Conclusion

A defunctioning ileostomy may decrease the anastomotic leakage rate, additionally significantly reducing the risk of reoperations but it may also increase the overall complication rate. The presence of the protective stoma has no effect on mortality, length of hospital stay and readmission rate.

Safety and efficacy of enhanced recovery after surgery (ERAS) programs in patients undergoing hepatectomy: A prospective randomized controlled trial

BACKGROUND AND AIM

Enhanced recovery after surgery (ERAS) programs, following a variety of perioperative treatments with evidence-based medical evidence, has indicated its validity to accelerate rehabilitation in a wide variety of surgical procedures. This randomized controlled trial (RCT) study was implemented to verify the safety and efficacy of the perioperative effects in patients undergoing hepatectomy with ERAS or with conventional surgery (CS).

METHODS

From August 2016 to November 2017, according to the inclusion criteria, 160 patients with liver diseases were suitable for participating in this experiment. Patients before liver resection were randomized into ERAS group (n = 80) and CS group (n = 80), and then the outcome measures were compared between the two groups.

RESULTS

Enhanced recovery after surgery group had significantly less complications than CS group (P = .009). Compared with CS group, patients in ERAS group had low peak of WBCs in postoperative day (POD1), ALT in POD1 and POD3 (P < .05), high value of ALB in POD3 and POD5 (P < .05), less pain and higher patient satisfaction (P < .001), earlier exhaust, oral feeding, ambulation and extubation time (P < .05),and also had less hospital stay and cost (P < .001). There were no significant differences in readmission rate (<30 days) between two groups (P = .772).

CONCLUSIONS

Enhanced recovery after surgery programs applied to patients undergoing hepatectomy can safely and effectively relieve stress response, reduce the incidence of complications, improve patient satisfaction, accelerate patient recovery, reduce financial burden, and bring economic benefits.

Primary tumor resection in stage IV unresectable colorectal cancer: what has changed?

Most current guidelines do not recommend primary tumor resection in stage IV unresectable colorectal cancer. Rapid chemotherapy development over the last decade has substantially changed the decision making. However, results of recently published trials and meta-analyses suggest that primary tumor resection may in fact be beneficial, principally in terms of prolonged survival. Additional factors, such as use of minimally invasive approach or protocols of enhanced recovery after surgery, affect clinical outcomes as well, but are often neglected when discussing the state of the art in this area. There are still no randomized studies determining the legitimacy of upfront surgery in asymptomatic patients. Also, quality of life also plays an important role in choosing appropriate treatment. Having said that, there is no data that would prove whether primary tumor resection has an advantage on that issue. With all the uncertainty, currently decision making in unresectable stage IV colorectal cancer is primarily up to clinicians' knowledge, common sense and patients' preferences.

Do we really need the full compliance with ERAS protocol in laparoscopic colorectal surgery? A prospective cohort study

BACKGROUND

Although the relation between adherence to the ERAS protocol and clinical outcomes was extensively studied, there is still ongoing discussion on the need and feasibility of full compliance in laparoscopic colorectal surgery. In this study, we aimed to verify whether a strict adherence to the protocol (>90%) leads to further improvement in clinical outcomes compared to high (70-90%) and low (<70%) compliance groups.

MATERIALS AND METHODS

The analysis included consecutive prospectively registered patients operated laparoscopically for colorectal cancer between January 2012 and December 2015. Patients were divided into three groups depending on the compliance with the ERAS protocol: <70% (Group 1), 70-90% (Group 2), >90% (Group 3). The measured outcomes were: complication rate, readmission rate, recovery parameters (tolerance of early oral diet on 1st postoperative day and mobilization of a patient on the day of surgery), length of stay (LOS).

RESULTS

Group 1 consisted of 70, Group 2 of 65 and Group 3 of 116 patients. There were no statistical differences between the groups based on demographic parameters, stage of cancer and operative parameters (operative time, blood loss, conversion rate). The overall compliance with the protocol in the study group was 85.6 ± 11.9%. There was a significant decrease in complication rate with increasing compliance (35.7% vs. 36.4% vs. 16.4%, p = 0.0024) and severity of complications according to the Clavien-Dindo classification (p = 0.0198). Moreover, we observed differences in recovery parameters between the groups: tolerance of oral diet on the 1st postoperative day (52.8% vs. 79.5% vs. 87.9%, p < 0.0001), mobilization of a patient on the day of surgery (68.6% vs. 92.3% vs. 99.1%, p < 0.0001), respectively. We also observed that with compliance increase, the median LOS decreased (6 vs. 4 vs. 3 days, p < 0.0001).

CONCLUSION

Full implementation of the ERAS protocol significantly improves short term outcomes both in comparison to the high- and low-compliant groups.