Life and death of the nasogastric tube in elective colonic surgery in the Netherlands

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization

BACKGROUND

Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach.

METHODS

Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1.

RESULTS

Twelve components of preoperative care were considered. Consensus was reached after three rounds.

CONCLUSIONS

These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.

Timing of nasogastric tube insertion and the risk of postoperative pneumonia: an international, prospective cohort study

AIM

Aspiration is a common cause of pneumonia in patients with postoperative ileus. Insertion of a nasogastric tube (NGT) is often performed, but this can be distressing. The aim of this study was to determine whether the timing of NGT insertion after surgery (before versus after vomiting) was associated with reduced rates of pneumonia in patients undergoing elective colorectal surgery.

METHOD

This was a preplanned secondary analysis of a multicentre, prospective cohort study. Patients undergoing elective colorectal surgery between January 2018 and April 2018 were eligible. Those receiving a NGT were divided into three groups, based on the timing of the insertion: routine NGT (inserted at the time of surgery), prophylactic NGT (inserted after surgery but before vomiting) and reactive NGT (inserted after surgery and after vomiting). The primary outcome was the development of pneumonia within 30 days of surgery, which was compared between the prophylactic and reactive NGT groups using multivariable regression analysis.

RESULTS

A total of 4715 patients were included in the analysis and 1536 (32.6%) received a NGT. These were classified as routine in 926 (60.3%), reactive in 461 (30.0%) and prophylactic in 149 (9.7%). Two hundred patients (4.2%) developed pneumonia (no NGT 2.7%; routine NGT 5.2%; reactive NGT 10.6%; prophylactic NGT 11.4%). After adjustment for confounding factors, no significant difference in pneumonia rates was detected between the prophylactic and reactive NGT groups (odds ratio 1.03, 95% CI 0.56-1.87, P = 0.932).

CONCLUSION

In patients who required the insertion of a NGT after surgery, prophylactic insertion was not associated with fewer cases of pneumonia within 30 days of surgery compared with reactive insertion.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

BACKGROUND

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.

METHODS

A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.

CONCLUSIONS

The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Demonstrating Value: A Case Study of Enhanced Recovery

An enhanced recovery after surgery strategy will be increasingly adopted in the era of value-based care. The various elements in each enhanced recovery after surgery protocol are likely to add value to the overall patient surgical journey. Although the evidence varies considerably based on type of surgery and patient group, the team-based approach of care should be universally applied to patient care. This article provides an overview of up-to-date techniques and methodology for enhanced recovery, including an overview of value-based care, delivery, and the evidence base supporting enhanced recovery after surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A meta-analysis on the effect of sham feeding following colectomy: should gum chewing be included in enhanced recovery after surgery protocols?

BACKGROUND

Sham feeding has been shown to hasten the return of GI function following colorectal surgery, before the advent of enhanced recovery after surgery protocols. Few data exist regarding the efficacy of sham feeding in the modern era, with rapid postoperative feeding.

OBJECTIVE

We sought to perform a meta-analysis on the effect of sham feeding in colorectal surgery, with a separate analysis on trials that used rapid postoperative feeding.

DATA SOURCES

Cochrane, MEDLINE, EMBASE, Scopus, and PubMed were searched by using the terms gum OR sham feeding OR chew AND (colorect OR resect).

STUDY SELECTION

All studies were randomized controlled trials (in any language) performed on adults, comparing standard care with gum chewing following colorectal resection. From 439 citations, 10 articles were included.

INTERVENTION

The intervention was sham feeding by means of gum chewing.

MAIN OUTCOME MEASURES

The outcome measures were time to return of flatus, time to first bowel movement, complication rates, length of hospital stay, readmission rates, and reoperation rates.

RESULTS

Ten randomized controlled trials (n = 612) were included. Sham feeding resulted in a reduction in time to flatus of 31 minutes (p = 0.003) and time to first bowel movement of 30 minutes (p = 0.05). Sham feeding also resulted in a reduction in length of stay by 0.5 days (p = 0.007), and a reduction in complication rates (relative risk = 0.687, p = 0.017), although this appeared to be associated with publication bias. Analysis of trials that used rapid postoperative feeding (n = 282) revealed no difference in postoperative GI function.

LIMITATIONS

This review was limited by the heterogeneity of postoperative feeding regimes, in addition to limited reporting by trials of postoperative morbidity.

CONCLUSIONS

Sham feeding following colorectal surgery is safe, results in small improvements in GI recovery, and is associated with a reduction in the length of hospital stay. It confers no advantage if patients are placed on a rapid postoperative feeding regime.

Contemporary perioperative care strategies

Background

Historically, the preoperative and postoperative care of patients with gastrointestinal cancer was provided by surgeons. Contemporary perioperative care is a truly multidisciplinary endeavour with implications for cancer-specific outcomes.

Methods

A literature review was performed querying PubMed and the Cochrane Library for articles published between 1966 to 2012 on specific perioperative interventions with the potential to improve the outcomes of surgical oncology patients. Keywords used were: fast-track, enhanced recovery, accelerated rehabilitation, multimodal and perioperative care. Specific interventions included normothermia, hyperoxygenation, surgical-site infection, skin preparation, transfusion, non-steroidal anti-inflammatory drugs, thromboembolism and antibiotic prophylaxis, laparoscopy, radiotherapy, perioperative steroids and monoclonal antibodies. Included articles had to be randomized controlled trials, prospective or nationwide series, or systematic reviews/meta-analyses, published in English, French or German.

Results

Important elements of modern perioperative care that improve recovery of patients and outcomes in surgical oncology include accelerated recovery pathways, thromboembolism and antibiotic prophylaxis, hyperoxygenation, maintenance of normothermia, avoidance of blood transfusion and cautious use of non-steroidal anti-inflammatory drugs, promotion of laparoscopic surgery, chlorhexidine–alcohol skin preparation and multidisciplinary meetings to determine multimodal therapy.

Conclusion

Multidisciplinary management of perioperative patient care has improved outcomes.

Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery, and to provide graded recommendations for items for an evidenced-based enhanced recovery protocol.

METHODS

Studies were selected with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group.

RESULTS

For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (evidence grade: high or moderate).

CONCLUSIONS

Based on the evidence available for each item of the multimodal perioperative care pathway, the Enhanced Recovery After Surgery (ERAS) Society, European Society for Clinical Nutrition and Metabolism (ESPEN) and International Association for Surgical Metabolism and Nutrition (IASMEN) present a comprehensive evidence-based consensus review of perioperative care for rectal surgery.

Effect of fast track surgery on clinical parameters and postoperative complications in patients with gastric cancer

AIM: To evaluate the effect of fast track surgery (FTS) on clinical parameters and postoperative complications in patients with gastric cancer.

METHODS: A non-randomized controlled study was undertaken. Data were collected from 168 patients with gastric cancer who were treated at General Hospital of Guangzhou Military Command from February 2008 to May 2011, including 82 patients having undergone FTS and 86 patients having undergone conventional perioperative care. Outcomes were assessed using the time to first flatus and defecation, the length of postoperative hospital stay, medical cost and postoperative complications.

RESULTS: The time to first flatus (2.6 d vs 4.6 d) and defecation (3.3 d vs 5.2 d) and the length of hospital stay (4.6 d vs 8.1d) in the FTS group were significantly shorter, and the medical cost (23 vs 29 thousand yuan) was significantly less than those in the conventional treatment group (all P < 0.05). The incidence of pulmonary complications (6.1% vs 16.3%, P < 0.01) was much lower in the FTS group than in the conventional treatment group. The incidence of digestive tract fistula was higher in the FTS group than in the conventional treatment group (4.9% vs 3.5%), but the difference had no statistical significance (P > 0.05). In four patients developing fistula in the FTS group, two patients received operation again, whereas all the three patients developing fistula in the conventional treatment group received non-operation treatment. The overall incidence of complications in the FTS group was lower than that in the conventional treatment group (26.8% vs 32.6%), but the difference had no statistical significance (P > 0.05). One patient died in each group. The rate of readmission in the FTS group was higher (4.9% vs 3.5%), but the difference had no statistical significance (P > 0.05).

CONCLUSION: Fast track surgery is effective and safe in patients with gastric cancer, and it might contribute to gut function recovery, shorten hospital stay time and reduce medical cost. FTS does not increase the incidence of postoperative complications, but might increase the difficulty of diagnosis and treatment of some severe complications such as digestive tract fistula and hemorrhage.

Fast-track colorectal surgery

In recent years, fast-track surgery has been attracting more and more attention; however, many people remain concerned about the safety and effectiveness of fast-track colorectal surgery. In this paper we discuss how the main components of fast-track colorectal surgery (no routine mechanical bowel preparation, epidural anaesthesia or analgesia, laparoscopic operation, early removal of nasogastric tube and drainage tube, early postoperative oral feeding) affect the incidence of postoperative complications. Meanwhile, we evaluate the effectiveness of fast-track colorectal surgery in terms of shortened length of hospital stay, facilitated recovery, reduced insulin resistance, and better preserved immune function. Besides, we summarize the difficulties confronted during the implementation of fast-track colorectal surgery. We conclude that fast-track colorectal surgery is a safe and effective approach that deserves to be popularized in clinical practice.

The role of nasogastric tube in decompression after elective colon and rectum surgery: a meta-analysis

OBJECTIVES

Nasogastric tubes (NGT) have been routinely used after abdominal procedures, largely due to the accepted tradition, especially in China. However, studies recently questioned the role of routine NGT intubation by stating that it was overused and many complications occurred from its use.

METHODS

Herein, we performed a systematic review and a meta-analysis evaluating the role of NGT in decompression after elective colon and rectum surgery.

RESULTS

Four fixed-effect models and three randomized-effect models were used for statistics pooling of the relative risks (RR) for the different outcomes. A total of seven articles (1,416 patients) fulfilled the inclusion criteria. Patients in NGT group had less vomiting (p < 0.00001; RR = 2.85; 95% CI [2.12, 3.83]), less nasogastric tube replacement (p < 0.00001; RR = 3.90; 95% CI [2.34, 6.52]), but more pharyngolaryngitis (p < 0.00001 RR = 0.14; 95% CI [0.08, 0.26]) and more respiratory infection (p = 0.004; RR = 0.37; 95% CI [0.19, 0.74]). No statistically significant differences were noted in nausea, wound infection or intestinal obstruction.

CONCLUSION

In conclusion, routine NGT decompression did no good to the time to return gastrointestinal function, but increased the morbidity of pharyngolaryngitis and respiratory infection significantly. Routine NGT was not recommended for patients after elective colon and rectum surgery.

Current perioperative practice in rectal surgery in Austria and Germany

OBJECTIVE

'Fast-track' rehabilitation is able to accelerate recovery, reduce general morbidity, and decrease hospital stay. This is widely accepted for colonic resections. Despite recent evidence that fast track concepts are safe and feasible in rectal resection, there is no information on the acceptance and utilization of these concepts among Austrian and German surgeons.

METHOD

A questionnaire concerning perioperative routines in elective, open rectal resection was sent to the chief surgeons of 1,270 German and 120 Austrian surgical centers.

RESULTS

The response rate was 63% in Austria (76 centers) and 30% in Germany (385 centers). Mechanical bowel preparation is only abandoned by 2% of the Germany and 7% of the Austrian surgeons. Nasogastric decompression tubes are rarely used; four of five of the questioned surgeons in both countries use intra-abdominal drains. Half of the surgical centers allow the intake of clear fluids on the day of surgery. Mobilization starts in half of the centers on the day of surgery. Epidural analgesia is used in three-fourths of the institutions. Institutions which have implemented fast track rehabilitation for rectal resections discharge the patients earlier then hospitals that adhere to traditional care.

CONCLUSION

In many perioperative procedures, Austrian and German Surgeons rely on their traditional approaches. Recent evidence-based adaptations of perioperative routines in rectal resections are only slowly introduced into daily routine; therefore, further efforts have to be done to optimizing patients' care.