Rehabilitación mutimodal en cirugía colorrectal. Sobre la resistencia al cambio en cirugía y las demandas de la sociedad

Intravascular volume status and stress markers in patients observing long and short duration of fasting: A prospective single blinded observational study

BACKGROUND

Preoperative fasting may lead to intravascular volume depletion and this volume depletion may be a cause of perioperative stress. This study intends to compare the levels of stress markers in patients undergoing long and short duration fasting before an elective laparoscopic surgery.

METHOD

This was a single blind, observational study. Based on the duration of fasting, 70 ASA I and II category patients undergoing elective laparoscopic cholecystectomy(LC) were divided into two groups of 35 patients each. If the surgeon had prescribed a fasting since midnight then patient was considered for inclusion in Long fasting (LF) group; if surgeon had allowed clear fluids till 2 h before surgery then the patient was considered for inclusion in the short fasting(SF) group. The extent of intravascular volume depletion was measured using inferior vena cava collapsibility index (IVCCI). Levels of relevant stress markers i.e. cortisol, Tetraiodothyronine (FT4), C-peptide, C-reactive protein(CRP) and blood glucose (BGL) were measured at 8 PM in the night before surgery, at 7 AM on the day of surgery, 2 h after the surgery and 24 h after the surgery.

RESULT

IVCCI was significantly more in the LF group; 27.66 ± 3.34% vs17.83 ± 2.22%, 95% CI 8.47-11.18, P-value <0.001). IVCCI had a significant correlation with the duration of fasting, Pearson's correlation r = 0.69,P-value <0.001. Repeated measures ANCOVA revealed that CRP, Free T4 and C-peptide levels got significantly elevated over the study duration, P-values <0.001,<0.001 and 0.03 respectively but with IVCCI, Age and Gender as the covariates, the increase in the levels of CRP, Free T4 and C-peptide were similar in both the groups.

CONCLUSION

Stress markers levels show significant elevation in the perioperative period, maximum over the study duration, but this change is similar in both the groups.

CLINICAL TRIAL NO

CTRI/2021/02/031456.

Implementation of an enhanced recovery after surgery protocol for head and neck cancer patients: Considerations and best practices

Enhanced recovery after surgery (ERAS) protocols have been developed in numerous surgical specialties as a means of systematically improving patient recovery, functional outcomes, cost savings, and resource utilization. Such multidisciplinary initiatives seek to minimize variability in several aspects of perioperative patient care, helping to reduce inpatient length of hospital stay, complications, and the overall resource and financial burden of surgical care. Head and neck oncology patients stand to benefit from the implementation of comprehensive ERAS protocols, as these patients have complex medical needs that may dramatically impact multiple aspects of their recovery, including breathing, eating, nutrition, pain, speech, swallowing, and communication. Implementing ERAS protocols for head and neck cancer patients may present unique challenges, and require significant interdisciplinary coordination and collaboration. We therefore sought to provide a comprehensive guide to the planning and institution of such ERAS systems at institutions undertaking care of head and neck cancer patients. Key elements to consider in the implementation of successful ERAS protocols for this population include organizing a team consisting of frontline leaders such as nursing staff, medical specialists, and associated health professionals; designing interventions based on systematically evaluated, high-quality literature; and instituting a clear methodology for regularly updating protocols and auditing the success or potential limitations of a given intervention. Potential obstacles to the success of ERAS interventions for head and neck cancer patients include challenges in systematically tracking progress of the protocol, as well as resource limitations in a given health system.

Early postoperative mobilization in patients undergoing abdominal surgery: a best practice implementation project

OBJECTIVES

The aim of this project was to improve early postoperative mobilization in patients undergoing abdominal surgery according to best practice.

INTRODUCTION

Early mobilization is a crucial element of postoperative care; however, there are challenges implementing early mobilization protocols in daily practice. This project used the evidence to improve awareness and practice of early mobilization in patients undergoing abdominal surgery.

METHODS

This study utilized clinical audit strategies under the JBI Practical Application of Clinical Evidence System (JBI PACES) module. An audit-feedback cycle was used from April 2018 to August 2018. The baseline audit was conducted using 18 nurses and 30 patients in a general surgery ward. The Getting Research into Practice audit and feedback tool was used to identify barriers, strategies, resources and outcomes. After implementing evidence-based strategies, a follow-up was conducted using the same number of samples and audit criteria. We analyzed the compliance with best practice and its impact on length of hospitalization, postoperative physical activities, gastrointestinal function and complications.

RESULTS

After implementing best-practice strategies, the compliance rate of the six criteria improved as follows: criterion 1 from 0% to 100% (P = 0.000), criterion 2 from 87% to 100% (χ = 4.29, P = 0.038), criterion 3 from 60% to 70% (χ = 6.67, P = 0.010), criterion 4 from 7% to 79% (χ = 52.55, P = 0.000), criterion 5 from 40% to 70% (χ = 35.00, P = 0.000), and criterion 6 from 0% to 100% (P = 0.000). The differences in the length of hospitalization and physical activities between the pre-implementation and post-implementation were statistically significant (all P < 0.05). The rate of postoperative complications did not show a significant difference because of low occurrence.

CONCLUSIONS

The results indicate that evidence-based practice is an effective method for enhancing early recovery in patients undergoing abdominal surgery through promoting early mobilization. Sustaining best practice should continue through further follow-up audits.

[Enhanced recovery program for colorectal surgery in cinical practice. Survey of surgeons of the Russian Federation]

AIM

To analyze RF surgeons' attitude to accelerated recovery program (ERP) and to determine how often it is used in daily work.

MATERIAL AND METHODS

223 physicians from 42 Russian regions were interviewed in 2017.

RESULTS

ERP is unknown among 11.7% of specialists; 8.9% heard about ERP but did not think that it is used in the Russian Federation; 16.6% know but do not apply the program; 55.6% use some elements of ERP; complete application of ERP was found in 7.2% of surgeons. This technique is more often used by more active surgeons (p = 0.001) and less often - by female surgeons (p = 0.0066). The most controversial and difficult elements of ERP are administration of carbohydrate mixtures prior to surgery, optimal body temperature maintenance, restrictive protocol of infusion therapy, refusal mechanical intestinal depuration and routine abdominal drainage, and administrative control over the protocol.

CONCLUSION

The majority of surgeons are ready to apply ERP. Some elements are difficult to apply for use in real healthcare. More educational activities are needed for wider and complete use of the protocol. New scientific available data should be used to improve this approach.

Impact of a diverting stoma in an enhanced recovery programme for rectal cancer

PURPOSE

The association of a loop ileostomy decreases the severity of complications after rectal surgery but can increase the postoperative stay. The aim of this study is to investigate if a diverting ileostomy influences the postoperative outcomes in a series of patients included in a multimodal rehabilitation program (MMRP).

METHODS

We analyzed a series of 104 patients that underwent elective surgery with primary anastomosis for rectal adenocarcinoma using a MMRP: 66 men and 38 women, with a median age of 64 (IQR: 55-75) years. Group A included patients with an associated loop ileostomy, and Group B, those without a protective stoma.

RESULTS

Group A = 58, group B = 46 patients without differences in age, ASA, BMI and other risk factors, nor in the surgical approach (laparoscopic in 34%), although there were more neoadjuvant treatments in group A: 77.5 vs. 36.9%; P=.001. In group A, the most common operation was total mesorectal excision (96%) and in the B, a subtotal mesorectal excision (90%). There were no differences in postoperative complications (Group A 34.4 vs. group B28.2%; P=.322), anastomotic leaks (8.3 vs. 10.8%; P=.475), or postoperative ileus (20.7 vs. 10.9%; P=.140), neither in postoperative stay (7.9 vs. 6.9 days; P= .058, readmissions (7 vs. 13.6%; P= .22), or postoperative stay, including readmissions (8.4 vs. 9.1 days; P= .49).

CONCLUSIONS

The association of a loop ileostomy does not extend the length of stay nor increases the rate of complications in patients that underwent a rectal resection with anastomosis included in a MMRP.

Influence of size and complexity of the hospitals in an enhanced recovery programme for colorectal resection

PURPOSE

The aim of this study was to see whether the application of the enhanced recovery programme for colorectal resection improves the results and, in turn, the influence of complexity and size of the hospitals in applying this and its results.

METHODS

A multi-centric prospective study was controlled with a retrospective group. The prospective operation group included 300 patients with elective colorectal resection due to cancer. The centres were divided depending on size and complexity in large reference centres (group 1) and area and basic general hospitals (group 2). The retrospective control group included 201 patients with the same characteristics attended before the application of the programme. Completion of categories of the protocol, complications, perioperative mortality and stay in hospital were recorded.

RESULTS

The introduction of the programme achieved a reduction in mortality (1 vs. 4 %), morbidity (26 vs. 39 %) and preoperative (<24 h vs. 3 days) and postoperative (7 vs. 11 days) stays (p < 0.01). There was greater fulfilment of protocol in group 2 with the mean number of items completed at 8.46 and 60 % completed compared with the hospitals in group 1 (7.70 completed items and 55 % completion). The size of the hospital had no relation to the rate of complications (21.3 vs. 26.5 %). In smaller sized and less complex hospitals, the average length of stay was 1.88 days less than in those of greater size (6.45 vs. 8.33 days).

CONCLUSION

Patients treated according to an enhanced recovery programme develop significantly fewer complications and have a shorter hospital stay. The carrying out of protocol is greater in smaller and less complex hospitals and is directly related to a shorter stay in hospital.

Enhanced recovery after surgery (ERAS) workshop: effect on attitudes of the perioperative care team

BACKGROUND

Enhanced recovery after surgery (ERAS) or 'fast track' surgery is heavily based on a multidisciplinary focused perioperative care model with all players being equally important for successful implementation. Several institutions run an ERAS course but few data are available on their effect on attitudes and perceptions to perioperative care principles.

METHODS

A ten item survey was designed for perioperative care clinicians attending an annual ERAS workshop. The survey was administered one week before and three weeks after the workshop.

RESULTS

Seventy seven eligible participants were identified. Forty four (57%) responded to the questionnaire prior to the course. On repeat administration of the survey three weeks after the course there were 28 (36%) responses. The results of the survey indicate that the majority of perioperative care staff were already aware of the evidence behind some of the principles applied in colectomy, with a high pre-course level of understanding shown. However the course significantly changed opinion regarding some other aspects of care to align opinion with evidence amongst the responders.

CONCLUSION

There appears to be a high rate of evidence agreement with some interventions but not others amongst perioperative staff. Attending a multidisciplinary ERAS workshop seems to align opinion with evidence.

[Results of applying a fast-track protocol in a colorectal surgery unit: comparative study]

OBJECTIVE

To implement a fast-track (FT) protocol in a colorectal surgery unit, checking its safety when applied to patients subjected to elective colorectal surgery, by evaluating the differences in morbidity and hospital stay compared to a control group with traditional care. We also analyse the functional recovery of the FT group.

MATERIAL AND METHOD

A prospective cohort study with non-concurrent control, was conducted on a group of 108 patients operated on for colorectal cancer between 2008 and 2009, to which the FT protocol was applied, and a control group (CG) of 147 patients subjected to surgery between 2005 and 2007 with similar characteristics, with traditional postoperative care.

RESULTS

The demographic characteristics, anaesthetic risk, and the surgical procedures performed were similar, with a higher number of patients with laparoscopic approach in the FT group. The compliance with the items in our FT protocol was high (72.2-92.6%). Complications were observed in 77 patients (52%) in the GC compared to 30 (27.8%) in the FT group (P<.001), mainly due to the decrease in surgical wound infection (P<.001). Mortality and the number of readmissions were less in the FT group, with no statistically significant differences. The median hospital stay was 14 days in the CG and 8 in the FT group (P<.001).

CONCLUSIONS

The applying of an FT program in colorectal surgery is safe, leading to a significant decrease in morbidity and hospital stay, without increasing the number of readmissions.

"Fast track surgery" in the north-west of Italy: influence on the orientation of surgical practice

Fast track surgery is a peri-operative management model, including different strategies to improve patients' convalescence, avoid metabolic alterations, reduce complications, and shorten hospital stay. Prerequisite is coordination between different practitioners (surgeon, anaesthetist, nurse, nutritionist, physiotherapist). The purpose of our investigation is to understand the level of fast track surgery application in Piedmont and to evidence analogies and differences among departments. We projected an investigation proposing, to every surgery department in Piedmont, a multiple-choice questionnaire evaluating the level of fast track surgery peri-operative interventions' application. Data analysis was conducted in two points of view: the transversal one with an overview of answer's percentages, the longitudinal one correlating data through Pearson's index (r). We collected answers by 78 % of balloted departments (38 on 49). Transversal analysis, including the evaluation of percentages of each question, shows that intra-operative period is the most influenced by fast track principles, and that only 12 departments of 38 apply complete protocols. Longitudinal analysis, estimating the whole of each department's answers, demonstrates the absence of statistical significance in the correlation between fast track surgery application and territorial (r = 0.18), economic (r = 0.31), or age (r = 0.06) variables. Influence of fast track surgery is significantly present in our territory, even though it is not fully concretized in protocols. The choice of fast track depends on the instruction, the environment and the sensibility of each surgeon. Knowledge of geographic distribution of departments applying this model can be useful to organize common protocols, starting from more experienced hospitals.

Perioperative quality of care is modulated by process management with clinical pathways for fast-track surgery of the colon

PURPOSE

Clinical pathways (CPs) are increasingly used to improve quality of care. However, evidence if such improvements are also feasible in fast-track colorectal surgery is lacking. This study evaluates effects of a CP for fast-track colonic resections with respect to process and outcome quality.

METHODS

We compared 78 consecutive patients undergoing colonic resections in 2008 and being treated with a CP (CP group) with 133 consecutive patients treated without CP between 2006 and 2007 (pre-CP group). Indicators for process quality were epidural catheter placement, postoperative mobilisation, resumption of solid diet, Foley catheter removal and length of stay. Outcome quality was measured through morbidity, mortality, re-operations and readmissions.

RESULTS

In the CP group, patients received epidural analgesia significantly more often (87.2% vs. 75.2%; p =0.04), were mobilized (38.9% vs. 20.6% on the day of surgery; p = 0.03) and resumed a solid diet earlier (60.5% vs. 49.6% on day 1; p = 0.002). Foley catheter removal and length of stay did not differ between the groups. There were no significant differences regarding morbidity (28.2% vs. 32.3%), mortality (1.2% vs. 2.3%), re-operations (6.4% vs. 9.0%) and readmissions (2.6% vs. 3.8%).

CONCLUSIONS

After CP implementation for fast-track surgery of the colon, several indicators of process quality improved while others such as length of stay remained unaltered. There were no significant changes in outcome parameters. CPs are a viable instrument to improve specific aspects of perioperative process management, but their selective benefits have to be critically weighed against the infrastructural and personal efforts required for design and implementation.

Perioperative care: a survey of New Zealand and Australian colorectal surgeons

AIM

Recent surveys in Europe and North America have demonstrated significant challenges in the implementation of evidence-based surgical practice.

METHOD

A survey of New Zealand and Australian colorectal surgeons was conducted to help understand current practice and perceived barriers to interventions in this region. Questions were based around elective colorectal resection care.

RESULTS

There were 152 eligible participants identified. Over a 60-day period, 82 (54%) surgeons responded but only 76 (50%) of the questionnaires were complete; they were used for data analysis. The majority of surgeons indicated a preference for laparoscopic techniques. Barriers to laparoscopy include lack of operating time, lack of adequate training and institutional pressures. Only 28 (37%) indicated that they cared for patients in a formalized enhanced recovery programme (ERAS). Barriers to implementing ERAS included lack of support from institutions and other specialities. Routine oral 'mechanical' bowel preparation for colon and rectal resection was preferred by 28% and 63%, respectively. Drainage after routine colon and rectal resection was not used by 62 (83%) and 39 (53%). Prophylactic nasogastric intubation afterwards was not used by 66 (87%) responders. The preferred mode of analgesia was patient-controlled opioid analgesia (PCA) for 52%. A 'restrictive' intravenous fluid therapy was preferred by 34 (49%) while 33 (48%) preferred no fluid restriction. A prolonged 'nil by mouth' status was preferred by 28%.

CONCLUSION

There appears to be a high rate of evidence in agreement with some interventions but not others. The systemic barriers to implementing evidence-based perioperative care need attention.

[Implementation of a perioperative multimodal rehabilitation protocol in elective colorectal surgery. A prospective randomised controlled study]

INTRODUCTION

Multimodal rehabilitation (MMR) consists of a combination of several methods for management of the surgical patient, designed to reduce the response to surgical stress and a more comfortable and earlier recovery.

OBJECTIVE

To assess the implementation of an MMR protocol in a Colorectal Surgery Unit, and to compare the results with the traditional model, as well as assessing its efficacy as regards recovery and hospital stay.

MATERIAL AND METHODS

A total of 119 patients who received elective surgery for colorectal diseases in a period during 2009-2010 were prospectively and randomly analysed. The patients were divided into 2 groups: 58 patients were assigned to the traditional group and 61 to the MMR group. The MMR group protocol consisted of, preoperative education, early feeding and mobilisation.

RESULTS

Both groups were homogeneous as regards the preoperative variables evaluated, the type of disease and the procedures carried out. The nasogastric tube was kept in place for 4 (1-9) days compared to 1 day (0-2) in the MMR group, with no differences in the number of re-insertions. Significant differences were found in the introduction of a liquid diet (3 [1-5] days traditional versus 0 [0-2] MMR) (P<.001), and passing of first flatulence (3 [1-6] days traditional versus 1 [1-3] MMR) (P<.001). The MMR group had a postoperative stay of 4.15±2.18 versus 9.23±6.97 days in the traditional group (P<.001). No significant differences were found in complications or readmissions.

CONCLUSIONS

MMR in colorectal surgery in the Spanish public health system is feasible and enables surgical patients to have a faster recovery without increasing complications, leading to an earlier hospital discharge.

[Multimodal (fast-track) rehabilitation in elective colorectal surgery: evaluation of the learning curve with 300 patients]

INTRODUCTION

The aim of this paper is to assess the learning curve on compliance to the application of a multimodal rehabilitation program (MMRP) protocol and patient recovery after elective colorectal surgery.

MATERIAL AND METHODS

A comparative prospective study of 3 consecutive cohorts of 100 patients (P1, P2 and P3) who had colonic or rectal surgery. The same MMRP protocol was applied in all cases. Compliance to the protocol, tolerance to the diet and walking have been analysed. The percentages of early hospital discharges have also been compared.

RESULTS

Compliance gradually improved, reaching statistical significance between P1 and P3. Starting the diet on day 1 post-surgery was 52% vs 86% (p=0.0001) and the removal of drips was 21% vs 40% (p=0.005). This difference remained during days 2 and 3. Tolerance to the diet on day 1 (P1: 34% vs. P3: 66%; p=0.0001) and walking on day 2 (P1: 41% vs. P3: 68%; p=0.0002) were also better in the third period. No differences in morbidity were found between the three periods. The percentage of hospital discharges on day 3 P1: 1% vs. P3: 15%; p=0.0003), day 4 (P1: 12% vs. P3: 32%; p=0.001) and day 5 (P1: 30% vs. P3: 50%; p=0.002) was higher in the third period.

CONCLUSIONS

The compliance to the protocol and the results of applying the MMRP improved significantly with the greater experience of the professionals involved.

[Retrospective analysis of the use of the Spanish words severo and severidad in CIRUGIA ESPANOLA during 2007]

INTRODUCTION

The Spanish words severo (severe) and severidad (severity) are usually used as a synonyms of grave (serious) and gravedad (seriousness), although the Spanish Royal Academy of Language (Real Academia Española [RAE]) specifically recommends not to use them in this sense. A retrospective analysis to evaluate the use of the words severo and severidad in Cirugía Española during 2007 was performed.

MATERIAL AND METHOD

All the articles published in Cirugía Española during 2007 were reviewed. The articles in which severo and/or severidad were present were selected. For each article, the month of publication, the type of article, the geographic origin and the exact sentence containing these words were analyzed. Correctness and incorrectness of their use was studied according to the RAE normative.

RESULTS

A total of 33 articles were selected. Every month (except for January) had, at least, 2 articles. Thirty-one of the articles were from Spain whereas 2 were from Hispano-America. Eleven cases were original articles, 7 reviews, 6 case reports, 3 editorials, 3 special articles and 3 letters to the editor.

CONCLUSIONS

The Spanish words severo and severidad are inadequately used too often in scientific texts. It must be avoided using them as a synonym of grave, importante or serio, incorrect translations of the English word severe.

Implementation of ERAS and how to overcome the barriers

BACKGROUND

Multimodal care or Enhanced Recovery after Surgery (ERAS) protocols are gaining popularity in order to modify surgical stress responses after colonic resection. However, these protocols are not straightforward to implement as peri-operative care is varied. We aimed to identify areas that may need attention in order to successfully change practice.

METHOD

The literature was reviewed for current practice, methods and issues in implementing ERAS. Based on this and our own experience we discuss several important areas that need particular attention in developing and sustaining an ERAS program.

RESULTS

International surveys have shown that current peri-operative care in colorectal resection is not evidence based. Important aspects of the ERAS philosophy including patient counselling, teamwork and attitude change are identified and discussed.

CONCLUSION

Implementing evidence-based peri-operative care into practice is challenging. Barriers to multimodal recovery pathways should be addressed.