Optimizing perioperative management of patients undergoing colorectal surgery: what is new?

Fast-Track Surgery in Intestinal Deep Infiltrative Endometriosis

Fast-track (FT), also known as enhanced recovery after surgery (ERAS), is an integrated management of patients undergoing surgery, which is focused on optimal recovery and improvement of the overall quality of care. Minimally invasive surgery is the gold standard to diagnose and treat endometriosis, and its beneficial role within the FT program was reviewed. A search was performed for recent medical literature regarding the findings of the FT approach applied to intestinal deep infiltrative endometriosis surgery. This pathway comprises a diverse number of procedures arranged in preoperative, intraoperative, and postoperative settings. Evidence-based findings in randomized clinical trials have repeatedly shown that these protocols lead to enhanced recovery after surgery, reduced morbidity and mortality with a reduction in postoperative complications, and with readmission rates similar to conventional regimes.

Fast-track colorectal surgery: protocol adherence influences postoperative outcomes

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Enhanced recovery for colorectal surgery: Practical hints, results and future challenges

Enhanced recovery after surgery (ERAS) protocols are now achieving worldwide diffusion in both university and district hospitals with special interest in colorectal surgery. The optimization of the patient’s preoperative clinical conditions, the careful intraoperative administration of fluids and drugs and the postoperative encouragement to resume the normal physiological functions as early as possible has produced results in a large amounts of studies. These approaches successfully challenged long-standing and well-established perioperative managements and finally achieved the status of gold standard treatments for the perioperative management of uncomplicated colorectal surgery. Even more important, it seems that the clinical improvement of the patient’s clinical management through ERAS protocols is now reaching his best outcomes (length of stay of 4-6 d after the operation) and therefore any further measures add little to the results already established (i.e., the adjunct of laparoscopic surgery to ERAS). Still dedicated meetings and courses around the world are exploring new aspects including the improvement the preoperative nutrition status to provide the energy necessary to face the surgical stress, the preoperative individuation of special requirements that could be properly addressed before the date of surgery and therefore would reduce the number of unnecessary days spent in hospital once fully recovered (i.e., rehabilitation, social discharges), and finally the development of an important web of out-of-hours direct access in order to individuate alarm symptoms in those patients at risk of complications that could prompt an early readmission.

Pre-operative nutrition and carbohydrate loading

An optimal nutritional state is an important consideration in providing successful operative outcomes. Unfortunately, many aspects of surgery are not constructive to providing this. In addition, the metabolic and immune response to injury induces a catabolic state and insulin resistance, a known risk factor of post-operative complications. Aggressive insulin therapy post-operatively has been shown to reduce morbidity and mortality but similar results can be achieved when insulin resistance is lessened by the use of pre-operative carbohydrate loading. Consuming carbohydrate-containing drinks up to 2 h before surgery has been found to be an effective way to attenuate insulin resistance, minimise protein losses, reduce hospital stays and improve patient comfort without adversely affecting gastric emptying. Enhanced recovery programmes have employed carbohydrate loading as one of several strategies aimed at reducing post-operative stress and improving the recovery process. Studies examining the benefits of these programmes have demonstrated significantly shorter post-operative hospital stays, faster return to normal functions and lower occurrences of surgical complications. As a consequence of the favourable evidence they are now being implemented in many surgical units. Further benefit to post-operative recovery may be found with the use of immune-enhancing diets, i.e. supplementation with n-3 fatty acids, arginine, glutamine and/or nucleotides. These have the potential to boost the immune system, improve wound healing and reduce inflammatory markers. Research exploring the benefits of immunonutrition and solidifying the use of carbohydrate loading is ongoing; however, there is strong evidence to link good pre-operative nutrition and improved surgical outcomes.

Fast-track protocols in colorectal surgery

Fast-track surgery (FTS) is a set of protocols aimed to reduce the physiological burden of surgery thus improving outcomes. FTS aims to use evidence-based practice to reduce complications, improve post-operative quality of life and decrease hospital length of stay. This review seeks to examine the evidence base for protocols employed in colorectal surgery in the areas of pre-operative preparation, anaesthetic management, intraoperative and surgical factors and post-operative care. Despite the evidence that recovery after colorectal surgery can be enhanced by using these approaches, implementation of FTS protocols has been slow. Acceptance of FTS protocols by all members of the multi-disciplinary team and a change in organisational structure to accommodate structured peri-operative care, are imperative to implementation.

[Accreditation and dedication in coloproctology is associated with good perioperative care]

Complex data analysis methods require optimisation techniques such as evolutionary algorithms in order to generate reliable results. The objective of this study is to analyse the relationships of particular perioperative care in colorectal surgery (CRS) with surgeon epidemiological data, performing partition grouping to look for significant relationships.

METHODS

Data were used from a survey of members of Spanish coloproctology associations on perioperative care in colorectal surgery, and analysing the responses associated with mechanical bowel preparation (MBP), nasogastric intubation (NGI), drainages (D), and early feeding (EF), over the existing scientific evidence (SE) which shows that the first ones are unnecessary and the importance of the last one. We applied a variant of particle swarm optimization (PSO), to group data conglomerates, optimising variables with statistical grouping criteria.

RESULTS

A total of 130 surveys were analysed, finding 2 clear groups which included 21.5% and 78.5% of the sample, respectively. Sixty eight per cent of the surgeons in Group A belonged to the European Board in Coloproctology, compared to none in Group B, and the former performed 80% of the coloproctology activity, compared to 60% of the rest. A responded homogeneously to questions on MBP, NGI, D and EF, those of group A following the SE, while the others did it randomly and without following it. Age, work position or academic range were not significant in the grouping.

CONCLUSIONS

The evolutionary algorithm was shown to be able to identify groups according to the use of perioperative care in CRS. Accreditation and dedication was associated with behaviour based on the SE.

A brief review of laparoscopic appendectomy: the issues and the evidence

Laparoscopic appendectomy was first performed more than 25 years ago. We performed a systematic literature search on laparoscopic appendectomy and selected related topics. The technique should be considered the gold standard for surgical removal of the appendix in women of childbearing age (level of evidence Ia). There is minor but consistent evidence that it should also be advocated for men (level of evidence III), obese (level of evidence III), and elderly (level of evidence IIb) patients, while there is some evidence of unfavorable results on pregnant women (level of evidence IIb). Studies reporting higher incidence of intra-abdominal abscesses after laparoscopic appendectomy are difficult to interpret due to a lack of standardization of the operative technique and lack of uniformity related to the different grades of disease (ranging from uninflamed appendix to diffuse peritonitis, gangrene, or perforation of the organ). As far as surgical technique, the three-port procedure is superior to needleoscopy and single port access (level of evidence Ia). Costly high-tech instruments for dissection are mostly unnecessary (level Ib). Mechanical closure of the stump might prove safer (level Ib). The quantity of peritoneal lavage fluid is generally scanty (level III), and abdominal drains are not useful (level Ia). Fast-track protocols should be implemented (level Ic). Training and technical standardization are the key to devising future trials on this topic.

Compliance with enhanced recovery programmes in elective colorectal surgery

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are often criticized for being difficult to implement outside clinical trials. This audit evaluated compliance with an ERAS protocol and compared it with that during a trial.

METHODS

Compliance was audited by case-note review of 100 consecutive patients undergoing colorectal surgery. This was compared with the compliance in a group of 95 patients who participated in a clinical trial.

RESULTS

Fewer patients in the audit group than in the study group received preoperative oral carbohydrate loading (61.0 versus 96 per cent; P < 0.001), a transverse incision (25.0 versus 39 per cent; P = 0.037), early fluid and diet reintroduction (73.0 versus 99 per cent; P < 0.001), and non-opiate postoperative oral analgesia (70.0 versus 99 per cent; P < 0.001). Lower non-opiate oral analgesia use in the audit group was not associated with a commensurate increase in opiate use (P = 0.061). There was no difference between groups in length of hospital stay (median (interquartile range) 7 (5-8) versus 6 (5-7) days respectively), septic morbidity or 30-day mortality rates.

CONCLUSION

Observance to some aspects of the ERAS protocol was lower outside the clinical trial. However, this made little difference to patient outcome.

Perioperative care in colorectal surgery: current practice patterns and opinions

Objective Evidence regarding perioperative care in colorectal surgery has recently increased, leading to changes in classical clinical procedures that make the perioperative period safer and shorter. This survey aimed to evaluate the opinions of Spanish colorectal surgeons on the perioperative management of their patients. Method Emailed surveys submitted to the members of Spanish Coloproctological Associations. Results One hundred and thirty-one (31.7%) of the 413 members participated in the study and responded thus: 21% use clinical pathways and 8% use fast track (FT); 36% use epidural analgesia in colonic surgery and 57% in rectal; 40% use warm air and 23% warm fluids to maintain intraoperative normothermia; 53% prescribe >/= 3000 ml. of iv fluids on the first postoperative day and 6.2%</= 2000 ml; 43% never use nasogastric tubes. Oral intake was initiated by 23.5% on the first day, and by 50% when peristalsis began, with an earlier tendency in laparoscopic surgery; 43% believed oral intake reduces ileus, but 12% considered it dangerous. Board accreditation and experience in Coloproctology were significantly associated with a lesser use of nasogastric tubes and earlier feeding. Sixty-nine per cent considered FT reduces postoperative stay and 44% thought that it minimizes complications. Conclusion Spanish surgeons maintain a classical procedural policy, but show tendencies towards optimizing patients' care.

Current technique of laparoscopic total mesorectal excision (TME): an international questionnaire among 368 surgeons

BACKGROUND

Current literature shows no consensus for the technique of laparoscopic total mesorectal excision (LTME). This study aimed to assess the current practice of LTME.

METHODS

From January to March 2008, members of the European Association for Endoscopic Surgery (EAES), the Indian Association of Gastrointestinal Endo-Surgeons (IAGES), and the Society of Laparoscopic Surgeons (SLS), together with renowned surgeons in the field of LTME, were invited to fill out an online questionnaire concerning aspects of LTME.

RESULTS

The 368 questionnaires showed that 77% of the study participants performed 1-20 LTMEs per year (low volume) and that 33% performed more than 20 LTMEs per year (high volume). Preoperative bowel preparation (PBP), Trendelenburg position, periumbilical insertion of a 30º laparoscope, medial-to-lateral dissection, ultrasonic hemostasis, high-tie ligation, splenic flexure mobilization, left ureteral identification, partial sigmoid resection, extraction of the specimen by a new minilaparotomy and wound protector, end-to-end stapled anastomosis using a 28- to 29-mm anvil with 3.5-mm staples, abdominal lavage, pelvic drainage, and diverting ileostoma were performed by a majority of the surgeons. Less consistency was observed in identification of the right ureter, dissection of Denonvilliers' fascia, location of the minilaparotomy, and construction of a colonic pouch. There were significant differences between high and low volume and between American and European surgeons. Significantly more low-volume surgeons indicated a preference for an open TME depending on the age and gender of the patient, the presence of comorbidity, previous laparotomy, and locally advanced tumor. More low-volume surgeons applied PBP (83.4% vs. 71.8%; p = 0.017). On the average, high-volume surgeons identified more autonomic pelvic nerves during dissection (2.6 vs. 1.8 nerves). The right ureter was identified by 66% of the American and 31.2% of the European surgeons. In the United States 91.5% and in Europe 61.2% created an end-to-end anastomosis. Pouches were created by 32% of the European and 6.8% of the American surgeons.

CONCLUSION

The respondents showed an apparent preference for several aspects of LTME. Differences were related to expertise and still more to continent.

Fast-track in open intestinal surgery: prospective randomized study (Clinical Trials Gov Identifier no. NCT00123456)

BACKGROUND

Studies have shown the value of using fast-track postoperative recovery. Standard procedures (non-fast-track strategies) remain in common use for perioperative care. Few prospective reports exist on the outcome of fast-tracking in Central Europe. The aim of our study was to assess the effect and safety of our own fast-track protocol with regard to the postoperative period after open bowel resection.

PATIENTS AND METHODS

One hundred and five patients with ASA score I-II scheduled for open intestinal resection in the period April 2005-December 2007 were randomly selected for the fast-track group (FT) and non-fast-track group (non-FT). A designed protocol was used in the FT group with the emphasis on an interdisciplinary approach. The control group (non-FT) was treated by standard established procedures. Postoperative pain, rehabilitation, gastrointestinal functions, postoperative complications, and post-op length of stay were recorded.

RESULTS

Of 105 patients, 103 were statistically analyzed. Patients in the FT group (n=51) and non-FT group (n=52) did not differ in age, surgical diagnosis, or procedure. The fast-track procedure led to significantly better control of postoperative pain and faster restoration of GI functions (bowel movement after 1.3 days vs. 3.1, p<0.001). Food tolerance was significantly better in the FT group and rehabilitation was also faster. Hospital stay was shorter in the FT group - median seven days (95% CI 7.0-7.7) versus ten days (95% CI 9.5-11.3) in non-FT (p<0.001). Postoperative complications within 30 postoperative days were also significantly lower in the FT group (21.6 vs. 48.1%, p=0.003). There were no deaths and no patients were readmitted within 30 days.

CONCLUSIONS

Following the FT protocol helped to reduce frequency of postoperative complications and reduced hospital stay. We conclude that the FT strategy is safe and effective in improving postoperative outcomes.

ESPEN Guidelines on Parenteral Nutrition: surgery

In modern surgical practice it is advisable to manage patients within an enhanced recovery protocol and thereby have them eating normal food within 1-3 days. Consequently, there is little room for routine perioperative artificial nutrition. Only a minority of patients may benefit from such therapy. These are predominantly patients who are at risk of developing complications after surgery. The main goals of perioperative nutritional support are to minimize negative protein balance by avoiding starvation, with the purpose of maintaining muscle, immune, and cognitive function and to enhance postoperative recovery. Several studies have demonstrated that 7-10 days of preoperative parenteral nutrition improves postoperative outcome in patients with severe undernutrition who cannot be adequately orally or enterally fed. Conversely, its use in well-nourished or mildly undernourished patients is associated with either no benefit or with increased morbidity. Postoperative parenteral nutrition is recommended in patients who cannot meet their caloric requirements within 7-10 days orally or enterally. In patients who require postoperative artificial nutrition, enteral feeding or a combination of enteral and supplementary parenteral feeding is the first choice. The main consideration when administering fat and carbohydrates in parenteral nutrition is not to overfeed the patient. The commonly used formula of 25 kcal/kg ideal body weight furnishes an approximate estimate of daily energy expenditure and requirements. Under conditions of severe stress requirements may approach 30 kcal/kg ideal body weights. In those patients who are unable to be fed via the enteral route after surgery, and in whom total or near total parenteral nutrition is required, a full range of vitamins and trace elements should be supplemented on a daily basis.

Gum chewing reduces postoperative ileus? A systematic review and meta-analysis

BACKGROUND

An important cause of delayed recovery from intestinal surgery is postoperative ileus. Gum chewing is a form of sham feeding, which could encourage gastrointestinal motility through cephalic-vagal stimulation.

METHODS

We sought to identify all randomized controlled trials comparing gum chewing with standard care after elective intestinal surgery. We searched electronic databases (Cochrane, Embase, and PubMed), reference lists and contacted authors to obtain further data. We assessed the identified trials for quality and performed a meta-analysis and systematic review. The main outcome measures examined were time to flatus and stool postoperatively and length of hospital stay, which were analysed using random effect models. We also examined clinical complication rates.

RESULTS

We identified nine eligible trials that had enrolled a total of 437 patients. The intervention was well tolerated and complication rates were low. There was statistical evidence of heterogeneity for the three main outcomes. Pooled estimates showed a reduction in time to flatus by 14 h (95% CI: -20 to -8h, p=0.001), time to bowel movement by 23 h (95% CI: -32 to -15 h, p<0.001) and a reduction in length of hospital stay by 1.1 days (95% CI: -1.9 to -0.2 days, p=0.016).

CONCLUSIONS

Chewing sugarless gum following elective intestinal resection is associated with improved outcomes. Insufficient data were available to demonstrate a reduced rate of clinical complications or reduced cost. An adequately powered, methodologically rigorous trial of gum chewing is required to confirm if there are any benefits and if these result in differences in clinical outcomes such as infection.

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.

Is laparoscopic resection appropriate for colorectal adenocarcinoma?

Oncologic safety has now been demonstrated for laparoscopy-assisted surgery for colon adenocarcinoma after 3 and 5 years of follow-up. Pooled data from large multicenter and smaller single-center trials demonstrate that the modality conveys significant short-term benefits as compared with open surgery, although the full potential has probably not yet been reached. Currently, the data supports improvements in wound morbidity, intraoperative blood loss, narcotic analgesia requirements, time to resumption of bowel movements, and time to discharge from hospital. There is a large potential for improved short-term results when combined with current and developing enhanced-recovery programs. For rectal cancer, the role of laparoscopic surgery is less clear. Data from the first large multicenter trial suggest that laparoscopic dissection may compromise the circumferential resection margin, and this issue will be the focus of ongoing and planned trials. Certain short-term benefits have been shown in pooled analyses of smaller nonrandomized trials, such as a decrease in overall morbidity and a marked reduction of duration of postoperative hospital stay.

[Use of nasogastric tubes and drains after colorectal surgery. Have attitudes changed in the last 10 years?]

OBJECTIVE

To evaluate attitudes and opinions of Spanish surgeons on the use of nasogastric tubes (NGT) and drainages after colorectal surgery.

MATERIAL AND METHOD

E-mail survey to the members of the Spanish Association of Coloproctology, and Coloproctology Division of the Spanish Surgical Association comparing the results with a previous survey from 1996.

RESULTS

Of the 413 surveys sent out, 131 (31.7%) were returned, this compared with 190 from 1996. NGT is routinely used by 22%, selectively by 35% and never by 43%, vs 62%, 31% and 7% in 1996 (p < 0.001). Experience and accreditation in colorectal surgery was associated with its lower use. NGT is removed by 16% 24 hours after surgery, 9% later and 51% when peristalsis begins vs. 6%, 21% and 66% in 1996 (p < 0.001). Of the total, 76% believe that the ileus is not reduced by NGT and 89% that it does not increase comfort vs 27% and 48% (p < 0.001). Drainages are routinely used by 38.5% and selectively by a 57.7%, more than in 1996 (25% and 63%) (p < 0.05). Board-Certification in colorectal surgery was associated with a lower use of drains (p < 0.0001). Drains are not used by 46% in right colon surgery; 22% in left colon and 3.1% in rectal surgery. A total of 66% believe that its used reduce fluid collections and 43% that they drain anastomosis leaks without any differences from previous survey. Drains are considered very useful by 16% in colon surgery and by 52% in rectal surgery.

CONCLUSIONS

There is a tendency to decrease the use of NGT. However, drainages continue to be widely employed.

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

Perioperative management is one of the fields of surgery most hide bound by tradition and conventional attitudes are difficult to modify even in the face of strong scientific evidence. One of the advances that has most helped to improve the results of colorectal surgery is multimodal or fast-track rehabilitation, which aims to enhance recovery, reduce morbidity, and shorten the length of hospital stay. This modality is based on a multidisciplinary approach provided by surgeons, anesthesiologists and other staff and aims to decrease the response to physiopathological changes induced by surgical aggression. There is evidence to support the use of preoperative oral carbohydrate therapy and oral bowel preparation, the avoidance of intraoperative fluid excess, and the maintenance of normothermia on postoperative recovery. Other factors that can also reduce complications are epidural analgesia, avoidance of drainage and nasogastric decompression, early oral feeding, and minimally invasive surgery. There is strong evidence that the combined use of these and other measures enhances postsurgical recovery, although many of these measures are currently little used in daily practice.