Randomized Controlled Trial of Extended Perioperative Counseling in Enhanced Recovery After Colorectal Surgery

Supportive Care Needs of Patients With Temporary Ostomy in Enhanced Recovery After Surgery: A Mixed-Methods Study

BACKGROUND

Enhanced recovery after surgery (ERAS), a global surgical quality improvement initiative, reduces the length of stay in the hospital. Temporary stoma care for rectal cancer is complex, and patients require prolonged care services to adjust to the stoma. The shorter stay durations in the new model challenge the conventional care pathways and create new patient needs.

PURPOSE

This study was designed to explore the supportive care needs of patients under the new surgical model to provide a reference for the design of ERAS nursing care plans.

METHODS

A convergent parallel mixed-methods design was used in this study. Patients with temporary stomas for rectal cancer were recruited using a convenience sampling method in gastrointestinal surgery wards and wound & stoma clinics in two public tertiary care hospitals in China. Standardized questionnaires were administered to 140 patients to collect quantitative data, and semistructured interviews were conducted individually with 13 patients to collect qualitative data. The questionnaire data were analyzed using descriptive statistics, and the interview data were analyzed using thematic analysis.

RESULTS

"Health system and information needs" and "care and support needs" were identified in both the qualitative and quantitative analyses as the most significant unmet needs of the participants. In addition, the qualitative analysis identified receiving focused stoma care instructions and easily understandable information as essential to fulfilling health system and information needs. Care and support needs included access to continued postdischarge services and attention from medical professionals.

CONCLUSION/IMPLICATIONS FOR PRACTICE

The participants in this study experienced a variety of unmet supportive care needs under the ERAS protocol, with gaps particularly notable in two categories: "health system and information needs" and "care and support needs." Increased perioperative care and shorter hospital stays under the ERAS protocol reduce opportunities for patients to receive targeted instruction and shift much of the ostomy education and care workload out of the hospital, requiring greater attention from clinical nurses to ensure quality of care.

Application of ERAS in older patients with gastric cancer

BACKGROUND

The purpose of this study was to investigate the effectiveness and feasibility of enhanced recovery after surgery (ERAS) in older gastric cancer (GC) patients by observing the changes in postoperative intestinal function recovery, nutritional indicators, and inflammatory markers following the surgery.

METHODS

A total of 61 older GC patients who underwent laparoscopic radical gastrectomy were selected as the subjects of this study. They were divided into an ERAS group (n = 28) and a conventional control group (n = 33) based on the different management modes during the perioperative period. General data, inflammatory response indicators, nutritional indicators, and perioperative indicators of the 2 groups were collected and compared. The changes in relevant indicators were analyzed, and the underlying reasons for these changes were explored.

RESULTS

There were no significant differences in general data and preoperative indicators between the 2 groups (P > .05). In the ERAS group, the inflammatory markers decreased more rapidly, and the nutritional indicators recovered more quickly after surgery. The differences between the 2 groups were statistically significant on the 5th and 7th postoperative days (P < .05). The ERAS group had significantly shorter postoperative hospital stay (10.07 ± 1.41 vs 13.04 ± 3.81), shorter time to first flatus (3.70 ± 0.72 vs 4.18 ± 1.17), shorter drainage tube retention time (8.96 ± 1.53 vs 10.93 ± 3.36), and shorter nasogastric tube retention time (3.36 ± 1.72 vs 6.14 ± 3.99) compared to the control group (P < .05).

CONCLUSION

The application of the ERAS program in older GC patients is effective and feasible, and significantly contributes to faster postoperative recovery in older patients.

[Structured implementation of fast-track pathways to enhance recovery after elective colorectal resection : First results from five German hospitals]

BACKGROUND

Multimodal optimized perioperative management (mPOM, fast-track, enhanced recovery after surgery, ERAS) leads to a significantly accelerated recovery of patients with elective colorectal resections. Nevertheless, fast-track surgery has not yet become established in everyday clinical practice in Germany. We present the results of a structured fast-track implementation in five German hospitals.

METHODS

Prospective data collection in the context of a 13-month structured fast-track implementation. All patients ≥ 18 years undergoing elective colorectal resection and who gave informed consent were included. After 3 months of preparation (pre-FAST), fast-track treatment was initiated and continued for 10 months (FAST). Outcome criteria were adherence to internationally recommended fast-track elements, postoperative complications, functional recovery, and postoperative hospital stay.

RESULTS

Data from 192 pre-FAST and 529 FAST patients were analyzed. Age, sex, patient risk, location, and type of disease were not different between both groups. The FAST patients were more likely to have undergone minimally invasive surgery (82% vs. 69%). Fast-track adherence increased from 52% (35-65%) under traditional treatment to 83% (65-96%) under fast-track treatment (p < 0.01). The duration until the end of infusion treatment, removal of the bladder catheter, first bowel movement, oral solid food, regaining autonomy, suitability for discharge and postoperative length of stay were significantly lower in the FAST group. Complications, reoperations, and readmission rates did not differ.

CONCLUSION

Fast-track adherence rates > 75% can also be achieved in German hospitals through structured fast-track implementation and the recovery of patients can be significantly accelerated.

Navigator nurse implementation within a fast track program of liver resections: How to improve the healthcare service and perioperative results

BACKGROUND

The introduction into the clinical practice of the navigator nurse (NaNu) to address the task of counseling and short term follow-up help the effective implementation of the fast track protocol. The aim of the present study was to investigate the impact of the standardization of the NaNu's role in patients undergoing liver surgery.

METHODS

Patients undergoing elective liver surgery for all diagnosis and approach, from 2015, received counseling and postoperative follow-up by NaNu and constituted the study group (n = 890). This group was compared with the control group (n = 712) including patients treated in the era before the implementation of the NaNu role (2011-2014). Outcome was evaluated in terms of discrepancy between functional recovery and discharge, number of ER accesses, number of readmissions.

RESULTS

Preoperative characteristics of patients and disease, as well as type of resection and postoperative outcomes were similar between the two groups. The proportion of laparoscopic cases was higher in the study group (51.2% vs. 32% in the control). Time for discharge, interval between functional recovery and discharge, number of ER accesses and number of readmissions were reduced in the study group. Benign diagnosis, absence of complications, laparoscopic approach and presence of NaNu were independent predictors of shorter length of stay. The positive effect of NaNu's activation was recorded in patients with complications and undergoing open surgery.

CONCLUSION

The implementation of NaNu's role has allowed to us optimize the level of healthcare service offered to patients. The wider benefit was offered in the setting of complex patients.

Preoperative Patient Education: Perceptions and Actual Practice among Nurses Working in Surgical Units

Introduction

Preoperative education is an essential nursing task that can be affected by the nurses' perception. Patients may be receiving insufficient vital information before surgery. However, the essential information that should be provided to patients undergoing surgery is not fully addressed.

Objective

To assess the essential elements of preoperative information as perceived by the surgical nurses.

Methods

This was a cross-sectional study. A convenience sample of 224 registered nurses who were working at surgical units was recruited from two hospitals. A preoperative teaching questionnaire was used.

Results

Details about the operation (4.39 ± 0.61) and preoperative preparation (4.36 ± 0.61) were the most important domains of preoperative education as perceived by nurses. The results show significant differences between the perceived and actual preoperative educational practice across all domains except the preoperative preparation.

Conclusions

The delivery of preoperative education could be affected by nurses' perceptions. Efforts to facilitate the implementation of effective education as perceived by nurses should be conducted by minimizing potential barriers.

eHealth interventions to support colorectal cancer patients' self-management after discharge from surgery-an integrative literature review

INTRODUCTION

Colorectal cancer (CRC) creates elevated self-management demands and unmet support needs post-discharge. Follow-up care through eHealth post-primary surgery may be an effective means of supporting patients' needs. This integrative review describes the evidence regarding eHealth interventions post-hospital discharge focusing on delivery mode, user-interface and content, patient intervention adherence, impact on patient-reported outcomes and experiences of eHealth.

METHODS

A university librarian performed literature searches in 2021 using four databases. After screening 1149 records, the authors read 30 full-text papers and included and extracted data from 26 papers. Two authors analysed the extracted data using the 'framework synthesis approach'.

RESULTS

The 26 papers were published between 2012 and 2022. The eHealth interventions were mainly delivered by telephone with the assistance of healthcare professionals, combined with text messages or video conferencing. The user interfaces included websites, applications and physical activity (PA) trackers. The interventions comprised the monitoring of symptoms or health behaviours, patient information, education and counselling. Evidence showed a better psychological state and improved PA. Patients reported high satisfaction with eHealth. However, patient adherence was inadequately reported.

CONCLUSIONS

eHealth interventions may positively impact CRC patients' anxiety and PA regardless of the user interface. Patients prefer technology combined with a human element.

Clinical Pathway for Enhanced Recovery in the Management of Non-Variceal Upper Gastrointestinal Bleeding: A Randomized Controlled Trial

Purpose

To explore the effects of the clinical pathway on the outcomes of patients with non-variceal upper gastrointestinal bleeding.

Materials and Methods

Randomized controlled trial. The study was conducted in two medical centers in China from 1 June 2022 to 31 December 2022. Patients with a diagnosis of non-variceal upper gastrointestinal bleeding who provided written informed consent were consecutively assigned to the intervention group. The patients in the intervention group were treated using the clinical pathway, while the control group received routine care and follow-up. Time, cost, complications, and prognostic indicators were analyzed. Intentional-to-treat analysis and per-protocol analysis were used for data analysis.

Results

A total of 114 eligible patients with non-variceal upper gastrointestinal bleeding were randomly divided into two groups and included in the intention-to-treat analysis. In addition, 106 patients were included in the per-protocol analysis. The median age of the 106 patients was 57 years (range, 18-92 years) and 83.0% were male. There were no significant differences between groups regarding the baseline characteristics. The intervention group demonstrated a statistically significantly shorter length of stay, lower hospital cost (ie, cost during hospitalization, cost in the emergency room, and cost in the ward), significantly fewer cases of complications, and a higher level of patient satisfaction when compared with the control group. There was no significant difference between the two groups in the rates of transfusion, repeat endoscopy, rebleeding readmission, and mortality.

Conclusion

The implementation of the clinical pathway for patients with non-variceal upper gastrointestinal bleeding may help improve patient outcomes and satisfaction.

Trial Registration Number

ChiCTR2200060316.

Registration Link

https://www.chictr.org.cn/.

Preoperative education in patients undergoing foot and ankle surgery: a scoping review

BACKGROUND

International guidelines promote preoperative education for patients undergoing orthopedic surgery. However, the evidence sustaining these recommendations comes mainly from studies for hip and knee replacement surgery. Little is known about patients undergoing foot and ankle surgery. We aimed to map and characterize all the available evidence on preoperative education for patients undergoing foot and ankle surgery.

METHODS

This study complies with the PRISMA-ScR guidelines. We searched eight databases, including MEDLINE, Embase, and CENTRAL. We performed cross-citations and revised the references of included studies. We included studies addressing preoperative education in patients undergoing foot and ankle surgery. We did not exclude studies because of the way of delivering education, the agent that provided it, or the content of the preoperative education addressed in the study. Two independent authors screened the articles and extracted the data. The aggregated data are presented in descriptive tables.

RESULTS

Of 1596 retrieved records, only 15 fulfilled the inclusion criteria. Four addressed preoperative education on patients undergoing foot and ankle surgery and the remaining 11 addressed a broader population, including patients undergoing foot and ankle surgery but did not provide separate data of them. Two studies reported that preoperative education decreases the length of stay of these patients, another reported that education increased the knowledge of the participants, and the other leaflets were well received by patients.

CONCLUSION

This scoping review demonstrates that evidence on preoperative education in foot and ankle surgery is scarce. The available evidence supports the implementation of preoperative education in patients undergoing foot and ankle surgery for now. The best method of education and the real impact of this education remain to be determined.

A framework for perioperative care for lower extremity vascular bypasses: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery

The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based suggestions for coordinated perioperative care for patients undergoing infrainguinal bypass surgery for peripheral artery disease. Structured around the ERAS core elements, 26 suggestions were made and organized into preadmission, preoperative, intraoperative, and postoperative sections.

Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons

The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.

Effect of 1 + N Extended Nursing Service on Functional Recovery of Colostomy Patients

To many hospitals' management as well as to patients, the nursing service is one of the most important aspects. Many diseases like sugar, blood pressure, urine passage, and gas are a little bit dangerous to handle by patients themselves. The earlier stage models are unable to give good services to patients; therefore, an advanced JHE: Effect of 1 + N extended nursing service is necessary to crossover the above limitations. Colostomy and colorectal cancers are very dangerous syndromes thus, disease monitoring is so difficult. In this research work, an extended JHE: Effect of 1 + N extended nursing service modeling is discussed with experimental modeling. Apart from conventional nursing care provided by the observation group, it was given online training as well as service providing. Self-efficacy and self-care competence were assessed in both groups 6 months after the discharge. Quality of life and mental health were also assessed. Besides, their dimensional and total self-care ability scores, and the observation group's self-efficacy ratings were substantially higher than those of the control group (P 0.05) after the intervention. It was observed that the intervention group's 6-month adjustment to the stoma was statistically more favorable than the control group's (P 0.001), and only the intervention group showed a significantly major change (P 0.001) between their two evaluations. This proposed methodology can improve the accuracy rate by 93.23%, and succussive treatment rate of 92.14% had been attained.

Safety and Feasibility of a Discharge within 23 Hours after Colorectal Laparoscopic Surgery

Background: Enhanced or accelerating recovery programs have significantly reduced hospital length stay after elective colorectal interventions. Our work aims at reporting an initial experience with ambulatory laparoscopic colectomy (ALC) to assess the criteria of discharge and outcomes. Methods: Between 2006 and 2016, data regarding patients having benefited from elective laparoscopic colorectal resections in two main centres in the United Kingdom have been analysed. Both benign and malignant pathologies were included. A standardised enhanced recovery program was performed for each patient, except epidural analgesia was replaced with single shot spinal infiltration. Patients were followed up through a telephone call system by a nurse. Short-term clinical outcomes were analysed. Results: A total of 833 patients were included and 51 (6.1%) were discharged within 24 h following surgery. Of these, 4 out of 51 (7.8%) patients came back hospital within 30 days of discharge; 2 (3.9%) required reoperation (Small bowel obstruction and wound abscess drainage). Conclusions: This study highlights that a 24-h discharge following elective laparoscopic colorectal interventions seems safe and feasible in selected patients. Although challenging to achieve, a standardised approach to laparoscopic surgery in combination with strict adherence to an enhanced recovery protocol are the fundamental elements of this path.

Optimized perioperative management (fast-track, ERAS) to enhance postoperative recovery in elective colorectal surgery

Aim

This manuscript provides information on the history, principles, and clinical results of Fast-track or ERAS concepts to optimize perioperative management (OPM).

Methods

With the focus on elective colorectal surgery description of the OPM concept and its elements for with special attention to the prevention of infectious complications and clinical results compared to traditional care will be given using recent systematic literature reviews. Additionally, clinical results for other major abdominal procedures are given.

Results

An optimized perioperative management protocol for elective colorectal resections will currently consist of 25 perioperative elements. These elements include the time from before hospital admission (patient education, screening, and treatment of possible risk factors like anemia, malnutrition, cessation of nicotine or alcohol abuse, optimization of concurrent systemic disease, physical prehabilitation, carbohydrate loading, adequate bowel preparation) to the preoperative period (shortened fasting, non-sedative premedication, prophylaxis of PONV and thromboembolic complications), intraoperative measures (systemic antibiotic prophylaxis, standardized anesthesia, normothermia and normovolemia, minimally invasive surgery, avoidance of drains and tubes) as well as postoperative actions (early oral feeding, enforced mobilization, early removal of a urinary catheter, stimulation of intestinal propulsion, control of hyperglycemia). Most of these elements are based on high-level evidence and will also have effects on the incidence of postoperative infectious complications.

Conclusion

Optimized perioperative management should be mandatory for elective surgery today as it enhances postoperative patient recovery, reduces morbidity and infectious complications.

Perioperative care in open aortic vascular surgery: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery

The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS®) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based recommendations related to all of the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites, for aortic aneurysm and aortoiliac occlusive disease). Structured around the ERAS® core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations.

Transition from hospital to home after elective colorectal surgery performed in an enhanced recovery program: An integrative review

AIM

This study aimed to investigate the transition from hospital to home after elective colorectal surgery performed in an Enhanced Recovery After Surgery (ERAS) programme.

DESIGN

An integrative review.

METHODS

A search of ten electronic databases was conducted. Data extraction and quality assessment were performed independently by two authors. Data analysis and synthesis were based on Meleis' Transitions Theory (2010).

RESULTS

Forty-two articles were included, and most (N = 27) were of good or very good quality. The researchers identified five categories to document the nature of transition postsurgery, three conditions affecting such transition, eleven indicators informing about the quality of the transition and several nursing interventions. Overall, this review revealed that the transition from hospital to home after ERAS colorectal surgery is complex. A holistic understanding of this phenomenon may help nurses to recognize what they need to do to optimize the in-home recovery of this clientele.

Enhanced Recovery After Major Gastrectomy for Cancer

Enhanced recovery after surgery (ERAS) protocols have gained increasing popularity over the past 10 years, and its overarching objectives are to improve perioperative morbidity and reduce postoperative length of stay. Consensus guidelines from the ERAS Society specific to major gastrectomy were published in 2014, however since that time, prospective and retrospective studies have expanded the collective evidence for both the content and efficacy of ERAS pathways for gastrectomy. This objective of this review was to summarize recent data pertinent to the preoperative, perioperative, and postoperative management of gastrectomy patients along an ERAS pathway.

Integrating Academic and Community Cancer Care and Research through Multidisciplinary Oncology Pathways for Value-Based Care: A Review and the City of Hope Experience

As the US transitions from volume- to value-based cancer care, many cancer centers and community groups have joined to share resources to deliver measurable, high-quality cancer care and clinical research with the associated high patient satisfaction, provider satisfaction, and practice health at optimal costs that are the hallmarks of value-based care. Multidisciplinary oncology care pathways are essential components of value-based care and their payment metrics. Oncology pathways are evidence-based, standardized but personalizable care plans to guide cancer care. Pathways have been developed and studied for the major medical, surgical, radiation, and supportive oncology disciplines to support decision-making, streamline care, and optimize outcomes. Implementing multidisciplinary oncology pathways can facilitate comprehensive care plans for each cancer patient throughout their cancer journey and across large multisite delivery systems. Outcomes from the delivered pathway-based care can then be evaluated against individual and population benchmarks. The complexity of adoption, implementation, and assessment of multidisciplinary oncology pathways, however, presents many challenges. We review the development and components of value-based cancer care and detail City of Hope’s (COH) academic and community-team-based approaches for implementing multidisciplinary pathways. We also describe supportive components with available results towards enterprise-wide value-based care delivery.

Reducing hospital stay for colorectal surgery in ERAS setting by means of perioperative patient education of expected day of discharge

PURPOSE

Despite the enhanced recovery after surgery (ERAS) protocol, length of stay (LOS) after colorectal surgery varies considerably. The majority of longer admissions is often not medically necessary. We aimed to investigate possible reduction of LOS by perioperative education with an expected discharge date (EDD).

METHODS

This single-centre retrospective study included 578 patients who underwent surgery for colorectal cancer in 2016 with standard care (ERAS) and in 2018 with the addition of EDD education program (ERAS+). A comparison was made of a 1-year period prior to and following the implementation of EDD. The EDD was discussed at the outpatient clinic, preoperatively and during admission (with both the patient and family members daily). Standard EDD varied between 3 and 5 days depending on the resection type. Primary outcome was LOS; secondary outcomes were readmission, serious complications and 90-day mortality.

RESULTS

Patients in ERAS+ (n = 242) had a shorter median LOS (4.0 vs. 5.0, p < 0.001) compared to patients in the regular ERAS group (n = 336). Fewer patients of ERAS+ experienced postoperative complications (71 (29.3%) vs. 198 (58.9%), p < 0.001). No difference was found in the number of readmissions (23 (9.5%) vs. 34 (10.1%), p = 0.807), reinterventions (25 (10.3%) vs. 30 (8.9%), p = 0.571) or mortality (5 (2.1%) vs. 9 (2.7%), p = 0.261) between the two groups.

CONCLUSION

It is possible to reduce LOS within the ERAS program, by better perioperative education and expectation management of patients with use of an EDD. This program ensures better understanding, faster discharge and lower costs for the hospital without added risk of readmissions or complications.

Patient education about recovery after colorectal surgery: systematic scoping review

AIM

Enhanced recovery after surgery (ERAS) protocols aim to optimize recovery through a series of evidence-based recommendations. A key component of ERAS is the provision of patient education. Whilst the recommendation for this is strong, the evidence to inform its format, timing and delivery is unclear. The aim of this review was to describe previous educational interventions used to improve recovery after colorectal surgery and to explore opportunities for future research.

METHODS

A systematic scoping review was performed. MEDLINE and Embase databases were searched between 1 January 1990 and 12 February 2020. Studies which described or assessed the effectiveness of a patient education or information resource to improve recovery after colorectal surgery were eligible. Outcomes of interest included the format, timing and delivery of interventions, as well as key features of intervention and study design. A narrative synthesis of data was produced through a process of charting and summarizing key results.

RESULTS

A total of 1298 papers were inspected, and 11 were eligible for inclusion. Five papers were reports of randomized controlled trials, and others reported a mix of non-randomized and qualitative studies. The design of educational interventions included audio-visual resources (n = 3), smartphone device applications (n = 3) and approaches to facilitate person-to-person counselling (n = 5). Most of the counselling interventions reported positive outcomes (mainly in length of hospital stay), whereas the other types reported mixed results. Patients and the public were seldom involved as collaborators in the design of interventions.

CONCLUSIONS

Patient education is generally advantageous, but there is insufficient evidence to optimize its design and delivery in the setting of colorectal surgery.

Benefits of Enhanced Recovery After Surgery in Patients Undergoing Endoscopic Sinus Surgery

Background

Although enhanced recovery after surgery (ERAS) protocols have been widely applied during perioperative periods for different diseases, there are few reports of ERAS in patients undergoing endoscopic sinus surgery (ESS). This study therefore aimed to evaluate the benefits of ERAS protocol compared to traditional care following ESS.

Methods

A total of 55 patients with chronic rhinosinusitis undergoing ESS were prospectively assigned to 1 of 5 treatment groups; ERAS groups with postoperative intravenous Flubiprofen Axetil or analgesia pump, traditional care with Flubiprofen Axetil or analgesia pump (NERAS groups), or traditional care without postoperative intravenous analgesia group (control). All patients completed the Kolcaba General Comfort Questionnaire, Medical Outcomes Study Sleep Scale, and Self-rating Anxiety Scale at admission and before discharge. Pain scores were recorded at 2, 6, 24, and 48 hours postsurgery and adverse reactions to analgesics were noted.

Results

Patients in ERAS group demonstrated significantly higher general comfort scores and lower self-rating anxiety scores compared to patients in NERAS and control groups. Compared to control patients, patients in ERAS group reported significantly lower pain scores at 6, 24, and 48 hours. Moreover, pain alleviated from 6 hours postsurgery in ERAS group compared to 48 hours in NERAS group. Patients using opioids experienced more adverse nausea events than patients using only nonsteroidal anti-inflammatory drugs (NSAIDs).

Conclusions

The use of patient-tailored ERAS programs following ESS may help to attain higher general comfort and to alleviate perioperative anxiety compared with traditional perioperative care. Adequate postoperative analgesia with NSAIDs in ERAS protocol may alleviate pain earlier with fewer adverse reactions.

Randomized Controlled Trial of Enhanced Recovery Program Dedicated to Elderly Patients After Colorectal Surgery

BACKGROUND

Enhanced recovery program is a multimodal, multidisciplinary-team, evidence-based care approach to reduce perioperative surgical stress, decrease morbidity and hospital stay, and improve recovery after surgery. This program may be most beneficial for elderly (≥70 y), but sparse series have investigated this question.

OBJECTIVE

Feasibility and efficiency of a dedicated enhanced recovery program in the elderly as compared with standard care were studied.

DESIGN

This was a nonblinded, randomized controlled study.

SETTINGS

This study was conducted in a single high-volume university hospital.

PATIENTS

A total of 150 eligible elderly patients undergoing elective colorectal surgery were included.

INTERVENTIONS

Enhanced recovery after colorectal elective surgery in elderly patients was studied.

MAIN OUTCOME MEASURES

The primary outcome was 30-day postoperative morbidity. Additional outcomes included hospital stay, readmission, postoperative pain, opioid consumption, independence preservation, and protocol compliance.

RESULTS

An enhanced recovery program reduces postoperative morbidity according to Clavien-Dindo classification by 47% as compared with standard care (35% vs 65%; p = 0.0003), total number of complications (54 vs 118; p = 0.0003), and infectious complications (13 vs 29; p = 0.001). No anastomotic leak was recorded in the enhanced recovery group versus 5 for the standard group (p = 0.01). The enhanced recovery program resulted in shorter hospital stay (7 vs 12 d; p = 0.003) and better independence preservation (home discharge, 87% vs 67%; p = 0.005). A high protocol compliance of 77.2% could be achieved in this population. According to multivariate analysis, enhanced recovery program was strongly associated with reduced morbidity (OR = 0.23 (95% CI, 0.09-0.57); p = 0.001), less severe complications (OR = 0.36 (95% CI, 0.15-0.84); p = 0.02), and shorter hospital stay (OR = 2.07 (95% CI, 1.33-3.22); p = 0.001).

LIMITATIONS

Limitations were a single-center recruitment and the impossibility of subject or healthcare professional blinding attributed to the nature of this multimodal program.

CONCLUSIONS

Enhanced recovery program is safe and improves postoperative recovery in elderly patients with decreased morbidity, shorter hospital stay, and better maintenance of independence. It should therefore be considered as a standard of care for elective colorectal surgery in elderly patients. See Video Abstract at http://links.lww.com/DCR/A981.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT01646190. ENSAYO CONTROLADO ALEATORIZADO DE UN PROGRAMA DE RECUPERACIÓN INTENSIFICADA DEDICADO A PACIENTES DE EDAD AVANZADA DESPUÉS DE CIRUGÍA COLORECTAL: El Programa de Recuperación Intensificada es un enfoque de atención multimodal, multidisciplinaria y basada en evidencia para reducir el estrés quirúrgico perioperatorio, disminuir la morbilidad y la estancia hospitalaria, y mejorar la recuperación después de la cirugía. Este programa puede ser más beneficioso para las personas mayores (≥70 años), pero pocas series han investigado esta pregunta.

OBJETIVO

Viabilidad y eficiencia del Programa de Recuperación Intensificada dedicado en personas de edad avanzada en comparación con la atención estándar. DISEÑO:: Este fue un estudio controlado, aleatorizado, sin método ciego.

ESCENARIO

Este estudio se realizó en un único hospital universitario de alto volumen.

PACIENTES

Un total de 150 pacientes de edad avanzada elegibles sometidos a cirugía colorrectal electiva fueron incluidos.

INTERVENCIONES

Recuperación Intensificada después de cirugía electiva colorrectal en pacientes de edad avanzada.

PRINCIPALES MEDIDAS DE RESULTADO

El resultado primario fue la morbilidad postoperatoria a 30 días. Los resultados adicionales incluyeron estancia hospitalaria, reingreso, dolor postoperatorio, consumo de opioides, preservación de la independencia y cumplimiento del protocolo.

RESULTADOS

El Programa de Recuperación Intensificada reduce la morbilidad postoperatoria según la clasificación de Clavien-Dindo en un 47% en comparación con la atención estándar (35% vs 65%; p = 0.0003), número total de complicaciones (54 vs 118; p = 0.0003) y complicaciones infecciosas (13 vs 29; p = 0.001). No se registró ninguna fuga anastomótica en el grupo de Recuperación Intensificada frente a 5 para el grupo estándar (p = 0.01). El Programa de Recuperación Intensificada dio como resultado una estancia hospitalaria más corta (7 contra 12 días; p = 0.003) y una mejor conservación de la independencia (alta hospitalaria: 87% vs 67%; p = 0.005). Se pudo lograr un alto cumplimiento del protocolo del 77.2% en esta población. De acuerdo con el análisis multivariable, el Programa de Recuperación Intensificada se asoció fuertemente con la reducción de morbilidad (OR = 0.23; IC 95%: 0.09-0.57; p = 0.001), menos complicaciones graves (OR = 0.36; IC 95%: 0.15-0.84; p = 0.02) y estancia hospitalaria más corta (OR = 2.07; IC 95%: 1.33-3.22; p = 0.001).

LIMITACIONES

Las limitaciones fueron un centro único de reclutamiento y la imposibilidad de que los pacientes o el profesional de la salud tuvieran cegamiento debido a la naturaleza de este programa multimodal.

CONCLUSIONES

El Programa de recuperación Intensificada es seguro y mejora la recuperación postoperatoria en pacientes de edad avanzada, con menor morbilidad, menor estancia hospitalaria y mejor mantenimiento de la independencia. Por lo tanto, debe considerarse como un estándar de atención para la cirugía colorrectal electiva en pacientes de edad avanzada. Vea el Resumen en video en http://links.lww.com/DCR/A981.

[Fast-tract: Therapist's role]

The modern model of inpatient surgical care of private and optimized state/govermental medical institutions allows us to change the paradigm of nosological attachment of the hospital bed to one profile of specialists for an adaptive model, when the wards can be reassigned depending on the needs of the hospital. In such multidisciplinary medical centers with mixed hospital beds without a nominal distinction in the nosological departments, a new therapeutic service is being developed - hospitalists, which provide a consistent curation of hospitalized patients, compensation of chronic therapeutic illnesses with patient's preparation for surgical interventions. Our work describes the experience of Fast Track recovery program with the active participation of a hospitalist in a surgical team, which is a new experience in the practice of Russian colorectal surgery.