Modified enhanced recovery after surgery protocols are beneficial for postoperative recovery for patients undergoing emergency surgery for obstructive colorectal cancer: A propensity score matching analysis

Management of obstructed colorectal carcinoma in an emergency setting: An update

Colorectal carcinoma is common, particularly on the left side. In 20% of patients, obstruction and ileus may be the first clinical manifestations of a carcinoma that has advanced (stage II, III or even IV). Diagnosis is based on clinical presentation, plain abdominal radiogram, computed tomography (CT), CT colonography and positron emission tomography/CT. The best management strategy in terms of short-term operative or interventional and long-term oncological outcomes remains unknown. For the most common left-sided obstruction, the first choice should be either emergency surgery or endoscopic decompression by self-expendable metal stents or tubes. The operative plan should be either one-stage or two-stage resection. One-stage resection with on-table bowel decompression and irrigation can be accompanied or not accompanied by proximal defunctioning stoma (colostomy or ileostomy). Primary anastomosis is more convenient but has increased risks of anastomotic leakage and morbidity. Two-stage resection (Hartmann's procedure) is safer and the most widely used despite temporally affecting quality of life. Damage control surgery in high-risk frail patients is less frequently performed since it can be successfully substituted with endoscopic stenting or tubing. For the less common right-sided obstruction, one-stage surgical resection is more beneficial than endoscopic decompression. The role of minimally invasive surgery (laparoscopic or robotic) is a subject of debate. Emergency laparoscopic-assisted management is advantageous to some extent but requires much expertise due to inherent difficulties in dissecting the distended colon and the risk of rupture and subsequent septic complications. The decompressing stent as a bridge to elective surgery more substantially decreases the risks of morbidity and mortality than emergency surgery for decompression and has equivalent medium-term overall survival and disease-free survival rates. Its combination with neoadjuvant chemotherapy or radiation may have a positive effect on long-term oncological outcomes. Management plans are crucial and must be individualized to better fit each case.

Protocolized care pathways in emergency general surgery: a systematic review and meta-analysis

BACKGROUND

Emergency abdominal surgery is associated with significant postoperative morbidity and mortality. The delivery of standardized pathways in this setting may have the potential to transform clinical care and improve patient outcomes.

METHODS

The OVID SP versions of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched between January 1950 and October 2022. All randomized and non-randomized cohort studies comparing protocolized care streams with standard care protocols in adult patients (>18 years old) undergoing major emergency abdominal surgery with 30-day follow-up data were included. Studies were excluded if they reported on standardized care protocols in the trauma or elective setting. Outcomes assessed included length of stay, 30-day postoperative morbidity, 30-day postoperative mortality and 30-day readmission and reoperations rates. Risk of bias was assessed using ROBINS-I for non-randomized studies and RoB-2 for randomized controlled trials. Meta-analysis was performed using random effects modelling.

RESULTS

Seventeen studies including 20 927 patients were identified, with 12 359 patients undergoing protocolized care pathways and 8568 patients undergoing standard care pathways. Thirteen unique protocolized pathways were identified, with a median of eight components (range 6-15), with compliance of 24-100%. Protocolized care pathways were associated with a shorter hospital stay compared to standard care pathways (mean difference -2.47, 95% c.i. -4.01 to -0.93, P = 0.002). Protocolized care pathways had no impact on postoperative mortality (OR 0.87, 95% c.i. 0.41 to 1.87, P = 0.72). A reduction in specific postoperative complications was observed, including postoperative pneumonia (OR 0.42 95% c.i. 0.24 to 0.73, P = 0.002) and surgical site infection (OR 0.34, 95% c.i. 0.21 to 0.55, P < 0.001).

DISCUSSION

Protocolized care pathways in the emergency setting currently lack standardization, with variable components and low compliance; however, despite this they are associated with short-term clinical benefits.

Cost saving in implementing ERAS protocol in emergency abdominal surgery

INTRODUCTION

ERAS (Enhanced Recovery After Surgery) protocol is now proposed as the standard of care in elective major abdominal surgery. Implementation of the ERAS protocol in emergency setting has been proposed but his economic impact has not been investigated. Aim of this study was to evaluate the cost saving of implementing ERAS in abdominal emergency surgery in a single institution.

METHODS

A group of 80 consecutive patients treated by ERAS protocol for gastrointestinal emergency surgery in 2021 was compared with an analogue group of 75 consecutive patients treated by the same surgery the year before implementation of ERAS protocol. Adhesion to postoperative items, length of stay, morbidity and mortality were recorded. Cost saving analysis was performed.

RESULTS

50% Adhesion to postoperative items was reached on day 2 in the ERAS group in mean. Laparoscopic approach was 40 vs 12% in ERAS and control group respectively (p ,002). Length of stay was shorter in ERAS group by 3 days (9 vs 12 days p ,002). Morbidity and mortality rate were similar in both groups. The ERAS group had a mean cost saving of 1022,78 € per patient.

CONCLUSIONS

ERAS protocol implementation in the abdominal emergency setting is cost effective resulting in a significant shorter length of stay and cost saving per patient.

Modified Enhanced Recovery After Surgery (ERAS) Protocol Versus Non-ERAS Protocol in Patients Undergoing Emergency Laparotomy for Acute Intestinal Obstruction: A Randomized Controlled Trial

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a multimodal approach with promising results in improving patient outcome. Only recently, is evidence emerging highlighting how similar principles of care can be applied to patients undergoing emergency abdominal surgery.

METHODS

A randomized controlled trial was conducted from November 2021 to April 2022 at PGIMER Chandigarh, which is a leading tertiary care hospital in northern India. 60 patients with acute intestinal obstruction requiring emergency laparotomy were randomized and assigned to ERAS or Non-ERAS group. ERAS protocol with some modifications was applied. Primary endpoints were post-operative hospital stay. Secondary end points were morbidity, 30-day readmission and mortality rate. Data analysis was done using SPSS 22.0. Independent t test or Mann-Whitney test and Chi-square or Fisher-exact test were used for analysis.

RESULTS

A significant 3-day reduction in hospital stay was observed in ERAS compared to non-ERAS group (median (interquartile range) 5.50 (4.75-8.25) vs 8.0 (6.0-11.0) p = 0.003) with no difference in 30-day readmission rate, mortality rate and complication rate (according to Clavien-Dindo classification). ERAS group was associated with early recovery of gastrointestinal functions including time to first passage of flatus (p < 0.001), stools (p = 0.014), early ambulation (p < 0.001), time to first fluid diet (p < 0.001), solid diet (p = 0.001) and reduced nasogastric tube reinsertion rates (p = 0.01) despite its early removal.

CONCLUSION

ERAS with some modifications can be applied in patients with intestinal obstruction. Thus, we can expedite post-operative recovery and early regain of gastrointestinal function with decreased hospital stay, comparable morbidity and mortality. Further studies are needed to assess ERAS role in emergency gastrointestinal surgeries. Trial registration Ctri.gov Identifier: CTRI/2022/04/042156.

Enhanced recovery after surgery protocols following emergency intra-abdominal surgery: a systematic review and meta-analysis

PURPOSE

The aim of this systematic review and meta-analysis was to evaluate whether Enhanced Recovery After Surgery (ERAS) protocols for patients undergoing emergency intra-abdominal surgery improve postoperative outcomes as compared to conventional care.

METHODS

MEDLINE, EMBASE, WoS, CENTRAL, and Pubmed were searched from inception to December 2022. Articles were eligible if they were randomized controlled trials (RCT) or non-randomized studies comparing ERAS protocols to conventional care for patients undergoing emergency intra-abdominal surgery. The outcomes included postoperative length of stay (LOS), postoperative morbidity, prolonged postoperative ileus (PPOI), and readmission. An inverse variance random effects meta-analysis was performed. A risk of bias was assessed with Cochrane tools. Certainty of evidence was assessed with GRADE.

RESULTS

After screening 1018 citations, 20 studies with 1615 patients in ERAS programs and 1933 patients receiving conventional care were included. There was a reduction in postoperative LOS in the ERAS group for patients undergoing upper gastrointestinal (GI) surgery (MD3.35, 95% CI 2.52-4.17, p < 0.00001) and lower GI surgery (MD2.80, 95% CI 2.62-2.99, p < 0.00001). There was a reduction in postoperative morbidity in the ERAS group for patients undergoing upper GI surgery (RR0.56, 95% CI 0.30-1.02, p = 0.06) and lower GI surgery (RR 0.66, 95%CI 0.52-0.85, p = 0.001). In the upper and lower GI subgroup, there were nonsignificant reductions in PPOI in the ERAS groups (RR0.59, 95% CI 0.30-1.17, p = 0.13; RR0.49, 95% CI 0.21-1.14, p = 0.10). There was a nonsignificant increased risk of readmission in the ERAS group (RR1.60, 95% CI 0.57-4.50, p = 0.50).

CONCLUSION

There is low-to-very-low certainty evidence supporting the use ERAS protocols for patients undergoing emergency intra-abdominal surgery. The currently available data are limited by imprecision.

Enhanced perioperative care in emergency general surgery: the WSES position paper

Enhanced perioperative care protocols become the standard of care in elective surgery with a significant improvement in patients' outcome. The key element of the enhanced perioperative care protocol is the multimodal and interdisciplinary approach targeted to the patient, focused on a holistic approach to reduce surgical stress and improve perioperative recovery. Enhanced perioperative care in emergency general surgery is still a debated topic with little evidence available. The present position paper illustrates the existing evidence about perioperative care in emergency surgery patients with a focus on each perioperative intervention in the preoperative, intraoperative and postoperative phase. For each item was proposed and approved a statement by the WSES collaborative group.

Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care

BACKGROUND

This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care.

METHODS

Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL.

RESULTS

Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process.

CONCLUSIONS

These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Enhanced recovery after surgery protocols and emergency surgery: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

This systematic review and meta-analysis seeks to assess the modified protocols used and patient outcomes when enhanced recovery after surgery (ERAS) protocols are utilized in an emergency setting.

METHODS

PubMed, MEDLINE, EMBASE and Cochrane Central Registry of Controlled Trials were comprehensively searched until 13 March 2023. The Cochrane Risk of Bias Assessment Tool was used to assess for bias, along with funnel plot asymmetry. We present log risk ratios for dichotomous variables and raw mean differences for continuous variables.

RESULTS

Seven randomized trials were included, comprising 573 patients. Results of the primary outcomes when comparing ERAS to standard care are as follows; withdrawal of nasogastric tube (raw mean difference -1.87 CI: -2.386 to -1.359), time to first liquid diet (raw mean difference -2.56 CI: -3.435 to -1.669), time to first solid diet (raw mean difference -2.35 CI: -2.933 to -1.76), time to first flatus (raw mean difference -2.73 CI: -5.726 to 0.257), time to first stool passed (raw mean difference -1.83 CI: -2.307 to -1.349), time to removal of drains (raw mean difference -3.23 CI: -3.609 to -2.852), time to removal of urinary catheter (raw mean difference -1.57 CI: -3.472 to 0.334), mean pain score (raw mean difference -1.79 CI: -2.222 to -1.351) and length of hospital stay (raw mean difference -3.16 CI: -3.688 to -2.63).

CONCLUSIONS

The adoption of ERAS protocols in an emergency surgery setting was observed to enhance patient recovery, while not indicating any statistically significant increase in adverse outcomes.

Assessing and managing frailty in emergency laparotomy: a WSES position paper

Many countries are facing an aging population. As people live longer, surgeons face the prospect of operating on increasingly older patients. Traditional teaching is that with older age, these patients face an increased risk of mortality and morbidity, even to a level deemed too prohibitive for surgery. However, this is not always true. An active 90-year-old patient can be much fitter than an overweight, sedentary 65-year-old patient with comorbidities. Recent literature shows that frailty-an age-related cumulative decline in multiple physiological systems, is therefore a better predictor of mortality and morbidity than chronological age alone. Despite recognition of frailty as an important tool in identifying vulnerable surgical patients, many surgeons still shun objective tools. The aim of this position paper was to perform a review of the existing literature and to provide recommendations on emergency laparotomy and in frail patients. This position paper was reviewed by an international expert panel composed of 37 experts who were asked to critically revise the manuscript and position statements. The position paper was conducted according to the WSES methodology. We shall present the derived statements upon which a consensus was reached, specifying the quality of the supporting evidence and suggesting future research directions.

Venous thromboembolism following colectomy for diverticular disease: an English population-based cohort study

AIM

This study reports venous thromboembolism (VTE) rates following colectomy for diverticular disease to explore the magnitude of postoperative VTE risk in this population and identify high risk subgroups of interest.

METHOD

English national cohort study of colectomy patients between 2000 and 2019 using linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data. Stratified by admission type, absolute incidence rates (IR) per 1000 person-years and adjusted incidence rate ratios (aIRR) were calculated for 30- and 90-day post-colectomy VTE.

RESULTS

Of 24,394 patients who underwent colectomy for diverticular disease, over half (57.39%) were emergency procedures with the highest VTE rate seen in patients ≥70-years-old (IR 142.27 per 1000 person-years, 95%CI 118.32-171.08) at 30 days post colectomy. Emergency resections (IR 135.18 per 1000 person-years, 95%CI 115.72-157.91) had double the risk (aIRR 2.07, 95%CI 1.47-2.90) of developing a VTE at 30 days following colectomy compared to elective resections (IR 51.14 per 1000 person-years, 95%CI 38.30-68.27). Minimally invasive surgery (MIS) was shown to be associated with a 64% reduction in VTE risk (aIRR 0.36 95%CI 0.20-0.65) compared to open colectomies at 30 days post-op. At 90 days following emergency resections, VTE risks remained raised compared to elective colectomies.

CONCLUSION

Following emergency colectomy for diverticular disease, the VTE risk is approximately double compared to elective resections at 30 days while MIS was found to be associated with a reduced risk of VTE. This suggests advancements in postoperative VTE prevention in diverticular disease patients should focus on those undergoing emergency colectomies.

The Application of Enhanced Recovery After Surgery for Gastrectomy and Colorectal Resection: A Systematic Review and Meta-Analysis

Purpose: Enhanced recovery after surgery (ERAS) protocols not only positively affect gastrointestinal surgery outcomes but may also increase the risk of some complications. This meta-analysis was conducted to assess the impact of ERAS on the recovery and complications following gastrointestinal surgery. Materials and Methods: Studies published before December 2022 were retrieved from the following databases, EMBASE, PubMed, Cochrane Library, and Web of Science, without limitations of language or race. The endpoints included lung infection, surgical site infection, postoperative ileus, length of hospitalization, urinary tract infection, readmission, anastomotic leakage, and C-reactive protein serum levels. Results: A total of 23 studies were included. The results of the meta-analysis revealed that there was a decrease in incidence of the lung infection (risk ratio = 0.46, 95% confidence interval 0.27-0.74, P = .002) and postoperative length of hospitalization (P < .00001). However, ERAS protocol groups had higher readmission rates, nausea, and vomiting. There was no significant difference in the incidence of anastomotic leakage, ileus, surgical site infection, and urinary tract infection between the experimental and control groups. Conclusions: ERAS protocols can reduce the risk of postoperative lung infections, shorten hospital stays, and expedite patient recovery. Furthermore, ERAS protocols are not associated with serious complications following gastrointestinal surgeries.

Implementing Enhanced Perioperative Care in Emergency General Surgery: A Prospective Multicenter Observational Study

INTRODUCTION

ERAS pathway has been proposed as the standard of care in elective abdominal surgery. Guidelines on ERAS in emergency surgery have been recently published; however, few evidences are still available in the literature. The aim of this study was to evaluate the feasibility of an enhanced recovery protocol in a large cohort of patients undergoing emergency surgery and to identify possible factors impacting postoperative protocol compliance.

METHODS

This is a prospective multicenter observational study including patients who underwent major emergency general surgery for either intra-abdominal infection or intestinal obstruction. The primary endpoint of the study is the adherence to ERAS postoperative protocol. Secondary endpoints are 30-day mortality and morbidity rates, and length of hospital stay.

RESULTS

A total of 589 patients were enrolled in the study, 256 (43.5%) of them underwent intestinal resection with anastomosis. Major complications occurred in 92 (15.6%) patients and 30-day mortality was 6.3%. Median adherence occurred on postoperative day (POD) 1 for naso-gastric tube removal, on POD 2 for mobilization and urinary catheter removal, and on POD 3 for oral intake and i.v. fluid suspension. Laparoscopy was significantly associated with adherence to postoperative protocol, whereas operative fluid infusion > 12 mL/Kg/h, preoperative hyperglycemia, presence of a drain, duration of surgery and major complications showed a negative association.

CONCLUSIONS

The present study supports that an enhanced recovery protocol in emergency surgery is feasible and safe. Laparoscopy was associated with an earlier recovery, whereas preoperative hyperglycemia, fluid overload, and abdominal drain were associated with a delayed recovery.

Associations Between Care Bundles and Postoperative Outcomes After Major Emergency Abdominal Surgery: A Systematic Review and Meta-Analysis

INTRODUCTION

Care bundles were found to improve postoperative outcomes in elective surgery. However, in major emergency general surgery studies show a divergent impact on mortality and length of stay. This meta-analysis aimed to evaluate associations between care bundles and mortality, complications, and length of stay when applied in major emergency general surgery.

METHODS

A systematic literature search in PubMed and Embase was performed on the May 1, 2021. Only comparative studies on care bundles in major emergency general surgery were included. Meta-analysis and trial sequential analysis were performed on 30-d mortality. We undertook a narrative approach of long-term mortality, complications, and length of stay.

RESULTS

Meta-analysis of 13 studies with 35,771 patients demonstrated that care bundles in emergency surgery were not associated with a significant reduction in odds of 30-d mortality (odds ratio = 0.8, 95% confidence interval 0.62-1.03). Trial sequential analysis confirmed that the meta-analysis was underpowered with a minimum of 78,901 patients required for firm conclusions. Seven studies reported complication rates whereof six reported lower complication rates using care bundles.

CONCLUSIONS

Care bundles were reported to decrease postoperative complications in five out of seven studies and seven out of 11 studies reported a shortening in length of stay.

Early discharge after colorectal cancer resection: trends and impact on patient outcomes

BACKGROUND

Implementation of early discharge in colorectal surgery has been effective in improving patient satisfaction and reducing healthcare costs. Readmission rates following early discharge among colorectal cancer patients are believed to be low, however, remain understudied. The objectives of this study were: (i) to describe trends in early post-operative discharge and the associated hospitalization costs; (ii) to explore patient outcomes and resource utilization following early discharge; and (ii) to identify predictors of readmission following early discharge.

METHODS

This was a retrospective cohort study using the Nationwide Readmissions Database. Adult patients admitted with a primary colorectal neoplasm who underwent colectomy or proctectomy between 2010 and 2017 were identified using ICD-9/10 codes. The exposure of interest was early post-operative discharge defined as ≤ 3 days from surgery. Main outcome measures were 30-day readmissions, post-operative complication rates, LOS and cost.

RESULTS

In total, 342,242 patients were identified, and of those, 51,977 patients (15.2%) had early discharges. During the study period, the proportion of early discharges significantly increased (R2 = 0.94), from 9.9 to 23.4%, while readmission rates in this group remained unchanged (mean 7.3% ± 0.5). Complications that required bounceback readmission (within 7 days) after early discharge, rather than during index admission, were an independent predictor of longer overall LOS (ß = 0.044, p < 0.001) and higher hospitalization costs (ß = 0.031, p < 0.001). On multiple logistic regression, factors independently associated with bounceback readmission following early discharge were: male gender (OR = 1.47, 95%CI 1.33-1.63); open surgery (OR = 1.37, 95%CI 1.23-1.52); presence of stoma (OR = 1.51, 95%CI 1.22-1.87); transfer to facility or discharge with home health service (OR = 1.53, 95%CI 1.34-1.75); and Medicare/Medicaid insurance (OR = 1.34, 95%CI 1.14-1.57), among others.

CONCLUSION

Early post-operative discharge of colorectal cancer patients is increasing despite a lack of improvement in readmission rates and an overall increase in hospitalization costs. Premature discharge of select patients may result in readmissions due to critical complications related to surgery resulting in increased resource utilization.

Framework, component, and implementation of enhanced recovery pathways

The introduction of enhanced recovery pathways (ERPs) has led to a considerable paradigm shift towards evidence-based, multidisciplinary perioperative care. Such pathways are now widely implemented in a variety of surgical specialties, with largely positive results. In this narrative review, we summarize the principles, components and implementation of ERPs, focusing on recent developments in the field. We also discuss ‘special cases’ in ERPs, including: surgery in frail patients; emergency procedures; and patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2/COVID-19).

Adapted ERAS Pathway Versus Standard Care in Patients Undergoing Emergency Surgery for Perforation Peritonitis-a Randomized Controlled Trial

BACKGROUND

Enhanced Recovery After Surgery (ERAS) pathways have an uncertain role in emergencies. To the best of our knowledge, there are no trials studying ERAS in perforation peritonitis across the GI tract, despite it being a common surgical emergency.

AIMS

To evaluate the safety, feasibility and efficacy of adapted ERAS protocols in emergency laparotomy for perforation peritonitis.

METHODS

This was an open-labeled, superiority randomized controlled trial conducted between October 2018 and June 2020 in patients with perforation peritonitis assigned to standard care or adapted ERAS groups using block randomization. Patients with refractory shock, ASA class 4E, localized peritonitis, etc. were excluded. Components of the adapted ERAS protocol included epidural analgesia, goal-directed fluid therapy, avoidance of opioids, early mobilization, early removal of tubes, drains and catheters, and early enteral feeding. The primary outcome, length of hospitalization (LOH), and the secondary outcomes, functional recovery parameters, were analyzed between both the groups.

RESULTS

A total of 59 patients in standard care group and 61 patients in adapted ERAS group were included and randomized, and were comparable in terms of demographic and clinico-pathological characteristics. LOH in adapted ERAS group was shorter by 3 days (p < 0.001), and patients showed reduction in time (days) to first flatus (2.84 vs 4.22, p < 0.001), first stool (4.38 vs 6.08, p < 0.001) and solid diet (4.67 vs 8.37, p < 0.001). Post-operative nausea, vomiting (p = 0.05) and surgical site infections (p < 0.001) were reduced in adapted ERAS group. Pre-existing malignancy, respiratory complications and high output stoma were reasons for delayed discharge in adapted ERAS group.

CONCLUSION

Adapted ERAS pathways considerably reduce LOH in patients undergoing emergency surgery for perforation peritonitis, with no adverse events in 30 days after discharge.

TRIAL REGISTRATION

Registered at http://ctri.nic.in/Clinicaltrials/login.php (CTRI/2019/02/017537).

Improving Outcomes for Elderly Patients Following Emergency Surgery: a Cutting-edge Review

Purpose of Review

The aim of this review is to explore the consequence of emergency general surgery in the elderly, and to summarise recent developments in the pre-, peri- and postoperative management of these patients, in order to improve outcomes.

Recent Findings

Preoperatively, accurate risk assessment is vital to ensure the right patients undergo emergency surgery. Perioperatively, there are multiple interventions specific to elderly patients that have been shown to improve outcomes. Postoperatively, elderly patients must be cared more in an appropriate setting in order to avoid failure to rescue and promote return to function.

Summary

This review of contemporary evidence identifies multiple pre-, peri- and postoperative interventions that can improve outcomes for elderly patients after emergency general surgery. These evidence-based recommendations should help direct care of elderly patients undergoing emergency surgery and foster further quality improvement measures and research investigations.

Enhanced recovery after surgery (ERAS) in patients undergoing emergency laparotomy after trauma: a prospective, randomized controlled trial

Background

The role of enhanced recovery after surgery (ERAS) has been established in elective operations. However, its role in emergency operations especially in trauma is under-recognized. The aim of this study was to explore the safety and efficacy of ERAS program in patients undergoing emergency laparotomy for trauma.

Methods

In this single-center study, patients who underwent emergency laparotomy after trauma were randomized to the ERAS protocol or conventional care. The ERAS protocol included early removal of catheters, early initiation of diet, use of postoperative prophylaxis and optimal usage of analgesia. The primary endpoint was duration of hospital stay. The secondary endpoints were recovery of bowel function, pain scores, complications and readmission rate.

Results

Thirty patients were enrolled in each arm. The ERAS group had significant reduction in duration of hospital stay (3.3±1.3 vs. 5.0±1.7; p<0.01). Time to remove nasogastric tube (1.1±0.1 vs. 2.2±0.9; p<0.01), urinary catheter (1.1±0.1 vs. 3.5±1.6; p<0.01), and drain (1.0±0.2 vs. 3.7±1.6; p<0.01) was shorter in the ERAS group. In ERAS group, there was earlier initiation of liquid diet (1.1±0.1 vs. 2.3±1.0; p<0.01) and solid diet (2.1±0.1 vs. 3.6±1.3; p<0.01). The usage of epidural analgesia (63% vs. 30%; p=0.01), non-steroidal anti-inflammatory drugs (93% vs. 67%; p-0.02) and deep vein thrombosis prophylaxis (100% vs. 70%; p<0.01) was higher in the ERAS group. There was no difference in the recovery of bowel function (2.4±1.0 vs. 2.1±0.9; p=0.15), pain scores (3.2±1.0 vs. 3.1±1.1; p=0.87), complications (27% vs. 23%; p=0.99) and readmission rates (07% vs. 10%; p=0.99) between the two groups.

Conclusion

ERAS protocol, when implemented in patients undergoing laparotomy for trauma, has decreased duration of hospital stay with no additional complications.

Level of evidence

Level 1, randomized controlled trial, care management.

Trial registration number

Clinical Trials Registry of India (CTRI/2019/06/019533).

The influence of predictive nursing on the emotions and self-management abilities of post-colostomy rectal cancer patients

OBJECTIVE

This study aimed to explore the influence of predictive nursing on the emotions and self-management abilities of post-colostomy rectal cancer patients.

METHODS

From March 2017 to October 2019, 130 patients with rectal cancer were recruited as the study cohort and placed into a predictive group (the PG) (n=80) that underwent predictive nursing or a normal group (the NG) (n=50) that underwent routine nursing. After the intervention, the operative indications, self-care abilities, nutritional indicators, mental health, postoperative recovery, complications, and nursing satisfaction of the two groups were compared.

RESULTS

After the intervention, compared with the NG, the average blood loss, operation times, gastrointestinal tract recovery times and durations of the hospital stays in the PG were shorter, and the self-care ability scores were higher, the nutritional conditions, namely the albumin (ALB), transferrin (TRF), and prealbumin (PAB) levels, were higher, the mental health, namely the self-rating anxiety scale (SAS) and self-rating depression scale (SDS) scores, was better, the total effective rate of the postoperative recovery and the nursing satisfaction were higher, and the incidence of complications was lower.

CONCLUSION

predictive nursing can improve the moods and self-management abilities of post-colostomy rectal cancer patients.

Enhanced Recovery After Surgery Protocol in Emergency Laparotomy: A Randomized Control Study

Introduction  There is established evidence on the role of enhanced recovery after surgery (ERAS) protocols in elective surgeries but its effectiveness in emergency surgeries has been nominally studied. We aimed at studying the feasibility and effectiveness of ERAS protocols in patients undergoing emergency abdominal surgery for intestinal perforation and small bowel obstruction and compare their surgical outcomes with conventional care.

Materials and methods  This prospective randomized study was performed for a period of 16 months. A total of 100 patients presenting either with intestinal perforation or acute small bowel obstruction were recruited; 50 each in the ERAS and the conventional care groups. The primary outcomes studied were the postoperative length of stay and 30-day morbidity and mortality.

Results  It was seen that the median (interquartile range) of the duration of hospital stay in the ERAS group was 4 (1) days while it was 7 (3) days in the conventional care group, which was statistically significant (W = 323.000, p ≤ 0.001). Similarly, postoperative morbidities like a chest infection and surgical site infections) were significant in the conventional care group.

Conclusion  The ERAS protocols are safe and effective in emergency surgeries and result in a better postoperative outcome.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Nasogastric tube after small bowel obstruction surgery could be avoided: a retrospective cohort study

PURPOSE

The safety and feasibility of early removal of nasogastric tube (NGT) after small bowel obstruction (SBO) surgery have not yet been assessed. Such a practice could allow to implement enhanced recovery after surgery (ERAS) protocols after acute SBO surgery. The aims of this study were to assess the safety of early NGT removal by comparing the short-term outcomes of patients with postoperative NGTs and those with no postoperative NGT.

METHODS

All patients undergoing surgery for strangulation or adhesive SBO between January the 1st of 2014 and December the 31st of 2017 were retrospectively included.

RESULTS

Among the 123 included, NGT was removed immediately after the end of the procedure in 26 cases (21.1%) and 19 patients required NGT replacement (15.4%). In univariate analysis, early removal of NGT was significantly associated with a reduction of overall morbidity, severe morbidity and postoperative ileus occurrence. Multivariate analysis confirmed that NGT left in place was a risk factor for postoperative ileus [Odd Ratio (OR) 4.9, Confidence Interval (CI) 95% 1.3-19.2; p = 0.02], while it has no incidence on severe morbidity.

CONCLUSIONS

Early NGT removal after ASBO surgery seemed to be feasible, safe and efficient, at least in selected patients. This primary study represents the initial foundations for building the implementation of ERAS protocols after ASBO surgery.

Feasibility of Enhanced Recovery in Emergency Colorectal Operation

BACKGROUND

Emergency colorectal operations account for considerable surgical morbidity, leading to increased recognition of the importance of standardized care. Enhanced recovery pathways (ERPs) have successfully provided a framework to standardize elective surgical care, with some ERP elements spreading to emergency procedures. This study aims to characterize the degree of spread and demonstrate feasibility of ERP extension to emergency colorectal operations.

STUDY DESIGN

Patients undergoing colorectal operations were identified from a national ERP collaborative. Adherence to ERP process measures-multimodal pain control, early Foley removal, postoperative venous thromboembolism prophylaxis, early mobilization, early feeding, and 30-day clinical outcomes-was analyzed. Multivariable logistic regression was used to evaluate association between process measure adherence and 30-day clinical outcomes.

RESULTS

A total of 31,511 patients underwent colorectal operations at 235 hospitals; 3,086 were emergencies and 28,425 were elective. For emergency cases, rates of early Foley removal (92.0%) and venous thromboembolism prophylaxis (75.7%) were highest. Rates of multimodal pain control (55.9%), early mobilization (37.1%), and early liquid intake (33.4%) were modest. Nonadherence was more common in patients younger than 65 years (43.4%), with independent functional status (94%), American Society of Anesthesiologists Physical Status Classification 1 to 3 (62.5%), and without physiologic derangement (39.9%). Lack of mobilization or liquid intake was independently associated with increased odds of ileus (odds ratio [OR] 1.43; 95% CI, 1.18 to 1.75 and OR 2.41; 95% CI, 1.96 to 2.95) and prolonged length of stay (OR 2.29; 95% CI, 1.85 to 2.83 and OR 2.05; 95% CI, 1.70 to 2.47).

CONCLUSIONS

Although the unplanned nature of emergency colorectal operations historically excluded patients from ERPs, our findings suggest ERPs have observable diffusion beyond elective surgical procedures. Deliberate implementation with adherence auditing can improve ERP uptake and outcomes in emergency colorectal operations.

Enhanced recovery after surgery in emergency resection for obstructive colorectal cancer: a systematic review and meta-analysis

PURPOSE

Enhanced recovery after surgery (ERAS) improves outcomes after elective colorectal operations. Whether it is beneficial for emergency colorectal surgery is unclear. This study aimed to systematically review and summarize evidence from all studies comparing ERAS versus conventional care in patients having emergency colectomy and/or proctectomy for obstructive colorectal cancer.

METHODS

EMBASE, MEDLINE, and PUBMED from 1981 to December 2019 were systematically searched. Any studies comparing our primary outcome of interest (length of hospitalization) among patients having emergency resection for obstructive colorectal cancer who received ERAS versus conventional care were selected. Primary outcome was length of hospitalization. Secondary outcomes were gastrointestinal recovery, postoperative complication, 30-day readmission and mortality, and time to start adjuvant therapy.

RESULTS

Three cohort studies with 818 participants (418 received ERAS and 400 received conventional care) were included. Length of hospitalization (mean reduction 3.07 days; 95% CI, - 3.91 to - 2.23) and risk of overall complication (risk ratio 0.78; 95% CI, 0.63 to 0.97) were significantly lower in ERAS than in conventional care. ERAS was also associated with quicker time to gastrointestinal recovery, a lower incidence of ileus, and a shorter interval between operation and commence of adjuvant chemotherapy. There was no significant difference in the rates of anastomotic leakage, surgical site infection, reoperation, readmission, and mortality within 30 days after surgery between groups.

CONCLUSIONS

ERAS had advantages over conventional care in patients undergoing emergency resection for obstructive colorectal cancer-including a shorter length of hospitalization, a lower incidence of overall complication, and a quicker gastrointestinal recovery.

Feasibility and effects of enhanced recovery vs. conventional care after emergency colon surgery for patients with left colon perforation

The impact of an enhanced recovery after surgery (ERAS) programme in emergency colorectal surgery has not yet been reported. The objective of this study was to evaluate the feasibility and the results of patients included in an ERAS protocol following emergency colon surgery for left colon perforation. For this purpose, patients with a low to moderate risk of mortality, according to a Peritonitis Severity Score (PSS), and treated with an ERAS protocol (ERAS group) after emergency surgery for left colon perforation were compared for a period of 40 months (March 2014–June 2017) with a control group of patients treated with conventional care (CC group) during the 38 months prior to implementation of the new ERAS protocol (January 2011–February 2014). The main endpoint was 90-day postoperative morbidity according to the Clavien–Dindo classification. Secondary endpoints included length of postoperative hospital stay, 90-day readmission rate, protocol compliance and mortality. Fifty patients were included in the study, 29 in the ERAS group and 21 in the CC group. There were no significant differences between the groups in the demographic data or in the operative characteristics. A reduction in the incidence of postoperative complications (20.7% vs. 38%; p > 0.05) and in the postoperative hospital stay (7.7 + /- 3.85 vs. 10.9 + /- 5.6 days; p = 0.009) were observed in the ERAS group. The 90-day readmission rate did not differ significantly between the two groups (2 vs. 1). No 90-day mortality was observed in either group. The ERAS group showed better results than the CC group in protocol compliance. We conclude that ERAS protocols are feasible and help to reduce morbidity and length of hospital stay without adversely affecting the rate of readmission or mortality.

A review of surgical and peri-operative factors to consider in emergency laparotomy care

Patients undergoing emergency laparotomy are a heterogeneous group with regard to comorbidity, pre-operative physiological state and surgical pathology. There are many factors to consider in the peri-operative period for these patients. Surgical duration should be as short as possible for adequate completion of the procedure. This is of particular importance in the elderly and comorbid population. To date, there are limited data addressing the role of damage control surgery in emergency general surgery. Dual consultant-led care in all stages of emergency laparotomy care is increasing, with increased presence out of hours and also for high-risk patients. The role of the stoma care team should be actively encouraged in all patients who may require a stoma. Due to the emergent and unpredictable nature of surgical emergencies, healthcare teams may need to employ novel strategies to ensure early input from the stoma care team. It is important for all members of the medical teams to ensure that patients have given consent for both anaesthesia and surgery before emergency laparotomy. Small studies suggest that patients and their families are not aware of the high risk of morbidity and mortality following emergency laparotomy before operative intervention. Elderly patients should have early involvement from geriatric specialists and careful attention paid to assessment of frailty due to its association with mortality and morbidity. Additionally, the use of enhanced recovery programmes in emergency general surgery has been shown to have some impact in reducing length of stay in emergency surgical patients. However, the emergent nature of this surgery has been shown to be a detrimental factor in full implementation of enhanced recovery programmes. The use of a national database to collect data on patients undergoing emergency laparotomy and their processes of care has led to reduced mortality and length of stay in the UK. However, internationally, fewer data are available to draw conclusions.

How best to palliate and treat emergency conditions in geriatric patients with colorectal cancer

Almost one third of colorectal cancer (CRC) cases are diagnosed in an emergency setting, mostly among geriatric patients. Clinical scenarios are often complex and decision making delicate. Besides the obvious need to consider the patient's and/or family and care givers' desires, the surgeon should be able to make the best educated guess on future outcomes in three areas: oncological prognosis, morbidity and mortality risk, and long-term functional loss. Using simple and brief tools for frailty screening reasonable treatment goals with curative or palliative intent can be planned. The most frequent clinical scenarios of CRC in emergency are bowel obstruction and perforation. We propose treatment algorithms based on assessment of the patient's overall reserve and discuss the indications, techniques and impact of a stoma in the geriatric patient. Bridge to surgery strategies may be best adapted to help the frail geriatric patient overcome the acute disease and maybe return to previous state of function. Post-operative morbidity and mortality rates are high in emergency surgery for CRC, but if the geriatric patient survives the post-operative period, oncological prognosis seems to be similar to younger patients. Because the occurrence of complications is the strongest predictor of functional decline and death, post-operative care plays a major role to optimize outcomes. Future studies should further investigate emergency surgery of CRC in the older adults focusing in particular on functional outcomes in order to help physicians counsel patients and families for a tailored treatment.

Clinical benefit of oral lactulose for postoperative care of pateints with complicated appendicitis using propensity score matching analysis

Objective

The aim of this study was to investigate the effect of oral lactulose for pediatric patients with complicated appendicitis, who underwent appendectomy.

Background

Oral lactulose was widely used for gastrointestinal function regulation. However, clinical benefit for oral lactulose regarding its effects on recent postoperative gastrointestinal (GI) recovery and long term adhesive small bowel obstruction (ASBO) incidence, especially in the postoperative pediatric population has not yet defined.

Methods

A total of 525 pediatric patients with complicated appendicitis underwent appendectomy were retrospectively reviewed. Among them, 317 cases were subjected to oral lactulose management and 208 patients without, served as control. Propensity score 1:1 matching was carried out to adjust for any potential baseline variables. In 189 paired patients, clinical outcomes, including gastrointestinal recovery variables, incidence of ABSO, as well as adverse events, were compared according to the oral lactulose administration or not.

Results

Patients who received oral lactulose administration achieved early gastrointestinal function recovery, including, first bowel movement (Risk ratio [RR], 1.34; 95% confidence interval [CI] 1.02–2.63, p = 0.005) and first solid feeding (RR, 1.26; 95% CI, 1.01–1.92, p = 0.012). A lower occurrence of ASBO (OR, 0.47; 95% CI, 0.25–0.87; p = 0.011) and lower constipation (Odds ratio [OR], 0.25; 95% CI, 0.13–0.46; p < 0.001), were noted in patients received oral lactulose than in patients without. Furthermore, significantly fewer patients required readmission (OR, 0.56; 95% CI, 0.32–0.99; p = 0.031) and reoperation (OR, 0.29; 95% CI, 0.09–0.92; p = 0.022) in the patients who received oral lactulose administration.

Conclusions

Beneficial effects of oral lactulose administration in pediatric patients undergone appendectomy were indicated, such as accelerating gastrointestinal function recovery, reducing the postoperative incidence of ASBO and constipation, so reduced readmission and reoperation.

Enhanced recovery after surgery in emergency colorectal surgery: Review of literature and current practices

Enhanced recovery after surgery (ERAS), a multidisciplinary program designed to minimize stress response to surgery and promote the recovery of organ function, has become a standard of perioperative care for elective colorectal surgery. In an elective setting, ERAS program has consistently been shown to decrease postoperative complication, reduce length of hospital stay, shorten convalescence, and lower healthcare cost. Recently, there is emerging evidence that ERAS program can be safely and effectively applied to patients with emergency colorectal conditions such as acute colonic obstruction and intraabdominal infection. This review comprehensively covers the concept and application of ERAS program for emergency colorectal surgery. The outcomes of ERAS program for this emergency surgery are summarized as follows: (1) The ERAS program was associated with a lower rate of overall complication and shorter length of hospital stay - without increased risks of readmission, reoperation and death after emergency colorectal surgery; and (2) Compliance with an ERAS program in emergency setting appeared to be lower than that in an elective basis. Moreover, scientific evidence of each ERAS item used in emergency colorectal operation is shown. Perspectives of ERAS pathway in emergency colorectal surgery are addressed. Finally, evidence-based ERAS protocol for emergency colorectal surgery is presented.