Fast-track rehabilitation in elective colorectal surgery patients: a prospective clinical and immunological single-centre study

Enhanced recovery after surgery: importance of compliance audits

Background: The enhanced recovery after surgery (ERAS) protocol is associated with improved clinical outcomes. However, implementation of ERAS in clinical practice is difficult because it requires a multidisciplinary approach and complex standardization. Moreover, maintenance and auditing of ERAS protocols is another challenge.Current Concepts: The ERAS society provides guidelines for surgery in almost all areas, and each guideline consists of approximately 20 items. Audits are performed to determine whether the items are being applied appropriately in a compliant manner as well as monitor and improve ERAS protocols. Numerous studies have reported that even with the application of the same ERAS protocol, postoperative short-term outcomes such as reductions of hospital stay and postoperative complications were better in the high-compliance group than in the low-compliance group. In addition, some recent studies have reported that application of ERAS protocols with high compliance can improve the long-term survival outcomes in cancer patients. In this regard, ERAS has been hypothesized to improve long-term oncological outcomes by minimizing surgical stress and reducing the postoperative inflammatory response and damage to immune function.Discussion and Conclusion: In addition to the development of appropriate protocols, auditing of compliance is also an important part of ERAS implementation. High compliance may lead to improved clinical outcomes.

Effect of single-incision laparoscopic distal gastrectomy guided by ERAS and the influence on immune function

Background

To evaluate the immune function of gastric cancer patients after single-incision laparoscopic distal gastrectomy (SIDG) or multiport laparoscopic distal gastrectomy (MLDG) guided by enhanced recovery after surgery (ERAS).

Methods

A retrospective cohort study was performed on 120 patients who underwent laparoscopic distal gastrectomy for gastric cancer. The patients were divided into two groups according to operation method: group A (MLDG) and group B (SIDG), both guided by ERAS concept. The indicators reflecting immune function and inflammation, such as CD3⁺, CD4⁺, CD8⁺ and NK cell count, CD4⁺/CD8⁺ cell ratios, IgA, IgM and IgG levels, C-reactive protein (CRP), total lymphocyte count (TLC) and neutrophil-to-lymphocyte ratio (NLR) were tested 3 days and 7 days after surgery.

Results

The skin incision length of patients in group B was significantly shorter than that in group A, but the operation time was significantly longer in group B than that in group A (P < 0.05). There were no significant differences in preoperative CD3+, CD4+, CD8+, natural killer (NK) cells, CD4+/CD8+, IgA, IgM and IgG levels between two groups (P < 0.05). Three days after surgery, the immune function indices were decreased in both groups, but with no significant difference between two groups (P > 0.05). On the 7th day after surgery, the immune indexes of both groups recovered somewhat, approaching the preoperative level (P > 0.05). Inflammation indexes increased 3 days after surgery and decreased 7 days after surgery in both groups, among them the CRP level in group A was higher than that in group B (P < 0.05). The 3-year survival rate were 96.7% in group A and 91.7% in group B, respectively, with no statistically significant difference.

Conclusion

Compared with MLDG guided by ERAS, SIDG under the guidance of the ERAS concept has better cosmetic effect and similar effect on immune function of gastric cancer patients.

Enhanced Recovery Protocol: Implementation at a County Institution with Limited Resources

The benefits of an enhanced recovery protocol (ERP) in colorectal surgery have been well described; however, data on the implementation process is minimal, especially in a resource-limited institution. The purpose of this study was to evaluate outcomes during implementation of a physician-driven ERP at a public-funded institution. We retrospectively reviewed all elective colorectal surgery during a transition from standard care to an ERP (implemented via a standard order sheet). Data regarding use of care plan, length of stay (LOS), and rates of postoperative complications and readmission were recorded. One hundred eleven patients were included in the study; however, complete use of the ERP after its introduction occurred in a total of 50 patients for a compliance rate of 60 per cent (95% confidence interval [CI], 49 to 70). Late implementation of ERP diet, analgesics, and activity were the most common process errors. Full application of the ERP reduced mean LOS by 3 days ( P = 0.002), and there was a trend toward decreased postoperative morbidity without an increase in readmission rate ( P = 0.61). Full implementation of an ERP for colorectal surgery faces many challenges in a resource-limited county institution; however, when fully applied, the ERP safely reduced overall LOS, which is important in cost containment.

Effects of perioperative enhanced recovery after surgery pathway management versus traditional management on the clinical outcomes of laparoscopic-assisted radical resection of distal gastric cancer: study protocol for a randomized controlled trial

Background

The incidence of gastric cancer in East Asia is much higher than the international average. Therefore, improving the prognosis of patients and establishing effective clinical pathways are important topics for the prevention and treatment of gastric cancer. At present, the enhanced recovery after surgery (ERAS) pathway is widely used in the field of gastric surgery. Many randomized controlled trial (RCT) studies have proven that the ERAS regimen can improve the short-term clinical outcomes of patients with gastric cancer. However, a prospective study on the effect of the ERAS pathway on the prognosis of patients with gastric cancer has not yet been reported. This trial aims to confirm whether the ERAS pathway can improve the disease-free survival and overall survival of patients undergoing laparoscopic-assisted radical resection for distal gastric cancer.

Methods/design

This study is a prospective, multicentre RCT. This experiment will consist of two groups – an experimental group and a control group – randomly divided in a 1:1 ratio. The perioperative period of the experimental group will be managed according to the ERAS pathway and that of the control group will be managed according to the traditional management mode. An estimated 400 patients will be enrolled. The main endpoint for comparison is the 3-year overall survival and disease-free survival between the two groups.

Discussion

The results of this RCT should clarify whether the ERAS pathway is superior to traditional treatment on inflammatory indexes, short-term clinical outcome and survival for laparoscopic-assisted radical resection of distal gastric cancer. It is hoped that our data will provide evidence that the ERAS pathway improves survival in patients with gastric cancer.

Trial registration

Chinese Clinical Trial Registry, CHiCTR1900022438. Registered on 11 April 2019.

Systematic scoping review of enhanced recovery protocol recommendations targeting return of gastrointestinal function after colorectal surgery

BACKGROUND

Post-operative ileus (POI) and delayed return of gastrointestinal (GI) function are common complications after colorectal surgery. There is a lack of uniformity in enhanced recovery protocols (ERPs) with regards to interventions used to target these complications. This systematic review aims to categorize and summarize management recommendations available from published ERPs.

METHODS

A systematic search of Ovid MEDLINE, Embase, Cochrane Library and PubMed databases was performed from January 1990 to May 2018. All studies publishing enhanced recovery or fast-track or multimodal pathway protocols for colorectal surgery in their full-text were included. Data on interventions aimed at reducing the duration of POI were extracted, as well as references quoted to support specific interventions.

RESULTS

Of 481 manuscripts screened, 37 published ERPs were identified from 37 studies (18 cohort, seven historical-control, five guidelines, four randomized controlled trials, one randomized controlled trial protocol, one case series and one narrative review). The most commonly recommended interventions were magnesium-based laxatives (18 of 37, 48.6%), chewing gum (13 of 37, 35.1%), Alvimopan (6 of 37, 16.2%), lactulose (4 of 37, 10.8%), neostigmine (2 of 37, 5.4%) and bisacodyl (2 of 37, 5.4%). Geographical trends were noted for the various interventions, but high-quality evidence was only referenced to support the use of Alvimopan.

CONCLUSION

ERP recommendations specific to interventions targeting POI and return of GI function are varied. While laxatives are the most commonly recommended intervention, there is only weak evidence reported to support this practice.

Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

Background

Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.

Objectives

To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.

Data sources

Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.

Review methods

Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.

Findings

A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.

Limitations

Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.

Conclusions

Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.

Future work

Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.

Study registration

This study is registered as PROSPERO CRD42017080637.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Patient Satisfaction and Quality of Life with Enhanced Recovery Protocols

While studies have demonstrated the benefits of Enhanced Recovery after Surgery (ERAS) programs in reducing length of stay and costs without increasing complications, fewer studies have evaluated patient satisfaction and quality of life (QOL) with enhanced recovery protocols. The aim of this project was to summarize the literature comparing satisfaction and quality of life after colorectal surgery following treatment within an ERAS protocol to standard postoperative care. The available evidence suggests patients suffer no detriment to satisfaction or quality of life with use of ERAS protocols, and may suffer less fatigue and return to activities sooner. Most publications reported no adverse effects on postoperative pain. However, a limited number of studies suggest patients may experience increased early postoperative pain with ERAS pathways, particularly following open colorectal procedures. Future research should focus on potential improvements in ERAS protocols to better manage postoperative pain. Overall, the evidence supports more widespread implementation of ERAS pathways in colorectal surgery.

Adherence to the ERAS protocol is Associated with 5-Year Survival After Colorectal Cancer Surgery: A Retrospective Cohort Study

BACKGROUND

Surgical stress can influence oncological outcome and survival. The enhanced recovery after surgery (ERAS) protocol is designed to reduce perioperative stress and has been shown to reduce postoperative morbidity. We studied if adherence to ERAS is associated with increased long-term survival.

METHODS

Between the years 2002 and 2007, 911 consecutive patients, operated with major colorectal cancer surgery at Ersta Hospital, Stockholm, Sweden were analyzed. The histopathological reports of the resected specimen, date, and cause of death of the patients as well as postoperative CRP levels were obtained. The relation between the rate of adherence to the ERAS protocol at the time of surgery, and the short-term outcomes in relation to 5-year overall and colorectal cancer-specific survival was determined in this retrospective cohort study.

RESULTS

In patients with ≥70 % adherence to ERAS interventions (N = 273,), the risk of 5-year cancer-specific death was lowered by 42 %, HR 0.58 (0.39-0.88, cox regression) compared to all other patients (<70 % adherence). Significant independent perioperative predictors of increased 5-year survival were avoiding overload of intravenous fluids, HR 0.53 (0.32-0.86); oral intake on the day of operation, HR 0.55 (0.34-0.78); and low CRP levels on postoperative day 1.

CONCLUSION

High adherence to the ERAS protocol may be associated with improved 5-year cancer-specific survival after colorectal cancer surgery.

The effects of fast-track surgery on inflammation and immunity in patients undergoing colorectal surgery

OBJECTIVE

The objective of this study is to explore the effects of the fast-track surgery (FTS) program on inflammation and immunity in patients undergoing colorectal surgery.

METHODS

From August 2014 to March 2015, a prospective and randomized controlled trial of 230 patients who underwent colorectal surgery was performed. The patients were randomly assigned to an FTS group (116 patients) or a traditional group (114 patients). Inflammatory mediators, immunological indicators, postoperative recovery indexes, and complications were compared between the two groups.

RESULTS

The inflammatory mediators (CRP, IL-6, TNF-α) were lower in the FTS group than in the traditional group (P < 0.05) on postoperative day (POD) 1, POD 4, and POD 6, and the immunological indicators (IgG, IgA, C3, C4) of the FTS group were superior to those of the traditional group (P < 0.05) on POD 4 and POD 6. The time to first aerofluxus, defecation, oral intake, and ambulation after surgery was shorter in the FTS group than in the traditional group (P < 0.05); however, the duration of postoperative hospitalization did not differ significantly between the two groups (P > 0.05). The total complications were significantly lower in the FTS group than in the traditional group (P < 0.05).

CONCLUSION

The FTS program can decrease inflammation, maintain immune homeostasis, and improve rehabilitation effects in colorectal surgery patients.

Fast-track surgery improves postoperative clinical recovery and cellular and humoral immunity after esophagectomy for esophageal cancer

Background

Our aim was to investigate the influence of FTS on human cellular and humoral immunity using a randomized controlled clinical study in esophageal cancer patients.

Methods

Between October 2013 and December 2014, 276 patients with esophageal cancer in our department were enrolled in the study. The patients were randomized into two groups: FTS pathway group and conventional pathway group. The postoperative hospital stay, hospitalization expenditure, and postoperative complications were recorded. The markers of inflammatory and immune function were measured before operation as well as on the 1st, 3rd, and 7th postoperative days (POD), including serum level of interleukin-6 (IL-6), C-reactive protein (CRP), serum globulin, immunoglobulin G (IgG), immunoglobulin M (IgM), immunoglobulin A (IgA) and lymphocyte subpopulations (CD3 lymphocytes, CD4 lymphocytes, CD8 lymphocytes and the CD4/CD8 ratio) in the patients between the two groups.

Results

In all, 260 patients completed the study: 128 in the FTS group and 132 in the conventional group. We found implementation of FTS pathway decreases postoperative length of stay and hospital charges (P < 0.05). In addition, inflammatory reactions, based on IL-6 and CRP levels, were less intense following FTS pathway compared to conventional pathway on POD1 and POD3 (P < 0.05). On POD1 and POD3, the levels of IgG, IgA, CD3 lymphocytes, CD4 lymphocytes and the CD4/CD8 ratio in FTS group were significantly higher than those in control group (All P < 0.05). However, there were no differences in the level of IgM and CD8 lymphocytes between the two groups.

Conclusions

FTS improves postoperative clinical recovery and effectively inhibited release of inflammatory factors via the immune system after esophagectomy for esophageal cancer.

Trial registration

ChiCTR-TRC-13003562, the date of registration: August 29, 2013.

Nausea, vomiting and return of bowel function after colorectal surgery

BACKGROUND

Although patterns of return of bowel function (ROBF) following colorectal surgery with enhanced recovery after surgery (ERAS) programmes have been well delineated, regular morphine use is uncommon. This study describes the patterns of post-operative nausea and vomiting (PONV) and ROBF in this context.

METHOD

Patients undergoing elective major colorectal surgery on an ERAS programme over 1 year were included. Patient details, intra-operative course, post-operative management, outcomes and complications were collected retrospectively from clinical records. Statistical analysis was performed using Stata version 12.

RESULTS

A total of 136/142 (96%) patients received morphine for post-operative analgesia. Most (112/142, 79%) experienced either no vomiting (87/142, 61%) or small amounts (25/142, 18%). On average, patients without an ileostomy passed flatus and opened their bowels after 2.4 and 4.3 days, those with an ileostomy taking 1.5 and 2.1 days. Vomiting was not related to ROBF (P = 0.370) or overall complications; wound complications (odds ratio (OR) = 8.1, 95% confidence interval (CI): 2.0-32.5), electrolyte abnormalities (OR = 2.9, 95% CI: 1.2-7.1) and length of stay (hazard ratio = 1.3, 95% CI: 1.2-1.5) were related.

CONCLUSION

Most patients do not experience PONV in this context. ROBF is predictable without prolonged delays. This information could be used to allow confident early discharge and identify patients whose deviation from normal may indicate complications.

Fast-track protocols in devascularization for cirrhotic portal hypertension

INTRODUCTION/OBJECTIVE

fast-tract surgery (FTS) has been rapidly embraced by surgeons as a mechanism for improving patient care and driving down complications and costs. The aim of this study was to determine if any improvement in outcomes occurred after FTS protocol for selective double portazygous disconnection with preserving vagus (SDPDPV) compared with non-FTS postoperative care.

METHODS

patients eligible for SDPDPV in the period January 2012-April 2014 were randomly selected for the FTS group or non-FTS group. A designed protocol was used in the FTS group with emphasis on an interdisciplinary approach. The non-FTS group was treated using previously established standard procedures. The number of postoperative complications, time of functional recovery and duration of hospital stay were recorded.

RESULTS

patients in the FTS group (n=59) and non-FTS group (n=57) did not differ in terms of preoperative data and operative details (p>0.05). The FTS procedure led to significantly better control and faster restoration of gastrointestinal functions, food tolerance, rehabilitation and hospital discharge (p<0.05). Postoperative complications, including nausea/vomiting, severe ascites, wound infection, urinary tract infection and pulmonary infection were all significantly lower in the FTS group (p<0.05). According to the postoperative morbidity classification used by Clavien, overall complications and grade I complications were both significantly lower in the FTS group compared with the non-FTS group (p<0.05).

CONCLUSION

adopting the FTS protocol helped to recover gastrointestinal functions, to reduce frequency of postoperative complications and to reduce hospital stay. The FTS strategy is safe and effective in improving postoperative outcomes.

Laparoscopic surgery contributes more to nutritional and immunologic recovery than fast-track care in colorectal cancer

BACKGROUND

Many clinical trials had repeatedly shown that fast-track perioperative care and laparoscopic surgery are both preferred in the treatment of colorectal cancer. But few studies were designed to explore the diverse biochemical impacts of the two counterparts on human immunologic and nutritional status.

METHODS

Ninety-two cases of colorectal cancer patients meeting the inclusion criteria were randomized to four groups: laparoscopy with fast-track treatment (LAFT); open surgery with fast-track treatment (OSFT); laparoscopy with conventional treatment (LAC); open surgery with conventional treatment (OSC). Peripheral blood tests including nutritional factors (albumin, prealbumin, and transferrin), humoral immunologic factors (IgG, IgM, and IgA), and cellular immunologic factors (T and NK cells) were evaluated. Blood samples were collected preoperatively (baseline) and 12 and 96 h after surgery (indicated as POH12 and POH96, respectively).

RESULTS

Albumin, transferrin, prealbumin, and IgG levels were the highest in the LAFT group for both POH12 and POH96 time intervals. Repeated measures (two-way ANOVA) indicated that the difference of albumin, transferrin, and IgG level were attributed to surgery type (P < 0.05) and not perioperative treatment (P > 0.05). Only in the laparoscopy-included groups, the relative albumin and IgG levels of POH96 were obviously higher than that of POH12.

CONCLUSION

Laparoscopic surgery accelerated postoperative nutrition and immune levels rising again while fast-track treatment retarded the drop of postoperative nutrition and immune levels. Laparoscopic surgery might play a more important role than fast-track treatment in the earlier postoperative recovery of nutritional and immunologic status. Combined laparoscopic surgery with fast-track treatment provided best postoperative recovery of nutrition and immune status. These results should be further compared with the clinical outcomes of our FTMDT trial (clinicaltrials.gov: NCT01080547).

Systematic review of outcomes used to evaluate enhanced recovery after surgery

BACKGROUND

Enhanced recovery pathways (ERPs) aim to improve patient recovery. However, validated outcome measures to evaluate this complex process are lacking. The objective of this review was to identify how recovery is measured in ERP studies and to provide recommendations for the design of future studies.

METHODS

A systematic search of MEDLINE, Embase and Cochrane databases was conducted. Prospective studies evaluating ERPs compared with traditional care in abdominal surgery published between 2000 and 2013 were included. All reported outcomes were classified into categories: biological and physiological variables, symptom status, functional status, general health perceptions and quality of life (QoL). The phase of recovery measured was defined as baseline, intermediate (in hospital) and late (following discharge).

RESULTS

A total of 38 studies were included based on the systematic review criteria. Biological or physiological variables other than postoperative complications were reported in 30 studies, and included return of gastrointestinal function (25 studies), pulmonary function (5) and physical strength (3). Patient-reported symptoms, including pain (16 studies) and fatigue (9), were reported less commonly. Reporting of functional status outcomes, including mobilization (16 studies) and ability to perform activities of daily living (4), was similarly uncommon. Health aspects of QoL were reported in only seven studies. Length of follow-up was generally short, with 24 studies reporting outcomes within 30 days or less. All studies documented in-hospital outcomes (intermediate phase), but only 17 reported postdischarge outcomes (late phase) other than complications or readmission.

CONCLUSION

Patient-reported outcomes, particularly postdischarge functional status, were not commonly reported. Future studies of the effectiveness of ERPs should include validated, patient-reported outcomes to estimate better their impact on recovery, particularly after discharge from hospital.

Enhanced recovery strategies in colorectal surgery: is the compliance with the whole program required to achieve the target?

PURPOSE

The complexity of "fast track" (FT) surgery might decrease its applicability in daily practice and extensive diffusion. The aim of this study was to understand if the positive effect of FT on the outcome might be affected by the number, type, level of evidence of the components, or their possible combinations.

METHODS

We performed a Medline, Embase, Pubmed, and Cochrane Library literature search of randomized and non-randomized trials comparing FT to conventional care (CC) in elective colorectal operations. By a meta-analytic approach, the effect of FT was estimated by the risk ratio (RR) with a 95 % confidence interval (CI) for the risk of post-operative complications.

RESULTS

The analysis included 53 studies (36 non-RCTs with and 17 RCTs), with 4,100 patients in the FT group and 4,424 patients in the CC group for a total of 8,524 patients. Fifty-six different item combinations were observed. The median rate of strategy implementation was 50 %. The positive effect of FT over CC was observed regardless the number (<10 vs. ≥10) of strategies used (RR = 0.80; 95 % CI 0.66-0.98 and RR = 0.75; 95 % CI 0.65-0.87, respectively), the application of items with strong vs. low level evidence (RR = 0.78; 95 % CI 0.67-0.90 and RR = 0.76; 95 % CI 0.63-0.92, respectively), or the frequency (≥80 vs. <80 %) of items implemented (RR = 0.80; 95 % CI 0.69-0.93 and RR = 0.73; 95 % CI 0.61-0.87, respectively).

CONCLUSION

The positive effects of FT seem to be achieved regardless the multiplicity and variance of item grouping.

Fast-track surgery in real life: how patient factors influence outcomes and compliance with an enhanced recovery clinical pathway after colorectal surgery

The aim of this prospective cohort study was to identify the patient factors that predict postoperative deviation from each item of a fast-track colorectal surgery protocol (FT) and these factors' influences on postoperative outcomes. A total of 606 patients with colorectal pathology from 2005 to 2011 were analyzed to assess the relationships between patient factors, the outcome variables, and the items of the FT program. The median length of stay was 5 days, and readmission rate was 2.3%. The morbidity rate was 26.7%. Independent predictors of prolonged length of stay were older than 75 years of age, ASA grade 3 and 4, and the presence of an ileostomy. Independent predictors of morbidity were age above 75 years old and ASA grade, whereas age was confirmed as an independent predictor of mortality. Male sex, age above 75 years old, and ASA 3 and 4 were identified as independent predictors of negative compliance to most of the postoperative FT items.

Fast-track surgery decreases the incidence of postoperative delirium and other complications in elderly patients with colorectal carcinoma

Objective

This study aims to investigate the role of fast-track surgery in preventing the development of postoperative delirium and other complications in elderly patients with colorectal carcinoma.

Methods

A total of 240 elderly patients with colorectal carcinoma (aged ≥70 years) undergoing open colorectal surgery was randomly assigned into two groups, in which the patients were managed perioperatively either with traditional or fast-track approaches. The length of hospital stay (LOS) and time to pass flatus were compared. The incidence of postoperative delirium and other complications were evaluated. Serum interleukin-6 (IL-6) levels were determined before and after surgery.

Results

The LOS was significantly shorter in the fast-track surgery (FTS) group than that in the traditional group. The recovery of bowel movement (as indicated by the time to pass flatus) was faster in the FTS group. The postoperative complications including pulmonary infection, urinary infection and heart failure were significantly less frequent in the FTS group. Notably, the incidence of postoperative delirium was significantly lower in patients with the fast track therapy (4/117, 3.4 %) than with the traditional therapy (15/116, 12.9 %; p = 0.008). The serum IL-6 levels on postoperative days 1, 2, and 3 in patients with the fast-track therapy were significantly lower than those with the traditional therapy (p < 0.001).

Conclusions

Compared to traditional perioperative management, fast-track surgery decreases the LOS, facilitates the recovery of bowel movement, and reduces occurrence of postoperative delirium and other complications in elderly patients with colorectal carcinoma. The lower incidence of delirium is at least partly attributable to the reduced systemic inflammatory response mediated by IL-6.

Potential benefits of fast-track concepts in paediatric colorectal surgery

BACKGROUND

Structured care pathways optimising peri-operative care have been shown to significantly enhance post-operative recovery. We aim to determine if enhanced recovery after surgery (ERAS) principles could provide benefit for paediatric patients undergoing major colorectal resection for inflammatory bowel disease (IBD).

METHODS

Children undergoing elective bowel resection for IBD at a regional paediatric unit using standard methods of peri-operative care were matched to adult cases from an associated tertiary referral university hospital already using an ERAS program. Cases were matched for disease type, gender, operative procedure, and ASA grade.

RESULTS

Forty-four children undergoing fifty procedures were identified. Thirty-four were matched to adult cases. Total length of stay in the paediatric group was significantly longer than in the adult group (6 vs. 9 days; P=0.001). Paediatric patients were slower to start solid diet (1 vs. 4 days; P<0.0001) and were slower to mobilize post-operatively (1 vs. 4 days; P<0.0001). No difference was seen in time to restoration of bowel function (2 vs. 3 days; P=0.49). Thirty day readmissions and total in-hospital morbidity were not significantly different between the groups.

CONCLUSION

Potentially, application of ERAS in paediatric surgery could accelerate recovery and reduce length of post-operative stay thereby improving quality and efficiency of care.

Fast-track surgery improves postoperative clinical recovery and immunity after elective surgery for colorectal carcinoma: randomized controlled clinical trial

Background

Few clinical studies or randomized clinical trial results have reported the impact of fast-track surgery on human immunity. This study aimed to investigate the clinical and immune impact of fast-track surgery in colorectal cancer patients undergoing elective open surgery.

Methods

A controlled randomized clinical trial was conducted from November 2008 to January 2009 with a 1-month postdischarge follow-up. A total of 70 patients with colorectal carcinoma requiring colorectal resection were randomized into two groups: a fast-track group (35 cases) and a conventional care group (35 cases). All included patients underwent elective open colorectal resection with combined tracheal intubation and general anesthesia. Clinical parameters and markers of immune function were evaluated in both groups postoperatively.

Results

In all, 62 patients completed the study: 32 in the fast-track group and 30 in the conventional care group. Our findings revealed a significantly shorter postoperative hospital stay and faster return of gastrointestinal function in patients undergoing fast-track rehabilitation. In addition, we found a quicker response of white blood cells in the fast-track group than in the conventional care group. We also found that blood levels of globulin, immunoglobulin G, and complement 4 on postoperative day 3 were higher in the fast-track group than in the conventional care group.

Conclusions

Fast-track surgery accelerates clinical recovery and improves postoperative immunity after elective open surgery for colorectal carcinoma.

Fast-track pathways in colorectal surgery

Enhanced recovery after surgery or "fast-track" pathways are a multimodal approach to the perioperative management of patients undergoing colorectal surgery designed to improve the overall quality of care. These pathways use existing evidence to streamline and standardize the perioperative management of patients to improve pain management, speed intestinal recovery, and ultimately facilitate a more rapid hospital discharge, thus minimizing complications, decreasing the use of hospital resources and health care costs, and improving overall patient care and satisfaction. Fast-track protocols are safe for patients and offer improvement in intestinal recovery and hospital discharge.

Clinical application of immune-enhanced enteral nutrition in patients with advanced gastric cancer after total gastrectomy

OBJECTIVE

To determine whether immune-enhanced enteral nutrition (EN) was effective on nutritional status, immune function, surgical outcomes and days of hospitalization after total gastrectomy for patients with advanced gastric cancer (AGC).

METHODS

From August 2005 to May 2011, 78 patients with AGC who underwent a total gastrectomy were enrolled and divided randomly into three groups: immune-enhanced EN (EN + glutamine [Gln]) group, standard EN group and control group. Serum parameters including total protein, albumin, proalbumin and transferrin were examined on preoperative day 1, postoperative day 2 and day 12. Levels of immunoglobulin M (IgM), immunoglobulin G (IgG), natural killer (NK) cells, CD4⁺ and CD8⁺ T cells were also compared.

RESULTS

The formulas were tolerated well in all the patients except 5 with mild complications. The EN + Gln and EN groups showed a faster onset of flatus and shorter hospitalization duration than the control group. On postoperative day 12, serum total protein, albumin, proalbumin and transferrin levels of the EN + Gln and EN groups were significantly higher than those of the control group (P < 0.05). CD4⁺ T cells, NK cells, IgM and IgG levels of the EN + Gln group increased prominently, and were significantly higher than those before the operation as well as those in the EN and control groups.

CONCLUSION

Immune-enhanced EN can improve nutritional status and immune function for the patients with AGC after total gastrectomy.

Immunologic response after laparoscopic colon cancer operation within an enhanced recovery program

OBJECTIVE

It has been demonstrated that colon operation combined with fast-track (FT) surgery and laparoscopic technique can shorten the length of hospital stay, accelerate recovery of intestinal function, and reduce the occurrence of post-operative complications. However, there are no reports regarding the combined effects of FT colon operation and laparoscopic technique on humoral inflammatory cellular immunity.

METHODS

This was a prospective, controlled study. One hundred sixty-three colon cancer patients underwent the traditional protocol and open operation (traditional open group, n=42), the traditional protocol and laparoscopic operation (traditional laparoscopic group, n=40), the FT protocol and open operation (FT open group, n=41), or the FT protocol and laparoscopic operation (FT laparoscopic group, n=40). Blood samples were taken prior to operation as well as on days 1, 3, and 5 after operation. The number of lymphocyte subpopulations was determined by flow cytometry, and serum interleukin-6 and C-reactive protein levels were measured. Post-operative hospital stay, post-operative morbidity, readmission rate, and in-hospital mortality were recorded.

RESULTS

Compared with open operation, laparoscopic colon operation effectively inhibited the release of post-operative inflammatory factors and yielded good protection via post-operative cell immunity. FT surgery had a better protective role with respect to the post-operative immune system compared with traditional peri-operative care. Inflammatory reactions, based on interleukin-6 and C-reactive protein levels, were less intense following FT laparoscopic operation compared to FT open operation; however, there were no differences in specific immunity (CD3+ and CD4+ counts, and the CD4+/CD8+ ratio) during these two types of surgical procedures. Post-operative hospital stay in patients randomized to the FT laparoscopic group was significantly shorter than in the other three treatment groups (P<0.01). Post-operative complications in patients who underwent FT laparoscopic treatment were less than in the other three treatment groups (P<0.05). There were no significant differences between the four treatment groups regarding readmission rate and in-hospital mortality.

CONCLUSIONS

The laparoscopic technique and FT surgery rehabilitation program effectively inhibited release of post-operative inflammatory factors with a reduction in peri-operative trauma and stress, which together played a protective role on the post-operative immune system. Combining two treatment measures during colon operation produced better protective effects via the immune system. The beneficial clinical effects support that the better-preserved post-operative immune system may also contribute to the improvement of post-operative results in FT laparoscopic patients.

A systematic review of enhanced recovery protocols in colorectal surgery

INTRODUCTION

Colorectal surgery has been associated with a complication rate of 15-20% and mean post-operative inpatient stays of 6-11 days. The principles of enhanced recovery after surgery (ERAS) are well established and have been developed to optimise peri-operative care and facilitate discharge. The purpose of this systematic review is to present an updated review of peri-operative care in colorectal surgery from the available evidence and ERAS group recommendations.

METHODS

Systematic searches of the PubMed and Embase™ databases and the Cochrane library were conducted. A hand search of bibliographies of identified studies was conducted to identify any additional articles missed by the initial search strategy.

RESULTS

A total of 59 relevant studies were identified. These included six randomised controlled trials and seven clinical controlled trials that fulfilled the inclusion criteria. These studies showed reductions in duration of inpatient stays in the ERAS groups compared with more traditional care as well as reductions in morbidity and mortality rates.

CONCLUSIONS

Reviewing the data reveals that ERAS protocols have a role in reducing post-operative morbidity and result in an accelerated recovery following colorectal surgery. Similarly, both primary and overall hospital stays are reduced significantly. However, the available evidence suggests that ERAS protocols do not reduce hospital readmissions or mortality. These findings help to confirm that ERAS protocols should now be implemented as the standard approach for peri-operative care in colorectal surgery.

"Fast Track" nasogastric decompression of rectal cancer surgery

This study evaluates the application of fast track (FT) nasogastric decompression in patients who underwent anterior resection of rectal cancer. A randomized control trial was performed comparing the group with the fast track treatment (n = 57) and the group with traditional nasogastric decompression (n = 84). Preoperative characteristics and postoperative recovery indices were recorded and analyzed. The results indicate no significant differences in gender (P = 0.614), age (P = 0.653), tumor location (P = 0.113), and TNM stages (P = 0.054) were observed between the 2 groups. The differences in the type of resection, anastomosis, and adoption of protective colostomy were all not significant between the FT and the traditional group. During the first 24 hours after surgery, the volume of nasogastric drainage averaged 197 ml in the FT group and 155 ml in the traditional group (P = 0.197). The initiation of test-meal (P = 0.000), semiliquid diet (P = 0.002), and ordinary diet (P = 0.008) were all significantly shorter in the FT group. Furthermore, compared with the other group, the patients in the FT group enjoyed earlier removal of the abdominal drainage, urinary catheter, and shorter hospital stays (P = 0.000). Based on a correlation test, the duration of nasogastric decompression is related to the time of test-meal and semiliquid diet. The routine usage of nasogastric decompression in rectal surgery is unnecessary. The fast track procedure might help in facilitating postoperative functional and diet recovery, reducing the time of catheterization, and shortening hospital stay.

Fast-track colorectal surgery

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

A simplified rehabilitation program for patients undergoing elective colonic surgery--randomized controlled clinical trial

BACKGROUND

We have proposed a simplified perioperative rehabilitation program for elective colonic surgery that is focused on early oral nutrition and that could reduce hospital stay and postoperative ileus time without raising complications and readmission rates.

PATIENTS AND METHODS

Fifty-four patients admitted for elective colonic surgery were prospectively randomized into two groups: (1) an early feeding group (EFG)-on the first postoperative day, patients initially received a oral liquid diet and were advanced to a regular diet within the next 24 h as tolerated and at their discretion; (2) a traditional care group-patients were managed by nothing per orus until the elimination of the first flatus and then submitted to an oral liquid diet, followed by a regular diet within the next 24 h as described for the EFG. All patients followed a well-defined, simplified rehabilitation program.

RESULTS

Patients' baseline characteristics were similar in the two groups. Hospital stay was significantly lower in the EFG (4.0 [±3.7] versus 7.6 [±8.1] days; p = 0.000). Diet tolerance and progression were similar between groups. Time to first flatus after surgery was significantly lower in the EFG (1.5 [±0.5] versus 2.0 [±0.7] days; p = 0.019). Complication and readmission rates were similar in both groups.

CONCLUSIONS

Early oral nutrition associated with a simplified perioperative rehabilitation program reduces postoperative length of hospital stay and ileus time after elective colonic resection without increasing rates of complications or readmissions.

Laparoscopy within a fast-track program enhances the short-term results after elective surgery for resectable colorectal cancer

BACKGROUND

Whether laparoscopic colorectal resection improved recovery within an enhanced recovery program was investigated.

METHODS

This study was designed as a query of a prospectively maintained colorectal database to identify 350 patients who underwent elective colorectal resection with primary anastomosis for colorectal cancer between January 1, 2005 and December 31, 2009. Patients were categorized into two groups (laparoscopic and open resection), and demographic, treatment, and outcome variables were independently reviewed for accuracy. A detailed fast-track protocol was prepared and distributed to all patients, department doctors, and nurses to standardize the treatment.

RESULTS

A total of 209 patients underwent laparoscopic-assisted colorectal resection, and 141 had open surgery. There was no difference between the two groups in terms of age, sex, BMI, ASA, comorbidity, previous abdominal surgery, preoperative chemoradiotherapy, cancer site, and AJCC 2002 staging. Twenty-three patients in the laparoscopic group required conversion to an open procedure due to hemorrhage, tumor extension, or technical difficulties. Laparoscopic patients had earlier tolerance of diet, bowel movement, flatus and stool canalization, mobilization, suction drain removal, and interruption of analgesic drug administration. Length of postoperative stay was shorter (4 vs. 7 days, p = 0.0004) and fewer postoperative nonsurgical complications (3 vs. 13% p = 0.009) were registered for the laparoscopic group.

CONCLUSIONS

This study suggests that within an enhanced recovery program, laparoscopic resection may provide the best short-term clinical outcomes for patients with resectable colorectal cancer.

Comparison of early mobilization and diet rehabilitation program with conventional care after laparoscopic colon surgery: a prospective randomized controlled trial

PURPOSE

Although laparoscopic surgery may permit earlier recovery compared with open surgery, no published randomized controlled trial has investigated the benefit of a multimodal rehabilitation program after laparoscopic colonic resection. This study aimed to evaluate the efficacy of a rehabilitation program after laparoscopic colon surgery in the context of a randomized controlled trial.

METHODS

Between September 2007 and October 2009, 100 patients who had received laparoscopic colon surgery were selected for the study and randomly assigned on a 1:1 basis to a rehabilitation program group with early mobilization and diet (n = 46) or conventional care group (n = 54). The rehabilitation program group received early oral feeding, early ambulation, and regular laxative. The primary outcome was recovery time, measured with criteria of tolerable diet for 24 hours, safe ambulation, analgesic-free, and afebrile status without major complications. Secondary outcomes were postoperative hospital stay, complications, quality of life by Short Form 36, pain by visual analog scale, and readmission. This study was registered (ID number NCT00606944, http://register.clinicaltrials.gov).

RESULTS

Recovery time was shorter in the rehabilitation program group than in the conventional care group (median (interquartile range), 4 (3-5) d vs 6 (5-7) d, respectively; P < .0001). There was no difference in postoperative hospital stay between the 2 groups (rehabilitation program group, 7 (6-8) d vs conventional care group, 8 (7-9) d; P = .065). There was no difference in complication rates between the rehabilitation program group and conventional care group (10.9% vs 20.4%, respectively; P = .136). Quality of life and pain were similar in both groups. There were no readmissions or mortality.

CONCLUSIONS

A rehabilitation program with early mobilization and diet after laparoscopic colon surgery results in reduced recovery time without increased complications. These results suggest that a multimodal rehabilitation program may increase the short-term benefits after laparoscopic colon surgery.

Effect of fast track surgery on serum levels of CRP, IL-6 and insulin resistance in patients with colorectal cancer

AIM: To investigate the effect of fast track surgery on serum levels of C-reactive protein (CRP), interleukin-6 (IL-6) and insulin resistance in patients with colorectal cancer.

METHODS: Eighty-six patients with colorectal cancer were randomly and equally assigned to two groups: one receiving fast track surgery (FTS group) and the other receiving conventional therapy (CM group). Peripheral blood samples were collected 1 d before and 1, 5, 7 d after the operation. Serum levels of CRP, IL-6, fasting blood glucose (FBG), and fasting insulin (FINS) were measured. The time to first passage of flatus and feces, rate of complications, length of hospital stay, and hospital costs were also compared between the two groups.

RESULTS: The FTS group was associated with a significantly earlier first passage of flatus and feces, shorter postoperative hospital stay, and less medical costs (P < 0.05) than the CM group, but there was no significant difference in morbidity between the two groups. Serum levels of CRP and IL-6 increased significantly on days 1 and 5 after operation in both groups (CM group: 82.03 mg/L ± 7.23 mg/L, 34.80 mg/L ± 5.21 mg/L vs 4.23 mg/L ± 0.92 mg/L; 202.15 μg/L ± 15.66 μg/L, 86.48 μg/L ± 9.33 μg/L vs 37.82 μg/L ± 8.99 μg/L; FTS group: 68.11 mg/L ± 3.55 mg/L, 15.50 mg/L ± 2.09 mg/L vs 3.33 mg/L ± 0.99 mg/L; 163.10 μg/L ± 12.98 μg/L, 47.69 μg/L ± 8.64 μg/L vs 40.52 μg/L ± 9.12 μg/L, all P < 0.05), and all these parameters were higher in the CM group than in the FTS group (all P < 0.05). On day 7 postoperatively, the levels of CRP and IL-6 returned to pre-operation levels in the FTS group (both P > 0.05), but still maintained high levels in the CM group (both P< 0.05). In both groups, HOMA-IR was significantly higher and IAI was significantly lower on the day after surgery (P < 0.05), and the changes were more significant in the CM group than in the FTS group (all P < 0.05). On day 5 postoperatively, HOMA-IR and IAI returned to pre-operation levels in the FTS group (both P > 0.05), but remained abnormal in the CM group (both P< 0.05).

CONCLUSION: Fast track surgery may enhance early recovery and decrease medical costs. Compared with conventional therapy for colorectal cancer, FTS has less influence on serum levels of CRP, IL-6, and insulin resistance, and is therefore associated with less immunosuppression, milder stress reaction, and shorter stress time.

Implementing fast-track protocol for colorectal surgery: a prospective randomized clinical trial

BACKGROUND

Fast-track protocols are followed by an enhanced recovery, early return to bowel function and to complete nutrition, and a reduced hospital stay. Our study was designed to implement fast-track protocol in our university hospital.

METHODS

The 96 consecutive patients with colorectal neoplasm included in the study were randomized in two equal groups: group 1 (FT) included patients undergoing colorectal surgery in a fast-track protocol, and group 2 (C) included patients undergoing colorectal surgery with a conventional care protocol. As with other fast-track protocols, our protocol included carbohydrate fluids load before operation, early mobilization and oral feeding, regular prokinetics, and multimodal postoperative analgesia. Time to restoration of bowel function, to complete mobilization and feeding, length of hospital stay, and incidence of complications and readmissions were monitored.

RESULTS

Time to mobilization, restoring of bowel function, and complete oral feeding were significantly shorter with fast-track protocol (p = 0.001, p = 0.042, and p = 0.01, respectively). Hospital stay also was shorter in the fast-track group (p = 0.001). The incidence of complications did not significantly differ with the study groups.

CONCLUSIONS

In our study, fast-track protocol resulted in a shorter time to mobilization, complete feeding, and discharge from hospital. Fast-track protocol did not increase the incidence of complications. However, we consider that our data require further confirmation with powered multicenter national studies.

Successful Enhanced Recovery Program after Colorectal Surgery in a County Institution

Enhanced recovery programs after colorectal surgery have gained acceptance recently as they have shown a decrease length of hospital stay. However, these pathways require strict adherence to standardized programs with patient education and high compliance. This study was designed to assess the feasibility of such a program in a large county hospital. A retrospective review was performed of 54 consecutive patients who underwent laparoscopic or open segmental colorectal resection without an ostomy. The first 27 patients were treated in a conventional manner, whereas the latter 27 were treated using a protocol promoting early feeding and ambulation with decreased intravenous fluids and narcotic use. There were no baseline differences between the groups, however, there was a significant difference in the patients treated with the enhanced recovery program in terms of less intravenous fluids administered in surgery ( P = 0.001), and over the subsequent 3 days ( P = 0.0017), with a decrease in length of hospital stay of 4 compared with 6 days ( P = 0.003). There were no differences in terms of complication and readmission rates. Based on this study, we conclude that strict adherence to a standard enhanced recovery program was effective in reducing hospital stay in patients undergoing colorectal resection without any increase in complications.

The humoral response after laparoscopic versus open colorectal surgery: a meta-analysis

BACKGROUND

The local and systemic humoral response after colorectal surgery is thought to affect postoperative recovery. It is commonly claimed that laparoscopic surgery elicits a diminished inflammatory response than equivalent open surgery. Despite these claims, the evidence is conflicting. Therefore, we aimed to systematically review the results from randomized controlled clinical trials comparing the humoral response associated with laparoscopic versus open colorectal surgery.

MATERIALS AND METHODS

A high-sensitivity search was conducted independently by two of the authors with no language restriction. Studies were identified from the Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Cochrane Library, Medline (January 1966 to January 2009), PubMed (1950 to January 2009), and Embase (1947 to January 2009). Relevant meeting abstracts and reference lists were manually searched. Data analysis was performed using Review Manager ver. 5.0.

RESULTS

Thirteen randomized controlled trials were included. Meta-analysis demonstrated a significantly higher serum IL-6 on d 1 after open colorectal resection for neoplasia (n = 97) compared with laparoscopic resection (n = 76, P = 0.0008) without significant heterogeneity. Data for plasma IL-6 were heterogeneous, with no apparent difference between groups. No other significant differences were identified, and there were not enough data on local peritoneal humoral factors to allow meta-analysis.

CONCLUSION

Open colorectal resection for neoplasia is associated with higher postoperative serum levels of IL-6 on d 1 than equivalent laparoscopic surgery. The aetiology and clinical significance of this finding is uncertain, and further studies are required to elucidate any differences in the local humoral response which may be more clinically relevant in surgery for this indication.

Fast-track surgery after laparoscopic colorectal surgery: is it feasible in a general surgery unit?

BACKGROUND

The aim of the "fast-track surgery" program is to decrease the peri-operative stress response to surgical trauma and thus to a decrease in complication rates after elective surgery. Critics of fast-track (FT) rehabilitation may argue that all reports of successful programs came from major specialized hospital units and that implementation in smaller or less specialized units may be difficult if not impossible.

METHODS

We retrospectively studied 101 patients who, from November 2004 to October 2007, underwent laparoscopic colorectal surgery in our institute. A detailed FT surgery protocol had been prepared and given to patients, physicians and nurses, with the aim to create a standard treatment. Data about demographics, ASA score, pre-operative complicating diseases, diagnosis, type of surgery, and postoperative clinical data were analyzed. Univariate analysis of the relationship between all factors (patient characteristics, intervention characteristics, protocol compliance and presence of complications) described here and length of hospital stay was performed.

RESULTS

We compared our results to published major trials and observed no substantial differences in morbidity, mortality and length of postoperative hospital stay between the 2. Univariate analysis showed that compliance to the elements of the FT protocol influences the length of postoperative period more significantly than patient characteristics or surgical procedure.

CONCLUSION

Based on 6 comparative single-center studies, the FT program was found to reduce length of hospital stay, and was deemed safe for major abdominal surgeries. Present study shows that enhanced recovery or FT program can also be implemented safely in a general surgery unit.

Effects of early oral feeding on surgical outcomes and recovery after curative surgery for gastric cancer: pilot study results

BACKGROUND

The aim of the present study was to determine whether early oral feeding after curative resection for gastric cancer can be tolerated and whether it has an effect on recovery.

METHODS

From September 2007 to January 2008, we provided early postoperative oral feeding for 35 patients who underwent curative distal gastrectomy for gastric cancer. These patients began a liquid diet on the second postoperative day (POD), followed by a soft diet beginning on the third POD until they were discharged. From April to August 2007, we enrolled 31 patients with a conventional diet schedule as a control group. We compared the clinicopathologic features and surgical outcomes, including morbidity, laboratory results, and hospitalized days between the two groups.

RESULTS

There were no significant differences in the clinical and operative factors between the two groups. Although there was no difference in the morbidity rate (P = 0.331), the early group was hospitalized for fewer days (8.03 +/- 1.43 vs. 9.97 +/- 2.07 days; P < 0.001) and had a faster onset of flatus (1.96 +/- 0.58 vs. 2.97 +/- 0.66 day; P < 0.001) than the control group. The laboratory findings showed that the early feeding group tended to have a lymphocyte count that recovered faster than the control group, although the difference was not statistically significant.

CONCLUSIONS

Early oral feeding following a gastrectomy for gastric cancer is feasible and can result in faster recovery of bowel function and a shorter hospitalization.

Fast-track vs standard care in colorectal surgery: a meta-analysis update

BACKGROUND

Fast-track (FT) protocols accelerate patient's recovery and shorten hospital stay as a result of the optimization of the perioperative care they offer. The aim of this review is to examine the latest evidence for fast-track protocols when compared with standard care in elective colorectal surgery involving segmental colonic and/or rectal resection.

MATERIALS AND METHODS

All randomized controlled trials and controlled clinical trials on FT colorectal surgery were reviewed systematically. The main end points were short-term morbidity, length of primary postoperative hospital stay, length of total postoperative stay, readmission rate, and mortality. Quality assessment and data extraction were performed independently by two observers.

RESULTS

Eleven studies were eligible for analysis (four randomized controlled trials (RCTs) and seven controlled clinical trials (CCT)), including 1,021 patients. Primary hospital stay (weighted mean difference -2.35 days, 95% confidence interval (CI) -3.24 to -1.46 days, P < 0.00001) and total hospital stay (weighted mean difference -2.46 days, 95% CI -3.43 to -1.48 days, P < 0.00001) were significantly lower for FT programs. Morbidity was also lower in the FT group. Readmission rates were not significantly different. No increase in mortality was found.

CONCLUSIONS

FT protocols show high-level evidence on reducing primary and total hospital stay without compromising patients' safety offering lower morbidity and the same readmission rates. Enhanced recovery programs should become a mainstay of elective colorectal surgery.