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Qin J, Gou LY, Zhang W, Pu X, Zhang P. Enhanced Recovery After Surgery versus Conventional Care in Cholecystectomy: A Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2024; 34:710-720. [PMID: 38976496 DOI: 10.1089/lap.2024.0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024] Open
Abstract
Objectives: The primary objective of this study was to evaluate the safety and efficacy of the enhanced recovery after surgery (ERAS) protocol in cholecystectomy, comparing it with standard care. Methods: A comprehensive literature search was conducted in December 2023, using globally recognized databases such as PubMed, Embase, and the Cochrane Library. Various parameters were compared using Review Manager software. This study was duly registered with PROSPERO (CRD420223). Results: The meta-analysis included nine studies, encompassing a total of 1920 patients. The findings revealed that the ERAS group, in comparison to traditional care, experienced shorter hospitalization periods (weighted mean difference [WMD]: -1.23, 95% confidence interval [CI]: -1.98 to -0.47; P = .001), lower visual analog scale at 24 hours (WMD: -1.10, 95% CI: -1.30 to -0.90; P < .00001), faster time to first flatus (WMD: -4.48, 95% CI: -4.50 to -4.46; P < .00001), and reduced operative times (WMD: -9.94, 95% CI: -17.88 to -0.96; P = .03). In addition, there was a notable decrease in instances of postoperative nausea and vomiting (odds ratio [OR]: 0.46, 95% CI: 0.28 to 0.74; P = .002). No significant differences were observed in readmission rates, blood loss, postoperative complications, or bile leakage between the two care methods. Conclusions: This study substantiates that the ERAS protocol is an advantageous perioperative care strategy for patients undergoing cholecystectomy. It significantly outperforms traditional care in reducing the length of stay, decreasing the likelihood of postoperative nausea/vomiting, alleviating postoperative pain, and accelerating the time to the first flatus. These findings highlight the effectiveness of ERAS in enhancing patient outcomes in cholecystectomy.
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Affiliation(s)
- Jiao Qin
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Ling-Yan Gou
- Surgical Center, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Wei Zhang
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xiao Pu
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Ping Zhang
- Anesthetic Surgery Sichuan Provincial People's Hospital, Nanchong, China
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Kong J, Wu MQ, Yan S, Zhao ZF, Yao H. Single-incision plus one-port laparoscopy surgery versus conventional multi-port laparoscopy surgery for colorectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 2024; 39:62. [PMID: 38684561 PMCID: PMC11058787 DOI: 10.1007/s00384-024-04630-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVE The efficacy of single-incision plus one-port laparoscopic surgery (SILS + 1) versus conventional laparoscopic surgery (CLS) for colorectal cancer treatment remains unclear. This study compares the short-term and long-term outcomes of SILS + 1 and CLS using a high-quality systematic review and meta-analysis. METHOD Literature search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, drawing from PubMed, Embase, Web of Science, and the Cochrane Library until December 10, 2023. Statistical analysis was conducted using RevMan and Stata. RESULT The review and meta-analysis included seven studies with 1740 colorectal cancer patients. Compared to CLS, SILS + 1 showed significant improvements in operation time (WMD = - 18.33, P < 0.00001), blood loss (WMD = - 21.31, P < 0.00001), incision length (WMD = - 2.07, P < 0.00001), time to first defecation (WMD = - 14.91, P = 0.009), time to oral intake (WMD = - 11.46, P = 0.04), and time to ambulation (WMD = - 11.52, P = 0.01). There were no significant differences in lymph node harvest, resection margins, complications, anastomotic leakage, hospital stay, disease-free survival, overall survival, and postoperative recurrence. CONCLUSIONS Compared to CLS, SILS + 1 demonstrates superiority in shortening the surgical incision and promoting postoperative recovery. SILS + 1 can provide a safe and feasible alternative to CLS.
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Affiliation(s)
- Jian Kong
- Department of General Surgery(Gastrointestinal Surgery), The Affiliated Hospital of Southwest Medical University, Sichuan Province, Luzhou, China
- Southwest Medical University, Sichuan Province, Luzhou, China
| | - Meng-Qi Wu
- Department of General Surgery(Gastrointestinal Surgery), The Affiliated Hospital of Southwest Medical University, Sichuan Province, Luzhou, China
- Southwest Medical University, Sichuan Province, Luzhou, China
| | - Shuai Yan
- Department of General Surgery(Gastrointestinal Surgery), The Affiliated Hospital of Southwest Medical University, Sichuan Province, Luzhou, China
- Southwest Medical University, Sichuan Province, Luzhou, China
| | - Zheng-Fei Zhao
- Department of General Surgery(Gastrointestinal Surgery), The Affiliated Hospital of Southwest Medical University, Sichuan Province, Luzhou, China
- Southwest Medical University, Sichuan Province, Luzhou, China
| | - Hui Yao
- Department of General Surgery(Gastrointestinal Surgery), The Affiliated Hospital of Southwest Medical University, Sichuan Province, Luzhou, China.
- Southwest Medical University, Sichuan Province, Luzhou, China.
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D’Souza J, Richards S, Eglinton T, Frizelle F. Incidence and risk factors for unplanned readmission after colorectal surgery: A meta-analysis. PLoS One 2023; 18:e0293806. [PMID: 37972100 PMCID: PMC10653493 DOI: 10.1371/journal.pone.0293806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 10/19/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Unplanned readmissions (URs) after colorectal surgery (CRS) are common, expensive, and result from failure to progress in postoperative recovery. These are considered preventable, although the true extent is yet to be defined. In addition, their successful prediction remains elusive due to significant heterogeneity in this field of research. This systematic review and meta-analysis of observational studies aimed to identify the clinically relevant predictors of UR after colorectal surgery. METHODS A systematic review was conducted using indexed sources (The Cochrane Database of Systematic Reviews, MEDLINE, and Embase) to search for published studies in English between 1996 and 2022. The search strategy returned 625 studies for screening of which, 150 were duplicates, and 305 were excluded for irrelevance. An additional 150 studies were excluded based on methodology and definition criteria. Twenty studies met the inclusion criteria and for the meta-analysis. Independent meta-extraction was conducted by multiple reviewers (JD & SR) in accordance with PRISMA guidelines. The primary outcome was defined as UR within 30 days of index discharge after colorectal surgery. Data were pooled using a random-effects model. Risk of bias was assessed using the Quality in Prognosis Studies tool. RESULTS The reported 30-day UR rate ranged from 6% to 22.8%. Increased comorbidity was the strongest preoperative risk factor for UR (OR 1.39, 95% CI 1.28-1.51). Stoma formation was the strongest operative risk factor (OR 1.54, 95% CI 1.38-1.72). The occurrence of postoperative complications was the strongest postoperative and overall risk factor for UR (OR 3.03, 95% CI 1.21-7.61). CONCLUSIONS Increased comorbidity, stoma formation, and postoperative complications are clinically relevant predictors of UR after CRS. These risk factors are readily identifiable before discharge and serve as clinically relevant targets for readmission risk-reducing strategies. Successful readmission prediction may facilitate the efficient allocation of healthcare resources.
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Affiliation(s)
- Joel D’Souza
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
| | - Simon Richards
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
| | - Timothy Eglinton
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
| | - Frank Frizelle
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
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D’Souza J, Eglinton T, Frizelle F. Readmission prediction after colorectal cancer surgery: A derivation and validation study. PLoS One 2023; 18:e0287811. [PMID: 37384713 PMCID: PMC10309978 DOI: 10.1371/journal.pone.0287811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/13/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Unplanned readmissions after colorectal cancer (CRC) surgery are common, expensive, and result from failure to progress in postoperative recovery. The context of their preventability and extent of predictability remains undefined. This study aimed to define the 30-day unplanned readmission (UR) rate after CRC surgery, identify risk factors, and develop a prediction model with external validation. METHODS Consecutive patients who underwent CRC surgery between 2012 and 2017 at Christchurch Hospital were retrospectively identified. The primary outcome was UR within 30 days after index discharge. Statistically significant risk factors were identified and incorporated into a predictive model. The model was then externally evaluated on a prospectively recruited dataset from 2018 to 2019. RESULTS Of the 701 patients identified, 15.1% were readmitted within 30 days of discharge. Stoma formation (OR 2.45, 95% CI 1.59-3.81), any postoperative complications (PoCs) (OR 2.27, 95% CI 1.48-3.52), high-grade PoCs (OR 2.52, 95% CI 1.18-5.11), and rectal cancer (OR 2.11, 95% CI 1.48-3.52) were statistically significant risk factors for UR. A clinical prediction model comprised of rectal cancer and high-grade PoCs predicted UR with an AUC of 0.64 and 0.62 on internal and external validation, respectively. CONCLUSIONS URs after CRC surgery are predictable and occur within 2 weeks of discharge. They are driven by PoCs, most of which are of low severity and develop after discharge. Atleast 16% of readmissions are preventable by management in an outpatient setting with appropriate surgical expertise. Targeted outpatient follow-up within two weeks of discharge is therefore the most effective transitional-care strategy for prevention.
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Affiliation(s)
- Joel D’Souza
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
| | - Timothy Eglinton
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
| | - Frank Frizelle
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
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Siragusa L, Pellino G, Sensi B, Panis Y, Bellato V, Khan J, Sica GS. Ambulatory laparoscopic colectomies: a systematic review. Colorectal Dis 2023. [PMID: 36790358 DOI: 10.1111/codi.16511] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/29/2022] [Accepted: 01/29/2023] [Indexed: 02/16/2023]
Abstract
AIM Ambulatory laparoscopic colectomy (ALC), meaning discharge within 24 h of surgical colonic resection, has recently been proposed in a few, selected patients. This systematic review was performed with the aim of reviewing protocols for ALC and assessing feasibility, safety and outcomes after ALC. METHOD A PRISMA-compliant systematic review and pooled analysis was performed searching all English studies published until October 2022 in PubMed, Cochrane Library, Web of Science (PROSPERO, CRD42022334463). Inclusion criteria were original articles including patients undergoing ALC, specifying at least one outcome of interest. Exclusion criteria were articles reporting a robotic-assisted procedure; unable to retrieve patient data from articles; the same patient series included in different studies. Primary outcomes were success, overall complications and readmission rates. Secondary outcomes included mortality and specific complications such us surgical site infection, anastomotic leak, ileus, bleeding, rate of ALC acceptance, and unscheduled consultation and reoperation rate. RESULTS Among 1087 studies imported for screening, 11 were included (1296 patients). The success rate was 47% with an overall morbidity of 14%. Readmission and reoperation rates were 5% and 1%, respectively. No mortality was recorded. Protocols of ALC differ significantly among published studies. CONCLUSIONS Overall, ALC appears to be safe and feasible in selected cases with an acceptable success rate and a low risk of readmission after hospital discharge. Future studies should evaluate patients' benefits and discharge criteria, as well as uniformity and standardization of eligibility criteria. This systematic review may help inform on ALC adoption in clinical practice.
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Affiliation(s)
- Leandro Siragusa
- Department of Surgical Sciences, Università degli studi di Roma 'Tor Vergata', Rome, Italy
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli studi della Campania Luigi Vanvitelli, Naples, Italy.,Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain
| | - Bruno Sensi
- Department of Surgical Sciences, Università degli studi di Roma 'Tor Vergata', Rome, Italy
| | - Yves Panis
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly sur Seine, France
| | - Vittoria Bellato
- Department of Surgical Sciences, Università degli studi di Roma 'Tor Vergata', Rome, Italy
| | - Jim Khan
- Colorectal Surgery, Portsmouth Hospitals University NHS Trust, University of Portsmouth, Portsmouth, UK
| | - Giuseppe S Sica
- Department of Surgical Sciences, Università degli studi di Roma 'Tor Vergata', Rome, Italy
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Li N, Liu Y, Chen H, Sun Y. Efficacy and Safety of Enhanced Recovery After Surgery Pathway in Minimally Invasive Colorectal Cancer Surgery: A Systemic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2023; 33:177-187. [PMID: 36074099 DOI: 10.1089/lap.2022.0349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: Enhanced recovery after surgery (ERAS) has been proven valuable for colorectal cancer (CRC) patients who received traditional surgery. While for those receiving minimally invasive surgery (MIS), its efficacy and safety remain debatable. Materials and Methods: Databases, including PubMed, EMBASE, Cochrane libraries, and Web of science, were searched for relevant articles from their inception to February 23, 2022. Eligible articles were subjected to quality assessment and data extraction. The comparison between ERAS and traditional care (TC) was performed. Primary outcomes of this study were postoperative length of stay (LOS), postoperative complications, and mortality. Secondary outcomes were 30-day readmission, 30-day reoperation, time to the first anal exhaust, and defecation. Results: Thirteen cohort studies covering 4308 patients were included. Patients in the ERAS group had significantly shorter LOS (weight mean differences [WMD]: -1.89; 95% confidence interval [CI]: -2.33 to -1.45; P < .001), lower incidence of postoperative complications (risk ratios [RR]: 0.73; 95% CI: 0.5-0.88; P < .001), lower 30-day readmission rate (RR: 0.75; 95% CI: 0.61-0.92; P < .05), and shorter time to the first defecation (WMD: -1.93; 95% CI: -3.26 to -0.59; P < .001), but unimproved mortality, reoperation rate, and time to the first anal exhaust (P > .05) compared with those in the TC group. Conclusions: ERAS was effective and safe for CRC patients receiving MIS from a real-world perspective. Hence, the implementation of ERAS should be recommended for minimally invasive CRC surgery. Clinical Trial Registration Number: CRD42022321333.
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Affiliation(s)
- Niu Li
- Department of Gastrointestinal Surgery and The First Hospital, China Medical University, Shenyang, People's Republic of China
| | - Yanbiao Liu
- Department of Breast Surgery, The First Hospital, China Medical University, Shenyang, People's Republic of China
| | - Huijuan Chen
- Department of Gastrointestinal Surgery and The First Hospital, China Medical University, Shenyang, People's Republic of China
| | - Yefei Sun
- Department of Gastrointestinal Surgery and The First Hospital, China Medical University, Shenyang, People's Republic of China
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Sinha R, Verma N, Bana R, Kalidindi N, Sampurna S, Mohanty GS. Intra- and post-operative outcomes in benign gynaecologic surgeries before and after the implementation of enhanced recovery after surgery protocols: A comparison. J Minim Access Surg 2023; 19:112-119. [PMID: 36722536 PMCID: PMC10034813 DOI: 10.4103/jmas.jmas_42_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/08/2022] [Accepted: 04/10/2022] [Indexed: 01/20/2023] Open
Abstract
Objective To compare intra- and post-operative outcomes in patients undergoing benign gynaecologic surgery before and after the implementation of enhanced recovery after surgery (ERAS) protocols. Introduction ERAS is a multidisciplinary teamwork with the aim to reduce the body's reaction to surgical stress. The key components of ERAS include pre-operative counselling, avoiding prolonged fasting, standardised analgesic and anaesthetic regimes, early mobilisation and early discharge. Materials and Methods Women undergoing hysterectomy and myomectomy were included in the study. The pre-ERAS group had 100 cases and the ERAS group had 104. Demographic data of both the groups were compared. Duration of surgery, amount of blood loss, intra-abdominal drain, oral feed, catheter removal, ambulation, passage of flatus and length of stay were compared. Results The demographic profiles of both the groups were comparable. Time taken to intake of liquids (P < 0.001), solid food (P < 0.001), passage of flatus (P = 0.001), removal of Foley's catheter (P = 0.023), ambulation (P = 0.007), pain score (P = 0.001) and length of stay in hospital (P < 0.001) were statistically significantly shorter in the ERAS group when compared to the pre-ERAS group. A significant difference was seen in the use of intraperitoneal drains in the ERAS group (81% vs. 23.1%), and if used, drains were removed early in the ERAS group (66.66% vs. 28.39%) within 40 h. Both the groups had similar intra- and immediate post-operative complications. Conclusion ERAS helps in reducing length of stay with early feeding and ambulation, leading to early discharge without increase in intra- and post-operative complications in women undergoing benign gynaecological surgeries.
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Affiliation(s)
- Rooma Sinha
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | - Neeru Verma
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | - Rupa Bana
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | - Nivya Kalidindi
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | - Sowmya Sampurna
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
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A’zim AZA, Zaid ZA, Yusof BNM, Jabar MF, Shahar ASM. Effectiveness of intensive perioperative nutrition therapy among adults undergoing gastrointestinal and oncological surgery in a public hospital: study protocol for a pragmatic randomized control trial. Trials 2022; 23:961. [DOI: 10.1186/s13063-022-06898-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/09/2022] [Indexed: 11/28/2022] Open
Abstract
Abstract
Background
Perioperative malnutrition is common in patients undergoing gastrointestinal-oncology surgery and is associated with longer hospital stays, increased postoperative complications, poorer quality of life, and lower survival rates. Current practice emphasizes the role of early perioperative nutrition therapy as an early intervention to combat the postoperative complications of patients and the implementation is now widely adopted. However, there is still a lack of research on determining the effectiveness of intensive nutrition therapy and providing ONS perioperative locally. This becomes the significance of this study and serves as a basis for management and guideline in the local hospital settings.
Methods
This is a pragmatic randomized control trial study where elective admitted patients will be randomly divided into the intervention (SS) or control (NN) group. All data will be collected during a face-to-face interview, anthropometric measurement, blood sampling (albumin, white blood count, hemoglobin, and c-reactive protein), handgrip strength, and postoperative complications. Group SS will be receiving a tailored lifestyle and intensively supplemented with oral nutrition support as compared to Group NN that will receive standard medical care. The primary outcome for this study is the length of stay in the hospital. Additional outcome measures are changes in biochemical profile and nutritional and functional status. The effects of intervention between groups on the outcome parameters will be analyzed by using the SPSS General Linear Model (GLM) for the repeated measure procedure.
Discussion
The intervention implemented in this study will serve as baseline data in providing appropriate nutritional management in patients undergoing gastrointestinal and oncological surgery.
Trial registration
ClinicalTrials.gov Protocol Registration and Results System (PRS) NCT04347772. Registered on 20 November 2019.
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Martínez-Escribano C, Arteaga Moreno F, Cuesta Peredo D, Blanco Gonzalez FJ, De la Cámara-de las Heras JM, Tarazona Santabalbina FJ. Before-and-After Study of the First Four Years of the Enhanced Recovery after Surgery (ERAS ®) Programme in Older Adults Undergoing Elective Colorectal Cancer Surgery. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15299. [PMID: 36430017 PMCID: PMC9691222 DOI: 10.3390/ijerph192215299] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/05/2022] [Accepted: 11/17/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The aim of this study was to determine whether the inclusion of older patients undergoing elective colorectal cancer resection in the Enhanced Recovery After Surgery (ERAS®) programme could improve clinical outcomes during hospital admission. METHODS A before-and-after study in ≥70-year-old patients electively admitted for colorectal cancer resection was designed. In total, 213 patients were included in the ERAS® group, and 158 were included in the control group. RESULTS The average age was 77.9 years old (SD 5.31) and 57.14% of them were men, with a Charlson Index score of 3.42 (SD 3.32). The ERAS® group presented a lower transfusion rate of 42 (19.7%), compared to 75 (47.5%) in the control group (p < 0.001). The crude odds ratio (OR) for transfusion was 0.27 (95% CI 0.17-0.43; p < 0.001), and the adjusted odds ratio was 0.26 (95% CI 0.14-0.48; p < 0.001). The ERAS® group had a lower percentage of patients with moderate-severe malnutrition on admission, at 23.4% (37 patients) against 36.2% in the control group (42 patients) (p = 0.023), with an OR of 0.47 (95% CI 0.29-0.75; p < 0.002) and an adjusted OR of 0.48 (95% CI 0.29-0.78; p = 0.003). The number of patients who required admission to the intensive care unit (ICU) was also markedly lower: 54 from the ERAS® group (25.4%) versus 71 from the control group (44.9%) (p < 0.001). CONCLUSIONS The inclusion of ≥70-year-old adults in the ERAS® programme resulted in a decrease in transfusions, number of erythrocyte concentrates transfused, and number of ICU admissions, along with improved nutritional status.
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Affiliation(s)
- Cristina Martínez-Escribano
- Anaesthesiology, Resuscitation and Therapeutics of Pain, Hospital Universitario de la Ribera, Ctra de Corbera, km 1, 46600 Alzira, Valencia, Spain
- Medical School, Universidad Católica de Valencia San Vicente Mártir, 46001 Valencia, Valencia, Spain
| | - Francisco Arteaga Moreno
- Medical School, Universidad Católica de Valencia San Vicente Mártir, 46001 Valencia, Valencia, Spain
| | - David Cuesta Peredo
- Quality of Care Department, Hospital Universitario de la Ribera, 46600 Alzira, Valencia, Spain
| | | | | | - Francisco J. Tarazona Santabalbina
- Geriatric Medicine Department, Hospital Universitario de la Ribera, 46600 Alzira, Valencia, Spain
- Centro de Investigación Biomédica en Red Fragilidad y Envejecimiento Saludable (CIBERFES), 28029 Madrid, Spain
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Cheong CM, Golder AM, Horgan PG, McMillan DC, Roxburgh CSD. Evaluation of clinical prognostic variables on short-term outcome for colorectal cancer surgery: An overview and minimum dataset. Cancer Treat Res Commun 2022; 31:100544. [PMID: 35248885 DOI: 10.1016/j.ctarc.2022.100544] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/22/2022] [Accepted: 02/27/2022] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Surgery for colorectal cancer is associated with post-operative morbidity and mortality. Multiple systematic reviews have reported on individual factors affecting short-term outcome following surgical resection. This umbrella review aims to synthesize the available evidence on host and other factors associated with short-term post-operative complications. METHODS A comprehensive search identified systematic reviews reporting on short-term outcomes following colorectal cancer surgery using PubMed, Cochrane Database of Systematic Reviews and Web of Science from inception to 8th September 2020. All reported clinicopathological variables were extracted from published systematic reviews. RESULTS The present overview identified multiple validated factors affecting short-term outcomes in patients undergoing colorectal cancer resection. In particular, factors consistently associated with post-operative outcome differed with the type of complication; infective, non-infective or mortality. A minimum dataset was identified for future studies and included pre-operative age, sex, diabetes status, body mass index, body composition (sarcopenia, visceral obesity) and functional status (ASA, frailty). A recommended dataset included antibiotic prophylaxis, iron therapy, blood transfusion, erythropoietin, steroid use, enhance recovery programme and finally potential dataset included measures of the systemic inflammatory response CONCLUSION: A minimum dataset of mandatory, recommended, and potential baseline variables to be included in studies of patients undergoing colorectal cancer resection is proposed. This will maximise the benefit of such study datasets.
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Affiliation(s)
- Chee Mei Cheong
- Academic Unit of Surgery, Glasgow Royal Infirmary, Glasgow United Kingdom.
| | - Allan M Golder
- Academic Unit of Surgery, Glasgow Royal Infirmary, Glasgow United Kingdom
| | - Paul G Horgan
- Academic Unit of Surgery, Glasgow Royal Infirmary, Glasgow United Kingdom
| | - Donald C McMillan
- Academic Unit of Surgery, Glasgow Royal Infirmary, Glasgow United Kingdom
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Liu L, He L, Qiu A, Zhang M. Rapid rehabilitation effect on complications, wound infection, anastomotic leak, obstruction, and hospital re-admission for gastrointestinal surgery subjects: A meta-analysis. Int Wound J 2022; 19:1539-1550. [PMID: 35191597 PMCID: PMC9493214 DOI: 10.1111/iwj.13753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 12/14/2021] [Accepted: 01/06/2022] [Indexed: 11/30/2022] Open
Abstract
We performed a meta‐analysis to evaluate the effect of rapid rehabilitation on the curative effect of gastrointestinal surgery subjects. A systematic literature search up to October 2021 was done and 31 studies included 4448 subjects with gastrointestinal surgery at the start of the study: 2242 of them were provided with rapid rehabilitation and 2206 were standard care. They were reporting relationships about the effect of rapid rehabilitation on the curative effect of gastrointestinal surgery subjects. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) to assess the effect of rapid rehabilitation on the curative effect of gastrointestinal surgery subjects using the dichotomous method with a random‐ or fixed‐effect model. Rapid rehabilitation had significantly lower complications (OR, 0.62; 95% CI, 0.54‐0.71, P < .001) and wound infection (OR, 0.73; 95% CI, 0.55‐0.98, P = .03) compared with standard care in subjects with gastrointestinal surgery. However, rapid rehabilitation had no significant effect on the anastomotic leak (OR, 0.90; 95% CI, 0.66‐1.22, P = .49), obstruction (OR, 0.92; 95% CI, −0.64 to 1.31, P = .65), and hospital re‐admission (OR, 0.78; 95% CI, 0.57‐1.08, P = .13) compared with standard care in subjects with gastrointestinal surgery. Rapid rehabilitation had significantly lower complications and wound infection, and had no significant effect on the anastomotic leak, obstruction, and hospital re‐admission compared with standard care in subjects with gastrointestinal surgery. Further studies are required to validate these findings.
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Affiliation(s)
- Lixiu Liu
- Department of Colorectal Surgery, Harbin Medical University Cancer Hospital, Heilongjiang Haerbin, China
| | - Lihuang He
- Department of Oncology, Affiliated Hospital of Xiangnan University, Chenzhou, China
| | - Afang Qiu
- Department of Internal Medicine, Yantai Qishan hospital, Yantai, China
| | - Min Zhang
- Department of Outpatient, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China (Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital), Chengdu, China
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Zhang X, Li G, Li X, Liang Z, Lan X, Mou T, Xu Z, Fu J, Wu M, Li G, Wang Y. Effect of single-incision plus one port laparoscopic surgery assisted with enhanced recovery after surgery on colorectal cancer: study protocol for a single-arm trial. Transl Cancer Res 2022; 10:5443-5453. [PMID: 35116390 PMCID: PMC8799928 DOI: 10.21037/tcr-21-1361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/05/2021] [Indexed: 12/20/2022]
Abstract
Background Studies have proved that the enhanced recovery after surgery (ERAS) protocol can significantly improve the recovery course of patients during the perioperative period. The application of minimally invasive surgery is a critical component of ERAS protocol. Single-incision plus one port laparoscopic surgery (SILS plus one) could achieve further minimally invasive surgical results than conventional laparoscopic surgery (CLS). The objective of this trial is to evaluate the safety and feasibility of SILS plus one with ERAS protocol in colorectal cancer. Methods This is a prospective, single-center, open-label, single-arm trial. A total of 120 eligible patients with colorectal cancer will receive SILS plus one followed by the ERAS management during the perioperative period. The primary endpoint is postoperative hospital stay. The secondary endpoints include rehabilitative rate of the fourth postoperative day, postoperative medical cost, postoperative pain score, postoperative recovery indexes, inflammatory immune response indexes, compliance with ERAS measures, 6 min postoperative walking test (6MWT), hospital readmissions, and early postoperative complications. Discussion This trial will be the first to evaluate the short-term outcomes of SILS plus one assisted with ERAS protocol for patients with colorectal cancer and will provide valuable clinical evidence on the benefit of the combination of these two techniques, hopefully, to provide patients with more safe, economic, feasible, and rapid surgery and perioperative strategies. Trial Registration Clinical Trial Registry, NCT0426829. Registered February 15, 2020 (https://clinicaltrials.gov/ct2/show/NCT04268290).
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Affiliation(s)
- Xuehua Zhang
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Gaohua Li
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaojing Li
- The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhenye Liang
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaoliang Lan
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tingyu Mou
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhenzhao Xu
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jie Fu
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Mingyi Wu
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Guoxin Li
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yanan Wang
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Garipov MR, Moskalenko AN, Cherepanova EV, Ayupov RT, Feoktistov DV, Tarasov NA, Lyadov VK, Galkin VN. [Fast track recovery protocols for extended pelvic surgery]. Khirurgiia (Mosk) 2022:59-65. [PMID: 36562674 DOI: 10.17116/hirurgia202212259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To compare the immediate results of extended pelvic surgery before and after introduction of standardized fast track surgery (FTS) protocol into routine clinical practice. MATERIAL AND METHODS The study included 111 patients with pelvic tumors who underwent extended pelvic surgery. The control group included 59 patients whose perioperative management implied traditional approaches (2018-2019), the main group - 52 patients with FTS protocol (2020-2021). Age, BMI and ECOG status were similar. In the main group, females (90.4% vs. 74.6%; p=0.046), patients with recurrent (46.2% vs. 22.0%; p=0.009) and complicated tumors (26.9% vs. 11.9%; p=0.054) prevailed. Obstructive resection without anastomosis was less common in the main group (28.8% vs. 47.5%; p=0.068). RESULTS Surgery time was higher (319±125 min vs. 236±79 min, p<0.001) in the main group, but blood loss (238±154 ml vs. 282±150 ml, p=0.029) and incidence of blood transfusions (23.1% vs. 42.4%, p=0.043) were lower. Moreover, complications (36.6% vs. 54.3%; p=0.086), mild complications (Clavien-Dindo class I-II) (11.6% vs. 28.8%; p=0.034) and local infectious complications (19.2% vs. 42.4%; p=0.009) were less common in the main group. Two patients died in the control group due to sepsis following colonic anastomosis and bladder suture failure, respectively. Postoperative hospital-stay was similar (14±9.1 days vs. 14.4±9 days; p=0.89). CONCLUSION FTS protocol is possible and safe in patients with locally advanced and recurrent malignant pelvic tumors. This approach reduces blood loss, the number of blood transfusions and risk of postoperative infections.
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Affiliation(s)
- M R Garipov
- City Clinical Oncology Hospital No. 1, Moscow, Russia
| | | | | | - R T Ayupov
- Republican Clinical Oncology Dispensary, Ufa, Russia
| | | | - N A Tarasov
- Republican Clinical Oncology Dispensary, Ufa, Russia
| | - V K Lyadov
- City Clinical Oncology Hospital No. 1, Moscow, Russia
| | - V N Galkin
- City Clinical Oncology Hospital No. 1, Moscow, Russia
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Abstract
INTRODUCTION Perioperative enhanced recovery after surgery (ERAS) concepts or fast-track are supposed to accelerate recovery after surgery, reduce postoperative complications and shorten the hospital stay when compared to traditional perioperative treatment. METHODS Electronic search of the PubMed database to identify systematic reviews with meta-analysis (SR) comparing ERAS and traditional treatment. RESULTS The presented SR investigated 70 randomized controlled studies (RCT) with 12,986 patients and 93 non-RCT (24,335 patients) concerning abdominal, thoracic and vascular as well as orthopedic surgery. The complication rates were decreased under ERAS following colorectal esophageal, liver and pulmonary resections as well as after implantation of hip endoprostheses. Pulmonary complications were reduced after ERAS esophageal, gastric and pulmonary resections. The first bowel movements occurred earlier after ERAS colorectal resections and delayed gastric emptying was less often observed after ERAS pancreatic resection. Following ERAS fast-track esophageal resection, anastomotic leakage was diagnosed less often as well as surgical complications after ERAS pulmonary resection. The ERAS in all studies concerning orthopedic surgery and trials investigating implantation of a hip endoprosthesis or knee endoprosthesis reduced the risk for postoperative blood transfusions. Regardless of the type of surgery, ERAS shortened hospital stay without increasing readmissions. CONCLUSION Numerous clinical trials have confirmed that ERAS reduces postoperative morbidity, shortens hospital stay and accelerates recovery without increasing readmission rates following most surgical operations.
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Targa S, Portinari M, Ascanelli S, Camerani S, Verri M, Volta CA, Anania G, Feo CV. Enhanced Recovery Program in Laparoscopic Colorectal Surgery: An Observational Controlled Trial. J Laparoendosc Adv Surg Tech A 2020; 31:363-370. [PMID: 33164667 DOI: 10.1089/lap.2020.0716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Most of the evidence for enhanced recovery programs (ERPs) in colorectal surgery relies on nonrandomized studies with control groups either historical or operated on at different facilities. The aim of this study was to investigate ERP in coeval groups admitted in different wards at the same hospital. Materials and Methods: A prospective cohort of consecutive patients (n = 100) undergoing elective laparoscopic colorectal resection completing a standardized ERP (ERP group) was compared with patients (n = 100) operated with traditional perioperative care in the same period at the same institution (non-ERP group). The two groups were located in separate wards and shared the same anesthesiologists. The exclusion criteria were: >80 years old, American Society of Anesthesia (ASA) IV, metastatic disease, and inflammatory bowel disease. The primary outcome was hospital length of stay (LoS), used as a proxy of functional recovery. Secondary outcomes included: postoperative complications, readmission rate, mortality, and protocol adherence. Results: The ERP group protocol adherence was 81%. The LoS was significantly reduced in the ERP group (4 versus 7 days). The number of 30-day postoperative complications was lower in the ERP group (P < .001). No increase was found in 30-day readmission or mortality. Conventional perioperative protocol was the only predictor of any postoperative complication and, together with male sex and age 65-74 years old, was the only factor associated with prolonged LoS. Conclusion: Implementing a colorectal ERP is feasible, safe, and efficient for functional recovery, but high protocol adherence is needed. Following traditional perioperative care is associated with more postoperative complications and prolonged LoS.
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Affiliation(s)
- Simone Targa
- Unit of General Surgery, Department of Surgery, S. Anna University Hospital of Ferrara, Ferrara, Italy.,Department of Morphology, Surgery, and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Mattia Portinari
- Unit of General Surgery, Department of Surgery, S. Anna University Hospital of Ferrara, Ferrara, Italy.,Department of Morphology, Surgery, and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Simona Ascanelli
- Unit of General Surgery, Department of Surgery, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Stefano Camerani
- Unit of Anaesthesia, Department of Emergency, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Marco Verri
- Unit of Anaesthesia, Department of Emergency, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Carlo Alberto Volta
- Department of Morphology, Surgery, and Experimental Medicine, University of Ferrara, Ferrara, Italy.,Unit of Anaesthesia, Department of Emergency, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Gabriele Anania
- Unit of General Surgery, Department of Surgery, S. Anna University Hospital of Ferrara, Ferrara, Italy.,Department of Morphology, Surgery, and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Carlo V Feo
- Unit of General Surgery, Department of Surgery, S. Anna University Hospital of Ferrara, Ferrara, Italy.,Department of Morphology, Surgery, and Experimental Medicine, University of Ferrara, Ferrara, Italy
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Yang J, He Y, Jiang L, Li K. Colorectal patients' readiness for hospital discharge following management of enhanced recovery after surgery pathway: A cross-sectional study from China. Medicine (Baltimore) 2020; 99:e19219. [PMID: 32080116 PMCID: PMC7034666 DOI: 10.1097/md.0000000000019219] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The aim of this study was to ascertain the status quo of perceived readiness for hospital discharge in colorectal cancer patients who underwent enhanced recovery pathway and identify the variables that affect patients' perceptions about their readiness for discharge.A cross-sectional survey was conducted in West China Hospital, Sichuan University. The Readiness for Hospital Discharge Scale and the Quality of Discharge Teaching Scale were delivered to 130 colorectal cancer (CRC) patients who underwent enhanced recovery pathway. Data collection was carried out 4 hours before discharge.The total score of readiness for hospital discharge was 149.86 ± 33.65. The multiple linear regression analysis revealed that the quality of discharge teaching, discharge to a rehabilitative institution were associated with the readiness for hospital discharge.The level of CRC patients' readiness for hospital discharge needs to be improved. Medical staff should improve the quality of discharge guidance and pay more attention to patients transferred to rehabilitation institutions when they leave hospital.
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Affiliation(s)
- Jie Yang
- Department of Gastrointestinal Surgery, West China Hospital
| | - Yuhua He
- Department of Gastrointestinal Surgery, West China Hospital
| | - Lili Jiang
- Department of Gastrointestinal Surgery, West China Hospital
| | - Ka Li
- West China School of Nursing, Sichuan University, Chengdu 610041, PR China
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Roh CK, Son SY, Lee SY, Hur H, Han SU. Clinical pathway for enhanced recovery after surgery for gastric cancer: A prospective single-center phase II clinical trial for safety and efficacy. J Surg Oncol 2020; 121:662-669. [PMID: 31930513 DOI: 10.1002/jso.25837] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 01/02/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND We aimed to evaluate the safety and efficacy of a clinical pathway (CP) for enhanced recovery after surgery (ERAS) in gastric cancer patients, including early oral feeding and discharge on postoperative day 4. METHODS We performed a prospective, single-center, phase II clinical trial. Based on proposed indications for an ERAS CP in our retrospective study, we enrolled 133 patients younger than 65 years who were undergoing minimally invasive subtotal gastrectomy. The primary endpoint was the ERAS CP completion rate. Secondary endpoints included complication, mortality, hospital stay, and readmission. RESULTS Among 133 patients, six patients were dropped out from this study. The ERAS CP completion rate (77.2%, 98 of 127) was comparable to the historical control group that completed a conventional CP (85.4%, P = .085). The postoperative complication incidence (13.4%, 15 of 127) was also similar to that of the conventional CP group (9.5%, P = .174). We identified reduced hospital stays (4.7 ± 1.3 vs 7.2±2.3 days; P < .001) and lower hospital costs ($7771 vs 8539; P < .001) in the ERAS CP group compared with the conventional CP group. CONCLUSIONS An ERAS CP can be safely and effectively adopted for patients with gastric cancer without increasing the complication rate and could shorten hospital stays. TRIAL REGISTRATION ClinicalTrials.gov (NCT01642953).
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Affiliation(s)
- Chul Kyu Roh
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Sang-Yong Son
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Sook Young Lee
- Department of Anesthesiology, Ajou University School of Medicine, Suwon, Korea
| | - Hoon Hur
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Sang-Uk Han
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
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Implementation of an Enhanced Recovery Protocol Is Associated With On-Time Initiation of Adjuvant Chemotherapy in Colorectal Cancer. Dis Colon Rectum 2019; 62:1305-1315. [PMID: 31567924 PMCID: PMC6785395 DOI: 10.1097/dcr.0000000000001486] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Delayed initiation of adjuvant chemotherapy negatively impacts long-term survival in patients with colorectal cancer. Colorectal enhanced recovery protocols result in decreased complications and length of stay; however, the impact of enhanced recovery on the timing of adjuvant chemotherapy remains unknown. OBJECTIVE This study aimed to identify factors associated with on-time delivery of adjuvant chemotherapy after colorectal cancer surgery, hypothesizing that implementation of an enhanced recovery protocol would result in more patients receiving on-time chemotherapy. DESIGN This was a retrospective cohort study comparing the rate of on-time adjuvant chemotherapy delivery after colorectal cancer resection before and after implementation of an enhanced recovery protocol. SETTINGS The study was conducted at a large academic medical center. PATIENTS All of the patients who underwent nonemergent colorectal cancer resections for curative intent from January 2010 to June 2017, excluding patients who had no indication for adjuvant chemotherapy, had received preoperative systemic chemotherapy, or did not have medical oncology records available were included. MAIN OUTCOME MEASURES Patients before and enhanced recovery were compared, with the rate of on-time adjuvant chemotherapy delivery as the primary outcome. Adjuvant chemotherapy delivery was considered on time if initiated ≤8 weeks postoperatively, and treatment was considered delayed or omitted if initiated >8 weeks postoperatively (delayed) or never received (omitted). Multivariable logistic regression identified predictors of on-time chemotherapy delivery. RESULTS A total of 363 patients met inclusion criteria, with 189 patients (52.1%) undergoing surgery after enhanced recovery implementation. Groups differed in laparoscopic approach and median procedure duration, both of which were higher after enhanced recovery. Significantly more patients received on-time chemotherapy after enhanced recovery implementation (p = 0.007). Enhanced recovery was an independent predictor of on-time adjuvant chemotherapy (p = 0.014). LIMITATIONS The study was limited by its retrospective and nonrandomized before-and-after design. CONCLUSIONS Enhanced recovery was associated with receiving on-time adjuvant chemotherapy. As prompt initiation of adjuvant chemotherapy improves survival in colorectal cancer, future investigation of long-term oncologic outcomes is necessary to evaluate the potential impact of enhanced recovery on survival. See Video Abstract at http://links.lww.com/DCR/B21. LA IMPLEMENTACIÓN DE UN PROTOCOLO DE RECUPERACIÓN ACELERADA SE ASOCIA CON EL INICIO A TIEMPO DE QUIMIOTERAPIA ADYUVANTE EN CÁNCER COLORRECTAL:: El inicio tardío de la quimioterapia adyuvante afecta negativamente la supervivencia a largo plazo en pacientes con cáncer colorrectal. Los protocolos de recuperación acelerada colorrectales dan lugar a una disminución de las complicaciones y la duración de estancia hospitalaria; sin embargo, el impacto de la recuperación acelerada en el momento de inicio de quimioterapia adyuvante sigue siendo desconocido.Este estudio tuvo como objetivo identificar los factores asociados con la administración a tiempo de la quimioterapia adyuvante después de la cirugía de cáncer colorrectal, con la hipótesis de que la implementación de un protocolo de recuperación acelerada daría lugar a que más pacientes reciban quimioterapia a tiempo.Estudio de cohorte retrospectivo que compara la tasa de administración de quimioterapia adyuvante a tiempo después de la resección del cáncer colorrectal antes y después de la implementación de un protocolo de recuperación acelerada.Centro médico académico grande.Todos los pacientes que se sometieron a resecciones de cáncer colorrectal no emergentes con intención curativa desde enero de 2010 hasta junio de 2017, excluyendo a los pacientes que no tenían indicación de quimioterapia adyuvante, que recibieron quimioterapia sistémica preoperatoria o no tenían registros médicos de oncología disponibles.Los pacientes se compararon antes y después de la implementación de la recuperación acelerada, con la tasa de administración de quimioterapia adyuvante a tiempo como el resultado primario. La administración de quimioterapia adyuvante se consideró a tiempo si se inició ≤8 semanas después de la operación, y el tratamiento se consideró retrasado / omitido si se inició> 8 semanas después de la operación (retrasado) o nunca fue recibido (omitido). La regresión logística multivariable identificó predictores de administración de quimioterapia a tiempo.363 pacientes cumplieron con los criterios de inclusión, con 189 (52.1%) pacientes sometidos a cirugía después de la implementación de recuperación acelerada. Los grupos difirieron en el abordaje laparoscópico y la duración media del procedimiento; ambos factores fueron mayores después de la recuperación acelerada. Significativamente más pacientes recibieron quimioterapia a tiempo después de la implementación de recuperación acelerada (p = 0.007). La recuperación acelerada fue un factor predictivo independiente de quimioterapia adyuvante a tiempo (p = 0.014).Diseño retrospectivo, tipo ¨antes y después¨ no aleatorizado.La recuperación acelerada se asoció con la recepción de quimioterapia adyuvante a tiempo. Debido a que el inicio rápido de la quimioterapia adyuvante mejora la supervivencia en el cáncer colorrectal, en el futuro será necesario investigar los resultados oncológicos a largo plazo para evaluar el impacto potencial de la recuperación acelerada en la supervivencia. Vea el Resumen en Video en http://links.lww.com/DCR/B21.
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Ni X, Jia D, Guo Y, Sun X, Suo J. The efficacy and safety of enhanced recovery after surgery (ERAS) program in laparoscopic digestive system surgery: A meta-analysis of randomized controlled trials. Int J Surg 2019; 69:108-115. [PMID: 31376511 DOI: 10.1016/j.ijsu.2019.07.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 07/20/2019] [Accepted: 07/25/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The enhanced recovery after surgery (ERAS) program has been applied to a variety of surgeries. However, the efficacy and safety of the ERAS program in laparoscopic digestive system surgery remain unclear. We conducted a meta-analysis to evaluate the ERAS program and traditional perioperative care (TPC) in laparoscopic digestive system surgery. METHODS We searched five electronic databases for eligible trials. STATA version 14.0 and Revman version 5.3 were used to analyze the data. The results were presented and analyzed by weighted mean difference (WMD) and risk ratio (RR) at their 95% confidence interval (CI). RESULTS Twenty-five randomized controlled trials (RCTs) of 2219 patients were included in our meta-analysis. The results revealed that the postoperative hospital stay (PHS) (WMD: 2.13 day, 95% CI: 2.56 to -1.70, p = 0.000), time to first flatus (WMD: 12.68 h, 95% CI: 15.95 to -9.41, p = 0.000), and time to defecation (WMD: 34.35 h, 95% CI: 46.82 to -21.88, p = 0.000) were significantly shorter in the ERAS group compared to the TPC group. Additionally, the overall postoperative complication rate (RR: 0.66, 95% CI: 0.49 to 0.88, p = 0.000) was markedly lower in patients using the ERAS program. CONCLUSION The results indicated that the ERAS program is associated with faster postoperative rehabilitation, shorter PHS, and better postoperative complication rates. The use of the ERAS program for laparoscopic digestive system surgery is more effective and safe than TPC, and it should be recommended. (PROSPERO registration number:CRD42018118551).
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Affiliation(s)
- Xiaofei Ni
- Department of Gastrointestinal Surgery, First Hospital of Jilin University, Changchun, Jilin Province, China.
| | - Dan Jia
- Department of Third Operation Room, First Hospital of Jilin University, Changchun, Jilin Province, China.
| | - Yuchen Guo
- Department of Gastrointestinal Surgery, First Hospital of Jilin University, Changchun, Jilin Province, China.
| | - Xuan Sun
- Department of Gastrointestinal Surgery, First Hospital of Jilin University, Changchun, Jilin Province, China.
| | - Jian Suo
- Department of Gastrointestinal Surgery, First Hospital of Jilin University, Changchun, Jilin Province, China.
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Is the Enhanced Recovery After Surgery (ERAS) Program Effective and Safe in Laparoscopic Colorectal Cancer Surgery? A Meta-Analysis of Randomized Controlled Trials. J Gastrointest Surg 2019; 23:1502-1512. [PMID: 30859422 DOI: 10.1007/s11605-019-04170-8] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 02/12/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) program has shown a few advantages in colorectal cancer surgery. However, the effectiveness of the ERAS program in laparoscopic colorectal cancer surgery is still unclear. We performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of ERAS program in laparoscopic colorectal cancer surgery compared with traditional perioperative care (TC). METHODS PubMed, EMBASE, Web of Science, The Cochrane Library, and ClinicalTrials.gov were searched for eligible RCTs comparing ERAS program with TC in laparoscopic colorectal cancer surgery. The main outcomes included the average length of postoperative hospital stay (PHS), time to first flatus and defecation, overall complication, readmission, and mortality rates were undertaken. RESULTS Thirteen RCTs involving 1298 patients were included in our study (639 in ERAS group and 659 in TC group). ERAS group had shorter average length of PHS (weighted mean difference [WMD] - 2.00 day, 95% confidence interval [CI] - 2.52 to - 1.48, p = 0.00), time to first flatus (WMD - 12.18 h, 95%CI - 16.69 to - 7.67, p = 0.00), and time to first defecation (WMD - 32.93 h, 95%CI - 45.36 to - 20.50, p = 0.00) than TC group. In addition, the overall complication rates (risk ratio [RR] 0.59, 95%CI 0.40 to 0.86, p < 0.01) were significantly lower in ERAS group compared with TC group. CONCLUSIONS The results indicated that ERAS program is a much better effective and safe protocol for laparoscopic colorectal cancer surgery compared with TC. Hence, ERAS program should be recommended in laparoscopic colorectal cancer surgery.
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Garmpis N, Dimitroulis D, Garmpi A, Diamantis E, Spartalis E, Schizas D, Angelou A, Margonis GA, Farmaki P, Antoniou EA, Mantas D, Markatos K, Kontzoglou K, Damaskos C. Enhanced Recovery After Surgery: Is It Time to Change Our Strategy Regarding Laparoscopic Colectomy? In Vivo 2019; 33:669-674. [PMID: 31028183 PMCID: PMC6559898 DOI: 10.21873/invivo.11525] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 02/10/2019] [Accepted: 02/13/2019] [Indexed: 02/08/2023]
Abstract
Enhanced recovery after surgery or 'fast-track' methods are evidence-based protocols designed to standardize post-operative medical care, improve patient outcomes, promote early recovery, and reduce healthcare expenditure. Fast-track surgery is a multifunctional concept involving pre-, peri- and post-operative measures aiming to reduce the length of hospital stay and morbidity and complication rates, following elective abdominal surgery. Through the optimization of peri-operative care and the recovery process in adherence to these fast-track protocols, improved outcomes are reached, surgical trauma and post-operative stress are reduced, with less surgical pain, reduced complications, and shorter length of hospital stay. Fast-track care requires a multidisciplinary collaboration of all healthcare professionals, as well as a high rate of protocol compliance and a good organizational structure. Despite the existing evidence of the benefits of fast-track protocols in a variety of surgical procedures and the similar outcomes of laparoscopic colonic surgery compared to open surgery, clear evidence of the benefits of fast-track care after laparoscopic colonic surgery is yet to be clearly demonstrated.
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Affiliation(s)
- Nikolaos Garmpis
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Dimitroulis
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Anna Garmpi
- Internal Medicine Department, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Eleftherios Spartalis
- N.S. Christeas Laboratory of Experimental Surgery and Surgical Research, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Schizas
- First Department of Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Paraskevi Farmaki
- First Department of Pediatrics, Agia Sofia Children's Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios A Antoniou
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Mantas
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Konstantinos Kontzoglou
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Christos Damaskos
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Beloeil H, Slim K. Sustainability of anaesthesia components of an enhanced recovery program (ERP) in colorectal and orthopaedics surgery. Anaesth Crit Care Pain Med 2019; 38:25-28. [DOI: 10.1016/j.accpm.2018.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 01/29/2018] [Accepted: 01/31/2018] [Indexed: 11/29/2022]
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Martviset P, Chaijaroenkul W, Muhamad P, Na-Bangchang K. Bioactive constituents isolated from Atractylodes lancea (Thunb.) DC. rhizome exhibit synergistic effect against cholangiocarcinoma cell. J Exp Pharmacol 2018; 10:59-64. [PMID: 30498376 PMCID: PMC6207387 DOI: 10.2147/jep.s177032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Cholangiocarcinoma (CCA) is the primary type of bile duct cancer with high morbidity and mortality, particularly in patients with advanced-stage disease. Treatment of CCA remains unsatisfactory due to the lack of sensitive and specific diagnostic tool for early detection as well as effective chemotherapeutics. Purpose To investigate cytotoxic interactions between the three major constituents of the rhizomes of Atractylodes lancea (Thunb.) DC., ie, β-eudesmol (BE), atractylodin (AT), and hinesol (HS), against CCA cell line. Methods Cytotoxic activities against the human CCA cells CL-6 of the dual (BE:AT, BE:HS, and AT:HS) and triple (BE:AT:HS) combinations were evaluated using MTT assay. The cytotoxic interaction of each dual combination was assessed at five concentration ratios (10:0, 7:3, 5:5, 3:7, and 0:10) using isobologram analysis. For triple combination, the concentration ratio used in the experiment was 1:1.5:2.5 (BE:AT:HS) and analysis of the interaction was performed using polygonogram analysis at the concentrations that inhibit cell growth by 50% and 90%, respectively. Results The BE:AT combination produced the additive effect with sum fractional inhibitory concentration of 0.967±0.02 (mean ± SD). The BE:HS and AT:HS combinations produced a synergistic effect with sum fractional inhibitory concentrations of 0.685±0.08 and 0.767±0.09, respectively. The mixture of the three compounds produced synergistic interaction with combination index values of 0.519±0.10 and 0.65±0.17 (mean ± SD) at the concentrations that inhibit cell growth at the 50% and 90% leveled, respectively. Conclusion Results obtained would guide further development of Atractylodes lancea (Thunb.) DC. as potential anti-CCA chemotherapeutics concerning the appropriate pharmaceutical dosage form.
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Affiliation(s)
- Pongsakorn Martviset
- Center of Excellence in Molecular Biology and Pharmacology of Malaria and Cholangiocarcinoma, Chulabhorn International College of Medicine, Thammasat University, Pathumthani, Thailand, .,School of Preclinic, Institute of Science, Suranaree University of Technology, Nakhon Ratchasima, Thailand
| | - Wanna Chaijaroenkul
- Center of Excellence in Molecular Biology and Pharmacology of Malaria and Cholangiocarcinoma, Chulabhorn International College of Medicine, Thammasat University, Pathumthani, Thailand, .,Graduate Program in Bioclinical Sciences, Chulabhorn International College of Medicine, Thammasat University, Pathumthani, Thailand,
| | - Phunuch Muhamad
- Center of Excellence in Molecular Biology and Pharmacology of Malaria and Cholangiocarcinoma, Chulabhorn International College of Medicine, Thammasat University, Pathumthani, Thailand, .,Drug Discovery and Development Center, Thammasat University, Pathumthani, Thailand
| | - Kesara Na-Bangchang
- Center of Excellence in Molecular Biology and Pharmacology of Malaria and Cholangiocarcinoma, Chulabhorn International College of Medicine, Thammasat University, Pathumthani, Thailand, .,Graduate Program in Bioclinical Sciences, Chulabhorn International College of Medicine, Thammasat University, Pathumthani, Thailand, .,WHO-TDR Clinical Coordination and Training Center in Asia and Western Pacific, Pathumthani, Thailand,
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Greer NL, Gunnar WP, Dahm P, Lee AE, MacDonald R, Shaukat A, Sultan S, Wilt TJ. Enhanced Recovery Protocols for Adults Undergoing Colorectal Surgery: A Systematic Review and Meta-analysis. Dis Colon Rectum 2018; 61:1108-1118. [PMID: 30086061 DOI: 10.1097/dcr.0000000000001160] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Enhanced surgical recovery protocols are designed to reduce hospital length of stay and health care costs. OBJECTIVE This study aims to systematically review and summarize evidence from randomized and controlled clinical trials comparing enhanced recovery protocols versus usual care in adults undergoing elective colorectal surgery with emphasis on recent trials, protocol components, and subgroups for surgical approach and colorectal condition. DATA SOURCES MEDLINE from 2011 to July 2017; reference lists of existing systematic reviews and included studies were reviewed to identify all eligible trials published before 2011. STUDY SELECTION English language trials comparing a protocol of preadmission, preoperative, intraoperative, and postoperative components with usual care in adults undergoing elective colorectal surgery were selected. INTERVENTION The enhanced recovery protocol for colorectal surgery was investigated. MAIN OUTCOME MEASURES Length of stay, perioperative morbidity, mortality, readmission within 30 days, and surgical site infection were the primary outcomes measured. RESULTS Twenty-five trials of open or laparoscopic surgery for cancer or noncancer conditions were included. Enhanced recovery protocols consisted of 4 to 18 components. Few studies fully described the various components. Length of stay (mean reduction, 2.6 days; 95% CI, -3.2 to -2.0) and risk of overall perioperative morbidity (risk ratio, 0.66; 95% CI, 0.54-0.80) were lower in enhanced recovery protocol groups than in usual care groups (moderate-quality evidence). All-cause mortality (rare), readmissions, and surgical site infection rates were similar between protocol groups (low-quality evidence). In predefined subgroup analyses, findings did not vary by surgical approach (open vs laparoscopic) or colorectal condition. LIMITATIONS Protocols varied across studies and little information was provided regarding compliance with, or implementation of, specific protocol components. CONCLUSIONS Enhanced recovery protocols for adults undergoing colorectal surgery improve patient outcomes with no increase in adverse events. Evidence was insufficient regarding which components, or component combinations, are key to improving patient outcomes. PROSPERO registration number: CRD42017067991.
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Affiliation(s)
- Nancy L Greer
- Minneapolis VA Evidence-based Synthesis Program Center and the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - William P Gunnar
- Department of Veteran Affairs, Veterans Health Administration, Washington DC, and The George Washington University, Washington DC
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System and Department of Urology, University of Minnesota, Minneapolis, Minnesota
| | - Alice E Lee
- Specialty Care - Colon and Rectal Surgery, Minneapolis VA Health Care System, and Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Roderick MacDonald
- Minneapolis VA Evidence-based Synthesis Program Center and the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Aasma Shaukat
- Minneapolis VA Evidence-based Synthesis Program Center and the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota.,Gastroenterology Section, Minneapolis VA Health Care System and Division of Gastroenterology, University of Minnesota, Minneapolis, Minnesota
| | - Shahnaz Sultan
- Minneapolis VA Evidence-based Synthesis Program Center and the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota.,Gastroenterology Section, Minneapolis VA Health Care System and Division of Gastroenterology, University of Minnesota, Minneapolis, Minnesota
| | - Timothy J Wilt
- Minneapolis VA Evidence-based Synthesis Program Center and the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota.,Section of General Internal Medicine, Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota
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Hassinger TE, Stukenborg GJ, Turrentine FE, Thiele RH, Sarosiek BM, McMurry TL, Friel CM, Hedrick TL. Acute Kidney Injury in the Age of Enhanced Recovery Protocols. Dis Colon Rectum 2018; 61:946-954. [PMID: 29994959 PMCID: PMC6042978 DOI: 10.1097/dcr.0000000000001059] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Acute kidney injury is a prevalent complication after abdominal surgery. With increasing adoption of enhanced recovery protocols, concern exists for concomitant increase in acute kidney injury. OBJECTIVE This study evaluated effects of enhanced recovery on acute kidney injury through identification of risk factors. DESIGN This was a retrospective cohort study comparing acute kidney injury rates before and after implementation of enhanced recovery protocol. SETTINGS The study was conducted at a large academic medical center. PATIENTS All of the patients undergoing elective colorectal surgery between 2010 and 2016, excluding patients with stage 5 chronic kidney disease, were included. MAIN OUTCOME MEASURES Patients before and after enhanced recovery implementation were compared, with rate of acute kidney injury as the primary outcome. Acute kidney injury was defined as a rise in serum creatinine ≥1.5 times baseline within 30 days of surgery. Multivariable logistic regression identified risk factors for acute kidney injury. RESULTS A total of 900 cases were identified, including 461 before and 439 after enhanced recovery; 114 cases were complicated by acute kidney injury, including 11.93% of patients before and 13.44% after implementation of enhanced recovery (p = 0.50). Five patients required hemodialysis, with 2 cases after protocol implementation. Multivariable logistic regression identified hypertension, functional status, ureteral stents, nonsteroidal anti-inflammatory drugs, operative time >200 minutes, and increased intravenous fluid administration on postoperative day 1 as predictors of acute kidney injury. Laparoscopic surgery decreased the risk of acute kidney injury. The enhanced recovery protocol was not independently associated with acute kidney injury. LIMITATIONS The study was limited by its retrospective and nonrandomized before-and-after design. CONCLUSIONS No difference in rates of acute kidney injury was detected before and after implementation of a colorectal enhanced recovery protocol. Independent predictors of acute kidney injury were identified and could be used to alter the protocol in high-risk patients. Future study is needed to determine whether protocol modifications will further decrease rates of acute kidney injury in this population. See Video Abstract at http://links.lww.com/DCR/A568.
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Affiliation(s)
- Taryn E. Hassinger
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - George J. Stukenborg
- School of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Florence E. Turrentine
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Robert H. Thiele
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Bethany M. Sarosiek
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Timothy L. McMurry
- School of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Charles M. Friel
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Traci L. Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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Acupuncture and Related Therapies for Treatment of Postoperative Ileus in Colorectal Cancer: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2018; 2018:3178472. [PMID: 30151019 PMCID: PMC6087601 DOI: 10.1155/2018/3178472] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 06/19/2018] [Indexed: 01/29/2023]
Abstract
Delays in recovery of intestinal function following abdominal surgery are associated with longer hospital stays, increased postoperative complications, and higher costs to the health care system. Studies of acupuncture for postoperative ileus and other postoperative issues have reported improvements. This systematic review and meta-analysis aimed to assess whether acupuncture assisted recovery following surgery for colorectal cancer (CRC). Randomized controlled trials (RCTs) were identified from major English and Chinese language biomedical databases. Participants (aged 18 years plus) had received surgical resection for CRC. 22 studies (1,628 participants) were included. Five were sham-controlled. Outcomes included gastrointestinal function recovery (21 studies), recovery of urinary function (1 study), postoperative abdominal distension (3 studies), and quality of life (1 study). Meta-analyses found significant reductions in time to first bowel sounds, first flatus, and first defecation in both the sham-controlled and nonblinded studies. These results suggested that the addition of acupuncture following CRC surgery improved recovery of gastrointestinal function based on four blinded good quality RCTs (281 participants) and 17 nonblinded lower quality RCTs (1,265 participants). The best available evidence was for interventions that included electroacupuncture at the point ST36 Zusanli and there is supporting evidence for other types of acupuncture therapies that involve stimulation of this point. This review is registered with the following: systematic review registration in PROSPERO: CRD42017079590.
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Yang J, Xiao J, Feng J, Li K. One-year Unplanned Readmission After Colorectal Cancer Surgery in Western China. J INVEST SURG 2018; 32:602-606. [PMID: 29851535 DOI: 10.1080/08941939.2018.1443176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Purpose: Readmissions are common after colorectal cancer surgery. There are limited data related one-year unplanned readmission after colorectal cancer surgery. The aim of this study was to ascertain the incidence rate of unplanned readmission in Western China, identify causes and risk factors of one-year unplanned readmission (UR) in patients who underwent enhanced recovery pathways for colorectal cancer (CRC) surgery. Materials and Methods: A retrospective study using a CRC surgery database of patients treated in West China Hospital was performed. Patients who underwent enhanced recovery pathways for colorectal cancer surgery between January 2013 and May 2016 were investigated. The postoperative follow-up data were all routinely recorded for up to one year or more, the one-year unplanned readmission rate after initial discharge and major reasons for UR were recorded. Multivariate logistic regression analyses was used to identify risk factors of UR. Results: A total of 446 patients were included, with 18.6% of patients readmitted. In a multivariable analysis, preoperative comorbidity was associated with the largest risk of readmission (odds ratio, 2.91[95% CI, 1.32- 6.99]). The main reason of readmission within 30 days after discharge was wound bleeding or infection. While intestinal obstruction was the major cause for readmission after 3 months of discharge. Conclusions: One-year unplanned readmission occurs frequently after CRC in Western China and is strongly associated with preoperative comorbidity. Attention should be paid to wound healing at the early stage of discharge, and bowel obstruction 3 months after discharge.
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Affiliation(s)
- Jie Yang
- Department of Gastrointestinal, West China Hospital, Sichuan University , Sichuan , P.R.China
| | - Jun Xiao
- Intensive Care Unit, West China Hospital, Sichuan University , Sichuan , P.R.China
| | - Jinhua Feng
- Department of Gastrointestinal, West China Hospital, Sichuan University , Sichuan , P.R.China
| | - Ka Li
- Department of Gastrointestinal, West China Hospital, Sichuan University , Sichuan , P.R.China
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Hewitt J, Marke M, Honeyman C, Huf S, Lai A, Dong A, Wright T, Blake S, Fallaize R, Hughes JL, Pearce L, McCarthy K. Cognitive impairment in older patients undergoing colorectal surgery. Scott Med J 2018; 63:11-15. [DOI: 10.1177/0036933017750988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background With increasing numbers of older people being referred for elective colorectal surgery, cognitive impairment is likely to be present and affect many aspects of the surgical pathway. This study is aimed to determine the prevalence of cognitive impairment and assess it against surgical outcomes. Methods The Montreal Cognitive Assessment (MoCA) was carried out in patients aged more than 65 years. We recorded demographic information. Data were collected on length of hospital stay, complications and 30-day mortality. Results There were 101 patients assessed, median age was 74 years (interquartile range = 68–80), 54 (53.5%) were women. In total, 58 people (57.4%) ‘failed’ the Montreal Cognitive Assessment test (score ≤ 25). There were two deaths (3.4%) within 30 days of surgery in the abnormal Montreal Cognitive Assessment group and none in the normal group. Twenty-nine (28.7%) people experienced a complication. The percentage of patients with complications was higher in the group with normal Montreal Cognitive Assessment (41.9%) than abnormal Montreal Cognitive Assessment (19.9%) ( p = 0.01) and the severity of those complications were greater (chi-squared for trend p = 0.01). The length of stay was longer in people with an abnormal Montreal Cognitive Assessment (mean 8.1 days vs. 5.8 days, p = 0.03). Conclusion Cognitive impairment was common, which has implications for informed consent. Cognitive impairment was associated with less postoperative complications but a longer length of hospital stay.
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Affiliation(s)
- Jonathan Hewitt
- Division of Population Medicine, Cardiff University, University Hospital Wales, UK
| | | | | | - Simon Huf
- North Bristol NHS Trust, Bristol, UK
| | - Aida Lai
- North Bristol NHS Trust, Bristol, UK
| | - Anni Dong
- North Bristol NHS Trust, Bristol, UK
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Li Z, Wang Q, Li B, Bai B, Zhao Q. Influence of enhanced recovery after surgery programs on laparoscopy-assisted gastrectomy for gastric cancer: a systematic review and meta-analysis of randomized control trials. World J Surg Oncol 2017; 15:207. [PMID: 29169362 PMCID: PMC5701340 DOI: 10.1186/s12957-017-1271-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/15/2017] [Indexed: 12/11/2022] Open
Abstract
Background This meta-analysis is aimed to evaluate the feasibility and safety of enhanced recovery after surgery (ERAS) programs in gastric cancer patients undergoing laparoscopy-assisted gastrectomy (LAG). Methods We performed a meta-analysis of randomized control trials involving either enhanced recovery after surgery (ERAS)/fast track surgery (FTS) for patients underwent LAG. EMBASE, Pubmed, Web of science, and Cochrane Library were searched. Primary outcomes included the length of postoperative hospital stay, cost of hospitalization, postoperative complications, and readmission rate. Results Five randomized control trials were eligible for analysis. There were 159 cases in FTS group and 156 cases in conventional care group. Compared with conventional care group, FTS group relates to shorter postoperative hospital stay (WMD − 2.16; 95% CI − 3.05 to − 1.26, P < 0.00001), less cost of hospitalization (WMD − 4.72; 95% CI − 6.88 to − 2.55, P < 0.00001), shorter time to first flatus (WMD − 9.72; 95% CI − 13.75 to − 5.81, P < 0.00001), lower level of C-reaction protein on postoperative days 3 or 4 (WMD − 19.66; 95% CI − 28.98 to − 10.34, P < 0.00001), higher level of albumin on postoperative day 4 (WMD 3.45; 95% CI 2.01 to 4.89, P < 0.00001), and postoperative day 7 (WMD 5.63; 95% CI 1.01 to 10.24, P = 0.02). Regarding postoperative complications, no significant differences were observed between FTS group and conventional care group (OR 0.63, 95% CI 0.37 to 1.09, P = 0.10). The readmission rate of FTS group was comparable to conventional care group (WMD 3.14; 95% CI 0.12 to 81.35, P = 0.49). Conclusions Among patients undergoing LAG, FTS is associated with shorter postoperative hospital stay, rapid postoperative recovery, and decreased cost without increasing complications or readmission rate. The combined effects of the two methods could further accelerate clinical recovery of gastric cancer patients.
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Affiliation(s)
- Zhengyan Li
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China
| | - Qian Wang
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China
| | - Bofei Li
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China
| | - Bin Bai
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China
| | - Qingchuan Zhao
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China.
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30
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Does a Combination of Laparoscopic Approach and Full Fast Track Multimodal Management Decrease Postoperative Morbidity? Ann Surg 2017; 266:729-737. [DOI: 10.1097/sla.0000000000002394] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Fabrizio AC, Grant MC, Siddiqui Z, Alimi Y, Gearhart SL, Wu C, Efron JE, Wick EC. Is enhanced recovery enough for reducing 30-d readmissions after surgery? J Surg Res 2017; 217:45-53. [PMID: 28602223 DOI: 10.1016/j.jss.2017.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/21/2017] [Accepted: 04/11/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Few enhanced recovery pathways (ERPs) include processes related to the hospital to home transfer. Little has been reported regarding readmissions in enhanced recovery programs. This study evaluates readmissions and identifies areas to optimize ERPs to prevent readmissions. METHODS We conducted an observational, retrospective study at a single tertiary care center. Patients in an ERP for colorectal surgery were compared with a similar cohort who underwent surgery before protocol implementation. We evaluated 30-d readmission, compliance to enhanced recovery protocol, and diagnoses and patient care experiences related to transition of care. RESULTS Readmission rates (17.6% versus 19.4%; P = 0.55) were similar. There was significant reduction in index hospitalization length of stay (5.3 versus 7.0 d; P < 0.001) and postoperative surgical site infection (7.3% versus 16.6%; P = 0.01). Although enhanced recovery was associated with reduced readmissions for surgical site infections (31% versus 50.7%, P = 0.02), there was a trend toward increased readmissions for small bowel obstruction-ileus (31% versus 19.1%, P = 0.13). ERPs did not impact perceptions of care transitions; however, those who were readmitted rated their transition lower than those that were not. CONCLUSIONS Although ERPs did not reduce readmissions, the program was associated with reduced length of stay and surgical site infections. ERPs did not influence perceptions of the transition to home. Transition process measures aimed at reducing readmission and improving patient outcomes, including use of transition guides, remote vital sign and symptom monitoring, and early clinical follow-up have not traditionally been part of ERP protocols but should be considered.
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Affiliation(s)
- Anne C Fabrizio
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Zishan Siddiqui
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yewande Alimi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Susan L Gearhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher Wu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elizabeth C Wick
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Shum NF, Choi HK, Mak JCK, Foo DCC, Li WC, Law WL. Randomized clinical trial of chewing gum after laparoscopic colorectal resection. Br J Surg 2017; 103:1447-52. [PMID: 27654648 DOI: 10.1002/bjs.10277] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/19/2016] [Accepted: 06/23/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Chewing gum may enhance intestinal motility after surgery. This trial studied whether chewing gum could lead to a further reduction in ileus in patients who had a laparoscopic colorectal resection and followed an enhanced recovery programme. METHODS Patients undergoing laparoscopic colorectal resection were randomized to a control or intervention group. Patients in the control group received a standardized recovery programme. Patients in the intervention group were, in addition, given chewing gum three times daily from day 1 until discharge. Primary outcome measures were time to first flatus and first bowel motion. Time to feeling hungry and hospital stay were secondary outcome measures. RESULTS Forty-one patients were randomized into each group. Thirty-seven patients underwent rectal resection and 45 had a colonic resection. Time to passage of flatus was shorter (18 versus 34 h; P = 0·007), first bowel motion occurred earlier (19 versus 44 h; P = 0·001) and time to feeling hungry was earlier (16 versus 25 h; P = 0·001) in the intervention group. There was no difference in the duration of hospital stay (5 days in the intervention group versus 5·5 days in the control group). Subgroup analyses revealed that the benefits of chewing gum were clearer in patients who had a colonic resection, with a shorter time to first flatus (20 versus 35 h; P = 0·043), first bowel motion (19 versus 53 h; P = 0·014) and feeling hungry (14 versus 40 h; P = 0·001). No adverse events were attributed to chewing gum. CONCLUSION Chewing gum is a simple intervention that speeds intestinal transit in patients managed with a recovery programme after laparoscopic colorectal resection. REGISTRATION NUMBER NCT02419586 (https://clinicaltrials.gov/).
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Affiliation(s)
- N F Shum
- Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - H K Choi
- Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - J C K Mak
- Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - D C C Foo
- Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - W C Li
- Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - W L Law
- Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong.
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Reducing Readmissions While Shortening Length of Stay: The Positive Impact of an Enhanced Recovery Protocol in Colorectal Surgery. Dis Colon Rectum 2017; 60:219-227. [PMID: 28059919 PMCID: PMC5268399 DOI: 10.1097/dcr.0000000000000748] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hospital readmission rates are an increasingly important quality metric since enactment of the 2012 Hospital Readmissions Reduction Program. The proliferation of enhanced recovery protocols and earlier discharge raises concerns for increased readmission rates. OBJECTIVE We evaluated the effect of enhanced recovery on readmissions and identified risk factors for readmission. DESIGN This study involved implementation of a multidisciplinary enhanced recovery protocol. SETTINGS It was conducted at a large academic medical center PATIENTS:: All patients undergoing elective colorectal surgery between 2011 and 2015 at our center were included. MAIN OUTCOME MEASURES This cohort study compared patients before and after enhanced recovery initiation, looking at 30-day readmission as the primary outcome. A multivariable logistic regression model identified predictors of 30-day readmission. Kaplan-Meier analysis identified differences in time to readmission. RESULTS A total of 707 patients underwent colorectal procedures between 2011 and 2015, including 383 patients before enhanced recovery protocol was implemented and 324 patients after enhanced protocol was implemented. Length of stay decreased from a median 5 days to a median 4 days before and after enhanced recovery implementation (p < 0.0001). Thirty-day readmission decreased from 19% (72/383) in the pre-enhanced recovery pathway to 12% (38/324) in the enhanced recovery pathway (p = 0.009). Twenty-one percent (21/99) of patients who underwent ileostomy were readmitted before enhanced recovery implementation compared with 19% (18/93) of patients who underwent ileostomy after enhanced recovery implementation (p = 0.16). Multivariable logistic regression identified ileostomy as increasing the risk of readmission (p = 0.04), whereas enhanced recovery protocol decreased the risk of readmission (p = 0.006). LIMITATIONS The study is limited because it was conducted at a single institution and used a before-and-after study design. CONCLUSIONS These data suggest that use of a standardized enhanced recovery protocol significantly reduces length of stay and readmission rates in an elective colorectal surgery population. However, the presence of an ileostomy maintains a high association with readmission, serving as a significant burden to patients and providers alike. Ongoing efforts are needed to further improve the management of patients undergoing ileostomy in the outpatient setting after discharge to prevent readmissions.
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Currie AC, Malietzis G, Jenkins JT, Yamada T, Ashrafian H, Athanasiou T, Okabayashi K, Kennedy RH. Network meta-analysis of protocol-driven care and laparoscopic surgery for colorectal cancer. Br J Surg 2016; 103:1783-1794. [PMID: 27762436 DOI: 10.1002/bjs.10306] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 06/28/2016] [Accepted: 07/25/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Laparoscopic approaches and standardized recovery protocols have reduced morbidity following colorectal cancer surgery. As the optimal regimen remains inconclusive, a network meta-analysis was undertaken of treatments for the development of postoperative complications and mortality. METHODS MEDLINE, Embase, trial registries and related reviews were searched for randomized trials comparing laparoscopic and open surgery within protocol-driven or conventional perioperative care for colorectal cancer resection, with complications as a defined endpoint. Relative odds ratios (ORs) for postoperative complications and mortality were estimated for aggregated data. RESULTS Forty trials reporting on 11 516 randomized patients were included with the network. Open surgery within conventional perioperative care was the index for comparison. The OR relating to complications was 0·77 (95 per cent c.i. 0·65 to 0·91) for laparoscopic surgery within conventional care, 0·69 (0·48 to 0·99) for open surgery within protocol-driven care, and 0·43 (0·28 to 0·67) for laparoscopic surgery within protocol-driven care. Sensitivity analyses excluding trials of low rectal cancer and those with a high risk of bias did not affect the treatment estimates. Meta-analyses demonstrated that mortality risk was unaffected by perioperative strategy. CONCLUSION Laparoscopic surgery combined with protocol-driven care reduces colorectal cancer surgery complications, but not mortality. The reduction in complications with protocol-driven care is greater for open surgery than for laparoscopic approaches. Registration number: CRD42015017850 (https://www.crd.york.ac.uk/PROSPERO).
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Affiliation(s)
- A C Currie
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, UK
| | - G Malietzis
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, UK
| | - J T Jenkins
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, UK
| | - T Yamada
- Department of Surgery, School of Medicine, Keio University, Shinjuku, Tokyo, Japan
| | - H Ashrafian
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - T Athanasiou
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - K Okabayashi
- Department of Surgery, School of Medicine, Keio University, Shinjuku, Tokyo, Japan
| | - R H Kennedy
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, UK
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Abstract
Postoperative ileus (POI) is a major focus of concern for surgeons because it increases duration of hospitalization, cost of care, and postoperative morbidity. The definition of POI is relatively consensual albeit with a variable definition of interval to resolution ranging from 2 to 7 days for different authors. This variation, however, leads to non-reproducibility of studies and difficulties in interpreting the results. Certain risk factors for POI, such as male gender, advanced age and major blood loss, have been repeatedly described in the literature. Understanding of the pathophysiology of POI has helped combat and prevent its occurrence. But despite preventive and therapeutic efforts arising from such knowledge, 10 to 30% of patients still develop POI after abdominal surgery. In France, pharmacological prevention is limited by the unavailability of effective drugs. Perioperative nutrition is very important, as well as limitation of preoperative fasting to 6 hours for solid food and 2 hours for liquids, and virtually no fasting in the postoperative period. Coffee and chewing gum also play a preventive role for POI. The advent of laparoscopy has led to a significant improvement in the recovery of gastrointestinal function. Enhanced recovery programs, grouping together all measures for prevention or cure of POI by addressing the mechanisms of POI, has reduced the duration of hospitalization, morbidity and interval to resumption of transit.
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Wiedenbein L, Kristiansen M, Adamsen L, Hjort D, Hendriksen C. Assessment of rehabilitation needs in colorectal cancer treatment: Results from a mixed audit and qualitative study in Denmark. Acta Oncol 2016; 55:705-11. [PMID: 26808254 DOI: 10.3109/0284186x.2015.1131332] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background Systematic assessments of cancer patients' rehabilitation needs are a prerequisite for devising appropriate survivorship programs. Little is known about the fit between needs assessment outlined in national rehabilitation policies and clinical practice. This study aimed to explore clinical practices related to identification and documentation of rehabilitation needs among patients with colorectal cancer at Danish hospitals. Material and methods A retrospective clinical audit was conducted utilizing data from patient files randomly selected at surgical and oncology hospital departments treating colorectal cancer patients. Forty patients were included, 10 from each department. Semi-structured interviews were carried out among clinical nurse specialists. Audit data was analyzed using descriptive statistics, qualitative data using thematic analysis. Results Documentation of physical, psychological and social rehabilitation needs initially and at end of treatment was evident in 10% (n = 2) of surgical patient trajectories and 35% (n = 7) of oncology trajectories. Physical rehabilitation needs were documented among 90% (n = 36) of all patients. Referral to municipal rehabilitation services was documented among 5% (n = 2) of all patients. Assessments at surgical departments were shaped by the inherent continuous assessment of rehabilitation needs within standardized fast-track colorectal cancer surgery. In contrast, the implementation of locally developed assessment tools inspired by the distress thermometer (DT) in oncology departments was challenged by a lack of competencies and funding, impeding integration of data into patient files. Conclusion Consensus must be reached on how to ensure more systematic, comprehensive assessments of rehabilitation needs throughout clinical cancer care. Fast-track surgery ensures systematic documentation of physical needs, but the lack of inclusion of data collected by the DT in oncological departments questions the efficacy of assessment tools and points to a need for distinguishing between surgical and oncological settings in national rehabilitation policies.
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Affiliation(s)
- Liza Wiedenbein
- Rigshospitalet, The University Hospitals Centre for Health Research (UCSF), Copenhagen, Denmark
| | - Maria Kristiansen
- Section for Health Services Research, Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lis Adamsen
- Rigshospitalet, The University Hospitals Centre for Health Research (UCSF), Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Dorte Hjort
- Section for Surgical Pathophysiology, Rigshospitalet and Glostrup Hospital, Copenhagen, Denmark
| | - Carsten Hendriksen
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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37
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Martin TD, Lorenz T, Ferraro J, Chagin K, Lampman RM, Emery KL, Zurkan JE, Boyd JL, Montgomery K, Lang RE, Vandewarker JF, Cleary RK. Newly implemented enhanced recovery pathway positively impacts hospital length of stay. Surg Endosc 2015; 30:4019-28. [PMID: 26694181 DOI: 10.1007/s00464-015-4714-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 12/01/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Enhanced recovery pathways (ERPs) are thought to improve surgical outcomes by standardizing perioperative patient care established in evidence-based literature. The objective of this study was to determine the impact of a colorectal surgery ERP on hospital length of stay (LOS) and other patient outcomes. METHODS This is a comparative effectiveness study of patients undergoing elective colorectal surgery 2 years prior (pre-ERP group) and 2 years after (ERP group) implementation of an ERP program. The primary outcome was hospital LOS. Secondary outcomes included postoperative complications, 30-day readmissions, and 30-day reoperations. Multivariable regression analyses were utilized to control for patient factors, general health factors, diagnosis, surgeon, colon versus rectal operations, and open versus minimally invasive operations-laparoscopic and robotic. An ERP checklist was developed to track adherence to components of the pathway. RESULTS The study population included 1036 patients: 523 in the pre-ERP group and 513 in the ERP group. Unadjusted LOS was significantly shorter in the ERP group than the control pre-ERP group [3 (IQR 3.5) vs 5 days (IQR 4.6); p < 0.0001]. Multivariable regression analysis confirmed the reduction in LOS, controlling for age, colon/rectum procedure, open/laparoscopic/robotic approach, primary diagnosis, and alvimopan use. Postoperative outcomes were not significantly different between groups except for 30-day readmissions, which were unexpectedly higher in the ERP group (14.6 vs 8.7 %, p = 0.04). CONCLUSIONS A newly implemented ERP on a dedicated colorectal surgery service in an academic non-university hospital setting resulted in shorter hospital LOS, but increased readmissions, for patients undergoing elective open and minimally invasive colon and rectal surgery. Future multi-institutional studies are needed to understand the impact of ERP on postoperative complications and readmissions.
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Affiliation(s)
- Thomas D Martin
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Talya Lorenz
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Jane Ferraro
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Kevin Chagin
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Richard M Lampman
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Karen L Emery
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Joan E Zurkan
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Jami L Boyd
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Karin Montgomery
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Rachel E Lang
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - James F Vandewarker
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Robert K Cleary
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA.
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38
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Francis NK, Mason J, Salib E, Allanby L, Messenger D, Allison AS, Smart NJ, Ockrim JB. Factors predicting 30-day readmission after laparoscopic colorectal cancer surgery within an enhanced recovery programme. Colorectal Dis 2015; 17:O148-54. [PMID: 25988303 DOI: 10.1111/codi.13002] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 04/07/2015] [Indexed: 12/11/2022]
Abstract
AIM Hospital readmission within 30 days of surgery has become a marker of poor quality patient care. This study aimed to investigate factors predictive of 30-day readmission after laparoscopic colorectal cancer surgery within an enhanced recovery after surgery (ERAS) programme. METHOD Consecutive patients undergoing laparoscopic surgery for colorectal cancer within an ERAS programme between 2002 and 2009 were included. Data were collected relating to patient demographics, neoadjuvant chemoradiotherapy, ERAS compliance, and operative and postoperative outcomes. A logistic regression model was used to identify factors associated with readmissions after adjusting for the potential effect of covariables simultaneously. RESULTS In all, 268 cancer patients underwent laparoscopic colorectal surgery (108 rectal resections), of whom 34 (12.7%) were readmitted due most commonly to bowel obstruction (29%) and surgical site infection (18%). The use of neoadjuvant therapy (odds ratio 4.49, 95% CI 1.41-14.35; P = 0.011) and ERAS compliance above 93% (odds ratio 0.38, 95% CI 0.18-0.84; P = 0.016) were independent predictors of readmission. CONCLUSION Poor ERAS compliance and preoperative chemoradiotherapy were significant predictors of readmission following laparoscopic colorectal cancer surgery. Further research is required to expand the scope of ERAS beyond hospital discharge.
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Affiliation(s)
- N K Francis
- Department of General Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, UK
| | - J Mason
- Department of General Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, UK
| | - E Salib
- Liverpool University, Liverpool, UK
| | - L Allanby
- Department of General Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, UK
| | - D Messenger
- Department of General Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, UK
| | - A S Allison
- Department of General Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, UK
| | - N J Smart
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - J B Ockrim
- Department of General Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, UK
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