Fast-track rehabilitation accelerates recovery after laparoscopic colorectal surgery

Enhanced recovery after surgery in patients undergoing laparoscopic common bile duct exploration: A retrospective study

Few reports have focused on the use of enhanced recovery after surgery (ERAS) in laparoscopic common bile duct exploration (LCBDE) to promote the postoperative recovery of patients with choledocholithiasis. Therefore, this study aimed to explore the advantages and safety of ERAS in patients who underwent LCBDE. From December 2016 to February 2020, 86 and 84 patients were retrospectively enrolled in the control and ERAS groups, respectively. The perioperative insulin resistance index, perioperative C-reactive protein level, time of postoperative analgesic use, time of postoperative first flatus, time of abdominal drainage tube removal, time of liver function recovery, and postoperative complications were analyzed between the two groups. The insulin resistance index (1, 3, and 5 days postoperatively) and C-reactive protein level (1, 3, 5, and 7 days postoperatively) in the ERAS group were significantly lower than those in the control group (all P < .05). In terms of the postoperative rehabilitation efficacy, the time of postoperative activity of the patient, time of postoperative first flatus, time of postoperative analgesic use, time of abdominal drainage tube removal, time of postoperative T-tube closing, and length of postoperative hospital stay in the ERAS group were significantly shorter than those in the control group (all P < .05). Additionally, the overall incidence of postoperative complications in the ERAS group had a decreasing trend when compared with that in the control group (P = .05). ERAS can reduce the postoperative stress response and postoperative complications of patients undergoing LCBDE, promote rehabilitation and shorten the length of postoperative hospital stay and therefore has good social and economic benefits.

Michigan Appropriate Perioperative (MAP) criteria for urinary catheter use in common general and orthopaedic surgeries: results obtained using the RAND/UCLA Appropriateness Method

BACKGROUND

Indwelling urinary catheters are commonly used for patients undergoing general and orthopaedic surgery. Despite infectious and non-infectious harms of urinary catheters, there is limited guidance available to surgery teams regarding appropriate perioperative catheter use.

OBJECTIVE

Using the RAND Corporation/University of California Los Angeles (RAND/UCLA) Appropriateness Method, we assessed the appropriateness of indwelling urinary catheter placement and different timings of catheter removal for routine general and orthopaedic surgery procedures.

METHODS

Two multidisciplinary panels consisting of 13 and 11 members (physicians and nurses) for general and orthopaedic surgery, respectively, reviewed the available literature regarding the impact of different perioperative catheter use strategies. Using a standardised, multiround rating process, the panels independently rated clinical scenarios (91 general surgery, 36 orthopaedic surgery) for urinary catheter placement and postoperative duration of use as appropriate (ie, benefits outweigh risks), inappropriate or of uncertain appropriateness.

RESULTS

Appropriateness of catheter use varied by procedure, accounting for procedure-specific risks as well as expected procedure time and intravenous fluids. Procedural appropriateness ratings for catheters were summarised for clinical use into three groups: (1) can perform surgery without catheter; (2) use intraoperatively only, ideally remove before leaving the operating room; and (3) use intraoperatively and keep catheter until postoperative days 1-4. Specific recommendations were provided by procedure, with postoperative day 1 being appropriate for catheter removal for first voiding trial for many procedures.

CONCLUSION

We defined the appropriateness of indwelling urinary catheter use during and after common general and orthopaedic surgical procedures. These ratings may help reduce catheter-associated complications for patients undergoing these procedures.

Meta-analysis of the effect of perioperative intravenous lidocaine on return of gastrointestinal function after colorectal surgery

BACKGROUND

Return of normal gastrointestinal (GI) function is a critical determinant of recovery after colorectal surgery. The aim of this meta-analysis was to evaluate whether perioperative intravenous (IV) lidocaine benefits return of gastrointestinal function after colorectal resection.

METHODS

A comprehensive search of Ovid Medline, PubMed, Embase, Cochrane library, and clinicaltrials.org was performed on 1st July 2018. A manual search of reference lists was also performed. Inclusion criteria were as follows: randomized controlled trials (RCTs) of intravenous (IV) lidocaine administered perioperatively compared to placebo (0.9% saline infusion) as part of a multimodal perioperative analgesic regimen, human adults (> 16 years), and open or laparoscopic colorectal resectional surgery.

EXCLUSION CRITERIA

non-colorectal surgery, non-placebo comparator, children, non-general anaesthetic, and pharmacokinetic studies. The primary endpoint was time to first bowel movement. Secondary endpoints were time to first passage of flatus, time to toleration of diet, nausea and vomiting, ileus, pain scores, opioid analgesia consumption, and length of stay.

RESULTS

One hundred and ninety one studies were screened, with 9 RCTs meeting inclusion criteria (405 patients, four laparoscopic and five open surgery studies). IV lidocaine reduced time to first bowel movement compared to placebo [seven studies, 325 patients, mean weighted difference - 9.54 h, 95% CI 18.72-0.36, p = 0.04]. Ileus, pain scores, and length of stay were reduced with IV lidocaine compared with placebo.

CONCLUSIONS

Perioperative IV lidocaine may improve recovery of gastrointestinal function after colorectal surgery. Large-scale effectiveness studies to measure effect size and evaluate optimum dose/duration are warranted.

Fast-Track in Bariatric and Metabolic Surgery: Feasibility and Cost Analysis Through a Matched-Cohort Study in a Single Centre

BACKGROUND

Due to the rise in severe obesity in Western countries and the increase in bariatric surgery, enhanced recovery (ER) pathways should be developed and promoted.

METHODS

A monocentric prospective series of 103 bariatric surgery patients managed with the ER pathway (group ER) was compared with a retrospective and immediately previous series of 103 patients managed with standard care (group CS). The aim of the present study was to assess and compare the differences in terms of mean postoperative length of stay (LOS), costs for surgery and recovery, and the differences in terms of complications, readmission, and reoperation rate in the short term between the ER and CS groups.

RESULTS

The mean LOS was 4.18 days in group CS and 1.79 days in group ER (p < 0.0001). The mean operative time (OT) per patient was 190.20 min in the group CS and 133.54 min in the group ER, resulting in an average cost of 7272.57€ per patient in group CS and 5424.09€ per patient in group ER. The average recovery cost was 1809.94€ for the group CS series and 775.07 for the group ER one. Overall complications (Clavien-Dindo up to II) occurred in 6 patients (5.8 %) in group CS and in 2 patients (1.9 %) in group ER (p = 0.149) and specific complications (Clavien-Dindo IIIb) occurred for 9 patients (8.7 %) in Group CS and for 14 patients (13.5 %) in group ER (p = 0.268) after hospital discharge within 1-month of follow-up. Twelve patients (11.5 %) in group CS and 13 (12.5 %) in group ER were readmitted after discharge (p = 0.831) within 1-month of follow-up; 8 patients (7.7 %) in group CS versus 9 patients (8.8 %) in group ER needed to be reoperated (p = 0.800) within 1-month follow-up.

CONCLUSIONS

Enhanced recovery pathway reduces significantly LOS in bariatric surgical patients and shortens the mean OT of the procedure, with no significant differences in terms of surgical outcomes. Furthermore, recovery charges were lower and operative time was shorter allowing for procedural cost reduction.

Application of Fast-Track Recovery Protocols in Single-Port Laparoscopic Surgery Versus Multiport Laparoscopic Surgery for Colon Resection

AIM

The aim of this study is to analyze whether fast-track (FT) recovery protocols can be applied to single-port laparoscopic surgery for colon resection, as they are in multiport laparoscopic surgery.

MATERIALS AND METHODS

Retrospective study comparing single-port laparoscopic surgery (SP-FT) versus multiport laparoscopic surgery (MP-FT) for colon resection, and the applicability of our FT recovery protocol in all patients between 2013 and 2014. Variables evaluated were American Society of Anesthesiologists (ASA) score, tumor size, number of nodes, surgery performed, postoperative morbidity, and length of hospital stay.

RESULTS

A total of 83 patients (28 SP-FT group and 55 MP-FT group) underwent FT recovery. The median age was 62 (11-85) years in SP-FT group and 72 (57-84) in MP-FT group. ASA score showed no significant difference (P = .973). The surgical procedures performed were as follows: SP-FT group 20 right hemicolectomy, 5 left hemicolectomy, and 3 subtotal colectomy and MP-FT group were 26 right hemicolectomy, 28 left hemicolectomy, and 1 subtotal colectomy. Mean operative time (minutes) was shorter in SP-FT group (151 ± 47.9 versus 182 ± 50.7), but no significant difference was observed. Regarding the tumor size (SP-FT 4.2 [2-7] cm versus MP-FT 4 [3-12] cm) and postoperative morbidity Clavien-Dindo ≥2 (SP-FT 10 patients versus MP-FT 20 patients), there were no significant differences (P = .535; P = .383). The median length of hospital stay was statistically significant: SP-FT 4.5 (3-53) days versus MP-FT 7 (4-33) days (P = .005).

CONCLUSIONS

FT rehabilitation is safe and reproducible in single-port laparoscopic surgery for colon pathologies, with postoperative results comparable with conventional laparoscopic surgery.

FASTING IN ELECTIVE SURGICAL PATIENTS: COMPARISON AMONG THE TIME PRESCRIBED, PERFORMED AND RECOMMENDED ON PERIOPERATIVE CARE PROTOCOLS

BACKGROUND

Prolonged preoperative fasting may impair nutritional status of the patient and their recovery. In contrast, some studies show that fasting abbreviation can improve the response to trauma and decrease the length of hospital stay.

AIM

Investigate whether the prescribed perioperative fasting time and practiced by patients is in compliance with current multimodal protocols and identify the main factors associated.

METHODS

Cross-sectional study with 65 patients undergoing elective surgery of the digestive tract or abdominal wall. We investigated the fasting time in the perioperative period, hunger and thirst reports, physical status, diabetes diagnosis, type of surgery and anesthesia.

RESULTS

The patients were between 19 and 87 years, mostly female (73.8%). The most performed procedure was cholecystectomy (47.69%) and general anesthesia the most used (89.23%). The most common approach was to start fasting from midnight for liquids and solids, and most of the patients received grade II (64.6%) to the physical state. The real fasting average time was 16 h (9.5-41.58) was higher than prescribed (11 h, 6.58 -26.75). The patients submitted to surgery in the afternoon were in more fasting time than those who did in the morning (p<0.001). The intensity of hunger and thirst increased in postoperative fasting period (p=0.010 and 0.027). The average period of postoperative fasting was 18.25 h (3.33-91.83) and only 23.07% restarted feeding on the same day.

CONCLUSION

Patients were fasted for prolonged time, higher even than the prescribed time and intensity of the signs of discomfort such as hunger and thirst increased over time. To better recovery and the patient's well-being, it is necessary to establish a preoperative fasting abbreviation protocol.