Peri-Operative Care in Colorectal Surgery in the Twenty-First Century

Abstract

Listen

Translate article

Under conventional circumstances, colorectal cancer resection has been associated with an often protracted recovery. Large published studies, randomized trials and meta-analyses suggest an average length of hospital stay of about ten days (Bokey et al., 1995; Abraham et al., 2004 & 2007). In an attempt to mimic the success of laparoscopic gall bladder surgery, laparoscopic colorectal resection was introduced in 1991 as a proposed less invasive alternative to the open technique (Jacobs, 1991; Redwine, 1991). Under conventional circumstances, in the first published series of 20 laparoscopic sigmoid colectomies, the authors reported that a five-day hospital stay was achieved in 70% of patients. However, subsequent larger studies including randomized trials reported an average length of stay of about eight days which is still an improvement of about 20% compared with conventional open resections (Abraham et al., 2004 & 2007; Schwenk et al., 2005). The last published large randomized controlled trial of the topic (The ALCCaS) showed no statistically significant difference in postoperative complications, reoperation rate, or perioperative mortality between laparoscopic and open resections (Allardyce et al., 2010). However, a recent meta-analysis showed that laparoscopic colorectal resections were associated with higher intra-operative complication rates than open resections (Sammour et al., 2011). The ALCCaS group also reported that reviews show that the short-term advantages for laparoscopic resection for colorectal cancer are arguably relatively minor and often subjective (Allardyce et al., 2010). In 1999, in a series of 16 open colectomies, the authors reported using a Fast Track (Enhanced Recovery after Surgery (ERAS)) Program with a median postoperative length of hospital stay of two days (Kehlet & Mogensen, 1999). However, subsequent larger studies reported a median length of stay of about five days (Abraham & Albayati, 2011). ERAS programs challenge the conventional approaches to peri-operative care in colorectal surgery in an evidence-based manner. These include conventional bowel preparation, peri-operative starvation, routine nasogastric decompression, routine prophylactic drainage, defunctioning ileostomy, vigorous intravenous hydration, narcotic analgesia, etc ... These traditional protocols and practices are replaced with evidence based protocols that enhance postoperative recovery.