Recovery Program For Colorectal Surgery Research Articles

Goal-Directed Fluid Therapy and Postoperative Outcomes in an Enhanced Recovery Program for Colorectal Surgery: A Propensity Score-Matched Multicenter Study.

Goal-directed fluid therapy (GDFT) has increasingly been utilized in major surgery as a key component to ensure fluid optimization and adequate tissue perfusion, showing improvements in the rate of morbidity and mortality under conventional care. It is unclear if patients derive similar benefit as part of an enhanced recovery program (ERP). Our group sought to assess the association between GDFT and postoperative outcomes within an ERP for colorectal surgery. A propensity score-matched analysis, based upon demographic characteristics, comorbidities, and ERP components, was utilized to assess the association between GDFT and outcomes in a multicenter prospective ERP for colorectal surgery cohort study. Outcomes included pulmonary edema, acute kidney injury (AKI), ileus, surgical site infection (SSI), and anastomotic dehiscence. The calipmatch module was used to match patients who received GDFT to non-GDFT in a 1-to-1 propensity score fashion. A total of 151 matched pairs were included in the analysis (n = 302, 23%). Both groups had comparable baseline demographics, as well as similar rates of compliance with enhanced recovery after surgery (ERAS) components. Goal-directed fluid therapy patients received significantly more colloid (237 ± 320mL vs. 140 ± 245mL, P < .01) than non-GDFT counterparts. Goal-directed fluid therapy was not associated with improved rates of postoperative AKI (odds ratios (OR) 1.00, 95% confidence intervals (CI) .39-2.59, P = 1.00), ileus (OR 1.40, 95% CI .82-2.41, P = .22), SSI (OR 1.06, 95% CI .54-2.08, P = .86), or length of hospital stay (LOS) (10.8 ± 8.9 vs. 11.1±13.2days, P = .84). There was no associated between GDFT and major postoperative outcomes within an ERAS program for colorectal surgery. Additional large-scale or pragmatic randomized trials are necessary to determine whether GDFT has a role in ERP for colorectal surgery.

The effect of adding goal-directed hemodynamic management for elective patients in an established enhanced recovery program for colorectal surgery: results of quasi-experimental pragmatic trial

BackgroundRecent literature has demonstrated that hemodynamic instability in the intraoperative period places patients at risk of poor outcomes. Furthermore, recent studies have reported that stroke volume optimization and protocolized hemodynamic management may improve perioperative outcomes, especially surgical site infection (SSI), in certain high-risk populations. However, the optimal strategy for intraoperative management of all elective patients within an enhanced recovery program remains to be elucidated.MethodsWe performed a pre-post quasi-experimental study to assess the effect of adding goal-directed hemodynamic therapy to an enhanced recovery program (ERP) for colorectal surgery on SSI and other outcomes. Three groups were compared: “Pre-ERP,” defined as historical control (before enhanced recovery program); “ERP,” defined as enhanced recovery program using zero fluid balance; and “ERP+GDHT,” defined as enhanced recovery program plus goal-directed hemodynamic therapy. Outcomes were obtained through our National Surgical Quality Improvement Program participation.ResultsA total of 623 patients were included in the final analysis (Pre-ERP = 246, ERP = 140, and ERP + GDHT = 237). Demographics and baseline clinical characteristics were balanced between groups. We did not observe statistically significant differences in SSI or composite complication rates in unadjusted or adjusted analysis. There was no evidence of association between study group and 30-day readmission. American Society of Anesthesiologists status ≥ 3 and open surgical approach were significantly associated with increased risk of SSI, composite complication, and 30-day readmission (p < 0.05 for all) in all groups.ConclusionsThere was no evidence that addition of goal-directed hemodynamic therapy for all patients in an enhanced recovery program for colorectal surgery affects the risk of SSI, composite complications, or 30-day readmission. Further research is needed to investigate whether there is benefit of goal-directed hemodynamic therapy for select high-risk populations.Trial registrationNCT03189550. Registered 16 June 2017–Retrospectively registered, https://www.clinicaltrials.gov/ct2/results?cond=&term=NCT03189550&cntry=&state=&city=&dist=

Impact of surgical indication on patient outcomes and compliance with enhanced recovery program for colorectal surgery: A Francophone multicenter retrospective analysis.

The impact of surgical indication on compliance with enhanced recovery program (ERP) and on outcomes has never been assessed. This study aims to assess the impact of surgical indication (malignant vs benign) on postoperative outcomes and ERP compliance. A multicenter nationwide database was analyzed. Patients who underwent colorectal surgery for benign disease and those who underwent colorectal surgery for cancer were compared. Inclusion criteria were elective colorectal resection with anastomosis. ERP components, postoperative morbidity, and hospital length of hospital stay data were collected. Among the 6472 patients registered in the database between October 2012 and June 2018, 4528 patients were included; 2647 in the malignant group and 1881 in the benign group. The ERP compliance over 70% was not different between groups. Postoperative morbidity rate was higher in the malignant group (22.5% vs 19.3%; P = .009) but not confirmed in multivariate analysis. Patients in the malignant group were more often readmitted after discharge, 6.6% vs 4.6% (P = .004). The mean LOS was 6.3 ± 5.0 days in the malignant group and 5.4 ± 4.7 days in the benign group (P < .001). Indication for colorectal surgery did not significantly influence peri-operative management and postoperative major complications, in patients managed within an enhanced recovery program.

A mobile device application (app) to improve adherence to an enhanced recovery program for colorectal surgery: a randomized controlled trial.

Increased adherence with enhanced recovery pathways (ERP) is associated with improved outcomes. However, adherence to postoperative elements that rely on patient participation remains suboptimal. Mobile device apps may improve delivery of health education material and have the potential to foster behavior change and improve patient compliance. The objective of this study was to estimate the extent to which a novel mobile device app affects adherence to an ERP for colorectal surgery in comparison to standard written education. This was a superiority, parallel-group, assessor-blind, sham-controlled randomized trial involving 97 patients undergoing colorectal resection. Participants were randomly assigned with a 1:1 ratio into one of two groups: (1) iPad including a novel mobile device app for postoperative education and self-assessment of recovery, or (2) iPad without the app. The primary outcome measure was mean adherence (%) to a bundle of five postoperative ERP elements requiring patient participation: mobilization, gastrointestinal motility stimulation, breathing exercises, and consumption of oral liquids and nutritional drinks. In the intervention group, app usage was high (94% completed surveys on POD0, 82% on POD1, 72% on POD2). Mean overall adherence to the bundle on the two first postoperative days was similar between groups: 59% (95% CI 52-66%) in the intervention group and 62% (95% CI 56-68%) in the control group [Adjusted mean difference 2.4% (95% CI - 5 to 10%) p = 0.53]. In this randomized trial, access to a mobile health application did not improve adherence to a well-established enhanced recovery pathway in colorectal surgery patients, when compared to standard written patient education. Future research should evaluate the impact of applications integrating novel behavioral change techniques, particularly in contexts where adherence is low.

Sustainability of enhanced recovery programs in colorectal surgery

It is important but difficult to sustain the gains of an effective intervention after its implementation. Although many studies have shown the benefits obtained by implementing enhanced recovery programs (ERPs), sustainability of the program over time after its introduction remains to be elucidated. Herein, I would like to introduce an interesting study by Dr. Veziant et al. , recently published in The Surgeon (1). They addressed the issue of whether the application of enhanced recovery surgical components (colonic preparation, surgical approach, nasogastric tube omission and absence of abdominal drainage) had been sustained for 2 years after initial implementation in colorectal surgery. That study retrospectively analyzed the sustainability of ERP in 2,565 patients from 63 colorectal centers using a prospectively maintained database. The results indicated that implementation of the surgical components in the ERP decreased over time.

Enhanced Recovery Program for Colorectal Surgery: a Focus on Elderly Patients Over 75 Years Old

BackgroundAn enhanced recovery after surgery (ERAS) protocol can effectively improve perioperative outcomes in surgical patients by reducing complication rates and hospital stay. However, its application in elderly patients has yielded contradictory results. The aim of this study was to evaluate surgical outcomes in a cohort of elderly patients undergoing colorectal resection in our unit before and after the introduction of ERAS. MethodsFrom 328 patients undergoing colorectal surgery in our unit over a 2-year period (2015–2016), 114 patients ≥ 75 years of age were selected. The patients were categorized according to perioperative treatment as pre-ERAS and ERAS patients (respectively, 53 vs 61 patients), and the groups were compared for statistical purposes. Outcome measures included length of hospital stay, recovery of bowel functions, oral feeding, postoperative complications, and readmissions. Compliance with the ERAS protocol was also measured. ResultsGroups were homogeneous for all the clinical-surgical variables, with the sole exception of the Charlson index, which was more severe in the ERAS group (p = 0.012). Compared with control patients, ERAS patients reported improved functional recovery (time to first flatus, stool, and oral feeding; p < 0.001). Hospital stay was reduced in ERAS patients overall and by side of resection, excluding rectal procedures. No differences were observed regarding postoperative complications. Of note, an optimal adherence to the protocol was reported, with 79% of items respected. ConclusionsERAS can be considered safe in elderly patients undergoing colorectal surgery with a high comorbidity index, providing a reduction in hospital stay and improving short-term postoperative outcomes. Finally, the protocol application was feasible, with a high adherence to the items in this subset of patients.

Sustainability of enhanced recovery programs in colorectal surgery

It is important but difficult to sustain the gains of an effective intervention after its implementation. Although many studies have shown the benefits obtained by implementing enhanced recovery programs (ERPs), sustainability of the program over time after its introduction remains to be elucidated. Herein, I would like to introduce an interesting study by Dr. Veziant et al. , recently published in The Surgeon (1). They addressed the issue of whether the application of enhanced recovery surgical components (colonic preparation, surgical approach, nasogastric tube omission and absence of abdominal drainage) had been sustained for 2 years after initial implementation in colorectal surgery. That study retrospectively analyzed the sustainability of ERP in 2,565 patients from 63 colorectal centers using a prospectively maintained database. The results indicated that implementation of the surgical components in the ERP decreased over time.

Reply to: does utilization of laparoscopy improve successful adherence to enhanced recovery programs in colorectal surgery?

Fast-track surgery has been initially applied in patients undergoing open colorectal resection (1) and minimally invasive surgery was not included in the multimodal enhanced recovery after surgery (ERAS) pathway (2). Laparoscopic surgery (LPS) was associated with a shorter length of hospital stay than open surgery even when postoperative morbidity was similar (3). The common practice suggests that patients who underwent LPS quickly recover oral feeding, mobilization, and self-care ability. Therefore, it seems reasonable to combine a minimally invasive surgical technique and a stress-reducing perioperative pathway. Previous randomized studies, systematic reviews and meta-analyses reported better postoperative outcomes when LPS and ERAS protocols were associated (4-6).

Reply to: does utilization of laparoscopy improve successful adherence to enhanced recovery programs in colorectal surgery?

Fast-track surgery has been initially applied in patients undergoing open colorectal resection (1) and minimally invasive surgery was not included in the multimodal enhanced recovery after surgery (ERAS) pathway (2). Laparoscopic surgery (LPS) was associated with a shorter length of hospital stay than open surgery even when postoperative morbidity was similar (3). The common practice suggests that patients who underwent LPS quickly recover oral feeding, mobilization, and self-care ability. Therefore, it seems reasonable to combine a minimally invasive surgical technique and a stress-reducing perioperative pathway. Previous randomized studies, systematic reviews and meta-analyses reported better postoperative outcomes when LPS and ERAS protocols were associated (4-6).

Does utilization of laparoscopy improve successful adherence to enhanced recovery programs in colorectal surgery

For several decades, enhanced recovery pathways (ERPs) have been shown to improve outcomes for patients undergoing colorectal surgery.

Does utilization of laparoscopy improve successful adherence to enhanced recovery programs in colorectal surgery?

Does utilization of laparoscopy improve successful adherence to enhanced recovery programs in colorectal surgery?

Enhanced recovery program for colorectal surgery in cinical practice. Survey of surgeons of the Russian Federation

To analyze RF surgeons' attitude to accelerated recovery program (ERP) and to determine how often it is used in daily work. 223 physicians from 42 Russian regions were interviewed in 2017. ERP is unknown among 11.7% of specialists; 8.9% heard about ERP but did not think that it is used in the Russian Federation; 16.6% know but do not apply the program; 55.6% use some elements of ERP; complete application of ERP was found in 7.2% of surgeons. This technique is more often used by more active surgeons (p = 0.001) and less often - by female surgeons (p = 0.0066). The most controversial and difficult elements of ERP are administration of carbohydrate mixtures prior to surgery, optimal body temperature maintenance, restrictive protocol of infusion therapy, refusal mechanical intestinal depuration and routine abdominal drainage, and administrative control over the protocol. The majority of surgeons are ready to apply ERP. Some elements are difficult to apply for use in real healthcare. More educational activities are needed for wider and complete use of the protocol. New scientific available data should be used to improve this approach.

Increasing patient engagement to move enhanced recovery forward

We read with great interest “Ensuring Early Mobilization Within an Enhanced Recovery Program for Colorectal Surgery A Randomized Controlled Trial” in the August issue of Annals of Surgery , and applaud Fiore and Feldman for highlighting an important concept.

Ensuring Early Mobilization Within an Enhanced Recovery Program for Colorectal Surgery: A Randomized Controlled Trial.

To estimate the extent to which the addition of staff-directed facilitation of early mobilization to an Enhanced Recovery Program (ERP) impacts recovery after colorectal surgery, compared with usual care. Early mobilization is considered an important component of ERPs but, despite guidelines recommendations, adherence remains quite low. The value of dedicating specific resources (eg, staff time) to increase early mobilization is unknown. This randomized trial involved 99 colorectal surgery patients in an established ERP (median age 63, 57% male, 80% laparoscopic) randomized 1:1 to usual care (including preoperative education about early mobilization with postoperative daily targets) or facilitated mobilization [staff dedicated to assist transfers and walking from postoperative days (PODs) 0-3]. Primary outcome was the proportion of patients returning to preoperative functional walking capacity (6-min walk test) at 4 weeks after surgery. We also explored the association of the intervention with in-hospital mobilization, time to achieve discharge criteria, time to recover gastrointestinal function, 30-day comprehensive complication index, and patient-reported outcome measures. In the facilitated mobilization group, adherence to mobilization targets was greater on POD0 [OR 4.7 (95% CI 1.8-11.9)], POD1 [OR 6.5 (95% CI 2.3-18.3)], and POD2 [OR 3.7 (95% CI 1.2-11.3)]. Step count was at least 2-fold greater on POD1 [mean difference 843.3 steps (95% CI 219.5-1467.1)] and POD2 [mean difference 1099.4 steps (95% CI 282.7-1916.1)] There was no between-group difference in recovery of walking capacity at 4 weeks after surgery [OR 0.77 (95% CI 0.30-1.97)]. Other outcome measures were also not different between groups. In an ERP for colorectal surgery, staff-directed facilitation of early mobilization increased out-of-bed activities during hospital stay but did not improve outcomes. This study does not support the value of allocating additional resources to ensure early mobilization in ERPs. ClinicalTrials.gov Identifier: NCT02131844.

Effects of Epidural Analgesia on Recovery After Open Colorectal Surgery

The use of epidural analgesia (EA) has been suggested as an integral part of an enhanced recovery program for colorectal surgery. However, the effects of EA on postoperative outcomes and hospital length of stay remain controversial. Data from the American College of Surgeons National Surgical Quality Improvement Program database for 2014 and 2015 were queried for adult patients who underwent elective open colorectal surgery. We included only cases with general anesthesia as the main anesthetic. Cases with other types of anesthesia were excluded. A 1:3 matched sample of EA versus non-EA cases was created based on propensity scores. The primary outcome of interest was the occurrence of major cardiopulmonary complications within 7 days of the surgery. Secondary outcome measures were hospital length of stay and 30-day mortality. A total of 24,927 patients were included in the analysis. EA was utilized in 15.02% (n = 3745). The cumulative risk over the study period for major cardiopulmonary complications was 2.52% (n = 627). There were no statistically significant differences in the rate of postoperative complications (relative risk 0.91, 95% CI 0.66–1.27, P = 0.59), length of stay (median [interquartile range], EA 6 [5–9] versus non-EA 6 [4–9] days, P = 0.36), and 30-day mortality rate (relative risk 0.71, 95% CI 0.42–1.20, P = 0.20) between the two propensity-matched cohorts. In conclusion, our study revealed that the benefits of EA in patients undergoing open colorectal surgery are limited, as it does not influence immediate postoperative cardiopulmonary complications or hospital length of stay.

Motivational interviewing: examining its role when siting patients for stoma surgery

Stoma care nurses (SCNs) have long agreed that preoperative stoma siting is of benefit to patients who are to undergo stoma foramtion, as it can help to reduce postoperative complications. With the evolving use of enhanced recovery programmes in colorectal surgery, the value of preoperative stoma education has become essential to maximise the efficiency of the stoma patient's care pathway, enabling shorter hospital stays and facilitating psychological adaptation to life with a stoma. However, the traditional approach with which stoma siting has been undertaken could be considered autocratic, with the SCN as the expert and the patient passively accepting the agreed stoma site. This article explores whether, by using motivational interviewing when siting a patient for stoma surgery, SCNs can motivate prospective ostomates to not only consent to the stoma site, but to feel they have maintained control in the decision-making process leading to surgery, thereby preparing them to be independent in their stoma management.

Enhanced recovery programmes in colorectal surgery are less enhanced later in the week: An observational study.

SummaryObjectivesSince the introduction and favourable early results of the enhanced recovery programme more than a decade ago, it has become increasingly popular following major abdominal surgery. The programme has now been adopted in the UK. The aim of our study was to see if the day of surgery affected hospital stay and we compared patients who had colorectal surgery early in the week (Monday to Wednesday) with those who had it later in the week (Thursday to Friday).DesignPatient outcomes were studied between May 2010 and April 2011 from a prospectively maintained database. All colorectal surgeons involved in the enhanced recovery programme in our unit have a flexible rota and so no surgeon was operating on a particular day to avoid bias. An enhanced recovery programme protocol was utilised for all the patients with no bowel preparation, early feeding and early mobilisation.SettingStudy was carried out at the University Hospitals of Leicester.ParticipantsPatients undergoing elective colorectal resection between Monday and Friday.Main outcome measureHospital stay.ResultsTwo hundred and twenty-seven patients underwent surgery and were on the enhanced recovery programme during this period. Two (0.9%) patients who had surgery on a Sunday were excluded. Two hundred and twenty-five patients were analysed of which 155 (69%) were in the group (Monday to Wednesday) and 70 (31%) in the group (Thursday to Friday). No significant differences were observed amongst the groups for age (p = 0.129), sex (p = 0.555), tumour location (p = 0.140), operation performed (p = 0.127), type of surgery (laparoscopy or open, p = 0.892), complications (p = 0.428). However, a significant shorter length of stay was present in the first group six days (interquartile range: 4–10) versus eight days (interquartile range: 5–11) (p = 0.045).ConclusionOperating on colorectal patients early in the week is associated with a significant decreased hospital stay. This should be put into consideration by units practising enhanced recovery programme if the maximal benefit of this is to be attained.

An overview and methodological assessment of systematic reviews and meta-analyses of enhanced recovery programmes in colorectal surgery

ObjectivesTo identify and critically assess the extent to which systematic reviews of enhanced recovery programmes for patients undergoing colorectal surgery differ in their methodology and reported estimates of effect.DesignReview of...

Enhanced recovery programmes in colorectal surgery: clinical implications

Since the first successful colorectal resection in 1833 by Reybard of Lyons, surgeons have sought to improve technical and perioperative strategies to minimize morbidity and mortality in colorectal surgery. In the last 10 years, evidence-based medicine has questioned the routine use of mechanical bowel preparation, abdominal drains, nasogastric tubes and prolonged perioperative fasting. A greater understanding of the metabolic response to surgery has led to strategies to minimize the complex cytokine cascades and other neurohumoral factors. These concepts, with attention to social and medical factors within a multidisciplinary framework, are the foundations of enhanced recovery programmes.