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Zhu QQ, Qu L, Su T, Zhao X, Ma XP, Chen Z, Fu J, Xu GP. Risk Factors of Acute Pain in Elderly Patients After Laparoscopic Radical Resection of Colorectal Cancer. Surg Laparosc Endosc Percutan Tech 2024; 34:43-47. [PMID: 38091493 DOI: 10.1097/sle.0000000000001254] [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: 07/11/2023] [Accepted: 10/23/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE To investigate the risk factors of acute pain after laparoscopic radical resection of colorectal cancer (CRC) in elderly patients. METHODS Totally, 143 elderly patients (≥ 60 y old) who received laparoscopic radical resection of CRC in the People's Hospital of Xinjiang Uygur Autonomous Region from March 2021 to August 2022 were retrospectively analyzed. The patients were divided into 2 groups according to visual analog scale (VAS) scores 24 h after surgery: mild pain group (VAS score ≤ 3, n=108) and moderate to severe pain group (VAS score >3, n=35). The data of the patients, including sex, age, height, body mass, intraoperative blood loss, intraoperative urine volume, intraoperative opioid dosage, operation duration, preoperative Hospital Anxiety and Depression Scale (HADS) scores, preoperative Mini-Mental State Examination scores, VAS scores, postoperative nausea and vomiting scores were recorded. Multivariate logistic regression analysis was used to screen the risk factors of postoperative acute pain in elderly patients undergoing laparoscopic radical resection of CRC. RESULTS The preoperative HADS score of the moderate to severe pain group was significantly increased compared with that of the mild pain group (10.8±2.4 vs. 6.2±1.9), as well as the operation duration (226.4±18.3 vs. 186.1±12.7), the intraoperative dosage of remifentanil (3.7±0.2 vs. 3.2±0.4), the preoperative VAS score [4(2, 7) vs. 2 (0, 4)] and postoperative VAS score [5 (4, 6) vs. 3 (2, 3)] ( P <0.05). Multivariate logistic regression analysis showed that high preoperative HADS score, long operation duration, and high preoperative VAS score ( P <0.05) were independent risk factors for acute pain after laparoscopic radical resection of CRC in elderly patients. CONCLUSION Preoperative anxiety and depression, preoperative pain, and long operation duration are risk factors for acute pain in elderly patients after laparoscopic radical resection of CRC.
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Affiliation(s)
- Qian-Qian Zhu
- Department of Anesthesiology, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Clinical Research Center for Anesthesia Management, Urumqi, China
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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: 8] [Impact Index Per Article: 4.0] [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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Tian Y, Li Q, Pan Y. Prospective study of the effect of ERAS on postoperative recovery and complications in patients with gastric cancer. Cancer Biol Med 2021; 19:j.issn.2095-3941.2021.0108. [PMID: 34259423 PMCID: PMC9425188 DOI: 10.20892/j.issn.2095-3941.2021.0108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objective: To study the efficacy of the enhanced recovery after surgery (ERAS) program on postoperative recovery and complications in patients with gastric cancer. Methods: Eighty patients in the perioperative period with radical gastrectomy were enrolled and randomly divided into 2 groups, the ERAS group and the non-ERAS group. The differences between the 2 groups in terms of postoperative recoveries and complications rate were determined. According to the body mass index (BMI) level, the ERAS group was divided into 2 subgroups, namely group A (BMI < 28 kg/m2, n = 16) and group B (BMI ≥ 28 kg/m2, n = 24). The non-ERAS group was also divided into group C (BMI < 28 kg/m2, n = 18) and group D (BMI ≥ 28 kg/m2, n = 22). The recovery and complications of each group were then determined. Results: The postoperative length of stay and visual analogue scale pain score were less in the ERAS group than the non-ERAS group (P < 0.05). Time to first postoperative exhaustion, first postoperative defecation, returning leukocyte count to normal, and stopping intravenous nutrition were significantly shorter in the ERAS group (n = 40), compared to the non-ERAS group (n = 40, all P < 0.05). The incidence of postoperative lower extremity intramuscular venous thrombosis was significantly higher in group D than in group B (χ2 = 4.800, P = 0.028). In addition, the incidence of lower extremity intermuscular venous thrombosis and lung infection in group D was higher than those in other groups. Conclusions: The perioperative ERAS program was associated with faster recovery in patients undergoing radical gastrectomy. For patients with higher BMI (BMI ≥ 28 kg/m2), the use of the perioperative ERAS program was more advantageous.
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Affiliation(s)
- Ye Tian
- Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Qiang Li
- Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Yuan Pan
- Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
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Enhanced Recovery: A Decade of Experience and Future Prospects at the Mayo Clinic. HEALTHCARE (BASEL, SWITZERLAND) 2021; 9:healthcare9050549. [PMID: 34066696 PMCID: PMC8150975 DOI: 10.3390/healthcare9050549] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/26/2021] [Accepted: 04/12/2021] [Indexed: 02/07/2023]
Abstract
This work aims to describe the implementation and subsequent learnings from the first decade after the full implementation of enhanced recovery pathway for colorectal surgery at a single institution. This paper will describe the diffusion efforts and plans through the Define, Measure, Analyze, Improve, Control (DMAIC) process of ongoing quality improvement and through research efforts. The information applies to all readers that provide surgical care within their organization as the fundamental principles of enhanced recovery for surgery are applicable regardless of the setting.
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Liska D, Novello M, Cengiz BT, Holubar SD, Aiello A, Gorgun E, Steele SR, Delaney CP. Enhanced Recovery Pathway Benefits Patients Undergoing Nonelective Colorectal Surgery. Ann Surg 2021; 273:772-777. [PMID: 32697898 DOI: 10.1097/sla.0000000000003438] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim of our study was to determine if an enhanced recovery pathway (ERP) can successfully be applied in nonelective colorectal surgery. BACKGROUND ERPs have been shown to reduce hospital length of stay (LOS), complications, and costs after elective colorectal surgery. Yet, little data exist regarding the benefits of ERPs in patients undergoing nonelective colorectal surgery. We hypothesized that ERP implementation in a nonelective colorectal surgery population is associated with decreased postoperative LOS. METHODS A prospectively-maintained database was used to identify consecutive patients undergoing colorectal surgery after emergency room (ER) or hospital transfer admissions over a period from 2 years before until 1 year after implementation of a comprehensive ERP. The primary endpoint was LOS. Secondary endpoints included total LOS [TLOS = postoperative LOS + LOS of readmission(s)], readmission rates, complication rates, 30-day mortality, and hospital costs. Univariate and multivariate analyses were performed to assess the relationship between ERP implementation and LOS. RESULTS We identified 269 pre-ERP and 135 ERP patients fulfilling the inclusion criteria. Admit source (ER 43.4% vs transfers 56.7%), Charlson comorbidity index, American Society of Anesthesiologists (ASA) status, diagnosis (inflammatory bowel disease 45.8%, malignancy 19.6%, benign intestinal obstructions 10.4%, diverticulitis 9.4%, others 10.4%), and blood loss were comparable (P > 0.05) between the cohorts. Pre-ERP patients had a higher number of previous abdominal surgeries, whereas post-ERP patients had more laparoscopy and more compliance with ERP elements. ERP patients had a shorter postoperative LOS [6 (4, 10) vs 7 (5, 12) days; P = 0.0007]. Hospital costs were 13.4% lower (P = 0.004). Postoperative 30-day morbidity, mortality, and readmissions were comparable, although reoperation rate was higher in the ERP group. On multivariate analysis, ERP implementation and laparoscopy were the only modifiable variables independently associated with shorter LOS, whereas longer operative times and higher ASA classification were associated with longer LOS. CONCLUSIONS Patients undergoing nonelective colorectal surgery after ER or hospital transfer admission benefit from the use of an ERP, demonstrating decreased LOS and costs without an increase in complications.
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Affiliation(s)
- David Liska
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH
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Migliore M, Giuffrida MC, Marano A, Pellegrino L, Giraudo G, Barili F, Borghi F. Robotic versus laparoscopic right colectomy within a systematic ERAS protocol: a propensity-weighted analysis. Updates Surg 2020; 73:1057-1064. [PMID: 32086772 DOI: 10.1007/s13304-020-00722-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 02/08/2020] [Indexed: 02/06/2023]
Abstract
The purpose of this study is to compare the early postoperative and pathological outcomes of robotic right colectomy (RRC) to those of laparoscopic right colectomy (LRC) with intracorporeal anastomosis (IA) within the systematic application of an enhanced recovery after surgery (ERAS) program. A single-institution prospective database of patients who underwent elective RRC or LRC with IA for neoplastic lesions between April 2010 and June 2018 was retrospectively reviewed. The patients' demographic characteristics, and perioperative and pathological outcomes were analyzed. Propensity-weighted analysis was employed to address potential selection biases of treatment allocation. A total of 216 patients (46 RRC, 170 LRC) were included. RRC demonstrated a significantly longer operative time (mean 242.43 min, SD 47.51) compared to LRC (mean 187.60 min, SD 56.60) (p = 0.001), confirmed by the propensity-weighted analysis (Coefficient 50.65; p < 0.001). Conversion rate between the two groups was comparable (p = 0.99). Median length of hospital stay (LOS) was the same in the RRC and the LRC group (4 days, p = 0.35). Readmission rate within 30 days in the RRC and LRC group was 2.2% and 2.4%, respectively (p = 0.99). Overall 30-day morbidity and 30-day mortality was 32.6% versus 27.1% (p = 0.46), and 0% versus 1.2% (p = 0.99) in the robotic and laparoscopic groups, respectively. No difference was found in the number of harvested lymph nodes (p = 0.75). In an ERAS environment, without the bias of mixed techniques of anastomosis, RRC had similar postoperative and pathological outcomes compared to the laparoscopic approach, but was associated with a longer operative time.
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Affiliation(s)
- Marco Migliore
- Department of Surgery, General and Oncologic Surgery Unit, Santa Croce e Carle Hospital, 12100, Cuneo, Italy
| | - Maria Carmela Giuffrida
- Department of Surgery, General and Oncologic Surgery Unit, Santa Croce e Carle Hospital, 12100, Cuneo, Italy
| | - Alessandra Marano
- Department of Surgery, General and Oncologic Surgery Unit, Santa Croce e Carle Hospital, 12100, Cuneo, Italy
| | - Luca Pellegrino
- Department of Surgery, General and Oncologic Surgery Unit, Santa Croce e Carle Hospital, 12100, Cuneo, Italy
| | - Giorgio Giraudo
- Department of Surgery, General and Oncologic Surgery Unit, Santa Croce e Carle Hospital, 12100, Cuneo, Italy
| | - Fabio Barili
- Department of Cardiac Surgery, Santa Croce e Carle Hospital, 12100, Cuneo, Italy
| | - Felice Borghi
- Department of Surgery, General and Oncologic Surgery Unit, Santa Croce e Carle Hospital, 12100, Cuneo, Italy.
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Liska D, Bora Cengiz T, Novello M, Aiello A, Stocchi L, Hull TL, Steele SR, Delaney CP, Holubar SD. Do Patients With Inflammatory Bowel Disease Benefit from an Enhanced Recovery Pathway? Inflamm Bowel Dis 2020; 26:476-483. [PMID: 31372647 DOI: 10.1093/ibd/izz172] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Enhanced recovery pathways (ERPs) have been shown to reduce length of stay (LOS), complications, and costs after colorectal surgery; yet, little data exists regarding patients with inflammatory bowel disease (IBD). We hypothesized that implementation of ERP for IBD patients is associated with shorter LOS and improved economic outcomes. METHODS An IRB-approved prospective clinical database was used to identify consecutive patients from 2015 to 2017. Patients were grouped as "pre-ERP" and "post-ERP" based on the date of implementation of a comprehensive ERP. Ileostomy closures, redo pouch operations, and outpatient operations were excluded. The relationship between ERP, LOS, and secondary outcomes was assessed using univariate and multivariate analysis. RESULTS Overall, a total of 671 patients were included: 345 (51.4%) with Crohn's disease (CD) and 326 (48.6%) with ulcerative colitis (UC). Of these, 425 were pre-ERP (63.4%), and 246 were post-ERP (36.6%). The groups did not differ in terms of age, gender, American Society of Anesthesiologist (ASA) scores, comorbidities, estimated blood loss, or ostomy construction. The post-ERP group had a significantly higher mean body mass index (BMI), more patients with CD, longer operative time, and more minimally invasive surgery (MIS; all P < 0.05). The post-ERP group had a significantly shorter LOS (6 vs 4.5 days, median), whereas mean hospital costs decreased by 15.7%. There was no difference in readmissions or complications. On multivariate analysis, MIS and ERP use were both associated with a shorter LOS. CONCLUSION Inflammatory bowel disease patients benefit from the use of ERP, demonstrating decreased LOS and costs without an increase in complications and readmissions. Enhanced recovery pathways should be routinely implemented in this often challenging patient population.
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Affiliation(s)
- David Liska
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA
| | - Turgut Bora Cengiz
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA
| | - Matteo Novello
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA
| | - Alexandra Aiello
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA
| | - Luca Stocchi
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA
| | - Tracy L Hull
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA
| | - Stefan D Holubar
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA
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Momeni A, Ramesh NK, Wan D, Nguyen D, Sorice SC. Postoperative analgesia after microsurgical breast reconstruction using liposomal bupivacaine (Exparel). Breast J 2019; 25:903-907. [DOI: 10.1111/tbj.13349] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 08/27/2018] [Accepted: 08/28/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Arash Momeni
- Division of Plastic and Reconstructive Surgery Stanford University Medical Center Palo Alto California
| | - Navneet K. Ramesh
- Division of Plastic and Reconstructive Surgery Stanford University Medical Center Palo Alto California
| | - Derrick Wan
- Division of Plastic and Reconstructive Surgery Stanford University Medical Center Palo Alto California
| | - Dung Nguyen
- Division of Plastic and Reconstructive Surgery Stanford University Medical Center Palo Alto California
| | - Sarah C. Sorice
- Division of Plastic and Reconstructive Surgery Stanford University Medical Center Palo Alto California
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Li Z, Zhao Q, Bai B, Ji G, Liu Y. Enhanced Recovery After Surgery Programs for Laparoscopic Abdominal Surgery: A Systematic Review and Meta-analysis. World J Surg 2018; 42:3463-3473. [PMID: 29750324 DOI: 10.1007/s00268-018-4656-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols or laparoscopic technique has been applied in various surgical procedures. However, the clinical efficacy of combination of the two methods still remains unclear. Thus, our aim was to assess the role of ERAS protocols in laparoscopic abdominal surgery. METHODS We performed a systematic literature search in various databases from January 1990 to October 2017. The results were analyzed according to predefined criteria. RESULTS In the present meta-analysis, the outcomes of 34 comparative studies (15 randomized controlled studies and 19 non-randomized controlled studies) enrolling 3615 patients (1749 in the ERAS group and 1866 in the control group) were pooled. ERAS group was associated with shorter hospital stay (WMD - 2.37 days; 95% CI - 3.00 to - 1.73; P 0.000) and earlier time to first flatus (WMD - 0.63 days; 95% CI - 0.90 to - 0.36; P 0.000). Meanwhile, lower overall postoperative complication rate (OR 0.62; 95% CI 0.51-0.76; P 0.000) and less hospital cost (WMD 801.52 US dollar; 95% CI - 918.15 to - 684.89; P 0.000) were observed in ERAS group. Similar readmission rate (OR 0.73, 95% CI 0.52-1.03, P 0.070) and perioperative mortality (OR 1.33; 95% CI 0.53-3.34; P 0.549) were found between the two groups. CONCLUSIONS ERAS protocol for laparoscopic abdominal surgery is safe and effective. ERAS combined with laparoscopic technique is associated with faster postoperative recovery without increasing readmission rate and perioperative mortality.
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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.
| | - Qingchuan Zhao
- 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
| | - Gang Ji
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China
| | - Yezhou Liu
- 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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Efficacy and Outcomes of Intrathecal Analgesia as Part of an Enhanced Recovery Pathway in Colon and Rectal Surgical Patients. Surg Res Pract 2018; 2018:8174579. [PMID: 29687077 PMCID: PMC5852855 DOI: 10.1155/2018/8174579] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 12/28/2017] [Indexed: 12/12/2022] Open
Abstract
Purpose Multimodal analgesia is an essential component of an enhanced recovery pathway (ERP). An ERP that includes the use of single-injection intrathecal analgesia (IA) has been shown to decrease morbidity and cost and shorten length of stay (LOS). Limited data exist on safety, feasibility, and the optimal IA regimen. Our objective was to characterize the efficacy, safety, and feasibility of IA within an ERP in a cohort of colorectal surgical patients. Methods We performed a retrospective review of all consecutive patients aged ≥ 18 years who underwent open or minimally invasive colorectal surgery from October 2012 to December 2013. All patients were enrolled in an institutional ERP that included the use of single-injection IA. Demographics, anesthetic management, efficacy (pain scores and opiate consumption), postoperative ileus (POI), adverse effects, and LOS are reported. Results 601 patients were identified. The majority received opioid-only IA (91%) rather than a multimodal regimen. Median LOS was 3 days. Overall rate of ileus was 16%. Median pain scores at 4, 8, 16, 24, and 48 hours were 3, 2, 3, 4, and 3, respectively. There was no difference in postoperative pain scores, LOS, or POI based on intrathecal medication or dose received. Overall, development of respiratory depression (0.2%) or pruritus (1.2%) was rare. One patient required blood patch for postdural headache. Conclusion Intrathecal analgesia is safe, feasible, and efficacious in the setting of ERP for colorectal surgery. All regimens and doses achieved a short LOS, low pain scores, and a low incidence of POI. This trial is registered with Clinicaltrails.gov NCT03411109.
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Luglio G, Terracciano F, Giglio MC, Sacco M, Peltrini R, Sollazzo V, Spadarella E, Bucci C, De Palma GD, Bucci L. Ileostomy reversal with handsewn techniques. Short-term outcomes in a teaching hospital. Int J Colorectal Dis 2017; 32:113-118. [PMID: 27599702 DOI: 10.1007/s00384-016-2645-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2016] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Fecal diversion is considered an effective procedure to protect bowel anastomosis at high risk for leak. Some concerns exist regarding the risk for a significant morbidity associated to ileostomy creation itself and moreover to its closure. Surgical expertise and closure techniques are considered potential factors influencing morbidity. Aim of the study is to present a single-institution experience with ileostomy closures, in a teaching hospital, whereas ileostomy reversal is mainly performed by young residents. METHODS A prospective database was investigated to extract data of patients who underwent loop ileostomy closure between January 2005 and December 2014. Ileostomy reversion was always realized in a handsewn fashion, performing either a direct closure (DC) or a resection plus end-to-end anastomosis (EEA). Postoperative morbidity was graded according to Clavien-Dindo classification. Outcomes after DC and EEA were compared by Fisher's exact test and Wilcoxon rank-sum test. RESULTS Two hundred ninety-eight patients were included. Ileostomy reversal was performed by EEA in 236 patients (79.19 %) and by DC in 62 patients (20.81 %). Surgery was performed with a peristomal access in 296 cases (99.33 %). Incidence of anastomotic leak was 0.67 % (2/298). Overall reoperation rate was 0.34 % (1/298). Short-term overall morbidity rate was 20.47 %; but major complications (≥ grade III) occurred in only one patient (0.34 %). Mortality was nil. No significant differences in postoperative morbidity were found between the DC and EEA group. CONCLUSION Loop ileostomy reversal is a safe procedure, associated to a low major morbidity and excellent results, even if performed with a handsewn technique by supervised trainee surgeons.
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Affiliation(s)
- Gaetano Luglio
- Department of Clinical Medicine and Surgery, University of Naples Federico II-Italy, Via Stellato, 26, 81054, San Prisco, CE, Italy.
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Napoli, Italy.
| | - Francesco Terracciano
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Napoli, Italy
| | - Mariano Cesare Giglio
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Napoli, Italy
| | - Michele Sacco
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Napoli, Italy
| | - Roberto Peltrini
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Napoli, Italy
| | - Viviana Sollazzo
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Napoli, Italy
| | - Emanuela Spadarella
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Napoli, Italy
| | - Cristina Bucci
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Napoli, Italy
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Napoli, Italy
| | - Luigi Bucci
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Napoli, Italy
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Khoury W, Dakwar A, Sivkovits K, Mahajna A. Fast-track rehabilitation accelerates recovery after laparoscopic colorectal surgery. JSLS 2016; 18:JSLS-D-14-00076. [PMID: 25489207 PMCID: PMC4254471 DOI: 10.4293/jsls.2014.00076] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Fast-track (FT) rehabilitation protocols have been shown to be successful in reducing both hospital stay and postoperative complications, as well as enhancing overall postoperative patient recovery. We are reporting the outcomes of our first group of patients undergoing colorectal surgery following the FT protocol. PATIENTS AND METHODS We performed a prospective study of patients, between January 1, 2007 and January 31, 2010, who underwent laparoscopic colorectal resections in accordance with the guidelines of FT rehabilitation protocol. Recovery parameters including time to removal of naso-gastric tube and urinary catheter, time to bowel function and to resume diet, and length of hospital stay were evaluated. Postoperative outcomes, that is, postoperative complications and mortality, reoperations, and readmissions were also studied. RESULTS A total of 71 patients, 30 women and 41 men, underwent FT rehabilitation for laparoscopic colorectal surgery. The mean age of the patients was 60 ± 16 years. The most common surgical procedures were right hemicolectomy 30% and anterior resection 27%. Liquid and regular diet were initiated on postoperative day 1.2 ± 0.4 and 2.1 ± 0.4, respectively. Overall postoperative morbidity was 8.5%. The mean length of stay was 4.4 ± 1.7 days, with only 3 readmissions. Forty-five patients fulfilled the FT care plan and were discharged on postoperative day 3. No reoperations or mortality were observed. CONCLUSIONS FT rehabilitation results in favorable postoperative outcomes. Our data provides evidence and suggests that FT protocols should be implemented as a reliable method of preparation and recovery for laparoscopic colorectal surgery.
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Affiliation(s)
- Wisam Khoury
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Anthony Dakwar
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Krina Sivkovits
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ahmad Mahajna
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
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Clark CJ, Ali SM, Zaydfudim V, Jacob AK, Nagorney DM. Safety of an Enhanced Recovery Pathway for Patients Undergoing Open Hepatic Resection. PLoS One 2016; 11:e0150782. [PMID: 26950852 PMCID: PMC4780831 DOI: 10.1371/journal.pone.0150782] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 02/17/2016] [Indexed: 01/22/2023] Open
Abstract
Background Enhanced recovery pathways (ERP) have not been widely implemented for hepatic surgery. The aim of this study was to evaluate the safety of an ERP for patients undergoing open hepatic resection. Methods A single-surgeon, retrospective observational cohort study was performed comparing the clinical outcomes of patients undergoing open hepatic resection treated before and after implementation of an ERP. Morbidity, mortality, and length of hospital stay (LOS) were compared between pre-ERP and ERP groups. Results 126 patients (pre-ERP n = 73, ERP n = 53) were identified for the study. Patient characteristics and operative details were similar between groups. Overall complication rate was similar between pre-ERP and ERP groups (37% vs. 28%, p = 0.343). Before and after pathway implementation, the median LOS was similar, 5 (IQR 4–7) vs. 5 (IQR 4–6) days, p = 0.708. After adjusting for age, type of liver resection, and ASA, the ERP group had no increased risk of major complication (OR 0.38, 95% CI 0.14–1.02, p = 0.055) or LOS greater than 5 days (OR 1.21, 95% CI 0.56–2.62, p = 0.627). Conclusions Routine use of a multimodal ERP is safe and is not associated with increased postoperative morbidity after open hepatic resection.
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Affiliation(s)
- Clancy J. Clark
- Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, United States of America
- * E-mail:
| | - Shahzad M. Ali
- Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Victor Zaydfudim
- Department of General Surgery, University of Virginia, Charlottesville, Virginia, United States of America
| | - Adam K. Jacob
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - David M. Nagorney
- Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota, United States of America
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Day RW, Fielder S, Calhoun J, Kehlet H, Gottumukkala V, Aloia TA. Incomplete reporting of enhanced recovery elements and its impact on achieving quality improvement. Br J Surg 2015; 102:1594-1602. [PMID: 26364714 DOI: 10.1002/bjs.9918] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 06/03/2015] [Accepted: 07/16/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Enhanced recovery (ER) protocols are used widely in surgical practice. As protocols are multidisciplinary with multiple components, it is difficult to compare and contrast reports. The present study examined compliance and transferability to clinical practice among ER publications related to colorectal surgery. METHODS PubMed, Embase and Cochrane Central Register databases were searched for current colorectal ER manuscripts. Each publication was assessed for the number of ER elements, whether the element was explained sufficiently so that it could be transferred to clinical practice, and compliance with the ER element. RESULTS Some 50 publications met the reporting criteria for inclusion. A total of 22 ER elements were described. The median number of elements included in each publication was 9, and the median number of included patients was 130. The elements most commonly included in ER pathways were early postoperative diet advancement (49, 98 per cent) and early mobilization (47, 94 per cent). Early diet advancement was sufficiently explained in 43 (86 per cent) of the 50 publications, but only 22 (45 per cent) of 49 listing the variable reported compliance. The explanation for early mobilization was satisfactory in 41 (82 per cent) of the 50 publications, although only 14 (30 per cent) of 47 listing the variable reported compliance. Other ER elements had similar rates of explanation and compliance. The most frequently analysed outcome measures were morbidity (49, 98 per cent), length of stay (47, 94 per cent) and mortality (45, 90 per cent). CONCLUSION The current standard of reporting is frequently incomplete. To transfer knowledge and facilitate implementation of pathways that demonstrate improvements in perioperative care and recovery, a consistent structured reporting platform is needed.
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Affiliation(s)
- Ryan W Day
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Herman Pressler, Unit 1484, Houston, Texas 77030
| | - Sharon Fielder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Herman Pressler, Unit 1484, Houston, Texas 77030
| | - John Calhoun
- Institute for Cancer Care Innovation at The University of Texas MD Anderson Cancer Center, 1400 Herman Pressler, Unit 1484, Houston, Texas 77030
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet Copenhagen University, Denmark
| | - Vijaya Gottumukkala
- Department of Anaesthesia, The University of Texas MD Anderson Cancer Center, 1400 Herman Pressler, Unit 1484, Houston, Texas 77030
| | - Thomas A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Herman Pressler, Unit 1484, Houston, Texas 77030
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Systematic review and meta-analysis for laparoscopic versus open colon surgery with or without an ERAS programme. Surg Endosc 2015; 29:3443-53. [PMID: 25801106 PMCID: PMC4648973 DOI: 10.1007/s00464-015-4148-3] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 02/13/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND In recent years, conventional colorectal resection and its aftercare have increasingly become replaced by laparoscopic surgery and enhanced recovery after surgery (ERAS) pathways, respectively. OBJECTIVE To ascertain whether combining laparoscopy and ERAS have additional value within colorectal surgery. METHODS A systematic review with meta-analysis was performed with two primary research questions; does laparoscopy offer an advantage when all patients receive ERAS perioperative care and does ERAS offer advantages in a laparoscopically operated patient population. All randomised and controlled clinical trials were identified using MEDLINE, EMBASE and Cochrane databases. RESULTS Primary search resulted in 319 hits. After inclusion criteria were applied, three RCTs and six CCTs were included in the meta-analysis. For laparoscopically operated patients with/without ERAS, no differences in morbidity were found and postoperative hospital stay favoured ERAS (MD -2.34 [-3.77, -0.91], Z = 3.20, p = 0.001). When comparing laparoscopy and open surgery within ERAS, major morbidity was significantly reduced in the laparoscopic group (OR 0.42 [0.26, 0.66], Z = 3.73, p = 0.006). Other outcome parameters showed no differences. Quality of included studies was considered moderate to poor overall with small sample sizes. CONCLUSION When laparoscopy and ERAS are combined, major morbidity and hospital stay are reduced. The reduction in morbidity seems to be due to laparoscopy rather than ERAS, so laparoscopy by itself offers independent advantages beyond ERAS care. Quality of included studies was moderate to poor, so conclusions should be regarded with some reservations.
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Zhao JH, Sun JX, Gao P, Chen XW, Song YX, Huang XZ, Xu HM, Wang ZN. Fast-track surgery versus traditional perioperative care in laparoscopic colorectal cancer surgery: a meta-analysis. BMC Cancer 2014; 14:607. [PMID: 25148902 PMCID: PMC4161840 DOI: 10.1186/1471-2407-14-607] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 08/20/2014] [Indexed: 12/21/2022] Open
Abstract
Background Both laparoscopic and fast-track surgery (FTS) have shown some advantages in colorectal surgery. However, the effectiveness of using both methods together is unclear. We performed this meta-analysis to compare the effects of FTS with those of traditional perioperative care in laparoscopic colorectal cancer surgery. Methods We searched the PubMed, EMBASE, Cochrane Library, and Ovid databases for eligible studies until April 2014. The main end points were the duration of the postoperative hospital stay, time to first flatus after surgery, time of first bowel movement, total postoperative complication rate, readmission rate, and mortality. Results Five randomized controlled trials and 5 clinical controlled trials with 1,317 patients were eligible for analysis. The duration of the postoperative hospital stay (weighted mean difference [WMD], –1.64 days; 95% confidence interval [CI], –2.25 to –1.03; p < 0.001), time to first flatus (WMD, –0.40 day; 95% CI, –0.77 to –0.04; p = 0.03), time of first bowel movement (WMD, –0.98 day; 95% CI, –1.45 to –0.52; p < 0.001), and total postoperative complication rate (risk ratio [RR], 0.67; 95% CI, 0.56–0.80; p < 0.001) were significantly reduced in the FTS group. No significant differences were noted in the readmission rate (RR, 0.64; 95% CI, 0.41–1.01; p = 0.06) or mortality (RR, 1.55; 95% CI, 0.42–5.71; p = 0.51). Conclusion Among patients undergoing laparoscopic colorectal cancer surgery, FTS is associated with a significantly shorter postoperative hospital stay, more rapid postoperative recovery, and, notably, greater safety than is expected from traditional care.
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Affiliation(s)
| | | | | | | | | | | | | | - Zhen-Ning Wang
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang 110001, People's Republic of China.
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Zhao LY, Liu H, Wang YN, Deng HJ, Xue Q, Li GX. Techniques and feasibility of laparoscopic extended right hemicolectomy with D3 lymphadenectomy. World J Gastroenterol 2014; 20:10531-10536. [PMID: 25132772 PMCID: PMC4130863 DOI: 10.3748/wjg.v20.i30.10531] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 03/23/2014] [Accepted: 04/28/2014] [Indexed: 02/06/2023] Open
Abstract
AIM To illustrate the critical techniques and feasibility of laparoscopic extended right hemicolectomy (LERH), according to our previous experience. METHODS Anatomical relationship and operative techniques were demonstrated. One hundred and five consecutive patients who underwent extended right hemicolectomy with D3 lymphadenectomy between January 2008 and May 2011 were included in the present study [laparoscopic group (n = 48) vs open group (n = 57)]. RESULTS The right retrocolic space was the main surgical plan of the LERH. The superior mesenteric vein was the most important anatomical landmark for vascular dissection. The medial-to-lateral dissection approach made the LERH performed efficiently. Compared with the open group, the LERH group had less blood loss (111.7 ± 127.8 mL vs 170.2 ± 49.7 mL, P = 0.023), faster return of flatus (3.0 ± 1.6 d vs 3.7 ± 1.3 d, P = 0.019), and earlier diet (4.2 ± 1.4 d vs 5.0 ± 1.2 d, P = 0.005). Five patients (10.4%) underwent conversion during laparoscopic surgery. The cancer recurrence rates between the two groups were comparable (laparoscopic vs open, 8.6% vs 9.1%, P = 0.335). CONCLUSION For an advanced tumor located at the hepatic flexure or proximal transverse colon, LERH with D3 lymphadenectomy using a medial-to-lateral approach seems to be safe and feasible when the superior mesenteric vein serves as the main anatomical landmark and the right retrocolic space severed as the surgical plan.
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Lovely JK, Larson DW, Quast JM. A Clinical Practice Agreement Between Pharmacists and Surgeons Streamlines Medication Management. Jt Comm J Qual Patient Saf 2014; 40:296-302. [DOI: 10.1016/s1553-7250(14)40039-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Zhao LY, Chi P, Ding WX, Huang SR, Zhang SF, Pan K, Hu YF, Liu H, Li GX. Laparoscopic vs open extended right hemicolectomy for colon cancer. World J Gastroenterol 2014; 20:7926-7932. [PMID: 24976728 PMCID: PMC4069319 DOI: 10.3748/wjg.v20.i24.7926] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 01/22/2014] [Accepted: 03/08/2014] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the feasibility, safety, and oncologic outcomes of laparoscopic extended right hemicolectomy (LERH) for colon cancer. METHODS Since its establishment in 2009, the Southern Chinese Laparoscopic Colorectal Surgical Study (SCLCSS) group has been dedicated to promoting patients' quality of life through minimally invasive surgery. The multicenter database was launched by combining existing datasets from members of the SCLCSS group. The study enrolled 220 consecutive patients who were recorded in the multicenter retrospective database and underwent either LERH (n = 119) or open extended right hemicolectomy (OERH) (n = 101) for colon cancer. Clinical characteristics, surgical outcomes, and oncologic outcomes were compared between the two groups. RESULTS There were no significant differences in terms of age, gender, body mass index (BMI), history of previous abdominal surgery, tumor location, and tumor stage between the two groups. The blood loss was lower in the LERH group than in the OERH group [100 (100-200) mL vs 150 (100-200) mL, P < 0.0001]. The LERH group was associated with earlier first flatus (2.7 ± 1.0 d vs 3.2 ± 0.9 d, P < 0.0001) and resumption of liquid diet (3.6 ± 1.0 d vs 4.2 ± 1.0 d, P < 0.0001) compared to the OERH group. The postoperative hospital stay was significantly shorter in the LERH group (11.4 ± 4.7 d vs 12.8 ± 5.6 d, P = 0.009) than in the OERH group. The complication rate was 11.8% and 17.6% in the LERH and OERH groups, respectively (P = 0.215). Both 3-year overall survival [LERH (92.0%) vs OERH (84.4%), P = 0.209] and 3-year disease-free survival [LERH (84.6%) vs OERH (76.6%), P = 0.191] were comparable between the two groups. CONCLUSION LERH with D3 lymphadenectomy for colon cancer is a technically feasible and safe procedure, yielding comparable short-term oncologic outcomes to those of open surgery.
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Larson DW, Lovely JK, Cima RR, Dozois EJ, Chua H, Wolff BG, Pemberton JH, Devine RR, Huebner M. Outcomes after implementation of a multimodal standard care pathway for laparoscopic colorectal surgery. Br J Surg 2014; 101:1023-30. [PMID: 24828373 DOI: 10.1002/bjs.9534] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of the study was to assess which aspects of an enhanced recovery programme are associated with better outcomes following laparoscopic colorectal surgery. METHODS A database of laparoscopic colorectal procedures performed in 2011 was reviewed. Elements of the enhanced recovery programme and compliance were evaluated for short-term (30-day) outcomes. Individual elements included gabapentin, celecoxib, intrathecal analgesia, diet, postoperative fluids, and paracetamol/non-steroidal anti-inflammatory drug pain management. RESULTS Five hundred and forty-one consecutive procedures were included. Compliance with the enhanced recovery programme elements ranged from 82.4 to 99.3 per cent. Median length of hospital stay was 3 (i.q.r. 2-5) days, with 25.9 per cent of patients discharged within 48 h. Patients without complications had a median length of stay of 3 (i.q.r. 2-4) days if compliant and 3 (3-5) days if not (P < 0.001). Low oral opiate intake (oral morphine equivalent of less than 30 mg) (odds ratio (OR) 1.97, 95 per cent confidence interval 1.29 to 3.03; P = 0.002), full compliance (OR 2.36, 1.42 to 3.90; P < 0.001) and high surgeon volume (more than 100 cases per year) (OR 1.50, 1.19 to 1.89; P < 0.001) were associated with discharge within 48 h. Compliance with the elements of oral intake and fluid management in the first 48 h was associated with a reduced rate of complications (8.1 versus 19.6 per cent; P = 0.001). Median oral opiate intake was 37.5 (i.q.r. 0-105) mg in 48 h, with 26.2 per cent of patients receiving no opiates. CONCLUSION Compliance with an enhanced recovery pathway was associated with less opiate use, fewer complications and a shorter hospital stay.
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Affiliation(s)
- D W Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
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Improving conventional recovery with enhanced recovery in minimally invasive surgery for rectal cancer. Dis Colon Rectum 2014; 57:557-63. [PMID: 24819094 DOI: 10.1097/dcr.0000000000000101] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Enhanced recovery pathways have been shown to decrease the length of hospital stay in patients undergoing colorectal surgery. Few reports have studied patients undergoing minimally invasive surgery for rectal cancer. OBJECTIVE Our aim was to review our experience in minimally invasive rectal cancer surgery. We report short-term outcomes and evaluate the potential advantages of the enhanced recovery protocol compared with our less intensive conventional pathway. DESIGN This is a consecutive retrospective study of all minimally invasive rectal cancers treated from February 2005 to December 2011. Multivariable logistic regression models were constructed to identify factors contributing to a short length of stay. SETTINGS This study was performed at Mayo Clinic, Rochester, Minnesota, between 2005 and 2011. PATIENTS A total of 346 patients were retrospectively reviewed. Seventy-eight patients were managed under the enhanced recovery pathway. Patients underwent either laparoscopic-, robotic-, or hand-assisted laparoscopic surgery for rectal cancer. INTERVENTIONS All patients followed either a standardized conventional pathway or an enhanced recovery pathway for perioperative care. MAIN OUTCOME MEASURES The primary outcome was the length of stay. Secondary outcomes were postoperative complications and 30-day readmissions. RESULTS Hospital stay was significantly decreased for patients who underwent minimally invasive surgery for rectal cancer and were managed with an enhanced recovery protocol, 4.1 days, vs 6.1 days for the conventional pathway (95% CI, -2.9 to -1.2 days; p < 0.0001). Rates of complications were similar between the 2 groups. Factors associated with shorter length of stay included the enhanced recovery protocol and laparoscopic or robotic surgery compared with hand-assisted laparoscopic surgery. LIMITATIONS This was a retrospective study at a single institution. Additional limitations include the comparison with historical controls and the potential for selection bias. CONCLUSION The enhanced recovery pathway is associated with a significantly decreased length of hospital stay after minimally invasive surgery for rectal cancer in this series. Decreased hospital stay was achieved without affecting short-term outcomes.
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Gianotti L, Beretta S, Luperto M, Bernasconi D, Valsecchi MG, Braga M. Enhanced recovery strategies in colorectal surgery: is the compliance with the whole program required to achieve the target? Int J Colorectal Dis 2014; 29:329-341. [PMID: 24337781 DOI: 10.1007/s00384-013-1802-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE The complexity of "fast track" (FT) surgery might decrease its applicability in daily practice and extensive diffusion. The aim of this study was to understand if the positive effect of FT on the outcome might be affected by the number, type, level of evidence of the components, or their possible combinations. METHODS We performed a Medline, Embase, Pubmed, and Cochrane Library literature search of randomized and non-randomized trials comparing FT to conventional care (CC) in elective colorectal operations. By a meta-analytic approach, the effect of FT was estimated by the risk ratio (RR) with a 95 % confidence interval (CI) for the risk of post-operative complications. RESULTS The analysis included 53 studies (36 non-RCTs with and 17 RCTs), with 4,100 patients in the FT group and 4,424 patients in the CC group for a total of 8,524 patients. Fifty-six different item combinations were observed. The median rate of strategy implementation was 50 %. The positive effect of FT over CC was observed regardless the number (<10 vs. ≥10) of strategies used (RR = 0.80; 95 % CI 0.66-0.98 and RR = 0.75; 95 % CI 0.65-0.87, respectively), the application of items with strong vs. low level evidence (RR = 0.78; 95 % CI 0.67-0.90 and RR = 0.76; 95 % CI 0.63-0.92, respectively), or the frequency (≥80 vs. <80 %) of items implemented (RR = 0.80; 95 % CI 0.69-0.93 and RR = 0.73; 95 % CI 0.61-0.87, respectively). CONCLUSION The positive effects of FT seem to be achieved regardless the multiplicity and variance of item grouping.
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Affiliation(s)
- Luca Gianotti
- Department of Surgery and Translational Medicine, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy,
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"How I do it"--radical right colectomy with side-to-side stapled ileo-colonic anastomosis. J Gastrointest Surg 2012; 16:1605-9. [PMID: 22639375 DOI: 10.1007/s11605-012-1909-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 04/30/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND OBJECTIVE Standardization of surgical technique helps to reproduce excellent clinical outcomes, especially in teaching institutions. We aim to describe in detail our established approach for oncological right colectomy. TECHNIQUE The right colon is mobilized in a five-step latero-inferior approach starting off with the terminal ileum, visualizing the duodenum and the head of pancreas. The ascending colon is dissected from the retroperitoneum, and takedown of the hepatic flexure is completed coming retrograde from the transverse colon. Transection of the remaining retroperitoneal attachments completes exposure of the duodenum and mobilization of the right colon. Ileocolic vessels are dissected out and divided close to their origin, and the mesocolon is divided. We then establish intestinal continuity by use of a side-to-side stapled technique. The arms of a linear cutting stapler are inserted via transverse incisions at the anti-mesenteric sides of the terminal ileum and the transverse colon (tenia) and fired. The enterotomy site is closed by removal of the specimen using a second transverse firing of the linear cutting stapler. An important final step is the reinforcement of the anastomotic ends and the crossing of the staple lines; an omental patch and closure of the mesenteric window are optional. CONCLUSION The suggested standardized five-step lateral-to-medial dissection of the right colon and the three-step side-to-side stapled technique for ileo-colonic anastomosis are easy to learn and to reproduce. Careful adherence to pivotal technical details will help to obtain an optimal oncological outcome and a consistently low leak rate around 2%.
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Immunologic response after laparoscopic colon cancer operation within an enhanced recovery program. J Gastrointest Surg 2012; 16:1379-88. [PMID: 22585532 DOI: 10.1007/s11605-012-1880-z] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 03/22/2012] [Indexed: 01/31/2023]
Abstract
OBJECTIVE It has been demonstrated that colon operation combined with fast-track (FT) surgery and laparoscopic technique can shorten the length of hospital stay, accelerate recovery of intestinal function, and reduce the occurrence of post-operative complications. However, there are no reports regarding the combined effects of FT colon operation and laparoscopic technique on humoral inflammatory cellular immunity. METHODS This was a prospective, controlled study. One hundred sixty-three colon cancer patients underwent the traditional protocol and open operation (traditional open group, n=42), the traditional protocol and laparoscopic operation (traditional laparoscopic group, n=40), the FT protocol and open operation (FT open group, n=41), or the FT protocol and laparoscopic operation (FT laparoscopic group, n=40). Blood samples were taken prior to operation as well as on days 1, 3, and 5 after operation. The number of lymphocyte subpopulations was determined by flow cytometry, and serum interleukin-6 and C-reactive protein levels were measured. Post-operative hospital stay, post-operative morbidity, readmission rate, and in-hospital mortality were recorded. RESULTS Compared with open operation, laparoscopic colon operation effectively inhibited the release of post-operative inflammatory factors and yielded good protection via post-operative cell immunity. FT surgery had a better protective role with respect to the post-operative immune system compared with traditional peri-operative care. Inflammatory reactions, based on interleukin-6 and C-reactive protein levels, were less intense following FT laparoscopic operation compared to FT open operation; however, there were no differences in specific immunity (CD3+ and CD4+ counts, and the CD4+/CD8+ ratio) during these two types of surgical procedures. Post-operative hospital stay in patients randomized to the FT laparoscopic group was significantly shorter than in the other three treatment groups (P<0.01). Post-operative complications in patients who underwent FT laparoscopic treatment were less than in the other three treatment groups (P<0.05). There were no significant differences between the four treatment groups regarding readmission rate and in-hospital mortality. CONCLUSIONS The laparoscopic technique and FT surgery rehabilitation program effectively inhibited release of post-operative inflammatory factors with a reduction in peri-operative trauma and stress, which together played a protective role on the post-operative immune system. Combining two treatment measures during colon operation produced better protective effects via the immune system. The beneficial clinical effects support that the better-preserved post-operative immune system may also contribute to the improvement of post-operative results in FT laparoscopic patients.
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Wongyingsinn M, Baldini G, Stein B, Charlebois P, Liberman S, Carli F. Spinal analgesia for laparoscopic colonic resection using an enhanced recovery after surgery programme: better analgesia, but no benefits on postoperative recovery: a randomized controlled trial. Br J Anaesth 2012; 108:850-6. [PMID: 22408272 DOI: 10.1093/bja/aes028] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This study was undertaken to determine the impact of an intrathecal mixture of bupivacaine and morphine, when compared with systemic morphine, on the quality of postoperative analgesia and other outcomes in the context of the enhanced recovery after surgery (ERAS) programme for laparoscopic colonic resection. METHODS Fifty patients undergoing general anaesthesia were randomly allocated to receive either a spinal mixture of bupivacaine and morphine followed by oral oxycodone (spinal group) or patient-controlled analgesia (PCA group). The primary outcome was consumption of opioids during the first three postoperative days. Secondary outcomes were pain scores, return of bowel function and dietary intake, readiness to hospital discharge, and length of hospital stay. RESULTS Postoperative opioid consumption in the spinal group was significantly less over the first three postoperative days (P<0.001). The quality of analgesia at rest in the first 24 h was better in the spinal group (P<0.005). Excessive sedation and respiratory depression were reported in two elderly patients with spinal analgesia. There were no differences between the two groups in other outcomes (return of bowel function and dietary intake, readiness to hospital discharge, and length of hospital stay). CONCLUSIONS When ERAS programme is used for laparoscopic colonic resection, an intrathecal mixture of bupivacaine and morphine was associated with less postoperative opioid consumption, but has no other advantages over systemic opioids.
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Affiliation(s)
- M Wongyingsinn
- Department of Anaesthesia, McGill University Health Centre, Montreal, QC, Canada H3G 1A4.
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Bakkum-Gamez JN, Langstraat CL, Martin JR, Lemens MA, Weaver AL, Allensworth S, Dowdy SC, Cliby WA, Gostout BS, Podratz KC. Incidence of and risk factors for postoperative ileus in women undergoing primary staging and debulking for epithelial ovarian carcinoma. Gynecol Oncol 2012; 125:614-20. [PMID: 22370599 DOI: 10.1016/j.ygyno.2012.02.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Revised: 02/17/2012] [Accepted: 02/18/2012] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Thorough primary cytoreduction for epithelial ovarian carcinoma (EOC) improves survival. The incidence of postoperative ileus (POI) in these patients may be underreported because of varying POI definitions and the evolving, increasingly complex contemporary surgical approach to EOC. We sought to determine the current incidence of POI and its risk factors in women undergoing debulking and staging for EOC. METHODS We retrospectively identified the records of women who underwent primary staging and cytoreduction for EOC between 2003 and 2008. POI was defined as a surgeon's diagnosis of POI, return to nothing-by-mouth status, or reinsertion of a nasogastric tube. Perioperative patient characteristics and process-of-care variables were analyzed. Univariate analyses were used to identify POI risk factors; variables with P ≤.20 were included in multivariate analysis. RESULTS Among 587 women identified, the overall incidence of POI was 30.3% (25.9% without bowel resection, 38.5% with bowel resection; P=.002). Preoperative thrombocytosis, involvement of bowel mesentery with carcinoma, and perioperative red blood cell transfusion were independently associated with increased POI. Postoperative ibuprofen use was associated with decreased POI risk. Women with POI had a longer length of stay (median, 11 vs 6 days) and increased time to recovery of the upper (7.5 vs 4 days) and lower (4 vs 3 days) gastrointestinal tract (P<.001 for each). CONCLUSIONS The rate of POI is substantial among women undergoing staging and cytoreduction for EOC and is associated with increased length of stay. Modifiable risk factors may include transfusion and postoperative ibuprofen use. Alternative interventions to decrease POI are needed.
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Zhou JJ, Li J, Ying XJ, Song YM, Chen R, Chen G, Yan M, Ding KF. Fast track multi-discipline treatment (FTMDT trial) versus conventional treatment in colorectal cancer--the design of a prospective randomized controlled study. BMC Cancer 2011; 11:494. [PMID: 22111914 PMCID: PMC3254142 DOI: 10.1186/1471-2407-11-494] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Accepted: 11/24/2011] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Laparoscopy-assisted surgery, fast-track perioperative treatment are both increasingly used in colorectal cancer treatment, for their short-time benefits of enhanced recovery and short hospital stays. However, the benefits of the integration of the Laparoscopy-assisted surgery, fast-track perioperative treatment, and even with the Xelox chemotherapy, are still unknown. In this study, the three treatments integration is defined as "Fast Track Multi-Discipline Treatment Model" for colorectal cancer and this model extends the benefits to the whole treatment process of colorectal cancer. The main purpose of the study is to explore the feasibility of "Fast Track Multi-Discipline Treatment" model in treatment of colorectal cancer. METHODS The trial is a prospective randomized controlled study with 2 × 2 balanced factorial design. Patients eligible for the study will be randomized to 4 groups: (I) Laparoscopic surgery with fast track perioperative treatment and Xelox chemotherapy; (II) Open surgery with fast track perioperative treatment and Xelox chemotherapy; (III) Laparoscopic surgery with conventional perioperative treatment and mFolfox6 chemotherapy; (IV) Open surgery with conventional perioperative treatment and mFolfox6 chemotherapy. The primary endpoint of this study is the hospital stays. The secondary endpoints are the quality of life, chemotherapy related adverse events, surgical complications and hospitalization costs. Totally, 340 patients will be enrolled with 85 patients in each group. CONCLUSIONS The study initiates a new treatment model "Fast Track Multi-Discipline Treatment" for colorectal cancer, and will provide feasibility evidence on the new model "Fast Track Multi-Discipline Treatment" for patients with colorectal cancer. TRIAL REGISTRATION ClinicalTrials.gov: NCT01080547.
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Affiliation(s)
- Jiao-Jiao Zhou
- Department of Surgical Oncology, Second Affiliated Hospital, and The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Zhejiang University College of Medicine, 88 Jie-Fang Rd, Hangzhou, Zhejiang 310009, China
| | - Jun Li
- Department of Surgical Oncology, Second Affiliated Hospital, and The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Zhejiang University College of Medicine, 88 Jie-Fang Rd, Hangzhou, Zhejiang 310009, China
| | - Xiao-Jiang Ying
- Department of Anorectum, People's Hospital of Shaoxing, 568 Zhong-Xing North Rd, Shaoxing, Zhejiang 312000, China
| | - Yong-Mao Song
- Department of Surgical Oncology, Second Affiliated Hospital, and The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Zhejiang University College of Medicine, 88 Jie-Fang Rd, Hangzhou, Zhejiang 310009, China
| | - Rong Chen
- Department of Anus and Large Intestine, Second Affiliated Hospital, Wenzhou Medicine College, 109 Xue-Yuan West Rd, Wenzhou, Zhejiang 325027, China
| | - Gang Chen
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University College of Medicine, 88 Jie-Fang Rd, Hangzhou, Zhejiang 310009, China
| | - Min Yan
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University College of Medicine, 88 Jie-Fang Rd, Hangzhou, Zhejiang 310009, China
| | - Ke-Feng Ding
- Department of Surgical Oncology, Second Affiliated Hospital, and The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Zhejiang University College of Medicine, 88 Jie-Fang Rd, Hangzhou, Zhejiang 310009, China
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Haverkamp MP, de Roos MAJ, Ong KH. The ERAS protocol reduces the length of stay after laparoscopic colectomies. Surg Endosc 2011; 26:361-7. [DOI: 10.1007/s00464-011-1877-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 07/29/2011] [Indexed: 10/16/2022]
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Lovely JK, Maxson PM, Jacob AK, Cima RR, Horlocker TT, Hebl JR, Harmsen WS, Huebner M, Larson DW. Case-matched series of enhanced versus standard recovery pathway in minimally invasive colorectal surgery. Br J Surg 2011; 99:120-6. [PMID: 21948187 DOI: 10.1002/bjs.7692] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Accelerated recovery pathways may reduce length of hospital stay after surgery but there are few data on minimally invasive colorectal operations. METHODS An enhanced recovery pathway (ERP) was instituted, including preoperative analgesia, limited intravenous fluids and opiates, and early feeding. Intrathecal analgesia was administered as needed, but epidural analgesia was not used. The first 66 patients subjected to the ERP were case-matched by surgeon, procedure and age (within 5 years) with patients treated previously in a fast-track pathway (FTP). Short-term and postoperative outcomes to 30 days were compared. RESULTS Hospital stay was shorter with the ERP than the FTP: median (interquartile range, i.q.r.) 3 (2-3) versus 3 (3-5) days (P < 0·001). A 2-day hospital stay was achieved in 44 and 8 per cent of patients respectively (P < 0·001). Patients in the ERP had a shorter time to recovery of bowel function: median (i.q.r.) 1 (1-2) versus 2 (2-3) days (P < 0·001). Thirty-day complication rates were similar (32 per cent ERP, 27 per cent FTP; P = 0·570). Readmissions within 30 days were more common with ERP, but the difference was not statistically significant (10 versus 5 patients; P = 0·170). Total hospital stay for those readmitted was shorter in the ERP group (18 versus 23 days). CONCLUSION ERP decreased the length of hospital stay after minimally invasive colorectal surgery.
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Affiliation(s)
- J K Lovely
- Hospital Pharmacy Services, Division of Colon and Rectal Surgery, 200 First Street SW, Rochester, Minnesota 55905, USA
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Pendlimari R, Holubar SD, Hassinger JP, Cima RR. Assessment of Colon Cancer Literacy in screening colonoscopy patients: a validation study. J Surg Res 2011; 175:221-6. [PMID: 21737097 DOI: 10.1016/j.jss.2011.04.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 03/03/2011] [Accepted: 04/18/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND Few, if any, instruments assess disease-specific health literacy in colon cancer patients. We aimed to validate the Assessment of Colon Cancer Literacy (ACCL) compared with a standard health literacy test, the Newest Vital Sign (NVS). MATERIALS AND METHODS A convenience sample of screening colonoscopy patients was surveyed. General health literacy was assessed with the NVS and colon cancer literacy with the ACCL. Contingency table analysis was performed. Results are frequency (proportion) or mean. RESULTS Sixty-one subjects completed our survey, mean age 64 ± 9 y, 33 (54%) were women, 28 (46%) had a college degree, 38 (62%) had prior colonoscopy, and 19 (31%) worked in healthcare. The sensitivity and specificity of NVS to identify limited colon cancer literacy was 45.7% and 86.7%, respectively, while the sensitivity and specificity of ACCL to identify limited general health literacy was 91.3% and 34.2%, respectively. CONCLUSIONS The ACCL is a valid, sensitive measure of health literacy. Furthermore, given its focus on clinically relevant content, this instrument may facilitate discussion of diagnosis, treatment, and prognosis with colon cancer patients. ACCL is a novel, valid health literacy instrument that may aid gastroenterologists, colorectal surgeons, and medical oncologists in optimizing patient education.
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Affiliation(s)
- Rajesh Pendlimari
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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Spiliotis J, Zoras O. Recovery after laparoscopic right hemicolectomy for colon cancer. Surg Endosc 2010; 25:1701-2. [PMID: 20976486 DOI: 10.1007/s00464-010-1423-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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