• Humans
• Colorectal Surgery
• Analgesics
• Nerve Block
• Laparoscopy
• Pain, Postoperative/drug therapy
• Pain, Postoperative/prevention & control
• Anesthetics, Local
• Analgesics, Opioid
• Ultrasonography, Interventional
• Abdominal Muscles

• Deep vein thrombosis
• Duration of risk
• Pulmonary embolism
• Surgery
• Thromboprophylaxis

• enhanced recovery after surgery
• post-operative recovery
• small bowel surgery

• Enhanced Recovery After Surgery
• early rehabilitation
• factor analysis
• stomach and colorectal operation

Enhanced recovery programs (ERP) represent a multimodal approach to perioperative patient care. The benefits of ERP are well demonstrated in colorectal surgery and Enhanced Recovery After Surgery (ERAS®) programs, that epitomise the ERP concept, have being introduced in different specialties, including vascular, gastric, pancreatic, urogynecologic and orthopaedic surgery. However, no ERP has been proposed for head and neck surgery. We developed an expert-opinion-based ERP for laryngeal surgery based on the key principles of colorectal surgery ERAS®. Twenty-four patients undergoing major laryngeal surgery (total and partial laryngectomies or surgical removal of oropharyngeal tumour with muscle flap reconstruction) were treated according to such an ERP protocol, which differed under several respects from our previous standard practice (described in 70 consecutive patients who underwent major laryngeal surgery before ERP implementation. The adherence rate to the different ERP items is reported. Adherence to ERP items was high. Nutritional assessment, antibiotic prophylaxis, postoperative nausea and vomit (PONV) prophylaxis and postoperative speech therapy targets were applied as required in 100% of cases. Some ERP items (antibiotic prophylaxis, intraoperative infusion rate, and postoperative speech therapy) were already frequently implemented before ERP adoption. Postoperative medical complications occurred in 8.3% of patients. Our expert opinion-based ERP protocol for major laryngeal surgery proved feasible. The degree of benefit deriving from its implementation has yet to be assessed.

• Enhanced Recovery After Surgery
• Enhanced Recovery Program
• Head and neck surgery
• Larynx cancer

• Adult
• Digestive System Physiological Phenomena
• Early Ambulation/standards
• Female
• Humans
• Inflammatory Bowel Diseases/complications
• Inflammatory Bowel Diseases/surgery
• Length of Stay/statistics & numerical data
• Male
• Middle Aged
• Patient Readmission/statistics & numerical data
• Postanesthesia Nursing/standards
• Postoperative Complications/etiology
• Postoperative Complications/prevention & control
• Practice Guidelines as Topic
• Urinary Tract Physiological Phenomena

Enhanced recovery after surgery (ERAS) protocols are now well-known to be useful for elective colorectal surgery, as they result in shorter hospital stays without adversely affecting morbidity. However, the efficacy and safety of ERAS protocols for patients with obstructive colorectal cancer have yet to be clarified.

We evaluated 122 consecutive resections for obstructive colorectal cancer performed between July 2008 and November 2012 at Tokyo Metropolitan Bokutoh Hospital. Patients with rupture or impending rupture and those who received simple colostomy were excluded. The first set of 42 patients was treated based on traditional protocols, and the latter 80 according to modified ERAS protocols. The main endpoints were length of postoperative hospital stay, postoperative short-term morbidity, rate of readmission within 30 days, and mortality. Differences in modified ERAS protocols relative to traditional care include intensive preoperative counseling (by both surgeons and anesthesiologists), perioperative fluid management (avoidance of sodium/fluid overload), shortening of postoperative fasting period and early provision of oral nutrition, intraoperative warm air body heating, enforced postoperative mobilization, stimulation of gut motility, early removal of urinary catheter, and a multidisciplinary team approach to care.

Median (interquartile range) postoperative hospital stay was 10 (10–14.25) days in the traditional group, and seven (7–8.75) days in the ERAS group, showing a 3-day reduction in hospital stay (p < 0.01). According to the Clavien-Dindo classification, overall incidences of grade 2 or higher postoperative complications for the traditional and ERAS groups were 15 and 10% (p = 0.48), and 30-day readmission rates were 0 and 1.3% (p = 1.00), respectively. As for mortality, one patient in the traditional group died and none in the ERAS group (p = 0.34).

Modified ERAS protocols for obstructive colorectal cancer reduced hospital stay without adversely affecting morbidity, indicating that ERAS protocols are feasible for patients with obstructive colorectal cancer.

• ERAS
• Length of hospital stay
• Obstructive colorectal cancer

• NSQIP database
• Rectal cancer
• Superficial SSI

• Feeding practice
• NPO
• Pediatric
• Postoperative
• Preoperative
• Surgery

• balance
• colorectal surgery
• complications
• diffusion
• emergency
• fluid
• general surgery
• perioperative care
• post-operative

Albumin is considered a negative acute-phase protein because its concentration decreases during injury and sepsis. Hypoalbuminemia is a risk factor for mortality, postoperative complications, and prolonged hospital stay. The magnitude of the systemic inflammatory response during the perioperative period, as indicated by the acute-phase proteins—C-reactive protein (CRP) in particular—, may help identify the risk of postoperative infectious complication. The correlation between serum albumin and CRP with gastrointestinal cancer has been reported. However, it is unclear whether antecedent CRP could be utilized to predict future hypoalbuminemia in the perioperative period in colorectal surgery. The primary endpoint of this study was to reveal that antecedent CRP could be utilized to predict future hypoalbuminemia in the perioperative period of colorectal surgery.

Thirty-seven patients who underwent elective open colorectal surgery were included in this study. Correlations between preoperative CRP and serum albumin on postoperative day (POD) 3, between preoperative CRP and serum albumin on POD 7 and between CRP on POD 3 and serum albumin on POD 7 were examined. Relationships between preoperative CRP and hypoalbuminemia on POD 3, between preoperative CRP and hypoalbuminemia on POD 7 and between CRP on POD 3 and hypoalbuminemia on POD 7 were examined by receiver operating characteristic analysis.

Three-quarters of patients were older than 65 years of age. Significant correlations were observed between preoperative CRP and serum albumin on POD 3 (p = 0.023), between preoperative CRP and serum albumin on POD 7 (p = 0.023) and between CRP on POD 3 and serum albumin on POD 7 (p < 0.001). The area under the receiver operating characteristic curve of CRP on POD 3 to development of hypoalbuminemia on POD 7 was 0.833 (95 % CI 0.679–0.987) with an optimal threshold of 12.43 mg/dL, sensitivity 75 % and specificity 80 %.

The present study revealed that antecedent CRP was associated with future serum albumin. Additionally, CRP on POD 3 could be useful in predicting the development of hypoalbuminemia on POD 7. This result suggests that CRP on POD 3 may be a valuable indicator for early nutritional intervention.

Japan has one of the highest five-year relative survival rates for colorectal cancer in the world, with its own traditions of perioperative care and a unique insurance system. The benefits of enhanced recovery after surgery (ERAS) protocols in the Japanese population have yet to be clarified.

We evaluated 352 consecutive cases of colorectal cancer resection at Tokyo Metropolitan Bokutoh Hospital between July 2009 and November 2012. Of these, 95 cases were performed according to traditional protocols (traditional group), and 257 according to ERAS protocols (ERAS group), which were introduced to the hospital in July 2010. Primary endpoints included length of postoperative hospital stay, postoperative short-term morbidity, and rate of readmission within 30 days. Intensive pre-admission counselling, no pre- and postoperative fasting (provision of oral nutrition), avoidance of sodium/fluid overload, intraoperative warm-air body heating, enforced postoperative mobilization, and multimodal team care were among the main changes brought about by the introduction of ERAS protocols.

The median (interquartile range) length of postoperative hospital stay was 10 (10–12.75) days in the traditional group and seven (6–8) days in the ERAS group, i.e., a three-day reduction (p < 0.05) in the ERAS group. Moreover, the proportion of patients discharged within one week dramatically increased from 1 % to 77 % in the ERAS group. The overall incidence of grade 2 and 3 postoperative complications according to the Clavien-Dindo classification was 9.5 % in the traditional group and 9.3 % in the ERAS group, and 30-day readmission rates were 8.3 % and 6.6 % in the traditional and ERAS groups, respectively. There were no significant differences between the two groups. Although operative time and blood loss did not differ significantly between the two groups, the volume of intraoperative infusion was significantly decreased in the ERAS group (p < 0.05), possibly due to ERAS recommendations to avoid dehydration (i.e., avoidance of sodium/fluid overload, no preoperative fasting).

ERAS protocols for colorectal surgery helped reduce the length of postoperative hospital stay without adversely affecting morbidity, indicating that ERAS protocols are feasible and effective in Japanese settings as well.

• Laparoscopy
• colorectal
• enhanced recovery
• prediction
• readmission

• Critical Pathways
• Diet Therapy/nursing
• Early Ambulation/nursing
• Hepatectomy/nursing
• Hepatectomy/rehabilitation
• Humans
• Length of Stay
• Liver Neoplasms/nursing
• Liver Neoplasms/surgery
• Pancreatectomy/nursing
• Pancreatectomy/rehabilitation
• Postoperative Care/nursing
• Randomized Controlled Trials as Topic
• Recovery of Function
• Treatment Outcome

AIM: To systematically review the evidence for the effectiveness of fast-track program vs traditional care in laparoscopic or open surgery for gastric cancer.

METHODS: PubMed, Embase and the Cochrane library databases were electronically searched for published studies between January 1995 and April 2013, and only randomized trials were included. The references of relevant studies were manually searched for further studies that may have been missed. Search terms included “gastric cancer”, “fast track” and “enhanced recovery”. Five outcome variables were considered most suitable for analysis: postoperative hospital stay, medical cost, duration to first flatus, C-reactive protein (CRP) level and complications. Postoperative hospital stay was calculated from the date of operation to the date of discharge. Fixed effects model was used for meta-analysis.

RESULTS: Compared with traditional care, fast-track program could significantly decrease the postoperative hospital stay [weighted mean difference (WMD) = -1.19, 95%CI: -1.79--0.60, P = 0.0001, fixed model], duration to first flatus (WMD = -6.82, 95%CI: -11.51--2.13, P = 0.004), medical costs (WMD = -2590, 95%CI: -4054--1126, P = 0.001), and the level of CRP (WMD = -17.78, 95%CI: -32.22--3.35, P = 0.0001) in laparoscopic surgery for gastric cancer. In open surgery for gastric cancer, fast-track program could also significantly decrease the postoperative hospital stay (WMD = -1.99, 95%CI: -2.09--1.89, P = 0.0001), duration to first flatus (WMD = -12.0, 95%CI: -18.89--5.11, P = 0.001), medical cost (WMD = -3674, 95%CI: -5025--2323, P = 0.0001), and the level of CRP (WMD = -27.34, 95%CI: -35.42--19.26, P = 0.0001). Furthermore, fast-track program did not significantly increase the incidence of complication (RR = 1.39, 95%CI: 0.77-2.51, P = 0.27, for laparoscopic surgery; and RR = 1.52, 95%CI: 0.90-2.56, P = 0.12, for open surgery).

CONCLUSION: Our overall results suggested that compared with traditional care, fast-track program could result in shorter postoperative hospital stay, less medical costs, and lower level of CRP, with no more complications occurring in both laparoscopic and open surgery for gastric cancer.

• Fast-track program
• Traditional care
• Gastric cancer
• Meta-analysis
• Laparoscopic and open surgery

• Cost Savings
• Cost-Benefit Analysis
• Critical Pathways
• Gastrectomy/economics
• Gastrectomy/methods
• Hospital Costs
• Humans
• Laparoscopy/economics
• Length of Stay/economics
• Postoperative Care/economics
• Postoperative Care/methods
• Program Evaluation
• Recovery of Function
• Stomach Neoplasms/economics
• Stomach Neoplasms/surgery
• Time Factors
• Treatment Outcome

AIM: To evaluate the effect of fast track surgery (FTS) on clinical parameters and postoperative complications in patients with gastric cancer.

METHODS: A non-randomized controlled study was undertaken. Data were collected from 168 patients with gastric cancer who were treated at General Hospital of Guangzhou Military Command from February 2008 to May 2011, including 82 patients having undergone FTS and 86 patients having undergone conventional perioperative care. Outcomes were assessed using the time to first flatus and defecation, the length of postoperative hospital stay, medical cost and postoperative complications.

RESULTS: The time to first flatus (2.6 d vs 4.6 d) and defecation (3.3 d vs 5.2 d) and the length of hospital stay (4.6 d vs 8.1d) in the FTS group were significantly shorter, and the medical cost (23 vs 29 thousand yuan) was significantly less than those in the conventional treatment group (all P < 0.05). The incidence of pulmonary complications (6.1% vs 16.3%, P < 0.01) was much lower in the FTS group than in the conventional treatment group. The incidence of digestive tract fistula was higher in the FTS group than in the conventional treatment group (4.9% vs 3.5%), but the difference had no statistical significance (P > 0.05). In four patients developing fistula in the FTS group, two patients received operation again, whereas all the three patients developing fistula in the conventional treatment group received non-operation treatment. The overall incidence of complications in the FTS group was lower than that in the conventional treatment group (26.8% vs 32.6%), but the difference had no statistical significance (P > 0.05). One patient died in each group. The rate of readmission in the FTS group was higher (4.9% vs 3.5%), but the difference had no statistical significance (P > 0.05).

CONCLUSION: Fast track surgery is effective and safe in patients with gastric cancer, and it might contribute to gut function recovery, shorten hospital stay time and reduce medical cost. FTS does not increase the incidence of postoperative complications, but might increase the difficulty of diagnosis and treatment of some severe complications such as digestive tract fistula and hemorrhage.

• Fast track surgery
• Gastric cancer
• Clinical parameter
• Postoperative complications

• Colorectal Neoplasms/epidemiology
• Colorectal Neoplasms/surgery
• Evidence-Based Medicine
• Forecasting
• Humans
• Laparoscopy/statistics & numerical data
• Laparoscopy/trends
• Minimally Invasive Surgical Procedures/statistics & numerical data
• Minimally Invasive Surgical Procedures/trends
• Practice Patterns, Physicians'/statistics & numerical data
• Quality Assurance, Health Care/statistics & numerical data
• Quality Assurance, Health Care/trends
• Randomized Controlled Trials as Topic