Bowel function recovery after laparoscopic transverse colectomy within an ERAS program: a comparison to right and left colectomy

Same-Day Discharge After a Minimally Invasive Colectomy: A Successful Approach to Patient Selection

BACKGROUND

Enhanced Recovery After Surgery (ERAS) protocols have been shown to decrease inpatient length of stay (LOS) and improve surgical outcomes in elective abdominal colorectal procedures. Discharging a patient home after a minimally invasive colectomy on the same calendar day is a multifactorial decision that takes into account the patient's decision and baseline condition, social factors, intraoperative findings, and postoperative recovery status. The aim of this study is to evaluate the outcomes of same-day discharge (SDD) following minimally invasive colectomy within an ERAS protocol in a community hospital setting in Houston, Texas.

METHODS

In this retrospective cohort study, all consecutive elective cases were performed by a single surgeon from April 2022 to April 2023. This retrospective analysis aims to report a single senior surgeon's experience of the safety, feasibility, and benefits of same-day discharge after minimally invasive colectomy in preselected patients. Same-day discharge was defined as a discharge on the same calendar day without an overnight stay. Differences between specific groups were compared using the Fisher's exact test and Mann-Whitney U test.

RESULTS

Of 86 non-emergent colectomies, 41 patients (47.7%) were successfully discharged on the same day. The median age of the patients was 63.50 years (interquartile range (IQR) 18). The cohort included 37 females (43%) and 49 males (57%). The median LOS was one day. The median operating time was 148.50 minutes (IQR 68.25). The median intraoperative fluid usage was 1500 mL (IQR 36.25), and the median estimated blood loss (EBL) was 25 mL (IQR 36.25). No readmissions among the SDD patients (0%), while three readmissions were reported in patients who stayed overnight (3.4%).  Conclusion: Same-day discharge after a minimally invasive colectomy is feasible when there is a well-established ERAS protocol and there is adequate education for patients and staff. Adequate patient selection is crucial. Patients with multiple comorbidities and a lack of a support network are not suitable candidates.

Oncological outcomes of open, laparoscopic and robotic colectomy in patients with transverse colon cancer

BACKGROUND

Literature concerning surgical management of transverse colon cancer is scarce, since many key trials excluded transverse colon cancer. The aim of this study was to evaluate clinical and oncological outcomes comparing open, laparoscopic and robotic transverse colon cancer resection.

METHODS

Consecutive patients who underwent elective surgery for transverse colon cancer between December 2005 and July 2021 were included. Data were kept in a prospective database approved by the institutional ethics committee. Primary outcome was overall and disease-free survival. Secondary outcomes included complications, operative time, length of stay and lymph node harvest. Statistical analysis was corrected for age and tumour localisation.

RESULTS

Two hundred and forty-six (38 robotic, 71 open and 137 laparoscopic resections) were recruited in this study. There were five conversions during laparoscopic procedures. Operative time was significantly shorter in robotic vs laparoscopic procedures (195 vs 238 min, p = 0.005) and length of stay was shorter in robotic vs laparoscopic and open group (7 vs 9 vs 15 days, p < 0.001). There was no difference in overall complications. R0 resections were similar. Lymph node harvest was highest in the robotic group vs. laparoscopic or open (32 vs. 29 vs. 21, p < 0.001). Overall survival was 97%, 85% and 60% (p < 0.001) and disease-free survival was 91%, 78% and 56% (p < 0.001) for the robotic, laparoscopic and open groups, respectively.

CONCLUSIONS

Minimally invasive surgery for transverse colon cancer is safe and offers good clinical and oncological outcomes. Robotic resection is associated with significantly shorter operating times, higher lymph node harvest, lower conversion rate and does not increase morbidity. Differences in disease-free and overall survival should be further explored in randomised controlled trials.

Bowel recovery after intra- vs extra-corporeal anastomosis for oncologic laparoscopic right hemicolectomy within an ERAS protocol: a retrospective study

OBJECTIVE

Restoring bowel continuity after laparoscopic right hemicolectomy with an intra-corporeal (IC) rather than an extra-corporeal (EC) ileocolic anastomosis may offer advantages in post-operative recovery. The aim of this study was to compare bowel function recovery between these two techniques, in a context of complete mesocolic excision within an enhanced recovery after surgery (ERAS) protocol.

METHODS

All consecutive patients who underwent oncologic laparoscopic right hemicolectomy from January 2012 to February 2021 in our institution were included in the study. Data were gathered from the prospectively maintained official ERAS (EIAS) database and completed through our institution's electronic health records. The primary endpoint was prolonged post-operative ileus (PPOI), defined as the need to insert a nasogastric tube, or refractory nausea VAS > 4, on or after the third post-operative day. Secondary endpoints were post-operative pain, morbidity and length of hospital stay (LoS). Groups were compared before and after propensity score matching based on age, gender, ASA score, use of epidural analgesia and post-operative complications.

RESULTS

A total of 108 patients met the inclusion criteria, 36 (30%) had IC and 72 (70%) EC anastomosis. In the unmatched population, baseline characteristics were similar except for more frequent use of epidural analgesia in the EC group (62 (72.9%) vs. 17 (47.2), p = 0.007). PSM analysis was carried out. Operative time was longer in the IC group (197 min (176-223) vs. 160 (140-189), p < 0.001). The rate of PPOI was similar (2 (5.6%) patients in the IC group vs. 10 (11.6%) in the EC group (p = 0.306)), but time to frist passage of flatus and stool was shorter in the IC group. There was no difference in morbidity but patients after IC anastomosis had lower pain VAS scores at 24 h (p = 0.004) and a trend for a shorter LoS (6 (5-8) days vs 7 (5-10) in the EC group, p = 0.054). After PSM, there were 36 patients in each group. PPOI, time to first flatus and stool, morbidity and LoS were not significantly different although there was a trend for better recovery outcomes in the IC group. Patients in the IC group had significantly longer operative times but less pain at 24 h.

CONCLUSIONS

Although IC anastomosis was not significantly associated to lower rates of PPOI, it showed trends of faster recovery and significantly less post-operative pain at the expense of longer operating times.

Prolonged postoperative ileus following right- versus left-sided colectomy: A systematic review and meta-analysis

AIM

Prolonged postoperative ileus (PPOI) is a common complication following colonic surgery, and is associated with longer hospital stay, greater risk of complications and substantial cost for patients and hospitals. Some reports have recently suggested that gastrointestinal (GI) recovery varies based on the side of resection (i.e., right-sided vs. left-sided colectomy). This systematic review and meta-analysis aimed to compare GI recovery by resection side.

METHODS

The MEDLINE, Embase, Cochrane Library and CENTRAL databases were systematically searched for articles reporting GI recovery outcomes in adults undergoing elective right- versus left-sided colectomy (excluding with ileostomy) of any surgical approach. The primary outcome was PPOI, and secondary outcomes included time to first passage of flatus, stool and tolerance of solid diet, and postoperative complications. Subgroup analyses of laparoscopic procedures and cohorts without inflammatory bowel disease and sensitivity analysis of adjusted multivariate results were also performed.

RESULTS

Nine studies were identified, of which seven were included in the meta-analysis, comprising 29 068 colectomies (14 581 right-sided; 14 487 left-sided). PPOI was heterogeneously defined and was significantly more likely following right-sided compared to left-sided colectomy regardless of the surgical approach (OR 1.78, 95% CI 1.32-2.39; P < 0.01; I²  = 51%), as well as on subgroup analyses and adjusted multivariate meta-analysis. Secondary outcomes were reported in only a few small studies; hence meta-analysis did not produce reliable results.

CONCLUSION

Based on heterogeneous definitions, consistently higher rates of PPOI were observed following right- versus left-sided colectomy. These differences are currently unexplained and highlight the need for further research into the pathophysiology of ileus.

Enhanced Recovery after Surgery (ERAS) Protocol Is a Safe and Effective Approach in Patients with Gastrointestinal Fistulas Undergoing Reconstruction: Results from a Prospective Study

BACKGROUND AND AIMS

An enterocutaneous fistula (ECF) poses a major surgical problem. The definitive surgical repair of persistent fistulas remains a surgical challenge with a high rate of re-fistulation and mortality, and the reasons for that is not the surgical technique alone. Enhanced Recovery after Surgery (ERAS®) is an evidence-based multimodal perioperative protocol proven to reduce postoperative complications. The aim of the study was to assess the clinical value of the ERAS protocol in surgical patients with ECF.

METHODS

ERAS protocol was used in all patients scheduled for surgery for ECF at the Stanley Dudrick's Memorial Hospital in Skawina between 2011 and 2020. A multidisciplinary team (MDT) was in charge of the program and performed annual audits. A consecutive series of 100 ECF patients (44 females, 56 males, mean age 54.1 years) were evaluated. Postoperative complications rate, readmission rate, length of hospital stay, prevalence of postoperative nausea and vomiting were assessed. Registered under ClinicalTrials.gov Identifier no. NCT04771832.

RESULTS

ERAS protocol was successfully introduced for ECF surgeries; however, eight modifications to the ERAS program was performed in 2015. They led to improvement of surgical outcomes: reduction of postoperative nausea and vomiting (15 vs. 17% patients, p = 0.025), overall complication rate (11 vs. 10, p = 0.021), median length of hospital stay (overall and after surgery, p = 0.022 and 0.002, respectively).

CONCLUSIONS

ERAS protocol can be successfully used for ECF patients. Prescheduled audits can contribute to the improvement of care.