The impact of perioperative fluid therapy on short-term outcomes and 5-year survival among patients undergoing colorectal cancer surgery - A prospective cohort study within an ERAS protocol

The ERAS nursing care strategy for patients undergoing transsphenoidal endoscopic pituitary tumor resection: A randomized blinded controlled trial

INTRODUCTION

Transsphenoidal endoscopic pituitary (TEP) tumor resection is performed through the nose via the sphenoid sinus to remove tumors from the pituitary gland. Also, enhanced recovery after surgery (ERAS) was adapted to reduce physical and physiological traumatic stress response of surgical patients.

METHODS

A total of 174 patients who underwent TEP tumor resection in our department from August 2021 to June 2022 were randomly divided into non-ERAS group and ERAS group. The main primary observational indicator was postoperative self-care ability parameters such as early urethral catheters' removal and postoperative food intake. Also, secondary indicators such as postoperative complications, average length of hospital stay (LOS), and total hospital cost were compared.

RESULTS

The overall self-care ability of the ERAS group was higher than that of the non-ERAS group 24 h after surgery (35 points vs 20 points, p < 0.001). Also, food intake on the first day after surgery was higher than that of the non-ERAS group (p < 0.001). Furthermore, the average LOS in the ERAS group was lower than that of the non-ERAS group (4 days vs 7 days, p < 0.01). Additionally, the average hospitalization cost in the ERAS group was lower than that of the non-ERAS group (32, 886 RMB vs 48, 125 RMB, p < 0.001).

CONCLUSION

ERAS nursing strategy promoted early recovery of self-care, shorten the average LOS, and reduce hospitalization costs without increasing the incidence of postoperative complications.

Enhanced Recovery After Surgery (ERAS) in Pancreatic Surgery: The Surgeon's Point of View

Pancreatic surgery is complex and associated with higher rates of morbidity and mortality compared to other abdominal surgeries. Over the past decade, the introduction of new technologies, such as minimally invasive approaches, improvements in multimodal treatments, advancements in anesthesia and perioperative care, and better management of complications, have collectively improved patient outcomes after pancreatic surgery. In particular, the adoption of Enhanced Recovery After Surgery (ERAS) recommendations has reduced hospital stays and improved recovery times, as well as post-operative outcomes. The aim of this narrative review is to highlight the surgeon's perspective on the ERAS program for pancreatic surgery, with a focus on its potential advantages for perioperative functional recovery outcomes.

Determinants of late recovery following elective colorectal surgery

BACKGROUND

Despite the implementation of enhanced recovery protocols, a significant proportion of patients experience delayed recovery. Identifying potential determinants of delayed recovery is crucial for optimizing perioperative protocols and tailoring patient pathways.

OBJECTIVE

This study aims to identify possible determinants of delayed recovery.

DESIGN

Retrospective observational study based on a prospectively collected dedicated register spanning from 2015 to 2022.

SETTING

Twenty-two Italian hospitals specializing in high-volume colorectal surgery and trained in enhanced recovery protocols.

PATIENTS

Patients undergoing elective colorectal resection for cancer or benign disease.

MAIN OUTCOME MEASURES

Recovery status on postoperative day 2. Late recovery was defined as the failure to meet at least two indicators of postoperative recovery (oral feeding, removal of the urinary catheter, cessation of intravenous fluids, and mobilization) on postoperative day 2.

RESULTS

A total of 1535 patients were analyzed. The median overall adherence to pre- and intraoperative enhanced recovery protocol items was 75.0% (range: 66.6%-83.3%). Delayed recovery was observed in 487 (31.7%) patients. Multiple regression analysis revealed six enhanced recovery protocol items that independently positively influenced postoperative recovery: pre-admission counseling (adjusted odds ratio [aOR] 2.596), a preoperative carbohydrate drink (aOR 1.948), intraoperative fluid infusions < 7 ml/kg/h (aOR 1.662), avoidance of thoracic epidural analgesia (aOR 2.137), removal of nasogastric tube at the end of surgery (aOR 4.939), and successful laparoscopy (aOR 2.341). The rate of delayed recovery progressively decreased with increasing adherence to these six positive items, reaching 13.0% when all items were applied (correlation coefficient [r] = - 0.99, p < 0.001).

LIMITATIONS

This study is limited by its retrospective analysis of a register containing data from multiple centers and a diverse patient population.

CONCLUSIONS

Adherence to specific pre- and intraoperative enhanced recovery protocol items, including counseling, preoperative carbohydrate intake, restrictive intraoperative fluid management, avoidance of thoracic epidural analgesia, early removal of nasogastric tube, and successful laparoscopy, appears crucial for promoting early recovery following elective colorectal resection.

Cost Analysis of Outpatient Colectomy in a Tertiary Center: A Projected Medico-Economic Evaluation

Aim of the study

Short stay processes are incentives to unburden chronically stressed healthcare systems. The aim of this study is to analyze financial implications of day admission (DAS) and outpatient strategies for colon resections in a prospective payment system (PPS) using Diagnosis Related Group (DRG) coding.

Methods

Consecutive patients undergoing left and right colonic resections between January 1, 2019 and December 31, 2020 were included. Medico-economic evaluations of the virtual outpatient and day admission surgery groups based on predefined criteria were compared to the identical group of patients who underwent surgery in the actual traditional inpatient setting. In a second step, postoperative complications of the virtual outpatient group were assessed. Cost-revenue analysis was performed using a micro-costing approach including direct medical costs.

Results

Overall (N = 257), 97 (37.7%) colectomies would have been potentially eligible for an outpatient strategy. The global costs of the actual inpatient strategy totaled USD 3 634 392 with a global revenue of USD 3 571 069, corresponding to a cost coverage rate of 98%. The result of the virtual DAS strategy would have been a net loss of USD 15 800 (coverage rate of 99%) due to 4 low length of stay outliers triggering a reimbursement reduction and preventing a positive net result of USD 16 208. The pilot reference outpatient case's revenue and cost amounted to respectively USD 7479 and USD 6911 (cost coverage of 108%).

Conclusion

From both any given hospital and healthcare system point of view, elective outpatient colectomy for selected patients is the most cost-saving option. However, in a prospective payment system implemented to avoid bad incentives, the latter can unintentionally disadvantage best performing hospitals and impede widespread adoption of high-value strategies.

A Comparative Analysis between Enhanced Recovery after Surgery and Traditional Care in the Management of Obstructive Colorectal Cancer

Enhanced Recovery After Surgery (ERAS) represents evidence-based transformation in perioperative care, which has been demonstrated to reduce both recovery times and postoperative complication rates. The aim of the present study was to evaluate the clinical significance of the ERAS program in comparison with conventional postoperative care. This longitudinal cohort observational study enrolled 120 consecutive patients diagnosed with intestinal obstruction caused by colorectal cancers, with 40 patients in the ERAS group and 80 patients receiving conventional postoperative care forming the non-ERAS group. Our study compares the effectiveness of ERAS protocols to non-ERAS methods, focusing on the time to first flatus, defecation, the resumption of normal diet, and early mobilization. The main endpoints are morbidity and hospitalization length. The results showed that despite a longer admission-to-surgery interval in the ERAS group, median hospitalization was significantly shorter compared to the non-ERAS group (p = 0.0002). The ERAS group showed a tendency towards a lower incidence of overall postoperative complications, indicating that implementing the ERAS protocol does not increase the risk of postoperative complications, ensuring the safety of enhanced recovery strategies for patients. Also, ERAS patients had notably fewer stomas than those in the non-ERAS group, indicating the potential effectiveness of reducing stoma necessity. This study shows that ERAS surpasses conventional care for colonic or rectal surgery patients, reducing hospital stays and costs while enhancing recovery. This highlights the comprehensive advantages of adopting ERAS in surgical settings.

Risk factors for anastomotic leakage in colonic procedures within an ERAS-protocol. A retrospective cohort study from the Swedish part of the international ERAS-database

BACKGROUND

Research on anastomotic leakage (AL) in colonic procedures within an Enhanced Recovery After Surgery (ERAS) protocol has not yet been conducted. The aim of this study was to identify risk factors for AL after colonic surgery.

METHODS

The study included all consecutively recorded patients operated with colonic resection surgery in the Swedish part of the international ERAS® Interactive Audit System (EIAS) between September 2009 and June 2022. The cohort was analyzed and evaluated regarding risk factors for AL.

RESULTS

Altogether 10,632 patients were included, 10,219 were without AL and 413 (3.9%) were with AL. After adjusted analysis, male sex (4.6% AL), OR: 1.49; 95% CI (1.16-1.90), obesity (4.8% AL), OR: 1.62; 95% CI (1.18-2.24), previous surgery (4.4% AL), OR: 1.45; 95% CI (1.14-1.86), open surgery (4.4% AL), OR: 1.36; 95% CI (1.02-1.83), anastomosis between small bowel and rectum (13.1% AL), OR: 3.97; 95% CI (2.23-7.10), stapled anastomosis (5.3% AL), OR: 2.46; 95% CI (1.79-3.38), inhalation anesthesia (4.2% AL), OR: 1.80; 95% CI (1.26-2.57), and conversion to open surgery (5.5% AL), OR 1.49; 95% CI (1.02-2.19) were significant risk factors for AL. Although pre and intraoperative compliance to the ERAS-protocol was similar, excess of fluids day 0 was an independent predictor for AL.

CONCLUSION

Male sex, obesity, previous surgery, open surgery, stapled anastomotic technique, anastomosis between small bowel and rectum, inhalation anesthesia, conversion to open surgery, and among ERAS interventions, excess of fluids day 0, were significant risk factors for AL.

The Impact of Enhanced Recovery on Long-Term Survival in Rectal Cancer

INTRODUCTION

Implementing perioperative interventions such as enhanced recovery pathways (ERPs) has improved short-term outcomes and minimized length of stay. Preliminary evidence suggests that adherence to the enhanced recovery after surgery protocol may also enhance 5-year cancer-specific survival (CSS) in colorectal cancer surgery. This retrospective study presents long-term survival outcomes and disease recurrence from a high-volume, single-center practice.

METHODS

All patients over 18 years of age diagnosed with rectal adenocarcinoma and undergoing elective minimally invasive surgery (MIS) were retrospectively reviewed between February 2005 and April 2018. Relevant data were extracted from Mayo electronic records and securely stored in a database. Short-term morbidity and long-term oncological outcomes were compared between patients enrolled in ERP and those who received non-enhanced care.

RESULTS

Overall, 600 rectal cancer patients underwent MIS, of whom 320 (53.3%) were treated according to the ERP and 280 (46.7%) received non-enhanced care. ERP was associated with a decrease in length of stay (3 vs. 5 days; p < 0.001) and less overall complications (34.7 vs. 54.3%; p < 0.001). The ERP group did not show an improvement in overall survival (OS) or disease-free survival (DFS) compared with non-enhanced care on multivariable (non-ERP vs. ERP OS: hazard ratio [HR] 1.268, 95% confidence interval [CI] 0.852-1.887; DFS: HR 1.050, 95% CI 0.674-1.635) analysis.

CONCLUSION

ERP was found to be associated with a reduction in short-term morbidity, with no impact on long-term oncological outcomes, such as OS, CSS, and DFS.

The impact of perioperative fluid therapy on the short-term outcomes after laparoscopic colorectal cancer surgery with ERAS protocol: a prospective observational study

The main goals of the Enhanced recovery after surgery (ERAS) protocol are focused on shortening the length of hospital stay (LOS), expediting convalescence, and reducing morbidity. A balanced perioperative fluid therapy is among the significant interventions incorporated by the ERAS protocol. The article contains extensive discussion surrounding the impact of this individual intervention on short-term outcomes. The aim of this study was to assess the impact of perioperative fluid therapy on short-term outcomes in patients after laparoscopic colorectal cancer surgery. The analysis included consecutive patients, who had undergone laparoscopic colorectal cancer operations between 2013 and 2020. Patients were divided into two groups: restricted (≤ 2500 ml) or excessive (> 2500 ml) perioperative fluid therapy. A standardized ERAS protocol was implemented in all patients. The study outcomes included recovery parameters and the morbidity rate, LOS and 30 days readmission rate. There were 361 and 80 patients in groups 1 and 2, respectively. There were no statistically significant differences between the groups in terms of demographic parameters and factors related to the surgical procedure. Logistic regression showed that restricted fluid therapy as a single intervention was associated with improvement in tolerance of diet on 1st postoperative day (OR 2.18, 95% CI 1.31-3.62, p = 0.003), accelerated mobilization on 1st postoperative day (OR 2.43, 95% CI 1.29-4.61, p = 0.006), lower risk of postoperative morbidity (OR 0.58, 95%CI 0.36-0.98, p = 0.046), shorter LOS (OR 0.49, 95% CI 0.29-0.81, p = 0.005) and reduced readmission rate (OR 0.48, 95% CI 0.23-0.98, p = 0.045). A balanced perioperative fluid therapy on the day of surgery may be associated with faster convalescence, lower morbidity rate, shorter LOS and lower 30 days readmission rate.

The Cancer Cachexia Index Can Be Used to Prognostically Predict Patients with Gastric Cancer Undergoing Gastrectomy

INTRODUCTION

Cancer cachexia occurs in cancer patients more frequently as the cancer progresses, with a negative impact on treatment outcomes. In this study, we sought to clarify the clinical impact of a cancer cachexia index (CXI) in patients with gastric cancer (GC) undergoing gastrectomy.

METHODS

Between January 2013 and December 2018, we reviewed data from 556 patients treated for GC at our hospital. CXI was calculated using skeletal muscle index (SMI), serum albumin, and neutrophil-lymphocyte ratios (NLR). Patients were divided into high (n = 414) or low CXI (n = 142) groups. We investigated the clinical impact of CXI in patients with GC undergoing gastrectomy.

RESULTS

Multivariate analyses of 5-year overall survival (OS) and cancer-specific survival (CSS) rates indicated that a low CXI was independently associated with unfavorable outcomes for patients with GC. In multivariate analyses, SMI was independent predictor of OS but not CSS. NLR was not an independent predictor of either OS or CSS. Complication incidences (≥ Clavien Dindo 3) were non-significantly higher in the low (vs. high) CXI group.

CONCLUSION

CXI was a more valuable prognostic biomarker when compared with SMI or NLR in GC patients undergoing gastrectomy. We suggest that patients with low CXI values should be given more comprehensive treatment, including exercise and nutritional therapy to improve clinical outcomes.

Frailty-originated early rehabilitation reduces postoperative delirium in brain tumor patients: Results from a prospective randomized study

Objective

To investigate the impact of frailty-originated, evidence-based early activity training on postoperative delirium in patients who have undergone brain tumor resection.

Methods

A randomized controlled trial was conducted at the Second Affiliated Hospital of Zhejiang University School of Medicine, from July 2019 to June 2020. Data on the patients' general information, incidence and duration of delirium, duration of hospital stay, and activities of daily living were collected. From the first day after surgery, the patients were randomly assigned to either the traditional care group or the frailty-originated rehabilitation towards intracranial tumors using distinct evidence (FORTITUDE) group. Non-parametric, chi-square, and log-rank tests were used to compare the onset time and duration of postoperative delirium and activities of daily living performed by the participants between the two groups.

Results

In total, 291 patients, 150 and 141 in the control group and FORTITUDE group, respectively, participated in the study. Patients in the FORTITUDE group had a lower incidence of postoperative delirium (15.6% vs. 28.7%, P ​= ​0.007), delayed onset of delirium (Z ​= ​-2.108, P ​= ​0.035), shorter duration of postoperative delirium (χ² ​= ​26.67, P ​< ​0.001), shorter hospital stay (Z ​= ​-2.037, P ​= ​0.042), and higher scores in the activities of daily living one week (Z ​= ​-2.304, P ​= ​0.021) and one month (Z ​= ​-2.724, P ​= ​0.006) after surgery than in the control group.

Conclusions

The FORTITUDE program was safe and effective in reducing the incidence and duration of postoperative delirium and improving the quality of life of patients who underwent brain tumor resection.

[Application and Effect Evaluation of Precision Nursing Care of Enhanced Rehabilitation After Surgery in the Perioperative Period of Colorectal Cancer]

Objective

To examine the effect of perioperative precision nursing care of enhanced recovery after surgery (ERAS) on the postoperative recovery, stress response, and psychological state of colorectal cancer patients.

Methods

A total of 100 patients undergoing elective laparoscopic colorectal cancer surgery were randomly assigned to an experimental group and a control group, with 50 patients in each group. The experimental group received systematic, standardized, and specialized precision nursing care in three stages, the preoperative, intraoperative, and postoperative stages, while the control group received routine nursing care. The main outcome indicators compared between the two groups included the time of the first postoperative passage of flatus and stool, ambulation, liquid-diet meal, postoperative length-of-stay, and C-reactive protein (CRP), interleukin-6 (IL-6), and homeostatic model assessment of insulin resistance (HOMR-IR) measured 1 day before surgery and 1, 3, and 5 days after surgery. Secondary outcome indicators included the anxiety and depression levels of patients measured upon admission to the hospital and 48 h after surgery by Self-rating Anxiety Scale (SAS) and Self-rating Sepression Scale (SDS), respectively.

Results

In the experimental group, the time of the first postoperative passage of flatus and stool, ambulation, and liquid-diet meal and the postoperative length-of-stay were all lower than those in the control group. The postoperative CRP and IL-6 levels of the two groups were significantly higher than the preoperative levels, and the control group had higher CRP and IL-6 levels than the experimental group did, all showing significant difference ( P<0.05). The two groups presented different stress states at different points of time after surgery, with the CRP and IL-6 levels reaching the highest 3 days after surgery and then dropping to some degree afterwards. The HOMR-IR of the patients in the experimental group was significantly lower than that of the control group and the difference was significant at both 1 d and 3 d after surgery ( P<0.05). Comparison of the difference in the anxiety and the depression scores in the two groups showed significant difference ( P<0.05). Before discharge, patient satisfaction of the experimental group was significantly higher than that of the control group ( P<0.05).

Conclusion

The implementation of ERAS precision nursing care can effectively promote the postoperative recovery of colorectal cancer patients, reduce the perioperative stress response, alleviate anxiety and depression, improve patient satisfaction, and hence should be extensively applied in clinical practice.

ERAS Protocol Applied to Oncological Colorectal Mini-invasive Surgery Reduces the Surgical Stress Response and Improves Long-term Cancer-specific Survival

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are known to reduce postoperative complications and improve short-term outcomes by minimizing the surgical stress response (SSR). Retrospective reviews of large cohorts suggest that they may also have an impact on long-term oncological outcomes. In 2016, Mari et al published a randomized trial on ERAS protocol and the impact on the SSR; they found that IL-6 was less expressed in patients who undergo laparoscopic colorectal surgery within an ERAS protocol compared with controls. The aim of the present study is to report the long-term oncological outcomes of patients enrolled 5 years after the conclusion of the study.

METHODS

Patients enrolled had received the indication for major colorectal surgery, aged between 18 and 80 years, with American Society of Anesthesiologists (ASA) grades I to III, autonomous for mobilization and walking, eligible for laparoscopic technique. In total, 140 patients were enrolled and randomized into 2 groups of 70 patients each. Among these patients, 52 in the ERAS group (EG) and 53 in the Standard group (SG) had colorectal cancer. For them, a 5-year oncological follow-up according to the NCCN 16 guidelines was planned. IL-6, C-reactive protein, prolactine, white blood cell count, albumin, and prealbumin were compared between oncological patients in the EG and in the SG.

RESULTS

EG showed lower IL-6 on postoperative day 1 (21.2±9.1 vs. 40.3 ±11.3; P <0.05) and on day 5 (14.9±6.2 vs. 38.7±8.9; P <0.05), lower C-reactive protein on day 1 (48.3±15.7 vs. 89.4±20.3; P <0.05) and on day 5 (38.3±11.4 vs. 74.3±19.7; P <0.05), and lower pre-albumine on day 5 (18.9±7.2 vs. 12.3±6.9; P <0.05) compared with SG. Median oncological follow-up was 57 months [46.5 to 60]. There was no statistically significant difference in overall survival (log rank=0.195) and disease-free survival (Log rank=0.089) between groups. Cancer-specific survival was significantly better (log rank=0.038) in the EG compared with patients in the SG.

CONCLUSIONS

ERAS protocol applied to colorectal laparoscopic surgery for cancer is able to minimize the SSR. As a possible result, cancer-specific survival seems to be improved in patients within enhanced protocols. However, even though there may be an association between an excess of SSR and worse oncological outcomes, the favorable effect of ERAS protocols toward better overall and disease-free survival is yet to be demonstrated.

Implementation of an enhanced recovery after surgery program with robotic surgery in high-risk patients obtains optimal results after colorectal resections

Enhanced recovery after surgery programs reduce postoperative complications and length of stay after laparoscopic colorectal surgery, but are still under evaluation after robotic colorectal surgery. To evaluate potential benefits in terms of length of stay and complications of an Enhanced recovery after surgery program in colorectal surgery. A subanalysis was performed to assess what combination of surgical approach and perioperative care had better outcomes. Prospective observational cohort study. 300 consecutive colorectal surgery patients: 150 were prospectively included in the enhanced recovery after Surgery program group and 150 retrospectively in the traditional care group, and subdivided according to the type of surgery, in Hospital Marques de Valdecilla, between 2013 and 2016. Postoperative complications decreased significantly (p = 0.002) from 46 to 28% (traditional care vs program group). The length of stay was decreased by 2 days (p < 0.001). Multivariate analysis indicated similar effect sizes after adjusting for age, gender, Charlson score, and type of surgery. Type of surgery was an independent predictive factor for postoperative complications and length of stay. Compared to open surgery, postoperative complications decreased by 50% (p < 0.001) after robotic surgery and by 40% (p = 0.01) after laparoscopic surgery, while the median length of stay decreased by three days (p < 0.001) after minimally invasive surgery. Enhanced recovery after surgery program and minimally invasive surgery were associated with decreased morbidity and length of stay after colorectal surgery compared to open surgery and traditional care. An enhanced recovery after surgery program with robotic surgery in high-risk patients might be beneficial.

Application of a perioperative nursing strategy in the surgical treatment of elderly patients: a narrative review†

With the steady increase of older people in society, a progressively greater number of patients belonging to the geriatric group need surgical treatment. Since elderly patients with reduced physiological reserve and organ failure often have chronic diseases, geriatric syndrome, and other clinical problems, the perioperative nursing of elderly patients is more complicated. Therefore, we need to comprehensively consider clinical issues, such as patients’ preoperative status, surgical risks, and postoperative quality of life and life expectancy, and conduct comprehensive evaluations and holistic, individualized, and continuous nursing and therapy through the participation of interdisciplinary teams to achieve better curative effects. Here, the perioperative nursing of elderly patients is reviewed, including preoperative evaluation and nursing, intraoperative management, and postoperative nursing.

Association between enrollment in an enhanced recovery program for colorectal cancer surgery and long-term recurrence and survival

INTRODUCTION

Enhanced Recovery After Surgery (ERAS) programs have been shown to minimize the surgical inflammatory response in colorectal cancer. Our objective was to determine the association between an ERAS program for colorectal cancer surgery and oncologic recurrence and survival.

METHODS

A before-after intervention study was designed, including patients who underwent colorectal cancer surgery between November 2010 and March 2016. Cox hazard regression analysis was performed per cumulative year of follow-up to evaluate the association between ERAS program exposure and overall survival. Subgroup analysis was performed by cancer stage (low [I/II] vs. advanced [III/IV]).

RESULTS

In total, 646 patients were included, of which 339 were pre-ERAS and 307 were ERAS. Our overall median compliance rate with ERAS interventions was 90% (interquartile range: 85%-95%). Overall survival rates were higher in the ERAS group within the first 2 years after surgery (89.2% vs.  83.2%; p = 0.04). Multivariable analysis revealed that the ERAS enrollment was associated with a significantly lower risk in 5-year oncologic recurrence (adjusted hazard ratio [aHR]: 0.55; 95% confidence interval [CI]: 0.33-0.94; p = 0.03) and higher 3-year survival (aHR: 0.55; 95% CI: 0.33-0.93; p = 0.03) among patients with advanced cancer stage compared to pre-ERAS counterparts.

CONCLUSIONS

Patients with advanced colorectal cancer were less likely to suffer oncologic recurrence when managed during the ERAS period.

Insufficient Post-operative Energy Intake Is Associated With Failure of Enhanced Recovery Programs After Laparoscopic Colorectal Cancer Surgery: A Prospective Cohort Study

Background: Although enhanced recovery after surgery (ERAS) has been proven to be beneficial after laparoscopic colorectal surgery, some of the patients may fail to complete the ERAS program during hospitalization. This prospective study aims to evaluate the risk factors associated with ERAS failure after laparoscopic colorectal cancer surgery.

Methods: This is a prospective study from a single tertiary referral hospital. Patients diagnosed with colorectal cancer who met the inclusion criteria were included in this study. Demographic and clinicopathological characteristics were collected. Post-operative activity time and 6-min walking distance (6MWD) were measured. Patients were divided into ERAS failure group and ERAS success according to decreased post-operative activity and 6MWD. Factors associated with ERAS failure were investigated by univariate and multivariate analysis.

Results: A total of 91 patients with colorectal cancer were included. The incidence of ERAS failure is 28.6% among all patients. Patients in ERAS failure group experienced higher rate of post-operative ileus and prolonged hospital stay (p < 0.001). Multivariate analysis revealed that older age (p = 0.006), body mass index ≥25.5 kg/m² (p = 0.037), smoking (p = 0.002), operative time (p = 0.048), and post-operative energy intake <18.5 kcal/kg•d (p = 0.045) were independent risk factors of ERAS failure after laparoscopic colorectal surgery.

Conclusions: Our findings indicated that a proportion of patients may fail the ERAS program after laparoscopic colorectal surgery. We for the first time showed that post-operative energy intake was an independent risk factor for ERAS failure. This may provide evidence for further investigation on precise measurement of nutritional status and selected high-risk patients for enhanced nutrition support.

Management of acute kidney injury in gastrointestinal tumor: An overview

Gastrointestinal tumors remain a global health problem. Acute kidney injury (AKI) is a common complication during the treatment of gastrointestinal tumors. AKI can cause a decrease in the remission rate and an increase in mortality. In this review, we analyzed the causes and risk factors for AKI in gastrointestinal tumor patients. The possible mechanisms of AKI were divided into three groups: pretreatment, intrafraction and post-treatment causes. Treatment and prevention measures were proposed according to various factors to provide guidance to clinicians and oncologists that can reduce the incidence of AKI and improve the quality of life and survival rate of gastrointestinal tumor patients.

[Implementation of fast-track measures in colorectal resections : A survey among members of the DGAI]

PURPOSE

The fast-track (FT) concept is a multimodal, interdisciplinary approach to perioperative patient care intended to reduce postoperative complications. Despite good evidence implementation seems to need improvement, whereby almost all studies focused on the implementation of surgical modules regardless of the interdisciplinary aspect. Adherence to the anesthesiological measures (prehabilitation, premedication, volume and temperature management, pain therapy), on the other hand, has been insufficiently studied. To assess the status quo a survey on the implementation of anesthesiological FT measures was conducted among members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) to analyze where potential for improvement exists.

METHODS

Using the SurveyMonkey® online survey tool, 28 questions regarding perioperative anesthesiological care of colorectal surgery patients were sent to DGAI members in order to analyze adherence to FT measures.

RESULTS

While some of the FT measures (temperature management, PONV prophylaxis) are already routinely used, there is a divergence between current recommendations and clinical implementation for other components. In addition to premedication, interdisciplinary measures (prehabilitation) and measures that affect multiple interfaces (operating theatre, recovery room, ward), such as volume management or perioperative pain management, are particularly affected.

CONCLUSION

The anesthesiological recommendations of the FT concept are only partially implemented in Germany. This particularly affects the interdisciplinary components as well as measures at the operating theatre, recovery room and ward interfaces. The establishment of an interdisciplinary FT team and interdisciplinary development of SOPs can optimize adherence, which in turn improves the short-term and long-term outcome of patients.

Development and validation of a prediction score for safe outpatient colorectal resections

BACKGROUND

Avoiding unnecessary inpatient stay may decrease hospital-acquired complications and costs while increasing patient satisfaction. This study aimed to develop and validate a score to identify patients eligible for safe same-day discharge after colorectal resections.

METHODS

This bi-institutional retrospective cohort study included consecutive patients undergoing elective colon and rectal resections (2011-2018) for benign and malignant indications. Two multivariable logistic models were developed based on demographic and surgical risk factors to predict a combined endpoint (ileus, anastomotic leak, intra-abdominal abscess, and readmission). Development and validation datasets were randomly sampled from the entire cohort. Areas under the receiver operating characteristic curves (AUC) were evaluated, and Hosmer-Lemeshow goodness-of-fit tests were used to assess validation model fit.

RESULTS

Of 5,389 patients, 1,182 (21.9%) experienced at least one complication of the combined endpoint. Male gender, open surgery, ASA ≥3, wound class ≥3, ileostomy, surgical duration >3 hours, and perioperative IV fluids >3 L all had significantly greater odds of the combined endpoint in the parsimonious multivariable model (all P < .05). The reduced model considering only the 4 variables with the highest OR (>1.5) contained open surgery, ASA ≥3, wound class ≥3, and surgical duration ≥3 hours as predictors (all P < .05, AUC of 0.65; 95% CI 0.63, 0.68). Both the parsimonious model and the reduced model demonstrated no lack of fit in the validation cohort.

CONCLUSION

The suggested score composed of preand intraoperative items may help physicians decide on patients' same-day discharge after colorectal resection.

Effect of different levels of stroke volume variation on the endothelial glycocalyx of patients undergoing colorectal surgery: A randomized clinical trial

NEW FINDINGS

What is the central question of this study? Massive infusion can destroy the endothelial glycocalyx. We compared the serum concentrations of endothelial glycocalyx components and atrial natriuretic peptide and the outcomes of patients with different levels of stroke volume variation (SVV). What is the main finding and its importance? With a decrease in SVV, the serum concentrations of endothelial glycocalyx components and atrial natriuretic peptide increased, whereas the oxygenation index decreased. When the intraoperative SVV was maintained at 7-10%, the patients had better postoperative recovery and shorter postoperative hospital stays. Therefore, it is advisable to maintain the SVV between 7 and 10%.

ABSTRACT

Dynamic haemodynamic parameters, such as stroke volume variation (SVV), can be used for blood volume monitoring. However, studies have determined the SVV threshold but not the optimal level. The endothelial glycocalyx (EG) plays an important role in maintaining vascular permeability. Moreover, rapid and massive infusion can lead to the degradation, shedding and destruction of the EG. We aimed to explore the effects of different SVV values (11-14, 7-10 or 3-6%) on the EG in 54 patients who were scheduled for elective colorectal tumour surgery and to identify the optimal peri-operative fluid therapy strategy. The concentrations of EG degradation products (heparin sulphate, hyaluronic acid and syndecan-1) and atrial natriuretic peptide were higher when the SVV was maintained between 3 and 6% after fluid therapy compared with pre-infusion (P < 0.05). Comparison of postoperative complications and hospitalization time among the three SVV levels was not statistically significant (P > 0.05). The postoperative hospitalization time in patients with SVV of 7-10% was shorter than that in patients with SVV of 3-6%. Infusion of a large volume of fluid, with increasing EG degeneration and atrial natriuretic peptide concentrations, might be related to postoperative outcomes.

Oncologic and long-term outcomes of enhanced recovery after surgery in cancer surgeries - a systematic review

Background

Clinical evidence has proved that enhanced recovery after surgery (ERAS) can improve short-term clinical outcomes after various types of surgeries, but the long-term benefits have not yet been examined, especially with respect to cancer surgeries. Therefore, a systematic review of the current evidence was conducted.

Methods

The Pubmed, Cochrane Library, Embase, and Web of Science databases were searched using the following key words as search terms: “ERAS” or “enhanced recovery” or “fast track”, “oncologic outcome”, “recurrence”, “metastasis”, “long-term outcomes”, “survival”, and “cancer surgery”. The articles were screened using the inclusion and exclusion criteria, and the data from the included studies were extracted and analyzed.

Results

A total of twenty-six articles were included in this review. Eighteen articles compared ERAS and conventional care, of which, 12 studies reported long-term overall survival (OS), and only 4 found the improvement by ERAS. Four studies reported disease-free survival (DFS), and only 1 found the improvement by ERAS. Five studies reported the outcomes of return to intended oncologic treatment after surgery (RIOT), and 4 found improvements in the ERAS group. Seven studies compared high adherence to ERAS with low adherence, of which, 6 reported the long-term OS, and 3 showed improvements by high adherence. One study reported high adherence could reduce the interval from surgery to RIOT. Four studies reported the effect of altering one single item within the ERAS protocol, but the results of 2 studies were controversial regarding the long-term OS between laparoscopic and open surgery, and 1 study showed improvements in OS with restrictive fluid therapy.

Conclusions

The use of ERAS in cancer surgeries can improve the on-time initiation and completion of adjuvant chemotherapy after surgery, and the high adherence to ERAS can lead to better outcomes than low adherence. Based on the current evidence, it is difficult to determine whether the ERAS protocol is associated with long-term overall survival or cancer-specific survival.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02306-2.

[Background, Necessity and Methodology of the S3 Guideline "Perioperative Management of Gastrointestinal Tumours (POMGAT)"]

Malignancies are among the most common diseases, especially in old age, and are responsible for 25% of all deaths in Germany. Especially carcinomas of the gastrointestinal tract can be cured in most cases only through extensive surgery with significant morbidity. About 25 years ago, the multimodal, perioperative Fast Track (FT) concept for reducing postoperative complications was introduced and additional elements were added in the following years. Meanwhile, there is growing evidence that adherence to the key elements of more than 70% leads to reduction in postoperative adverse events as well as a shorter hospital stay and could be associated with an improved oncological outcome. Despite the high level of awareness and the proven advantages of the FT concept, the implementation and maintenance of the measures is difficult and results in an adherence of only 20 - 40%. There are many reasons for this: In addition to a lack of interdisciplinary and interprofessional cooperation and the time consuming and extended logistical efforts, limited human resources are often listed as one of the main causes. We took these aspects as an opportunity and started to develop a S3 guideline for perioperative treatment to accelerate the recovery of patients with gastrointestinal malignancies. By creating a consensus- and evidence-based, multidisciplinary guideline, many of the problems listed above could probably be solved by optimising and standardising interdisciplinary care, which is particularly important in a setting with many different disciplines and their competing interests. Furthermore, the standardisation of the perioperative procedures will reduce the time and logistical effort. The presentation of the evidence allows increased transparency and justifies the additional personnel expenditure on hospital medicine and health insurance companies. In addition, the evidence-based quality indicators generated during the development of the guideline make it possible to include perioperative standards in certification systems and thus to measure and check the quality of perioperative care.

Perioperative nursing principles guided by the concept of enhanced recovery after surgery†

Objective

To explore the clinical effect of perioperative nursing guided by the concept of enhanced recovery after surgery and summarize them.

Methods

Pubmed, Chinese National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Wanfang Database, and VIP Database were searched to obtain the relevant literature involving enhanced recovery after surgery (ERAS) guidance, obtain the effective clinical data, review the reports in literature, and obtain the effective scheme.

Results

Compared with the traditional nursing program, perioperative nursing principles guided by the concept of ERAS provide more accurate nursing care to patients and reduce the occurrence of intraoperative stress events through comprehensive nursing measures such as preoperative pre-rehabilitation measures, intraoperative body temperature and fluid management, postoperative analgesia, prevention of nausea and vomiting, early mobilization, catheter nursing, and better out-of-hospital follow-up.

Conclusions

Perioperative nursing principles guided by the concept of ERAS can significantly reduce the incidence of perioperative complications, shorten the hospital stay of patients, and promote postoperative rehabilitation of patients. The transformation and implementation of this concept can bring significant benefits to hospitals, medical care, and patients.

The Effect of Intraoperative Fluid Management According to Stroke Volume Variation on Postoperative Bowel Function Recovery in Colorectal Cancer Surgery

Stroke volume variation (SVV) has been used to predict fluid responsiveness; however, it remains unclear whether goal-directed fluid therapy using SVV contributes to bowel function recovery in abdominal surgery. This prospective randomized controlled trial aimed to compare bowel movement recovery in patients undergoing colon resection surgery between groups using traditional or SVV-based methods for intravenous fluid management. We collected data between March 2015 and July 2017. Bowel function recovery was analyzed based on the gas-passing time, sips of water time, and soft diet (SD) time. Finally, we analyzed data from 60 patients. There was no significant between-group difference in the patients’ characteristics. Compared with the control group (n = 30), the SVV group (n = 30) had a significantly higher colloid volume and lower crystalloid volume. Moreover, the gas-passing time (77.8 vs. 85.3 h, p = 0.034) and SD time (67.6 vs. 85.1 h, p < 0.001) were significantly faster in the SVV group than in the control group. Compared with the control group, the SVV group showed significantly lower scores of pain on a numeric rating scale and morphine equivalent doses during post-anesthetic care, at 24 postoperative hours, and at 48 postoperative hours. Our findings suggested that, compared with the control group, the SVV group showed a faster postoperative SD time, reduced acute postoperative pain intensity, and lower rescue analgesics. Therefore, SVV-based optimal fluid management is expected to potentially contribute to postoperative bowel function recovery in patients undergoing colon resection surgery.

Short-term outcome in robotic vs laparoscopic and open rectal tumor surgery within an ERAS protocol: a retrospective cohort study from the Swedish ERAS database

BACKGROUND

Advantages of robotic technique over laparoscopic technique in rectal tumor surgery have yet to be proven. Large multicenter, register-based cohort studies within an optimized perioperative care protocol are lacking. The aim of this retrospective cohort study was to compare short-term outcomes in robotic, laparoscopic and open rectal tumor resections, while also determining compliance to the enhanced recovery after surgery (ERAS)®Society Guidelines.

METHODS

All patients scheduled for rectal tumor resection and consecutively recorded in the Swedish part of the international ERAS® Interactive Audit System between January 1, 2010 to February 27, 2020, were included (N = 3125). Primary outcomes were postoperative complications and length of stay (LOS) and secondary outcomes compliance to the ERAS protocol, conversion to open surgery, symptoms delaying discharge and reoperations. Uni- and multivariate comparisons were used.

RESULTS

Robotic surgery (N = 827) had a similar rate of postoperative complications (Clavien-Dindo grades 1-5), 35.9% compared to open surgery (N = 1429) 40.9% (OR 1.15, 95% CI (0.93, 1.41)) and laparoscopic surgery (N = 869) 31.2% (OR 0.88, 95% CI (0.71, 1.08)). LOS was longer in the open group, median 9 days (IRR 1.35, 95% CI (1.27, 1.44)) and laparoscopic group, 7 days (IRR 1.14, 95% CI (1.07, 1.21)) compared to the robotic group, 6 days. Pre- and intraoperative compliance to the ERAS protocol were similar between groups.

CONCLUSIONS

In this multicenter cohort study, robotic surgery was associated with shorter LOS compared to both laparoscopic and open surgery and had lower conversion rates vs laparoscopic surgery. The rate of complications was similar between groups.

Risk Factors for Anastomotic Leakage in Patients with Rectal Tumors Undergoing Anterior Resection within an ERAS Protocol: Results from the Swedish ERAS Database

Background

Research on risk factors for anastomotic leakage (AL) alone within an Enhanced Recovery After Surgery (ERAS) protocol has not yet been conducted. The aim of this study was to identify risk factors for AL and study short-term outcome after AL in patients operated with anterior resection (AR).

Methods

All prospectively and consecutively recorded patients operated with AR in the Swedish part of the international ERAS® Interactive Audit System (EIAS) between January 2010 and February 2020 were included. The cohort was evaluated regarding risk factors for AL and short-term outcomes, including uni- and multivariate analysis. Pre-, intra- and postoperative compliance to ERAS®Society guidelines was calculated and evaluated.

Results

Altogether 1900 patients were included, 155 (8.2%) with AL and 1745 without AL. Male gender, obesity, peritoneal contamination, year of surgery 2016–2020, duration of primary surgery and age remained significant predictors for AL in multivariate analysis. There was no significant difference in overall pre- and intraoperative compliance to ERAS®Society guidelines between groups. Only preadmission patient education remained as a significant ERAS variable associated with less AL. AL was associated with longer length of stay (LOS), higher morbidity rate and higher rate of reoperations.

Conclusion

Male gender, obesity, peritoneal contamination, duration of surgery, surgery later in study period, age and preadmission patient education were associated with AL in patients operated on with AR. Overall pre- and intraoperative compliance to the ERAS protocol was high in both groups and not associated with AL.

Perioperative fluid balance and major postoperative complications in surgery for advanced epithelial ovarian cancer

OBJECTIVE

Appropriate fluid balance in the perioperative period is important as both hypo- and hypervolemia are associated with increased risk of complications. Women undergoing cytoreductive surgery (CRS) for advanced epithelial ovarian cancer (EOC) may have major fluid shifts. The optimal perioperative fluid balance in these women is yet to be determined. Our objective was to investigate the association between perioperative fluid balance and major postoperative complications.

METHODS

Women with advanced stage EOC who underwent surgery at Karolinska University Hospital, Stockholm, Sweden were identified from the institutional database. Women subjected to surgery with curative intent were included in the analysis. Additional data were retrieved from medical records. The association between perioperative fluid balance and major postoperative complications was investigated by multivariable regression and adjusted for predefined confounders.

RESULTS

Of the 270 women identified in the institutional database during 2014-2017, 184 women were included in the analyses. Of these women, 22% (n = 40) experienced a major postoperative complication. The fully adjusted odds of major postoperative complications increased when perioperative fluid balance exceeded >3000 mL, (Odds Ratio (OR) 4.85, 95% Confidence Interval (CI) 1.23-19.2, p = 0.02) and > 5000 mL (OR 33.7, 95% CI 4.13-275, p < 0.01). There was no association between negative fluid balance and major postoperative complications (OR 3.33, 95% CI 0.25-44.1, p = 0.36).

CONCLUSIONS

Fluid balance >3000 mL perioperatively during surgery for advanced EOC increased the odds of major postoperative complications. Management of perioperative fluid balance in advanced EOC surgery remains a challenge.

[Perioperative fluid management in major abdominal surgery]

Intravascular fluid administration belongs to the cornerstones of perioperative treatment with a substantial impact on surgical outcome especially with respect to major abdominal surgery. By avoidance of hypovolemia and hypervolemia, adequate perioperative fluid management significantly contributes to the reduction of insufficient tissue perfusion as a determinant of postoperative morbidity and mortality. The effective use of intravascular fluids requires detailed knowledge of the substances as well as measures to guide fluid therapy. Fluid management already starts preoperatively and should be continued in the postoperative setting (recovery room, peripheral ward) considering a patient-adjusted and surgery-adjusted hemodynamic monitoring. Communication between all team members participating in perioperative care is essential to optimize fluid management.

Surgical treatment for colorectal cancer: analysis of the influence of an enhanced recovery programme on long-term oncological outcomes-a study protocol for a prospective, multicentre, observational cohort study

INTRODUCTION

The evidence currently available from enhanced recovery after surgery (ERAS) programmes concerns their benefits in the immediate postoperative period, but there is still very little evidence as to whether their correct implementation benefits patients in the long term. The working hypothesis here is that, due to the lower response to surgical aggression and lower rates of postoperative complications, ERAS protocols can reduce colorectal cancer-related mortality. The main objective of this study is to analyse the impact of an ERAS programme for colorectal cancer on 5-year survival. As secondary objectives, we propose to analyse the weight of each of the predefined items in the oncological results as well as the quality of life.

METHODS AND ANALYSIS

A multicentre prospective cohort study was conducted in patients older than 18 years of age who are scheduled to undergo surgery for colorectal cancer. The study involved 12 hospitals with an implemented enhanced recovery protocol according to the guidelines published by the Spanish National Health Service. The intervention group includes patients with a minimum implementation level of 70%, and the control group includes those who fail to reach this level. Compliance will be studied using 18 key performance indicators, and the results will be analysed using cancer survival indicators, including overall survival, cancer-specific survival and relapse-free survival. The time to recurrence, perioperative morbidity and mortality, hospital stay and quality of life will also be studied, the latter using the validated EuroQol Five questionnaire. The propensity index method will be used to create comparable treatment and control groups, and a multivariate regression will be used to study each variable. The Kaplan-Meier estimator will be used to estimate survival and the log-rank test to make comparisons. A p value of less than 0.05 (two-tailed) will be considered to be significant.

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained from the Aragon Ethical Committee (C.P.-C.I. PI20/086) on 4 March 2020. The findings of this study will be submitted to peer-reviewed journals (BMJ Open, JAMA Surgery, Annals of Surgery, British Journal of Surgery). Abstracts will be submitted to relevant national and international meetings.

TRIAL REGISTRATION NUMBER

NCT04305314.

Management of Acute Kidney Injury Following Major Abdominal Surgery: A Contemporary Review

Acute kidney injury (AKI) is a frequent occurrence following major abdominal surgery and is independently associated with both in-hospital and long-term mortality, as well as with a higher risk of progressing to chronic kidney disease (CKD) and cardiovascular events. Postoperative AKI can account for up to 40% of in-hospital AKI cases. Given the differences in patient characteristics and the pathophysiology of postoperative AKI, it is inappropriate to assume that the management after noncardiac and nonvascular surgery are the same as those after cardiac and vascular surgery. This article provides a comprehensive review on the available evidence on the management of postoperative AKI in the setting of major abdominal surgery.

Impact of intraoperative zero-balance fluid therapy on the occurrence of acute kidney injury in patients who had undergone colorectal cancer resection within an enhanced recovery after surgery protocol: a propensity score matching analysis

PURPOSE

An enhanced recovery after surgery (ERAS) protocol for colorectal cancer resection encourages perioperative euvolemic status, and zero-balance fluid therapy is recommended for low-risk patients. Recently, several studies have reported concerns of increased acute kidney injury (AKI) in patients within an ERAS protocol. In the present study, we investigated the impact of intraoperative zero-balance fluid therapy within an ERAS protocol on postoperative AKI.

METHODS

Patients who underwent elective surgery for primary colorectal cancer were divided into zero-balance and non-zero-balance fluid therapy groups according to intraoperative fluid amount and balance. After propensity score (PS) matching, 210 patients from each group were selected. Incidences of AKI were compared between the two groups according to the Kidney Disease Improving Global Outcomes criteria. Postoperative kidney functions and surgical outcomes were also compared.

RESULTS

AKI was significantly higher in the zero-balance fluid therapy group compared to the non-zero-balance fluid therapy group (21.4% vs. 13.8%, p = 0.040) in PS-matched patients. The decrease in the estimated glomerular filtration rate on the day of surgery was significantly higher in the zero-balance fluid therapy group (- 5.9 mL/min/1.73 m² vs. - 1.4 mL/min/1.73 m², p = 0.005). There were no differences in general morbidity or mortality rate, although surgery-related complications were more common in the zero-balance group.

CONCLUSIONS

Despite the proven benefits of zero-balance fluid therapy in colorectal ERAS protocols, care should be taken to monitor for postoperative AKI. Further studies regarding the clinical significance of postoperative AKI occurrence and optimised intraoperative fluid therapy are needed in a colorectal ERAS setting.

Role of intraoperative oliguria in risk stratification for postoperative acute kidney injury in patients undergoing colorectal surgery with an enhanced recovery protocol: A propensity score matching analysis

BACKGROUND

The enhanced recovery after surgery (ERAS) protocol for colorectal cancer resection recommends balanced perioperative fluid therapy. According to recent guidelines, zero-balance fluid therapy is recommended in low-risk patients, and immediate correction of low urine output during surgery is discouraged. However, several reports have indicated an association of intraoperative oliguria with postoperative acute kidney injury (AKI). We investigated the impact of intraoperative oliguria in the colorectal ERAS setting on the incidence of postoperative AKI.

PATIENTS AND METHODS

From January 2017 to August 2019, a total of 453 patients underwent laparoscopic colorectal cancer resection with the ERAS protocol. Among them, 125 patients met the criteria for oliguria and were propensity score (PS) matched to 328 patients without intraoperative oliguria. After PS matching had been performed, 125 patients from each group were selected and the incidences of AKI were compared between the two groups. Postoperative kidney function and surgical outcomes were also evaluated.

RESULTS

The incidence of AKI was significantly higher in the intraoperative oliguria group than in the non-intraoperative oliguria group (26.4% vs. 11.2%, respectively, P = 0.002). Also, the eGFR reduction on postoperative day 0 was significantly greater in the intraoperative oliguria than non-intraoperative oliguria group (-9.02 vs. -1.24 mL/min/1.73 m2 respectively, P < 0.001). In addition, the surgical complication rate was higher in the intraoperative oliguria group than in the non-intraoperative oliguria group (18.4% vs. 9.6%, respectively, P = 0.045).

CONCLUSIONS

Despite the proven benefits of perioperative care with the ERAS protocol, caution is required in patients with intraoperative oliguria to prevent postoperative AKI. Further studies regarding appropriate management of intraoperative oliguria in association with long-term prognosis are needed in the colorectal ERAS setting.

Challenges to accomplish stringent fluid management standards 7 years after enhanced recovery after surgery implementation-The surgeon's perspective

BACKGROUND

This study aimed to analyze fluid management standards in 2 high-volume, enhanced recovery after surgery institutions 7 years after implementation.

METHODS

Retrospective analysis of consecutive patients undergoing elective, segmental colonic and extensive colorectal resections for benign and malignant pathology (2011-2017). Administration and composition of intravenous fluids, postoperative weight gain, and factors impeding compliance to preidentified fluid thresholds (3L fluid administration, 2.5 kg weight gain) were assessed. Multivariable logistic regression was performed to identify risk factors for postoperative adverse events.

RESULTS

A total of 5,155 patients were included. Among them, 2,320 patients (45.1%) received >3 L intravenous fluids at postoperative day 0. Fluid totals remained unchanged over the 7-year observation period. Fluid overload was independently associated with postoperative weight gain ≥2.5 kg at postoperative day 2 (odds ratio 1.34, P < .001). Patients with high American Society of Anesthesiologists score (≥3) undergoing open and longer (≥180 minutes) procedures were more likely to exceed both thresholds according to multivariable analysis (all P < .001). Other than open surgery, American Society of Anesthesiologists score ≥3, contamination class ≥3, and malignancy, both thresholds (≥3 L: odds ratio 1.76, 95% confidence interval 1.44-2.15, ≥ 2.5 kg: odds ratio 1.62, 95% confidence interval 1.33-1.97) were independent risk factors for postoperative adverse outcomes (occurring in 28.1% of patients).

CONCLUSION

Compliance with fluid thresholds appears to be challenging in patients with comorbidities undergoing open and long procedures. Efforts are encouraged because both thresholds are linked to adverse outcomes and appear to be potentially modifiable in selected patients.

High compliance to ERAS protocol does not improve overall survival in patients treated for resectable advanced gastric cancer

Introduction

The ERAS (Enhanced Recovery after Surgery) protocol revolutionized perioperative care for gastrointestinal surgical procedures. However, little is known about the association between adherence to the ERAS protocol in gastric cancer surgery and the oncological outcome.

Aim

To explore the relation between adherence to the ERAS protocol and the oncological outcome in gastric cancer patients.

Material and methods

We performed a retrospective analysis of a prospectively collected database of patients treated for gastric cancer between 2013 and 2016. All patients were treated perioperatively with a 14-item ERAS protocol. Every patient underwent regular follow-up every 3 months for 3 years after surgery. 80% compliance to the ERAS protocol was the goal during perioperative care. Based on the level of compliance, patients were divided into group 1 and group 2 (compliance of ≥ 80% and < 80%, respectively).

Results

Compliance to the ERAS protocol was not a risk factor for diminished overall survival – probability of 3-year survival was 63% in group 1 and 56% in group 2 (p = 0.75). The proportional Cox model revealed that only stage III gastric cancer was a risk factor of poor prognosis in patients operated on for gastric cancer (HR = 7.89, 95% CI: 2.96–20.89; p = 0.0001).

Conclusions

High adherence to the ERAS protocol did not improve overall survival in our 3-year observation. Only the stage of the disease, according to the AJCC classification, was identified as a risk factor for poor prognosis.

Identification of patients eligible for discharge within 48 h of colorectal resection

BACKGROUND

This study aimed to identify patients eligible for a 48-h stay after colorectal resection, to provide guidance for early discharge planning.

METHODS

A bi-institutional retrospective cohort study was undertaken of consecutive patients undergoing major elective colorectal resection for benign or malignant pathology within a comprehensive enhanced recovery pathway between 2011 and 2017. Overall and severe (Clavien-Dindo grade IIIb or above) postoperative complication and readmission rates were compared between patients who were discharged within 48 h and those who had hospital stay of 48 h or more. Multinominal logistic regression analysis was performed to ascertain significant factors associated with a short hospital stay (less than 48 h).

RESULTS

In total, 686 of 5122 patients (13·4 per cent) were discharged within 48 h. Independent factors favouring a short hospital stay were age below 60 years (odds ratio (OR) 1·34; P = 0·002), ASA grade less than III (OR 1·42; P = 0·003), restrictive fluid management (less than 3000 ml on day of surgery: OR 1·46; P < 0·001), duration of surgery less than 180 min (OR 1·89; P < 0·001), minimally invasive approach (OR 1·92; P < 0·001) and wound contamination grade below III (OR 4·50; P < 0·001), whereas cancer diagnosis (OR 0·55; P < 0·001) and malnutrition (BMI below 18 kg/m² : OR 0·42; P = 0·008) decreased the likelihood of early discharge. Patients with a 48-h stay had fewer overall (10·8 per cent versus 30·6 per cent in those with a longer stay; P < 0·001) and fewer severe (2·6 versus 10·2 per cent respectively; P < 0·001) complications, and a lower readmission rate (9·0 versus 11·8 per cent; P = 0·035).

CONCLUSION

Early discharge of selected patients is safe and does not increase postoperative morbidity or readmission rates. In these patients, outpatient colorectal surgery should be feasible on a large scale with logistical optimization.

Goal-Directed Fluid Therapy Does Not Improve Early Glomerular Filtration Rate in a Porcine Renal Transplantation Model

BACKGROUND:

Insufficient fluid administration intra- and postoperatively may lead to delayed renal graft function (DGF), while fluid overload increases the risk of heart failure, infection, and obstipation. Several different fluid protocols have been suggested to ensure optimal fluid state. However, there is a lack of evidence of the clinical impact of these regimens. This study aimed to determine whether individualized goal-directed fluid therapy (IGDT) positively affects the initial renal function compared to a high-volume fluid therapy (HVFT) and to examine the effects on renal endothelial glycocalyx, inflammatory and oxidative stress markers, and medullary tissue oxygenation. The hypothesis was that IGDT improves early glomerular filtration rate (GFR) in pigs subjected to renal transplantation.

METHODS:

This was an experimental randomized study. Using a porcine renal transplantation model, animals were randomly assigned to receive IGDT or HVFT during and until 1 hour after transplantation from brain-dead donors. The kidneys were exposed to 18 hours of cold ischemia. The recipients were observed until 10 hours after reperfusion, which included GFR measured as clearance of chrom-51-ethylendiamintetraacetat (⁵¹Cr-EDTA), animal weight, and renal tissue oxygenation by fiber optic probes. The renal expression of inflammatory and oxidative stress markers as well as glomerular endothelial glycocalyx were analyzed in the graft using polymerase chain reaction (PCR) technique and immunofluorescence.

RESULTS:

Twenty-eight recipient pigs were included for analysis. We found no evidence that IGDT improved early GFR compared to HVFT (P = .45), while animal weight increased more in the HVFT group (a mean difference of 3.4 kg [1.96–4.90]; P < .0001). A better, however nonsignificant, preservation of glomerular glycocalyx (P = .098) and significantly lower levels of the inflammatory marker cyclooxygenase 2 (COX-2) was observed in the IGDT group when compared to HVFT. COX-2 was 1.94 (1.50–2.39; P = .012) times greater in the HVFT group when compared to the IGDT group. No differences were observed in outer medullary tissue oxygenation or oxidative stress markers.

CONCLUSIONS:

IGDT did not improve early GFR; however, it may reduce tissue inflammation and could possibly lead to preservation of the glycocalyx compared to HVFT.

Enhanced recovery after surgery in pediatric gastrointestinal surgery

Objective

Enhanced recovery after surgery (ERAS) protocols help optimize inpatient care and minimize discomfort. This study was performed to explore the safety, feasibility, and clinical and social value of ERAS in pediatric gastrointestinal surgery.

Methods

This study included all children (n = 125) who underwent appendectomy, pyloromyotomy, transabdominal Soave’s procedure, Meckel’s diverticulum resection, or reduction of intussusception in our institution from January to September 2018. We compared surgical outcomes between children who underwent surgery under conventional perioperative regimens (control group, n = 57) and those who were treated with ERAS protocols (ERAS group, n = 68).

Results

There were no significant intergroup differences in demographic or surgical data. However, the bowel function recovery time, postoperative intravenous nutrition time, duration of postoperative hospital stay, and hospital costs were significantly lower in the ERAS group than control group. There was no significant intergroup difference in the complication rate.

Conclusions

Our results indicate that implementation of ERAS protocols is safe and feasible in pediatric gastrointestinal surgery. They can improve patient comfort, shorten the duration of the postoperative hospital stay, reduce hospital costs, and accelerate postoperative rehabilitation without increasing the risk of postoperative complications. Therefore, ERAS protocols deserve wider implementation and promotion.

Tumor immune microenvironment and nano-immunotherapeutics in colorectal cancer

Colorectal cancer (CRC) is predicted to be the second leading cause of cancer-related death in United States in 2019. Immunotherapies such as checkpoint inhibitors have proven efficacy in patients with high level of microsatellite instability and refractory to routine chemotherapy. Despite this, immunotherapy-based treatment is seriously limited by cancer immunogenicity which has evolved to evade immune surveillance in many circumstances. Efforts are made by researchers using nanoparticles (NPs) to override cancer-mediated immunosuppression, induce immune response against cancer cells or even generate memory immune cells for long-term disease control. These engineered NPs offer great opportunities in delivering cancer immunotherapy due to their unique properties, such as a high drug/antigen loading capacity, adjustable particle size, and versatile surface modification. In this review, we will highlight recent researches on the initiation and development of CRC, the immune microenvironment of CRC, and recent trends in engineering novel NPs-based immunotherapies in the treatment of CRC.

Association of perioperative weight-based fluid balance with 30-day mortality and acute kidney injury among patients in the surgical intensive care unit

PURPOSE

Perioperative positive fluid balance has negative effects on short-term outcomes, such as surgical complications, although the associations with postoperative mortality remain unclear. This study evaluated the associations of perioperative fluid balance (FB) with 30-day mortality and acute kidney injury (AKI) after postoperative intensive care unit (ICU) admission.

METHODS

This retrospective study evaluated data from adult patients who were admitted to the ICU after surgery during 2012-2016. Weight-based cumulative FB (%) was calculated for 3 time periods [postoperative day (POD) 0 (24 h), 0-1 (48 h), and 0-2 (72 h)] and was categorized as positive (≥ 5%), mild to moderate positive (5-10%), severe positive (> 10%), normal (0-5%), or negative (< 0%).

RESULTS

Data from 7896 patients were included in the analysis. The multivariable Cox regression model revealed that increased 30-day mortality was associated with positive FB groups (≥ 5%) compared to normal FB groups (0-5%) during 3 time periods [hazard ratio (HR) on POD 0 (24 h): 1.87, HR on POD 1 (48 h): 1.91, and HR on POD 2 (72 h): 4.62, all P < 0.05]. These trends were more evident in the severe positive FB group across the three time periods. Additionally, similar association was found for incidence of AKI during POD 0-2.

CONCLUSION

Perioperative cumulative weight-based FB was positively associated with increased postoperative 30-day mortality or postoperative AKI in ICU patients; this association was consistent with the positive FB on POD 0 (24 h), 0-1 (48 h), and 0-2 (72 h).

Impact of enhanced recovery after surgery programs on long-term survival among patients undergoing digestive tract tumor surgery: A meta-analysis

BACKGROUND

Enhanced recovery after surgery (ERAS) programs refer to a series of optimization measures based on evidence-based medical evidence to reduce perioperative stress response and speed up the recovery of organ function after surgery through a multi-disciplinary collaboration model. ERAS has been popularized in many disciplines and proved to improve the short-term prognosis of patients, while the study of long-term prognosis of patients is limited.

AIM

To evaluate the impact of ERAS programs on the long-term survival among patients undergoing digestive tract tumor surgery.

METHODS

Computer searches were performed in databases including Wanfang, CNKI, VIP, PubMed, Cochrane Library, and EMBASE for randomized controlled trials or case-control studies describing ERAS programs in patients undergoing digestive tract tumor surgery published between January 1995 and November 2018. Two researchers independently evaluated the quality of studies that met the inclusion criteria and performed a meta-analysis using RevMan5.3.5 software.

RESULTS

A total of ten studies including 2477 patients were selected for the meta-analysis, including the ERAS group (n = 751) and the control group (n = 1726, undergoing traditional perioperative management). Compared with the control group, the ERAS group had improved 3-year survival (OR = 0.48, 95%CI: 0.30-0.78, P < 0.05) and 5-year survival (OR = 0.51, 95%CI: 0.40-0.65, P < 0.05). However, no significant difference was observed in 1-year survival (OR = 1.13, 95%CI: 0.63-2.02, P > 0.05) or 2-year survival (OR = 1.19, 95%CI: 0.38-3.73, P > 0.05) between the two groups.

CONCLUSION

Perioperative implementation of ERAS programs can improve outcomes and 3- and 5-year survival among patients undergoing digestive tract tumor surgery.

Does enhanced recovery improve the survival rates of patients 3 years after undergoing surgery to remove a tumor in the colon?

PURPOSE

The advantages of enhanced recovery programs (ERP) after colorectal surgery for morbidity and length of stay are well known. On a longer term, evidence is much more limited. The aim of this study is to determine the impact of ERP on survival after 3 years of follow-up, following colorectal cancer surgery.

METHODS

All the patients undergoing resection for colorectal cancer between the years 2010 and 2014 were included. Patients were classified according to their compliance with the ERP (< 70 or ≥ 70%).

RESULTS

Among the 206 patients included during the period, 129 were male (62.6%). The 3-year overall survival rate was 70.4% (145 patients) and relapse-free survival was 59.2% (122 patients). The survival after 3 years was influenced by the initial metastatic status (p < 0.0001), operative morbidity (p < 0.001), and the presence of peritumoral emboli (p = 0.006). However, the compliance with the ERP ≥ 70% did not influence overall survival (p = 0.63), nor relapse-free survival (p = 0.93). The same observations were found among the "at-risk" population (synchronous metastasis and postoperative complication).

CONCLUSION

The ERP does not seem to influence the 3-year relapse-free survival after colorectal resection for cancer.

Receiver operating characteristic analysis to determine optimal fluid management during open colorectal surgery

AIM

The present study aimed to analyse fluid management and to define optimal fluid-related thresholds for elective open colorectal surgery.

METHOD

A retrospective analysis was made of all consecutive elective open colorectal resections performed in our tertiary centre between May 2011 and May 2017. The main outcomes were postoperative complications [overall (I-V) and severe (IIIB-V) according to the Clavien classification], respiratory complications and postoperative ileus (POI). Critical thresholds regarding perioperative fluid management and postoperative weight gain were identified by using receiver operator characteristic (ROC) analysis. Independent risk factors for overall complications were identified by multivariable logistic regression analysis.

RESULTS

Of 121 patients who had open operations, 84 (69%) had some complication and 26 (21%) had severe complications. Respiratory complications and POI occurred in 15 (12%) and 46 patients (38%), respectively. The thresholds for intravenous fluids were 3.5 l at postoperative day (POD) 0 [area under ROC curve (AUROC) 0.7 for any 0.69 for respiratory complications] and 3.5 kg weight gain at POD 2 (AUROC 0.82 for respiratory complications). Multivariable analysis revealed weight gain of > 3.5 kg at POD 2 (OR 5.9; 95% CI 1.3-16.6) as a significant risk factor for overall complications. Acute kidney injury was observed in five patients (4%), three (5%) in the group with > 3.5 l at POD 0 and two (3%) in the group with < 3.5 l at POD 0 (P = 0.64). Creatinine increase was transitory and all patients regained baseline levels before discharge.

CONCLUSION

A weight gain of > 3.5 kg at POD 2 has been identified as the critical threshold for overall and respiratory complications and prolonged length of stay after open elective colorectal surgery.

Robotic vs laparoscopic rectal tumour surgery: a cohort study

AIM

The aim of this study was to compare robotic and laparoscopic rectal surgery in terms of perioperative data, short-term outcome and compliance to the Enhanced Recovery After Surgery (ERAS) protocol.

METHOD

In this cohort study, 224 patients scheduled for rectal resection for cancer or adenoma between January 2011 and January 2017 were evaluated. In the first time period (12 January 2011 to 23 April 2014), 47 (46%) of 102 patients had laparoscopic surgery. In the second time period (24 April 2014 to 30 January 2017), 72 (59%) of 122 patients had robotic surgery. Perioperative data and short-term outcome were collected from the ERAS database and patient charts. Data obtained from laparoscopic and robotic surgery in the two time periods studied were compared. Primary outcome was hospital length of stay (LOS) and secondary outcomes were compliance to the ERAS protocol, difference in postoperative complications and conversion to open surgery.

RESULTS

Compliance to the ERAS protocol was 81.1% in the robotic group and 83.4% in the laparoscopic group (P = 0.890). Robotic surgery was associated with shorter median LOS (3 days vs 7 days, P < 0.001), lower conversion rate (11.1% vs 34.0%, P = 0.002), lower rate of postoperative complications (25% vs 49%, P < 0.01) and longer duration of surgery (5.8 h vs 4.5 h, P < 0.001). The differences remained after multivariate analysis.

CONCLUSION

Robotic surgery was associated with shorter LOS, lower conversion rates and fewer postoperative complications compared with laparoscopic surgery. Robotic surgery may add benefits to the ERAS protocol.

Is It Possible to Maintain High Compliance with the Enhanced Recovery after Surgery (ERAS) Protocol?-A Cohort Study of 400 Consecutive Colorectal Cancer Patients

The aim of our study was to evaluate the implementation and degree of adherence to the Enhanced Recovery after Surgery (ERAS) protocol in a group of 400 patients operated laparoscopically for colorectal cancer, and to assess its impact on the short-term results. The prospective study included patients with histologically confirmed colorectal cancer undergoing elective laparoscopic resection from years 2012 to 2017. For the purpose of further analysis, patients were divided into four groups: 100 consecutive patients were in each group. There were no statistically significant differences between groups in demographic parameters. The mean compliance with the ERAS protocol in the entire study group was 84.8%. Median adherence differed between the groups 76.9% vs. 92.3% vs. 84.6% vs. 84.6%, respectively (p < 0.0001). There were statistically significant differences between groups in the tolerance of oral diet (54% vs. 83% vs. 83% vs. 64%) and mobilization (74% vs. 92% vs. 91% vs. 94%) on the first postoperative day. In subsequent groups, time to first flatus decreased (2.5 vs. 2.1 vs. 2.0 vs. 1.7 days, p = 0.0001). There were no statistical differences in the postoperative morbidity rate between groups (p = 0.4649). The median length of hospital stay in groups was 5 vs. 4 vs. 4 vs. 4 days, respectively (p = 0.0025). Maintaining high compliance with the ERAS protocol is possible, despite the slight decrease that occurs within a few years after its implementation. This decrease in compliance does not affect short-term results, which are comparable to those shortly after overcoming the learning curve.