The Application of Enhanced Recovery After Surgery for Gastrectomy and Colorectal Resection: A Systematic Review and Meta-Analysis

Ultrasound guided-transabdominal plane block (UG-TAPB) reduces pain, opioid consumption and PONV, and is associated with faster recovery for patients undergoing bariatric surgery: a retrospective analysis in a high-volume Italian center

Ultrasound-guided Transversus Abdominis Plane Block (UG-TAPB) reduces post-operative pain better than i.v. painkillers in patients operated with laparoscopic surgery. This study aims to compare the postoperative course of patients undergoing bariatric surgery treated with UG-TABP to that of patients treated with standard analgesic therapy. We retrospectively analyzed patients who have undergone bariatric surgery from November 2021 to April 2023, comparing patients treated with UG-TAPB (Group A) with patients treated with standard i.v. analgesic therapy (Group B). Post-operative numeric-pain rating scale (NRS), nausea and vomiting (PONV), opioid and antiemetic consumption were compared between the two groups until postoperative day (POD) 2. 41 patients underwent bariatric surgery in the aforementioned period. 11 patients were included in group A, whereas 30 patients were included in group B. The two groups were homogeneous for age, BMI, surgery type and comorbidities. Females were more common in Group B (64% vs. 80%; p = 0.019). NRS was significantly lower in Group A than Group B from POD0 to POD2 (3.8 ± 1.2 vs. 6.1 ± 2; p = 0.001 and 1.1 ± 0.3 vs. 3.1 ± 1.3; p < 0.001 after surgery and on POD2 8 pm, respectively). On POD 0, opioid consumption (9% vs. 57%; p = 0.011 and 9% vs. 47%; p = 0.033 after surgery and at 8 pm, respectively), PONV (27% vs. 90%; p < 0.001 and 9% vs. 57%; p = 0.011) and antiemetic consumption (36% vs. 90%; p = 0.001 and 9% vs. 53%; p = 0.014) were higher in Group B. Patients in Group A can be discharged earlier than patients in Group B (1.45 ± 0.82 vs. 2.67 ± 1.39 days; p = 0.005). UG-TAPB is associated with a better and faster recovery after bariatric surgery and should be considered in ERABS.

Association between preoperative sarcopenia and postoperative delirium in older patients undergoing gastrointestinal cancer surgery

Background

Postoperative delirium (POD) is a usual neurological complication, often leading to poor prognoses. Early identification of high-risk patients is crucial for preventing POD. Sarcopenia is an age-related geriatric syndrome characterized by the loss of skeletal muscle mass and function, and previous studies indicated that preoperative low muscle mass might be a predictor for POD. However, the association between preoperative sarcopenia and POD remains to be fully elucidated. This study was to explore the correlation between preoperative sarcopenia and POD following gastrointestinal cancer surgery in older patients.

Methods

Older patients (≥60 years) undergoing gastrointestinal cancer surgery were enrolled. Sarcopenia was defined based on the Special Interest Group on sarcopenia of the International Society of Physical and Rehabilitation Medicine (ISarcoPRM), which combined the loss of muscle mass (evaluated by ultrasound) and function (assessed by chair stand test and handgrip strength) before surgery. POD assessment was performed using the Confusion Assessment Method (CAM) or CAM for the intensive care unit (CAM-ICU) during the first 7 days after surgery or before discharge. Multivariate logistic regression analysis examined the correlation between preoperative sarcopenia and POD. Moreover, the receiver operator characteristic (ROC) curve was applied to analyze the predictive effect of the preoperative sarcopenia in POD.

Results

One hundred and thirty patients were finally included, of which 43 patients presented with sarcopenia before surgery. Twenty-four patients ultimately developed POD, and the incidence was 18.5%. The results of the multivariate analyses demonstrated that preoperative sarcopenia was still independently associated with POD after adjusting for age ≥70 years, preoperative Mini-Mental State Examination score, and intraoperative blood transfusion. The area under the ROC curve of preoperative sarcopenia in predicting POD was 0.680 (95% confidence interval 0.557-0.804).

Conclusion

Preoperative sarcopenia defined by ISarcoPRM criteria was independently associated with POD in geriatric patients after gastrointestinal cancer surgery.

Caffeine intake enhances bowel recovery after colorectal surgery: a meta-analysis of randomized and non-randomized studies

Postoperative ileus (POI) after colorectal surgery is a major problem that affects both patient recovery and hospital costs highlighting the importance of preventive strategies. Therefore, we aimed to perform a systematic analysis of the effects of postoperative caffeine consumption on bowel recovery and surgical morbidity after colorectal surgery. A comprehensive literature search was conducted through September 2023 for randomized and non-randomized trials comparing the effect of caffeinated versus non-caffeinated drinks on POI by evaluating bowel movement resumption, time to first flatus and solid food intake, and length of hospital stay (LOS). Secondary outcome analysis included postoperative morbidity in both groups. After data extraction and inclusion in a meta-analysis, odds ratios (ORs) for dichotomous variables and standardized mean differences (SMDs) for continuous outcomes with 95% confidence intervals (CIs) were calculated. Subgroup analyses were performed in cases of substantial heterogeneity. Six randomized and two non-randomized trials with a total of 610 patients were included in the meta-analysis. Caffeine intake significantly reduced time to first bowel movement [SMD -0.39, (95% CI -0.66 to -0.12), p = 0.005] and time to first solid food intake [SMD -0.41, (95% CI -0.79 to -0.04), p = 0.03] in elective laparoscopic colorectal surgery, while time to first flatus, LOS, and the secondary outcomes did not differ significantly. Postoperative caffeine consumption may be a reasonable strategy to prevent POI after elective colorectal surgery. However, larger randomized controlled trials (RCTs) with homogeneous study protocols, especially regarding the dosage form of caffeine and coffee, are needed.

Role of robotic surgery as an element of Enhanced Recovery After Surgery protocol in patients undergoing pancreatoduodenectomy

BACKGROUND

Although the current trend in pancreatoduodenectomy (PD) has shifted from open surgery to minimally invasive surgery (MIS), evidence on the role of MIS as an element of Enhanced Recovery After Surgery (ERAS) in PD is limited. This study aimed to investigate the effect of robotic surgery using the ERAS protocol on the outcomes of patients undergoing PD.

METHODS

This retrospective study included 252 patients who underwent open PD (OPD) or robotic PD (RPD) managed using the ERAS protocol between January 2017 and March 2023. Outcomes stratified by the surgical approach were compared. Multivariable analyses were performed to evaluate the effect of ERAS items, including robotic surgery, on outcomes after PD.

RESULTS

Of 252 patients, 202 (80.2%) underwent OPD, and 50 (19.2%) underwent RPD. Multivariable analyses demonstrated that perioperative management center support (odds ratio [OR], 2.85; 95% CI, 1.14-7.72; P = .025), robotic surgery (OR, 6.40; 95% CI, 1.94-26.1; P = .002), early solid intake (OR, 2.84; 95% CI, 1.46-5.63; P = .002), and early drain removal (OR, 3.77; 95% CI, 2.04-7.06; P < .001) were significant ERAS items related to early discharge after PD.

CONCLUSION

Our study demonstrated that employing the ERAS protocol for OPD and RPD is feasible and safe. Moreover, our results suggested the role of robotic surgery as an element of the ERAS protocol for PD. A combination of ERAS protocols and MIS may be safe and feasible for accelerating postoperative recovery after PD.

[Structured implementation of fast-track pathways to enhance recovery after elective colorectal resection : First results from five German hospitals]

BACKGROUND

Multimodal optimized perioperative management (mPOM, fast-track, enhanced recovery after surgery, ERAS) leads to a significantly accelerated recovery of patients with elective colorectal resections. Nevertheless, fast-track surgery has not yet become established in everyday clinical practice in Germany. We present the results of a structured fast-track implementation in five German hospitals.

METHODS

Prospective data collection in the context of a 13-month structured fast-track implementation. All patients ≥ 18 years undergoing elective colorectal resection and who gave informed consent were included. After 3 months of preparation (pre-FAST), fast-track treatment was initiated and continued for 10 months (FAST). Outcome criteria were adherence to internationally recommended fast-track elements, postoperative complications, functional recovery, and postoperative hospital stay.

RESULTS

Data from 192 pre-FAST and 529 FAST patients were analyzed. Age, sex, patient risk, location, and type of disease were not different between both groups. The FAST patients were more likely to have undergone minimally invasive surgery (82% vs. 69%). Fast-track adherence increased from 52% (35-65%) under traditional treatment to 83% (65-96%) under fast-track treatment (p < 0.01). The duration until the end of infusion treatment, removal of the bladder catheter, first bowel movement, oral solid food, regaining autonomy, suitability for discharge and postoperative length of stay were significantly lower in the FAST group. Complications, reoperations, and readmission rates did not differ.

CONCLUSION

Fast-track adherence rates > 75% can also be achieved in German hospitals through structured fast-track implementation and the recovery of patients can be significantly accelerated.

Preoperative Immunocyte-Derived Ratios Predict Postoperative Recovery of Gastrointestinal Motility after Colorectal Cancer Surgery

The aim of this study was to assess the role of immunocyte-derived ratios (IDRs), such as the systemic immune-inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR), as markers for the postoperative recovery of gastrointestinal function following colorectal cancer surgery. A retrospective analysis was conducted on a consecutive cohort of 260 patients who underwent radical colorectal cancer surgery within the timeframe spanning from January 2016 to December 2022. Data concerning the postoperative recovery of gastrointestinal function included the I-FEED score, time to pass flatus, toleration for liquids in the first 48 h, and the need for nasogastric tube reinsertion in the immediate postoperative period. A special emphasis was allocated towards the examination of IDRs and their interrelation with the postoperative gastrointestinal functional parameters. The I-FEED score exhibited a positive correlation with the NLR, SII, and PLR. The univariate analysis indicated that all IDRs, multiorgan resection, hemoglobin and protein levels, regional nodal extent of the tumor (N), and obesity significantly affected nasogastric tube reinsertion. The multivariate analysis showed that the SII and N1 stages were risk factors for nasogastric tube reinsertion after colorectal cancer surgery. The SII and multiorgan resection were the only classifiers that remained significant in the multivariable analysis for the toleration for liquids. In summation, certain preoperative IDRs, such as the SII, PLR, and NLR, may hold potential as predictive determinants for postoperative gastrointestinal functional recovery following colorectal cancer surgery.