A multicentre comparison of a fast track or conventional postoperative protocol following laparoscopic or open elective surgery for colorectal cancer surgery

ECCO Topical Review: Roadmap to Optimal Peri-Operative Care in IBD

BACKGROUND AND AIMS

Despite the advances in medical therapies, a significant proportion of patients with inflammatory bowel diseases [IBD] require surgical intervention. This Topical Review aims to offer expert consensus practice recommendations for peri-operative care to optimize outcomes of IBD patients who undergo surgery.

METHODS

A multidisciplinary panel of IBD healthcare providers systematically reviewed aspects relevant to peri-operative care in IBD. Consensus statements were developed using Delphi methodology.

RESULTS

A total of 20 current practice positions were developed following systematic review of the current literature covering use of medication in the peri-operative period, nutritional assessment and intervention, physical and psychological rehabilitation and prehabilitation, and immediate postoperative care.

CONCLUSION

Peri-operative planning and optimization of the patient are imperative to ensure favourable outcomes and reduced morbidity. This Topical Review provides practice recommendations applicable in the peri-operative period in IBD patients undergoing surgery.

Enhanced recovery after surgery in patients undergoing laparoscopic common bile duct exploration: A retrospective study

Few reports have focused on the use of enhanced recovery after surgery (ERAS) in laparoscopic common bile duct exploration (LCBDE) to promote the postoperative recovery of patients with choledocholithiasis. Therefore, this study aimed to explore the advantages and safety of ERAS in patients who underwent LCBDE. From December 2016 to February 2020, 86 and 84 patients were retrospectively enrolled in the control and ERAS groups, respectively. The perioperative insulin resistance index, perioperative C-reactive protein level, time of postoperative analgesic use, time of postoperative first flatus, time of abdominal drainage tube removal, time of liver function recovery, and postoperative complications were analyzed between the two groups. The insulin resistance index (1, 3, and 5 days postoperatively) and C-reactive protein level (1, 3, 5, and 7 days postoperatively) in the ERAS group were significantly lower than those in the control group (all P < .05). In terms of the postoperative rehabilitation efficacy, the time of postoperative activity of the patient, time of postoperative first flatus, time of postoperative analgesic use, time of abdominal drainage tube removal, time of postoperative T-tube closing, and length of postoperative hospital stay in the ERAS group were significantly shorter than those in the control group (all P < .05). Additionally, the overall incidence of postoperative complications in the ERAS group had a decreasing trend when compared with that in the control group (P = .05). ERAS can reduce the postoperative stress response and postoperative complications of patients undergoing LCBDE, promote rehabilitation and shorten the length of postoperative hospital stay and therefore has good social and economic benefits.

Inflammatory Bowel Diseases Benefit from Enhanced Recovery After Surgery [ERAS] Protocol: A Systematic Review with Practical Implications

BACKGROUND

Enhanced Recovery After Surgery [ERAS] is widely adopted in patients undergoing colorectal surgery, with demonstrated benefits. Few studies have assessed the feasibility, safety, and effectiveness of ERAS in patients with inflammatory bowel diseases [IBD]. The aim of this study was to investigate the current adoption and outcomes of ERAS in IBD.

METHODS

This PRISMA-compliant systematic review of the literature included all articles reporting on adult patients with IBD who underwent colorectal surgery within an ERAS pathway. PubMed/MEDLINE, Cochrane Library, and Web of Science were searched. Endpoints included ERAS adoption, perioperative outcomes, and ERAS items more consistently reported, with associated evidence levels [EL] [PROSPERO CRD42021238653].

RESULTS

Out of 217 studies, 16 totalling 2347 patients were included. The median number of patients treated was 50.5. Malnutrition and anaemia optimisation were only included as ERAS items in six and four articles, respectively. Most of the studies included the following items: drinking clear fluids until 2 h before the surgery, fluid restriction, nausea prophylaxis, early feeding, and early mobilisation. Only two studies included postoperative stoma-team and IBD-team evaluation before discharge. Highest EL were observed for ileocaecal Crohn's disease resection [EL2]. Median in-hospital stay was 5.2 [2.9-10.7] days. Surgical site infections and anastomotic leaks ranged between 3.1-23.5% and 0-3.4%, respectively. Complications occurred in 5.7-48%, and mortality did not exceed 1%.

CONCLUSIONS

Evidence on ERAS in IBD is lacking, but this group of patients might benefit from consistent adoption of the pathway. Future studies should define if IBD-specific ERAS pathways and selection criteria are needed.

Role of the triad of procalcitonin, C-reactive protein, and white blood cell count in the prediction of anastomotic leak following colorectal resections

PURPOSE

The enhanced recovery after surgery (ERAS) program expedites patient recovery after major surgery. This study aimed to investigate the role of the triad of procalcitonin (PCT), C-reactive protein (CRP), and white blood cells (WBC) trajectories as a predictive biomarker for the anastomotic leak (AL) after colorectal surgery.

METHOD

Patients who had colorectal anastomosis were prospectively included. Postoperative clinical and laboratory parameters and outcomes were collected and analyzed. The 5-day trajectories of PCT, CRP, and WBC were evaluated. Based on the trajectory of the three biomarkers, we compared patients with and without AL as detected during the first 30 days after surgery using the area under receiver operator characteristic curves (AUC) for logistic estimation.

RESULTS

This study included 205 patients, of whom 56% were men and 43.9% were women with a mean age of 56.4 ± 13.1 years. Twenty-two patients (10.7%) had AL; 77.3% underwent surgery, and 22.7% were treated with drainage and antibiotics. Procalcitonin was the best predictor for AL compared to CRP and WBC at three days postoperatively (AUC: 0.84, 0.76, 0.66, respectively). On day 5, a cutoff value of 4.93 ng/mL for PCT had the highest sensitivity, specificity, and negative predictive value. The predictive power of PCT was substantially improved when combined with either CRP or WBC, or both (AUC: 0.92, 0.92, 0.93, respectively).

CONCLUSION

The 5-day trajectories of combined CRP, PCT, and WBC had a better predictive power for AL than the isolated daily measurements. Combining the three parameters may be a reliable predictor of early patient discharge, which would be highly beneficial to ERAS programs.

Assessing Criteria for a Safe Early Discharge After Laparoscopic Colorectal Surgery

Importance

Early discharge after colorectal surgery has been advocated. However, there is little research evaluating clinical and/or laboratory criteria to determine who can be safely discharged early.

Objective

To evaluate the diagnostic performance of a C-reactive protein (CRP) level combined with 4 clinical criteria in ruling out an anastomotic leak and therefore allowing an early discharge on postoperative day 2 or 3.

Design, Setting, and Participants

This prospective, single-center cohort study was performed between February 2012 and July 2017. All consecutive adult patients undergoing laparoscopic colorectal surgery were included. All patients were followed up for 30 days postoperatively. Data analysis was performed in May 2021.

Exposures

Whether the 5 discharge criteria were fulfilled on postoperative day 3 (or day 2 for patients discharged on day 2). Fulfillment was defined as a CRP level less than 150 mg/dL on the day of discharge, a return of bowel function, tolerance of a diet, pain less than 5 of 10 on a visual analog scale, and being afebrile during the entire stay.

Main Outcomes and Measures

The primary outcome measurement was the diagnostic performance of the 5 discharge criteria in anticipating anastomotic leak development. The diagnostic performance of CRP level alone and 4 clinical criteria alone was also evaluated. Secondary measures were anastomotic leaks and mortality rates up to postoperative day 30. A discharge was successful if the patient left the hospital on postoperative day 2 or 3 without any complications or readmissions.

Results

A total of 287 patients were included (median [IQR] age, 58 [20] years; 141 men [49%] and 146 women [51%]). Mortality was 0%. There were 17 anastomotic leaks, of which 2 were on day 1 and were excluded. A total of 128 patients fulfilled all criteria, and 125 did not, including 34 for whom data were missing. Two leaks occurred in patients who had fulfilled all criteria vs 13 leaks in patients who did not (hazard ratio, 0.15 [95% CI, 0.03-0.69]; P = .01). Seventy-six of 128 patients (59.4%) were discharged successfully by postoperative day 3. The negative predictive value in ruling out an anastomotic leak was at least 96.9% for CRP alone (96.9% [95% CI, 93.3%-98.8%]), the 4 clinical criteria (98.4% [95% CI, 95.3%-99.7%]), and all 5 criteria combined (98.4% [95% CI, 94.5%-99.8%]). False-negative rates were 40% (95% CI, 16.3%-67.7%) for CRP level alone, 20% (95% CI, 4.3%-48.1%) for the other 4 criteria, and 13.3% (95% CI, 0%-40.5%) for all 5 criteria.

Conclusions and Relevance

These 5 criteria have a high negative predictive value and the lowest false-negative rate, indicating they have the potential to allow for safe early discharge after laparoscopic colorectal surgery.

Improving postoperative outcome in rectal cancer surgery: Enhanced Recovery After Surgery in an era of increasing laparoscopic resection

PURPOSE

The Enhanced Recovery After Surgery (ERAS) protocol reduces complications and length of stay (LOS) in colon cancer, but implementation in rectal cancer is different because of neo-adjuvant therapy and surgical differences. Laparoscopic resection may further improve outcome. The aim of this study was to evaluate the effects of introducing ERAS on postoperative outcome after rectal cancer resection in an era of increasing laparoscopic resections.

MATERIALS AND METHODS

Patients who underwent elective rectal cancer surgery from 2009 till 2015 were included in this observational cohort study. In 2010, ERAS was introduced and adherence to the protocol was registered. Open and laparoscopic resections were compared. With regression analysis, predictive factors for postoperative outcome and LOS were identified.

RESULTS

A total of 499 patients were included. The LOS decreased from 12.3 days in 2009 to 5.7 days in 2015 (p = 0.000). Surgical site infections were reduced from 24% in 2009 to 5% in 2015 (p = 0.013) and postoperative ileus from 39% in 2009 to 6% in 2015 (p = 0.000). Only postoperative ERAS items and laparoscopic surgery were associated with an improved postoperative outcome and shorter LOS.

CONCLUSIONS

ERAS proved to be feasible, safe, and contributed to improving short-term outcome in rectal cancer resections. The benefits of laparoscopic surgery may in part be explained by reaching better ERAS adherence rates. However, the laparoscopic approach was also associated with anastomotic leakage. Despite the potential of bias, this study provides an insight in effects of ERAS and laparoscopic surgery in a non-randomized real-time setting.

Enhanced recovery after surgery (ERAS) pathway optimizes outcomes and costs for minimally invasive radical prostatectomy

Objective

To evaluate the impact of an enhanced recovery after surgery (ERAS) pathway on patients undergoing minimally invasive radical prostatectomy at a single institute.

Methods

In this retrospective study, 301 patients who underwent laparoscopic or robot-assisted laparoscopic radical prostatectomy from May 2014 to September 2018 were consecutively recruited. Before April 2017, the patients were treated with conventional care; all patients were treated with the ERAS pathway thereafter. The primary outcome was the postoperative length of hospital stay (LOS). The secondary outcomes were hospitalization costs and postoperative complications.

Results

In total, 138 patients were treated with the ERAS pathway, and the remaining patients underwent conventional care. The postoperative LOS was significantly shorter in the ERAS group than in the conventional group (median, 6 vs. 8 days). The hospitalization costs were also significantly lower in the ERAS group ($4086 vs. $5530). Ten (6.1%) patients in the ERAS group and 17 (12.3%) patients in the conventional group developed postoperative complications. The multivariable analysis showed that ERAS care was a significant independent predictive factor for a shortened LOS and reduced hospitalization costs.

Conclusions

The ERAS pathway was associated with a shortened LOS and reduced hospitalization costs for patients undergoing minimally invasive radical prostatectomy.

The Pertinent Literature of Enhanced Recovery after Surgery Programs: A Bibliometric Approach

Background and Objectives: The programs of enhanced recovery after surgery are the new revolution in surgical departments; however, features of this concept have not been systematically explored. Therefore, the purpose of this study was to explore Enhanced recovery after surgery (ERAS)-related research using bibliometric analysis. Materials and Methods: The search strategy of ERAS programs was conducted in the Web of Science database. Bibliometric analysis was further performed by Excel and Bibliometrix software. The relationship between citation counts and Mendeley readers was assessed by linear regression analysis. Results: 8539 studies from 1994-2019 were included in the present research, with reporting studies originating from 91 countries using 18 languages. The United States (US) published the greatest number of articles. International cooperation was discovered in 82 countries, with the most cooperative country being the United Kingdom. Henrik Kehlet was found to have published the highest number of studies. The journal Anesthesia and Analgesia had the largest number of articles. Linear regression analysis presented a strong positive correlation between citations and Mendeley readers. Most research was related to gastrointestinal surgery in this field. Conclusion: This bibliometric analysis shows the current status of ERAS programs from multiple perspectives, and it provides reference and guidance to scholars for further research.

Enhanced recovery programs in gastrointestinal surgery: Actions to promote optimal perioperative nutritional and metabolic care

The enhanced recovery after surgery (ERAS) pathway is an evidence-based approach to the use of care elements along the patient perioperative pathway. All care elements that may impact on clinically relevant outcomes have been considered and reviewed. The combined ERAS actions allow a quicker return to bowel function, oral feeding, nutritional and metabolic equilibrium, normal activity and ultimately to achieve better outcomes. Because of the multi factorial approach and the commitment of all the professionals caring for the patient, it is necessary to have the engagement of all disciplines, such as surgery, anesthesiology, clinical nutrition, nursing, physiatry, involved. ERAS is a dynamic process and new evidence are constantly integrated into the program. The primary endpoint of this review is to give updated information on the key ERAS actions to achieve optimal perioperative nutritional and metabolic care.

Enhanced Recovery After Emergency Surgery: Utopia or Reality?

Enhanced Recovery After Surgery (ERAS) constitutes the application of a series of perioperative measures based on the evidence, in order to achieve a better recovery of the patient and a decrease of the complications and the mortality. These ERAS programs initially proved their advantages in the field of colorectal surgery being progressively adopted by other surgical areas within the general surgery and other surgical specialties. The main excluding factor for the application of such programs has been the urgent clinical presentation, which has caused that despite the large volume of existing literature on ERAS in elective surgery, there are few studies that have investigated the effectiveness of these programs in surgical patients in emergencies. The aim of this article is to show ERAS measures currently available according to the existing evidence for emergency surgery.

Feasibility and effects of enhanced recovery vs. conventional care after emergency colon surgery for patients with left colon perforation

The impact of an enhanced recovery after surgery (ERAS) programme in emergency colorectal surgery has not yet been reported. The objective of this study was to evaluate the feasibility and the results of patients included in an ERAS protocol following emergency colon surgery for left colon perforation. For this purpose, patients with a low to moderate risk of mortality, according to a Peritonitis Severity Score (PSS), and treated with an ERAS protocol (ERAS group) after emergency surgery for left colon perforation were compared for a period of 40 months (March 2014–June 2017) with a control group of patients treated with conventional care (CC group) during the 38 months prior to implementation of the new ERAS protocol (January 2011–February 2014). The main endpoint was 90-day postoperative morbidity according to the Clavien–Dindo classification. Secondary endpoints included length of postoperative hospital stay, 90-day readmission rate, protocol compliance and mortality. Fifty patients were included in the study, 29 in the ERAS group and 21 in the CC group. There were no significant differences between the groups in the demographic data or in the operative characteristics. A reduction in the incidence of postoperative complications (20.7% vs. 38%; p > 0.05) and in the postoperative hospital stay (7.7 + /- 3.85 vs. 10.9 + /- 5.6 days; p = 0.009) were observed in the ERAS group. The 90-day readmission rate did not differ significantly between the two groups (2 vs. 1). No 90-day mortality was observed in either group. The ERAS group showed better results than the CC group in protocol compliance. We conclude that ERAS protocols are feasible and help to reduce morbidity and length of hospital stay without adversely affecting the rate of readmission or mortality.

Prospective evaluation of muscle strength and spine joint motility of patients who underwent surgery for colorectal cancer by open and laparoscopic methods

Introduction

The current trend in oncological surgery is to minimize its degree of invasiveness while maintaining a satisfactory survival rate. Surgical treatments within the large intestine are applied through traditional open surgery (OS) or laparoscopic surgery (LS).

Aim

The purpose of this nonrandomized, prospective, single-centered clinical examination was to compare motility within the spine joints and evaluate abdominal muscle strength of patients who underwent LS or OS for colorectal cancer.

Material and methods

Seventy-two patients were included in the study. Open surgery was applied to 35 patients and LS was applied to 37 patients. Motility range of the thoracic and lumbar spine, muscle strength of abdominal muscles, and pain evaluation by the Visual Analogue Scale (VAS) of the studied group were evaluated twice (on the day of admission to the ward and on the fifth day after the surgery).

Results

Both types of surgical intervention resulted in a decrease of the rectus abdominis and abdominal oblique muscle strength as well as a decrease of the range of thoracic and lumbar spine joint motility (p < 0.001). In the first research period, no statistically significant differences of tested parameters between the groups were found. In the second period, patients who underwent LS achieved better results within the extension of lumbar spine section (p = 0.0339), rectus abdominis strength (p = 0.0105), and left abdominal oblique muscles (p = 0.004).

Conclusions

Both types of surgical intervention (LS and OS) result in reduction of spine joint motility range and abdominal muscle strength. Laparoscopic surgery disrupts the spine joint motility and abdominal muscle strength to a lesser extent than OS.

Systematic scoping review of enhanced recovery protocol recommendations targeting return of gastrointestinal function after colorectal surgery

BACKGROUND

Post-operative ileus (POI) and delayed return of gastrointestinal (GI) function are common complications after colorectal surgery. There is a lack of uniformity in enhanced recovery protocols (ERPs) with regards to interventions used to target these complications. This systematic review aims to categorize and summarize management recommendations available from published ERPs.

METHODS

A systematic search of Ovid MEDLINE, Embase, Cochrane Library and PubMed databases was performed from January 1990 to May 2018. All studies publishing enhanced recovery or fast-track or multimodal pathway protocols for colorectal surgery in their full-text were included. Data on interventions aimed at reducing the duration of POI were extracted, as well as references quoted to support specific interventions.

RESULTS

Of 481 manuscripts screened, 37 published ERPs were identified from 37 studies (18 cohort, seven historical-control, five guidelines, four randomized controlled trials, one randomized controlled trial protocol, one case series and one narrative review). The most commonly recommended interventions were magnesium-based laxatives (18 of 37, 48.6%), chewing gum (13 of 37, 35.1%), Alvimopan (6 of 37, 16.2%), lactulose (4 of 37, 10.8%), neostigmine (2 of 37, 5.4%) and bisacodyl (2 of 37, 5.4%). Geographical trends were noted for the various interventions, but high-quality evidence was only referenced to support the use of Alvimopan.

CONCLUSION

ERP recommendations specific to interventions targeting POI and return of GI function are varied. While laxatives are the most commonly recommended intervention, there is only weak evidence reported to support this practice.

Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

Background

Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.

Objectives

To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.

Data sources

Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.

Review methods

Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.

Findings

A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.

Limitations

Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.

Conclusions

Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.

Future work

Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.

Study registration

This study is registered as PROSPERO CRD42017080637.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

BACKGROUND

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.

METHODS

A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.

CONCLUSIONS

The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Laparoscopy Combined with Enhanced Recovery Pathway in Ileocecal Resection for Crohn's Disease: A Randomized Study

Background and Aims

Laparoscopic approach is recommended as the first-choice option for simple ileocecal resections. However, there are no randomized trials that have focused on patients with Crohn's disease (CD) treated by laparoscopy and enhanced recovery pathway. The aim of the present study is to prospectively evaluate the feasibility, safety, and short-term outcomes of laparoscopy with enhanced recovery pathway for CD patients undergoing ileocecal resection.

Methods

A consecutive cohort of 32 CD patients who underwent laparoscopic ileocecal resection between December 2015 and December 2016 was randomized to enhanced recovery after surgery (ERAS) group or standard care group. Primary outcome was total postoperative hospital stay. Secondary outcomes were time to first flatus and stool, pain scores, morbidity, reoperation rate, readmission rate, and in-hospital costs.

Results

Compliance with the ERAS was high for all items (≥90%) except the items of abdominal drains and early fluid intake. A significantly earlier return of bowel function was observed in the ERAS group. Compared with the standard care group, patients in the ERAS group had shorter postoperative hospital stay and lower in-hospital costs (5.19 ± 1.28 versus 9.94 ± 3.33 days, P < 0.001; 2.70 ± 0.50 versus 3.73 ± 0.75 ten thousand RMB, P < 0.001, respectively). Other parameters did not show any significant differences between the two groups.

Conclusions

Laparoscopic approach within an ERAS perioperative care program is a safe and effective treatment combination for CD patients requiring ileocecal resection. This study is registered at ClinicalTrials.gov (NCT02777034).

Enhanced Recovery After Surgery Programs for Laparoscopic Abdominal Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols or laparoscopic technique has been applied in various surgical procedures. However, the clinical efficacy of combination of the two methods still remains unclear. Thus, our aim was to assess the role of ERAS protocols in laparoscopic abdominal surgery.

METHODS

We performed a systematic literature search in various databases from January 1990 to October 2017. The results were analyzed according to predefined criteria.

RESULTS

In the present meta-analysis, the outcomes of 34 comparative studies (15 randomized controlled studies and 19 non-randomized controlled studies) enrolling 3615 patients (1749 in the ERAS group and 1866 in the control group) were pooled. ERAS group was associated with shorter hospital stay (WMD - 2.37 days; 95% CI - 3.00 to - 1.73; P 0.000) and earlier time to first flatus (WMD - 0.63 days; 95% CI - 0.90 to - 0.36; P 0.000). Meanwhile, lower overall postoperative complication rate (OR 0.62; 95% CI 0.51-0.76; P 0.000) and less hospital cost (WMD 801.52 US dollar; 95% CI - 918.15 to - 684.89; P 0.000) were observed in ERAS group. Similar readmission rate (OR 0.73, 95% CI 0.52-1.03, P 0.070) and perioperative mortality (OR 1.33; 95% CI 0.53-3.34; P 0.549) were found between the two groups.

CONCLUSIONS

ERAS protocol for laparoscopic abdominal surgery is safe and effective. ERAS combined with laparoscopic technique is associated with faster postoperative recovery without increasing readmission rate and perioperative mortality.

Outcome of Discharge Within 72 Hours of Robotic Gastrectomy Using Enhanced Recovery After Surgery Programs

AIMS

To evaluate the safety and outcome of discharge within 72 hours of a robotic gastrectomy together with enhanced recovery after surgery (ERAS) programs.

MATERIALS AND METHODS

In total, 108 consecutive patients received elective robotic gastrectomy for gastric cancer from April 2017 to September 2017. All patients attended ERAS programs, which do not routinely use nasogastric tubes but include early feeding, early ambulation, and standard discharge criteria, among other items.

RESULTS

The mean age was 58.7 ± 10.4 years old, and the mean body mass index was 22.9 ± 2.8 kg/m². The mean postoperative length of hospital stay was 5.6 ± 8.0 days, and 13 patients (12.0%) exhibited a complication within 30 days with no mortality. A total of 38 patients (35.2%) were discharged within 72 hours of surgery. Patients were grouped based on being discharged within or after 72 hours. The rate of complications was significantly lower in patients discharged within 72 hours than patients discharged after 72 hours (1/38, 2.6% versus 12/70, 17.1%, P = .028). Although patients discharged within 72 hours showed lower readmission numbers, this difference was not statistically significant (1/38, 2.6% versus 8/70, 11.4%, P = .116). One month after surgery, loss of weight, loss of total protein, loss of albumin, and loss of prealbumin in patients discharged within 72 hours were less than those of patients discharged after 72 hours.

CONCLUSION

Complication and readmission rates are low in patients discharged within 72 hours of robotic gastrectomy when ERAS programs and standard discharge criteria are used.

Acupuncture and Related Therapies for Treatment of Postoperative Ileus in Colorectal Cancer: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Delays in recovery of intestinal function following abdominal surgery are associated with longer hospital stays, increased postoperative complications, and higher costs to the health care system. Studies of acupuncture for postoperative ileus and other postoperative issues have reported improvements. This systematic review and meta-analysis aimed to assess whether acupuncture assisted recovery following surgery for colorectal cancer (CRC). Randomized controlled trials (RCTs) were identified from major English and Chinese language biomedical databases. Participants (aged 18 years plus) had received surgical resection for CRC. 22 studies (1,628 participants) were included. Five were sham-controlled. Outcomes included gastrointestinal function recovery (21 studies), recovery of urinary function (1 study), postoperative abdominal distension (3 studies), and quality of life (1 study). Meta-analyses found significant reductions in time to first bowel sounds, first flatus, and first defecation in both the sham-controlled and nonblinded studies. These results suggested that the addition of acupuncture following CRC surgery improved recovery of gastrointestinal function based on four blinded good quality RCTs (281 participants) and 17 nonblinded lower quality RCTs (1,265 participants). The best available evidence was for interventions that included electroacupuncture at the point ST36 Zusanli and there is supporting evidence for other types of acupuncture therapies that involve stimulation of this point. This review is registered with the following: systematic review registration in PROSPERO: CRD42017079590.

Procalcitonin and C-reactive protein as early markers of anastomotic leak after laparoscopic colorectal surgery within an enhanced recovery after surgery (ERAS) program

BACKGROUND

C-reactive protein (CRP) and procalcitonin (PCT) have been described as good predictors of anastomotic leak after colorectal surgery, obtaining the highest diagnostic accuracy on the 5th postoperative day. However, if an enhanced recovery after surgery (ERAS) program is performed, early predictors are needed in order to ensure a safe and early discharge. The aim of this study was to investigate the efficacy of CRP, PCT, and white blood cell (WBC) count determined on first postoperative days, in predicting septic complications, especially anastomotic leak, after laparoscopic colorectal surgery performed within an ERAS program.

METHODS

We conducted a prospective study including 134 patients who underwent laparoscopic colorectal surgery within an ERAS program between 2015 and 2017. The primary endpoint investigated was anastomotic leak. CRP, PCT, and WBC count were determined in the blood sample extracted on postoperative day 1 (POD 1), POD 2 and POD 3.

RESULTS

Anastomotic leak (AL) was detected in 6 patients (4.5%). Serum levels of CRP and PCT, but not WBC, determined on POD 1, POD 2, and POD 3 were significantly higher in patients who had AL in the postoperative course. Using ROC analysis, the best AUC of the CRP and PCT levels was on POD 3 (0.837 and 0.947, respectively). A CRP cutoff level at 163 mg/l yielded 85% sensitivity, 80% specificity, and 99% negative predictive value (NPV). A PCT cutoff level at 2.5 ng/ml achieved 85% sensitivity, 95% specificity, 44% positive predictive value, and 99% NPV.

CONCLUSIONS

CRP and PCT are relevant markers for detecting postoperative AL after laparoscopic colorectal surgery. Furthermore, they can ensure an early discharge with a low probability of AL when an ERAS program is performed.

Implementation of the Spanish ERAS program in bariatric surgery

Introduction: The essence of Enhanced Recovery After Surgery (ERAS) programs is the multimodal approach, and many authors have demonstrated safety and feasibility in fast track bariatric surgery. According to this concept, a multidisciplinary ERAS program for bariatric surgery has been developed by the Spanish Fast Track Group (ERAS Spain). The aim of this study was to analyze the initial implementation of this Spanish National ERAS protocol in bariatric surgery, comparing it with a historical cohort receiving standard care. Material and methods: A multi-centric prospective study was performed, including 233 consecutive patients undergoing bariatric surgery during 2015 and following ERAS protocol. It was compared with a historical cohort of 286 patients, who underwent bariatric surgery at the same institutions between 2013 and 2014 and following standard care. Compliance with the protocol, morbidity, mortality, hospital stay and readmission were evaluated. Results: Bariatric techniques performed were Roux-en-Y gastric bypass and sleeve gastrectomy. There were no significant differences in complications, mortality and readmission. Postoperative pain and hospital stay were significantly lower in the ERAS group. The total compliance to protocol was 80%. Conclusion: The Spanish National ERAS protocol is a safe issue, obtaining similar results to standard care in terms of complications, reoperations, mortality and readmissions. It is associated with less postoperative pain and earlier hospital discharge.

Influence of Enhanced Recovery Pathway on Surgical Site Infection after Colonic Surgery

BACKGROUND

The present study aimed to evaluate a potential effect of ERAS on surgical site infections (SSI).

METHODS

Colonic surgical patients operated between May 2011 and September 2015 constituted the cohort for this retrospective analysis. Over 100 items related to demographics, surgical details, compliance, and outcome were retrieved from a prospectively maintained database. SSI were traced by an independent National surveillance program. Risk factors for SSI were identified by univariate and multinomial logistic regression.

RESULTS

Fifty-four out of 397 patients (14%) developed SSI. Independent risk factors for SSI were emergency surgery (OR 1.56; 95% CI 1.09-1.78, p = 0.026), previous abdominal surgery (OR 1.7; 95% CI 1.32-1.87, p = 0.004), smoking (OR 1.71; 95% CI 1.22-1.89, p = 0.014), and oral bowel preparation (OR 1.86; 95% CI 1.34-1.97, p = 0.013), while minimally invasive surgery (OR 0.3; 95% CI 0.16-0.56, p < 0.001) protected against SSI. Compliance to ERAS items of >70% was not retained as a protective factor for SSI after multivariate analysis (OR 0.94; 95% CI 0.46-1.92, p = 0.86).

CONCLUSIONS

Smoking, open and emergency surgery, and bowel preparation were risk factors for SSI. ERAS pathway had no independent impact while minimally invasive approach did. This study was registered under ResearchRegistry.com (UIN researchregistry2614).

Accelerated discharge within 72 hours of colorectal cancer resection using simple discharge criteria

Introduction Short hospital stays and accelerated discharge within 72 hours following colorectal cancer resections have not been widely achieved. Series reporting on accelerated discharge involve heterogeneous patient populations and exclude important groups. Strict adherence to some discharge requirements may lead to delays in discharge. The aim of this study was to evaluate the safety and feasibility of accelerated discharge within 72 hours of all elective colorectal cancer resections using simple discharge criteria. Methods Elective colorectal cancer resections performed between August 2009 and December 2015 by a single surgeon were reviewed. Perioperative care was based on an enhanced recovery programme. A set of simplified discharge criteria were used. Outcomes including postoperative complications, readmissions and reoperations were compared between patients discharged within 72 hours and those with a longer postoperative stay. Results Overall, 256 colorectal cancer resections (90% laparoscopic) were performed. The mean patient age was 70.8 years. The median length of stay was 3 days. Fifty-eight per cent of all patients and sixty-three per cent of patients undergoing laparoscopic surgery were discharged within 72 hours. Accelerated discharge was not associated with adverse outcomes compared with delayed discharge. Patients discharged within 72 hours had significantly fewer postoperative complications, readmissions and reoperations. Open surgery and stoma formation were associated with discharge after 72 hours but not age, co-morbidities, neoadjuvant chemoradiation or surgical procedure. Conclusions Accelerated discharge within 72 hours of elective colorectal resection for cancer is safely achievable for the majority of patients without compromising short-term outcomes.

Enhanced recovery programme following laparoscopic colorectal resection for elderly patients

BACKGROUND

The aim of this study was to investigate the feasibility and safety of an enhanced recovery programme (ERP) in patients aged ≥75 years who undergo laparoscopic surgery for colorectal cancer.

METHODS

Patients were divided into two groups according to perioperative management: the ERP group (Group A, n = 94) and the conventional perioperative care group (Group B, n = 157). The postoperative outcomes were compared between two groups.

RESULTS

There were no differences in terms of age, gender, American Society of Anesthesiologists score, operative time or blood loss between two groups. Postoperative return of gastrointestinal function was significantly faster in Group A compared to Group B, including time to first flatus (2 versus 3 days, P < 0.001), first stool (3 versus 4 days, P = 0.001) and oral intake (1 versus 4 days, P < 0.001). Group A was associated with lower overall postoperative complication rate (26.6% versus 44.6%, P = 0.004) and general complication rate (14.9% versus 31.2%, P = 0.004). The median postoperative hospital stay was 6 days in Group A and 8 days in Group B (P < 0.001), respectively.

CONCLUSIONS

ERP following laparoscopic colorectal resection for elderly patients is associated with faster postoperative recovery, shorter postoperative hospital stay and fewer complications compared with conventional perioperative care.

ERAS Protocol Reduces IL-6 Secretion in Colorectal Laparoscopic Surgery: Results From a Randomized Clinical Trial

BACKGROUND

Enhanced Recovery After Surgery (ERAS) program applied to colorectal laparoscopic surgery is well known to reduce hospitalization improving short-terms outcomes. Its goal is to minimize the surgical stress response in order to maintain the physiological homeostasis altered by surgery. However, there is little knowledge about the involved dynamics in the reduction of the surgical stress that these programs allow. The primary aim of this study was to compare the level of immune and nutritional serum investigators across surgery in patients undergoing elective colorectal laparoscopic surgery within an ERAS protocol or according to a standard care program.

MATERIALS AND METHODS

One hundred forty patients undergoing major colorectal laparoscopic surgery were enrolled and randomized in 2 groups (70 per arm).Cortisol, C-reactive protein (CRP), white blood cell count, prolactin, interleukin (IL)-6 levels were collected preoperatively, 1, 3, and 5 days after surgery. Transferrin, prealbumin, albumin, and triglyceride level were collected preoperatively, 1 and 5 days after surgery. Short-term outcomes were also prospectively assessed.

RESULTS

IL-6 levels were lower in the ERAS group on 1, 3, and 5 days postoperatively (P<0.05). IL-6 levels in the enhanced group, differently from control group, returned to preoperative level 3 days after surgery. CRP level was lower in the enhanced group on day 1, 3, and 5 (P<0.05). There was no difference in cortisol and prolactin levels between groups. Prealbumin serum level was higher on day 5 (P<0.05) compared to standard group.

CONCLUSIONS

ERAS protocol applied to colorectal laparoscopic surgery affects surgical stress response, decreasing IL-6 and CRP levels postoperatively and improving prealbumin postoperative synthesis.

The effects of fast-track surgery on inflammation and immunity in patients undergoing colorectal surgery

OBJECTIVE

The objective of this study is to explore the effects of the fast-track surgery (FTS) program on inflammation and immunity in patients undergoing colorectal surgery.

METHODS

From August 2014 to March 2015, a prospective and randomized controlled trial of 230 patients who underwent colorectal surgery was performed. The patients were randomly assigned to an FTS group (116 patients) or a traditional group (114 patients). Inflammatory mediators, immunological indicators, postoperative recovery indexes, and complications were compared between the two groups.

RESULTS

The inflammatory mediators (CRP, IL-6, TNF-α) were lower in the FTS group than in the traditional group (P < 0.05) on postoperative day (POD) 1, POD 4, and POD 6, and the immunological indicators (IgG, IgA, C3, C4) of the FTS group were superior to those of the traditional group (P < 0.05) on POD 4 and POD 6. The time to first aerofluxus, defecation, oral intake, and ambulation after surgery was shorter in the FTS group than in the traditional group (P < 0.05); however, the duration of postoperative hospitalization did not differ significantly between the two groups (P > 0.05). The total complications were significantly lower in the FTS group than in the traditional group (P < 0.05).

CONCLUSION

The FTS program can decrease inflammation, maintain immune homeostasis, and improve rehabilitation effects in colorectal surgery patients.

Perioperative Standard Oral Nutrition Supplements Versus Immunonutrition in Patients Undergoing Colorectal Resection in an Enhanced Recovery (ERAS) Protocol: A Multicenter Randomized Clinical Trial (SONVI Study)

To compare immunonutrition versus standard high calorie nutrition in patients undergoing elective colorectal resection within an Enhanced Recovery After Surgery (ERAS) program.Despite progress in recent years in the surgical management of patients with colorectal cancer (ERAS programs), postoperative complications are frequent. Nutritional supplements enriched with immunonutrients have recently been introduced into clinical practice. However, the extent to which the combination of ERAS protocols and immunonutrition benefits patients undergoing colorectal cancer surgery is unknown.The SONVI study is a prospective, multicenter, randomized trial with 2 parallel treatment groups receiving either the study product (an immune-enhancing feed) or the control supplement (a hypercaloric hypernitrogenous supplement) for 7 days before colorectal resection and 5 days postoperatively.A total of 264 patients were randomized. At baseline, both groups were comparable in regards to age, sex, surgical risk, comorbidity, and analytical and nutritional parameters. The median length of the postoperative hospital stay was 5 days with no differences between the groups. A decrease in the total number of complications was observed in the immunonutrition group compared with the control group, primarily due to a significant decrease in infectious complications (23.8% vs. 10.7%, P = 0.0007). Of the infectious complications, wound infection differed significantly between the groups (16.4% vs. 5.7%, P = 0.0008). Other infectious complications were lower in the immunonutrition group but were not statistically significantly different.The implementation of ERAS protocols including immunonutrient-enriched supplements reduces the complications of patients undergoing colorectal resection.This study is registered with ClinicalTrial.gov: NCT02393976.

Anastomotic Leakage After Low Anterior Resection for Rectal Cancer Is Different Between Minimally Invasive Surgery and Open Surgery

OBJECTIVE

To review and compare clinical manifestations of and risk factors for anastomotic leakage (AL) after low anterior resection for rectal cancer between minimally invasive surgery (MIS) and open surgery (OS).

BACKGROUND

MIS for rectal cancer has become popular, and its clinical course is different from OS. Many studies have reported on the risk factors and oncologic influence of AL. However, few have directly compared clinical manifestations and risk factors for AL between MIS and OS.

METHODS

From January 2004 to December 2012, a total of 1704 consecutive patients who underwent elective low anterior resection with colorectal anastomosis for rectal cancer were eligible. The variables associated with short-term outcomes and risk factors were analyzed.

RESULTS

The overall AL incidence was 6.4%. In the MIS-AL group, the time to diagnosis of AL and the time to second operation were shorter. A majority of the patients (77.8%) in the MIS-AL group underwent second MIS operation, whereas none in the OS-AL group. The hospital stays after second MIS were shorter than those after second open operation. Multivariate analyses revealed that male sex, smoking and alcohol intake history, previous abdominal surgery, longer operation times, low-lying tumor, and using 2 or more staplers for distal rectal resection were independent risk factors in the MIS-AL group, whereas smoking and alcohol intake history, operation times, and blood loss were significant in the OS-AL group.

CONCLUSIONS

The clinical manifestations of and risk factors for AL were different between MIS and OS. AL after MIS may be more influenced by factors related to technical difficulties. Close attention should be given to patients undergoing surgery with risk factors for AL.

Meta-analysis of the laparoscopic versus open colorectal surgery within fast track surgery

BACKGROUND

Laparoscopic methods and fast-track surgery (FTS) can enhance recovery and reduce postoperative hospital stay. However, whether laparoscopic surgery can provide short-term benefits within FTS is controversial. Thus, we conducted a meta-analysis of published studies to evaluate the effect of laparoscopic colorectal surgery within FTS.

METHODS

We searched PubMed, EMBASE, Cochrane Library, and Ovid databases for eligible studies. Endpoints were duration of postoperative hospital stay, time to first bowel movement, total postoperative complication rate, readmission rate, mortality within 30 days after surgery, and conversation rate of laparoscopic surgery.

RESULTS

Four randomized controlled trials and six clinical controlled trials (1510 patients) were eligible for analyses. Duration of postoperative hospital stay (weighted mean difference, -1.65 days; p < 0.001), time to first bowel movement (-1.13 days; p < 0.001), total postoperative complication rate (risk ratio [RR], 0.65; p < 0.001), readmission rate (0.46; p < 0.001), and mortality (0.45; p < 0.001) were significantly reduced in the laparoscopic surgery group. Overall conversion rate of laparoscopic surgery was 11.1%. Subgroup analyses based on each FT element demonstrated that studies without the element "prevention of hypothermia," "no bowel preparation," or "no routine use of drains" did not show significant differences between two groups with regard to duration of postoperative hospital stay or total prevalence of postoperative complications.

CONCLUSION

Within FTS, laparoscopic methods can significantly shorten postoperative hospital stay, accelerate postoperative recovery, and enhance safety in colorectal surgery. The FT elements "prevention of hypothermia," "no bowel preparation," and "no routine use of drains" may play important parts in the combined effect of these two methods.

Enhanced recovery care after colorectal surgery in elderly patients. Compliance and outcomes of a multicenter study from the Spanish working group on ERAS

PURPOSE

ERAS (enhanced recovery after surgery) programs have proven to reduce morbidity and hospital stay in colorectal surgery. However, the feasibility of these programs in elderly patients has been questioned. The aim of this study is to assess the implementation and outcomes of an ERAS program for colorectal cancer in elderly patients.

METHODS

This is a multicenter observational study of a cohort of elderly patients undergoing colorectal surgery within an ERAS program. A total of 188 consecutive patients over 70 years who underwent elective colorectal surgery within an ERAS program at three institutions during a 2-year period were included. The compliance with the ERAS protocol interventions was measure. Complications were evaluated according to Clavien-Dindo classification. Data on length of stay and readmission rates were analyzed.

RESULTS

Early intake and early mobilization were the most successfully carried out interventions. There was a global compliance rate of 56 % of patients for whom compliance was achieved with all measured interventions. The median hospital length of stay was 6 days. Almost 60 % of patients had no complications, 24 % had minor complications while 13 % had major complications; of them, 8 % patients were reoperated. The readmission rate was 6.4 %.

CONCLUSIONS

ERAS after colorectal surgery in elderly patients presents as safe and feasible based on good reported outcomes of compliance rates, complications, readmissions, and needs for reoperation.

Laparoscopic surgery: A qualified systematic review

AIM: To review current applications of the laparoscopic surgery while highlighting the standard procedures across different fields.

METHODS: A comprehensive search was undertaken using the PubMed Advanced Search Builder. A total of 321 articles were found in this search. The following criteria had to be met for the publication to be selected: Review article, randomized controlled trials, or meta-analyses discussing the subject of laparoscopic surgery. In addition, publications were hand-searched in the Cochrane database and the high-impact journals. A total of 82 of the findings were included according to matching the inclusion criteria. Overall, 403 full-text articles were reviewed. Of these, 218 were excluded due to not matching the inclusion criteria.

RESULTS: A total of 185 relevant articles were identified matching the search criteria for an overview of the current literature on the laparoscopic surgery. Articles covered the period from the first laparoscopic application through its tremendous advancement over the last several years. Overall, the biggest advantage of the procedure has been minimizing trauma to the abdominal wall compared with open surgery. In the case of cholecystectomy, fundoplication, and adrenalectomy, the procedure has become the gold standard without being proven as a superior technique over the open surgery in randomized controlled trials. Faster recovery, reduced hospital stay, and a quicker return to normal activities are the most evident advantages of the laparoscopic surgery. Positive outcomes, efficiency, a lower rate of wound infections, and reduction in the perioperative morbidity of minimally invasive procedures have been shown in most indications.

CONCLUSION: Improvements in surgical training and developments in instruments, imaging, and surgical techniques have greatly increased safety and feasibility of the laparoscopic surgical procedures.

Efficacy of fast track surgery in elderly patients with colorectal cancer undergoing laparoscopic treatment: A meta-analysis

AIM: To evaluate the efficacy of fast track surgery in elderly patients with colorectal cancer undergoing laparoscopic treatment.

METHODS: We searched randomized controlled trials (RCTs), clinical controlled trials (CCTs) or case-control studies on fast track surgery in elderly patients with colorectal cancer undergoing laparoscopic treatment from databases including Wanfang, CNKI, CBM, VIP, PubMed, EMBACE and Cochrane Library between January 1989 and March 2015. Meta-analysis was performed with RevMan 5.3.

RESULTS: There were 5 RCTs and 2 CCTs involving 476 patients, including 244 patients in the FTS group and 232 in the control group. Compared with the control group, the time to passage of flatus [weighted mean of difference (WMD) = -36.46, 95%CI: -40.91--32.02, P < 0.0001], time to resumption of diet/drink (WMD = -43.90, 95%CI: -48.79--39.01, P < 0.0001), time to ambulation (WMD = -6.60, 95%CI: -7.71--5.49, P < 0.0001), and hospital stay (WMD = -4.53, 95%CI: -5.13--3.92, P < 0.0001) were significantly shorter, and the incidence of postoperative complications was significantly lower in the FTS group [odds ratio (OR) = 0.18, 95%CI: 0.11-0.31, P < 0.0001].

CONCLUSION: Fast track surgery can promote bowel function recovery and decrease hospital stay time and the incidence of postoperative complications in elderly patients with colorectal cancer undergoing laparoscopic treatment.

Single-incision laparoscopic surgery for diverticulitis in overweight patients

AIM

Single-incision laparoscopic surgery (SILS) has been introduced as a new technique for the treatment of various colorectal diseases. Recurrent or complicated diverticulitis of the sigmoid colon is a frequent indication for minimally invasive sigmoid colectomy. The aim of this study was to investigate the impact of obesity on the outcome of SILS sigmoid colectomy.

METHODS

From September 2009 to October 2014, data from 377 patients who had intended SILS sigmoid colectomy for diverticulitis at our institution were collected in a prospective database. The patients were categorized in the following subgroups: group 1 (normal weight, body mass index (BMI) < 25 kg/m(2)), group 2 (overweight, BMI 25-29.9 kg/m(2)), group 3 (obesity, BMI 30-34.9 kg/m(2)), and group 4 (morbid obesity, BMI > 35 kg/m(2)).

RESULTS

The groups were equivalent for sex, age, status of diverticulitis, the presence of acute inflammation in the specimen, and the percentage of teaching operations, but the percentage of patients with accompanying diseases was significantly more frequent in groups 2, 3, and 4 (p = 0.04, 0.008, and 0.018, respectively). As compared to group 1, the conversion rate was significantly increased in groups 2 and 4 (2.3 vs. 9.3% (p = 0.013) and 2.3 vs. 12.5% (p = 0.017), respectively). The duration of surgery, hospitalization, and morbidity did not differ between the four groups.

CONCLUSION

Up to a body mass index of 35 kg/m(2), increased body weight does not significantly reduce the feasibility and outcome of single-incision laparoscopic surgery for diverticulitis.

Feasibility of Fast-Track Surgery in Elderly Patients with Gastric Cancer

BACKGROUND

The aim of this study was to investigate the role of the fast-track surgery (FTS) program in elderly patients (aged ≥75 years) who underwent open surgery for gastric cancer (GC) in China.

METHODS

A total of 256 patients with GC were randomly assigned to four groups, each of which consisted of 64 cases: the 45-74-year-old age group was subdivided into the FTS-1 group and the conventional care (CC)-1 group, and the 75-89-year-old age group was subdivided into the FTS-2 group and the CC-2 group. All patients underwent open gastrectomy by the same experienced surgical team. We compared the differences between the pairs of groups in different age ranges with respect to the postoperative recovery index, complications, and medical costs.

RESULTS

Compared with the CC-1 group, the FTS-1 group exhibited earlier postoperative flatus, a shorter postoperative hospital stay, lower medical costs, and a decreased incidence of sore throat (P = 0.010, P = 0.000, P = 0.000, and P = 0.019, respectively). Compared with the CC-2 group, the FTS-2 group had more nausea and vomiting, stomach retention, and intestinal obstruction, as well as a higher readmission rate (P = 0.015, P = 0.011, P = 0.041, and P = 0.013, respectively).

CONCLUSION

The application of FTS can significantly speed up postoperative rehabilitation, shorten the hospitalization time, and lower the medical costs for 45-74-year-old GC patients, but this procedure does not show the same benefits for elderly patients. These findings suggest that we should carefully consider whether the FTS program should be applied to elderly patients with GC.

Outcomes of an enhanced recovery after surgery programme for pancreaticoduodenectomy

BACKGROUND

Enhanced recovery after surgery (ERAS) has demonstrated in colorectal surgery a reduction in morbidity and length of stay without compromising security. Experience with ERAS programs in pancreatoduodenectomy (PD) is still limited. The aims of this study were first to evaluate the applicability of an ERAS program for PD patients in our hospital, and second to analyze the postoperative results.

METHODS

A retrospective study using a prospectively maintained database identified 41 consecutive PD included in an ERAS program. Key elements studied were early removal of tubes and drainages, early oral feeding and early mobilization. Variables studied were mortality, morbidity, perioperative data, length of stay, re-interventions and inpatient readmission. This group of patients was compared with an historic control group of 44 PD patients with a standard postoperative management.

RESULTS

A total of 85 pancreatoduodenectomies were analyzed (41 patients in the ERAS group, and 44 patients in the control group. General mortality was 2.4% (2 patients) belonging to the control group. There were no statistical differences in mortality, length of stay in intensive care, reoperationss, and readmissions. ERAS group had a lower morbidity rate than the control group (32 vs. 48%; P=.072), as well as a lower length of stay (14.2 vs. 18.7 days). All the key ERAS proposed elements were achieved.

CONCLUSIONS

ERAS programs may be implemented safely in pancreaticoduodenectomy. They may reduce the length of stay, unifying perioperative care and diminishing clinical variability and hospital costs.

Minimally invasive surgery for inflammatory bowel disease

Surgical management of inflammatory bowel disease is a challenging endeavor given infectious and inflammatory complications, such as fistula, and abscess, complex often postoperative anatomy, including adhesive disease from previous open operations. Patients with Crohn's disease and ulcerative colitis also bring to the table the burden of their chronic illness with anemia, malnutrition, and immunosuppression, all common and contributing independently as risk factors for increased surgical morbidity in this high-risk population. However, to reduce the physical trauma of surgery, technologic advances and worldwide experience with minimally invasive surgery have allowed laparoscopic management of patients to become standard of care, with significant short- and long-term patient benefits compared with the open approach. In this review, we will describe the current state-of the-art for minimally invasive surgery for inflammatory bowel disease and the caveats inherent with this practice in this complex patient population. Also, we will review the applicability of current and future trends in minimally invasive surgical technique, such as laparoscopic "incisionless," single-incision laparoscopic surgery (SILS), robotic-assisted, and other techniques for the patient with inflammatory bowel disease. There can be no doubt that minimally invasive surgery has been proven to decrease the short- and long-term burden of surgery of these chronic illnesses and represents high-value care for both patient and society.

Fast-track surgery versus traditional perioperative care in laparoscopic colorectal cancer surgery: a meta-analysis

Background

Both laparoscopic and fast-track surgery (FTS) have shown some advantages in colorectal surgery. However, the effectiveness of using both methods together is unclear. We performed this meta-analysis to compare the effects of FTS with those of traditional perioperative care in laparoscopic colorectal cancer surgery.

Methods

We searched the PubMed, EMBASE, Cochrane Library, and Ovid databases for eligible studies until April 2014. The main end points were the duration of the postoperative hospital stay, time to first flatus after surgery, time of first bowel movement, total postoperative complication rate, readmission rate, and mortality.

Results

Five randomized controlled trials and 5 clinical controlled trials with 1,317 patients were eligible for analysis. The duration of the postoperative hospital stay (weighted mean difference [WMD], –1.64 days; 95% confidence interval [CI], –2.25 to –1.03; p < 0.001), time to first flatus (WMD, –0.40 day; 95% CI, –0.77 to –0.04; p = 0.03), time of first bowel movement (WMD, –0.98 day; 95% CI, –1.45 to –0.52; p < 0.001), and total postoperative complication rate (risk ratio [RR], 0.67; 95% CI, 0.56–0.80; p < 0.001) were significantly reduced in the FTS group. No significant differences were noted in the readmission rate (RR, 0.64; 95% CI, 0.41–1.01; p = 0.06) or mortality (RR, 1.55; 95% CI, 0.42–5.71; p = 0.51).

Conclusion

Among patients undergoing laparoscopic colorectal cancer surgery, FTS is associated with a significantly shorter postoperative hospital stay, more rapid postoperative recovery, and, notably, greater safety than is expected from traditional care.

What should we intend for minimally invasive treatment of colorectal cancer?

Non-inferiority of laparoscopic treatment of colorectal cancer (CRC) has been demonstrated in randomized controlled trials although operative and perioperative management varies widely among centers. Literature data in English language published up to April 15, 2014 were analyzed in order to give an up to date analysis that would highlights the key aspects of a modern and factual minimally invasive treatment of CRC. Laparoscopic resection is the first choice treatment of colon cancer. Laparoscopic resection of rectal cancer should be considered an investigational procedure to be performed in high volume centers with special interest in laparoscopy and colorectal surgery. Less invasive approaches should be taken into account with the aim of reducing surgical stress. The adoption of ERAS programs has demonstrated to optimize short-term results. Future research should be directed to prove possible long-term advantages, in terms of overall and disease-free survival, of minimally invasive treatment of CRC.