Perioperative care in colorectal surgery: current practice patterns and opinions

Are we ready for the ERAS protocol in colorectal surgery?

Introduction

Modern perioperative care principles in elective colorectal surgery have already been established by international surgical authorities. Nevertheless, barriers to the introduction of routine evidence-based clinical care and changing dogmas still exist. One of the factors is the surgeon.

Aim

To assess perioperative care trends in elective colorectal surgery among general surgery consultants in surgical departments in Malopolska Voivodeship, Poland.

Material and methods

An anonymous standardized 20-question questionnaire was developed based on ERAS principles and sent out to Malopolska Voivodeship general surgery departments. Answers of general surgery consultants showed the level of acceptance of elements of perioperative care.

Results

The overall response rate was 66%. Several elements (antibiotic and antithrombotic prophylaxis, postoperative oxygen therapy, no nasogastric tubes) had quite a high acceptance rate. On the other hand, most crucial surgical perioperative elements (lack of mechanical bowel preparation, preoperative oral carbohydrate loading, use of laparoscopy and lack of drains, early fluid and oral diet intake, early mobilization) were not followed according to evidence-based ERAS protocol recommendations. Surgeons were not willing to change their practice, but were supportive of changes in anesthesiologist-dependent elements of perioperative care, such as restrictive fluid therapy, use of transversus abdominis plane blocks, etc.

Conclusions

Many elements of perioperative care in elective colorectal surgery in Malopolska Voivodeship are still dictated by dogma and are not evidence-based. The level of acceptance of many important ERAS protocol elements is low. Surgeons are ready to accept only changes that do not interfere with their practice.

Pain control for laparoscopic colectomy: an analysis of the incidence and utility of epidural analgesia compared to conventional analgesia

PURPOSE

The aim of this study was to compare short-term outcomes between epidural analgesia and conventional intravenous analgesia for patients undergoing laparoscopic colectomy. This paper uses a large national database to add a current perspective on trends in analgesia and the outcomes associated with two analgesia options. Our evidence augments the opinions of recent randomized controlled trials.

METHODS

The University HealthSystem Consortium, an alliance of more than 300 academic and affiliate institutions, was reviewed for the time period of October 2008 through September 2014. International Classification of Disease 9th Clinical Modification codes for laparoscopic colectomy and epidural catheter placement were used.

RESULTS

A total of 29,429 patients met our criteria and underwent laparoscopic colectomy during the study period. One hundred and ten (0.374%) patients had an epidural catheter placed for analgesia. Baseline patient demographics were similar for the epidural and conventional analgesia groups. Total charges were significantly higher in the epidural group ($52,998 vs. $39,277; p < 0.001). Median length of stay was longer in the epidural group (6 vs. 5 days; p < 0.001). There was no statistical difference between the epidural and conventional analgesia groups in death (0 vs. 0.03%; p = 0.999), urinary tract infection (0 vs. 0.1%; p = 0.999), ileus (11.8 vs. 13.6%; p = 0.582), or readmission rate (9.1 vs. 9.3%; p = 0.942).

CONCLUSION

Compared to conventional analgesic techniques, epidural analgesia does not reduce the rate of postoperative ileus, and it is associated with increased cost and increased length of stay. Based on our data, routine use of epidural analgesia for laparoscopic colectomy cannot be justified.

Impact of a diverting stoma in an enhanced recovery programme for rectal cancer

PURPOSE

The association of a loop ileostomy decreases the severity of complications after rectal surgery but can increase the postoperative stay. The aim of this study is to investigate if a diverting ileostomy influences the postoperative outcomes in a series of patients included in a multimodal rehabilitation program (MMRP).

METHODS

We analyzed a series of 104 patients that underwent elective surgery with primary anastomosis for rectal adenocarcinoma using a MMRP: 66 men and 38 women, with a median age of 64 (IQR: 55-75) years. Group A included patients with an associated loop ileostomy, and Group B, those without a protective stoma.

RESULTS

Group A = 58, group B = 46 patients without differences in age, ASA, BMI and other risk factors, nor in the surgical approach (laparoscopic in 34%), although there were more neoadjuvant treatments in group A: 77.5 vs. 36.9%; P=.001. In group A, the most common operation was total mesorectal excision (96%) and in the B, a subtotal mesorectal excision (90%). There were no differences in postoperative complications (Group A 34.4 vs. group B28.2%; P=.322), anastomotic leaks (8.3 vs. 10.8%; P=.475), or postoperative ileus (20.7 vs. 10.9%; P=.140), neither in postoperative stay (7.9 vs. 6.9 days; P= .058, readmissions (7 vs. 13.6%; P= .22), or postoperative stay, including readmissions (8.4 vs. 9.1 days; P= .49).

CONCLUSIONS

The association of a loop ileostomy does not extend the length of stay nor increases the rate of complications in patients that underwent a rectal resection with anastomosis included in a MMRP.

Bowel Preparation before Elective Surgery

Mechanical bowel preps were initially thought to decrease the bacterial load of the colon and therefore decrease infection. Traditional bowel preps include osmotic, laxative, and combination regimen. Data demonstrate that mechanical bowel preps are generally equivalent; however, the addition of oral antibiotics may further reduce the risk of infection. Recent data suggest that mechanical bowel preparations may not be necessary, and that dietary restrictions before surgery may also be obsolete. In this review, the authors address the types of mechanical bowel preparations (MBPs), differences in outcomes between MBPs, the role of oral antibiosis and enemas, the benefits of no MBP, and dietary preparations for elective colon and rectal surgery.

A Prospective Single-Institution Evaluation of Current Practices of Early Postoperative Feeding after Elective Intestinal Surgery

Postoperative diet advancement in patients undergoing elective small bowel or colorectal surgery by general surgeons (GSs) and colorectal surgeons (CRSs) was prospectively evaluated. Demographic (age and gender), disease location (small bowel or colorectum), surgical approach (laparoscopic or open), and surgeon characteristics (GS or GRS) were tabulated. Postoperative feeding after surgery on postoperative Day (POD) 1 was assessed. Operations involved the colorectum (n = 43 [72%]) or small bowel (n = 17 [28%]) and were performed using laparoscopy (n = 38 [63%]) or open (n = 22 [37%]) techniques. Operations were performed by GSs (n = 30) or CRSs (n = 30). Early feeding was ordered on POD 1 on 34 patients (57%). The remaining 26 patients (43%) were kept nothing by mouth. Factors associated with early feeding included age younger than 50 years (P 5.004), surgery done by CRSs ( P < 0.0001), operations on the colorectum ( P = 0.04), and laparoscopic surgery ( P = 0.07). Multivariable analysis revealed that age younger than 50 years (odds ratio [OR], 9.5; 95% confidence interval [CI], 1.8 to 52; P = 0.01), surgery done by CRSs (OR, 16.3; 95% CI, 3.4 to 79.6; P = 0.001), and use of laparoscopic surgery (OR, 12; 95% CI, 2.1 to 67; P = 0.007) were associated with early postoperative feeding. Early postoperative feeding does not appear to be applied commonly in clinical practice. Younger patient age, surgery done by CRSs, and laparoscopy are associated with the use of early postoperative feeding after elective intestinal surgery.

Which fast track elements predict early recovery after colon cancer surgery?

AIM

It is questioned whether all separate fast track elements are essential for enhanced postoperative recovery. We aimed to determine which baseline characteristics and which fast track elements are independent predictors of faster postoperative recovery in patients undergoing resection for colon cancer.

METHOD

Data from the LAFA trial database were used. In this trial, fast track care was compared with standard perioperative care in 400 patients undergoing laparoscopic or open surgery for colonic cancer. During admission 19 fast track elements per patient were prospectively evaluated and scored whether or not they were successfully applied. To identify predictive factors six baseline characteristics and those fast track items that were successfully achieved were entered in a univariate and multivariate linear regression analysis with total postoperative hospital stay (THS) as the primary outcome.

RESULTS

In 400 patients, two baseline characteristics and two fast track elements were found to be significant independent predictors of THS: female sex [B = 0.85; 95% CI 0.75-0.96; reduction of 15% (CI 14-25%) in THS], laparoscopic resection [B = 0.85; 95% CI 0.75-0.96; reduction of 15% (CI 14-25%) in THS], 'normal diet at postoperative days 1, 2 and 3' [B = 0.70; 95% CI 0.61-0.81; reduction of 30% (CI 19-39%) in THS] and 'enforced mobilization at postoperative days 1, 2 and 3' [B = 0.68; 95% CI 0.59-0.80; reduction of 32% (CI 20-41%) in THS].

CONCLUSION

Evaluating only those fast track elements that were successfully achieved, enforced advancement of oral intake, early mobilization, laparoscopic surgery and female sex were independent determinants of early recovery.

Metabolic conditioning to attenuate the adverse effects of perioperative fasting and improve patient outcomes

PURPOSE OF REVIEW

To review recent articles, published between October 2009 and September 2011, that examined the adverse metabolic consequences of perioperative fasting and interventions that may be utilized to minimize these effects.

RECENT FINDINGS

Fasting induces metabolic stress and insulin resistance consequent upon effects on cellular mitochondria, gene and protein expression. Development of perioperative insulin resistance leads to increased postoperative morbidity and mortality. Preoperative carbohydrate loading attenuates insulin resistance via effects on cellular gene and protein expression, but its effects on clinical outcomes remain unclear. Perioperative arginine-supplemented diets were shown to be associated with significant reductions in infectious complications and length of hospital stay in patients undergoing elective surgery. Perioperative metabolic conditioning using glutamine and L-carnitine may be used to modulate insulin sensitivity but further studies need to determine whether these interventions result in clinical benefit. Finally, energy and protein provision to critically ill patients remains inadequate and is hampered by a number of factors including reliance on inaccurate means of estimating energy expenditure and enteral feed tolerance, conflicting data on the effects of energy deficit on clinical outcomes, and poor methodological quality of studies of perioperative nutritional interventions.

SUMMARY

Numerous perioperative interventions are available, which if utilized should help attenuate the adverse effects of perioperative fasting and lead to improved patient outcomes.

[Implementation of a perioperative multimodal rehabilitation protocol in elective colorectal surgery. A prospective randomised controlled study]. Cir Esp. 2011;89:159-166. [PMID: 21345423 DOI: 10.1016/j.ciresp.2010.12.004]

INTRODUCTION

Multimodal rehabilitation (MMR) consists of a combination of several methods for management of the surgical patient, designed to reduce the response to surgical stress and a more comfortable and earlier recovery.

OBJECTIVE

To assess the implementation of an MMR protocol in a Colorectal Surgery Unit, and to compare the results with the traditional model, as well as assessing its efficacy as regards recovery and hospital stay.

MATERIAL AND METHODS

A total of 119 patients who received elective surgery for colorectal diseases in a period during 2009-2010 were prospectively and randomly analysed. The patients were divided into 2 groups: 58 patients were assigned to the traditional group and 61 to the MMR group. The MMR group protocol consisted of, preoperative education, early feeding and mobilisation.

RESULTS

Both groups were homogeneous as regards the preoperative variables evaluated, the type of disease and the procedures carried out. The nasogastric tube was kept in place for 4 (1-9) days compared to 1 day (0-2) in the MMR group, with no differences in the number of re-insertions. Significant differences were found in the introduction of a liquid diet (3 [1-5] days traditional versus 0 [0-2] MMR) (P<.001), and passing of first flatulence (3 [1-6] days traditional versus 1 [1-3] MMR) (P<.001). The MMR group had a postoperative stay of 4.15±2.18 versus 9.23±6.97 days in the traditional group (P<.001). No significant differences were found in complications or readmissions.

CONCLUSIONS

MMR in colorectal surgery in the Spanish public health system is feasible and enables surgical patients to have a faster recovery without increasing complications, leading to an earlier hospital discharge.

[Selective intestinal preparation in a multimodal rehabilitation program. Influence on preoperative comfort and the results after colorectal surgery]

INTRODUCTION

Despite there being no evidence of the advantages of its use, mechanical bowel preparation (MBP) continues to be routine in colorectal surgery. Our objective is to analyse the impact of its selective use, as regards patient comfort and results, comparing a perioperative multimodal rehabilitation program (MMRH) with conventional care (CC).

MATERIAL AND METHODS

A prospective study of 108 patients proposed for elective surgery, assigned consecutively 2:1 to an MMRH protocol which only included MBP in rectal surgery with low anastomosis, or to CC in whom MBP was used except in right colon surgery. We also studied two Groups (A and B) with and without the use of MBP. Their tolerance, results and postoperative recovery variables were analysed.

RESULTS

Thirty-nine patients were included in Group A, and 69 in Group B. A MMRH protocol was used in another 69 patients. The Group A patients had more abdominal pain, anal discomfort, nausea and thirst, but there were no differences as regards, death, overall or local complications, whilst there was less complications, suture failures and death in the MMRH when compared with CC Group (P<.05). There were no advantages observed in the use of MBP as regards the start of bowel movements, tolerance to diet or hospital stay, but these parameters were favourable to the MMRH when compared with CC Group.

CONCLUSIONS

The restriction of MBP is safe, and associated with an MMRH program, contributes to a faster and more comfortable recovery, without increasing complications.

[Accreditation and dedication in coloproctology is associated with good perioperative care]

Complex data analysis methods require optimisation techniques such as evolutionary algorithms in order to generate reliable results. The objective of this study is to analyse the relationships of particular perioperative care in colorectal surgery (CRS) with surgeon epidemiological data, performing partition grouping to look for significant relationships.

METHODS

Data were used from a survey of members of Spanish coloproctology associations on perioperative care in colorectal surgery, and analysing the responses associated with mechanical bowel preparation (MBP), nasogastric intubation (NGI), drainages (D), and early feeding (EF), over the existing scientific evidence (SE) which shows that the first ones are unnecessary and the importance of the last one. We applied a variant of particle swarm optimization (PSO), to group data conglomerates, optimising variables with statistical grouping criteria.

RESULTS

A total of 130 surveys were analysed, finding 2 clear groups which included 21.5% and 78.5% of the sample, respectively. Sixty eight per cent of the surgeons in Group A belonged to the European Board in Coloproctology, compared to none in Group B, and the former performed 80% of the coloproctology activity, compared to 60% of the rest. A responded homogeneously to questions on MBP, NGI, D and EF, those of group A following the SE, while the others did it randomly and without following it. Age, work position or academic range were not significant in the grouping.

CONCLUSIONS

The evolutionary algorithm was shown to be able to identify groups according to the use of perioperative care in CRS. Accreditation and dedication was associated with behaviour based on the SE.

Current perioperative practice in rectal surgery in Austria and Germany

OBJECTIVE

'Fast-track' rehabilitation is able to accelerate recovery, reduce general morbidity, and decrease hospital stay. This is widely accepted for colonic resections. Despite recent evidence that fast track concepts are safe and feasible in rectal resection, there is no information on the acceptance and utilization of these concepts among Austrian and German surgeons.

METHOD

A questionnaire concerning perioperative routines in elective, open rectal resection was sent to the chief surgeons of 1,270 German and 120 Austrian surgical centers.

RESULTS

The response rate was 63% in Austria (76 centers) and 30% in Germany (385 centers). Mechanical bowel preparation is only abandoned by 2% of the Germany and 7% of the Austrian surgeons. Nasogastric decompression tubes are rarely used; four of five of the questioned surgeons in both countries use intra-abdominal drains. Half of the surgical centers allow the intake of clear fluids on the day of surgery. Mobilization starts in half of the centers on the day of surgery. Epidural analgesia is used in three-fourths of the institutions. Institutions which have implemented fast track rehabilitation for rectal resections discharge the patients earlier then hospitals that adhere to traditional care.

CONCLUSION

In many perioperative procedures, Austrian and German Surgeons rely on their traditional approaches. Recent evidence-based adaptations of perioperative routines in rectal resections are only slowly introduced into daily routine; therefore, further efforts have to be done to optimizing patients' care.