Case controlled study of the hospital stay and return to full activity following laparoscopic and open colorectal surgery before and after the introduction of an enhanced recovery programme

Potential considerations in decision making on laparoscopic colorectal resections in Hungary based on administrative data

Background

Laparoscopic colorectal surgeries offer numerous advantages over their open counterparts. To compare these measurable short-time outcomes of open and laparoscopic resections in Hungary, data of colorectal surgeries were collected and analysed. The study focused on identifying patients’ characteristics that can influence the decision on laparoscopic colorectal resections and on comparing efficiency of Hungarian colorectal operations with international data.

Methods

Using patients’ data of laparoscopic and open colorectal surgery performed in 2015 and 2016 from the National Health Insurance Fund of Hungary, a countrywide retrospective comparative analysis was done. Logistic regression was used to explore main influencing factors for laparoscopic colorectal surgery.

Results

A total of 17,876 colorectal surgical cases, including 14,876 open and 3,000 laparoscopic resections were selected and analysed. Laparoscopy was used only in 16.78% of all cases. Comparison of age groups showed that odds ratio (OR) of laparoscopic colorectal resections was significantly lower in over 40 years than in younger patients (18–39 years). In university institutes patients had higher odds (OR: 2.23 p<0.0001) for laparoscopic colorectal resections. Presence of comorbidity codes and preoperative treatment in internal medicine department decreased odds for laparoscopic colorectal operations.

Conclusions

Patients’ age, comorbidities and hospital type influenced the likelihood of decision on laparoscopic colorectal resection. Selection of patients contributed to improved laparoscopic outcomes.

Postoperative Work and Activity Restrictions After Abdominal Surgery: A Systematic Review

OBJECTIVE

This systematic review aims to assess what is known about convalescence following abdominal surgery. Through a review of the basic science and clinical literature, we explored the effect of physical activity on the healing fascia and the optimal timing for postoperative activity.

BACKGROUND

Abdominal surgery confers a 30% risk of incisional hernia development. To mitigate this, surgeons often impose postoperative activity restrictions. However, it is unclear whether this is effective or potentially harmful in preventing hernias.

METHODS

We conducted 2 separate systematic reviews using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The first assessed available basic science literature on fascial healing. The second assessed available clinical literature on activity after abdominal surgery.

RESULTS

Seven articles met inclusion criteria for the basic science review and 22 for the clinical studies review. The basic science data demonstrated variability in maximal tensile strength and time for fascial healing, in part due to differences in layer of abdominal wall measured. Some animal studies indicated a positive effect of physical activity on the healing wound. Most clinical studies were qualitative, with only 3 randomized controlled trials on this topic. Variability was reported on clinician recommendations, time to return to activity, and factors that influence return to activity. Interventions designed to shorten convalescence demonstrated improvements only in patient-reported symptoms. None reported an association between activity and complications, such as incisional hernia.

CONCLUSIONS

This systematic review identified gaps in our understanding of what is best for patients recovering from abdominal surgery. Randomized controlled trials are crucial in safely optimizing the recovery period.

Patient Satisfaction and Quality of Life with Enhanced Recovery Protocols

While studies have demonstrated the benefits of Enhanced Recovery after Surgery (ERAS) programs in reducing length of stay and costs without increasing complications, fewer studies have evaluated patient satisfaction and quality of life (QOL) with enhanced recovery protocols. The aim of this project was to summarize the literature comparing satisfaction and quality of life after colorectal surgery following treatment within an ERAS protocol to standard postoperative care. The available evidence suggests patients suffer no detriment to satisfaction or quality of life with use of ERAS protocols, and may suffer less fatigue and return to activities sooner. Most publications reported no adverse effects on postoperative pain. However, a limited number of studies suggest patients may experience increased early postoperative pain with ERAS pathways, particularly following open colorectal procedures. Future research should focus on potential improvements in ERAS protocols to better manage postoperative pain. Overall, the evidence supports more widespread implementation of ERAS pathways in colorectal surgery.

Short-term and Long-term Outcomes Regarding Laparoscopic Versus Open Surgery for Low Rectal Cancer: A Systematic Review and Meta-Analysis

PURPOSE

It is to disclose whether the laparoscopic technique is feasible or not in the treatment of low rectal cancer.

MATERIALS AND METHODS

We systematically searched PubMed, Embase, Ovid, Web of Science, Science Direct, SpringerLink, EBSCO, and the Cochrane Library databases for the eligible studies. Review Manager 5.2 was used to test the heterogeneity and to evaluate the overall test performance.

RESULTS

Twelve studies met the final inclusion criteria (total n=2973). The pooled analyses showed, despite longer operation times, that there were significantly less blood loss, fewer transfusions, shorter times to bowel function recovery, resumed diet and hospital durations, and lower overall complication and wound infection rates. The compared results of the lymph node harvest number, distal resection margin, circumferential resection margin involvement, local and distant recurrences, disease-free survival, and overall survival were similar between both the groups.

CONCLUSION

Laparoscopic surgery is safe and feasible for the treatment of low rectal cancer.

Laparoscopic skill improvement after virtual reality simulator training in medical students as assessed by augmented reality simulator

INTRODUCTION

Definitive assessment of laparoscopic skill improvement after virtual reality simulator training is best obtained during an actual operation. However, this is impossible in medical students. Therefore, we developed an alternative assessment technique using an augmented reality simulator.

METHODS

Nineteen medical students completed a 6-week training program using a virtual reality simulator (LapSim). The pretest and post-test were performed using an object-positioning module and cholecystectomy on an augmented reality simulator(ProMIS). The mean performance measures between pre- and post-training on the LapSim were compared with a paired t-test.

RESULTS

In the object-positioning module, the execution time of the task (P < 0.001), left and right instrument path length (P = 0.001), and left and right instrument economy of movement (P < 0.001) were significantly shorter after than before the LapSim training. With respect to improvement in laparoscopic cholecystectomy using a gallbladder model, the execution time to identify, clip, and cut the cystic duct and cystic artery as well as the execution time to dissect the gallbladder away from the liver bed were both significantly shorter after than before the LapSim training (P = 0.01).

CONCLUSIONS

Our training curriculum using a virtual reality simulator improved the operative skills of medical students as objectively evaluated by assessment using an augmented reality simulator instead of an actual operation. We hope that these findings help to establish an effective training program for medical students.

Laparoscopic Versus Open Surgery for Mid-Low Rectal Cancer: a Systematic Review and Meta-Analysis on Short- and Long-Term Outcomes

BACKGROUND

The safety of laparoscopic surgery for mid-low rectal cancer treatment has remained controversial, especially regarding the long-term outcomes. The aim of this study was to demonstrate whether the laparoscopic technique is feasible.

METHODS

We searched all of studies that compared the short- or long-term outcomes regarding laparoscopic and open rectal cancer surgeries (the tumour distance from anal verge within 10 cm). The data sources included PubMed, EMBASE, OVID, Web of Science and the Cochrane Library databases. The combined outcome of the dichotomous variables was expressed as an estimation of the odds ratios and continuous variables were presented in the form of weighted mean differences with 95% credible intervals. Subgroup, publication bias and sensitivity analyses were performed.

RESULTS

Thirteen studies met the final inclusion criteria (total n = 3,678). The pooled analyses showed, despite longer operation times, that there were significantly less blood loss, fewer transfusions, shorter times to bowel function recovery, resumed diet and hospital durations, and lower overall complication and wound infection rates. The compared results of the lymph node harvest number, distal resection margin, circumferential resection margin involvement, local and distant recurrences, disease-free survival and overall survival were similar between both groups.

CONCLUSIONS

This study suggests that the safety and feasibility of laparoscopic surgery appear to be equivalent to open surgery for treatment of mid- low rectal cancer, with the more favourable short-term benefits, fewer complications, comparable pathological outcomes and long-term outcomes.

A qualitative study assessing the barriers to implementation of enhanced recovery after surgery

BACKGROUND

Previous studies have quantitatively assessed Enhanced Recovery After Surgery (ERAS) guideline implementation and compliance, and identified the existence of compliance issues with the programs. This is the first study to qualitatively assess the reasons behind compliance issues in ERAS programs. The aim of this study was to elicit barriers to implementation and functioning of the ERAS program at Royal Prince Alfred Hospital.

METHODS

A series of interviews were carried out with key stakeholders in order to explore barriers preventing effective functioning of the program 1 year after implementation. Interview transcripts were analysed. Data analysis involved a grounded theory methodology.

RESULTS

Analysis of the data identified four key themed areas of practice that presented barriers: patient-related factors, staff-related factors, practice-related issues, and resources. These overarching themes were generated from subcategories that were linked to generate theory.

CONCLUSIONS

For the ERAS program to be implemented successfully with high levels of element compliance, the four key areas need to be addressed. As barriers to ongoing effective care become apparent, these should be managed in order to optimize the synergistic effects of this multimodal program of patient care.

Simultaneous laparoscopic colorectal resection and pulmonary resection by minithoracotomy: report of four cases

The aim of the present study was to determine the feasibility of simultaneous resection of colorectal cancer by laparoscopy and a pulmonary lesion through minithoracotomy. Four patients underwent laparoscopic resection of colorectal cancer followed by pulmonary resection. The mean operative duration was 390 min and the mean blood loss was 133 mL. The postoperative course was uneventful. The indication for simultaneous resection of colorectal cancer by the laparoscopic approach and a pulmonary lesion is controversial. This method is safe and feasible in selected patients, but whether colorectal resection or pulmonary surgery is performed first should be determined on a case-by-case basis.

Laparoscopic versus open surgery following neoadjuvant chemoradiotherapy for rectal cancer: a systematic review and meta-analysis

BACKGROUND

This meta-analysis aimed to evaluate the short-term and pathological outcomes of laparoscopic surgery (LS) versus open surgery (OS) following neoadjuvant chemoradiotherapy (NCRT) for rectal cancer.

METHODS

PubMed, Embase, Web of Science, Cochrane Library, and Chinese Biomedicine Literature databases were searched for eligible studies published up to July 2013. The rates of postoperative complication, positive circumferential resection margin (CRM), and the number of lymph nodes harvested were evaluated.

RESULTS

Three randomized controlled trials (RCTs) and five non-RCTs enrolling 953 patients were included. Compared to OS, LS had similar rate of postoperative complication [odds ratio (OR) 0.86; 95% confidence interval (CI), 0.60 to 1.22], comparable rate of positive CRM (OR 0.41; 95% CI, 0.16 to 1.02), and smaller number of lymph nodes (weighted mean difference -0.8; 95% CI, -1.1 to -0.5). LS also had significantly less blood loss, faster bowel movement recovery, and shorter postoperative hospitalization than those of OS.

CONCLUSION

LS is associated with favorable short-term benefits, similar postoperative complication rate, and comparable pathological outcomes for rectal cancer after NCRT compared to OS despite a slight difference in the number of lymph nodes. Additional high-quality studies are needed to validate long-term outcomes of LS following NCRT.

Deviation and failure of enhanced recovery after surgery following laparoscopic colorectal surgery: early prediction model

AIM

Enhanced recovery after surgery (ERAS) programmes are well established, but deviation from the postoperative elements may result in delayed discharge. Early identification of such patients may allow remedial action to be taken. The aims of this study were to investigate factors associated with delayed discharge and to produce a predictive scoring system for ERAS failure.

METHOD

A retrospective review was carried out of case notes of patients who underwent elective laparoscopic colorectal resection and ERAS at Yeovil District Hospital between 2002 and 2009. Univariate and multivariate analyses were performed and binary logistic regression was used to model a predictive scoring system.

RESULTS

In all, 385 patient records were reviewed with a median length of stay of 6 days; 122 (31%) patients stayed longer than 1 week (delayed discharge) and 159 (41%) deviated in up to two postoperative ERAS factors. Patient demographic factors were not predictive of delayed discharge. Deviation from ERAS factors at the end of the first postoperative day, including continued intravenous fluid infusion, lack of functioning epidural, inability to mobilize, vomiting requiring nasogastric tube insertion and re-insertion of urinary catheter, were strongly associated with delayed discharge. A five-element predictive scoring system for ERAS failure and delayed discharge was formulated.

CONCLUSION

Enhanced recovery failure and delayed discharge after laparoscopic colorectal surgery can be predicted by the early deviation from postoperative factors of an ERAS programme.

Enhanced recovery for colorectal surgery: Practical hints, results and future challenges

Enhanced recovery after surgery (ERAS) protocols are now achieving worldwide diffusion in both university and district hospitals with special interest in colorectal surgery. The optimization of the patient’s preoperative clinical conditions, the careful intraoperative administration of fluids and drugs and the postoperative encouragement to resume the normal physiological functions as early as possible has produced results in a large amounts of studies. These approaches successfully challenged long-standing and well-established perioperative managements and finally achieved the status of gold standard treatments for the perioperative management of uncomplicated colorectal surgery. Even more important, it seems that the clinical improvement of the patient’s clinical management through ERAS protocols is now reaching his best outcomes (length of stay of 4-6 d after the operation) and therefore any further measures add little to the results already established (i.e., the adjunct of laparoscopic surgery to ERAS). Still dedicated meetings and courses around the world are exploring new aspects including the improvement the preoperative nutrition status to provide the energy necessary to face the surgical stress, the preoperative individuation of special requirements that could be properly addressed before the date of surgery and therefore would reduce the number of unnecessary days spent in hospital once fully recovered (i.e., rehabilitation, social discharges), and finally the development of an important web of out-of-hours direct access in order to individuate alarm symptoms in those patients at risk of complications that could prompt an early readmission.

Laparoscopic vs open resection for rectal cancer: a meta-analysis of randomized clinical trials

AIM

Laparoscopic and open rectal resection for cancer were compared by analysing a total of 26 end points which included intraoperative and postoperative recovery, short-term morbidity and mortality, late morbidity and long-term oncological outcomes.

METHOD

We searched for published randomized clinical trials, presenting a comparison between laparoscopic and open rectal resection for cancer using the following electronic databases: PubMed, OVID, Medline, Cochrane Database of Systematic Reviews, EBM Reviews, CINAHL and EMBASE.

RESULTS

Nine randomized clinical trials (RCTs) were included in the meta-analysis incorporating a total of 1544 patients, having laparoscopic (N = 841) and open rectal resection (N = 703) for cancer. Laparoscopic surgery for rectal cancer was associated with a statistically significant reduction in intraoperative blood loss and in the number of blood transfusions, earlier resuming solid diet, return of bowel function and a shorter duration of hospital stay. We also found a significant advantage for laparoscopy in the reduction of post-operative abdominal bleeding, late intestinal adhesion obstruction and late morbidity. No differences were found in terms of intra-operative and late oncological outcomes.

CONCLUSION

The meta-analysis indicates that laparoscopy benefits patients with shorter hospital stay, earlier return of bowel function, reduced blood loss and number of blood transfusions and lower rates of abdominal postoperative bleeding, late intestinal adhesion obstruction and other late morbidities.

Fifty ways to reduce length of stay: an inventory of how hospital staff would reduce the length of stay in their hospital

PURPOSE AND SETTING

In this study we present a bottom up approach to developing interventions to shorten lengths of stay. Between 1999 and 2009 we applied the approach in 21 Dutch clinical wards in 12 hospitals. We present the complete inventory of all interventions.

DESIGN

We organised, on the hospital ward level, structured meetings with the staff in order to first identify barriers to reduce the length of stay and then later to link them to interventions. The key components of the approach were a benchmark with the fifteenth percentile and the use of a matrix, that on one side was arranged along the main phases of the care process--the admission, stay and discharge--and on the other side to the degree to which the length of stay could be shortened by the medical specialists and nurses themselves or by involving others.

FINDINGS AND CONCLUSIONS

The matrix consists of a wide variety of interventions that mainly cover what we found in published research. As a bottom up approach is more likely to succeed, we would advise wards that have to reduce length of stay to make the inventory themselves, using appropriate benchmark data, and by using the matrix.

Enhanced recovery for non-colorectal surgery

In recent years the advent of programs for enhanced recovery after major surgery (ERAS) has led to modifications of long-standing and well-established perioperative treatments. These programs are used to target factors that have been shown to delay postoperative recovery (pain, gut dysfunction, immobility) and combine a series of interventions to reduce perioperative stress and organ dysfunction. With due differences, the programs of enhanced recovery are generally based on the preoperative amelioration of the patient’s clinical conditions with whom they present for the operation, on the intraoperative and postoperative avoidance of medications that could slow the resumption of physiological activities, and on the promotion of positive habits in the early postoperative period. Most of the studies were conducted on elective patients undergoing colorectal procedures (either laparotomic or laparoscopic surgery). Results showed that ERAS protocols significantly improved the lung function and reduced the time to resumption of oral diet, mobilization and passage of stool, hospital stay and return to normal activities. ERAS’ acceptance is spreading quickly among major centers, as well as district hospitals. With this in mind, is there also a role for ERAS in non-colorectal operations?

Augmented reality in laparoscopic surgical oncology

Minimally invasive surgery represents one of the main evolutions of surgical techniques aimed at providing a greater benefit to the patient. However, minimally invasive surgery increases the operative difficulty since the depth perception is usually dramatically reduced, the field of view is limited and the sense of touch is transmitted by an instrument. However, these drawbacks can currently be reduced by computer technology guiding the surgical gesture. Indeed, from a patient's medical image (US, CT or MRI), Augmented Reality (AR) can increase the surgeon's intra-operative vision by providing a virtual transparency of the patient. AR is based on two main processes: the 3D visualization of the anatomical or pathological structures appearing in the medical image, and the registration of this visualization on the real patient. 3D visualization can be performed directly from the medical image without the need for a pre-processing step thanks to volume rendering. But better results are obtained with surface rendering after organ and pathology delineations and 3D modelling. Registration can be performed interactively or automatically. Several interactive systems have been developed and applied to humans, demonstrating the benefit of AR in surgical oncology. It also shows the current limited interactivity due to soft organ movements and interaction between surgeon instruments and organs. If the current automatic AR systems show the feasibility of such system, it is still relying on specific and expensive equipment which is not available in clinical routine. Moreover, they are not robust enough due to the high complexity of developing a real-time registration taking organ deformation and human movement into account. However, the latest results of automatic AR systems are extremely encouraging and show that it will become a standard requirement for future computer-assisted surgical oncology. In this article, we will explain the concept of AR and its principles. Then, we will review the existing interactive and automatic AR systems in digestive surgical oncology, highlighting their benefits and limitations. Finally, we will discuss the future evolutions and the issues that still have to be tackled so that this technology can be seamlessly integrated in the operating room.

Short-term outcomes following laparoscopic resection for colon cancer

BACKGROUND

Laparoscopic resection for colon cancer has been proven to have a similar oncological efficacy compared to open resection. Despite this, it is performed by a minority of colorectal surgeons. The aim of our study was to evaluate the short-term clinical, oncological and survival outcomes in all patients undergoing laparoscopic resection for colon cancer.

METHODS

From July 2005 to December 2008, 202 consecutive patients underwent laparoscopic resection for colon cancer. Surgery was analysed on an intention to treat basis. The mean follow-up was 24.3 months.

RESULTS

Two hundred twenty-two patients underwent resection for colon cancer. Two hundred two underwent laparoscopic resection (91%). One hundred sixteen were male patients. Mean age was 65.9 years (range = 24-91). The median length of stay was 6.6 days (mean = 7.1 days). One hundred eighty-eight of 202 (93.1%) were completed laparoscopically. Fourteen (6.9%) were converted. The overall morbidity rate was 15.8%. There were three clinically apparent anastomotic leaks. The 30-day mortality was 1 (0.5%). The mean nodal yield was 13.4 (range = 8-37) nodes. There were no positive margins detected. Overall survival in laparoscopically treated colon cancer was 88.1%. In those patients with non-metastatic disease, the overall survival was 90.7% (165/182).

CONCLUSION

Laparoscopic resection for colon cancer is achievable in 85% (188/222) of patients. This facilitates adequate oncological clearance. It is associated with a low morbidity rate and favourable short-term survival outcomes. This data reflects the potential outcomes dedicated MIS colorectal units will have to offer colon cancer patients once laparoscopic colorectal surgery becomes the de facto surgical approach.