Comparison of early mobilization and diet rehabilitation program with conventional care after laparoscopic colon surgery: a prospective randomized controlled trial

Impact of interventions to improve recovery of older adults following planned hospital admission on quality-of-life following discharge: linked-evidence synthesis

Objectives

To understand the impact of multicomponent interventions to improve recovery of older adults following planned hospital treatment, we conducted two systematic reviews, one of quantitative and one of qualitative evidence, and an overarching synthesis. These aimed to: • understand the effect of multicomponent interventions which aim to enhance recovery and/or reduce length of stay on patient-reported outcomes and health and social care utilisation • understand the experiences of patients, carers and staff involved in the delivery of interventions • understand how different aspects of the content and delivery of interventions may influence patient outcomes.

Review methods

We searched bibliographic databases including MEDLINE ALL, Embase and the Health Management Information Consortium, CENTRAL, and Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database, conducted forward and backward citation searching and examined reference lists of topically similar qualitative reviews. Bibliographic database searches were completed in May/June 2021 and updated in April 2022. We sought primary research from high-income countries regarding hospital inpatients with a mean/median age of minimum 60 years, undergoing planned surgery. Patients experienced any multicomponent hospital-based intervention to reduce length of stay or improve recovery. Quantitative outcomes included length of stay and any patient-reported outcome or experience or service utilisation measure. Qualitative research focused on the experiences of patients, carers/family and staff of interventions received. Quality appraisal was undertaken using the Effective Public Health Practice Project Quality Assessment Tool or an adapted version of the Wallace checklist. We used random-effects meta-analysis to synthesise quantitative data where appropriate, meta-ethnography for qualitative studies and qualitative comparative analysis for the overarching synthesis.

Results

Quantitative review: Included 125 papers. Forty-nine studies met criteria for further synthesis. Enhanced recovery protocols resulted in improvements to length of stay, without detriment to other outcomes, with minimal improvement in patient-reported outcome measures for patients admitted for lower-limb or colorectal surgery. Qualitative review: Included 43 papers, 35 of which were prioritised for synthesis. We identified six themes: 'Home as preferred environment for recovery', 'Feeling safe', 'Individualisation of structured programme', 'Taking responsibility', 'Essential care at home' and 'Outcomes'. Overarching synthesis: Intervention components which trigger successful interventions represent individualised approaches that allow patients to understand their treatment, ask questions and build supportive relationships and strategies to help patients monitor their progress and challenge themselves through early mobilisation.

Discussion

Interventions to reduce hospital length of stay for older adults following planned surgery are effective, without detriment to other patient outcomes. Findings highlight the need to reconsider how to evaluate patient recovery from the perspective of the patient. Trials did not routinely evaluate patient mid- to long-term outcomes. Furthermore, when they did evaluate patient outcomes, reporting is often incomplete or conducted using a narrow range of patient-reported outcome measures or limited through asking the wrong people the wrong questions, with lack of longer-term evaluation. Findings from the qualitative and overarching synthesis will inform policy-making regarding commissioning and delivering services to support patients, carers and families before, during and after planned admission to hospital.

Study registration

This trial is registered as PROSPERO registration number CRD42021230620.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 130576) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 23. See the NIHR Funding and Awards website for further award information.

Effects of early postoperative mobilization following gastrointestinal surgery: systematic review and meta-analysis

BACKGROUND

Early postoperative mobilization is considered a key element of enhanced recovery after surgery protocols. The aim of this study was to summarize the effect of early postoperative mobilization following gastrointestinal operations on patient recovery, mobility, the morbidity rate and duration of hospital stay.

METHODS

A systematic literature search was conducted in December, 2022, using PubMed, Web of Science and the Cochrane Central Register of Controlled Trials. Controlled trials reporting the effects of early postoperative mobilization after gastrointestinal surgery were included. The risk of bias was assessed using a modified Downs and Black tool and the Cochrane Collaboration tool for randomized trials. The outcomes of interest were gastrointestinal recovery (defined passage of first flatus or bowel movements), mobility (step count on postoperative day 3), the morbidity rate and duration of hospital stay.

RESULTS

After elimination of duplicates, 3678 records were identified, and 71 full-text articles were screened. Finally, 15 studies (eight RCTs) reporting on 3538 patients were included. Most trials evaluated early postoperative mobilization after different gastrointestinal operations, including upper gastrointestinal (n = 8 studies), hepatopancreatobiliary (n = 10 studies) and colorectal resections (n = 10 studies). The investigated early postoperative mobilization protocols, operative techniques (minimally invasive or open) and outcome parameters were heterogeneous between the studies. Early postoperative mobilization seemed to significantly accelerate clinical gastrointestinal recovery (mean difference, hours: -11.53 (-22.08, -0.97), P = 0.03). However, early postoperative mobilization did not significantly improve the morbidity rate (risk ratio: 0.93 (0.70, 1.23), P = 0.59), postoperative mobility of patients (step count mean difference: 1009 (-803, 2821), P = 0.28) or shorten the duration of hospital stay (mean difference, days: -0.25 (-0.99,0.43), P = 0.47) in randomized trials.

CONCLUSION

There is a large heterogeneity among the study cohorts, operations and interventions. The available evidence currently does not support specific early postoperative mobilization protocols as an isolated element to further reduce the morbidity rate and duration of hospital stay. Further well-designed trials are required to identify effective early postoperative mobilization protocols.

Effects of a Mobilization Program Applied to Bariatric Surgery Patients on Preventing Gastrointestinal Complications: a Quasi-Experimental Study

PURPOSE

To investigate the effects of a planned early targeted mobilization program applied to patients that underwent bariatric surgery with the laparoscopic sleeve gastrectomy method on gastrointestinal complications (nausea-vomiting, abdominal distention, delayed flatus-defecation, and intolerance of early oral intake).

MATERIALS AND METHODS

This prospective, controlled group, quasi-experimental design study was conducted between July 2019 and March 2020 in the general surgery clinic of a training and research hospital with 70 patients who underwent sleeve gastrectomy and met the inclusion criteria. The prepared mobilization program was applied to the patients on the 0th, 1st, and 2nd postoperative days, and the gastrointestinal functions of the patients were monitored.

RESULTS

The intervention group had a significantly shorter time to first flatus, defecation, and oral intake; higher frequency of defecation; lower pain, abdominal distention, and nausea; better tolerance of oral intake; and higher total oral intake compared to the control group (p < 0.05).

CONCLUSION

Planned, early, and targeted mobilization was determined to be a feasible, safe, and cost-effective nursing intervention to prevent gastrointestinal complications in patients undergoing sleeve gastrectomy.

Postoperative inpatient exercise facilitates recovery after laparoscopic surgery in colorectal cancer patients: a randomized controlled trial

BACKGROUND

Early mobilization is an integral part of an enhanced recovery program after colorectal cancer surgery. The safety and efficacy of postoperative inpatient exercise are not well known. The primary objective was to determine the efficacy of a postoperative exercise program on postsurgical recovery of stage I-III colorectal cancer patients.

METHODS

We randomly allocated participants to postoperative exercise or usual care (1:1 ratio). The postoperative exercise intervention consisted of 15 min of supervised exercise two times per day for the duration of their hospital stay. The primary outcome was the length of stay (LOS) at the tertiary care center. Secondary outcomes included patient-perceived readiness for hospital discharge, anthropometrics (e.g., muscle mass), and physical function (e.g., balance, strength).

RESULTS

A total of 52 (83%) participants (mean [SD] age, 56.6 [8.9] years; 23 [44%] male) completed the trial. The median LOS was 6.0 days (interquartile range; IQR 5-7 days) in the exercise group and 6.5 days (IQR 6-7 days) in the usual-care group (P = 0.021). The exercise group met the targeted LOS 64% of the time, while 36% of the usual care group met the targeted LOS (colon cancer, 5 days; rectal cancer, 7 days). Participants in the exercise group felt greater readiness for discharge from the hospital than those in the usual care group (Adjusted group difference = 14.4; 95% CI, 6.2 to 22.6; P < 0.01). We observed a small but statistically significant increase in muscle mass in the exercise group compared to usual care (Adjusted group difference = 0.63 kg; 95% CI, 0.16 to 1.1; P = 0.03).

CONCLUSION

Postsurgical inpatient exercise may promote faster recovery and discharge after curative-intent colorectal cancer surgery.

TRIAL REGISTRATION

The study was registered at WHO International Clinical Trials Registry Platform (ICTRP; URL http://apps.who.int/trialsearch ); Trial number: KCT0003920 .

Effect of acupuncture on postoperative ileus after laparoscopic elective colorectal surgery: A prospective, randomised, controlled trial

BACKGROUND

Postoperative ileus after colorectal surgery is a frequent problem that significantly delays recovery, increases perioperative costs, and negatively impacts on daily life, physical and psychosocial functioning, and wellbeing. We investigated the effect of acupuncture at different single acupoint combined with standard care on postoperative ileus.

METHODS

In this single-centre, three-arm, prospective, randomised trial, we enrolled patients with primary colorectal cancer undergoing elective colorectal resection at Cancer Hospital Chinese Academy of Medical Science in Beijing, China. Patients were randomly assigned (1:1:1) to receive either electroacupuncture (EA) at ST36 or ST25 combined with standard care (two EA groups) once daily from post-operative days 1-4, or standard care alone (standard care group). The co-primary outcomes were time to first flatus and time to defecation assessed in the intention-to-treat population. This study is registered with Chictr.org.cn, ChiCTR1900027466.

FINDING

Between Nov 15, 2019, and Sep 30, 2020, 129 patients were assessed for eligibility, 105 patients (35 patients per group) were enrolled and included in the intention-to-treat analysis. After receiving EA at ST36, the time to first flatus and defecation were shorter (between-group difference -10.98 [97.5% CI -21.41 to -0.56], p = 0·02 for flatus; -25.41 [-47.89 to -2.93], p = 0·02 for defecation). However, we did not observe a significant difference in time to first flatus and defecation between the EA at ST25 group and standard care group (between-group difference -5.54 [97.5% CI -15.78 to 4.70], p = 0·26 for flatus; -17.69 [-40.33 to 4.95], p = 0·08 for defecation). There were no serious adverse events.

INTERPRETATION

Compared with standard care alone, standard care combined with EA at ST36, but not ST25, significantly enhances bowel function recovery in a postoperative setting to patients with colorectal cancer with laparoscopic elective colorectal resection.

FUNDING

The National Key R&D Program of China (No: 2019YFC1712100) and the National Science Fund for Distinguished Young Scholars (No:81825024).

Perioperative Pain Management Issues Unique to Older Adults Undergoing Surgery: A Narrative Review

INTRODUCTION

The older population is growing and with this growth there is a parallel rise in the operations performed on this vulnerable group. The perioperative pain management strategy for older adults is unique and requires a team-based approach for provision of high-quality surgical care.

METHODS

Literature search was performed using PubMed in addition to review of relevant protocols and guidelines from geriatric, surgical, and anesthesia societies. Systematic reviews and meta-analyses, randomized trials, observational studies, and society guidelines were summarized in this review.

MANAGEMENT

The optimal approach to a pain management strategy for older adults undergoing surgery involves addressing all phases of perioperative care. For example, preoperative assessment of a patient's cognitive function and presence of chronic pain may impact the pain management plan. Consideration should be also given to intraoperative strategies to improve pain control and minimize both the dose and side effects from opioids (e.g. regional anesthetic techniques). Postoperative pain control (e.g. under or over treatment of pain) may impact the development of elderly-specific complications such as postoperative delirium and functional decline. Finally, pain management does not stop after the older adult patient leaves the hospital. Both discharge planning and post-operative clinic follow-up provide important opportunities for collaboration and intervention.

CONCLUSIONS

An opioid-sparing pain management strategy for older adults can be accomplished with a comprehensive and collaborative interdisciplinary strategy addressing all phases of perioperative care.

Financial incentives and wearable activity monitors to increase ambulation after cystectomy: A randomized controlled trial

OBJECTIVES

Financial incentive programs are effective in increasing physical activity for overweight, ambulatory adults. We sought to determine the potential effect size and direction of financial incentives on ambulation after radical cystectomy.

MATERIALS AND METHODS

We performed a pilot randomized controlled trial of daily financial incentives to meet postoperative step goals among adults with Eastern Cooperative Oncology Group performance status ≤2 who underwent radical cystectomy for bladder cancer at a single center. Step counts were measured over a 3- to 14-day preoperative period and 30-day postoperative period using a wearable activity monitor. Postoperative daily step goals of 10%, 25%, 40%, and 55% of mean preoperative daily step counts were set for postoperative weeks 1 through 4, respectively. The primary outcome was the number of postoperative days on which the step goals were met. Secondary outcomes included the number of daily postoperative steps taken and the length of stay. Participants randomized to the intervention arm received $1.50 for every day the goal was met with a 20% chance of a $100 reward if the step goal was met on >75% of the first 30 postoperative days. Questionnaires assessing self-reported physical activity, disability, and social support were administered preoperatively at 30 days postoperatively.

RESULTS

Thirty-three patients were analyzed, 11 in the control and 22 in the intervention arms. There were no statistically significant differences between incentive and control arms for the primary outcome (4.5/30 days vs. 9/30 days, P = 0.53). Results after adjusting for differences in baseline characteristics were similar (RR 1.00, 95% CI 0.24-4.19, P = 1.00). There were also no differences in average daily postoperative steps (median 979 vs. 1191, 95% CI -810 to 1,400, P = 0.59), length of stay (7.5 vs. 7, 95% CI -2.7 to 5.1, P = 0.56), or self-reported measures of disability, activity, and social support.

CONCLUSIONS

While this trial was a pilot study and not powered to detect a difference between groups, there was no suggestion of any clinically important impact of this financial incentive on postoperative ambulation. While a fully-powered trial is feasible, given the small range of plausible benefit, such a trial would be unlikely to influence clinical practice.

Objective recovery time with end-to-side versus side-to-side anastomosis after laparoscopic right hemicolectomy for colon cancer: a randomized controlled trial

BACKGROUND

Despite reports of the short-term benefits of end-to-side versus side-to-side anastomosis, we are aware of no prospective studies in which these methods were compared. We hypothesized the superiority of end-to-side over side-to-side anastomosis in terms of recovery after laparoscopic right hemicolectomy for colon cancer under an enhanced recovery program.

METHODS

From September 2016 to August 2019, 130 patients were randomly allocated to receive end-to-side or side-to-side anastomosis at a single tertiary hospital in Korea. The primary outcome was the cumulative recovery rate seven days after surgery, defined as the percentage of patients who met all four recovery criteria: diet tolerance, no analgesia, safe ambulation, and an afebrile status. Student's t test, the Mann-Whitney U test, the χ² test, and Fisher's exact test were used to compare variables, as applicable.

RESULTS

The cumulative recovery rate at seven days did not differ between patients receiving end-to-side (92.3%, 60/65) or side-to-side anastomosis (92.3%, 60/65; P ≥ 0.999). The end-to-side and side-to-side groups had similar cumulative recovery rates at postoperative days 4, 5, and 6 (end-to-side vs. side-to-side: 41.5% vs 35.4%, P = 0.589; 73.8% vs 63.1%, P = 0.257; and 86.2% vs 81.5%, P = 0.634, respectively). None of the secondary endpoints differed for end-to-side vs. side-to-side anastomosis: the median length of postoperative hospitalization (5 [IQR 5-7] vs. 6 [IQR 5-7] days, respectively, P = 0.376), the 30-day complication rate (16.9% vs. 12.3%, respectively, P = 0.620), the enhanced recovery protocol failure rate (10.8% vs. 7.7%, respectively, P = 0.763), and the 30-day readmission rate (4.6% vs. 3.1%, respectively, P ≥ 0.999).

CONCLUSIONS

End-to-side anastomosis was not superior to side-to-side anastomosis in terms of recovery criteria after laparoscopic right hemicolectomy. These findings do not provide evidence for a functional advantage of end-to-side compared to side-to-side anastomosis.

Enhanced Recovery After Major Gastrectomy for Cancer

Enhanced recovery after surgery (ERAS) protocols have gained increasing popularity over the past 10 years, and its overarching objectives are to improve perioperative morbidity and reduce postoperative length of stay. Consensus guidelines from the ERAS Society specific to major gastrectomy were published in 2014, however since that time, prospective and retrospective studies have expanded the collective evidence for both the content and efficacy of ERAS pathways for gastrectomy. This objective of this review was to summarize recent data pertinent to the preoperative, perioperative, and postoperative management of gastrectomy patients along an ERAS pathway.

Early oral protein-containing diets following elective lower gastrointestinal tract surgery in adults: a meta-analysis of randomized clinical trials

Background

Although current guidelines make consensus recommendations for the early resumption of oral intake after surgery, a recent comprehensive meta-analysis failed to identify any patient-centered benefits. We hypothesized this finding was attributable to pooling studies providing effective protein-containing diets with ineffective non-protein liquid diets. Therefore, the aim of this paper was to investigate the safety and efficacy of early oral protein-containing diets versus later (traditional) feeding after elective lower gastrointestinal tract surgery in adults.

Methods

PubMed, Embase, and the China National Knowledge Infrastructure databases were searched from inception until 1 August 2019. Reference lists of retrieved studies were hand searched to identify randomized clinical trials reporting mortality. No language restrictions were applied. Study selection, risk of bias appraisal and data abstraction were undertaken independently by two authors. Disagreements were settled by obtaining an opinion of a third author. Majority decisions prevailed. After assessment of underlying assumptions, a fixed-effects method was used for analysis. The primary outcome was mortality. Secondary outcomes included surgical site infections, postoperative nausea and vomiting, serious postoperative complications and other key measures of safety and efficacy.

Results

Eight randomized clinical trials recruiting 657 patients were included. Compared with later (traditional) feeding, commencing an early oral protein-containing diet resulted in a statistically significant reduction in mortality (odds ratio [OR] 0.31, P = 0.02, I² = 0%). An early oral protein-containing diet also significantly reduced surgical site infections (OR 0.39, P = 0.002, I² = 32%), postoperative nausea and vomiting (OR 0.62, P = 0.04, I² = 37%), serious postoperative complications (OR 0.60, P = 0.01, I² = 25%), and significantly improved other major outcomes. No harms attributable to an early oral protein-containing diet were identified.

Conclusions

The results of this systematic review can be used to upgrade current guideline statements to a grade A recommendation supporting an oral protein-containing diet commenced before the end of postoperative day 1 after elective lower gastrointestinal surgery in adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-021-00179-3.

Enhanced recovery after surgery for laparoscopic gastrectomy in gastric cancer: A prospective study

BACKGROUND

Laparoscopic distal gastrectomy (LDG) has been highlighted for its safety and better short-term clinical outcomes in treating gastric cancer. However, only a slight reduction of the post-operative hospital stay was observed in gastric cancer patients undergoing LDG with conventional perioperative management, compared to patients undergoing open surgery. Thus, an enhanced recovery after surgery (ERAS) program for LDG is needed to further reduce the post-operative hospital stays. This prospective, open-label, single-arm cohort study aimed to assess the safety and efficacy of the ERAS program for gastric cancer patients undergoing LDG.

MATERIAL AND METHODS

All patients with gastric cancer indicated for LDG were consecutively enrolled from December 2016 to January 2018. The ERAS program included short fasting time, effective perioperative pain management, early, goal-oriented ambulation, and oral feeding. The safety assessment was the incidence of post-operative complications, mortality, and readmission in 30 days. The primary efficacy assessment was recovery time defined by post-operative hospital stays and rehabilitative rate on post-operative day 4.

RESULTS

Ninety-eight of 114 patients were finally enrolled. The incidence of post-operative complication, mortality, and readmission in 30 days was 20. 4%, 0%, 7.1%, respectively. The Clavien-Dindo grade III complication rate was 6.1%, while the pulmonary complication rate was 1% only. The median post-operative stay was 6 days (5.0-7.0 days), and the rehabilitative rate on post-operative day 4 was 78%.

CONCLUSIONS

The ERAS program might be optimal perioperative management for gastric cancer patients after LDG without compromising safety.

TRIAL NUMBER

NCT03016026.

Comparing Activity Trackers With vs. Without Alarms to Increase Postoperative Ambulation: A Randomized Control Trial

Early ambulation is a key component to postoperative recovery; however, measuring steps taken is often inconsistent and nonstandardized. This study aimed to determine whether an activity tracker with alarms would increase postoperative ambulation in patients after elective colorectal procedures. Forty-eight patients were randomly assigned to either trackers with 5 daily alarms or activity trackers alone. Over 223 total patient days, the trackers recorded a complete data set for 216 patient days (96.9%). Increasing the postoperative day significantly affected the number of steps taken, while age, sex, Risk Analysis Index score, and approach (laparoscopic versus open) did not show a significant effect. The mean steps per day in the intervention group were 1468 (median 495; interquartile range (IQR) 1345) and in the control group was 1645 (median 1014; IQR 2498). The use of trackers with alarms did not significantly affect the number of daily steps compared to trackers alone (ANOVA, P = .93). Although activity trackers with alarms did not increase postoperative ambulation compared with trackers with no alarms, we demonstrated a strategy to operationalize the use of trackers into postoperative care to provide a quantitative value for ambulation. This enables quantification of a key component in the Enhanced Recovery After Surgery protocol.

Enhanced Recovery Program in Laparoscopic Colorectal Surgery: An Observational Controlled Trial

Background: Most of the evidence for enhanced recovery programs (ERPs) in colorectal surgery relies on nonrandomized studies with control groups either historical or operated on at different facilities. The aim of this study was to investigate ERP in coeval groups admitted in different wards at the same hospital. Materials and Methods: A prospective cohort of consecutive patients (n = 100) undergoing elective laparoscopic colorectal resection completing a standardized ERP (ERP group) was compared with patients (n = 100) operated with traditional perioperative care in the same period at the same institution (non-ERP group). The two groups were located in separate wards and shared the same anesthesiologists. The exclusion criteria were: >80 years old, American Society of Anesthesia (ASA) IV, metastatic disease, and inflammatory bowel disease. The primary outcome was hospital length of stay (LoS), used as a proxy of functional recovery. Secondary outcomes included: postoperative complications, readmission rate, mortality, and protocol adherence. Results: The ERP group protocol adherence was 81%. The LoS was significantly reduced in the ERP group (4 versus 7 days). The number of 30-day postoperative complications was lower in the ERP group (P < .001). No increase was found in 30-day readmission or mortality. Conventional perioperative protocol was the only predictor of any postoperative complication and, together with male sex and age 65-74 years old, was the only factor associated with prolonged LoS. Conclusion: Implementing a colorectal ERP is feasible, safe, and efficient for functional recovery, but high protocol adherence is needed. Following traditional perioperative care is associated with more postoperative complications and prolonged LoS.

Comparison of the impact of propofol versus sevoflurane on early postoperative recovery in living donors after laparoscopic donor nephrectomy: a prospective randomized controlled study

Background

Enhancing postoperative recovery of the donor is important to encourage living kidney donation. We investigated the effects of anesthetic agents (intravenous [IV] propofol versus inhaled [IH] sevoflurane) on the quality of early recovery of healthy living kidney donors after hand-assisted laparoscopic nephrectomy (HALN) under analgesic intrathecal morphine injection.

Methods

This single-center, prospective randomized controlled study enrolled 80 living donors undergoing HALN from October 2019 to June 2020 at Seoul St. Mary’s Hospital. Donors were randomly assigned to the IV propofol group or IH sevoflurane group. To measure the quality of recovery, we used the Korean version of the Quality of Recovery-40 questionnaire (QoR-40 K) on postoperative day (POD) 1, and ambulation (success rate, number of footsteps) 6–12 h after surgery and on POD 1. The pain score for the wound site, IV opioid requirement, postoperative complications including incidences of nausea/vomiting, and length of in-hospital stay were also assessed.

Results

The global QoR-40 K score and all subscale scores (physical comfort, emotional state, physical independence, psychological support, and pain) were significantly higher in the IV propofol group than in the IH sevoflurane group. The numbers of footsteps at all time points were also higher in the IV propofol group. Donors in the IV propofol group had a lower incidence of nausea/vomiting, and a shorter hospitalization period.

Conclusions

Total IV anesthesia with propofol led to better early postoperative recovery than that associated with IH sevoflurane.

Trial registration

Clinical Research Information Service, Republic of Korea (approval number: KCT0004351) on October 18, 2019.

Effects of physical activity on quality of life and physical function in postoperative patients with gastrointestinal cancer

OBJECTIVES

This study was to clarify changes in physical function and quality of life (QOL) for postoperative, and to examine the influence of the amount of physical activity on these variables.

METHODS

This study included 29 patients who underwent gastrointestinal cancer surgery. The QOL measurement was used to the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire for preoperative and 2nd and 4th postoperative weeks. Physical function measured knee extension strength, 4 m walk time, 5 times sit-to-stand test, and 6-minute walk for preoperative and 1st and 2nd postoperative weeks. The amount of physical activity score was based on METs-hours, which is estimated from cumulative physical activity. As basic characteristics were investigated cancer stage, comorbidities and complications, and operative. Statistical analysis was repeated measures analysis of variance was performed to observe postoperative changes in physical function and QOL. Furthermore, stepwise multiple regression analysis was used to the parameters of physical function and QOL affected by the physical activity score were investigated.

RESULTS

Physical function decreased postoperatively and generally improved 2nd postoperative week. Though scores on the QOL functional scales improved, some items did not improve sufficiently. Multiple regression analysis showed that physical activity score had an effect on constipation and emotion functioning.

CONCLUSIONS

Improvement in symptom scales is not sufficient in a short period of time, and they need to be followed up by increasing the amount of physical activity and promoting instantaneous exercise.

Comprehensive literature review of randomized clinical trials examining novel treatment advances in patients with colon cancer

The treatment of colon cancer has had numerous recent advances, in terms of surgical approach, adjuvant therapies, and more. In this review, the authors examine randomized clinical trials comparing open surgery to laparoscopic surgery (including total mesocolic excision), and also examine the role of robotic surgery. Novel surgical techniques including the no-touch technique, side-to-side anastomosis, suture technique, complete mesocolic excision (CME) with central vascular ligation (CVL), and natural orifice transluminal endoscopic surgery (NOTES) are outlined. The role of placing endoscopic self-expandable metal stents (SEMS) for colonic obstruction is compared and contrasted with the surgical approach, and the effect that the anti-VEGF inhibitor bevacizumab may have on this side effect profile is further explored. The role of the resection of the primary tumor in the setting of metastatic disease is examined with respect to survival benefit. Pathways of perioperative care which can accelerate post-surgical recovery, including enhanced recovery after surgery (ERAS) are examined. The role of adjuvant chemotherapy in patients with high-risk stage II and patients with stage III disease is examined, along with the role on circulating tumor DNA (ctDNA) as well as with the biologic targeted agents cetuximab and bevacizumab. Lastly, the authors detail the postoperative surveillance schedules after surgical resection with respect to survival outcomes.

Heated fennel therapy promotes the recovery of gastrointestinal function in patients after complex abdominal surgery: A single-center prospective randomized controlled trial in China

BACKGROUND

Postoperative gastrointestinal dysfunction remains a major determinant of the duration of stay after complex abdominal surgery. This study was performed to evaluate the effectiveness of heated fennel therapy in accelerating the recovery of gastrointestinal function.

METHODS

This surgeon-blinded, prospective randomized controlled study included 381 patients with hepatobiliary, pancreatic, and gastric tumors who were divided into 2 groups. The patients in the experimental groups received heated fennel therapy, and those in the control groups received heated rice husk therapy. We compared the baseline characteristics, time to first postoperative flatus and defecation, fasting time, duration of postoperative hospital stay, grading of abdominal pain, classification of abdominal distension, inflammatory markers, and nutritional status indicators.

RESULTS

The time to first flatus and first defecation and the fasting time were statistically significantly less in the heated fennel therapy group than those in the control groups (P < .05 each); and abdominal distension was also relieved in the experimental groups (P < .001). Heated fennel therapy had no obvious beneficial effect on inflammatory markers but improved the serum albumin (ALB) level of the patients at postop day 9 (P < .001). Among the patients with alimentary tract reconstruction, those in the heated fennel therapy group had a clinically important, lesser hospital stay than those in the control group (9.2 5 ± 5.1 versus 11.1 ± 6.4; P < .023).

CONCLUSION

Heated fennel therapy facilitated the gastrointestinal motility function of patients early postoperatively.

Influence of the Enhanced Recovery After Surgery Protocol on Postoperative Inflammation and Short-term Postoperative Surgical Outcomes After Colorectal Cancer Surgery

Purpose

Many studies have shown that the enhanced recovery after surgery (ERAS) protocols improve postoperative surgical outcomes. The purpose of this study was to observe the effects on postoperative inflammatory markers and to explore the effects of a high degree of compliance and the use of epidural anesthesia on inflammation and surgical outcomes.

Methods

Four hundred patients underwent colorectal cancer surgery at 2 hospitals during 2 different periods, namely, from January 2006 to December 2009 and from January 2017 to July 2017. Data related to the patient’s clinicopathological features, inflammatory markers, percentage of compliance with elements of the ERAS protocol, and use of epidural anesthesia were collected from a prospectively maintained database.

Results

The complication rate and the length of hospital stay (LOS) were less in the ERAS group than in the conventional group (P = 0.005 and P ≤ 0.001, respectively). The postoperative white blood cell count and the duration required for leukocytes to normalize were reduced in patients following the ERAS protocol (P ≤ 0.001). Other inflammatory markers, such as lymphocyte count (P = 0.008), neutrophil/lymphocyte ratio (P = 0.032), and C-reactive protein level (P ≤ 0.001), were lower in the ERAS protocol group. High compliance ( ≥ 70%) was strongly associated with the complication rate and the LOS (P = 0.008 and P ≤ 0.001, respectively).

Conclusion

ERAS protocols decrease early postoperative inflammation and improves short-term postoperative recovery outcomes such as complication rate and the LOS. High compliance ( ≥ 70%) with the ERAS protocol elements accelerates the positive effects of ERAS on surgical outcomes; however, the effect on inflammation was very small.

Comparison of life-behavior-promoting mobilization care with walking-only mobilization care in post-gastrointestinal surgery patients: A quasi-experimental study

AIM

This study evaluated the effects of a new form of mobilization care called life-behavior-promotion care by comparing its effectiveness with that of conventional mobilization care, which promotes only walking.

METHODS

This was a quasi-experimental study that non-randomly allocated post-gastrointestinal surgery patients from a surgical ward into two groups: conventional care and life-behavior-promotion care. The participants received their respective care from ward nurses for the first 3 postoperative days and were asked to wear a pedometer and answer a self-administered questionnaire concerning these first 3 days. In addition, time to recover gastrointestinal function, time to completion of oxygen administration, and the number of days to achieve discharge criteria were collected from medical records.

RESULTS

Overall, 23 participants in the conventional-care group and 19 in the life-behavior-promotion-care group were analyzed. The latter group performed significantly more types of out-of-bed life behaviors during the 3 postoperative days. Among the questionnaire items concerning awareness of recovery, an interaction between intervention and length of postoperative days was confirmed for items reading "I was interested in surrounding events" and "I could spend a day like myself." In addition, in the life-behavior-promotion-care group, time to completion of oxygen administration was significantly shorter, and it took fewer days to achieve discharge criteria.

CONCLUSIONS

The results of this study suggest that life-behavior-promotion care may promote out-of-bed life behaviors during the early postoperative period, and may improve mental and physical recovery in patients who have undergone gastrointestinal surgery.

CLINICAL TRIAL REGISTRATION

The study was registered in the UMIN Clinical Trials Registry (trial ID: UMIN000021883).

Failure of enhanced recovery programs after laparoscopic radical gastrectomy: a single-center retrospective study

BACKGROUND

Enhanced recovery programs (ERPs), as a rapid rehabilitation method, have been widely used in gastric cancer patients. Although many related studies have confirmed their effectiveness, some patients may still experience poor clinical outcomes. This study analyzed risk factors associated with ERP failure after laparoscopic radical gastrectomy.

METHODS

We analyzed the outcomes of 212 patients who underwent ERP following laparoscopic radical gastrectomy between March 2017 and December 2019. The ERP included preoperative education, short periods of fasting, non-mechanical intestinal preparation, early ambulation and oral feeding. ERP failure was defined as more than 7 days of hospitalization due to postoperative complications, unplanned readmission within 30 days of surgery, or death.

RESULTS

The mean patient age was 62 years (range 39-89 years). Surgical procedures included total gastrectomy (n = 161) and distal gastrectomy (n = 51). Overall, 38 (17.9%) patients failed to complete the program, with no mortality. Univariable analysis (P < 0.15) revealed that ERP failure was associated with age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) grade, tumor location, preoperative education, combined operation, long operation time, and significant blood loss. Multivariable analysis (P < 0.05) showed that age, ASA grade III, combined operation and preoperative education were independent risk factors for ERP failure.

CONCLUSIONS

We showed that an advanced age, a high ASA grade, lack of a preoperative education and combined surgery were independent risk factors associated with ERP failure after laparoscopic gastrectomy. Therefore, a preoperative patient evaluations and education are important for the success of ERPs.

Patients' refusal as major limitation of early discharge after colorectal resection in an enhanced recovery program

PURPOSE

The reduction of length of hospitalization without compromising the patient's safety constitutes the challenge of the enhanced recovery after surgery (ERAS) programs. Our aim was to evaluate the feasibility and safety of a 3-day hospitalization after colectomy and 5-day hospitalization after proctectomy in the setting of an ERAS program.

METHODS

An ERAS program was prospectively proposed to all patients who required a colorectal resection (January 2014-December 2018) with a 3- or 5-day discharge objective. The success of the program was defined by a 3-/5-day hospitalization without complications and without readmissions.

RESULTS

Among 283 patients included, 232 patients had a colectomy (82%) and 51 (18%) patients a proctectomy. Eighty-six patients experienced complications (30%) including fifteen severe complications (5%). Mean hospital stay was 5.1 ± 3.7 (2-33) days. A total of 136 patients (48%) were discharged at 3-/5-day, within 9 were readmitted (3%). Discharge was delayed after 3-/5-day for complications (n = 65, 23%), CRP > 120 (n = 45, 16%) or refusal without medical reason (n = 37, 13%). The success rate of the program was 45% (n = 127). This success rate was similar between colectomy and proctectomy (p = 0.277) and between right and left colectomy (p = 0.450). In multivariate analysis, predictive factors associated with the program success were intraoperative use of lidocaine (OR 2.1 [1.1-4.1], p = 0.022), time to remove perfusion ≤ 2 days (OR 10.3 [5.4-19.6], p = 0.001), time to recover bowel movement ≤ 2 days (OR 4.0 [1.7-9.6], p = 0.002) and time to walk out of the room ≤ 2 days (OR 2.6 [1.1-6.0], p = 0.022).

CONCLUSION

Integrating a realistic hospitalization duration objective into an ERAS program guarantees its safety, feasibility and effectiveness in reducing hospitalization duration.

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.

Comparison of the effects of an ERAS program and a single-port laparoscopic surgery on postoperative outcomes of colon cancer patients

Advancement of the surgical modality and perioperative care are the two main dimensions for the modern improvement of surgical outcome. The purpose of this study was to compare the effectiveness of the two by using the data from the single-port laparoscopic surgery and the early recovery after surgery (ERAS) program. Patients who underwent elective surgery for primary adenocarcinoma of the colon were divided into three groups and compared: ERAS (multi-port laparoscopic surgery with ERAS perioperative care), Conventional-SILS (single-port surgery with conventional perioperative care), or Conventional-Multi (multi-port laparoscopic surgery with conventional perioperative care). Ninety-one, 83, and 96 patients were registered, respectively. There were no differences among the three groups in baseline characteristics except pathological stage and operation site in colon. Although the ERAS group started a soft diet earlier and had earlier discharge, there were no differences in intra- and post-operative morbidity rate, readmission rate, or reoperation rate. The ERAS perioperative care was a significant factor for reducing length of hospital stay in the multivariate analysis, while single-port surgery was not. In modern laparoscopic colon cancer treatment, a systemic approach such as the ERAS program appears to be more effective than a technical approach for significantly improving short-term surgical outcomes.

The efficacy and safety of enhanced recovery after surgery (ERAS) program in laparoscopic digestive system surgery: A meta-analysis of randomized controlled trials

BACKGROUND

The enhanced recovery after surgery (ERAS) program has been applied to a variety of surgeries. However, the efficacy and safety of the ERAS program in laparoscopic digestive system surgery remain unclear. We conducted a meta-analysis to evaluate the ERAS program and traditional perioperative care (TPC) in laparoscopic digestive system surgery.

METHODS

We searched five electronic databases for eligible trials. STATA version 14.0 and Revman version 5.3 were used to analyze the data. The results were presented and analyzed by weighted mean difference (WMD) and risk ratio (RR) at their 95% confidence interval (CI).

RESULTS

Twenty-five randomized controlled trials (RCTs) of 2219 patients were included in our meta-analysis. The results revealed that the postoperative hospital stay (PHS) (WMD: 2.13 day, 95% CI: 2.56 to -1.70, p = 0.000), time to first flatus (WMD: 12.68 h, 95% CI: 15.95 to -9.41, p = 0.000), and time to defecation (WMD: 34.35 h, 95% CI: 46.82 to -21.88, p = 0.000) were significantly shorter in the ERAS group compared to the TPC group. Additionally, the overall postoperative complication rate (RR: 0.66, 95% CI: 0.49 to 0.88, p = 0.000) was markedly lower in patients using the ERAS program.

CONCLUSION

The results indicated that the ERAS program is associated with faster postoperative rehabilitation, shorter PHS, and better postoperative complication rates. The use of the ERAS program for laparoscopic digestive system surgery is more effective and safe than TPC, and it should be recommended. (PROSPERO registration number:CRD42018118551).

Is the Enhanced Recovery After Surgery (ERAS) Program Effective and Safe in Laparoscopic Colorectal Cancer Surgery? A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Enhanced recovery after surgery (ERAS) program has shown a few advantages in colorectal cancer surgery. However, the effectiveness of the ERAS program in laparoscopic colorectal cancer surgery is still unclear. We performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of ERAS program in laparoscopic colorectal cancer surgery compared with traditional perioperative care (TC).

METHODS

PubMed, EMBASE, Web of Science, The Cochrane Library, and ClinicalTrials.gov were searched for eligible RCTs comparing ERAS program with TC in laparoscopic colorectal cancer surgery. The main outcomes included the average length of postoperative hospital stay (PHS), time to first flatus and defecation, overall complication, readmission, and mortality rates were undertaken.

RESULTS

Thirteen RCTs involving 1298 patients were included in our study (639 in ERAS group and 659 in TC group). ERAS group had shorter average length of PHS (weighted mean difference [WMD] - 2.00 day, 95% confidence interval [CI] - 2.52 to - 1.48, p = 0.00), time to first flatus (WMD - 12.18 h, 95%CI - 16.69 to - 7.67, p = 0.00), and time to first defecation (WMD - 32.93 h, 95%CI - 45.36 to - 20.50, p = 0.00) than TC group. In addition, the overall complication rates (risk ratio [RR] 0.59, 95%CI 0.40 to 0.86, p < 0.01) were significantly lower in ERAS group compared with TC group.

CONCLUSIONS

The results indicated that ERAS program is a much better effective and safe protocol for laparoscopic colorectal cancer surgery compared with TC. Hence, ERAS program should be recommended in laparoscopic colorectal cancer surgery.

Patient-Controlled Nutrition After Abdominal Surgery: Novel Concept Contrary to Surgical Dogma

Purpose

According to surgical dogma, patients who are recovering from general anesthesia after abdominal surgery should begin with a clear liquid diet, progress to a full liquid diet and then to a soft diet before taking regular meals. We propose patient-controlled nutrition (PCN), which is a novel concept in postoperative nutrition after abdominal surgery.

Methods

A retrospective pilot study was conducted to evaluate the feasibility and effects of PCN. This study was carried out with a total of 179 consecutive patients who underwent a laparoscopic appendectomy between August 2014 and July 2016. In the PCN group, diet was advanced depending on the choice of the patients themselves; in the traditional group, diet was progressively advanced to a full liquid or soft diet and then a regular diet as tolerated. The primary endpoints were time to tolerance of regular diet and postoperative hospital stay.

Results

Time to tolerance of a regular diet (P < 0.001) and postoperative hospital stay (P < 0.001) showed statistically significant differences between the groups. Multivariate analysis using linear regression showed that the traditional nutrition pattern was the only factor associated with postoperative hospital stay (P < 0.001). Multivariate analysis using logistic regression showed that traditional nutrition was the only risk factor associated with prolonged postoperative hospital stay (≥3 days).

Conclusion

After abdominal surgery, PCN may be a feasible and effective concept in postoperative nutrition. In our Early Recovery after Surgery program, our PCN concept may reduce the time to tolerance of a regular diet and shorten the postoperative hospital stay.

Short-term outcomes after elective colon cancer surgery: an observational study from the Norwegian registry for gastrointestinal and HPB surgery, NoRGast

BACKGROUND

To describe the real burden of major complications after elective surgery for colon cancer in Norway, and to assess which predictors that are significantly associated with the short-term outcome.

METHODS

An observational, multi-centre analysis of prospectively registered colon resections registered into the Norwegian Registry for Gastrointestinal Surgery, NoRGast, between January 2014 and December 2016. A propensity score-adjusted subgroup analysis for surgical access groups was attempted, with laparoscopic resections grouped as intention-to-treat.

RESULTS

Out of 1812 resections, 14.0% of patients experienced a major complication within 30 days following surgery. The over-all reoperation rate was 8.7%, and rate of reoperation for anastomotic leak was 3.8%. Twenty patients (1.1%) died within 30 days after surgery. Higher age was not a significant predictor of major complications, including 30-day mortality. After correction for all co-variables, open access surgery was associated with higher rates of major complications (OR 1.67 (CI 1.22-2.29), p = 0.002), higher 30-day mortality (OR 4.39 (CI 1.19-16.13) p = 0.026) and longer length-of-stay (HR 0.58 (CI 0.52-0.65) p < 0.001).

CONCLUSIONS

Our results indicate a low complication burden and high rate of uneventful patient journeys after elective surgery for colon cancer in Norway. Age was not associated with higher morbidity or mortality rates. Open access surgery was associated with an inferior short-term outcome.

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.

Implementation of an Enhanced Recovery After Spine Surgery program at a large cancer center: a preliminary analysis

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) programs follow a multimodal, multidisciplinary perioperative care approach that combines evidence-based perioperative strategies to accelerate the functional recovery process and improve surgical outcomes. Despite increasing evidence that supports the use of ERAS programs in gastrointestinal and pelvic surgery, data regarding the development of ERAS programs in spine surgery are scarce. To evaluate the impact of an Enhanced Recovery After Spine Surgery (ERSS) program in a US academic cancer center, the authors introduced such a program and hypothesized that ERSS would have a significant influence on meaningful clinical measures of postoperative recovery, such as pain management, postoperative length of stay (LOS), and complications.

METHODS

A multimodal, multidisciplinary, continuously evolving team approach was used to develop an ERAS program for all patients undergoing spine surgery for metastatic tumors at The University of Texas MD Anderson Cancer Center from April 2015 through September 2016. This study describes the introduction of that ERSS program and compares 41 patients who participated in ERSS with a retrospective cohort of 56 patients who underwent surgery before implementation of the program. The primary objectives were to assess the effect of an ERSS program on immediate postoperative pain scores and in-hospital opioid consumption. The secondary objectives included assessing the effect of ERSS on postoperative in-hospital LOS, 30-day readmission rates, and 30-day postoperative complications.

RESULTS

The ERSS group showed a trend toward better pain scores and decreased opioid consumption compared with the pre-ERSS group. There were no significant differences in LOS, 30-day readmission rate, or 30-day complication rate observed between the two groups.

RESULTS

An ERSS program is feasible and potentially effective on perioperative pain control and opioid consumption, and can expedite recovery in oncological spine surgery patients. Larger-scale research on well-defined postoperative recovery outcomes is needed.

Multimodal Enhanced Recovery After Surgery (ERAS) Program is the Optimal Perioperative Care in Patients Undergoing Totally Laparoscopic Distal Gastrectomy for Gastric Cancer: A Prospective, Randomized, Clinical Trial

BACKGROUND

The application of ERAS protocol has widely gained acceptance after gastrointestinal surgery. Well-designed, randomized, control trials are needed to evaluate fully its safety and efficacy in the field of gastric cancer. This study aims to compare the enhanced recovery after surgery (ERAS) protocol and the conventional perioperative care program after totally laparoscopic distal gastrectomy (TLDG) in gastric cancer.

METHODS

Patients with gastric cancer indicated for TLDG were randomly assigned to either the ERAS group or the conventional group. The ERAS protocol included short fasting time, fluid restriction, early oral feeding, immediate mobilization, and use of epidural patient-controlled analgesia. Primary endpoint was recovery time, which was defined with the criteria of tolerable diet, safe ambulation, no requirement of additional analgesics, and afebrile state. Hospital stay, pain score, complications, and readmission rate were secondary endpoints.

RESULTS

A total of 97 patients who underwent TLDG from October 2012 to August 2014 were enrolled (ERAS = 46, conventional = 51). The ERAS group had faster recovery time (111.6 ± 34.3 vs. 126.7 ± 30.7 h; p = 0.026) and significantly less pain through postoperative days 1-4. Possible hospital stay also was faster in the ERAS group (5.0 ± 1.9 vs. 5.7 ± 1.6 days, p = 0.038), but there was no difference in actual hospital stay. No difference was found in complication, and there was no mortality or readmission in both groups.

CONCLUSIONS

ERAS is safe and enhances postoperative recovery after TLDG in gastric cancer.

TRIAL REGISTRATION

The trial was registered in ClinicalTrials.gov (NCT01938313).

Is preoperative hypocholesterolemia a risk factor for severe postoperative pain? Analysis of 1,944 patients after laparoscopic colorectal cancer surgery

Purpose

This study aimed to identify the effect of preoperative serum total cholesterol on postoperative pain outcome in patients who had undergone laparoscopic colorectal cancer surgery.

Methods

We retrospectively reviewed the medical records of patients diagnosed with colorectal cancer who had undergone laparoscopic colorectal surgery from January 1, 2011, to June 30, 2017, to identify the relationship of total cholesterol levels within a month prior to surgery with the numeric rating scale (NRS) scores and total opioid consumption on postoperative days (PODs) 0–2.

Results

We included 1,944 patients. No significant correlations were observed between total cholesterol and the NRS (POD 0), NRS (POD 1), and oral morphine equivalents (PODs 0–2) (P>0.05). There was no significant difference between the low (<160 mg/dL), medium (160–199 mg/dL), and high (≥200 mg/dL) groups in NRS scores on PODs 0, 1, or 2 (P>0.05). Furthermore, there was no significant association in multivariate linear regression analysis for postoperative opioid consumption according to preoperative serum total cholesterol level (coefficient 0.08, 95% CI −0.01 to 0.18, P=0.81).

Conclusion

This study showed that there was no meaningful association between preoperative total cholesterol level and postoperative pain outcome after laparoscopic colorectal cancer surgery.

ACERTO guidelines of perioperative nutritional interventions in elective general surgery

ABSTRACT Objective: to present recommendations based on the ACERTO Project (Acceleration of Total Post-Operative Recovery) and supported by evidence related to perioperative nutritional care in General Surgery elective procedures. Methods: review of relevant literature from 2006 to 2016, based on a search conducted in the main databases, with the purpose of answering guiding questions previously formulated by specialists, within each theme of this guideline. We preferably used randomized controlled trials, systematic reviews and meta-analyzes but also selected some cohort studies. We contextualized each recommendation-guiding question to determine the quality of the evidence and the strength of this recommendation (GRADE). This material was sent to authors using an open online questionnaire. After receiving the answers, we formalized the consensus for each recommendation of this guideline. Results: the level of evidence and the degree of recommendation for each item is presented in text form, followed by a summary of the evidence found. Conclusion: this guideline reflects the recommendations of the group of specialists of the Brazilian College of Surgeons, the Brazilian Society of Parenteral and Enteral Nutrition and the ACERTO Project for nutritional interventions in the perioperative period of Elective General Surgery. The prescription of these recommendations can accelerate the postoperative recovery of patients submitted to elective general surgery, with decrease in morbidity, length of stay and rehospitalization, and consequently, of costs.

Standardizing the Protocols for Enhanced Recovery From Colorectal Cancer Surgery: Are We a Step Closer to Ideal Recovery?

PURPOSE

Enhanced recovery protocols are being implemented into the standard of care in surgical practice. This study aimed to insert a steadfast set of elements into the perioperative care pathway to establish an improved recovery program for colorectal cancer patients.

METHODS

Seventy patients planned for elective laparoscopic colorectal resection were randomized into 2 groups: conventional recovery group (n = 35) and enhanced recovery group (n = 35). The primary outcome was the length of hospital stay. Secondary outcomes included the times of removal of nasogastric tubes (NGTs), successful enteral feeding, and removal of drains, postoperative complications, intra-hospital mortality, and rate of readmission.

RESULTS

The mean postoperative hospital stay was 4.49 ± 0.85 days vs. 13.31 ± 6.9 days (P < 0.001), the mean time of removal of NGTs was 0.77 ± 1.031 days vs. 3.26 ± 2.737 days (P < 0.001), the mean time of successful enteral feeding was 1.89 ± 1.13 days vs. 5.46 ± 1.67 days (P < 0.001), and the mean time for removal of intra-abdominal drains was 2.94 ± 1.056 days vs. 9.06 ± 3.757 days (P < 0.001) for the enhanced and the conventional groups, respectively. Complications were significantly lower among patients in the enhanced group (25.7% vs. 65.7%) (P = 0.001). The rates of readmission were similar in the 2 groups.

CONCLUSION

Applying definite evidence-based elements to the colorectal rehabilitation program significantly boosts the recovery pathway with favorable outcomes, including faster recovery of gastrointestinal tract functions, lower morbidities, and eventually earlier discharge from the hospital.

Network meta-analysis of protocol-driven care and laparoscopic surgery for colorectal cancer

BACKGROUND

Laparoscopic approaches and standardized recovery protocols have reduced morbidity following colorectal cancer surgery. As the optimal regimen remains inconclusive, a network meta-analysis was undertaken of treatments for the development of postoperative complications and mortality.

METHODS

MEDLINE, Embase, trial registries and related reviews were searched for randomized trials comparing laparoscopic and open surgery within protocol-driven or conventional perioperative care for colorectal cancer resection, with complications as a defined endpoint. Relative odds ratios (ORs) for postoperative complications and mortality were estimated for aggregated data.

RESULTS

Forty trials reporting on 11 516 randomized patients were included with the network. Open surgery within conventional perioperative care was the index for comparison. The OR relating to complications was 0·77 (95 per cent c.i. 0·65 to 0·91) for laparoscopic surgery within conventional care, 0·69 (0·48 to 0·99) for open surgery within protocol-driven care, and 0·43 (0·28 to 0·67) for laparoscopic surgery within protocol-driven care. Sensitivity analyses excluding trials of low rectal cancer and those with a high risk of bias did not affect the treatment estimates. Meta-analyses demonstrated that mortality risk was unaffected by perioperative strategy.

CONCLUSION

Laparoscopic surgery combined with protocol-driven care reduces colorectal cancer surgery complications, but not mortality. The reduction in complications with protocol-driven care is greater for open surgery than for laparoscopic approaches. Registration number: CRD42015017850 (https://www.crd.york.ac.uk/PROSPERO).

Factors predicting outcome from enhanced recovery programmes in laparoscopic colorectal surgery: a systematic review

OBJECTIVE

To perform a systematic review of published literature for the factors reported to predict outcomes of enhanced recovery after surgery (ERAS) programmes following laparoscopic colorectal surgery.

BACKGROUND

ERAS programmes and the use of laparoscopy have been widely adopted in colorectal surgery bringing short-term patient benefit. However, there is a minority of patients that do not benefit from these strategies and their identification is not well characterised. The factors that underpin outcomes from ERAS programmes for laparoscopic patients are not understood.

METHODS

A systematic search of the MEDLINE, Embase and Cochrane databases was conducted to identify suitable articles published between 2000 and 2015. The search strategy captured terms for ERAS, colorectal resection, prediction and outcome measures.

RESULTS

Thirty-four studies containing 10,861 laparoscopic resections were included. Thirty-one (91 %) studies were confined to elective cases. Predictive analysis of outcome was most frequently based on length of stay (LOS), morbidity and readmission which were the main outcome measures of 29 (85 %), 26 (76 %) and 18 (53 %) of the included studies, respectively. Forty-seven percentage of included studies investigated the impact of ERAS programme compliance on these outcomes. Reduced protocol compliance was the most frequently identified modifiable predictive factor for adverse LOS, morbidity and readmission.

CONCLUSION

Protocol compliance is the most frequently reported predictive factor for outcomes of ERAS programmes following laparoscopic colorectal resection. Reduced compliance increases LOS, morbidity and readmission to hospital. The impact of compliance with individual ERAS protocol elements is insufficiently studied, and the lack of a standardised framework for evaluating ERAS programmes makes it difficult to draw definite conclusions about which factors exert the greatest impact on outcome after laparoscopic colorectal resection.

Successful implementation of an Enhanced Recovery After Surgery program shortens length of stay and improves postoperative pain, and bowel and bladder function after colorectal surgery

Background

Despite international data indicating that Enhanced Recovery After Surgery (ERAS) programs, which combine evidence-based perioperative strategies, expedite recovery after surgery, few centers have successfully adopted this approach within the U.S. We describe the implementation and efficacy of an ERAS program for colorectal abdominal surgery in a tertiary teaching center in the U.S.

Methods

We used a multi-modal and continuously evolving approach to implement an ERAS program among all patients undergoing colorectal abdominal surgery at a single hospital at the University of California, San Francisco. 279 patients who participated in the Enhanced Recovery after Surgery program were compared to 245 previous patients who underwent surgery prior to implementation of the program. Primary end points were length of stay and readmission rates. Secondary end points included postoperative pain scores, opioid consumption, postoperative nausea and vomiting, length of urinary catheterization, and time to first solid meal.

Results

ERAS decreased both median total hospital length of stay (6.4 to 4.4 days) and post-procedure length of stay (6.0 to 4.1 days). 30-day all-cause readmission rates decreased from 21 to 9.4 %. Pain scores improved on postoperative day 0 (3.2 to 2.1) and day 1 (3.2 to 2.6) despite decreased opioid. Median time to first solid meal decreased from 4.7 to 2.7 days and duration of urinary catheterization decreased from 74 to 46 h. Similar improvements were observed in all other secondary end points.

Conclusions

These results confirm that a multidisciplinary, iterative, team-based approach is associated with a reduction in hospital stay and an acceleration in recovery without increasing readmission rates.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-016-0223-0) contains supplementary material, which is available to authorized users.