Can the combination of laparoscopy and enhanced recovery improve long-term survival after elective colorectal cancer surgery?

AIM

Enhanced recovery after surgery (ERAS) programmes and laparoscopic techniques both provide short-term benefits to patients undergoing colorectal cancer surgery. ERAS protocol compliance may improve long-term survival in those undergoing open colorectal resection but as laparoscopic data has not been reported. Therefore, we aimed to investigate the impact of the combination of laparoscopy and ERAS management on 5-year overall survival.

METHODS

A dedicated prospectively populated colorectal cancer surgery database was reviewed. Patient inclusion criteria were biopsy-proven colorectal adenocarcinoma, undergoing elective surgery undertaken with curative intent. All patients were managed within an established ERAS programme and routinely followed up for 5 years. Overall survival was measured using the log-rank Kaplan-Meier method at 5 years.

RESULTS

Eight hundred fifty-four patients met the inclusion criteria. Four hundred eighty-one (56%) cases were laparoscopic with 98 patients (20%) requiring conversion. There were no differences in patient or tumour demographics between the surgical groups. Median ERAS protocol compliance was 93% (range 53-100%). Five-year overall survival was superior in laparoscopic cases compared with that of converted and open surgery (78 vs 68 vs 70%, respectively, p < 0.007). An open approach (HR 1.55, 95%CI 1.16-2.06, p = 0.002) and delayed hospital discharge (> 7 days, HR 1.5, 95%CI 1.13-1.9, p = 0.003) were the only modifiable risk factors associated with poor survival.

CONCLUSIONS

The use of a laparoscopic approach with enhanced recovery after surgery management appears to have long-term survival benefits following colorectal cancer resection.

Factors predicting 30-day readmission after laparoscopic colorectal cancer surgery within an enhanced recovery programme

AIM

Hospital readmission within 30 days of surgery has become a marker of poor quality patient care. This study aimed to investigate factors predictive of 30-day readmission after laparoscopic colorectal cancer surgery within an enhanced recovery after surgery (ERAS) programme.

METHOD

Consecutive patients undergoing laparoscopic surgery for colorectal cancer within an ERAS programme between 2002 and 2009 were included. Data were collected relating to patient demographics, neoadjuvant chemoradiotherapy, ERAS compliance, and operative and postoperative outcomes. A logistic regression model was used to identify factors associated with readmissions after adjusting for the potential effect of covariables simultaneously.

RESULTS

In all, 268 cancer patients underwent laparoscopic colorectal surgery (108 rectal resections), of whom 34 (12.7%) were readmitted due most commonly to bowel obstruction (29%) and surgical site infection (18%). The use of neoadjuvant therapy (odds ratio 4.49, 95% CI 1.41-14.35; P = 0.011) and ERAS compliance above 93% (odds ratio 0.38, 95% CI 0.18-0.84; P = 0.016) were independent predictors of readmission.

CONCLUSION

Poor ERAS compliance and preoperative chemoradiotherapy were significant predictors of readmission following laparoscopic colorectal cancer surgery. Further research is required to expand the scope of ERAS beyond hospital discharge.

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.