|
1
|
Smith BP, Hollis RH, Shao CC, Gleason L, Wood L, McLeod MC, Kay DI, Oates GR, Pisu M, Chu DI. The association of social vulnerability with colorectal enhanced recovery program failure. Surg Open Sci 2023; 13:1-8. [PMID: 37012979 PMCID: PMC10066546 DOI: 10.1016/j.sopen.2023.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/20/2023] [Indexed: 04/05/2023] Open
Abstract
Background Enhanced recovery programs (ERPs) improve outcomes, but over 20 % of patients fail ERP and the contribution of social vulnerability is unknown. This study aimed to characterize the association between social vulnerability and ERP adherence and failure. Methods This was a retrospective cohort study of colorectal surgery patients between 2015 and 2020 utilizing ACS-NSQIP data. Patients who failed ERP (LOS > 6 days) were compared to patients not failing ERP. The CDC's social vulnerability index (SVI) was used to assess social vulnerability. Result 273 of 1191 patients (22.9 %) failed ERP. SVI was a significant predictor of ERP failure (OR 4.6, 95 % CI 1.3-16.8) among those with >70 % ERP component adherence. SVI scores were significantly higher among patients non-adherent with 3 key ERP components: preoperative block (0.58 vs. 0.51, p < 0.01), early diet (0.57 vs. 0.52, p = 0.04) and early foley removal (0.55 vs. 0.50, p < 0.01). Conclusions Higher social vulnerability was associated with non-adherence to 3 key ERP components as well as ERP failure among those who were adherent with >70 % of ERP components. Social vulnerability needs to be recognized, addressed, and included in efforts to further improve ERPs. Key message Social vulnerability is associated with non-adherence to enhanced recovery components and ERP failure among those with high ERP adherence. Social vulnerability needs to be addressed in efforts to improve ERPs.
Collapse
Affiliation(s)
- Burkely P. Smith
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Robert H. Hollis
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Connie C. Shao
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Lauren Gleason
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Lauren Wood
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Marshall C. McLeod
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Danielle I. Kay
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Gabriela R. Oates
- University of Alabama at Birmingham, Department of Pediatrics, 1600 7th Ave S, Birmingham, AL 35233, United States of America
| | - Maria Pisu
- University of Alabama at Birmingham, Division of Preventive Medicine and O'Neal Comprehensive Cancer Center, 1808 7th Ave S, Birmingham, AL 35233, United States of America
| | - Daniel I. Chu
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| |
Collapse
|
|
2
|
Meillat H, Serenon V, Brun C, de Chaisemartin C, Faucher M, Lelong B. Impact of fast-track care program in laparoscopic rectal cancer surgery: a cohort-comparative study. Surg Endosc 2022; 36:4712-4720. [DOI: 10.1007/s00464-021-08811-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 10/17/2021] [Indexed: 11/29/2022]
|
|
3
|
Liu S, Zhang S, Li Z, Li M, Zhang Y, He M, Jin C, Gao C, Gong J. Insufficient Post-operative Energy Intake Is Associated With Failure of Enhanced Recovery Programs After Laparoscopic Colorectal Cancer Surgery: A Prospective Cohort Study. Front Nutr 2022; 8:768067. [PMID: 34993219 PMCID: PMC8724790 DOI: 10.3389/fnut.2021.768067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/11/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Although enhanced recovery after surgery (ERAS) has been proven to be beneficial after laparoscopic colorectal surgery, some of the patients may fail to complete the ERAS program during hospitalization. This prospective study aims to evaluate the risk factors associated with ERAS failure after laparoscopic colorectal cancer surgery. Methods: This is a prospective study from a single tertiary referral hospital. Patients diagnosed with colorectal cancer who met the inclusion criteria were included in this study. Demographic and clinicopathological characteristics were collected. Post-operative activity time and 6-min walking distance (6MWD) were measured. Patients were divided into ERAS failure group and ERAS success according to decreased post-operative activity and 6MWD. Factors associated with ERAS failure were investigated by univariate and multivariate analysis. Results: A total of 91 patients with colorectal cancer were included. The incidence of ERAS failure is 28.6% among all patients. Patients in ERAS failure group experienced higher rate of post-operative ileus and prolonged hospital stay (p < 0.001). Multivariate analysis revealed that older age (p = 0.006), body mass index ≥25.5 kg/m2 (p = 0.037), smoking (p = 0.002), operative time (p = 0.048), and post-operative energy intake <18.5 kcal/kg•d (p = 0.045) were independent risk factors of ERAS failure after laparoscopic colorectal surgery. Conclusions: Our findings indicated that a proportion of patients may fail the ERAS program after laparoscopic colorectal surgery. We for the first time showed that post-operative energy intake was an independent risk factor for ERAS failure. This may provide evidence for further investigation on precise measurement of nutritional status and selected high-risk patients for enhanced nutrition support.
Collapse
Affiliation(s)
- Shuang Liu
- Department of Gastrointestinal Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Sheng Zhang
- Department of Gastrointestinal Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Zike Li
- Department of Gastrointestinal Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Meng Li
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yujie Zhang
- Department of Gastrointestinal Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Min He
- Department of Gastrointestinal Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Chengcheng Jin
- Department of Gastrointestinal Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Chun Gao
- Department of Gastrointestinal Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Jianping Gong
- Department of Gastrointestinal Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
|
4
|
Sun SD, Wu PP, Zhou JF, Wang JX, He QL. Failure of enhanced recovery after surgery in laparoscopic colorectal surgery: a systematic review. Int J Colorectal Dis 2020; 35:1007-1014. [PMID: 32361938 DOI: 10.1007/s00384-020-03600-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Enhanced recovery after surgery programs has been applied extensively in laparoscopic colorectal surgery. However, several studies have found that some patients fail from ERAS programs. It is important to identify these patients so that remedial action can be taken in a timely manner. The aim of this study was to perform a systematic review of ERAS failure and related risk factors following laparoscopic colorectal surgery. METHODS A literature search of the PubMed, EMBASE, OVID, and Cochrane databases was performed. The search strategy involved terms related to ERAS, failure, and colorectal surgery. The main outcomes were definitions of ERAS failure and related risk factors. RESULTS Seven studies including 1463 patients were analyzed. The definition of ERAS failure was mostly associated with a prolonged postoperative length-of-stay (poLOS). Twenty-four kinds of identified risk factors were divided into three parts, the operative part, the pathophysiological part, and the ERAS elements, of which operative factors including more intraoperative blood loss and longer operative duration were the most frequently identified. CONCLUSIONS ERAS failure was mostly related to a prolonged poLOS, and operative factors were the most frequently identified risk factors for ERAS failure following laparoscopic colorectal surgery. These findings will help physicians to take remedial action in a timely manner. Nonetheless, high-quality randomized controlled trials following a standardized framework for evaluating ERAS programs are needed in the future.
Collapse
Affiliation(s)
- Si-Da Sun
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, China
| | - Ping-Ping Wu
- Department of Cadre's Ward, The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, China
| | - Jun-Feng Zhou
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, China
| | - Jia-Xing Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, China
| | - Qing-Liang He
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, China.
| |
Collapse
|
|
5
|
Zhang Y, Xin Y, Sun P, Cheng D, Xu M, Chen J, Wang J, Jiang J. Factors associated with failure of Enhanced Recovery After Surgery (ERAS) in colorectal and gastric surgery. Scand J Gastroenterol 2019; 54:1124-1131. [PMID: 31491354 DOI: 10.1080/00365521.2019.1657176] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background: The Enhanced Recovery After Surgery (ERAS) pathway is widely applied in the perioperative period of stomach and colorectal surgery, and can decrease the length of hospital stay of the patients without compromising the safety of the patients. However, some patients are removed from this pathway for various reasons. Here we found some factors that taking the patients out from the procedures. Methods: A retrospective analysis of collected data of 550 patients over a 3-year period was conducted, with 292 in the ERAS group and 258 in the conventional care group. Then various basic elements were analyzed to explore the reasons for the failure to complete the ERAS program. Results: Total length of hospital stay after surgery was significantly shorter in the ERAS group, and a similar incidence of complication rates were observed in the two groups. In this study, the significant factors that associated with complications were advanced age (OR 2.18; p = .031), history of abdominal surgery (OR 2.03; p = .04), incomplete gastrointestinal obstruction (OR 3.42; p < .001), laparoscopic surgery (OR 0.39; p = .004) and intraoperative neostomy (OR 2.37; p = .006). Conclusions: We found that advanced age (>80 years old), history of abdominal surgery, gastrointestinal obstruction and stoma formation were the risk factors. We anticipated to design a risk assessment system upon the high-risk patients from the present ERAS pathway, and make a modified ERAS pathway for those patients.
Collapse
Affiliation(s)
- Yunpeng Zhang
- Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Yufang Xin
- Institute for Personalized Medicine, Shanghai Jiao Tong University , Shanghai , China
| | - Peng Sun
- Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Daqing Cheng
- Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Ming Xu
- Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Ji Chen
- Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Jue Wang
- Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Jianling Jiang
- Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , China
| |
Collapse
|
|
6
|
Hu JM, Chu CH, Jiang JK, Lai YL, Huang IP, Cheng AYM, Yang SH, Chen CC. Robotic transanal total mesorectal excision assisted by laparoscopic transabdominal approach: A preliminary twenty-case series report. Asian J Surg 2019; 43:330-338. [PMID: 31320234 DOI: 10.1016/j.asjsur.2019.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/13/2019] [Accepted: 06/18/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Laparoscopy-assisted robotic transanal total mesorectal excision is a novel surgical technique for rectal cancer resection. Compared to prior DaVinci Si system case series, this case series is the first to report robotic taTME assisted by laparoscopy (r-taTME) in which the "transanal team" operates via the DaVinci Xi system. As a result, we aim to delineate and discuss preliminary findings from our robotic taTME experiences. METHODS A total of twenty patients (twelve males) who underwent robotic taTME assisted by laparoscopy (r-taTME) between January 2016 and November 2016 at a single institution were documented. Surgical outcomes, including complications, pathological outcomes, and short-term results, were then retrospectively analyzed. RESULTS All patients underwent r-taTME via a two-team approach. The "abdominal team" operated via a single port method (ileostomy site), while the "transanal team" operated via the DaVinci Xi system. The mean patient age was 56.7 ± 14.3 years (range 31-79), and the mean distance from tumor to anal verge was 6.0 ± 2.7 cm (range 2-10). The mean estimated intraoperative blood loss was 88 ± 107 ml (range 30-500), and circular stapling was utilized to restore continuity in 80% of study patients. The overall postoperative complication rate was 35%, and the mean distal margin length was 3.1 ± 1.3 cm. There were three patients who had a circumferential margin (CRM) involved by cancer cells (≤1 mm). CONCLUSION Our preliminary series report demonstrates that utilization of r-taTME assisted by laparoscopy is safe and feasible. Development of a novel transanal approach that allows single-port access alongside a multi-arm robotic system may increase the convenience and efficiency of future operation.
Collapse
Affiliation(s)
- Je-Ming Hu
- Division of Colorectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Chun-Ho Chu
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan; College of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jeng-Kae Jiang
- College of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Colorectal Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Ling Lai
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - I-Ping Huang
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Andy Yi-Ming Cheng
- Department of Medicine, Division of Hospital Medicine, University of Pittsburgh Medical Center Shadyside Hospital, United States of America
| | - Shung-Haur Yang
- College of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Colorectal Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; National Yang-Ming University Hospital, Yilan, Taiwan
| | - Chien-Chih Chen
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan; College of Medicine, National Yang-Ming University, Taipei, Taiwan.
| |
Collapse
|
|
7
|
Cintorino D, Ricotta C, Bonsignore P, Di Francesco F, Li Petri S, Pagano D, Tropea A, Checchini G, Tuzzolino F, Gruttadauria S. Preliminary Report on Introduction of Enhanced Recovery After Surgery Protocol for Laparoscopic Rectal Resection: A Single-Center Experience. J Laparoendosc Adv Surg Tech A 2018; 28:1437-1442. [PMID: 29733252 DOI: 10.1089/lap.2018.0234] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Laparoscopic rectal surgery seems to improve postoperative recovery of patients who undergo surgery for rectal cancer. The aim of this study was to evaluate preliminary results of implementation of enhanced recovery after surgery (ERAS) protocol for laparoscopic rectal resection (LRR) for cancer at our institute. MATERIALS AND METHODS We conducted a retrospective analysis of prospectively collected data. Patients who underwent LRR for cancer at our institute after introduction of enhanced recovery protocol were compared with a control group of patients who previously underwent surgery with traditional protocol. Primary endpoints evaluated were length of stay (LOS) and rates of complications and readmissions. RESULTS We studied 150 consecutive patients, 56 operated with the traditional approach and 94 according to ERAS protocol. The mean (range) LOS was 10 (4-27) days for patients in control group versus 8.5 (3-32) days for patients in the ERAS group (P = .0823). No evidence of a different rate (P = .227) of complications was registered between the two groups. One patient in each group was readmitted. CONCLUSIONS The introduction of the ERAS protocol in LRR for cancer at our institute led to an initial reduction in hospital LOS, without increase in morbidity or readmission rate compared with our previous experience with traditional protocol.
Collapse
Affiliation(s)
- Davide Cintorino
- 1 Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| | - Calogero Ricotta
- 1 Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| | - Pasquale Bonsignore
- 1 Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| | - Fabrizio Di Francesco
- 1 Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| | - Sergio Li Petri
- 1 Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| | - Duilio Pagano
- 1 Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| | - Alessandro Tropea
- 1 Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| | - Giuliana Checchini
- 1 Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| | - Fabio Tuzzolino
- 2 Research Office, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| | - Salvatore Gruttadauria
- 1 Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| |
Collapse
|
|
8
|
Vignali A, Elmore U, Cossu A, Lemma M, Calì B, de Nardi P, Rosati R. Enhanced recovery after surgery (ERAS) pathway vs traditional care in laparoscopic rectal resection: a single-center experience. Tech Coloproctol 2016; 20:559-566. [PMID: 27262309 DOI: 10.1007/s10151-016-1497-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 02/21/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of this study was to compare the outcome of an enhanced recovery after surgery (ERAS) pathway with traditional perioperative care in laparoscopic rectal resection. METHODS A retrospective analysis of prospectively collected data was conducted. Single-center consecutive patients who underwent laparoscopic rectal surgery after an ERAS program were compared with patients who received traditional care over an 8-year period. Primary and total length of stay, and readmission, morbidity and mortality rates were analyzed. For ERAS group, the actual adherence to protocol was also evaluated. RESULTS Two hundred and ninety-seven patients, 162 in the ERAS group and 135 in conventional care, were studied. Median primary and total length of stay were significantly shorter in the ERAS group (9 vs 12 days; p = 0.0001; 10 vs 12 days; p = 0.01; respectively). The ERAS group experienced a faster recovery of bowel function than the traditional care group (p = 0.0001). A similar morbidity rate was observed in the two groups (32.3 % in ERAS vs 36.1 % in traditional care p = 0.41). Readmission rates were 4.9 % in the ERAS versus 1.5 % in the traditional care group (p = 0.19). There was no mortality in either group. Overall mean compliance with the ERAS protocol was 85.7 % (range 54.4-100 %). CONCLUSIONS The introduction of the ERAS protocol in laparoscopic rectal resection led to a reduction in primary and total length of hospital stay without an increase in morbidity or readmission rates when compared to traditional care.
Collapse
Affiliation(s)
- A Vignali
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Via Olgettina 60, 20132, Milan, Italy.
| | - U Elmore
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Via Olgettina 60, 20132, Milan, Italy
| | - A Cossu
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Via Olgettina 60, 20132, Milan, Italy
| | - M Lemma
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Via Olgettina 60, 20132, Milan, Italy
| | - B Calì
- Department of General and Minimally-Invasive Surgery, Humanitas Research Hospital, University of Milan, Rozzano, Milan, Italy
| | - P de Nardi
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Via Olgettina 60, 20132, Milan, Italy
| | - R Rosati
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Via Olgettina 60, 20132, Milan, Italy
| |
Collapse
|
|
9
|
Martin TD, Lorenz T, Ferraro J, Chagin K, Lampman RM, Emery KL, Zurkan JE, Boyd JL, Montgomery K, Lang RE, Vandewarker JF, Cleary RK. Newly implemented enhanced recovery pathway positively impacts hospital length of stay. Surg Endosc 2015; 30:4019-28. [PMID: 26694181 DOI: 10.1007/s00464-015-4714-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 12/01/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Enhanced recovery pathways (ERPs) are thought to improve surgical outcomes by standardizing perioperative patient care established in evidence-based literature. The objective of this study was to determine the impact of a colorectal surgery ERP on hospital length of stay (LOS) and other patient outcomes. METHODS This is a comparative effectiveness study of patients undergoing elective colorectal surgery 2 years prior (pre-ERP group) and 2 years after (ERP group) implementation of an ERP program. The primary outcome was hospital LOS. Secondary outcomes included postoperative complications, 30-day readmissions, and 30-day reoperations. Multivariable regression analyses were utilized to control for patient factors, general health factors, diagnosis, surgeon, colon versus rectal operations, and open versus minimally invasive operations-laparoscopic and robotic. An ERP checklist was developed to track adherence to components of the pathway. RESULTS The study population included 1036 patients: 523 in the pre-ERP group and 513 in the ERP group. Unadjusted LOS was significantly shorter in the ERP group than the control pre-ERP group [3 (IQR 3.5) vs 5 days (IQR 4.6); p < 0.0001]. Multivariable regression analysis confirmed the reduction in LOS, controlling for age, colon/rectum procedure, open/laparoscopic/robotic approach, primary diagnosis, and alvimopan use. Postoperative outcomes were not significantly different between groups except for 30-day readmissions, which were unexpectedly higher in the ERP group (14.6 vs 8.7 %, p = 0.04). CONCLUSIONS A newly implemented ERP on a dedicated colorectal surgery service in an academic non-university hospital setting resulted in shorter hospital LOS, but increased readmissions, for patients undergoing elective open and minimally invasive colon and rectal surgery. Future multi-institutional studies are needed to understand the impact of ERP on postoperative complications and readmissions.
Collapse
Affiliation(s)
- Thomas D Martin
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Talya Lorenz
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Jane Ferraro
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Kevin Chagin
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Richard M Lampman
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Karen L Emery
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Joan E Zurkan
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Jami L Boyd
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Karin Montgomery
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Rachel E Lang
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - James F Vandewarker
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Robert K Cleary
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA.
| |
Collapse
|
|
10
|
Chen CC, Lai YL, Jiang JK, Chu CH, Huang IP, Chen WS, Cheng AYM, Yang SH. Transanal Total Mesorectal Excision Versus Laparoscopic Surgery for Rectal Cancer Receiving Neoadjuvant Chemoradiation: A Matched Case-Control Study. Ann Surg Oncol 2015; 23:1169-76. [PMID: 26597369 DOI: 10.1245/s10434-015-4997-y] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Neoadjuvant chemoradiation therapy (nCRT) has been indicated for locally advanced rectal cancer. While utilization of laparoscopy in rectal cancer surgery has been popular in recent years, tumors receiving nCRT is still a surgical challenge. Transanal total mesorectal excision (TaTME) has emerged as a focused area of laparoscopic surgery that is becoming an increasingly acceptable approach in the field of rectal surgery. METHODS Between December 2013 and April 2015, a total of 50 patients (38 males) with post-nCRT middle or lower rectal cancer who then underwent TaTME at two separate institutions were prospectively documented. Overall, 100 matched control cohorts who received conventional laparoscopic rectal surgery (LapTME) were simultaneously retrieved from a prospectively registered database. Four parameters of sex, age, clinical stage, and American Society of Anesthesiologists (ASA) score were matched for surgical outcomes, and short-term oncological results, including complications and pathological outcomes, were analyzed. RESULTS Both the TaTME and LapTME groups received 5-fluorouracil-based chemotherapy and 5 weeks of long-course radiation therapy. Mean operative time for the TaTME group was 182.1 ± 55.4 min (156.6 ± 37.8 min in two-team-approach cases) and 178.7 ± 34.8 min for the LapTME group. The TaTME group yielded longer distal margin lengths. No significant differences were observed in blood loss, intraoperative complication rate, conversion rate, anastomosis type, and free circumferential margin rate. CONCLUSION This matched case-control study demonstrated that TaTME is safe and feasible. Compared with LapTME, TaTME not only achieves identical circumferential margin status without compromising other operative and quality parameters but also benefits patients by achieving a longer distal margin. Thus, TaTME has the potential to become an option in managing irradiated rectal cancer.
Collapse
Affiliation(s)
- Chien-Chih Chen
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan.,College of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Ling Lai
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Jeng-Kae Jiang
- College of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Colorectal Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chun-Ho Chu
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan.,College of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - I-Ping Huang
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Wei-Shone Chen
- College of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Colorectal Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Shung-Haur Yang
- College of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Division of Colorectal Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.
| |
Collapse
|
|
11
|
Chen CC, Lai YL, Jiang JK, Chu CH, Huang IP, Chen WS, Cheng AYM, Yang SH. The evolving practice of hybrid natural orifice transluminal endoscopic surgery (NOTES) for rectal cancer. Surg Endosc 2014; 29:119-26. [PMID: 24986014 DOI: 10.1007/s00464-014-3659-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 05/23/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Natural orifice transluminal endoscopic surgery (NOTES) has emerged as the area of focus in laparoscopic surgery. Hybrid NOTES (hNOTES) has some potential advantages for treating rectal cancer. METHODS Between May 2013 and November 2013, a total of 20 patients (11 males) who received hNOTES at two institutes participating in the study were documented and reviewed. Surgical outcomes, including complications and pathological outcomes, were analyzed. RESULTS The mean age of patients was 57.8 ± 10.1 years (range 34-78). Eleven patients received preoperative neoadjuvant chemoradiotherapy, with the mean distance between tumor and anal verge being 5.9 ± 1.7 cm (mean 2-8). The mean estimated intraoperative blood loss was 68 ± 106 ml (range 30-500), with one case converted to open procedure due to uncontrolled bleeding. Eight cases underwent simultaneous two-team approach. The mean operative time was 200.8 ± 47.7 min (range 110-285). Circular stapling was performed for 14 cases (70 %) as the anastomosis, and protective stoma performed for 17 cases (85 %). The overall postoperative complication rate was 25 %. Two cases (10 %) develop pelvic abscess due to leakage, which were controlled by medical treatments. The distal and circumferential margins were all free of tumor cells, and the mean distal margin length was 2.4 ± 0.98 cm (range 0.5-4). CONCLUSIONS Hybrid NOTES for rectal cancer is safe and feasible. Rapid experience-building accelerates its evolution, as reflected here by the high stapling rate and the idea of a two-team approach. It has the potential to become an option of treating rectal cancers.
Collapse
Affiliation(s)
- Chien-Chih Chen
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | | | | | | | | | | | | | | |
Collapse
|
|
12
|
Kim DW, Kang SB, Lee SY, Oh HK, In MH. Early rehabilitation programs after laparoscopic colorectal surgery: evidence and criticism. World J Gastroenterol 2013; 19:8543-51. [PMID: 24379571 PMCID: PMC3870499 DOI: 10.3748/wjg.v19.i46.8543] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 11/01/2013] [Accepted: 11/12/2013] [Indexed: 02/06/2023] Open
Abstract
During the past several decades, early rehabilitation programs for the care of patients with colorectal surgery have gained popularity. Several randomized controlled trials and meta-analyses have confirmed that the implementation of these evidence-based detailed perioperative care protocols is useful for early recovery of patients after colorectal resection. Patients cared for based on these protocols had a rapid recovery of bowel movement, shortened length of hospital stay, and fewer complications compared with traditional care programs. However, most of the previous evidence was obtained from studies of early rehabilitation programs adapted to open colonic resection. Currently, limited evidence exists on the effects of early rehabilitation after laparoscopic rectal resection, although this procedure seems to be associated with a higher morbidity than that reported with traditional care. In this article, we review previous studies and guidelines on early rehabilitation programs in patients undergoing rectal surgery. We investigated the status of early rehabilitation programs in rectal surgery and analyzed the limitations of these studies. We also summarized indications and detailed protocol components of current early rehabilitation programs after rectal surgery, focusing on laparoscopic resection.
Collapse
|
|
13
|
|
|
14
|
Lee SM, Kang SB, Jang JH, Park JS, Hong S, Lee TG, Ahn S. Early rehabilitation versus conventional care after laparoscopic rectal surgery: a prospective, randomized, controlled trial. Surg Endosc 2013; 27:3902-9. [PMID: 23708720 DOI: 10.1007/s00464-013-3006-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2012] [Accepted: 04/29/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although early rehabilitation programs have been reported to be effective after laparoscopic colectomy, there is no report of the efficacy of rehabilitation programs after rectal cancer surgery. This study was designed to evaluate the efficacy of an early rehabilitation program after laparoscopic low anterior resection for mid or low rectal cancer in a randomized, controlled trial. METHODS Ninety-eight patients who had undergone a laparoscopic low anterior resection with defunctioning ileostomy were randomized on a 1:1 basis to an early rehabilitation program (n = 52) or conventional care (n = 46). The primary endpoint was recovery rate at 4 days postoperatively. The secondary endpoints were recovery time, postoperative hospital stay, complications, readmission rates, pain on a visual analogue scale, and quality of life (QOL) according to Short Form 36. RESULTS The recovery rates were not different in both groups (rehabilitation, 25 % vs. conventional, 13 %, p = 0.135). Recovery time and postoperative hospital stay was similar between the groups (rehabilitation, 137 h [107-188] vs. conventional, 146.5 h [115-183], p = 0.47; 7.5 days [7-11] vs. 8.0 days [7-10], p = 0.882). The complication rates did not differ between the two groups, but more complications were noted in the rehabilitation program group (42.3 vs. 24.0 %, p = 0.054), which was related to postoperative ileus (28.8 vs. 13.0 %, p = 0.057) and acute voiding difficulty (19.6 vs. 4.7 %, p = 0.032). There was no readmission within 1 month of surgery. Pain and QOL were similar in both groups. CONCLUSIONS This randomized trial did not show that an early rehabilitation program is beneficial after laparoscopic low anterior resection. Our results confirm that postoperative ileus and acute voiding difficulty are major obstacles to fast-track surgery for mid or low rectal cancer. This study was registered (registration number NCT00606944).
Collapse
Affiliation(s)
- Sung-Min Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang, Seongnam, 463-707, South Korea
| | | | | | | | | | | | | |
Collapse
|
|
15
|
Ahmad NZ, Racheva G, Elmusharaf H. A systematic review and meta-analysis of randomized and non-randomized studies comparing laparoscopic and open abdominoperineal resection for rectal cancer. Colorectal Dis 2013; 15:269-77. [PMID: 22958456 DOI: 10.1111/codi.12007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Evidence supporting the role of laparoscopy in abdominoperineal resection (APR) is limited. This study compared the short-term and long-term outcomes and complications associated with open and laparoscopic APR. METHOD The Medline, Cochrane and Embase databases were searched for publications comparing open and laparoscopic APR. The rates of local and distant recurrence of rectal cancer were compared as the primary end-point. The occurrence of complications related to the two procedures was studied as the secondary end-point. The adequacy of cancer resection and postoperative recovery were also compared in a secondary analysis. Combined and separate analyses were performed for randomized and non-randomized studies. RESULTS Eight publications comparing open and laparoscopic APR were identified. The rates of local and distant disease recurrence were lower after laparoscopic surgery compared with open APR (odds ratio 2.736 and 1.994, 95% confidence interval 1.137-6.584 and 1.062-3.742, P = 0.025 and P = 0.032, respectively). Early postoperative complications were fewer after laparoscopic APR (OR 2.159, 95% CI 1.426-3.269, P = 0.000). No significant benefit of either technique was observed in the secondary analysis. CONCLUSION The long-term oncological benefits of laparoscopic APR are not convincingly superior to open surgery and need further validation. The laparoscopic approach is apparently associated with fewer postoperative complications, yet its role in improving the short-term outcomes is uncertain.
Collapse
Affiliation(s)
- N Z Ahmad
- Department of Surgery, Letterkenny General Hospital, Letterkenny, County Donegal, Ireland.
| | | | | |
Collapse
|
|
16
|
Unselected rectal cancer patients undergoing low anterior resection with defunctioning ileostomy can be safely managed within an Enhanced Recovery Programme. Tech Coloproctol 2012; 17:73-8. [DOI: 10.1007/s10151-012-0886-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 08/12/2012] [Indexed: 12/14/2022]
|
|
17
|
Trastulli S, Cirocchi R, Listorti C, Cavaliere D, Avenia N, Gullà N, Giustozzi G, Sciannameo F, Noya G, Boselli C. Laparoscopic vs open resection for rectal cancer: a meta-analysis of randomized clinical trials. Colorectal Dis 2012; 14:e277-96. [PMID: 22330061 DOI: 10.1111/j.1463-1318.2012.02985.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
Collapse
Affiliation(s)
- S Trastulli
- Department of General Surgery, S Maria Hospital, University of Perugia, Terni, Italy.
| | | | | | | | | | | | | | | | | | | |
Collapse
|