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Navarra A, Porcellini I, Mongelli F, Popeskou SG, Grass F, Christoforidis D. Long-term outcomes in elderly patients after elective surgery for colorectal cancer within an ERAS protocol: a retrospective analysis. Langenbecks Arch Surg 2023; 408:438. [PMID: 37978074 DOI: 10.1007/s00423-023-03179-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE The number of elderly patients with a diagnosis of colorectal cancer (CRC) is increasing. Considering short life expectancy and multiple comorbidities, surgery may not always be the best treatment option. METHODS We included all consecutive patients aged 80 years and older who underwent elective resection for CRC following Enhanced Recovery after Surgery (ERAS) protocol between January 2011 and May 2021. The primary endpoint was overall survival, secondary endpoints were 30-day morbidity, and the rate of return to pre-operative living conditions 3 months after surgery. RESULTS Ninety-four patients were included. Mean age was 84.6 ± 3.6 years, 49 patients (52%) were female. Most patients (77.6%) were ASA score ≥ 3. Laparoscopic resections were performed in 85 patients (90.4%), involving 69 (73.4%) colonic and 25 (26.6%) rectal resections. A stoma was constructed in 22 patients (23%), and reversed in 12 (54.5%). Twenty-two patients (23.4%) experienced a Clavien-Dindo ≥ 3 complication, and 2 patients (2.1%) died. The median length of hospital stay was 8 (interquartiles: 6-15) days. Sixty-six patients (70.2%) were discharged home directly and 26 (27.7%) to rehabilitation or postacute care institutes. At three months after surgery, eighty-two patients (96.5%) returned to their pre-operative living conditions directly or after short-term rehabilitation. Mean follow-up was 53 ± 33 months, estimated 5-year overall survival was 60.3% (95%CI 49.5-71.1%), and disease-free survival was 86.3% (95%CI 78.1-94.4%). CONCLUSIONS Our study suggests that elderly patients undergoing elective surgery have a high potential to return to preoperative living conditions and good overall- and disease-free survivals, despite significant postoperative morbidity.
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Affiliation(s)
- Andrea Navarra
- University of Lausanne, Quartier Centre, 1015, Lausanne, Switzerland
| | - Iride Porcellini
- Department of Surgery, Ospedale Regionale Di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
| | - Francesco Mongelli
- Department of Surgery, Ospedale Regionale Di Bellinzona E Valli, EOC, Via Ospedale 12, 6500, Bellinzona, Switzerland.
- Faculty of Biomedical Science, Università Della Svizzera Italiana, Via La Santa 1, 6900, Lugano, Switzerland.
| | | | - Fabian Grass
- University of Lausanne, Quartier Centre, 1015, Lausanne, Switzerland
- Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Dimitri Christoforidis
- Department of Surgery, Ospedale Regionale Di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
- Faculty of Biomedical Science, Università Della Svizzera Italiana, Via La Santa 1, 6900, Lugano, Switzerland
- Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
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Thacker J, Morin N. Optimizing Outcomes with Enhanced Recovery. THE ASCRS TEXTBOOK OF COLON AND RECTAL SURGERY 2022:121-139. [DOI: 10.1007/978-3-030-66049-9_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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3
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Improving Outcomes for Elderly Patients Following Emergency Surgery: a Cutting-edge Review. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00500-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Purpose of Review
The aim of this review is to explore the consequence of emergency general surgery in the elderly, and to summarise recent developments in the pre-, peri- and postoperative management of these patients, in order to improve outcomes.
Recent Findings
Preoperatively, accurate risk assessment is vital to ensure the right patients undergo emergency surgery. Perioperatively, there are multiple interventions specific to elderly patients that have been shown to improve outcomes. Postoperatively, elderly patients must be cared more in an appropriate setting in order to avoid failure to rescue and promote return to function.
Summary
This review of contemporary evidence identifies multiple pre-, peri- and postoperative interventions that can improve outcomes for elderly patients after emergency general surgery. These evidence-based recommendations should help direct care of elderly patients undergoing emergency surgery and foster further quality improvement measures and research investigations.
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Technical Evidence Review for Emergency Major Abdominal Operation Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery. J Am Coll Surg 2020; 231:743-764.e5. [PMID: 32979468 DOI: 10.1016/j.jamcollsurg.2020.08.772] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023]
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Chan DKH, Ang JJ, Tan JKH, Chia DKA. Age is an independent risk factor for increased morbidity in elective colorectal cancer surgery despite an ERAS protocol. Langenbecks Arch Surg 2020; 405:673-689. [DOI: 10.1007/s00423-020-01930-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023]
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Feasibility and effects of enhanced recovery vs. conventional care after emergency colon surgery for patients with left colon perforation. Sci Rep 2020; 10:7346. [PMID: 32355193 PMCID: PMC7193622 DOI: 10.1038/s41598-020-64242-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 03/05/2020] [Indexed: 02/04/2023] Open
Abstract
The impact of an enhanced recovery after surgery (ERAS) programme in emergency colorectal surgery has not yet been reported. The objective of this study was to evaluate the feasibility and the results of patients included in an ERAS protocol following emergency colon surgery for left colon perforation. For this purpose, patients with a low to moderate risk of mortality, according to a Peritonitis Severity Score (PSS), and treated with an ERAS protocol (ERAS group) after emergency surgery for left colon perforation were compared for a period of 40 months (March 2014–June 2017) with a control group of patients treated with conventional care (CC group) during the 38 months prior to implementation of the new ERAS protocol (January 2011–February 2014). The main endpoint was 90-day postoperative morbidity according to the Clavien–Dindo classification. Secondary endpoints included length of postoperative hospital stay, 90-day readmission rate, protocol compliance and mortality. Fifty patients were included in the study, 29 in the ERAS group and 21 in the CC group. There were no significant differences between the groups in the demographic data or in the operative characteristics. A reduction in the incidence of postoperative complications (20.7% vs. 38%; p > 0.05) and in the postoperative hospital stay (7.7 + /- 3.85 vs. 10.9 + /- 5.6 days; p = 0.009) were observed in the ERAS group. The 90-day readmission rate did not differ significantly between the two groups (2 vs. 1). No 90-day mortality was observed in either group. The ERAS group showed better results than the CC group in protocol compliance. We conclude that ERAS protocols are feasible and help to reduce morbidity and length of hospital stay without adversely affecting the rate of readmission or mortality.
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Minimizing the impact of colorectal surgery in the older patient: The role of enhanced recovery programs in older patients. Eur J Surg Oncol 2020; 46:338-343. [DOI: 10.1016/j.ejso.2019.12.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 09/04/2019] [Accepted: 12/19/2019] [Indexed: 02/07/2023] Open
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Boyd-Carson H, Gana T, Lockwood S, Murray D, Tierney GM. A review of surgical and peri-operative factors to consider in emergency laparotomy care. Anaesthesia 2020; 75 Suppl 1:e75-e82. [PMID: 31903572 DOI: 10.1111/anae.14821] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2019] [Indexed: 12/12/2022]
Abstract
Patients undergoing emergency laparotomy are a heterogeneous group with regard to comorbidity, pre-operative physiological state and surgical pathology. There are many factors to consider in the peri-operative period for these patients. Surgical duration should be as short as possible for adequate completion of the procedure. This is of particular importance in the elderly and comorbid population. To date, there are limited data addressing the role of damage control surgery in emergency general surgery. Dual consultant-led care in all stages of emergency laparotomy care is increasing, with increased presence out of hours and also for high-risk patients. The role of the stoma care team should be actively encouraged in all patients who may require a stoma. Due to the emergent and unpredictable nature of surgical emergencies, healthcare teams may need to employ novel strategies to ensure early input from the stoma care team. It is important for all members of the medical teams to ensure that patients have given consent for both anaesthesia and surgery before emergency laparotomy. Small studies suggest that patients and their families are not aware of the high risk of morbidity and mortality following emergency laparotomy before operative intervention. Elderly patients should have early involvement from geriatric specialists and careful attention paid to assessment of frailty due to its association with mortality and morbidity. Additionally, the use of enhanced recovery programmes in emergency general surgery has been shown to have some impact in reducing length of stay in emergency surgical patients. However, the emergent nature of this surgery has been shown to be a detrimental factor in full implementation of enhanced recovery programmes. The use of a national database to collect data on patients undergoing emergency laparotomy and their processes of care has led to reduced mortality and length of stay in the UK. However, internationally, fewer data are available to draw conclusions.
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Affiliation(s)
- H Boyd-Carson
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - T Gana
- Bradford Royal Infirmary, Yorkshire and Humber Deanery, Leeds, UK
| | | | - D Murray
- James Cook University Hospital, Middlesbrough, UK
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Lohsiriwat V, Jitmungngan R. Enhanced recovery after surgery in emergency colorectal surgery: Review of literature and current practices. World J Gastrointest Surg 2019; 11:41-52. [PMID: 30842811 PMCID: PMC6397799 DOI: 10.4240/wjgs.v11.i2.41] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 02/06/2023] Open
Abstract
Enhanced recovery after surgery (ERAS), a multidisciplinary program designed to minimize stress response to surgery and promote the recovery of organ function, has become a standard of perioperative care for elective colorectal surgery. In an elective setting, ERAS program has consistently been shown to decrease postoperative complication, reduce length of hospital stay, shorten convalescence, and lower healthcare cost. Recently, there is emerging evidence that ERAS program can be safely and effectively applied to patients with emergency colorectal conditions such as acute colonic obstruction and intraabdominal infection. This review comprehensively covers the concept and application of ERAS program for emergency colorectal surgery. The outcomes of ERAS program for this emergency surgery are summarized as follows: (1) The ERAS program was associated with a lower rate of overall complication and shorter length of hospital stay - without increased risks of readmission, reoperation and death after emergency colorectal surgery; and (2) Compliance with an ERAS program in emergency setting appeared to be lower than that in an elective basis. Moreover, scientific evidence of each ERAS item used in emergency colorectal operation is shown. Perspectives of ERAS pathway in emergency colorectal surgery are addressed. Finally, evidence-based ERAS protocol for emergency colorectal surgery is presented.
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Affiliation(s)
- Varut Lohsiriwat
- Division of Colon and Rectal Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Romyen Jitmungngan
- Division of Colon and Rectal Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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Singh M, Askari R, Stopfkuchen-Evans M. Enhanced Recovery After Surgery: Are the Principles Applicable to Adult and Geriatric Acute Care and Trauma Surgery? Anesthesiol Clin 2018; 37:67-77. [PMID: 30711234 DOI: 10.1016/j.anclin.2018.10.001] [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: 12/15/2022]
Abstract
The incorporation of enhanced recovery after surgery (ERAS) fundamentals into perioperative medicine has improved the patient care experience and hastened recovery time while reducing hospital costs. Research studies have shown that incorporating ERAS principles in the adult or geriatric acute care surgery populations minimizes time to resumption of preoperative activity and reduces hospital length of stay. ERAS principles are widely applicable to these patient cohorts and may be applicable in trauma patients. Increased physician and nursing education to promote widespread utilization of enhanced recovery protocols will further improve quality of health care administered in the twenty-first century.
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Affiliation(s)
- Mandeep Singh
- Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, Keck Medical Center, University of Southern California, 1450 San Pablo Street, Suite 3600, Los Angeles, CA 90033, USA.
| | - Reza Askari
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Matthias Stopfkuchen-Evans
- Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, CWN L1, Boston, MA 02115, USA
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11
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Tejedor P, Pastor C, Gonzalez-Ayora S, Ortega-Lopez M, Guadalajara H, Garcia-Olmo D. Short-term outcomes and benefits of ERAS program in elderly patients undergoing colorectal surgery: a case-matched study compared to conventional care. Int J Colorectal Dis 2018; 33:1251-1258. [PMID: 29721734 DOI: 10.1007/s00384-018-3057-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of the study was to evaluate the benefits of implementing Enhanced Recovery After Surgery (ERAS) protocols in elderly patients undergoing elective colorectal surgery. METHODS A retrospective non-randomized cohort study was conducted from September 2012 to December 2016. We included patients ≥ 70 years undergoing elective colorectal surgery. Outcome measures, compliance with interventions, and postoperative complications of patients treated under ERAS were case-matched (based on gender, age, type of surgery, and the presence/absence of a temporal stoma) to a retrospective group of patients ≥ 70 years treated under conventional care. RESULTS A total of 312 patients (156 ERAS vs. 156 non-ERAS) were included in the study. The ERAS group had a significant reduction of grade III/IV Dindo-Clavien's postoperative complications when compared with conventional care. ERAS had a positive effect in reducing anastomotic leakage (14.7% non-ERAS vs. 9%) and postoperative mortality (11.5% non-ERAS vs. 1.9% ERAS; p = 0.001). A reduction of 2 days in length of hospital stay was achieved after implementing ERAS (8 (6.75) vs. 6 (5.25); p < 0.0001), while readmission rates remained unaffected. The average of global compliance (GC) with all ERAS interventions was 42%. GC was significantly lower in patients with permanent/temporary stomas and in patients in whom an open approach was performed. CONCLUSION In our experience, ERAS should be implemented without reservations in elderly patients expecting the same goals and benefits as with other age groups. Barriers in achieving a high compliance rate are common and will require a great effort in patient's education, an intensive perioperative care, and sometimes a change in the surgeons' practice.
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Affiliation(s)
- Patricia Tejedor
- Department of General Surgery, Division of Colorectal Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain.
| | - Carlos Pastor
- Department of General Surgery, Division of Colorectal Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Santiago Gonzalez-Ayora
- Department of General Surgery, Division of Colorectal Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Mario Ortega-Lopez
- Department of General Surgery, Division of Colorectal Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Hector Guadalajara
- Department of General Surgery, Division of Colorectal Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Damian Garcia-Olmo
- Department of General Surgery, Division of Colorectal Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
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12
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Pędziwiatr M, Mavrikis J, Witowski J, Adamos A, Major P, Nowakowski M, Budzyński A. Current status of enhanced recovery after surgery (ERAS) protocol in gastrointestinal surgery. Med Oncol 2018; 35:95. [PMID: 29744679 PMCID: PMC5943369 DOI: 10.1007/s12032-018-1153-0] [Citation(s) in RCA: 190] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 05/03/2018] [Indexed: 02/07/2023]
Abstract
Enhanced Recovery After Surgery (ERAS) is an evidence-based paradigm shift in perioperative care, proven to lower both recovery time and postoperative complication rates. The role of ERAS in several surgical disciplines was reviewed. In colorectal surgery, ERAS protocol is currently well established as the best care. In gastric surgery, 2014 saw an establishment of ERAS protocol for gastrectomies with resulting meta-analysis showing ERAS effectiveness. ERAS has also been shown to be beneficial in liver surgery with many centers starting implementation. The advantages of ERAS in pancreatic surgery have been strongly established, but there is still a need for large-scale, multicenter randomized trials. Barriers to implementation were analyzed, with recent studies concluding that successful implementation requires a multidisciplinary team, a willingness to change and a clear understanding of the protocol. Additionally, the difficulty in accomplishing necessary compliance to all protocol items calls for new implementation strategies. ERAS success in different patient populations was analyzed, and it was found that in the elderly population, ERAS shortened the length of hospitalization and did not lead to a higher risk of postoperative complications or readmissions. ERAS utilization in the emergency setting is possible and effective; however, certain changes to the protocol may need to be adapted. Therefore, further research is needed. There remains insufficient evidence on whether ERAS actually improves patients’ course in the long term. However, since most centers started to implement ERAS protocol less than 5 years ago, more data are expected.
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Affiliation(s)
- Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Krakow, Poland. .,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland.
| | - Judene Mavrikis
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Krakow, Poland
| | - Jan Witowski
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Krakow, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Alexandros Adamos
- Carol Davila University of Medicine and Pharmacy, Sector 1, Strada Dionisie Lupu 37, 030167, Bucharest, Romania
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Krakow, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Michał Nowakowski
- Department of Medical Education, Jagiellonian University Medical College, św. Łazarza 16, 31-530, Krakow, Poland
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Krakow, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
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Oliveira RA, Guatura GMGBDS, Peniche ADCG, Costa ALS, Poveda VDB. An Integrative Review of Postoperative Accelerated Recovery Protocols. AORN J 2017; 106:324-330.e5. [PMID: 28958318 DOI: 10.1016/j.aorn.2017.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/02/2017] [Accepted: 08/04/2017] [Indexed: 02/07/2023]
Abstract
We undertook an integrative literature review of articles pertaining to perioperative nursing care provided to patients using postoperative accelerated recovery protocols. To select the articles, we searched the MEDLINE, PubMed, Cumulative Index to Nursing and Allied Health Literature, and LiteraturaLatino-Americana e do Caribe em Ciências da Saúde databases. We identified 329 studies, 13 of which met our inclusion criteria and described perioperative nursing care activities. Nursing activities noted in these articles were hypothermia prevention and maintenance of normothermia, restriction of IV fluids, assessment of vital signs, management of symptoms and pain, support of early ambulation, care for tubes and drains, oral administration of carbohydrate-rich foods, assessment of ability to tolerate diet, and encouragement to resume activities of daily living. There was a lack of research on this topic by nursing professionals; additional research by nursing professionals is needed regarding nurses' roles in providing this care.
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Pirrera B, Lucchi A, Gabbianelli C, Alagna V, Martorelli G, Berti P, Panzini I, Fabbri E, Garulli G. E.R.A.S. pathway in colorectal surgery in elderly: Our experience: A retrospective cohort study. Int J Surg 2017; 43:101-106. [PMID: 28483663 DOI: 10.1016/j.ijsu.2017.05.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/29/2017] [Accepted: 05/02/2017] [Indexed: 02/08/2023]
Abstract
AIM Numerous geriatric patients develop colorectal disease. Elderly patients are often considered high-risk surgical candidates. Enhanced recovery after surgery (E.R.A.S.) has been proven to be beneficial for patients. The aim of the study was to evaluate the results of an ERAS protocol in older patients that underwent colorectal surgery compared to younger patients. METHOD In the period between January 2010 to December 2015 a total of 589 patients underwent elective colorectal surgical interventions treated within the E.R.A.S pathway: 211 patients younger than 65 years, 175 patients aged from 66 years to 75 years, and 203 patients older than 75 years. End point of interest were postoperative complications, 90-day mortality, length of hospital stay and readmission within 30 days. RESULTS Significant differences between the three groups were observed for comorbidities (p:0.001); in particular older patients had significantly more diabetes, renal, cardiac, and respiratory diseases, ASA (p < 0.001), presence of malignancy (p < 0.001). However there were not differences between the groups in surgical procedures (p = 0.095), operative time (p = 0.823), anastomotic leakage (p = 0.960), hospital stay (p = 0.081), readmission rate (p = 0.904), 90-days mortality (p = 0.183) and morbidity (p = 0.973) in accordance with Clavien-Dindo classification. Multivariate logistic regression analysis showed that advanced age in E.R.A.S. pathway is not a predictive factor of morbidity, readmission within 30 days and 90-day mortality. CONCLUSION There was no significant difference in morbidity, 90-day mortality, length of stay or readmission rate in patients aged over 75 years compared with younger patients. Old age does not represent a contraindication to the implementation of the E.R.A.S protocol in patients that underwent colorectal surgery. WHAT DOES THIS PAPER ADD TO THE EXISTING LITERATURE?: In the literature there are not many studies that address the impact of older age in the treatment of colorectal disease in an ERAS program. The aging of the population raises new questions in the management of the colorectal surgery in the elderly. ERAS pathway has been proven to be beneficial for patients, which results in a reduction of postoperative morbidity. Compared to what is reported in the literature this study confirms that ERAS program in colorectal surgery can be applied in older patients with no significant difference in morbidity, 90-day mortality, length of stay or readmission rate compared with younger.
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Affiliation(s)
- Basilio Pirrera
- General, Thoracic and Minimally Invasive Surgery, Ceccarini Hospital, Riccione, Italy.
| | - Andrea Lucchi
- General, Thoracic and Minimally Invasive Surgery, Ceccarini Hospital, Riccione, Italy
| | - Carlo Gabbianelli
- General, Thoracic and Minimally Invasive Surgery, Ceccarini Hospital, Riccione, Italy
| | - Vincenzo Alagna
- General, Thoracic and Minimally Invasive Surgery, Ceccarini Hospital, Riccione, Italy
| | - Giacomo Martorelli
- General, Thoracic and Minimally Invasive Surgery, Ceccarini Hospital, Riccione, Italy
| | - Pierluigi Berti
- General, Thoracic and Minimally Invasive Surgery, Ceccarini Hospital, Riccione, Italy
| | - Ilaria Panzini
- General, Thoracic and Minimally Invasive Surgery, Ceccarini Hospital, Riccione, Italy
| | - Elisabetta Fabbri
- General, Thoracic and Minimally Invasive Surgery, Ceccarini Hospital, Riccione, Italy
| | - Gianluca Garulli
- General, Thoracic and Minimally Invasive Surgery, Ceccarini Hospital, Riccione, Italy
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Forsmo HM, Erichsen C, Rasdal A, Körner H, Pfeffer F. Enhanced Recovery After Colorectal Surgery (ERAS) in Elderly Patients Is Feasible and Achieves Similar Results as in Younger Patients. Gerontol Geriatr Med 2017; 3:2333721417706299. [PMID: 28516129 PMCID: PMC5419065 DOI: 10.1177/2333721417706299] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 03/22/2017] [Accepted: 03/27/2017] [Indexed: 12/17/2022] Open
Abstract
Aim: Enhanced recovery after surgery (ERAS) is a multimodal approach that aims to optimize perioperative treatment. Whether elderly patients receiving colorectal surgery can adhere to and benefit from an ERAS approach is uncertain. The aim of this study was to compare patients in different age groups participating in an ERAS program. Method: In this substudy of a randomized controlled trial, we analyzed the interventional ERAS arm of adult patients eligible for laparoscopic or open colorectal resection with regard to the importance of age. Patients were divided into three groups based on age: ≤65 years (n = 79), 66-79 years (n = 56), and ≥80 years (n = 19). The primary end point was total postoperative hospital stay (THS). Secondary end points were postoperative hospital stay, postoperative complications, postoperative C-reactive protein levels, readmission rate, mortality, and patient adherence to the different ERAS elements. All parameters and measuring the adherence to the ERAS protocol were recorded before surgery, on the day of the operation, and daily until discharge. Results: There were no significant differences in length of THS between age groups (≤65 years, median 5 [range 2-47] days; 66-79 years, median 5.5 [range 2-36] days; ≥80 years, median 7 [range 3-50] days; p = .53). All secondary outcomes were similar between age groups. Patient adherence to the ERAS protocol was as good in the elderly as it was in the younger patients. Conclusion: Elderly patients adhered to and benefited from an ERAS program, similar to their younger counterparts.
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Affiliation(s)
| | | | - Anne Rasdal
- Haukeland University Hospital, Bergen, Norway
| | - Hartwig Körner
- University of Bergen, Norway.,Stavanger University Hospital, Norway
| | - Frank Pfeffer
- Haukeland University Hospital, Bergen, Norway.,University of Bergen, Norway
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16
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Enhanced recovery ERAS for elderly: a safe and beneficial pathway in colorectal surgery. Int J Colorectal Dis 2017; 32:215-221. [PMID: 27770249 DOI: 10.1007/s00384-016-2691-6] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) pathway includes recovery goals requiring active participation of the patients; this may be perceived as "aggressive" care in older patients. The aim of the present study was to assess whether ERAS was feasible and beneficial in older patients. METHODS Since June 2011, all consecutive colorectal patients were included in an ERAS pathway and documented in a dedicated prospective database. This retrospective analysis included 513 patients, 311 younger patients (<70 years) and 202 older patients (≥70 years). Outcomes were adherence to the ERAS pathway, functional recovery, postoperative complications, and hospital stay. RESULTS Older patients had significantly more diabetes, malignancies, cardiac, and respiratory co-morbidities; both groups underwent similar surgical procedures. Overall adherence to the ERAS pathway was in median 78 % in younger and 74 % in older patients (P = 0.86). In older patients, urinary drains were kept longer (P = 0.001), and oral fluid intake was reduced from day 0 to day 3 (P < 0.001). There were no differences in mobilization and intake of nutritional supplements. Postoperative complications were similar for both comparative groups (51.5 vs. 46.6 %, P = 0.32). Median length of stay was 7 days (IQR 5-13) in older patients vs. 6 days (IQR 4-10) in the younger group (P = 0.001). CONCLUSION Adherence to the ERAS pathway was equally high in older patients. Despite more co-morbidities, older patients did not experience more complications. Recovery was similar and hospital stay was only 1 day longer than in younger patients. ERAS pathway is of value for all patients and does not need any adaptation for the elderly.
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Cui L, Shi Y, Zhang GN. Fast-track surgery after gynaecological oncological surgery: study protocol for a prospective randomised controlled trial. Trials 2016; 17:597. [PMID: 27978842 PMCID: PMC5159978 DOI: 10.1186/s13063-016-1688-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 11/09/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Fast-track surgery (FTS), also known as enhanced recovery after surgery, is a multidisciplinary approach to accelerate recovery, reduce complications, minimise hospital stay without increasing readmission rates, and reduce health care costs, all without compromising patient safety. The advantages of FTS in abdominal surgery most likely extend to gynaecological surgery, but this is an assumption, as FTS in elective gynaecological surgery has not been well studied. No consensus guidelines have been developed for gynaecological oncological surgery although surgeons have attempted to introduce slightly modified FTS programmes for patients undergoing such surgery. To our knowledge, there are no published randomised controlled trials; however, some studies have shown that FTS in gynaecological oncological surgery leads to early hospital discharge with high levels of patient satisfaction. The aim of this study is whether FTS reduces the length of stay in hospital compared to traditional management. The secondary aim is whether FTS is associated with any increase in post-surgical complications compared to traditional management (for both open and laparoscopic surgery). METHODS/DESIGN This trial will prospectively compare FTS and traditional management protocols. The primary endpoint is the length of post-operative hospitalisation (days, mean ± standard deviation), defined as the number of days between the date of discharge and the date of surgery. The secondary endpoints are complications in both groups (FTS versus traditional protocol) occurring during the first 3 months post-operatively including infection (wound infection, lung infection, intraperitoneal infection), post-operative nausea and vomiting, ileus, post-operative haemorrhage, post-operative thrombosis, and the Acute Physiology and Chronic Health Enquiry II score. DISCUSSION The advantages of FTS most likely extend to gynaecology, although, to our knowledge, there are no randomised controlled trials. The aim of this study is to compare the post-operative length of hospitalisation after major gynaecological or gynaecological oncological surgery and to analyse patients' post-operative complications. This trial may reveal whether FTS leads to early hospital discharge with few complications after gynaecological surgery. TRIAL REGISTRATION NUMBER NCT02687412 . Approval Number: SCCHEC20160001. Date of registration: registered on 23 February 2016.
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Affiliation(s)
- Ling Cui
- Department of Gynaecological Oncology, Sichuan Cancer Hospital, Chengdu, 610041, Sichuan, People's Republic of China
| | - Yu Shi
- Department of Gynaecological Oncology, Sichuan Cancer Hospital, Chengdu, 610041, Sichuan, People's Republic of China
| | - G N Zhang
- Department of Gynaecological Oncology, Sichuan Cancer Hospital, Chengdu, 610041, Sichuan, People's Republic of China.
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Launay-Savary MV, Mathonnet M, Theissen A, Ostermann S, Raynaud-Simon A, Slim K. Are enhanced recovery programs in colorectal surgery feasible and useful in the elderly? A systematic review of the literature. J Visc Surg 2016; 154:29-35. [PMID: 27842907 DOI: 10.1016/j.jviscsurg.2016.09.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Enhanced recovery programs (ERP) are no longer questionable in the management of patients undergoing surgery. However, there is some doubt as to their feasibility and efficacy in the elderly. Our goal was to systematically review the evidence-based literature concerning the feasibility of ERP in elderly patients undergoing colorectal surgery. MATERIAL AND METHODS The PubMed and Cochrane Database for systematic reviews as well as the "grey" literature between 2000 and 2015 were sought. Articles were selected if they compared ERP in elderly patients to ERP in young patients (feasibility) or compared ERP to traditional post-operative management in the elderly (efficacy). RESULTS Sixteen articles were identified according to the inclusion criteria. All showed that an ERP was feasible in the elderly although post-operative morbidity was higher compared to younger patients. Compared to traditional management, ERP was effective since it decreased (as in the young) the overall rate of complications and thus the duration of hospital stay. There were not enough data on the degree of implementation of ERP and the medico-economic aspects to come to any formal conclusions. CONCLUSION This comprehensive systematic review of the literature showed that ERP was feasible and effective in the elderly undergoing colorectal surgery. Protocols should be adapted to the particular aspects of this population. Future research should target pre-operative evaluation and the place of pre-habilitation in geriatric ERP.
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Affiliation(s)
| | - M Mathonnet
- Service de Chirurgie Digestive, Centre Hospitalo-Universitaire Limoges, France
| | - A Theissen
- Service d'Anesthésie-Réanimation, centre Hospitalier Princesse Grace, Monaco
| | - S Ostermann
- Service de Chirurgie Digestive, Clinique de la Colline Hirslanden, Genève, Suisse
| | - A Raynaud-Simon
- Service de Gériatrie, Centre Hospitalo-Universitaire de Bichat, Paris, France
| | - K Slim
- Service de Chirurgie Digestive, Centre Hospitalo-Universitaire Estaing, Clermont-Ferrand, France.
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- 9 allée du Riboulet, Beaumont, France
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Wisely JC, Barclay KL. Effects of an Enhanced Recovery After Surgery programme on emergency surgical patients. ANZ J Surg 2016; 86:883-888. [PMID: 26990499 DOI: 10.1111/ans.13465] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) programmes have been used in elective surgery since the 1990s to optimize peri-operative care, reducing post-operative complications, length of stay and overall costs. Following the local introduction of an ERAS programme for colorectal elective patients, it was suggested an increase in the use of ERAS-type principles in emergency patients may have occurred. The aims of this study were to determine whether management changes could be demonstrated and if there was a difference in outcomes. METHOD A retrospective cohort study comparing emergency patients undergoing major abdominal surgery October 2008 to May 2010 (pre-ERAS) and January 2011 to December 2012 (post-ERAS) was performed. Details collected included admission and operative details, post-operative management and outcomes. RESULTS A total of 370 patients were studied. Baseline variables were comparable. Post-ERAS, intra-operative (P < 0.001) and post-operative 48 h totals (P < 0.001) of intravenous fluids were significantly reduced. Significantly fewer patients in the post-ERAS group had a catheter (P < 0.001), drain (P = 0.001) and patient controlled analgesia (P = 0.01) for more than two days. Major complications (P = 0.002) and individual minor complications such as urinary tract infections (P = 0.02), urinary retention (P = 0.001) and chest infections (P = 0.001) were all significantly reduced in the post-ERAS period. CONCLUSION This study demonstrates a significant change in management towards ERAS principles in emergency patients following the introduction of such a programme in elective patients. The lack of increased complications in the second period suggests the use of ERAS principles is not harmful. The wider application of ERAS principles could improve outcomes in emergency surgery and deserves further study.
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Affiliation(s)
- Jessica C Wisely
- The Department of General Surgery, Northern Health, Melbourne, Victoria, Australia.,The Academic Department of Surgery, NCHER, The University of Melbourne, Melbourne, Victoria, Australia
| | - Karen L Barclay
- The Department of General Surgery, Northern Health, Melbourne, Victoria, Australia. .,The Academic Department of Surgery, NCHER, The University of Melbourne, Melbourne, Victoria, Australia.
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Feasibility of Fast-Track Surgery in Elderly Patients with Gastric Cancer. J Gastrointest Surg 2015; 19:1391-8. [PMID: 25943912 DOI: 10.1007/s11605-015-2839-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 04/24/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to investigate the role of the fast-track surgery (FTS) program in elderly patients (aged ≥75 years) who underwent open surgery for gastric cancer (GC) in China. METHODS A total of 256 patients with GC were randomly assigned to four groups, each of which consisted of 64 cases: the 45-74-year-old age group was subdivided into the FTS-1 group and the conventional care (CC)-1 group, and the 75-89-year-old age group was subdivided into the FTS-2 group and the CC-2 group. All patients underwent open gastrectomy by the same experienced surgical team. We compared the differences between the pairs of groups in different age ranges with respect to the postoperative recovery index, complications, and medical costs. RESULTS Compared with the CC-1 group, the FTS-1 group exhibited earlier postoperative flatus, a shorter postoperative hospital stay, lower medical costs, and a decreased incidence of sore throat (P = 0.010, P = 0.000, P = 0.000, and P = 0.019, respectively). Compared with the CC-2 group, the FTS-2 group had more nausea and vomiting, stomach retention, and intestinal obstruction, as well as a higher readmission rate (P = 0.015, P = 0.011, P = 0.041, and P = 0.013, respectively). CONCLUSION The application of FTS can significantly speed up postoperative rehabilitation, shorten the hospitalization time, and lower the medical costs for 45-74-year-old GC patients, but this procedure does not show the same benefits for elderly patients. These findings suggest that we should carefully consider whether the FTS program should be applied to elderly patients with GC.
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Enhanced recovery after colorectal surgery in elderly patients. Wideochir Inne Tech Maloinwazyjne 2015; 10:30-6. [PMID: 25960790 PMCID: PMC4414102 DOI: 10.5114/wiitm.2015.48697] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 10/30/2014] [Accepted: 11/02/2014] [Indexed: 02/04/2023] Open
Abstract
Introduction The elderly will soon constitute 20% of the population. Their number is constantly rising, particularly in developed countries. It was found that they particularly benefit from the use of minimally invasive surgery. The Enhanced Recovery After Surgery (ERAS) protocol may further improve clinical outcomes in this group of patients. Aim To assess the implementation of the ERAS protocol in elderly patients submitted to laparoscopic colorectal surgery. Material and methods Ninety-two patients who underwent elective laparoscopic colorectal surgery were included in the study. Patients were divided into group 1 (≤ 65 years) and group 2 (> 65 years). Perioperative care was based on ERAS Society guidelines. Length of hospital stay, time of first stool passage, perioperative complications and readmissions were analyzed. Results Group 2 patients had higher ASA grades in comparison to group 1. In all cases, oral fluid intake started on the day of surgery. The groups did not differ according to oral fluid tolerance, first stool passage time or length of hospital stay. Number and character of perioperative complications were comparable between the two groups. Four patients were readmitted within 30 days after discharge. One patient required reoperation. Conclusions Implementation of the ERAS protocol is possible regardless of the age of surgical patients. Its use in the elderly allows the length of hospitalization to be shortened and is not associated with higher risk of postoperative complications or readmissions.
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Bagnall NM, Malietzis G, Kennedy RH, Athanasiou T, Faiz O, Darzi A. A systematic review of enhanced recovery care after colorectal surgery in elderly patients. Colorectal Dis 2014; 16:947-56. [PMID: 25039965 DOI: 10.1111/codi.12718] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 05/17/2014] [Indexed: 02/06/2023]
Abstract
AIM Enhanced recovery after surgery (ERAS) can decrease complications and reduces hospital stay. Less certain is whether elderly patients can fully adhere to and benefit from ERAS. We aimed to determine the safety, feasibility and efficacy of enhanced recovery after colorectal surgery in patients aged ≥ 65 years old. METHOD A systematic search of Medline, EMBASE and Cochrane was performed to identify (i) studies comparing elderly patients managed with ERAS vs traditional care, (ii) cohort studies of ERAS with results of elderly vs younger patients and (iii) any case series of ERAS in elderly patients. End-points of interest were length of hospital stay, complications, mortality, readmission and re-operation, and ERAS protocol adherence. RESULTS Sixteen studies were included. Two randomized controlled trials demonstrated shorter hospital stay in elderly patients with ERAS compared with elderly patients with non-ERAS (9 vs 13.2 days, P < 0.001; 5.5 vs 7 days, P < 0.0001). Fewer complications occurred with ERAS in both randomized controlled trials (27.4% vs 58.6%, P < 0.0001; 5% vs 21.1%, P = 0.045). The majority of observational studies did not show differences in outcome between elderly and younger patients in terms of hospital stay, morbidity or mortality. Inconsistent findings between cohort studies may reflect the disparities in ERAS protocol definitions or differences in study populations. CONCLUSION ERAS can be safely applied to elderly patients to reduce complications and shorten length of hospital stay. Further studies are required to assess whether elderly patients are able to adhere to, and benefit from, ERAS protocols to the same extent as younger patients.
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Affiliation(s)
- N M Bagnall
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, Paddington, London, UK
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Lawrence J, Delaney CP. Integrating hospital administrative data to improve health care efficiency and outcomes: "the socrates story". Clin Colon Rectal Surg 2013; 26:56-62. [PMID: 24436649 PMCID: PMC3699139 DOI: 10.1055/s-0033-1333662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Evaluation of health care outcomes has become increasingly important as we strive to improve quality and efficiency while controlling cost. Many groups feel that analysis of large datasets will be useful in optimizing resource utilization; however, the ideal blend of clinical and administrative data points has not been developed. Hospitals and health care systems have several tools to measure cost and resource utilization, but the data are often housed in disparate systems that are not integrated and do not permit multisystem analysis. Systems Outcomes and Clinical Resources AdministraTive Efficiency Software (SOCRATES) is a novel data merging, warehousing, analysis, and reporting technology, which brings together disparate hospital administrative systems generating automated or customizable risk-adjusted reports. Used in combination with standardized enhanced care pathways, SOCRATES offers a mechanism to improve the quality and efficiency of care, with the ability to measure real-time changes in outcomes.
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Affiliation(s)
- Justin Lawrence
- Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Conor P. Delaney
- Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
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Spinelli A, Bazzi P, Sacchi M, Danese S, Fiorino G, Malesci A, Gentilini L, Poggioli G, Montorsi M. Short-term outcomes of laparoscopy combined with enhanced recovery pathway after ileocecal resection for Crohn's disease: a case-matched analysis. J Gastrointest Surg 2013; 17:126-32; discussion p.132. [PMID: 22948838 DOI: 10.1007/s11605-012-2012-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 08/14/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopy combined with an enhanced recovery pathway (ERP) is widely considered to be the first-choice option for patients with colorectal cancer. However, no previous reports have focused on patients with Crohn's disease (CD) treated by laparoscopy and ERP. METHODS Twenty patients with CD underwent laparoscopic ileocecal resection with an ERP at two institutions. The ERP protocol included no bowel preparation nor fasting, no nasogastric tube, no abdominal drains, early removal of urinary catheter, early solid dietary intake and mobilization, opioid-sparing analgesia and restrictive fluid management. This group was compared with a matched historical control group of 70 CD patients who underwent laparoscopic ileocecal resection treated with conventional care. RESULTS Compliance with the ERP was high (≥80 %) for all items except no drain placement. A significantly earlier return of bowel function (time to first flatus and stool) was observed in the ERP group. Mean postoperative and total length of stay were significantly shorter in the ERP group. Postoperative complications were similar in both groups. CONCLUSIONS This is the first reported experience of laparoscopy with ERP in CD patients and suggests that optimized perioperative care combined with minimally invasive techniques may lead to further improvements in surgical outcomes for CD patients.
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Affiliation(s)
- Antonino Spinelli
- Department and Chair of General Surgery, Istituto Clinico Humanitas-IRCCS, University of Milan, Via Alessandro Manzoni 56, 20089, Rozzano, Milan, Italy.
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Spinelli A, Bazzi P, Sacchi M, Danese S, Fiorino G, Malesci A, Gentilini L, Poggioli G, Montorsi M. Short-term outcomes of laparoscopy combined with enhanced recovery pathway after ileocecal resection for Crohn's disease: a case-matched analysis. J Gastrointest Surg 2013. [PMID: 22948838 DOI: 10.1016/s1873-9946(12)60385-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopy combined with an enhanced recovery pathway (ERP) is widely considered to be the first-choice option for patients with colorectal cancer. However, no previous reports have focused on patients with Crohn's disease (CD) treated by laparoscopy and ERP. METHODS Twenty patients with CD underwent laparoscopic ileocecal resection with an ERP at two institutions. The ERP protocol included no bowel preparation nor fasting, no nasogastric tube, no abdominal drains, early removal of urinary catheter, early solid dietary intake and mobilization, opioid-sparing analgesia and restrictive fluid management. This group was compared with a matched historical control group of 70 CD patients who underwent laparoscopic ileocecal resection treated with conventional care. RESULTS Compliance with the ERP was high (≥80 %) for all items except no drain placement. A significantly earlier return of bowel function (time to first flatus and stool) was observed in the ERP group. Mean postoperative and total length of stay were significantly shorter in the ERP group. Postoperative complications were similar in both groups. CONCLUSIONS This is the first reported experience of laparoscopy with ERP in CD patients and suggests that optimized perioperative care combined with minimally invasive techniques may lead to further improvements in surgical outcomes for CD patients.
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Affiliation(s)
- Antonino Spinelli
- Department and Chair of General Surgery, Istituto Clinico Humanitas-IRCCS, University of Milan, Via Alessandro Manzoni 56, 20089, Rozzano, Milan, Italy.
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Wodlin NB, Nilsson L. The development of fast-track principles in gynecological surgery. Acta Obstet Gynecol Scand 2012; 92:17-27. [PMID: 22880948 DOI: 10.1111/j.1600-0412.2012.01525.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Fast-track is a multimodal strategy aimed at reducing the physiological burden of surgery to achieve an enhanced postoperative recovery. The strategy combines unimodal evidence-based interventions in the areas of preoperative preparation, anesthesia, surgical factors and postoperative care. The advantages of fast-track most likely extend to gynecology, although so far have scarcely been reported. This review summarizes current evidence concerning use of fast-track in general and in gynecological surgery. The main findings of this review are that there are benefits within elective gynecological surgery, but studies of quality of life, patient satisfaction and health economics in elective surgery are needed. Studies of fast-track within the field of non-elective gynecological surgery are lacking. Widespread education is needed to improve the rate of implementation of fast-track. Close involvement of the entire surgical team is imperative to ensure a structured perioperative care aiming for enhanced postoperative recovery.
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Affiliation(s)
- Ninnie Borendal Wodlin
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden.
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