Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation
Abstract
The rate of postoperative recovery is determined by pain, stress-induced organ dysfunction, and limitations in conventional postoperative care. We attempted to provide "stress-free" colonic resection for neoplastic disease in eight elderly high-risk patients by a combination of laparoscopically assisted surgery, epidural analgesia, and early oral nutrition and mobilisation. Effective pain relief allowed early mobilisation, and hospital stay was reduced to 2 days without nausea, vomiting, or ileus. Postoperative fatigue and impairment in functional activity were avoided. Major advances in postoperative recovery can be achieved by early aggressive perioperative care in elderly high-risk patients undergoing colonic surgery.
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Cited by (529)
The incidence of venous thromboembolism after curative colon cancer surgery within an enhanced recovery after surgery programme
2024, Thrombosis ResearchBased on three randomised controlled trials performed more than a decade ago, several national guidelines recommend prolonged venous thromboprophylaxis for 28 days following elective surgery for colon cancer. None of these studies were conducted within enhanced recovery after surgery setting. Newer studies indicate that prolonged prophylaxis might not be necessary with enhanced recovery after surgery. We aimed to provide further evidence to this unresolved discussion.
Retrospective study of patients undergoing elective surgery for colon cancer stage I-III with enhanced recovery after surgery in the Capital Region of Denmark from 2014 to 2017. Patients were excluded if discharged on postoperative day 28 or later, dying before discharge, undergoing concomitant rectum resection, or discharged with vitamin K antagonists, direct-oral anticoagulants, or low molecular weight heparin treatment. All patients received only low-dose low molecular weight heparin as prophylaxis during their admission.
The primary endpoint was symptomatic lower limb deep venous thrombosis or pulmonary embolism diagnosed within 60 days postoperatively.
Out of the included population of 1806 patients, only three experienced a symptomatic venous thromboembolic event; none was fatal. Two had pulmonary embolism associated with pneumonia, while one patient was diagnosed with lower limb deep venous thrombosis at postoperative day 15 after an uncomplicated course with first discharge at postoperative day 2.
The risk of symptomatic venous thromboembolism after elective surgery for colon cancer with enhanced recovery after surgery seems negligible even without prolonged prophylaxis. The current guidelines need to be reconsidered.
Bringing Enhanced Recovery After Surgery to the NICU: An Implementation Trial
2024, Journal of Pediatric SurgeryEnhanced Recovery After Surgery (ERAS) guidelines are bundled evidence-informed recommendations implemented to improve quality and safety of perioperative care. This study aims to determine feasibility of NICU implementation of an ERAS Guideline for Intestinal Resection, describing clinical outcomes and adherence to recommendations following light-touch implementation.
Infants <28 days undergoing laparotomy for intestinal resection in a closed-NICU were prospectively enrolled. Exclusion criteria included prematurity (<32wks), instability, or major comorbidity. Clinical data reflecting 13 ERAS recommendations were collected through chart review. Descriptive statistics are presented as median [interquartile range]. Thirty-day post-discharge outcomes include NICU and hospital length of stay (LOS), ventilator days, surgical site infection (SSI), re-intubation, readmission, reoperation, and mortality. Adherence was calculated as the percentage of patients eligible for each recommendation whose care was adherent.
Ten infant-parent dyads were enrolled (five females; GA 37 weeks [35, 38.8]; birthweight 2.97 kg [2.02, 3.69]). Surgical diagnoses included intestinal atresia/web (n = 6), anorectal malformation (n = 3), and segmental volvulus (n = 1). NICU LOS was 16 days [11, 21], hospital LOS 20 days [18, 30], and 2.5 ventilator days/patient [2, 3]. There was reduced opioid use, no SSIs, one re-intubation, three readmissions, three reoperations, and no mortalities. Adherence to ERAS recommendations ranged 0–100 % with a pooled adherence rate of 73 %.
It is feasible to introduce ERAS to the NICU with acceptable overall adherence. Assessing adherence was challenging for some measures. There were promising early clinical findings including a reduction in opioid use. This implementation trial will inform development of an ERAS protocol for surgical NICUs.
IV (Cohort Study).
Use of the Obstetric Quality-of-Recovery score (ObsQoR-11) to measure the impact of an enhanced recovery programme for elective caesarean section
2024, International Journal of Obstetric AnesthesiaEnhanced recovery after caesarean (ERAC) has been shown to postoperatively reduce opioid consumption, reduce pain scores, and shorten hospital stay. Arguably, none of these measures provide for a patient-centred approach. We believe that patient-reported outcome measures (PROMs) represent a more holistic approach to the reporting of outcomes. One such PROM is the Obstetric Quality-of-Recovery Score (ObsQoR-11). This has been shown to be a valid and reliable assessment of recovery after elective caesarean section.
This before-and-after quality improvement programme studied consecutive patients undergoing elective caesarean section. We implemented an ERAC pathway with the aim of improving quality of recovery and patient satisfaction. Our primary outcome was the change in the ObsQoR-11 score.
A total of 318 medical records were reviewed (n = 93 before ERAC, n = 225 after ERAC). There was a significant improvement in ObsQoR-11 score in ERAC patients compared with pre-ERAC patients (85.0 vs 82.3, P < 0.001). Morphine consumption (MMEQ) was reduced by 10% overall in the ERAC group, with no increase in pain scores at day 1 postoperatively and a decrease in pain scores on day 2 in the ERAC group (P = 0.02). The length of hospital stay was significantly shorter in ERAC patients (63.1 h vs 79.9 h, P < 0.001).
Our study demonstrated an improved ObsQoR-11 score after ERAC implementation. This is the first example in the literature of using ObsQoR-11 in ERAC. We believe this is a more comprehensive way to assess patient recovery and the impact of an ERAC programme.
Electro-acupuncture for gastrointestinal dysfunction after colorectal cancer surgery: A protocol for three-arm randomized controlled trial
2023, European Journal of Integrative MedicinePostoperative gastrointestinal dysfunction (POGD) is one of the most common complications after colorectal cancer (CRC) surgery and seriously affects the prognosis of patients. Furthermore, current clinical treatment measures have controversial efficacy or strong side effects. Electro-acupuncture (EA) is a safe therapeutic modality for POGD; however, high-quality evidence is scarce at present. This study will aim to evaluate the efficacy and safety of EA for POGD in patients with CRC.
A total of 270 patients with POGD after CRC surgery will be recruited from five hospitals in China and assigned to EA, sham electro-acupuncture (SA), and routine treatment (RT) groups in a 1:1:1 ratio. Patients in the RT group will receive treatment based on enhanced recovery after surgery (ERAS), health education, and routine care. Patients in the EA and SA groups will be treated with EA or SA on the basis of RT, respectively, from postoperative days one to three, once per day. Follow-up will be performed at seven and fourteen days after surgery. The primary outcome is the time to the first postoperative passing flatus. Secondary outcomes include the following: time of first postoperative bowel movement, postoperative bowel sound recovery time, gastrointestinal symptom rating scale, I-FEED (intake, feeling nauseated, emesis, physical exam, duration of symptoms) scale, postoperative surgical site pain degree, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Version 3.0 (EORTC QLQ-C30 (V3.0)), EORTC Quality of Life Questionnaire-Colorectal Cancer 29 (EORTC QLQ-CR29), postoperative complications, adverse acupuncture events, etc.
This study design is rigorous, and a scientific placebo acupuncture method is used. The advantages are (1) multi-center, prospective, large sample randomized control with strict quality control; (2) the placebo control method can minimize the true acupuncture effect on the basis of blinding patients as much as possible; (3) the gastrointestinal function and quality of life of POGD patients after passing flatus and defecation will be analyzed.
The findings of the 3-arm clinical trial will demonstrate whether EA is effective and safe for patients with POGD after CRC surgery.
ChiCTR2200062275 (registered on 31–07–2022).
Enhanced Recovery After Surgery and Elderly Patients: Advances
2023, Anesthesiology ClinicsGuidelines on perioperative optimization protocol for the adult patient 2023
2023, Anaesthesia Critical Care and Pain MedicineThe French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs.
A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.
Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a “formalized expert recommendations” format.
The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations.
Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.