Enhanced Recovery Protocols for Adults Undergoing Colorectal Surgery

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Abstract

Enhanced surgical recovery protocols are designed to reduce hospital length of stay and health care costs.

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Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study).

Malaika S. Vlug, Jan Wind, Markus W Hollmann … (2011)

To investigate which perioperative treatment, ie, laparoscopic or open surgery combined with fast track (FT) or standard care, is the optimal approach for patients undergoing segmental resection for colon cancer. Important developments in elective colorectal surgery are the introduction of laparoscopy and implementation of FT care, both focusing on faster recovery. In a 9-center trial, patients eligible for segmental colectomy were randomized to laparoscopic or open colectomy, and to FT or standard care, resulting in 4 treatment groups. Primary outcome was total postoperative hospital stay (THS). Secondary outcomes were postoperative hospital stay (PHS), morbidity, reoperation rate, readmission rate, in-hospital mortality, quality of life at 2 and 4 weeks, patient satisfaction and in-hospital costs. Four hundred patients were required to find a minimum difference of 1 day in hospital stay. Median THS in the laparoscopic/FT group was 5 (interquar-tile range: 4-8) days; open/FT 7 (5-11) days; laparoscopic/standard 6 (4.5-9.5) days, and open/standard 7 (6-13) days (P < 0.001). Median PHS in the laparoscopic/FT group was 5 (4-7) days; open/FT 6 (4.5-10) days; laparoscopic/standard 6 (4-8.5) days and open/standard 7 (6-10.5) days (P < 0.001). Secondary outcomes did not differ significantly among the groups. Regression analysis showed that laparoscopy was the only independent predictive factor to reduce hospital stay and morbidity. Optimal perioperative treatment for patients requiring segmental colectomy for colon cancer is laparoscopic resection embedded in a FT program. If open surgery is applied, it is preferentially done in FT care. This study was registered under NTR222 (www.trialregister.nl).

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Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials.

Cheng-Le Zhuang, Xing-Zhao Ye, Xiao-Dong Zhang … (2013)

Enhanced recovery after surgery programs in colorectal surgery aim to attenuate the surgical stress response, reduce complications and shorten hospital stay. This study aimed to assess the safety and efficacy of enhanced recovery after surgery programs in colorectal surgery in comparison with traditional care. PubMed, Embase, and Cochrane databases were electronically searched (date range, January 1966 to July 2012). Randomized controlled trials were selected that compared enhanced recovery after surgery programs with traditional care in elective colorectal surgery. Articles were reviewed independently by 2 reviewers, who extracted the data and assessed the quality of the included studies. The outcome measures were analyzed, and the quality of evidence for each outcome was assessed by using the Grading of Recommendations Assessment, Development, and Evaluation system. The primary outcome measures were primary and total postoperative hospital stay, readmission rates, total postoperative complications (including general and surgical complications), and mortality. Thirteen studies (total, 1910 patients) were included in the meta-analysis. In comparison with traditional care, enhanced recovery after surgery programs were associated with significantly decreased primary hospital stay (weighted mean difference, -2.44 days; 95% CI, -3.06 to -1.83 days; p < 0.00001), total hospital stay (weighted mean difference, -2.39 days; 95% CI, -3.70 to -1.09 days; p = 0.0003), total complications (relative risk, 0.71; 95% CI, 0.58-0.86; p = 0.0006), and general complications (relative risk, 0.68; 95% CI, 0.56-0.82; p < 0.0001). No significant differences were found for readmission rates, surgical complications, and mortality. This study was limited by the risk of bias in most included studies. Enhanced recovery after surgery programs are safe and effective, and increased implementation is justified for perioperative care in colorectal surgery. Future studies may examine the benefits of enhanced recovery after surgery programs in elderly patients and in other GI surgery.

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Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol.

Timothy Miller, Julie Thacker, William D White … (2014)

Enhanced recovery after surgery (ERAS) is a multimodal approach to perioperative care that combines a range of interventions to enable early mobilization and feeding after surgery. We investigated the feasibility, clinical effectiveness, and cost savings of an ERAS program at a major U. S. teaching hospital. Data were collected from consecutive patients undergoing open or laparoscopic colorectal surgery during 2 time periods, before and after implementation of an ERAS protocol. Data collected included patient demographics, operative, and perioperative surgical and anesthesia data, need for analgesics, complications, inpatient medical costs, and 30-day readmission rates. There were 99 patients in the traditional care group, and 142 in the ERAS group. The median length of stay (LOS) was 5 days in the ERAS group compared with 7 days in the traditional group (P < 0.001). The reduction in LOS was significant for both open procedures (median 6 vs 7 days, P = 0.01), and laparoscopic procedures (4 vs 6 days, P < 0.0001). ERAS patients had fewer urinary tract infections (13% vs 24%, P = 0.03). Readmission rates were lower in ERAS patients (9.8% vs 20.2%, P = 0.02). Implementation of an enhanced recovery protocol for colorectal surgery at a tertiary medical center was associated with a significantly reduced LOS and incidence of urinary tract infection. This is consistent with that of other studies in the literature and suggests that enhanced recovery programs could be implemented successfully and should be considered in U.S. hospitals.

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Author and article information

Journal

Title: Diseases of the Colon & Rectum

Abbreviated Title: Diseases of the Colon & Rectum

Publisher: Ovid Technologies (Wolters Kluwer Health)

ISSN (Print): 0012-3706

Publication date Created: 2018

Publication date (Print): September 2018

Volume: 61

Issue: 9

Pages: 1108-1118

Article

DOI: 10.1097/DCR.0000000000001160

SO-VID: 8a1fe747-4765-4f3f-941b-328500d26ea3

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Enhanced Recovery Protocols for Adults Undergoing Colorectal Surgery : A Systematic Review and Meta-analysis

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Most cited references 38

Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study).

Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials.

Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol.

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