Enhanced recovery program following colorectal resection in the elderly patient.

BACKGROUND: The enhanced recovery program (ERP) aims to reduce the metabolic response to surgery, hastening recovery and shortening hospital stay. Concerns exist regarding morbidity and hospital stay in elderly patients. The present study aimed to compare the outcomes and compliance of elderly patients managed by an ERP protocol with a younger group. METHODS: A review was performed of a prospective database of patients undergoing colorectal resection managed under the ERP protocol between 2005 and 2010. Patients were grouped into <80 years and ≥ 80 years, and perioperative data were collated. The postoperative outcomes were compared with the goals set out by the ERP protocol. RESULTS: A total of 688 patients were included, 558 were <80 years (median: 66 years; range: 17-79 years) and 130 were ≥ 80 years (median: 83 years; range: 80-95 years). Some 96% of operations were planned laparoscopically. Median total length of hospital stay was 6 days (range: 1-108 days) for the <80 year group and 8 days (range: 1-167 days; P 0.363) for the elderly group, with a 30 day readmission rate of 8.6% for the population and no significant differences between groups. The 30 day mortality was 5%, with a significant difference between the two groups (P < 0.0001). Differences in protocol adherence were identified in the discontinuation of intravenous fluids, catheter removal, and early mobilization. CONCLUSIONS: An enhanced recovery program is feasible for colorectal surgery patients ≥ 80 years of age, with similar compliance as the younger group to some aspects of the protocol and an acceptable readmission rate. Attention to improving compliance in the postoperative phase is necessary, particularly in such high-risk patients, as such improvement may reduce the morbidity and mortality.

Training higher surgical trainees in laparoscopic common bile duct exploration.

BACKGROUND: Laparoscopic common bile duct (CBD) exploration is regarded as a safe, definitive procedure for ductal calculi, avoiding the complications of endoscopic retrograde cholangiopancreatography. We aimed to evaluate the outcomes of laparoscopic CBD exploration carried out by trainees compared to those of an experienced consultant (R.W.M.). METHODS: A prospective database of all cases of laparoscopic CBD exploration over a 15-year period was analyzed retrospectively. All patients underwent a four-port technique and intraoperative cholangiography. Patient demographics, operative technique, success, and complications were analyzed. RESULTS: The median age of patients undergoing laparoscopic CBD exploration was 65 years (range 14-94 years). In all, 187 (79%) of the CBD explorations were performed by one consultant and 48 (21%) by trainees. Calculi were successfully cleared in 141 (88%) and 43 (96%), respectively. There were two (<1%) conversions to an open procedure in the total group. The median operating time was 130 minutes in the consultant group versus 150 minutes in the trainee group (p < 0.05, Mann-Whitney U-test). There was no significant difference in CBD clearance rate, surgical approach, or complication rate between consultant and trainees (Fisher's exact test). CONCLUSIONS: Laparoscopic CBD exploration is a safe procedure in both consultant and trainee hands. With appropriate training, surgical trainees can achieve equivalent outcomes in CBD clearance with no significant difference in complication rates.