Randomized Controlled Trial of Enhanced Recovery Program Dedicated to Elderly Patients After Colorectal Surgery.

BACKGROUND: Enhanced recovery program is a multimodal, multidisciplinary-team, evidence-based care approach to reduce perioperative surgical stress, decrease morbidity and hospital stay, and improve recovery after surgery. This program may be most beneficial for elderly (≥70 y), but sparse series have investigated this question. OBJECTIVE: Feasibility and efficiency of a dedicated enhanced recovery program in the elderly as compared with standard care were studied. DESIGN: This was a nonblinded, randomized controlled study. SETTINGS: This study was conducted in a single high-volume university hospital. PATIENTS: A total of 150 eligible elderly patients undergoing elective colorectal surgery were included. INTERVENTIONS: Enhanced recovery after colorectal elective surgery in elderly patients was studied. MAIN OUTCOME MEASURES: The primary outcome was 30-day postoperative morbidity. Additional outcomes included hospital stay, readmission, postoperative pain, opioid consumption, independence preservation, and protocol compliance. RESULTS: An enhanced recovery program reduces postoperative morbidity according to Clavien-Dindo classification by 47% as compared with standard care (35% vs 65%; p = 0.0003), total number of complications (54 vs 118; p = 0.0003), and infectious complications (13 vs 29; p = 0.001). No anastomotic leak was recorded in the enhanced recovery group versus 5 for the standard group (p = 0.01). The enhanced recovery program resulted in shorter hospital stay (7 vs 12 d; p = 0.003) and better independence preservation (home discharge, 87% vs 67%; p = 0.005). A high protocol compliance of 77.2% could be achieved in this population. According to multivariate analysis, enhanced recovery program was strongly associated with reduced morbidity (OR = 0.23 (95% CI, 0.09-0.57); p = 0.001), less severe complications (OR = 0.36 (95% CI, 0.15-0.84); p = 0.02), and shorter hospital stay (OR = 2.07 (95% CI, 1.33-3.22); p = 0.001). LIMITATIONS: Limitations were a single-center recruitment and the impossibility of subject or healthcare professional blinding attributed to the nature of this multimodal program. CONCLUSIONS: Enhanced recovery program is safe and improves postoperative recovery in elderly patients with decreased morbidity, shorter hospital stay, and better maintenance of independence. It should therefore be considered as a standard of care for elective colorectal surgery in elderly patients. See Video Abstract at http://links.lww.com/DCR/A981. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01646190. ENSAYO CONTROLADO ALEATORIZADO DE UN PROGRAMA DE RECUPERACIÓN INTENSIFICADA DEDICADO A PACIENTES DE EDAD AVANZADA DESPUÉS DE CIRUGÍA COLORECTAL: El Programa de Recuperación Intensificada es un enfoque de atención multimodal, multidisciplinaria y basada en evidencia para reducir el estrés quirúrgico perioperatorio, disminuir la morbilidad y la estancia hospitalaria, y mejorar la recuperación después de la cirugía. Este programa puede ser más beneficioso para las personas mayores (≥70 años), pero pocas series han investigado esta pregunta. OBJETIVO: Viabilidad y eficiencia del Programa de Recuperación Intensificada dedicado en personas de edad avanzada en comparación con la atención estándar. DISEÑO:: Este fue un estudio controlado, aleatorizado, sin método ciego. ESCENARIO: Este estudio se realizó en un único hospital universitario de alto volumen. PACIENTES: Un total de 150 pacientes de edad avanzada elegibles sometidos a cirugía colorrectal electiva fueron incluidos. INTERVENCIONES: Recuperación Intensificada después de cirugía electiva colorrectal en pacientes de edad avanzada. PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario fue la morbilidad postoperatoria a 30 días. Los resultados adicionales incluyeron estancia hospitalaria, reingreso, dolor postoperatorio, consumo de opioides, preservación de la independencia y cumplimiento del protocolo. RESULTADOS: El Programa de Recuperación Intensificada reduce la morbilidad postoperatoria según la clasificación de Clavien-Dindo en un 47% en comparación con la atención estándar (35% vs 65%; p = 0.0003), número total de complicaciones (54 vs 118; p = 0.0003) y complicaciones infecciosas (13 vs 29; p = 0.001). No se registró ninguna fuga anastomótica en el grupo de Recuperación Intensificada frente a 5 para el grupo estándar (p = 0.01). El Programa de Recuperación Intensificada dio como resultado una estancia hospitalaria más corta (7 contra 12 días; p = 0.003) y una mejor conservación de la independencia (alta hospitalaria: 87% vs 67%; p = 0.005). Se pudo lograr un alto cumplimiento del protocolo del 77.2% en esta población. De acuerdo con el análisis multivariable, el Programa de Recuperación Intensificada se asoció fuertemente con la reducción de morbilidad (OR = 0.23; IC 95%: 0.09-0.57; p = 0.001), menos complicaciones graves (OR = 0.36; IC 95%: 0.15-0.84; p = 0.02) y estancia hospitalaria más corta (OR = 2.07; IC 95%: 1.33-3.22; p = 0.001). LIMITACIONES: Las limitaciones fueron un centro único de reclutamiento y la imposibilidad de que los pacientes o el profesional de la salud tuvieran cegamiento debido a la naturaleza de este programa multimodal. CONCLUSIONES: El Programa de recuperación Intensificada es seguro y mejora la recuperación postoperatoria en pacientes de edad avanzada, con menor morbilidad, menor estancia hospitalaria y mejor mantenimiento de la independencia. Por lo tanto, debe considerarse como un estándar de atención para la cirugía colorrectal electiva en pacientes de edad avanzada. Vea el Resumen en video en http://links.lww.com/DCR/A981.

Reconstructive operations for enteric and colonic fistulas: Low mortality and recurrence in a single-surgeon series with long follow-up.

BACKGROUND: The aim of the study was to evaluate the outcomes of 100 consecutive patients undergoing reconstructive operation for enteric and colonic fistulas. These fistulas cause dramatic morbidity and profoundly diminish quality of life. Fistula takedown has been associated with high rates of recurrence. METHODS: Consecutive patients undergoing definitive fistula reconstruction by a single surgeon were reviewed retrospectively. Major adverse outcomes included bowel leak, fistula recurrence, death, total parenteral nutrition dependence, and incidence of new stomas. RESULTS: Among the 100 patients, median follow-up was 2.7 years. A total of 11 patients had postoperative leaks that evolved to 5 fistula recurrences. Of these patients 3 underwent successful secondary or tertiary takedown. The 30-day mortality rate was 1%, and the combined postoperative and fistula-related mortality rate at follow-up was 3%. New postoperative total parenteral nutrition dependence occurred in 2 patients (2%), and 9 (9%) had placement of a new stoma. Leaks were more frequent for patients who had a history of open abdomen than for patients who did not. CONCLUSIONS: With minimal patient selection and a methodic approach to evaluation and management, we achieved a 96% fistula-free survival rate. Few patients acquired new total parenteral nutrition dependence or a new stoma. These results compare favorably with outcomes published elsewhere.

Clinical outcomes of the very elderly undergoing enhanced recovery programmes in elective colorectal surgery.

Introduction Enhanced recovery programmes (ERPs) have been shown to improve short-term outcomes after major colorectal surgery. Benefits of the ERP in patients who are very elderly (VE) are less well understood. We aimed to evaluate the role of the ERP in the VE population, which for the purpose of this study was defined as any patient aged 75 years or over. Methods A prospectively compiled database was used to identify all patients aged ≥75 years who underwent elective colorectal resection in our unit between January 2011 and September 2012. These data were analysed to study the short-term outcomes in these patients and compared with those of patients aged <75 years. Results Overall, 352 patients underwent elective surgery during this period; 106 were identified as VE. The median length of stay (LOS) in the VE group was 7 days (5 days in non-VE group; p=0.002). Two-thirds (62%) underwent laparoscopic surgery. The median LOS of VE patients undergoing laparoscopic surgery was 6 days (11 days for open surgery; p=0.003). A third (33%) of the VE cohort was discharged by day 5. Of these patients, 85% underwent laparoscopic surgery. There was no statistical difference in overall complication rates (VE vs non-VE). Conclusions Accepting that some VE patients may stay in hospital for longer, this study supports our current policy of including everyone in the ERP regardless of age. Patients undergoing laparoscopic surgery appear to benefit, with a shorter LOS. Further large scale trials are required to support the results of this study and to identify long-term outcomes.

Outcomes after implementation of a multimodal standard care pathway for laparoscopic colorectal surgery.

BACKGROUND: The aim of the study was to assess which aspects of an enhanced recovery programme are associated with better outcomes following laparoscopic colorectal surgery. METHODS: A database of laparoscopic colorectal procedures performed in 2011 was reviewed. Elements of the enhanced recovery programme and compliance were evaluated for short-term (30-day) outcomes. Individual elements included gabapentin, celecoxib, intrathecal analgesia, diet, postoperative fluids, and paracetamol/non-steroidal anti-inflammatory drug pain management. RESULTS: Five hundred and forty-one consecutive procedures were included. Compliance with the enhanced recovery programme elements ranged from 82.4 to 99.3 per cent. Median length of hospital stay was 3 (i.q.r. 2-5) days, with 25.9 per cent of patients discharged within 48 h. Patients without complications had a median length of stay of 3 (i.q.r. 2-4) days if compliant and 3 (3-5) days if not (P < 0.001). Low oral opiate intake (oral morphine equivalent of less than 30 mg) (odds ratio (OR) 1.97, 95 per cent confidence interval 1.29 to 3.03; P = 0.002), full compliance (OR 2.36, 1.42 to 3.90; P < 0.001) and high surgeon volume (more than 100 cases per year) (OR 1.50, 1.19 to 1.89; P < 0.001) were associated with discharge within 48 h. Compliance with the elements of oral intake and fluid management in the first 48 h was associated with a reduced rate of complications (8.1 versus 19.6 per cent; P = 0.001). Median oral opiate intake was 37.5 (i.q.r. 0-105) mg in 48 h, with 26.2 per cent of patients receiving no opiates. CONCLUSION: Compliance with an enhanced recovery pathway was associated with less opiate use, fewer complications and a shorter hospital stay.

[Multimodal rehabilitation program in elective colorectal surgery: Impact on hospital costs]. / Impacto de un programa de rehabilitación multimodal en cirugía electiva colorrectal sobre los costes hospitalarios.

INTRODUCTION: Multimodal rehabilitation (MMRH) programs in surgery have proven to be beneficial in functional recovery of patients. The aim of this study is to evaluate the impact of a MMRH program on hospital costs. METHOD: A comparative study of 2 consecutive cohorts of patients undergoing elective colorectal surgery has been designed. In the first cohort, we analyzed 134 patients that received conventional perioperative care (control group). The second cohort included 231 patients treated with a multimodal rehabilitation protocol (fast-track group). Compliance with the protocol and functional recovery after fast-track surgery were analyzed. We compared postoperative complications, length of stay and readmission rates in both groups. The cost analysis was performed according to the system «full-costing¼. RESULTS: There were no differences in clinical features, type of surgical excision and surgical approach. No differences in overall morbidity and mortality rates were found. The mean length of hospital stay was 3 days shorter in the fast-track group. There were no differences in the 30-day readmission rates. The total cost per patient was significantly lower in the fast-track group (fast-track: 8.107 ± 4.117 euros vs. control: 9.019 ± 4.667 Euros; P=.02). The main factor contributing to the cost reduction was a decrease in hospitalization unit costs. CONCLUSION: The application of a multimodal rehabilitation protocol after elective colorectal surgery decreases not only the length of hospital stay but also the hospitalization costs without increasing postoperative morbidity or the percentage of readmissions.

Impact of an enhanced recovery program on short-term outcomes after scheduled laparoscopic colon resection.

INTRODUCTION: Both enhanced recovery programs (ERP) and laparoscopy can reduce complications and length of stay (LOS) in colon surgery. We investigated whether ERP further improved the short-term outcomes of scheduled laparoscopic colectomies. METHODS: We performed an audit of all patients undergoing scheduled laparoscopic colon resection between January 2003 and August 2010 in our institution. An ERP including accelerated introduction of oral nutrition, mobilization, pain control, and catheter management was introduced in 2005. Demographic data, intra and postoperative details and 30-day ER visit and readmission rate were collected. We compared LOS and short-term outcomes for patients on the program with those receiving traditional postoperative care using Chi-square and regression models. Data are presented as median [25th, 75th percentile]. Statistical significance was defined as p < 0.05. RESULTS: 136 (46%) of 297 eligible patients were enrolled in the ERP. At baseline, the two groups had similar demographic characteristics, but patients in the ERP were more likely to have their operation by a colorectal surgeon (p = 0.01). Patients in the ERP ate solids earlier (p < 0.001) and had earlier removal of their urinary catheter (p < 0.001). LOS was 4 [3, 6] days for both groups (p < 0.01), with more patients in the ERP discharged by POD 3 (p < 0.001). After adjusting for other variables, ERP enrolment remained an independent predictor of LOS (p < 0.01), along with age (p < 0.01) and in-hospital complications (p < 0.001). Complication rates were similar between the two groups. Patients in the ERP had significantly fewer ER visits (p = 0.02), but there were no differences in readmission rates. CONCLUSION: In patients undergoing scheduled laparoscopic colectomy in a university-based clinical teaching unit, ERP can further reduce length of stay and postoperative ER visits without increasing readmission rates.

Adoption of enhanced recovery after surgery (ERAS) strategies for colorectal surgery at academic teaching hospitals and impact on total length of hospital stay.

OBJECTIVE: The objective of enhanced recovery after surgery (ERAS) programs is to incorporate strategies into the perioperative care plan to decrease complications, hasten recovery, and shorten hospital stay. This study was designed to determine which ERAS strategies contribute to overall shortened length of hospital stay in patients undergoing elective colorectal surgery in hospitals. METHODS: A retrospective cohort study of 336 consecutive patients at seven hospitals was performed. Demographic and data on 18 ERAS components identified from a systematic review of the literature were collected. A multiregression analysis was performed to assess for factors independently associated with a total length of hospital stay of 5 days or less. RESULTS: Fifty-five percent were male (mean age, 62 years), 57.5% had an ASA III or IV, 76.9% had cancer, and 28.6% had low rectal procedures; 46.3% were completed laparoscopically. The median length of stay was 6.5 days with a mean of 8.6 days. On bivariate analysis, strategies associated with a stay ≤ 5 days were preoperative counseling, avoidance of oral bowel preparation, use of a laparoscopic approach, use of a transverse incision, introduction of clear fluids on day of surgery, and early discontinuation of the Foley catheter (all P < 0.05). On multivariate analysis, factors that remained significantly associated with a stay ≤ 5 days included use of a laparoscopic approach (odds ratio (OR), 1.24; 95% confidence interval (CI), 1.12-1.38), preoperative counseling (OR, 1.26; 95% CI, 1.15-1.38), intraoperative fluid restriction (OR, 1.26; 95% CI, 1.15-1.37), clear fluids on day of surgery (OR, 1.09; 95% CI, 1.00-1.2), and Foley urinal catheter discontinued within 24 h of colon surgery and 72 h of rectal surgery (OR, 1.13; 95% CI, 1.01-1.27). CONCLUSIONS: In hospitals with variable uptake of ERAS strategies, preoperative counseling, intraoperative fluid restriction, use of a laparoscopic approach, immediate initiation of clear fluids after surgery, and early discontinuation of the Foley catheter are all independently associated with shortened length of stay.

Enhanced recovery after colon surgery in a community hospital system.

BACKGROUND: Enhanced recovery after colon surgery has not been widely adopted in the United States and Europe, despite evidence that postoperative complications and hospital length of stay are decreased. OBJECTIVE: We sought to evaluate the introduction of a comprehensive care process for enhanced recovery after colon surgery in 8 community hospitals. DESIGN: A system-wide, surgeon-directed, multidisciplinary committee developed a comprehensive enhanced-care quality-improvement program. Surgeons and operations leaders in each hospital developed the internal structure to implement the process. PATIENTS: Surgeons had the option of entering or not entering patients in the enhanced-care pathway. Other than trauma patients, there were no exclusion criteria. MAIN OUTCOME MEASURES: To limit selection bias, the study population included all patients undergoing colon resections (those entered and not entered in the care process). Length of stay, postoperative days, hospital costs, 30-day readmission rate, and return to surgery for the study population were compared with a 2-year historical baseline. RESULTS: Forty-two percent of the study population was entered in the enhanced-care process. The average length of stay and the number of postoperative days in the study population decreased by 1.5 (P < .0001) and 1.3 (P < .0001) days. The rate of readmissions and returns to surgery remained stable (P > .05), and the average hospital cost decreased by $1763 (P = .02). Generalized linear regression analysis demonstrated that the enhanced-care process was a more significant variable than was the surgical approach (laparoscopic vs open surgery) in decreasing length of stay. LIMITATIONS: The degree of compliance with care process elements and the relative contribution of each element of the care process are unknown. CONCLUSIONS: A comprehensive enhanced-care colon surgery care process was successfully introduced in a community hospital system, as indicated by the clinical outcome measures.

Enhanced recovery programme in colorectal surgery: a challenging approach.

The enhanced recovery programme in colorectal surgery is an exciting and innovative new approach for pre- and postoperative management of surgical patients. It challenges some of the non-evidence-based practices and myths which have been entrenched in the minds of clinicians for decades.

Feedback on an enhanced recovery programme for colorectal surgery.

UNLABELLED: This article describes a study carried out to examine service users' views on an enhanced recovery programme (ERP) for colorectal surgery patients, in order to improve service provision. BACKGROUND: ERPs combine elements to enhance patients' recovery before, during and after surgery, but patient experiences are unknown. METHOD: 50 patients were invited to attend one of three focus groups in May and June 2009. FINDINGS: Ten users attended the focus groups. All were generally very satisfied with the ERP, primarily because they could leave hospital quickly and felt empowered to take charge of their own recovery. Areas of concern included support after discharge, postoperative diet and achieving optimum analgesia following discontinuation of continuous analgesic infusions. CONCLUSIONS: This patient sample indicated that the ERP offers clear benefits. Feedback was turned into realistic action plans, concerns were addressed and the service enhanced. Obtaining feedback is vital for improving the quality of care and keeping patients at the centre of health services.

Fertility after colorectal resection for endometriosis: results of a prospective study comparing laparoscopy with open surgery.

OBJECTIVE: To determine whether the surgical route of colorectal resection for endometriosis is a determinant factor for fertility. DESIGN: Prospective study. SETTING: Tertiary-care university hospital. PATIENT(S): Fifty-two patients with endometriosis were randomly assigned to laparoscopic or open surgery. INTERVENTION(S): Laparoscopically assisted vs. open colorectal resection. MAIN OUTCOME MEASURE(S): Evaluation of fertility outcomes spontaneously and after assisted reproductive therapy. RESULT(S): The mean follow-up was 29 months. Among the 28 patients wishing to conceive, 11 (39.3%) became pregnant. Overall cumulative pregnancy rate at 52 months for these patients was 45.1%. For patients with or without infertility, the cumulative pregnancy rate was 37.6% and 55.6%, respectively, and the cumulative spontaneous pregnancy rate 13.3% and 36.5%, respectively. All the spontaneous pregnancies were observed in the laparoscopy group. CONCLUSION(S): This study demonstrates that spontaneous pregnancy is more frequent after laparoscopy compared with open surgery for colorectal endometriosis.

Short hospital stay and low complication rate are possible with a fully implemented fast-track model after elective colonic surgery.

PURPOSE: The aim was to implement a fast-track model in a colorectal unit. We evaluated its effects on hospital stay and complication rate after elective open colonic surgery. METHODS: A fast-track programme was fully implemented, with a dedicated staff and a schedule for all perioperative procedures which included provision of information to patients, surgical guidelines, mobilisation and postoperative care. All previously existing procedures were modified according to previously published guidelines. Criteria for success with regard to the length of hospital stay and rates and types of complications were defined. Fast-tracked patients were compared with patients not included in the programmes that were operated during the same period. RESULTS: 131 fast-tracked patients were compared with 39 control patients. The fast track significantly reduced the median hospital stay from 7 to 3 days (p < 0.0001). There was no difference in complication rates between the two groups, and no major complications were observed after early discharge from the hospital. The readmission rate was 15% in the fast-track group and 16% with the control patients. CONCLUSION: Implementation of a fast track after open elective colonic surgery is safe and reduces the length of hospital stay.

Comparison of early mobilization and diet rehabilitation program with conventional care after laparoscopic colon surgery: a prospective randomized controlled trial.

PURPOSE: Although laparoscopic surgery may permit earlier recovery compared with open surgery, no published randomized controlled trial has investigated the benefit of a multimodal rehabilitation program after laparoscopic colonic resection. This study aimed to evaluate the efficacy of a rehabilitation program after laparoscopic colon surgery in the context of a randomized controlled trial. METHODS: Between September 2007 and October 2009, 100 patients who had received laparoscopic colon surgery were selected for the study and randomly assigned on a 1:1 basis to a rehabilitation program group with early mobilization and diet (n = 46) or conventional care group (n = 54). The rehabilitation program group received early oral feeding, early ambulation, and regular laxative. The primary outcome was recovery time, measured with criteria of tolerable diet for 24 hours, safe ambulation, analgesic-free, and afebrile status without major complications. Secondary outcomes were postoperative hospital stay, complications, quality of life by Short Form 36, pain by visual analog scale, and readmission. This study was registered (ID number NCT00606944, http://register.clinicaltrials.gov). RESULTS: Recovery time was shorter in the rehabilitation program group than in the conventional care group (median (interquartile range), 4 (3-5) d vs 6 (5-7) d, respectively; P < .0001). There was no difference in postoperative hospital stay between the 2 groups (rehabilitation program group, 7 (6-8) d vs conventional care group, 8 (7-9) d; P = .065). There was no difference in complication rates between the rehabilitation program group and conventional care group (10.9% vs 20.4%, respectively; P = .136). Quality of life and pain were similar in both groups. There were no readmissions or mortality. CONCLUSIONS: A rehabilitation program with early mobilization and diet after laparoscopic colon surgery results in reduced recovery time without increased complications. These results suggest that a multimodal rehabilitation program may increase the short-term benefits after laparoscopic colon surgery.

Impact of an enhanced recovery programme in colorectal surgery.

Surgery is undergoing revolutionary change as a result of newer approaches to pain control, the introduction of techniques that reduce the post-operative stress response, and the use of minimally invasive operations, such as laparoscopic surgery. As demand for hospital beds continues to escalate, it is paramount that patients recover from surgery quickly and safely; the use of evidence-based interventions to hasten recovery within an enhanced recovery programme (ERP) can play a vital role in achieving this, as well as reducing costs by shortening hospital stay. This article outlines the principles and key elements of an ERP, and discusses how it can help to achieve an improved and safe recovery and shorter hospital stay for patients, thereby reducing the cost to the NHS of inpatient treatment and recovery. The literature surrounding the development of 'enhanced recovery' (also called 'fast-track') surgery is reviewed to determine whether it is appropriate for patients undergoing elective colorectal surgery.

Randomized clinical trial of prehabilitation in colorectal surgery.

BACKGROUND: 'Prehabilitation' is an intervention to enhance functional capacity in anticipation of a forthcoming physiological stressor. In patients scheduled for colorectal surgery, the extent to which a structured prehabilitation regimen of stationary cycling and strengthening optimized recovery of functional walking capacity after surgery was compared with a simpler regimen of walking and breathing exercises. METHODS: Some 112 patients (mean(s.d.) age 60(16) years) were randomized to either the structured bike and strengthening regimen (bike/strengthening group, 58 patients) or the simpler walking and breathing regimen (walk/breathing group, 54 patients). Randomization was done at the surgical planning visit; the mean time to surgery available for prehabilitation was 52 days; follow-up was for approximately 10 weeks after surgery. RESULTS: There were no differences between the groups in mean functional walking capacity over the prehabilitation period or at postoperative follow-up. The proportion showing an improvement in walking capacity was greater in the walk/breathing group than in the bike/strengthening group at the end of the prehabilitation period (47 versus 22 per cent respectively; P = 0.051) and after surgery (41 versus 11 per cent; P = 0.019). CONCLUSION: There was an unexpected benefit from the recommendation to increase walking and breathing, as designed for the control group. Adherence to recommendations was low. An examination of prehabilitation 'responders' would add valuable information.

Colorectal endometriosis: benefits of long-term follow-up in patients who underwent laparoscopic surgery.

In this retrospective cohort study, three groups of patients were included: 60 women who underwent endometriosis surgery with colorectal segmental resection, 40 women with surgical evidence of bowel endometriosis who underwent endometriosis removal without bowel resection, and 55 women affected by moderate or severe endometriosis with at least one endometrioma and deep infiltrating endometriosis but without bowel involvement. The results of a long-term ambulatory follow-up showed that if colorectal endometriosis was present, postoperative pain regression was more frequent, and among patients with bowel endometriosis the rate of recurrence was lower if segmental resection was performed.

[Quicker recovery from elective colon surgery: anaesthesiological aspects of the fast-track programme]. / Sneller beter na een electieve colonoperatie. Aesthesiologische aspecten van het 'sneltraject'-programma.

A multidisciplinary approach for patients who will undergo colonic resection was introduced in 2006 and 2007 in 26 Dutch hospitals, following several other European centres. This approach aims to place the patient in an optimal metabolic state before operation, with subsequent rapid mobilisation and resumption of oral intake of liquids and solid food. The surgeon, anaesthetist, and nursing staff collaborate in this approach, each taking responsibility for specific tasks. The anaesthesiological tasks consist of withholding preoperative intake of drink and food, appropriate pain reduction, perioperative fluid balance management, use of inotropic and vasopressor drugs, prevention of post-operative nausea and vomiting, and addressing possible immunological consequences of surgery.

An enhanced-recovery protocol improves outcome after colorectal resection already during the first year: a single-center experience in 168 consecutive patients.

PURPOSE: This study was designed to investigate the clinical outcome and recovery before and immediately after implementation of the enhanced recovery after surgery enhanced recovery after surgery protocol in colonic and rectal resection. METHODS: One hundred and sixty-eight consecutive patients in a single center underwent colorectal surgery before (traditional, n = 69) and immediately after implementing enhanced recovery after surgery (n = 99). Rectal surgery was performed in 77 patients. Postoperative food and fluid intake, mobilization, physiologic function, and clinical outcome were measured prospectively. RESULTS: Resumption of oral diet was achieved on postoperative day postoperative day 1 in the enhanced recovery after surgery group. In the enhanced recovery after surgery group, mobilization more than 6 hours daily was achieved on postoperative day 2 to 3 and passage of stool occurred on postoperative day 2 vs. postoperative day 5 in the traditional group (P < 0.0001). Muscle strength and lung function were less reduced in the enhanced recovery after surgery group (P < 0.05). Median hospital stay was reduced by 2 days (P < 0.01). Readmission rates increased (4 percent vs. 15 percent, P < 0.01) but total hospital stay was still lower in the enhanced recovery after surgery group (P < 0.01). After colonic resection, postoperative complications decreased in enhanced recovery after surgery (37 percent vs. 18 percent, P < 0.05), whereas no change was found after rectal resection. CONCLUSION: Immediately after implementing enhanced recovery after surgery, recovery was improved and length of hospital stay was reduced. Notably, postoperative morbidity decreased only in patients undergoing colonic resection.

A prospective study on the influence of a fast-track program on postoperative fatigue and functional recovery after major colonic surgery.

INTRODUCTION: Enhanced Recovery After Surgery (ERAS) programs have demonstrated significant reduction in hospital stay for patients undergoing colonic surgery; however, their impact on long-term outcomes, such as postoperative fatigue (POF), has not been fully established. AIM: To assess the impact of an ERAS program on POF and recovery following elective open colonic surgery. METHOD: In a prospective study, 26 consecutive patients undergoing open colonic surgery under a conventional care plan were compared with 26 consecutive patients in an ERAS program. RESULTS: Demographic and clinical characteristics were comparable at baseline. The median duration of total hospital stay (4 versus 7 d, P < 0.001), rates of urinary tract infections (P = 0.028) and ileus (P = 0.042) were significantly smaller in the ERAS group. Postoperatively, POF significantly increased in both groups. However, peak POF score was significantly lower in the ERAS group (P = 0.001). In the first 30 d after surgery, Fatigue Consequence scores were also significantly smaller in the ERAS group. Overall, the total fatigue experience (P = 0.035) and the total fatigue impact (P = 0.005) were significantly smaller in the ERAS group. CONCLUSION: The impact of ERAS programs may extend beyond the commonly reported short-term outcomes, and ERAS may accelerate overall recovery and return to normal function.