Effect of beta-blocker therapy on early mortality after emergency colonic cancer surgery.

BACKGROUND: Emergency colorectal cancer surgery is associated with significant mortality. Induced adrenergic hyperactivity is thought to be an important contributor. Downregulating the effects of circulating catecholamines may reduce the risk of adverse outcomes. This study assessed whether regular preoperative beta-blockade reduced mortality after emergency colonic cancer surgery. METHODS: This cohort study used the prospectively collected Swedish Colorectal Cancer Registry to recruit all adult patients requiring emergency colonic cancer surgery between 2011 and 2016. Patients were subdivided into those receiving regular beta-blocker therapy before surgery and those who were not (control). Demographics and clinical outcomes were compared. Risk factors for 30-day mortality were evaluated using Poisson regression analysis. RESULTS: A total of 3187 patients were included, of whom 685 (21·5 per cent) used regular beta-blocker therapy before surgery. The overall 30-day mortality rate was significantly reduced in the beta-blocker group compared with controls: 3·1 (95 per cent c.i. 1·9 to 4·7) versus 8·6 (7·6 to 9·8) per cent respectively (P < 0·001). Beta-blocker therapy was the only modifiable protective factor identified in multivariable analysis of 30-day all-cause mortality (incidence rate ratio 0·31, 95 per cent c.i. 0·20 to 0·47; P < 0·001) and was associated with a significant reduction in death of cardiovascular, respiratory, sepsis and multiple organ failure origin. CONCLUSION: Preoperative beta-blocker therapy may be associated with a reduction in 30-day mortality following emergency colonic cancer surgery.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018.

BACKGROUND: This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. METHODS: A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS: All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. CONCLUSIONS: The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Can an Enhanced Recovery After Surgery(ERAS) programme improve colorectal cancer outcomes in South Africa?

Colorectal cancer (CRC) is the third most common cancer worldwide and the fourth most common cause of cancer related deaths. It is estimated that CRC is amongst the top five malignancies in South Africa (SA) with an age standardised incidence rate of 10.2 and 6.1 per 100 000 for males and females respectively. The incidence is projected to increase in South Africa as a result of ageing, a growing population and an increase in prevalence of risk factors.

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice.

BACKGROUND: The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme. METHODS: Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English-language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature. RESULTS: This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations. CONCLUSIONS: Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi-institutional prospective and adequately powered randomized trials.

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations.

BACKGROUND: The present article has been written to convey concepts of anaesthetic care within the context of an Enhanced Recovery After Surgery (ERAS) programme, thus aligning the practice of anaesthesia with the care delivered by the surgical team before, during and after surgery. METHODS: The physiological principles supporting the implementation of the ERAS programmes in patients undergoing major abdominal procedures are reviewed using an updated literature search and discussed by a multidisciplinary group composed of anaesthesiologists and surgeons with the aim to improve perioperative care. RESULTS: The pathophysiology of some key perioperative elements disturbing the homoeostatic mechanisms such as insulin resistance, ileus and pain is here discussed. CONCLUSIONS: Evidence-based strategies aimed at controlling the disruption of homoeostasis need to be evaluated in the context of ERAS programmes. Anaesthesiologists could, therefore, play a crucial role in facilitating the recovery process.

A review of the scope and measurement of postoperative quality of recovery.

To date, postoperative quality of recovery lacks a universally accepted definition and assessment technique. Current quality of recovery assessment tools vary in their development, breadth of assessment, validation, use of continuous vs dichotomous outcomes and focus on individual vs group recovery. They have progressed from identifying pure restitution of physiological parameters to multidimensional assessments of postoperative function and patient-focused outcomes. This review focuses on the progression of these tools towards an as yet unreached ideal that would provide multidimensional assessment of recovery over time at the individual and group level. A literature search identified 11 unique recovery assessment tools. The Postoperative Quality of Recovery Scale assesses recovery in multiple domains, including physiological, nociceptive, emotive, activities of daily living, cognition and patient satisfaction. It addresses recovery over time and compares individual patient data with base line, thus describing resumption of capacities and is an acceptable method for identification of individual patient recovery.

Recommendations from the ERAS® Society for standards for the development of enhanced recovery after surgery guidelines.

BACKGROUND: ERAS® Society guidelines are holistic, multidisciplinary tools designed to improve outcomes after surgery. The enhanced recovery after surgery (ERAS) approach was initially developed for colorectal surgery and has been implemented successfully across a large number of settings, resulting in improved patient outcomes. As the ERAS approach is increasingly being adopted worldwide and new guidelines are being generated for new populations, there is a need to define an ERAS® Society guideline and the methodology that should be followed in its development. METHODS: The ERAS® Society recommended approach for developing new guidelines is based on the creation of multidisciplinary guideline development groups responsible for defining topics, planning the literature search, and assessing the quality of the evidence. RESULTS: Clear definitions for the elements of an ERAS guideline involve multimodal and multidisciplinary approaches impacting on multiple patient outcomes. Recommended methodology for guideline development follows a rigorous approach with systematic identification and evaluation of evidence, and consensus-based development of recommendations. Guidelines should then be evaluated and reviewed regularly to ensure that the best and most up-to-date evidence is used consistently to support surgical patients. CONCLUSION: There is a need for a standardized, evidence-informed approach to both the development of new ERAS® Society guidelines, and the adaptation and revision of existing guidelines.

ANTECEDENTES: Las guías de la sociedad ERAS® (Enhanced Recovery After Surgery) son herramientas holísticas y multidisciplinares diseñadas para mejorar los resultados después de la cirugía. Los programas ERAS (guías de recuperación intensificada) se desarrollaron inicialmente para la cirugía colorrectal y se han implementado con éxito en muchos otros ámbitos, lo que resulta en mejores resultados para los pacientes. A medida que los programas ERAS se adoptan cada vez más en todo el mundo y se generan nuevas guías para nuevas poblaciones, es necesario definir una guía clínica de la sociedad ERAS® y la metodología a seguir para su desarrollo. MÉTODOS: La sociedad ERAS® recomienda que el enfoque para desarrollar las nuevas guías se base en el establecimiento de grupos multidisciplinares responsables de la definición de los temas, planteamiento de la revisión de la literatura y valoración de la calidad de la evidencia. RESULTADOS: Las definiciones precisas de los elementos de una guía ERAS implican enfoques multimodales y multidisciplinares que tengan en cuenta los múltiples resultados que afectan a los pacientes. La metodología recomendada para el desarrollo de guías debe seguir un enfoque riguroso con identificación sistemática y evaluación de evidencia, y el desarrollo de recomendaciones basadas en el consenso. Posteriormente, las guías deben evaluarse y revisarse regularmente para garantizar que la evidencia mejor y más actualizada se aplique al manejo de los pacientes quirúrgicos. CONCLUSIÓN: Es necesario un enfoque estandarizado, basado en la evidencia, tanto para el desarrollo de nuevas guías de la sociedad ERAS® como para la adaptación y revisión de las guías ya existentes.

Haemoglobin A1c as a predictor of postoperative hyperglycaemia and complications after major colorectal surgery.

BACKGROUND: Hyperglycaemia following major surgery increases morbidity, but may be improved by use of enhanced-recovery protocols. It is not known whether preoperative haemoglobin (Hb) A1c could predict hyperglycaemia and/or adverse outcome after colorectal surgery. METHODS: Some 120 patients without known diabetes underwent major colorectal surgery within an enhanced-recovery protocol. HbA1c was measured at admission and 4 weeks after surgery. All patients received an oral diet beginning 4 h after operation. Plasma glucose was monitored five times daily. Patients were stratified according to preoperative levels of HbA1c (within normal range of 4.5-6.0 per cent, or higher). RESULTS: Thirty-one patients (25.8 per cent) had a preoperative HbA1c level over 6.0 per cent. These had higher mean(s.d.) postoperative glucose (9.3(1.5) versus 8.0(1.5) mmol/l; P < 0.001) and C-reactive protein (137(65) versus 101(52) mg/l; P = 0.008) levels than patients with a normal HbA1c level. Postoperative complications were more common in patients with a high HbA1c level (odds ratio 2.9 (95 per cent confidence interval 1.1 to 7.9)). CONCLUSION: Postoperative hyperglycaemia is common among patients with no history of diabetes, even within an enhanced-recovery protocol. Preoperative measurement of HbA1c may identify patients at higher risk of poor glycaemic control and postoperative complications.

Determinants of outcome after colorectal resection within an enhanced recovery programme.

BACKGROUND: Postoperative outcomes were studied in relation to adverse nutritional risk (body mass index (BMI) below 20 kg/m(2)), advanced age (80 years or more) and co-morbidity (American Society of Anesthesiologists (ASA) grade III-IV) in patients undergoing colorectal resection within an enhanced recovery after surgery programme. METHODS: Outcomes were audited prospectively in 1035 patients. Morbidity and mortality were compared with those predicted using the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity, and a multivariable model was used to determine independent predictors of outcome. RESULTS: Postoperative morbidity was lower than predicted (observed to expected 0.68; P < 0.001). Independent predictors of delayed mobilization were ASA III-IV (P < 0.001) and advanced age (P = 0.025). Prolonged hospital stay was related to advanced age (P = 0.002), ASA III-IV (P < 0.001), male sex (P = 0.037) and rectal surgery (P < 0.001). Morbidity was related to ASA III-IV (P = 0.004), male sex (P = 0.023) and rectal surgery (P = 0.002). None of the factors predicted 30-day mortality. CONCLUSION: Age and nutritional status were not independent determinants of morbidity or mortality. Pre-existing co-morbidity was an independent predictor of several outcomes.

Nausea and vomiting in a colorectal ERAS program: Impact on nutritional recovery and the length of hospital stay.

BACKGROUND & AIMS: Postoperative nausea and vomiting (PONV) and its impact on the hospital length of stay (LOS), have been extensively studied. However, most previous publications focused their studies on PONV during the first 24 h, and less is known about this complication during the ensuing days, its impact on nutritional recovery or its relation to other complications and the course of care. METHODS: An observational study involving 806 consecutive patients in a colorectal Enhanced Recovery After Surgery (ERAS) programme was performed. The primary objective was to analyse the incidence of early PONV on the day of surgery and the following 2 postoperative days (late PONV). Secondary objectives included evaluation of the influence of late PONV over the LOS and the nutritional recovery adjusted for confounding factors. RESULTS: PONV tended to increase over time (7% vs 7% and 10%, postop days 0, 1 and 2, respectively; p < 0.05). PONV on day 2 was associated in an adjusted analysis with poor oral intake, delayed solid food tolerance and an average increase in LOS of 2 nights. Risk factors for the presence of PONV on day 2 were the use of opioids on the same day, PONV on the day of the surgery and rectal procedures. CONCLUSIONS: PONV continues to be frequent after the first 24 h in colorectal surgery despite high compliance to current anti emetic recommendations. PONV during day 2 negatively affects the nutritional postoperative recovery and independently prolongs the hospital stay. The findings of the current study highlight the adverse effects of opioids and the need of further discussion on how to best audit, prevent and treat late PONV in ERAS colorectal programmes.

Pre-operative carbohydrate loading may be used in type 2 diabetes patients.

BACKGROUND: Post-operative insulin resistance and hyperglycaemia are associated with an impaired outcome after surgery. Pre-operative oral carbohydrate loading (CHO) reduces post-operative insulin resistance with a reduced risk of hyperglycaemia during post-operative nutrition. Insulin-resistant diabetic patients have not been given CHO because the effects on pre-operative glycaemia and gastric emptying are unknown. METHODS: Twenty-five patients (45-73 years) with type 2 diabetes [glycated haemoglobin (HbA1c) 6.2 +/- 0.2%, mean +/- SEM] and 10 healthy control subjects (45-72 years) were studied. A carbohydrate-rich drink (400 ml, 12.5%) was given with paracetamol 1.5 g for determination of gastric emptying. RESULTS: Peak glucose was higher in diabetic patients than in healthy subjects (13.4 +/- 0.5 vs. 7.6 +/- 0.5 mM; P<0.01) and occurred later after intake (60 vs. 30 min; P<0.01). Glucose concentrations were back to baseline at 180 vs. 120 min in diabetic patients and healthy subjects, respectively (P<0.01). At 120 min, 10.9 +/- 0.7% and 13.3 +/- 1.2% of paracetamol remained in the stomach in diabetic patients and healthy, subjects respectively. Gastric half-emptying time (T50) occurred at 49.8 +/- 2.2 min in diabetics and at 58.6 +/- 3.7 min in healthy subjects (P<0.05). Neither peak glucose, glucose at 180 min, gastric T50, nor retention at 120 min differed between insulin (HbA1c 6.8 +/- 0.7%)- and non-insulin-treated (HbA1c 5.6 +/- 0.4%) patients. CONCLUSIONS: Type 2 diabetic patients showed no signs of delayed gastric emptying, suggesting that a carbohydrate-rich drink may be safely administrated 180 min before anaesthesia without risk of hyperglycaemia or aspiration pre-operatively.

Minimal effect on energy intake by additional evening meal for frail elderly service flat residents--a pilot study.

BACKGROUND: Nutritional problems are common in frail elderly individuals receiving municipal care. OBJECTIVE: To evaluate if an additional evening meal could improve total daily food intake, nutritional status, and health-related quality of life (HRQOL) in frail elderly service flat (SF) residents. DESIGN: Out of 122 residents in two SF complexes, 60 subjects agreed to participate, of which 49 subjects (median 84 (79-90) years, (25th-75th percentile)) completed the study. For six months 23 residents in one SF complex were served 530 kcal in addition to their regular meals, i.e. intervention group (I-group). Twenty-six residents in the other SF building were controls (C-group). Nutritional status, energy and nutrient intake, length of night time fast, cognitive function and HRQOL was assessed before and after the intervention. RESULTS: At the start, the Mini Nutritional Assessment classified 27% as malnourished and 63% as at risk for malnutrition, with no difference between the groups. After six months the median body weight was unchanged in the I-group, +0.6 (-1.7-+1.6) kg (p=0.72) and the C-group -0.6 (-2.0-+0.5) kg (p=0.15). Weight change ranged from -13% to +15%. The evening meal improved the protein and carbohydrate intake (p<0.01) but the energy intake increased by only 180 kcal/day (p=0.15). The night time fast decreased in the I-group from 15.0 (13.0-16.0) to 13.0 (12.0-14.0) hours (p<0.05). There was no significant difference in cognitive function or HRQOL between the groups. CONCLUSION: Nine out of ten frail elderly SF residents had nutritional problems. Serving an additional evening meal increased the protein and carbohydrate intake, but the meal had no significant effect on energy intake, body weight or HRQOL. The variation in outcome within each study group was large.

A multicentre qualitative study assessing implementation of an Enhanced Recovery After Surgery program.

BACKGROUND & AIMS: The existence of enhanced recovery specific guidelines (ERAS) is not enough to change patient management practice since many barriers exist to successful ERAS implementation. The present survey aimed to analyse motivations for implementation as well as encountered difficulties and challenges. Further, relevance and importance of perioperative care items and postoperative recovery targets were assessed. METHODS: A multicentre qualitative study was conducted between August and December 2016 among surgeons, anaesthesiologists and nurses from implemented ERAS centres in Switzerland (n = 16) and Sweden (n = 14). An online survey (31 closed questions) was sent by email, with reminders at 4, 8 and 12 weeks. RESULTS: Seventy-seven out of 146 experts completed the survey (response rate 52.7%). Main motivations to implement ERAS were the expectation to reduce complications (91%), higher patient satisfaction (73%) and shorter hospital stay (62%). The application of ERAS program represented major changes in clinical practice for 57% of participants without significant differences between various specialities (surgeons: 63%, nurses: 63%, anaesthesiologists: 36%, p = 0.185). The most important barriers for straightforward implementation were time restraints (69%), opposing colleagues (68%) and logistical reasons (66%). The 3 most frequently cited patient-related barriers to adopt ERAS were opposing personality (52%), co-morbidities (49%) and language barriers (31%). CONCLUSIONS: Implementing ERAS care into practice was challenging and required important changes in clinical practice for all involved specialities. Main reasons for implementation were the expectation to reduce complications and hospital stay with improved patients' satisfaction. Main barriers were time restraints, reluctance to change and logistics.