[A prehabilitation program for patients undergoing elective resection of a colorectal carcinoma: effects on the postoperative hospital stay and complication burden]. / Prehabilitatie bij resectie van colorectaal carcinoom.

OBJECTIVE: To investigate the effect of a prehabilitation program on the postoperative hospital stay and complication burden in patients undergoing elective resection of a colorectal carcinoma. DESIGN: Comparative retrospective cohort study. METHOD: The study population consisted of patients who had undergone elective resection of a colorectal carcinoma between 2017 and 2020 at the Elkerliek hospital in Helmond. Patients in the intervention group had surgery from May 1, 2019 and they followed a three to six-week prehabilitation program, focusing on physical condition, nutritional status and psychosocial well-being. Patients in the control group had surgery until May 1, 2019 and did not follow a prehabilitation program. The primary outcome measures were hospital stay and complication burden according to the Comprehensive Complication Index (CCI). The secondary outcome measures were the number and type of complications up to 90 days postoperatively. RESULTS: The intervention group (n=85) and control group (n=197) were almost comparable in preoperative patient and treatment characteristics. The intervention group had a shorter hospital stay (median 5 versus 6 days, p<0.001) and less often a heavy complication burden (18% versus 36%, p=0.002). The intervention group also contained fewer patients with a complication (25% versus 44%, p=0.002). Specifically, infection (4% vs 13%, p=0.018), pulmonary complication (2% vs 12%, p=0.009) and delirium (1% vs 9%, p=0.019) were less common. CONCLUSION: A prehabilitation program can shorten the postoperative hospital stay and reduce the postoperative complication burden in patients undergoing elective resection for colorectal carcinoma.

Enhanced recovery after surgery versus conventional perioperative care in rectal surgery.

BACKGROUND: Enhanced recovery after surgery programs have been developed to improve recovery, shorten hospital stays, and reduce morbidity. OBJECTIVE: The aim of the current study was to examine the effects of the enhanced recovery program on the outcome of rectal surgery. DESIGN: A cohort of patients who underwent open rectal surgery after an enhanced recovery program was compared with a historic case-matched control group receiving conventional perioperative care. Patients were matched for type of surgery, disease, comorbidity, and demographic characteristics. Data regarding fast-track targets, length of hospital stay, mortality, complications, relaparotomies, and readmissions were collected. RESULTS: Forty-one patients in the enhanced recovery group were compared with 82 case-matched patients receiving conventional care. The length of hospital stay (median: 8 days vs 12 days, P < .005) was reduced in the enhanced recovery after surgery group. There were no significant differences in epidural use, mortality, morbidity, and readmission rates between groups. LIMITATIONS: This study performed an intention-to-treat analysis for the multimodal enhanced recovery program in rectal surgery. Specific elements of the program were not analyzed separately. The study used nonrandomly assigned historic controls for comparison. CONCLUSION: Enhanced recovery after surgery programs help to reduce the length of hospital stay after rectal surgery.

Predictive value of POSSUM and ACPGBI scoring in mortality and morbidity of colorectal resection: a case-control study.

BACKGROUND: Preoperative risk prediction to assess mortality and morbidity may be helpful to surgical decision making. The aim of this study was to compare mortality and morbidity of colorectal resections performed in a tertiary referral center with mortality and morbidity as predicted with physiological and operative score for enumeration of mortality and morbidity (POSSUM), Portsmouth POSSUM (P-POSSUM), and colorectal POSSUM (CR-POSSUM). The second aim of this study was to analyze the accuracy of different POSSUM scores in surgery performed for malignancy, inflammatory bowel diseases, and diverticulitis. POSSUM scoring was also evaluated in colorectal resection in acute vs. elective setting. In procedures performed for malignancy, the Association of Coloproctology of Great Britain and Ireland (ACPGBI) score was assessed in the same way for comparison. METHODS: POSSUM, P-POSSUM, and CR-POSSUM predictor equations for mortality were applied in a retrospective case-control study to 734 patients who had undergone colorectal resection. The total group was assessed first. Second, the predictive value of outcome after surgery was assessed for malignancy (n = 386), inflammatory bowel diseases (n = 113), diverticulitis (n = 91), and other indications, e.g., trauma, endometriosis, volvulus, or ischemia (n = 144). Third, all subgroups were assessed in relation to the setting in which surgery was performed: acute or elective. In patients with malignancy, the ACPGBI score was calculated as well. In all groups, receiver operating characteristic (ROC) curves were constructed. RESULTS: POSSUM, P-POSSUM, and CR-POSSUM have a significant predictive value for outcome after colorectal surgery. Within the total population as well as in all four subgroups, there is no difference in the area under the curve between the POSSUM, P-POSSUM, and CR-POSSUM scores. In the subgroup analysis, smallest areas under the ROC curve are seen in operations performed for malignancy, which is significantly worse than for diverticulitis and in operations performed for other indications. For elective procedures, P-POSSUM and CR-POSSUM predict outcome significantly worse in patients operated for carcinoma than in patients with diverticulitis. In acute surgical interventions, CR-POSSUM predicts mortality better in diverticulitis than in patients operated for other indications. The ACPGBI score has a larger area under the curve than any of the POSSUM scores. Morbidity as predicted by POSSUM is most accurate in procedures for diverticulitis and worst when the indication is malignancy. CONCLUSION: The POSSUM scores predict outcome significantly better than can be expected by chance alone. Regarding the indication for surgery, each POSSUM score predicts outcome in patients operated for diverticulitis or other indications more accurately than for malignancy. The ACPGBI score is found to be superior to the various POSSUM scores in patients who have (elective) resection of colorectal malignancy.

Enhanced recovery after surgery (ERAS) versus conventional postoperative care in colorectal surgery.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) programs are associated with reduced hospital morbidity and mortality. The aim of the present study was to evaluate whether the introduction of ERAS care improved the adverse events in colorectal surgery. In a cohort study, mortality, morbidity, and length of stay were compared between ERAS patients and carefully matched historical controls. METHODS: Patients were matched for their type of disease, the type of surgery, P-Possum (Portsmouth-Possum), CR-Possum (Colorectal-Possum) Physiological and Operative Score for Enumeration of Mortality and Morbidity (POSSUM), gender, and American Society of Anesthesiologists (ASA) grade. The primary outcome measures of this study were mortality and morbidity. Secondary outcome measures were fluid intake, length of hospital stay, the number of relaparotomies, and the number of readmissions within 30 days. Data on the ERAS patients were collected prospectively. RESULTS: Sixty-one patients treated according to the ERAS program were compared with 122 patients who received conventional postoperative care. The two groups were comparable with respect to age, ASA grade, P-Possum (Portsmouth-Possum), CR-Possum (Colorectal-Possum) score, type of surgery, stoma formation, type of disease, and gender. Morbidity was lower in the ERAS group compared to the control group (14.8% versus 33.6% respectively; P = <0.01). Patients in the ERAS group received significantly less fluid and spent fewer days in the hospital (median 6 days, range 3-50 vs. median 9 days, range 3-138; P = 0.032). There was no difference between the ERAS and the control group for mortality (0% vs. 1.6%; P = 0.55) and readmission rate (3.3% vs. 1.6%; P = 0.60). CONCLUSION: Enhanced Recovery After Surgery program reduces morbidity and the length of hospital stay for patients undergoing elective colonic or rectal surgery.

A Lethal Case of Fat Embolism Syndrome in a Nine-Year-Old Child: Options for Prevention.

We report a lethal case of fat embolism syndrome in a nine-year-old child after a direct blunt trauma leading to a pelvic fracture. On the second day, signs of bowel perforation and septic shock led to an acute aggravation of the pulmonary symptoms, cardiac arrest and death. Fat embolism is seldom thought to occur in pediatric trauma patients; however, this case illustrates it can lead to disastrous sequela. Since there is no specific treatment for it, prevention by early fracture stabilization is the only option.