Perioperative Enhanced Recovery Concepts Significantly Improve Postoperative Outcome in Patients with Crohn`s Disease.

BACKGROUND AND AIMS: Despite recent advancements in medical and surgical techniques in patients suffering from Crohn`s Disease (CD), postoperative morbidity remains relevant due to a long-standing, non-curable disease burden. As demonstrated for oncological patients, perioperative enhanced recovery concepts provide great potential to improve postoperative outcome. However, robust evidence about the effect of perioperative enhanced recovery concepts in the specific cohort of CD patients is lacking. METHODS: In a prospective single-center study, all patients receiving ileocecal resection due to CD between 2020 and 2023 were included. A specific perioperative enhanced recovery concept (ERC) was implemented and patients were divided into two groups (before and after implementation). The primary outcome focused on postoperative complications as measured by the Comprehensive Complication Index (CCI), secondary endpoints were severe complications, length of hospital stay, and rates of re-admission. RESULTS: 83 patients were analyzed of which 33 patients participated in the enhanced recovery program (postERC). While patient characteristics were comparable between both groups, ERC resulted in significantly decreased rates of overall and severe postoperative complications (CCI: 21.4 versus 8.4, p=0.0036; Clavien Dindo >2: 38% versus 3.1%, p=0.0002). Additionally, postERC-patients were earlier ready for discharge (6.5 days versus 5 days, p=0.001) and rates of re-admission were significantly lower (20% versus 3.1%, p=0.03). In a multivariate analysis, the recovery concept was identified as independent factor to reduce severe postoperative complications (p=0.019). CONCLUSION: A specific perioperative enhanced recovery concept significantly improves the postoperative outcome of patients suffering from Crohn`s Disease.

[Structured implementation of fast-track pathways to enhance recovery after elective colorectal resection : First results from five German hospitals]. / Strukturierte Fast-track-Implementierung zur beschleunigten Genesung nach elektiven kolorektalen Resektionen : Erste Erfahrungen 5 deutscher Kliniken.

BACKGROUND: Multimodal optimized perioperative management (mPOM, fast-track, enhanced recovery after surgery, ERAS) leads to a significantly accelerated recovery of patients with elective colorectal resections. Nevertheless, fast-track surgery has not yet become established in everyday clinical practice in Germany. We present the results of a structured fast-track implementation in five German hospitals. METHODS: Prospective data collection in the context of a 13-month structured fast-track implementation. All patients ≥ 18 years undergoing elective colorectal resection and who gave informed consent were included. After 3 months of preparation (pre-FAST), fast-track treatment was initiated and continued for 10 months (FAST). Outcome criteria were adherence to internationally recommended fast-track elements, postoperative complications, functional recovery, and postoperative hospital stay. RESULTS: Data from 192 pre-FAST and 529 FAST patients were analyzed. Age, sex, patient risk, location, and type of disease were not different between both groups. The FAST patients were more likely to have undergone minimally invasive surgery (82% vs. 69%). Fast-track adherence increased from 52% (35-65%) under traditional treatment to 83% (65-96%) under fast-track treatment (p < 0.01). The duration until the end of infusion treatment, removal of the bladder catheter, first bowel movement, oral solid food, regaining autonomy, suitability for discharge and postoperative length of stay were significantly lower in the FAST group. Complications, reoperations, and readmission rates did not differ. CONCLUSION: Fast-track adherence rates > 75% can also be achieved in German hospitals through structured fast-track implementation and the recovery of patients can be significantly accelerated.

Optimized perioperative management (fast-track, ERAS) to enhance postoperative recovery in elective colorectal surgery.

Aim: This manuscript provides information on the history, principles, and clinical results of Fast-track or ERAS concepts to optimize perioperative management (OPM). Methods: With the focus on elective colorectal surgery description of the OPM concept and its elements for with special attention to the prevention of infectious complications and clinical results compared to traditional care will be given using recent systematic literature reviews. Additionally, clinical results for other major abdominal procedures are given. Results: An optimized perioperative management protocol for elective colorectal resections will currently consist of 25 perioperative elements. These elements include the time from before hospital admission (patient education, screening, and treatment of possible risk factors like anemia, malnutrition, cessation of nicotine or alcohol abuse, optimization of concurrent systemic disease, physical prehabilitation, carbohydrate loading, adequate bowel preparation) to the preoperative period (shortened fasting, non-sedative premedication, prophylaxis of PONV and thromboembolic complications), intraoperative measures (systemic antibiotic prophylaxis, standardized anesthesia, normothermia and normovolemia, minimally invasive surgery, avoidance of drains and tubes) as well as postoperative actions (early oral feeding, enforced mobilization, early removal of a urinary catheter, stimulation of intestinal propulsion, control of hyperglycemia). Most of these elements are based on high-level evidence and will also have effects on the incidence of postoperative infectious complications. Conclusion: Optimized perioperative management should be mandatory for elective surgery today as it enhances postoperative patient recovery, reduces morbidity and infectious complications.

[Elective colorectal fast-track resections-Treatment adherence due to coordination by specialized nursing personnel]. / Elektive kolorektale Fast-track-Resektionen ­ Behandlungsadhärenz bei Koordination durch spezialisierte Fast-track-Assistenz.

Fast-track treatment pathways reduce the frequency of postoperative complications in elective colorectal resections by approximately 40% and due to the rapid recovery reduce the postoperative duration of hospitalization by approximately 50%. Specialized nursing personnel (enhanced recovery after surgery, ERAS, nurses) have already been appointed internationally to accompany and monitor the execution of multimodal perioperative treatment. In November 2018 a fast-track assistant was appointed in the Clinic for General and Visceral Surgery of the Municipal Clinic in Solingen for coordination of the fast-track treatment pathway. The results confirmed that a high adherence to perioperative fast-track treatment concepts can also be achieved in the German healthcare system by the assignment of specialized nursing personnel, with the known advantages for patients, nursing personnel, physicians and hospital sponsors.

[Background, Necessity and Methodology of the S3 Guideline "Perioperative Management of Gastrointestinal Tumours (POMGAT)"]. / Hintergrund, Notwendigkeit und Methodik der S3-Leitlinie "Perioperatives Management bei gastrointestinalen Tumoren (POMGAT)".

Malignancies are among the most common diseases, especially in old age, and are responsible for 25% of all deaths in Germany. Especially carcinomas of the gastrointestinal tract can be cured in most cases only through extensive surgery with significant morbidity. About 25 years ago, the multimodal, perioperative Fast Track (FT) concept for reducing postoperative complications was introduced and additional elements were added in the following years. Meanwhile, there is growing evidence that adherence to the key elements of more than 70% leads to reduction in postoperative adverse events as well as a shorter hospital stay and could be associated with an improved oncological outcome. Despite the high level of awareness and the proven advantages of the FT concept, the implementation and maintenance of the measures is difficult and results in an adherence of only 20 - 40%. There are many reasons for this: In addition to a lack of interdisciplinary and interprofessional cooperation and the time consuming and extended logistical efforts, limited human resources are often listed as one of the main causes. We took these aspects as an opportunity and started to develop a S3 guideline for perioperative treatment to accelerate the recovery of patients with gastrointestinal malignancies. By creating a consensus- and evidence-based, multidisciplinary guideline, many of the problems listed above could probably be solved by optimising and standardising interdisciplinary care, which is particularly important in a setting with many different disciplines and their competing interests. Furthermore, the standardisation of the perioperative procedures will reduce the time and logistical effort. The presentation of the evidence allows increased transparency and justifies the additional personnel expenditure on hospital medicine and health insurance companies. In addition, the evidence-based quality indicators generated during the development of the guideline make it possible to include perioperative standards in certification systems and thus to measure and check the quality of perioperative care.

[Structured Implementation of a Fast-Track Program - How Does it Work?] / Strukturelle Implementierung eines Fast-Track-Programms ­ wie geht das?

Fast-track or ERAS programs can give clinically relevant benefits for patients undergoing surgery. They also have financial advantages for the hospital. Despite these facts, fast-track has been implemented in only very few hospitals in Germany. Neither scientific evidence nor reimbursement regulations explain this lack of fast-track acceptance. It seems however that a structured process of change from traditional perioperative medicine to evidence based fast-track therapy is missing in Germany. In other countries, structured programs for fast-track or ERAS implementation have been successful in many hospitals. This article describes structured fast-track implementation divided into three consecutive steps: organisational preparation, clinical implementation and continuous examination of fast-track adherence, functional recovery, morbidity and postoperative length of hospital stay. Due to its complex nature, fast-track implementation should be guided by external fast-track experts.

[Enhanced recovery after surgery-Does the ERAS concept keep its promises]. / Beschleunigte Genesung nach Operationen ­ Hält das "ERAS"-Konzept, was es verspricht?

INTRODUCTION: Perioperative enhanced recovery after surgery (ERAS) concepts or fast-track are supposed to accelerate recovery after surgery, reduce postoperative complications and shorten the hospital stay when compared to traditional perioperative treatment. METHODS: Electronic search of the PubMed database to identify systematic reviews with meta-analysis (SR) comparing ERAS and traditional treatment. RESULTS: The presented SR investigated 70 randomized controlled studies (RCT) with 12,986 patients and 93 non-RCT (24,335 patients) concerning abdominal, thoracic and vascular as well as orthopedic surgery. The complication rates were decreased under ERAS following colorectal esophageal, liver and pulmonary resections as well as after implantation of hip endoprostheses. Pulmonary complications were reduced after ERAS esophageal, gastric and pulmonary resections. The first bowel movements occurred earlier after ERAS colorectal resections and delayed gastric emptying was less often observed after ERAS pancreatic resection. Following ERAS fast-track esophageal resection, anastomotic leakage was diagnosed less often as well as surgical complications after ERAS pulmonary resection. The ERAS in all studies concerning orthopedic surgery and trials investigating implantation of a hip endoprosthesis or knee endoprosthesis reduced the risk for postoperative blood transfusions. Regardless of the type of surgery, ERAS shortened hospital stay without increasing readmissions. CONCLUSION: Numerous clinical trials have confirmed that ERAS reduces postoperative morbidity, shortens hospital stay and accelerates recovery without increasing readmission rates following most surgical operations.

The Perioperative Care of Older Patients.

BACKGROUND: Elderly patients are a growing and vulnerable group with an elevated perioperative risk. Perioperative treatment pathways that take these patients' special risks and requirements into account are often not implemented in routine clinical practice. METHODS: This review is based on pertinent publications retrieved by a selective search in PubMed, the AWMF guideline database, and the Cochrane database for guidelines from Germany and abroad, meta-analyses, and Cochrane reviews. RESULTS: The care of elderly patients who need surgery calls for an interdisciplinary, interprofessional treatment concept. One component of this concept is preoperative preparation of the patient ("prehabilitation"), which is best initiated before hospital admission, e.g., correction of deficiency states, optimization of chronic drug treatment, and respiratory training. Another important component consists of pre-, intra-, and postoperative measures to prevent delirium, which can lower the frequency of this complication by 30-50%: these include orientation aids, avoidance of inappropriate drugs for elderly patients, adequate analgesia, early mobilization, short fasting times, and a perioperative nutrition plan. Preexisting cognitive impairment predisposes to postoperative delirium (odds ratios [OR] ranging from 2.5 to 4.5). Frailty is the most important predictor of the postoperative course (OR: 2.6-11). It follows that preoperative assessment of the patient's functional and cognitive status is essential. CONCLUZION: The evidence-based and guideline-consistent care of elderly patients requires not only close interdisciplinary, interprofessional, and cross-sectoral collaboration, but also the restructuring and optimization of habitual procedural pathways in the hospital. Elderly patients' special needs can only be met by a treatment concept in which the entire perioperative phase is considered as a single, coherent process.

Complications After Ostomy Surgery: Emergencies and Obese Patients are at Risk-Data from the Berlin OStomy Study (BOSS).

BACKGROUND: Complications are common after ostomy surgery. Data from the Berlin OStomy Study were evaluated to determine risk factors for complications. PATIENTS AND METHODS: Patients with a bowel ostomy were questioned using a questionnaire concerning patients' characteristics and history as well as the ostomy and its complications. The questionnaire also contained a nine-fielded abdominal sketch to determine the exact ostomy location. RESULTS: Over 42 months, 2647 patients completed the questionnaire. Obese patients and patients after emergency surgery were more prone to ostomy-related complications. This result was independent of the kind of ostomy (small bowel ostomy or colostomy) and of the abdominal location. The overall ostomy complication rate was 55.6%. CONCLUSION: Significantly more complications were recorded after emergency surgery and in obese patients than after elective surgery and in non-obese patients, respectively. There was no preferential abdominal location for avoiding general ostomy complications. The results emphasized the importance of preoperative ostomy site marking by qualified personnel such as ostomy nurses or surgeons to reduce complication rates by respecting individual abdominal configurations. With an increasing prevalence of obesity, ostomy surgery will become even more challenging in the future. A division of the abdominal wall into nine regions might be helpful and more precise for describing and examining ostomy-related complications in the future.

Quality of life and need for care in patients with an ostomy: a survey of 2647 patients of the Berlin OStomy-Study (BOSS).

BACKGROUND: Although ostomies are sometimes necessary, it is unclear which type of ostomy is advantageous for quality of life (QoL). In an observational study of 2647 patients, QoL after colostomy (CS) and small bowel stoma (SBS) formation was evaluated. METHODS: The European Organisation for Research and Treatment of Cancer (EORTC)-QLQ-C30 and CR-38 questionnaires were used. Patient characteristics, retrospective information about the ostomy and previous treatments, and current stoma-related complications were recorded. All questionnaires were distributed and collected by stoma therapists at the homecare company PubliCare®. RESULTS: In all, 1790 patients had a CS, and 756 had an SBS. The mean Global Health Score (mGHS-a general QoL indicator) was 52.33 in CS and 49.40 in SBS patients (p = 0.004), but the effect size (Cohen's d) was 0.1. In SBS patients, all functional scores were lower and most of the symptom scores were higher. CONCLUSIONS: QoL differed significantly for CS and SBS patients, but the effect size was marginal. The care of certain patient groups, particularly (female) patients who receive emergency surgeries, must be improved. More professional education and guidance are necessary for a larger proportion of patients. This survey provided reference data for quality of life in patients with an ostomy.

Effects of psychological interventions and patients' affect on short-term quality of life in patients undergoing colorectal surgery.

Psychological interventions can improve Quality of Life (QoL). Object of interest was if different psychological interventions influence short-term QoL after colonic resection for carcinoma. Furthermore, we wanted to see if there is a correlation between patients` preoperative affect and postoperative QoL. Sixty patients that underwent colorectal surgery were divided into three groups. Group one (n = 20) received Guided Imagery and group 2 (n = 22) Progressive Muscle Relaxation. The third group (Control, n = 18) had no intervention. Quality of Life (QoL) was measured using the EORTC QLQ-C30 and the Gastrointestinal Quality of life Index (GIQLI). Patients' affect was measured by the PANAS questionnaire. The higher the preoperative Negative Affect was, the lower were the scores for QoL on the 30th postoperative day. Patients' QoL was highest preoperatively and lowest on the third postoperative day. On the 30th postoperative day scores for QoL were almost as high as preoperative without difference between the three groups. Neither Guided Imagery nor Progressive Relaxation was influencing short-term QoL measured by the EORTC QLQ-C30 and the GIQLI questionnaire after colorectal surgery for cancer. Screening patients' with the PANAS questionnaire might help to identify individuals that are more likely to have a worse QoL postoperatively.

Vagus-preserving technique during minimally invasive esophagectomy: the effects on cardiac parameters in a swine model.

BACKGROUND: Cardiac complications are an important cause of morbidity and mortality observed after esophageal resections. We examined whether an high intrathoracic vagotomy during abdominothoracic esophagectomy would have an effect on intraoperative and early postoperative cardiac function in the setting of a minimally invasive resection. Two hypotheses were generated for this study: (1) Vagotomy would cause cardiac changes, and (2) vagus-preserving esophagectomy would prevent cardiac problems during resection and in the early postoperative phase. METHODS AND RESULTS: Thirty male pigs were operated on while cardiac parameters (heart rate [HR], cardiac index [CI], preload recruitable stroke work [PRSW], contractility speed [dp/dtmax], relaxation speed [dp/dtmin], and relaxation time [tau]) were monitored using a conductance catheter and the thermodilution method. Animals were randomized into 4 groups (each n = 7): (1) control, thoracoscopy only, (2) thoracoscopy with vagotomy, (3) esophageal resection with vagotomy, and (4) esophageal resection with vagus nerve preservation. To evaluate the first hypothesis, we compared groups 1 and 2; to evaluate the second hypothesis, we compared groups 3 and 4. HR, CI, PRSW, dp/dtmax, and tau were different in the 2 groups without resection (area under the curve; each P < .05). Vagotomy with esophagectomy resulted in nonsignificant differences between groups 3 and 4. The requirement for metoprolol administration to avoid severe tachycardia was greater in the groups that underwent vagotomy (P < .05; Fisher's exact test). CONCLUSION: An high intrathoracic vagotomy results in loss of vagal tone and a greater rate of tachycardia during thoracoscopy and esophagectomy. There were no differences, however, in cardiac dynamics between the esophagectomy groups. Thus, vagal injury is not the sole reason for cardiac dysfunction after esophagectomy.

Symptoms and clinical course of EHEC O104 infection in hospitalized patients: a prospective single center study.

OBJECTIVES: Shiga-toxin producing O157:H7 Entero Haemorrhagic E. coli (STEC/EHEC) is one of the most common causes of Haemolytic Uraemic Syndrome (HUS) related to infectious haemorrhagic colitis. Nearly all recommendations on clinical management of EHEC infections refer to this strain. The 2011 outbreak in Northern Europe was the first to be caused by the serotype O104:H4. This EHEC strain was found to carry genetic features of Entero Aggregative E. coli (EAEC) and extended spectrum ß lactamase (ESBL). We report symptoms and complications in patients at one of the most affected centres of the 2011 EHEC O104 outbreak in Northern Germany. METHODS: The courses of patients admitted to our hospital due to bloody diarrhoea with suspected EHEC O104 infection were recorded prospectively. These data include the patients' histories, clinical findings, and complications. RESULTS: EHEC O104 infection was confirmed in 61 patients (female = 37; mean age: 44±2 years). The frequency of HUS was 59% (36/61) in our cohort. An enteric colonisation with co-pathogens was found in 57%. Thirty-one (51%) patients were treated with plasma-separation/plasmapheresis, 16 (26%) with haemodialysis, and 7 (11%) with Eculizumab. Patients receiving antibiotic treatment (n = 37; 61%) experienced no apparent change in their clinical course. Twenty-six (43%) patients suffered from neurological symptoms. One 83-year-old patient died due to comorbidities after HUS was successfully treated. CONCLUSIONS: EHEC O104:H4 infections differ markedly from earlier reports on O157:H7 induced enterocolitis in regard to epidemiology, symptomatology, and frequency of complications. We recommend a standard of practice for clinical monitoring and support the renaming of EHEC O104:H4 syndrome as "EAHEC disease".

Impact of prolapse mass on Contour Transtar technique for third-degree rectal prolapse.

PURPOSE: Contour Transtar procedure for rectal prolapse is a promising technique according to safety and efficacy. One potential surgical problem is failure of the stapler due to the thick rectal wall. In order to evaluate the practicability and the impending limitations of the Contour Transtar technique, we reviewed our data with special respect to the necessity of additional anastomosis suturing. METHODS: A prospective analysis of 25 consecutive patients, which underwent Contour Transtar procedure from January 2009 to July 2012, was performed. For statistic analysis, the groups with and without additional suturing of the anastomosis were evaluated according to patient characteristics and surgical outcome. RESULTS: Twenty-five patients, three men and 22 women, underwent transanal Contour Transtar stapling procedure for rectal prolapse. Due to stapling failure, additional suturing of the anastomosis was necessary in 4 of 25 procedures (16%). Age (74.1 vs. 83.1 years) and body mass index (30.8 vs. 22.7 kg/m(2)) were significantly different with and without additional suturing. Operative time was longer (62 vs. 31 min), more cartridges were used (12 vs. 6), and the specimen weight was higher (220 vs. 107 g) in patients with additional suturing. Early postoperative complications were observed in two patients without anastomosis suturing including one patient with bleeding and systemic inflammatory reaction in one case. Postoperative stay did not differ between both groups. CONCLUSION: Patients with extensive obesity, which present with a substantial rectal prolapse, may need additional suturing of the rectal anastomosis after Contour Transtar stapling. This causes prolonged operative time. However, this does not correlate with complications and it is not related to significant longer hospital stay.

Laparoscopic assisted sigmoid resection for diverticular disease.

PURPOSE: Laparoscopic assisted sigmoid resection (LASR) has become a widely accepted procedure in colorectal surgery. In the last decade, numerous variations of surgical details have been established. In order to demonstrate a feasible technique, this video is provided. METHODS: LASR is performed using four ports. The first port is inserted via open access by a minilaparotomy in the right paraumbilical region. Two ports are sited in the right lower abdomen, including one 12-mm port in the following incision above the pubic symphysis. The forth port is inserted in the left upper abdomen. The procedure starts with the removal of adhesions, the peritoneal incision is performed medially, and a medial to lateral approach to the mesocolon and the inferior mesenteric artery (IMA) is carried out. After identifying the left ureter, the IMA is either clipped or sealed about 1.5 to 2 cm from the origin in order to preserve the autonomous plexus. Then dissection is continued on Gerota's fascia. After lifting the rectosigmoid, dissection is continued in the avascular plane until the mesentery of the upper rectum is mobilized. Then the remaining lateral adhesions are dissected with preservation of the gonadal vessels and the left ureter. The distal resection line is always in the upper rectum, which is easily identified by the lack of tenia. After sealing the mesorectum, the rectum is dissected using a linear stapler. Thereafter, a minilaparotomy above the pubic symphysis is performed and a device for protection and retraction of the wound is inserted. Dissection of the mesosigmoid and the descending colon is carried out extracorporally. The anvil of a circular stapling device is inserted in the descending colon, which is then returned into the peritoneal cavity. Running sutures closes the incision, and the anastomosis is carried out laparoscopically in a "double stapling" technique. CONCLUSION: The video describes the efficacy and technical feasibility of laparoscopic surgery for diverticular disease and demonstrates its effect regarding perioperative morbidity and functional outcome.

Thoracoscopic resection of a combined esophageal leiomyoma and diverticulum: a case report.

We report the case of a 66-year-old male patient with a combined esophageal leiomyoma and diverticulum. On account of the low incidence, there is little literature available with regard to the management of those conditions. Our patient underwent a simultaneous thoracoscopic enucleation of the leiomyoma and resection of the diverticulum. Though endoscopic enucleations of myoma and resections of diverticula have been described earlier, to our knowledge, we are the first, who performed those procedures in a single operation, which seems to be feasible and safe.