Does Bowel Function Change After Colectomy for Colon Malignancy?

BACKGROUND: Colon cancer patients often ask how surgery will affect bowel function. Current understanding is informed by conflicting data, making preoperative patient counseling difficult. We aimed to evaluate patient-reported bowel function changes after colectomy for colon malignancy. MATERIAL AND METHODS: This was a retrospective analysis of a prospectively collected institutional database from July 2015 to June 2019. The included patients underwent colectomy for adenocarcinoma of the colon, and completed the Colorectal Functional Outcome (COREFO) questionnaire at preoperative presentation and postoperative followup. Preoperative and postoperative scores were compared using paired t-tests. Multivariable analysis was performed using domains demonstrating statistical significance on bivariate analysis, assessing the factors that were associated with symptomatic bowel function. RESULTS: We identified 117 patients with a mean age of 64 ± 13 y. The median time between preoperative and postoperative questionnaire completion was 52 d (interquartile range 45-70). Bowel movement frequency increased significantly from a mean preoperative score of 9.72 to a mean postoperative score of 14.2 (P = 0.003). There were no significant differences in the remaining four domains of bowel function or global function. Multivariable analysis demonstrated higher likelihood of symptomatic postoperative frequency scores in male patients (OR 3.85, 95% CI 1.44-11.11, P = 0.007) and patients with symptomatic preoperative frequency (OR 5.56, 95% CI 1.62-19.02, P = 0.006). CONCLUSIONS: Patient-reported bowel movement frequency worsens at postoperative follow-up after colectomy for colon cancer, while overall bowel function does not change. Men and patients with preoperative symptomatic frequency have an increased likelihood of reporting symptomatic postoperative frequency. These findings should guide more personalized and evidence-based preoperative patient counseling.

Anaesthetic technique and outcomes after colorectal cancer surgery.

INTRODUCTION: Previous studies have suggested that choice of anaesthesia can affect long-term outcome. In this study, the association between type of anaesthesia and outcomes in terms of survival, recurrence, post-operative complications and recovery after surgery for colorectal cancer was investigated in an Enhanced Recovery after Surgery (ERAS) setting. METHODS: This was a retrospective study including patients undergoing elective curative-intended surgery for colorectal cancer between April 2013 and May 2015 at Zealand University Hospital, Denmark. Patients were stratified by anaesthetic technique. The primary outcome was cancer recurrence. Cox regression analyses were used for time-to-event variables; recurrence, disease-free survival, mortality, length of hospitalisation and time to bowel movement. Odds ratios for post-operative complications and time to discharge were estimated using logistic regression. RESULTS: A total of 534 patients were included, 51 were exposed to inhalational anaesthesia and 483 had total intravenous anaesthesia. We found no statistically significant difference in recurrence (hazard ratio (HR) = 0.70; 95% confidence interval (CI): 0.21-1.68; p = 0.421). Patients in the inhalational aneasthesia group had a significantly lower chance of discharge per post-operative day (HR = 0.66; 95% CI: 0.48-0.91; p = 0.012). The same was seen for time to bowel movement (HR = 0.65; 95% CI: 0.46-0.90; p = 0.011). No statistically significant differences were seen for the other outcomes. CONCLUSION: Anaesthetic technique might influence time to discharge and bowel function in an ERAS setting. FUNDING: none TRIAL REGISTRATION: The study was approved by the Danish Data Protection Agency (record number 2008-58-0020). Under Danish law, consent from participants is not required in observational studies.

Impact of visceral obesity and sarcobesity on surgical outcomes and recovery after laparoscopic resection for colorectal cancer.

BACKGROUND & AIMS: Studies analyzing the impact of visceral fat excess on surgical outcomes after resection for colorectal cancer (CRC) have yielded conflicting results. Visceral obesity (VO) and sarcobesity (SO) have been recently addressed as risk factors for poor short-term results while no data are available for recovery goals after surgery. No data are available on the protective effect of ERAS in VO and SO patients. The aim of this study was to assess clinical implications of computed tomography (CT) assessed VO and SO on surgical and recovery outcomes after minimally invasive resection for CRC before and after ERAS protocol implementation. METHODS: Visceral adipose tissue (VAT) and skeletal muscle area (SMA) were retrospectively assessed using pre-operative CT studies of 261 patients who underwent laparoscopic resection for CRC between January 2012 and April 2019; ERAS protocol was adopted in 160 patients operated on after March 2014. Patients' surgical and recovery outcomes were compared according to BMI categories, VO and SO which was defined using the VAT/SMA ratio (Sarcobesity Index). Predictive factors for poor surgical and recovery outcomes were evaluated by univariate and multivariate analyses. RESULTS: Of the 261 patients, 12.6% were BMI obese while 68.6% presented visceral obesity. BMI was not associated to any of the outcomes considered. No differences in intra-operative results were found except for a lower number of retrieved lymph nodes both in VO and SO patients. While VO showed no impact on post-operative course, SO resulted an independent risk factor for cardiac complications and prolonged post-operative ileus (PPOI) at logistic regression analysis. Furthermore, sarcobese patients showed delayed recovery after surgery. Patients enrolled in the ERAS protocol showed improved recovery outcomes for both VO and SO groups, although ERAS did not result to be a protective factor for cardiac complications and PPOI. CONCLUSIONS: A high Sarcobesity Index is a risk factor for developing cardiac complications and PPOI after laparoscopic resection for CRC. A reduced number of lymph nodes retrieved is associated to VO and SO. These conditions should then be considered in clinical practice for the risk of down staging the N stage. Effect of VO and SO on recovery items after surgery should be further investigated. ERAS protocol application should be implemented to improve recovery outcomes in VO and SO patients undergoing laparoscopic colorectal resection.

Feasibility of perioperative volatile organic compound breath testing for prediction of paralytic ileus following laparoscopic colorectal resection.

BACKGROUND: Despite implementation of enhanced recovery after surgery (ERAS) and laparoscopic techniques, postoperative ileus (POI) remains frequent after colorectal surgery, impacting the patient, their recovery and health-care resources. Presently there are no tests that reliably predict or enable early POI diagnosis. Volatile organic compounds (VC) are products of human and microbiota cellular metabolism and we hypothesised that a detectable alteration occurs in POI. METHOD: This was a prospective observational study of patients undergoing laparoscopic colorectal resection within an established ERAS programme. Standardized end-expiratory breath sampling was performed on the morning of surgery and on the first three postoperative mornings. The concentrations of VCs commonly found in intestinal gas were analysed using selected ion flow tube mass spectrometry and GastroCH4 ECK®. Feasibility data, bowel preparation, postoperative oral intake, POI and 30-day morbidity were recorded. RESULTS: Of the 75 potentially eligible patients, 58 (77%) agreed to participate. Per-protocol breath sampling was successfully completed in 94%. There were no analytical failures. Baseline and postoperative concentrations of VCs were broadly comparable and were not altered by bowel preparation or postoperative oral intake. POI developed in 14 (29%) patients. Preoperative ammonia concentration was higher in patients who developed POI [830 parts per billion (ppb) vs 510 ppb, P = 0.027]. There was an increase in the concentration of acetic acid detected on day 2 in patients who developed POI (99 ppb vs 171 ppb, P = 0.021). CONCLUSION: Repeated VC breath sampling and analysis is feasible in the perioperative setting. An elevated ammonia concentration on the morning of surgery may be a potential predictor of POI.

Implementation of an Enhanced Recovery Protocol Is Associated With On-Time Initiation of Adjuvant Chemotherapy in Colorectal Cancer.

BACKGROUND: Delayed initiation of adjuvant chemotherapy negatively impacts long-term survival in patients with colorectal cancer. Colorectal enhanced recovery protocols result in decreased complications and length of stay; however, the impact of enhanced recovery on the timing of adjuvant chemotherapy remains unknown. OBJECTIVE: This study aimed to identify factors associated with on-time delivery of adjuvant chemotherapy after colorectal cancer surgery, hypothesizing that implementation of an enhanced recovery protocol would result in more patients receiving on-time chemotherapy. DESIGN: This was a retrospective cohort study comparing the rate of on-time adjuvant chemotherapy delivery after colorectal cancer resection before and after implementation of an enhanced recovery protocol. SETTINGS: The study was conducted at a large academic medical center. PATIENTS: All of the patients who underwent nonemergent colorectal cancer resections for curative intent from January 2010 to June 2017, excluding patients who had no indication for adjuvant chemotherapy, had received preoperative systemic chemotherapy, or did not have medical oncology records available were included. MAIN OUTCOME MEASURES: Patients before and enhanced recovery were compared, with the rate of on-time adjuvant chemotherapy delivery as the primary outcome. Adjuvant chemotherapy delivery was considered on time if initiated ≤8 weeks postoperatively, and treatment was considered delayed or omitted if initiated >8 weeks postoperatively (delayed) or never received (omitted). Multivariable logistic regression identified predictors of on-time chemotherapy delivery. RESULTS: A total of 363 patients met inclusion criteria, with 189 patients (52.1%) undergoing surgery after enhanced recovery implementation. Groups differed in laparoscopic approach and median procedure duration, both of which were higher after enhanced recovery. Significantly more patients received on-time chemotherapy after enhanced recovery implementation (p = 0.007). Enhanced recovery was an independent predictor of on-time adjuvant chemotherapy (p = 0.014). LIMITATIONS: The study was limited by its retrospective and nonrandomized before-and-after design. CONCLUSIONS: Enhanced recovery was associated with receiving on-time adjuvant chemotherapy. As prompt initiation of adjuvant chemotherapy improves survival in colorectal cancer, future investigation of long-term oncologic outcomes is necessary to evaluate the potential impact of enhanced recovery on survival. See Video Abstract at http://links.lww.com/DCR/B21. LA IMPLEMENTACIÓN DE UN PROTOCOLO DE RECUPERACIÓN ACELERADA SE ASOCIA CON EL INICIO A TIEMPO DE QUIMIOTERAPIA ADYUVANTE EN CÁNCER COLORRECTAL:: El inicio tardío de la quimioterapia adyuvante afecta negativamente la supervivencia a largo plazo en pacientes con cáncer colorrectal. Los protocolos de recuperación acelerada colorrectales dan lugar a una disminución de las complicaciones y la duración de estancia hospitalaria; sin embargo, el impacto de la recuperación acelerada en el momento de inicio de quimioterapia adyuvante sigue siendo desconocido.Este estudio tuvo como objetivo identificar los factores asociados con la administración a tiempo de la quimioterapia adyuvante después de la cirugía de cáncer colorrectal, con la hipótesis de que la implementación de un protocolo de recuperación acelerada daría lugar a que más pacientes reciban quimioterapia a tiempo.Estudio de cohorte retrospectivo que compara la tasa de administración de quimioterapia adyuvante a tiempo después de la resección del cáncer colorrectal antes y después de la implementación de un protocolo de recuperación acelerada.Centro médico académico grande.Todos los pacientes que se sometieron a resecciones de cáncer colorrectal no emergentes con intención curativa desde enero de 2010 hasta junio de 2017, excluyendo a los pacientes que no tenían indicación de quimioterapia adyuvante, que recibieron quimioterapia sistémica preoperatoria o no tenían registros médicos de oncología disponibles.Los pacientes se compararon antes y después de la implementación de la recuperación acelerada, con la tasa de administración de quimioterapia adyuvante a tiempo como el resultado primario. La administración de quimioterapia adyuvante se consideró a tiempo si se inició ≤8 semanas después de la operación, y el tratamiento se consideró retrasado / omitido si se inició> 8 semanas después de la operación (retrasado) o nunca fue recibido (omitido). La regresión logística multivariable identificó predictores de administración de quimioterapia a tiempo.363 pacientes cumplieron con los criterios de inclusión, con 189 (52.1%) pacientes sometidos a cirugía después de la implementación de recuperación acelerada. Los grupos difirieron en el abordaje laparoscópico y la duración media del procedimiento; ambos factores fueron mayores después de la recuperación acelerada. Significativamente más pacientes recibieron quimioterapia a tiempo después de la implementación de recuperación acelerada (p = 0.007). La recuperación acelerada fue un factor predictivo independiente de quimioterapia adyuvante a tiempo (p = 0.014).Diseño retrospectivo, tipo ¨antes y después¨ no aleatorizado.La recuperación acelerada se asoció con la recepción de quimioterapia adyuvante a tiempo. Debido a que el inicio rápido de la quimioterapia adyuvante mejora la supervivencia en el cáncer colorrectal, en el futuro será necesario investigar los resultados oncológicos a largo plazo para evaluar el impacto potencial de la recuperación acelerada en la supervivencia. Vea el Resumen en Video en http://links.lww.com/DCR/B21.

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.

Why still in hospital after laparoscopic colorectal surgery within an enhanced recovery programme?

AIM: Enhanced recovery after surgery programmes in elective colorectal surgery have been developed and implemented widely, but a subgroup of patients may still require longer hospital stays than expected. The aim of this study was to identify and describe factors compromising early postoperative recovery by asking 'why is the patient still in hospital today?' after laparoscopic colorectal cancer surgery within an enhanced recovery after surgery programme. METHOD: Patients undergoing elective laparoscopic colorectal cancer resection were evaluated postoperatively with predefined potential reasons for still being in hospital. The primary outcome was 'reason for still being in hospital' on postoperative day 0-4 and secondarily length of stay with a focus on differences between patients with and without a stoma. RESULTS: Ninety-six patients having colorectal cancer surgery were included. The median length of stay for the whole group was 3 days (range 1-14). The four dominant causes for patients without a stoma to be in hospital were lack of gastrointestinal function, lack of early mobilization, lack of normal micturition and nausea. Patients with a stoma stayed in hospital due to stoma training, lack of gastrointestinal function, lack of free micturition and a miscellaneous 'others' group. CONCLUSION: Delayed gastrointestinal function, insufficient mobilization, poor urinary function and stoma care training have been characterized as dominant compromising factors for postoperative recovery. Together with a focus on frailty, future studies should focus on improving early mobilization, prevention and treatment of postoperative urinary retention and improved stoma care training, in order to minimize delay in postoperative recovery and discharge.

The LAPLAP study: a randomized placebo-controlled clinical trial assessing postoperative functional recovery using intraperitoneal local anaesthetic in laparoscopic colorectal surgery.

AIM: Postoperative pain remains a major factor in recovery from colorectal resection. There is increasing interest in opioid-sparing analgesia, and intraperitoneal local anaesthetic (IPLA) has recently been shown to be useful in minor laparoscopic and open colorectal procedures. The aim of this study was to evaluate the impact of IPLA on functional recovery following major laparoscopic surgery. In this controlled trial, mobility, as measured by the De Morton Mobility Index (DEMMI), was used as a surrogate for postoperative functional recovery. METHOD: Patients undergoing laparoscopic colorectal resection were randomized either to continuous ropivacaine (0.2% at 4-6 ml/h) or to saline (0.9%) which were administered via intraperitoneal catheter for 3 days postoperatively. Results were analysed in a double-blind manner. DEMMIs were assessed on postoperative days 1, 2, 3, 7 and 30, and data on pain, opioid consumption, gut and respiratory function, length of stay (LOS) and complications were recorded. RESULTS: Ninety-six patients were recruited. There was no difference in primary outcome (i.e., functional recovery) between IPLA and placebo groups. Opioid consumption and LOS were similar between groups, and no differences were found for any secondary outcome measure. There were no adverse events related to ropivacaine. CONCLUSION: Infusional intraperitoneal local anaesthetic appears to be safe but does not improve functional recovery or analgesic consumption following elective laparoscopic colorectal surgery, in the setting of an established enhanced recovery programme.

Outcome of Enhanced Recovery After Surgery (ERAS) for Colorectal Surgery in Early Elderly and Late Elderly Patients.

INTRODUCTION: This study aimed to determine the outcome of enhanced recovery after surgery (ERAS) programme in elderly colorectal surgery patients. MATERIALS AND METHODS: Details and surgical outcomes of elderly patients undergoing elective colectomy and/or proctectomy according to ERAS protocol from 2011 to 2017 were retrospectively reviewed. Patients were divided into 2 groups: early elderly (EE, n = 107) aged 65-74 years old and late elderly (LE, n = 74) aged ≥75 years old. RESULTS: This study included 181 patients. The LE group had poorer baseline characteristics, but the operative details in both groups were comparable. Overall complication and severe complication rates were 28% and 3.3%, respectively. The LE group had a higher overall complication rate (38% vs 22%; P = 0.016) but comparable rate of severe complications (2.7% vs 3.7%; P = 1.00). Median postoperative stay was 4 days (interquartile range [IQR], 4-6 days) and it was not significantly different between both groups (5 days for LE vs 4 days for EE; P = 0.176). No difference was seen in time to gastrointestinal recovery and 30-day mortality or readmission between both groups. Overall compliance with ERAS protocol was 76% (IQR, 65-82%) and it did not vary significantly between the LE (71%) and EE (76%) groups (P = 0.301). However, the LE group had lower compliance with fluid management, nutrition therapy and use of multimodal analgesia. CONCLUSION: ERAS is a safe and effective protocol that can be used in EE and LE colorectal surgery patients.

The impact of ileal pouch-anal anastomosis on graft survival following liver transplantation for primary sclerosing cholangitis.

BACKGROUND: Liver transplantation is the only life-extending intervention for primary sclerosing cholangitis (PSC). Given the co-existence with colitis, patients may also require colectomy; a factor potentially conferring improved post-transplant outcomes. AIM: To determine the impact of restorative surgery via ileal pouch-anal anastomosis (IPAA) vs retaining an end ileostomy on liver-related outcomes post-transplantation. METHODS: Graft survival was evaluated across a prospectively accrued transplant database, stratified according to colectomy status and type. RESULTS: Between 1990 and 2016, 240 individuals with PSC/colitis underwent transplantation (cumulative 1870 patient-years until first graft loss or last follow-up date), of whom 75 also required colectomy. A heightened incidence of graft loss was observed for the IPAA group vs those retaining an end ileostomy (2.8 vs 0.4 per 100 patient-years, log-rank P = 0.005), whereas rates between IPAA vs no colectomy groups were not significantly different (2.8 vs 1.7, P = 0.1). In addition, the ileostomy group experienced significantly lower graft loss rates vs. patients retaining an intact colon (P = 0.044). The risks conferred by IPAA persisted when taking into account timing of colectomy as related to liver transplantation via time-dependent Cox regression analysis. Hepatic artery thrombosis and biliary strictures were the principal aetiologies of graft loss overall. Incidence rates for both were not significantly different between IPAA and no colectomy groups (P = 0.092 and P = 0.358); however, end ileostomy appeared protective (P = 0.007 and 0.031, respectively). CONCLUSION: In PSC, liver transplantation, colectomy + IPAA is associated with similar incidence rates of hepatic artery thrombosis, recurrent biliary strictures and re-transplantation compared with no colectomy. Colectomy + end ileostomy confers more favourable graft outcomes.

Pelvic floor symptoms, physical, and psychological outcomes of patients following surgery for colorectal cancer.

BACKGROUND: Little has been published regarding general and pelvic floor-related health status in patients who have undergone surgery for colorectal cancer (CRC). OBJECTIVE: The objective of the study was to assess changes in pelvic floor symptoms, physical activity levels, psychological status, and health-related quality of life (HRQoL) in patients with CRC from pre- to 6 months postoperatively. METHODS: Pelvic floor symptoms, physical activity levels, anxiety and depression, and HRQoL of 30 participants who were undergoing surgery for stages I-III CRC were evaluated pre- and 6 months postoperatively. RESULTS: Six months postoperatively, there were no significant changes in severity of pelvic floor symptoms, or other secondary outcomes (physical activity levels, depression, global HRQoL) compared to preoperative levels (p > 0.05). However, fecal incontinence (p = 0.03) and hair loss (p = 0.003) measured with the HRQoL instrument were significantly worse. Participants were engaged in low levels of physical activity before (42.3%) and after surgery (47.4%). CONCLUSION: The findings of a high percentage of participants with persistent low physical activity levels and worse bowel symptoms after CRC surgery compared to preoperative levels suggest the need for health-care professionals to provide information about the benefits of physical activity and bowel management at postoperative follow-ups. Further investigation in larger studies is warranted.

Selecting post-acute care settings after abdominal surgery: Are we getting it right?

BACKGROUND: We investigated whether variation in post-acute care (PAC) services could be explained by surgeons discharging clinically similar patients to different PAC destinations, including home health (HH), skilled nursing facilities (SNF), and inpatient rehabilitation (IR). METHODS: We studied patients having colectomy, pancreatectomy or hepatectomy in the 2008-2011 Nationwide Inpatient Sample. We used propensity matching to determine: 1. Proportion of patients discharged to SNF/IR who could be matched to clinically similar patients discharged with HH. 2. Potential cost savings from greater use of HH. RESULTS: 30,843 patients were discharged with HH and 23,172 to SNF or IR. 14,163 (61%) SNF/IR patients could be matched to similar patients discharged with HH. Potential cost savings from increasing use of HH as an alternative to SNF/IR ranged from $2.5-$438 million annually. CONCLUSIONS: There is considerable potential for reducing variation in PAC use and costs by better understanding how surgeons make decisions about PAC placement.

Incidence of venous thromboembolic events in enhanced recovery after surgery for colon cancer: a retrospective, population-based cohort study.

AIM: Both the Danish and the National Institute of Clinical Excellence (NICE) guidelines recommend prolonged thromboprophylaxis (PT) with low-molecular-weight heparin (LMWH) for 28 days postoperatively after elective surgery for colon cancer. The evidence relies on data from two randomized clinical trials (RCTs) that included not only colon cancers but also other abdominal cancers or benign colorectal diseases. Neither of those studies investigated the risk of venous thromboembolism (VTE) under enhanced recovery after surgery (ERAS). We aim to describe the risk of VTE and estimate the cost of preventing one case of VTE by PT under ERAS. METHOD: This was a retrospective study of 2230 patients undergoing elective surgery for colon cancer Stage I-III in the Capital Region of Denmark, 1 June 2008 to 31 December 2013. Patients who were discharged on postoperative day 28 or later, died during admission or were discharged with a vitamin K antagonist, novel oral anticoagulants or LMWH were excluded. Patients with rectal cancer only were not included. End-points were symptomatic VTE diagnosed within 60 days postoperatively. RESULTS: Three-hundred and thirty patients were excluded. For the remaining 1893, the median length of stay (LOS) was 4 [interquartile range (IQR): 3-5] days. Of these 1893 patients, four (0.20%) experienced a nonfatal symptomatic VTE. All four patients had other postoperative complications before the VTE. The cost of each symptomatic VTE prevented is estimated to be between £63 709 and £111 455 when medication and home-care nursing are included. CONCLUSION: The risk of symptomatic VTE after uncomplicated, elective surgery for colon cancer with ERAS seems negligible and the cost-effectiveness of PT to prevent one symptomatic VTE seems questionable.

Racial and Socioeconomic Differences Manifest in Process Measure Adherence for Enhanced Recovery After Surgery Pathway.

BACKGROUND: Adherence to care processes and surgical outcomes varies by population subgroups for the same procedure. Enhanced recovery after surgery pathways are intended to standardize care, but their effect on process adherence and outcomes for population subgroups is unknown. OBJECTIVE: This study aims to demonstrate the association between recovery pathway implementation, process measures, and short-term surgical outcomes by population subgroup. DESIGN: This study is a pre- and post-quality improvement implementation cohort study. SETTING: This study was conducted at a tertiary academic medical center. INTERVENTION: A modified colorectal enhanced recovery after surgery pathway was implemented. PATIENTS: Patients were included who had elective colon and rectal resections before (2013) and following (2014-2016) recovery pathway implementation. MAIN OUTCOME MEASURE: Thirty-day outcomes by race and socioeconomic status were analyzed using a difference-in-difference approach with correlation to process adherence. RESULTS: We identified 639 cases (199 preimplementation, 440 postimplementation). In these cases, 75.2% of the patients were white, and 91.7% had a high socioeconomic status. Groups were similar in terms of other preoperative characteristics. Following pathway implementation, median lengths of stay improved in all subgroups (-1.0 days overall, p ≤ 0.001), but with no statistical difference by race or socioeconomic status (p = 0.89 and p = 0.29). Complication rates in both racial and socioeconomic groups were no different (26.4% vs 28.8%, p = 0.73; 27.3% vs 25.0%, p = 0.86) and remained unchanged with implementation (p = 0.93, p = 0.84). By race, overall adherence was 31.7% in white patients and 26.5% in nonwhite patients (p = 0.32). Although stratification by socioeconomic status demonstrated decreased overall adherence in the low-status group (31.8% vs 17.1%, p = 0.05), white patients were more likely to have regional pain therapy (57.1% vs 44.1%, p = 0.02) with a similar trend seen with socioeconomic status. LIMITATIONS: Data were collected primarily for quality improvement purposes. CONCLUSIONS: Differences in outcomes by race and socioeconomic status did not arise following implementation of an enhanced recovery pathway. Differences in process measures by population subgroups highlight differences in care that require further investigation. See Video Abstract at http://links.lww.com/DCR/A386.

Does hospital readmission following colorectal cancer resection and enhanced recovery after surgery affect long term survival?

AIM: Hospital readmission is undesirable for patients and care providers as this can affect short-term recovery and carries financial consequences. It is unknown if readmission has long-term implications. We aimed to investigate the impact of 30-day readmission on long-term overall survival (OS) following colorectal cancer resection within enhanced recovery after surgery (ERAS) care and explore the reasons for and the severity and details of readmission episodes. METHOD: A dedicated, prospectively populated database was reviewed. All patients were managed within an established ERAS programme. Five-year OS was calculated using the Kaplan-Meier method. The number, reason for and severity of 30-day readmissions were classified according to the Clavien-Dindo (CD) system, along with total (initial and readmission) length of stay (LoS). Multivariate analysis was used to identify factors predicting readmission. RESULTS: A total of 1023 consecutive patients underwent colorectal cancer resection between 2002 and 2015. Of these, 166 (16%) were readmitted. Readmission alone did not have a significant impact on 5-year OS (59% vs 70%, P = 0.092), but OS was worse in patients with longer total LoS (20 vs 14 days, P = 0.04). Of the readmissions, 121 (73%) were minor (CD I-II) and 27 (16%) required an intervention of which 16 (10%) were returned to theatre. Gut dysfunction 32 (19%) and wound complications 23 (14%) were the most frequent reasons for readmission. Prolonged initial LoS, rectal cancer and younger age predicted for hospital readmission. CONCLUSION: Readmission does not have a significant impact on 5-year OS. A broad range of conditions led to readmission, with the majority representing minor complications.

Impact of elemental diet on early recovery after laparoscopic colectomy: findings of a randomized controlled trial.

PURPOSE: An amino acid-containing elemental diet (ED) does not require digestion for nutritional absorption, making it a good option for patients with gastrointestinal malabsorption. We conducted a randomized trial to confirm that perioperative ED enhanced the recovery of patients undergoing laparoscopic colectomy. METHODS: Patients in the intervention arm received commercially available ED from the day prior to surgery until postoperative day (POD) 3, whereas patients in the control group received a conventional perioperative diet program. To verify the endpoints, "estimated minimum length of stay in hospital after surgery" (emLOS) was defined as the number of days necessary to reach all the five criteria; namely, "sufficient oral intake", "sufficient pain control", "withdrawal of intravenous alimentation", "no abnormal findings in routine examinations", and "no rise in fever". RESULTS: A total of 102 patients were randomized, 94 of whom were analyzed (ED 45, control 49). There was no morbidity or mortality. Shorter emLOS (POD 4 vs. POD 7; p = 0.018), earlier resumption of sufficient oral intake (POD 3 vs. POD 4; p = 0.034) and faster recovery to defecation (2.2 vs. 3.1 days; p = 0.005) were observed in the ED group vs. the control group. CONCLUSIONS: The perioperative ingestion of ED by patients undergoing laparoscopic colectomy is safe and can reduce the postoperative hospital stay by supporting the acceleration of oral intake.

Application of Fast-Track Recovery Protocols in Single-Port Laparoscopic Surgery Versus Multiport Laparoscopic Surgery for Colon Resection.

AIM: The aim of this study is to analyze whether fast-track (FT) recovery protocols can be applied to single-port laparoscopic surgery for colon resection, as they are in multiport laparoscopic surgery. MATERIALS AND METHODS: Retrospective study comparing single-port laparoscopic surgery (SP-FT) versus multiport laparoscopic surgery (MP-FT) for colon resection, and the applicability of our FT recovery protocol in all patients between 2013 and 2014. Variables evaluated were American Society of Anesthesiologists (ASA) score, tumor size, number of nodes, surgery performed, postoperative morbidity, and length of hospital stay. RESULTS: A total of 83 patients (28 SP-FT group and 55 MP-FT group) underwent FT recovery. The median age was 62 (11-85) years in SP-FT group and 72 (57-84) in MP-FT group. ASA score showed no significant difference (P = .973). The surgical procedures performed were as follows: SP-FT group 20 right hemicolectomy, 5 left hemicolectomy, and 3 subtotal colectomy and MP-FT group were 26 right hemicolectomy, 28 left hemicolectomy, and 1 subtotal colectomy. Mean operative time (minutes) was shorter in SP-FT group (151 ± 47.9 versus 182 ± 50.7), but no significant difference was observed. Regarding the tumor size (SP-FT 4.2 [2-7] cm versus MP-FT 4 [3-12] cm) and postoperative morbidity Clavien-Dindo ≥2 (SP-FT 10 patients versus MP-FT 20 patients), there were no significant differences (P = .535; P = .383). The median length of hospital stay was statistically significant: SP-FT 4.5 (3-53) days versus MP-FT 7 (4-33) days (P = .005). CONCLUSIONS: FT rehabilitation is safe and reproducible in single-port laparoscopic surgery for colon pathologies, with postoperative results comparable with conventional laparoscopic surgery.

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.

Laparoscopic and open right-sided colonic resection in daily routine practice. A prospective multicentre study within an Enhanced Recovery After Surgery (ERAS) protocol.

AIM: The study compared the outcome of laparoscopic and open surgery in daily practice when performed in a strict Enhanced Recovery After Surgery (ERAS) environment. METHOD: Two-hundred and ninety-two consecutive patients who received elective surgery, in three Swedish ERAS centres, for cancer or adenoma in the right colon in the period 1 January 2011 to 31 December 2012, were prospectively registered in a Web-based ERAS database. Peri-operative data were collected from the database and patient charts. The primary end-points included postoperative recovery and morbidity. The secondary objective was to identify preoperative variables that influenced the selection of patients for laparoscopic or open surgery. RESULTS: One-hundred and twenty-three (42%) patients were selected for laparoscopic surgery. The overall preoperative ERAS-compliance rate was 87% and no significant difference was seen between the surgical techniques. In multivariate analysis, patients treated with laparoscopy had significantly earlier pain control (2.4 ± 3.2 days vs 4.2 ± 5.9 days; P = 0.016) and a shorter length of hospital stay (LOS) (4 days vs 6 days; P = 0.002) compared with open surgery. There was no significant difference in the complication rate [18.7% vs 21.3%; OR = 1.0 (95% CI: 0.5-2.0)], the number of lymph nodes removed or the rate of R0 resection between laparoscopic and open surgery. Tumours selected for laparoscopy were generally smaller, had a lower T-stage and were predominantly situated in the caecum and the ascending colon compared with those of patients selected for open surgery. CONCLUSION: The use of laparoscopy in routine right-sided colectomy in an ERAS environment, with data on outcome corrected for selection bias, may result in faster recovery compared with open surgery.