Clinical study: the impact of goal-directed fluid therapy on volume management during enhanced recovery after surgery in gastrointestinal procedures.

Background: Goal-directed fluid therapy, as a crucial component of accelerated rehabilitation after surgery, plays a significant role in expediting postoperative recovery and enhancing the prognosis of major surgical procedures. Methods: In line with this, the present study aimed to investigate the impact of target-oriented fluid therapy on volume management during ERAS protocols specifically for gastrointestinal surgery. Patients undergoing gastrointestinal surgery at our hospital between October 2019 and May 2021 were selected as the sample population for this research. Results: 41 cases of gastrointestinal surgery patients were collected from our hospital over 3 recent years. Compared with T1, MAP levels were significantly increased from T2 to T5; cardiac output (CO) was significantly decreased from T2 to T3, and significantly increased from T4 to T5; and SV level was significantly increased from T3 to T5. Compared with T2, HR and cardiac index (CI) were significantly elevated at T1 and at T3-T5. Compared with T3, SVV was significantly decreased at T1, T2, T4, and T5; CO and stroke volume (SV) levels were increased significantly at T4 and T5. In this study, pressor drugs were taken for 23 days, PACU residence time was 40.22 ± 12.79 min, time to get out of bed was 12.41 ± 3.97 h, exhaust and defecation time was 18.11 ± 7.52 h, and length of postoperative hospital stay was 4.47 ± 1.98 days. The average HAMA score was 9.11 ± 2.37, CRP levels were 10.54 ± 3.38 mg/L, adrenaline levels were 132.87 ± 8.97 ng/L, and cortisol levels were 119.72 ± 4.08 ng/L. Prealbumin levels were 141.98 ± 10.99 mg/L at 3 d after surgery, and 164.17 ± 15.84 mg/L on the day of discharge. Lymphocyte count was 1.22 ± 0.18 (109/L) at 3 d after surgery, and 1.47 ± 0.17 (109/L) on the day of discharge. Serum albumin levels were 30.51 ± 2.28 (g/L) at 3 d after surgery, and 33.52 ± 2.07 (g/L) on the day of discharge. Conclusion: Goal-directed fluid therapy (GDFT) under the concept of Enhanced Recovery After Surgery (ERAS) is helpful in volume management during radical resection of colorectal tumors, with good postoperative recovery. Attention should be paid to the influence of pneumoperitoneum and intraoperative posture on GDFT parameters.

Quality and clinical generalizability of feasibility outcomes in exercise prehabilitation before colorectal cancer surgery - A systematic review.

Suboptimal quality of feasibility assessments might partially explain inconsistencies observed in the effectiveness of exercise prehabilitation before colorectal cancer (CRC) surgery. This systematic review aimed to assess the reporting quality and clinical generalizability of feasibility outcomes in feasibility studies addressing exercise prehabilitation before CRC surgery. PubMed/Medline, Embase, Cochrane, and CINAHL were searched to identify all feasibility studies focussing on exercise prehabilitation in CRC surgery. Reporting quality was assessed using the Thabane et al. checklist and the Consolidated Standards of Reporting Trials extension for feasibility studies. Clinical generalizability was evaluated by appraising patient participation in all steps of the study and intervention. Twelve studies were included. The main feasibility outcome in all studies was adherence to the intervention by the study sample. Based on adherence, 10 studies (83%) concluded exercise prehabilitation to be feasible. Six studies (50%) reported all details to assess patient participation showing retention rates between 18.4% and 58.2%, which was caused by non-participation and drop-out. Three feasibility studies (25%) discussed patient-reported barriers to participation and five additional studies (41%) described potential selection bias. Four studies (33%) reported lessons learned to solve issues hampering feasibility and clinical generalizability. Results suggest that true feasibility of exercise prehabilitation before CRC surgery remains questionable due to poor reporting quality, insufficient clarity regarding the representativeness of the study sample for the target population, and limited attention for clinical generalizability. Feasibility of exercise prehabilitation might be improved by offering supervised community- or home-based interventions tailored to the physical and mental abilities of the patient.

Cystine and Theanine as Stress-Reducing Amino Acids-Perioperative Use for Early Recovery after Surgical Stress.

Perioperative nutritional therapy requires the consideration of metabolic changes, and it is desirable to reduce stress aiming at early metabolic normalization. Glutathione (GSH) is a tripeptide composed of glutamic acid, cysteine, and glycine. It is one of the strongest antioxidants in the body and important for adjusting immune function. Cystine and theanine (γ-glutamylethylamide) provide substrates of GSH, cysteine and glutamic acid, promoting the synthesis of GSH. It has been reported that the ingestion of cystine (700 mg) and theanine (280 mg) exhibits inhibitory effects against excess inflammation after strong exercise loads in athletes, based on which its application for invasive surgery has been tried. In patients undergoing gastrectomy, ingestion of cystine (700 mg) and theanine (280 mg) for 10 days from 5 days before surgery inhibited a postoperative increase in resting energy expenditure, promoted recovery from changes in interleukin-6, C-reactive protein, lymphocyte ratio, and granulocyte ratio and inhibited an increase in body temperature. In a mouse small intestine manipulation model, preoperative 5-day administration of cystine/theanine inhibited a postoperative decrease in GSH in the small intestine and promoted recovery from a decrease in behavior quantity. Based on the above, cystine/theanine reduces surgical stress, being useful for perioperative management as stress-reducing amino acids.

Application of Accelerated Rehabilitation Surgery in Gastrointestinal Surgery.

Adding timely rehabilitation surgery is an optimized perioperative measure that can reduce physical stress, reduce surgical risks, and postoperative complications and promote the recovery of organ function. Therefore, it is of great value to study its application in gastrointestinal surgery (GS). To this end, this article applies retrospective analysis and statistical methods to conduct targeted investigations and studies on GS patients. The results of the survey showed that 26.7% of patients were effective in ARS and 40% were effective in treatment. Compared with traditional treatment methods, its effective treatment rate is 13.4% higher.

Enhanced recovery after surgery programmes in older patients undergoing hepatopancreatobiliary surgery: what benefits might prehabilitation have?

Due to an aging population and the related growing number of less physically fit patients with multiple comorbidities, adequate perioperative care is a new and rapidly developing clinical science that is becoming increasingly important. This narrative review focuses on enhanced recovery after surgery (ERAS®) programmes and the growing interest in prehabilitation programmes to improve patient- and treatment-related outcomes in older patients undergoing hepatopancreatobiliary (HPB) surgery. Future steps required in the further development of optimal perioperative care in HPB surgery are also discussed. Multidisciplinary preoperative risk assessment in multiple domains should be performed to identify, discuss, and reduce risks for optimal outcomes, or to consider alternative treatment options. Prehabilitation should focus on high-risk patients based on evidence-based cut-off values and should aim for (partly) supervised multimodal prehabilitation tailored to the individual patient's risk factors. The program should be executed in the living context of these high-risk patients to improve the participation rate and adherence, as well as to involve the patient's informal support system. Developing tailored (multimodal) prehabilitation programmes for the right patients, in the right context, and using the right outcome measures is important to demonstrate its potential to further improve patient- and treatment-related outcomes following HPB surgery.

Comparing Activity Trackers With vs. Without Alarms to Increase Postoperative Ambulation: A Randomized Control Trial.

Early ambulation is a key component to postoperative recovery; however, measuring steps taken is often inconsistent and nonstandardized. This study aimed to determine whether an activity tracker with alarms would increase postoperative ambulation in patients after elective colorectal procedures. Forty-eight patients were randomly assigned to either trackers with 5 daily alarms or activity trackers alone. Over 223 total patient days, the trackers recorded a complete data set for 216 patient days (96.9%). Increasing the postoperative day significantly affected the number of steps taken, while age, sex, Risk Analysis Index score, and approach (laparoscopic versus open) did not show a significant effect. The mean steps per day in the intervention group were 1468 (median 495; interquartile range (IQR) 1345) and in the control group was 1645 (median 1014; IQR 2498). The use of trackers with alarms did not significantly affect the number of daily steps compared to trackers alone (ANOVA, P = .93). Although activity trackers with alarms did not increase postoperative ambulation compared with trackers with no alarms, we demonstrated a strategy to operationalize the use of trackers into postoperative care to provide a quantitative value for ambulation. This enables quantification of a key component in the Enhanced Recovery After Surgery protocol.

Preliminary Results of an Exercise Program After Laparoscopic Resective Colorectal Cancer Surgery in Non-Metastatic Adenocarcinoma: A Pilot Study of a Randomized Control Trial.

Performing physical exercise after a colorectal cancer diagnosis is associated with lower mortality related to the tumor itself. In order to improve physical recovery after elective surgery, there are no specific exercise protocols after discharge from the hospital. The purpose of this study is to show the preliminary results of an exercise program after colorectal cancer surgery. Six patients with non-metastatic colorectal adenocarcinoma addressed to respective laparoscopic were randomly assigned to a mixed supervised/home-based exercise program for six months and compared to a control group without exercise. To assess the effectiveness of the program, functional and body composition parameters were evaluated. Three months after surgery, the exercise group increased flexibility (p < 0.01, ES = 0.33), strength of lower limbs (p < 0.01, ES = 0.42) and aerobic capacity (p < 0.01, ES = 0.28). After surgery, the six patients experienced a significant reduction in body mass index (BMI) and free fat mass. More specifically, fat mass reached the lowest values, with a concomitant increase in cell mass after six months (p < 0.01, ES = 0.33). This did not occur in the control group. Colorectal cancer treatment induces a reduction in physical function, particularly during the first six months after treatment. A mixed exercise approach appears promising in countering this process after colorectal cancer surgery.

Comparison of Footsteps Using Connected Bracelets with the Timed Up-and-Go Test and the 6-Minutes Walking Test in a Prospective Colorectal Surgery Cohort.

Preoperative physical activity and early postoperative mobilization are key components of enhanced recovery programs but both difficult to assess. The aim of this prospective study was therefore to compare different ways to measure preoperative physical activity and to correlate those tests with postoperative physical activity (footsteps). The daily number of footsteps was recorded from preoperative day 5 to postoperative day (POD) 3 in a prospective cohort of colorectal patients using connected wrist bracelets. Timed Up-and-Go Test (TUGT) and 6-Minutes Walking Test (6MWT) were assessed preoperatively. Pearson correlation and multivariable regression were used to study the predictive potential of these tests for postoperative footsteps. A total of 50 patients were included. Mean number of preoperative and postoperative footsteps were 6163 (SD 4274) and 1183 (SD 1828), respectively. There was no correlation between preoperative footsteps and preoperative tests (TUGT and 6MWT) as well as between preoperative tests (TUGT and 6MWT) and postoperative footsteps. Postoperative physical activity was significantly correlated with mean number of preoperative footsteps (Rho = 0.527, IC 95 [0.28;0.709]; p < 0.001). Thereby, preoperative footsteps measurement was the only tool permitting to predict postoperative footsteps. Other preoperative tests as TUGT and 6MWT could not predict immediate postoperative physical activity.

The application of enhanced recovery after surgery for upper gastrointestinal surgery: Meta-analysis.

BACKGROUND: Although enhanced recovery after surgery (ERAS) has made great progress in the field of surgery, the guidelines point to the lack of high-quality evidence in upper gastrointestinal surgery. METHODS: Randomized controlled trials in four electronic databases that involved ERAS protocols for upper gastrointestinal surgery were searched through December 12, 2018. The primary endpoints were lung infection, urinary tract infection, surgical site infection, postoperative anastomotic leakage and ileus. The secondary endpoints were postoperative length of stay, the time from end of surgery to first flatus and defecation, and readmission rates. Subgroup analysis was performed based on the type of surgery. RESULTS: A total of 17 studies were included. The results of the meta-analysis indicate that there was a decrease in rates of lung infection (RR = 0.50, 95%CI: 0.33 to 0.75), postoperative length of stay (MD = -2.53, 95%CI: - 3.42 to - 1.65), time until first postoperative flatus (MD = -0.64, 95%CI: - 0.84 to - 0.45) and time until first postoperative defecation (MD = -1.10, 95%CI: - 1.74 to - 0.47) in patients who received ERAS, compared to conventional care. However, other outcomes were not significant difference. There was no significant difference between ERAS and conventional care in rates of urinary tract infection (P = 0.10), surgical site infection (P = 0.42), postoperative anastomotic leakage (P = 0.45), readmissions (P = 0.31) and ileus (P = 0.25). CONCLUSIONS: ERAS protocols can reduce the risk of postoperative lung infection and accelerating patient recovery time. Nevertheless, we should also consider further research ERAS should be performed undergoing gastrectomy and esophagectomy.

An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study.

PURPOSE: To investigate the feasibility of conducting a rehabilitation program for patients following surgery for abdomino-pelvic cancer. METHODS: A non-randomised controlled before-and-after study. Patients who had undergone surgery for stage I-III abdomino-pelvic cancer (colorectal, gynaecological or prostate cancer) were recruited. The rehabilitation group (n = 84) received an 8-week, bi-weekly education and exercise program conducted by a physiotherapist, exercise physiologist, health psychologist and dietician, supplemented by exercise diaries and telephone coaching sessions. The comparator group (n = 104) completed postal questionnaires only. Feasibility measures, functional exercise capacity, muscle strength, physical activity levels, pelvic floor symptoms, anxiety and depression, health-related quality of life (HRQoL) and self-efficacy were measured at baseline (time 1), immediately post-intervention (time 2) and at 6 months post-baseline (time 3) and compared within- and between-groups. RESULTS: The consent rate to the rehabilitation program was 24%. Eighty-one percent of the rehabilitation group attended 85-100% of 16 scheduled sessions. Overall satisfaction with the program was 96%. Functional exercise capacity, handgrip strength in males, bowel symptoms, physical activity levels, depression and HRQoL were significantly improved in the rehabilitation group (p < 0.05) at time 2. The improvements in all these outcomes were sustained at time 3. The rehabilitation group had significantly improved physical activity levels, depression and HRQoL compared with the comparator group at times 2 and 3 (p < 0.05). CONCLUSION: Recruitment to this oncology rehabilitation program was more difficult than expected; however, attendance and patient satisfaction were high. This program had positive effects on several important clinical outcomes in patients following abdomino-pelvic cancer treatment. TRIAL REGISTRATION: ANZCTR 12614000580673.

Intolerance to early oral feeding in enhanced recovery after colorectal surgery: an early red flag?

AIM: Enhanced recovery programmes (ERPs) involve early postoperative oral feeding. The aim of this study was to test the hypothesis that intolerance to early feeding was associated with a complicated postoperative course. METHOD: A retrospective cohort analysis of the prospective multicentre database developed by the Francophone Group for Enhanced Recovery after Surgery (GRACE) was undertaken. Seventy-one centres in Belgium, France and Switzerland participated in the study. All patients were encouraged to eat within 24 h after surgery. Patients were separated into two groups according to whether early feeding was well tolerated (WT) or poorly tolerated (PT). The primary outcome measure was overall postoperative complications. Secondary outcome measures were unplanned reoperation, early mobilization rate and duration of postoperative hospital stay. RESULTS: Among the cohort of 3034 patients, early feeding was WT in 2614 patients (WT group) and PT in 420 patients (PT group). There were significantly more postoperative complications in the PT group than in the WT group (52.1% vs 17.0%, respectively; P = 0.001), namely more unplanned reoperations, less early mobilization and longer postoperative hospital stay. Multivariate analyses confirmed that PT early feeding was the main and dominant independent factor for postoperative complications [OR 4.47 (95% CI3.49-5.72); P < 0.001], more unplanned reoperations and longer hospital stay. CONCLUSIONS: This study demonstrates a close relationship between intolerance to early feeding and a complicated postoperative course. Whenever this simple very early red flag is observed, discharge should not be planned until postoperative complications have been ruled out.

Feasibility of a novel exercise prehabilitation programme in patients scheduled for elective colorectal surgery: a feasibility randomised controlled trial.

BACKGROUND AND OBJECTIVES: To investigate the feasibility of delivering a functional exercise-based prehabilitation intervention and its effects on postoperative length of hospital stay, preoperative physical functioning and health-related quality of life in elective colorectal surgery. MATERIALS AND METHODS: In this randomised controlled feasibility trial, 22 elective colorectal surgery patients were randomly assigned to exercise prehabilitation (n = 11) or standard care (n = 11). Feasibility of delivering the intervention was assessed based on recruitment and compliance to the intervention. Impact on postoperative length of hospital stay and complications, preoperative physical functioning (timed up and go test, five times sit to stand, stair climb test, handgrip dynamometry and 6-min walk test) and health-related quality of life were also assessed. RESULTS: Over 42% of patients (84/198) screened were deemed ineligible for prehabilitation due to insufficient time existing prior to scheduled surgery. Of those who were eligible, approximately 18% consented to the trial. Median length of hospital stay was 8 [range 6-27] and 10 [range 5-12] days respectively for the standard care and prehabilitation groups. Patterns towards preoperative improvements for the timed up and go test, stair climb test and 6-min walk test were observed for all participants receiving prehabilitation but not standard care. CONCLUSIONS: Despite prehabilitation appearing to convey positive benefits on physical functioning, short surgical wait times and patient engagement represent major obstacles to implementing exercise prehabilitation programmes in colorectal cancer patients.

Influence of Early versus Late supplemental ParenteraL Nutrition on long-term quality of life in ICU patients after gastrointestinal oncological surgery (hELPLiNe): study protocol for a randomized controlled trial.

BACKGROUND: Nutrition plays a major role in intensive care unit (ICU) treatment, influencing ICU length of stay and patient's survival. If preferable enteral nutrition administration is not feasible, ESPEN and ASPEN guidelines recommend initiation of a supplemental parenteral route between the first and seventh day, but exact timing remains elusive. While rapid development in critical care enabled significant reduction in the mortality rate of ICU patients, this improvement also tripled the number of patients going to rehabilitation. Thus, it is quality of life after ICU that has become the subject of interest of clinicians and healthcare policy-makers. A growing body of evidence indicates that protein turnover in the early phase of critical illness may play a crucial role in the preservation of lean body mass. A negative protein balance may lead to muscle wasting that persists weeks and months after ICU stay, resulting in deterioration of physical functioning. Folliwing oncological gastrointestinal tract surgery, patients are threatened with negative protein turnover due to cancer and extensive surgical insult. METHODS: This is a multi-centre, single-blinded, randomised controlled trial. The study population includes patients admitted to ICU units after major oncological gastrointestinal surgery that require supplemental parenteral nutrition. After initiation of enteral nutrition, the intervention group receives remaining daily requirement via supplemental parenteral nutrition on the first day of ICU stay while the control group is not supplemented parenterally until the seventh day of ICU stay while enteral nutrition is gradually increased. Primary endpoint: long-term quality of life measured in the physical component score (PCS) of SF-36 questionnaire at 3 and 6 months after ICU admission. DISCUSSION: To our knowledge, this is the first trial to investigate the influence of early supplemental parenteral nutrition on long-term quality of life after major oncological gastrointestinal surgery. We assume that, particularly in this population of patients, early supplemental parenteral nutrition may increase the long-term quality of life. The study construction also allows establishment of patients' PCS SF-36 score prior to surgery and mean change in PCS SF-36 score during the recovery period, which is rarely seen in studies on critically ill patients. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03699371 registered on 12 October 2018.

Objectively measured mobilisation is enhanced by a new behaviour support tool in patients undergoing abdominal cancer surgery.

INTRODUCTION: Mobilisation reduces the risk of complications after abdominal surgery. Despite that, patients spend most of their time immobilised during hospital stay. Hence, the aim of this study was to evaluate a tool called the Activity board, which includes behaviour change techniques, regarding effects on mobilisation and postoperative recovery after abdominal cancer surgery. MATERIAL AND METHODS: Patients who were planned for abdominal surgery due to colorectal, ovarian or urinary bladder cancer, and at least three postoperative days at Karolinska University Hospital were included in this non-randomised controlled trial, from January 2017 to May 2018. The patients were allocated to Activity board or standard treatment when they were admitted to hospital. Mobilisation was evaluated objectively with activity monitor the first three postoperative days, and postoperative recovery was assessed continuously during hospital stay. RESULTS: In total, 133 patients, mean (sd) age 68.1 (12.3) years were included. The patients with the Activity board had postoperatively higher levels of mobilisation, compared to standard treatment, as mean value over the first three days, steps, median (min-max) 1057 (3-10433) and 360 (0-6546), respectively (p = 0.001), and for each day separately. Further, the group with the Activity board had a shorter length of stay, 6 (3-13), compared to standard treatment 7 (3-14) (p = 0.027). CONCLUSION: The Activity board is an effective tool to enhance mobilisation after abdominal surgery due to cancer, in hospital settings. Using the Activity board could lead to improved postoperative recovery.

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

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

Cholestasis affects enteral tolerance and prospective weight gain in the NICU.

BACKGROUND: Intestinal Failure-Associated Liver Disease is characterized by cholestasis and hepatic dysfunction due to parenteral nutrition (PN) therapy. We described key features of cholestatic infants receiving PN to assess overall outcomes in this population at our institution. METHODS: This is a retrospective single center study of 163 neonates grouped into cholestatic (n = 63) and non-cholestatic (n = 100) as defined by peak conjugated bilirubin of ≥2.0 mg/dL or < 0.8 mg/dL, respectively. Univariate and multiple regression models were used to study associations between variables and outcomes of interest. RESULTS: Lower Apgar scores (4 ± 3 vs. 6 ± 3, p-value = <0.005 at 1 min; 6 ± 2 vs. 7 ± 2, p < 0.005 at 5 min) and lower birth weight (adj ß [SE] = 0.62 [0.27], p-value = 0.024) were risk factors for developing cholestasis. Cholestatic infants were more likely to have had gastrointestinal surgery (31 [49%] vs. 15 [15%], p-value <0.005), received PN for a longer duration (40 ± 39 days vs. 11 ± 7 days, p-value <0.005), and started enteral feeds later in life (86 ± 23 days vs. 79 ± 20 days, p-value <0.005) when compared to non-cholestatic infants. Weight percentiles in cholestatic infants were lower both at hospital discharge (14 ± 19 vs. 24 ± 22, p-value <0.005) and at 6 months of age (24 ± 28 vs. 36 ± 31, p-value = 0.05). CONCLUSIONS: Cholestasis in the NICU is a multifactorial process, but it has a long lasting effect on prospective weight gain in infants who receive PN in the NICU. This finding highlights the importance of follow-up for adequate growth and the potential benefit from aggressive nutritional support.

Systematic review of definitions and outcome measures for return of bowel function after gastrointestinal surgery.

Background: Ileus is common after gastrointestinal surgery and has been identified as a research priority. Several issues have limited previous research, including a widely accepted definition and agreed outcome measure. This review is the first stage in the development of a core outcome set for the return of bowel function after gastrointestinal surgery. It aims to characterize the extent of variation in current outcome reporting. Methods: A systematic search of MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and the Cochrane Library was performed for 1990-2017. RCTs of adults undergoing gastrointestinal surgery, including at least one reported measure relating to return of bowel function, were eligible. Trial registries were searched across the same period for ongoing and completed (but not published) RCTs. Definitions of ileus and outcome measures describing the return of bowel function were extracted. Results: Of 5670 manuscripts screened, 215 (reporting 217 RCTs) were eligible. Most RCTs involved patients undergoing colorectal surgery (161 of 217, 74·2 per cent). A total of 784 outcomes were identified across all published RCTs, comprising 73 measures (clinical: 63, 86 per cent; radiological: 6, 8 per cent; physiological: 4, 5 per cent). The most commonly reported outcome measure was 'time to first passage of flatus' (140 of 217, 64·5 per cent). The outcomes 'ileus' and 'prolonged ileus' were defined infrequently and variably. Conclusion: Outcome reporting for the return of bowel function after gastrointestinal surgery is variable and not fit for purpose. An agreed core outcome set will improve the consistency, reliability and clinical value of future studies.

Enhanced Recovery Program for Colorectal Surgery: a Focus on Elderly Patients Over 75 Years Old.

BACKGROUND: An enhanced recovery after surgery (ERAS) protocol can effectively improve perioperative outcomes in surgical patients by reducing complication rates and hospital stay. However, its application in elderly patients has yielded contradictory results. The aim of this study was to evaluate surgical outcomes in a cohort of elderly patients undergoing colorectal resection in our unit before and after the introduction of ERAS. METHODS: From 328 patients undergoing colorectal surgery in our unit over a 2-year period (2015-2016), 114 patients ≥ 75 years of age were selected. The patients were categorized according to perioperative treatment as pre-ERAS and ERAS patients (respectively, 53 vs 61 patients), and the groups were compared for statistical purposes. Outcome measures included length of hospital stay, recovery of bowel functions, oral feeding, postoperative complications, and readmissions. Compliance with the ERAS protocol was also measured. RESULTS: Groups were homogeneous for all the clinical-surgical variables, with the sole exception of the Charlson index, which was more severe in the ERAS group (p = 0.012). Compared with control patients, ERAS patients reported improved functional recovery (time to first flatus, stool, and oral feeding; p < 0.001). Hospital stay was reduced in ERAS patients overall and by side of resection, excluding rectal procedures. No differences were observed regarding postoperative complications. Of note, an optimal adherence to the protocol was reported, with 79% of items respected. CONCLUSIONS: ERAS can be considered safe in elderly patients undergoing colorectal surgery with a high comorbidity index, providing a reduction in hospital stay and improving short-term postoperative outcomes. Finally, the protocol application was feasible, with a high adherence to the items in this subset of patients.

A qualitative exploration of patients' experiences with and perceptions of recommencing feeding after colorectal surgery.

BACKGROUND: Many patients who undergo lower gastrointestinal surgery neither recommence feeding within timeframes outlined by evidence-based guidelines, nor meet their nutrition requirements in hospital. Given that the success of timely and adequate post-operative feeding is largely reliant on patient adherence, the present study explored patients' perceptions of recommencing feeding after colorectal surgery to determine areas of improvement to meet their needs and expectations. METHODS: This qualitative study involved one-on-one, semi-structured interviews with patients receiving care after colorectal surgery in an Australian tertiary teaching hospital. Purposive sampling was used to ensure maximal variation in age, sex, procedural type and post-operative nutrition care experience. Interviews were audio recorded, with data transcribed verbatim before being thematically analysed. Emergent themes and subthemes were discussed by all investigators to ensure consensus of interpretation. RESULTS: Sixteen patients were interviewed (female 56%; age 61.5 ± 12.3 years). Three overarching themes emerged from the data: (i) patients make food-related decisions based on ideologies, experience and trust; (ii) patients appreciate the opportunity to participate in their nutrition care; and (iii) how dietary information is communicated influences patients' perceptions of and behaviours towards nutrition. CONCLUSIONS: Enabling patients to select from a wide range of foods from post-operative day 1 (by prescribing an unrestricted diet in line with evidence-based practice guidelines) in conjunction with delivering clear, simple and encouraging dietary-related information may facilitate patient participation in care and increase oral intakes among patients who have undergone colorectal surgery.

Functional dependence versus frailty in gastrointestinal surgery: Are they comparable in predicting short-term outcomes?

BACKGROUND: Frailty and functional dependence are important factors in assessing preoperative risk. No studies to date have compared frailty with functional dependence as a predictor of surgical outcomes. We sought to compare the impact of frailty and functional dependence on early outcomes after gastrointestinal surgery. METHODS: Patients who underwent gastrointestinal surgery were identified using the American College of Surgeons National Surgical Quality Improvement Program database (2012-2015). Propensity score matching analysis was used to separately match dependent and independent patients, and patients with modified frailty index <3 and modified frailty index ≥3 on baseline characteristics. Multivariable logistic regression analysis was used. Postoperative outcomes were compared. RESULTS: Of 765,082 patients, 1.71% were dependent and 1.49% had a modified frailty index score ≥3. Similar outcomes were observed in matched cohorts for those who were dependent and patients with a modified frailty index score ≥3: readmission (15.61% dependent and 15.75% modified frailty index ≥3), overall morbidity (37.91% and 34.81%), serious morbidity (19.06% and 17.06%), mortality (6.73% and 5.43%), and reoperation (7.01% and 6.48%). Dependent and modified frailty index ≥3 patients had similar odds of outcomes on adjusted multivariable logistic analysis and shared 3 of the top 5 indicators for readmission: complication of surgical procedure (11.46% dependent and 11.23% mFI ≥3), intestinal obstruction (10.70% and 7.65%), and organ space surgical site infection (7.93% and 8.65%). Comparable outcomes and reasons for readmission were also obtained for dependent patients and colectomy patients with a modified frailty index score ≥3. CONCLUSION: Frailty and functional dependence are comparable in predicting postoperative outcomes after gastrointestinal surgery. Functional dependence should be considered an acceptable and practical alternative for preoperative risk stratification in a clinical setting.