Multimodal prerehabilitation for elderly patients with sarcopenia in colorectal surgery.

Sarcopenia, which is characterized by progressive and generalized loss of skeletal muscle mass and strength, has been well described to be associated with numerous poor postoperative outcomes, such as increased perioperative mortality, postoperative sepsis, prolonged length of stay, increased cost of care, decreased functional outcome, and poorer oncological outcomes in cancer surgery. Multimodal prehabilitation, as a concept that involves boosting and optimizing the preoperative condition of a patient prior to the upcoming stressors of a surgical procedure, has the purported benefits of reversing the effects of sarcopenia, shortening hospitalization, improving the rate of return to bowel activity, reducing the costs of hospitalization, and improving quality of life. This review aims to present the current literature surrounding the concept of sarcopenia, its implications pertaining to colorectal cancer and surgery, a summary of studied multimodal prehabilitation interventions, and potential future advances in the management of sarcopenia.

Pre-operative erector spinae plane block should be considered a viable option for laparoscopic colectomies.

BACKGROUND: The Erector Spinae Plane (ESP) block is a recent development in the field of regional anaesthesia and has been increasingly explored for abdominal surgeries to reduce opioid use and improve pain control. Colorectal cancer is the commonest cancer in multi-ethnic Singapore and requires surgery for curative treatment. ESP is a promising alternative in colorectal surgeries, but few studies have evaluated its efficacy in such surgeries. Therefore, this study aims to evaluate the use of ESP blocks in laparoscopic colorectal surgeries to establish its safety and efficacy in this field. METHODS: A prospective two-armed interventional cohort study comparing T8-T10 ESP blocks with conventional multimodal intravenous analgesia for laparoscopic colectomies was conducted in a single institution in Singapore. The decision for doing an ESP block versus conventional multimodal intravenous analgesia was made by a consensus between the attending surgeon and anesthesiologist. Outcomes measured were total intra-operative opioid consumption, post-operative pain control and patient outcome. Post-operative pain control was measured by pain score, analgesia use, and amount of opioids consumed. Patient outcome was determined by presence of ileus. RESULTS: A total of 146 patients were included, of which 30 patients received an ESP block. Overall, the ESP group had a significantly lower median opioid usage both intra-operatively and post-operatively (p = 0.031). Fewer patients required patient-controlled analgesia and rescue analgesia post-operatively for pain control (p < 0.001) amongst the ESP group. Pain scores were similar and post-operative ileus was absent in both groups. Multivariate analysis found that the ESP block had an independent effect on reducing intra-opioid consumption (p = 0.014). Multivariate analysis of post-operative opioid use and pain scores did not yield statistically significant results. CONCLUSIONS: The ESP block was an effective alternative regional anaesthesia for colorectal surgery that reduced intra-operative and post-operative opioid use while attaining satisfactory pain control.

Systematic review and meta-analysis of postoperative pain and symptoms control following laser haemorrhoidoplasty versus Milligan-Morgan haemorrhoidectomy for symptomatic haemorrhoids: a new standard.

PURPOSE: Haemorrhoidal disease (HD) plagues one in every ten people, with a plethora of surgical treatment modalities, of which laser haemorrhoidoplasty (LHP) is a relatively novel option. This systematic review and meta-analysis objectively evaluated the efficacy, safety, and tolerability of LHP compared against conventional (Milligan-Morgan) open haemorrhoidectomy (CoH). METHOD: A comprehensive search of MEDLINE, EMBASE, CENTRAL, and Google Scholar was conducted. Randomised controlled trials (RCTs) and comparative cohort studies (CCSs) which compared LHP against CoH were included, with postoperative pain as the primary outcome. Secondary outcomes included intraoperative characteristics, short- and moderate-term outcome, and complications. RESULTS: A total of 12 studies (6 RCTs and 6 CCSs), with a total of 1824 patients, were analysed. LHP resulted in reduced postoperative pain for the first day (mean difference of 2.07 visual analogue scale units), week, and month. The mean dosage and duration of postoperative analgesia use was similarly lower, with a mean difference of 4.88 mg (morphine) and 2.25 days, respectively. Crucially, recurrence was equivocal (HR: 0.72, CI: 0.21-2.40) at a mean follow-up duration of 8.58 ± 9.55 months. LHP resulted in lower blood loss and was 12.74 min shorter on average. LHP's postoperative recovery time was 9.03 days less with equivalent or decreased risk of most short- and moderate-term complications except anal thrombosis. CONCLUSION: Our study suggests that LHP is more tolerable than CoH, providing patients with superior postoperative quality of life at equivalent moderate-term efficacy. These findings contribute to improved understanding of LHP and its potential at enhancing the quality of HD care.

Did the COVID-19 lockdown result in a delay of colorectal cancer presentation and outcomes? A single centre review.

PURPOSE: The COVID-19 pandemic and resultant lockdown measures potentially delay management of non-communicable, life-limiting diseases like colorectal cancer (CRC) through avoidance of healthcare facilities by the public and diversion of resources within healthcare systems. This study aims to evaluate the impact of Singapore's "Circuit Breaker (CB)" lockdown measures on CRC disease presentation and short-term surgical outcomes, while comparing Singapore's approach against other countries which employed similar lockdown measures. METHODS: Patients whose initial diagnosis of CRC was made within the 6-month pre-CB (6/10/19-6/4/20) ("pre-CB group") and post-CB (7/4/20-7/10/20) ("post-CB group") period were enrolled retrospectively. The groups were compared based on severity of disease on presentation and short-term operative outcomes. RESULTS: In total, 105 patients diagnosed with CRC were enrolled in this study. When comparing pre-CB and post-CB groups, there was no significant difference in stage of CRC on presentation (p = 0.850). There was also no increase in need for emergent operations (p = 0.367). For patients who had undergone an operation, postoperative morbidity was not significantly higher in the post-CB group (p = 0.201). Both groups of patients had similar length of stay in the hospital (p = 0.438). CONCLUSION: Unlike similar high-income countries, Singapore did not see later stage disease on presentation and poorer operative outcomes after lockdown measures. Possible reasons include lesser healthcare avoidance behaviours amongst Singaporeans, and adequate preparation of resources and contingency plans formed by hospitals after previous pandemics.

Structured presurgery prehabilitation for aged patients undergoing elective surgery significantly improves surgical outcomes and reduces cost: A nonrandomized sequential comparative prospective cohort study.

BACKGROUND: With increasing global life expectancy, the number of major surgeries performed on aged adults invariably increases. This study aimed to examine the effectiveness of a structured prehabilitative program for aged colorectal cancer patients in improving short-term surgical outcomes. METHODS: A prospective philanthropically sponsored Programme for Enhanced Elderly Recovery at Sengkang General Hospital (PEERS) was initiated in February 2017 for patients ≥70-years-old who were due to undergo elective colectomies. These patients were put through a 2- to 4-week-long program before surgery, which included geriatric assessment, nutrition supplementation, and resistance training. They were compared with patients from a similar age group before PEERS was introduced (non-PEERS). RESULTS: Fifty-eight patients, with a median age of 78.5 (70-93) years, were recruited from a single institution to undergo PEERS. Baseline characteristics between the groups were similar. There was no significant improvement of anthropometric and functional characteristics before and after PEERS. Duration of hospitalization was shorter in the PEERS group (9 vs 11 days, P = 0.01). Both groups had similar 30-days' morbidity rates (8.6% vs 17.4%, P = 0.26). The PEERS group had significant improvement in their median EuroQol-5 Dimension score (0.70 presurgery to 0.80 6-months' postsurgery, P = 0.01). After multivariate analysis, the average duration of hospitalization in the PEERS group was 6.8 days shorter (P = 0.018; CI, 1.2-12.4) after adjusting for modality of surgery and complications. This represented a cost saving of USD$11,838.80. CONCLUSION: A standardized prehabilitation program for aged adults reduced the duration of hospitalization, improved the quality of life after surgery, and reduced costs.