Postoperative Complications and Stoma Rates After Laparoscopic Resection of Deep Infiltrating Endometriosis with Bowel Involvement / Complicações pós-operatórias e taxas de estomia após ressecção laparoscópica de endometriose infiltrativa profunda com envolvimento intestinal

Abstract Objective The purpose was to assess the rates of postoperative complications and the need of temporary stoma of laparoscopic surgical treatment for bowel endometriosis in a referral center. Methods The surgical indication, type of operation, operative time, length of hospital stay, need for a temporary stoma, rate of conversion to open surgery, postoperative complications were evaluated. Results One-hundred and fifty patients were included. The average duration of surgery was significantly longer for segmental resection (151 minutes) than for disc excision (111.5 minutes, p < 0.001) and shaving (96.8 minutes, p < 0.001). Patients with segmental resection had longer postoperative lengths of hospital stay (1.87 days) compared with patients with disc excision (1.43 days, p < 0.001) and shaving (1.03 days, p < 0.001). A temporary stoma was performed in 2.7% of patients. Grade II and III postoperative complications occurred in 6.7% and 4.7% patients, respectively. Conclusion Laparoscopic intestinal resection has an acceptable postoperative complication rate and a low need for a temporary stoma.

Resumo Objetivo O objetivo foi avaliar as taxas de complicações pós-operatórias e a necessidade de estomia temporária do tratamento cirúrgico laparoscópico para endometriose intestinal em um centro de referência. Métodos Foram avaliados a indicação cirúrgica, tipo de operação, tempo operatório, tempo de internação, necessidade de estomia temporária, taxa de conversão para cirurgia aberta, complicações pós-operatórias. Resultados Cento e cinquenta pacientes foram incluídos. A duração média da cirurgia foi significativamente maior para a ressecção segmentar (151 minutos) do que para a excisão do disco (111,5 minutos, p < 0,001) e shaving (96,8 minutos, p < 0,001). Pacientes com ressecção segmentar tiveram maior tempo de internação pós-operatória (1,87 dias) em comparação com pacientes com excisão de disco (1,43 dias, p < 0,001) e shaving (1,03 dias, p < 0,001). Um estoma temporário foi realizado em 2,7% dos pacientes. Complicações pós-operatórias de grau II e III ocorreram em 6,7% e 4,7% dos pacientes, respectivamente. Conclusão A ressecção intestinal laparoscópica apresenta taxa aceitável de complicações pós-operatórias e baixa necessidade de estomia temporária.

Impacto del grado de cumplimiento de un protocolo ERAS en la recuperación funcional después de cirugía colorrectal / ERAS protocol compliance impact on functional recovery in colorectal surgery

INTRODUCCIÓN: El grado de cumplimiento de los protocolos de Enhanced Recovery After Surgery (ERAS) es una medida de calidad del proceso, que además se asocia a mejores resultados. El objetivo del presente estudio es analizar la relación existente entre el grado de cumplimiento del protocolo, el estrés quirúrgico y la recuperación funcional. Se plantea como objetivo secundario, la identificación de factores independientes asociados a la recuperación funcional. MÉTODOS: Estudio retrospectivo observacional unicéntrico de pacientes sometidos a cirugía colorrectal programada dentro de un programa ERAS entre enero de 2017 y junio de 2018. Se analizó el grado de cumplimiento del protocolo porcentual y su relación con el estrés quirúrgico (definido por los niveles plasmáticos de proteína C reactiva al tercer día), y la recuperación funcional (definida por el cumplimiento de los criterios de alta el quinto día postoperatorio o antes). Se llevó a cabo un análisis multivariante de factores independientes asociados a recuperación funcional. RESULTADOS: Se analizaron 313 pacientes. Por cada punto porcentual de cumplimiento adicional del protocolo disminuye 1,46 mg/dL la proteína C reactiva del tercer día y aumenta un 7% la probabilidad de cumplir criterios de alta (p < 00,1 ambos). Los factores asociados a recuperación funcional fueron ASA III-IV (OR 0,26; 0,14-0,48), puntuación CR-POSSUM quirúrgico (OR 0,68; 0,57-0,83), movilización precoz (OR 4,22; 1,43-12,4) y retirada precoz de sonda vesical (OR 3,35; 1,79-6,27), todos ellos p < 0,001. CONCLUSIÓN: El aumento del grado de cumplimiento del protocolo ERAS en cirugía colorrectal, disminuye el estrés quirúrgico y acelera la recuperación funcional

INTRODUCTION: Compliance to ERAS protocols is a process quality measure that is associated to better outcomes. The main objective of this study is to analyze the association between protocol compliance, surgical stress and functional recovery. The secondary objective is to identify independent factors associated to functional recovery. METHODS: A prospective observational single-centre study was performed. Patients who had scheduled colorectal surgery within an ERAS program from January 2017 to June 2018 were included. We analysed the relationship between protocol compliance percentage and surgical stress (defined by C reactive protein [CRP] blood levels on postoperative 3rd day), and functional recovery (defined by the proportion of patients who meet the discharge criteria on the 5th PO day or before). Multivariate analysis was performed to asses independent factor associated to functional recovery. RESULTS: 313 were included. For every additional percentage point of compliance to the protocol 3rd day C reactive protein plasmatic level decreases 1,46 mg/dL and increases 7% the probability to meet the discharge criteria (p < 0.001 both). Independent factors associated to functional recovery were ASA III-IV (OR 0.26; 0.14-0.48), surgical CR-POSSUM score (OR 0.68; 0.57-0.83), early mobilization (OR 4.22; 1.43-12.4) and removal of urinary catheter (OR 3.35; 1.79-6.27), p < 0,001 each of them. CONCLUSION: Better copliance to ERAS protocol in colorectal surgery decreases surgical stress and accelerates functional recovery

Características clínicas de Soiling en pacientes postoperados de enfermedades anales en el Hospital General San Juan de Dios / Clinical settings of patients with postoperative Soiling at San Juan de Dios Hospital

Introducción: El soiling es el escape inconsciente de pequeñas cantidades de materia fecal después de una evacuación normal. Se ha reportado una prevalencia del 7-23% en otros países y se ha observado una alta incidencia después de esfinterotomías y fistulotomías (35-45%). Material y Métodos: Se realizó un estudio observacional que incluyó 80 pacientes con patologías anales que acudieron a la consulta externa del Hospital General San Juan de Dios donde se aplicó un cuestionario de 8 ítems. Resultados: Se evaluaron 80 pacientes, la mayoría son hombres, de la quinta década. La enfermedad anal más frecuente son las hemorroides y el tratamiento quirúrgico más frecuente la hemorroidectomía. La incidencia de soiling definitivo (presencia de manchado a los 6 meses) es del 22.5%. Las variables asociadas fueron el género masculino, el tipo de enfermedad y procedimiento quirúrgico, el enrojecimiento, la picazón anal, el uso de protector en la región anal, la sensación de materia fecal y la limpieza en región anal. El ser hombre presenta un riesgo 6 veces mayor y el presentar enrojecimiento en la región anal aumenta el riesgo de 27 veces de presentar soiling definitivo. Conclusión: El soiling se presenta en un quinto de los pacientes que son operados de patologías anales en el Hospital General San Juan de Dios. La presencia de eritema, picazón anal, el uso de protector en la región anal, la sensación de materia fecal y la limpieza en región anal son variables estadísticamente asociadas al mismo. (AU)

Introduction: Soiling is the unconscious escape of small amounts of fecal matter after a normal bowel movement. A prevalence of 7-23% was reported in other countries and a high incidence was observed after sphincterotomies and fistulotomies (35-45%). Material and Methods: A observational study that included 80 patients with anal pathologies who attended the outpatient clinic of the San Juan de Dios General Hospital during 2018-2019, where an 8-item questionnaire was applied. Results: Eighty patients were evaluated, the majority are men, in their fifth decade. The most common anal disease is hemorrhoids, and the most common surgical treatment is hemorrhoidectomy. The incidence of definitive soiling (presence of spotting at 6 months) is 22.5%. The variables associated with definitive soiling were male gender, type of disease and surgical procedure, redness, anal itching, use of a protector in the anal region, the sensation of fecal matter, and cleanliness in the anal region. Being male presents a 6 times greater risk of definitive soiling and having redness in the anal region presents a 27 times greater risk of definitive soiling. Conclusion: Soiling occurs in a fifth of the patients operated for anal pathologies at the San Juan de Dios General Hospital. The presence of erythema, anal itching, the use of a protector in the anal region, the sensation of stool, and cleanliness in the anal region are statistically associated variables with soiling. (AU)

Programa ERAS® - Cuidados de enfermagem à pessoa submetida a cirurgia colorretal / Programa ERAS®: cuidados de enfermería para personas sometidas a cirugía colorrectal / ERAS® Program - Nursing care for patients undergoing colorectal surgery

Resumo Objetivo Identificar os cuidados de Enfermagem associados ao programa Enhanced Recovery After Surgery® na área da cirurgia colorretal. Métodos Realizou-se uma Scoping Review de publicações no período entre 2009 e 2019, segundo as recomendações do Joanna Briggs Institute, com base na questão de pesquisa: "Quais os cuidados de Enfermagem à pessoa submetida a cirurgia colorretal, no âmbito do programa Enhanced Recovery After Surgery®?". A pesquisa realizou-se entre 02/12/2019 a 12/12/2019 através da pesquisa boolena nas bases de dados eletrónicas CINAHL Complete, MEDLINE Complete, Nursing & Allied Health Collection: Comprehensive, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cochrane Methodology Register, Library, Information Science & Technology Abstracts, MedicLatina e no repositório b-ON, com os descritores MeSH "nursing", "colorectal" e a palavra-chave "enhanced". Resultados Foram selecionados 13 artigos que evidenciam uma adaptação e uma complementaridade nos cuidados de Enfermagem assegurados pelo Enfermeiro coordenador do programa e Enfermeiro Estomaterapeuta. No pré-operatório destaca-se como intervenção o ensino e otimização da pessoa, no intra-operatório, uma abordagem minimamente invasiva com gestão multimodal da dor e no período pós-operatório, um retorno precoce da alimentação, reabilitação e acompanhamento telefônico aquando a alta. Conclusão Os Enfermeiros desempenham um papel crucial na adoção e sustentação das práticas clínicas sugeridas pelo programa verificando um impacto positivo na experiência cirúrgica dos pacientes de colorretal.

Resumen Objetivo Identificar los cuidados de enfermería relacionados con el programa Enhanced Recovery After Surgery® en el área de la cirugía colorrectal. Métodos Se realizó una Scoping Review de publicaciones del período entre 2009 y 2019, de acuerdo con las recomendaciones del Joanna Briggs Institute, con base en la pregunta de investigación: "¿Cuáles son los cuidados de enfermería para personas sometidas a una cirugía colorrectal, en el contexto del programa Enhanced Recovery After Surgery®?". La investigación se llevó a cabo del 02/12/2019 al 12/12/2019 mediante una búsqueda booleana en las bases de datos electrónicas CINAHL Complete, MEDLINE Complete, Nursing & Allied Health Collection: Comprehensive, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cochrane Methodology Register, Library, Information Science & Technology Abstracts, MedicLatina y en el repositorio b-ON, con los descriptores MeSH "nursing", "colorectal" y la palabra clave "enhanced". Resultados Se seleccionaron 13 artículos que evidencian una adaptación y una complementariedad en los cuidados de enfermería garantizados por el enfermero coordinador del programa y el enfermero estomaterapeuta. En el preoperatorio se destaca como intervención la enseñanza y optimización de la persona, en el intraoperatorio, un enfoque mínimamente invasivo con gestión multimodal del dolor, y en el período posoperatorio, un retorno precoz de la alimentación, rehabilitación y seguimiento telefónico después del alta. Conclusión Los enfermeros desempeñan un papel crucial para adoptar y sustentar las prácticas clínicas sugeridas por el programa, lo que confirma un impacto positivo en la experiencia quirúrgica de los pacientes de cirugía colorrectal.

Abstract Objective To identify the nursing care associated with the Enhanced Recovery After Surgery® program in the field of colorectal surgery. Methods According to the recommendations of the Joanna Briggs Institute, a Scoping Review of publications from 2009 to 2019 was carried out based on the research question: "What is the nursing care for patients undergoing colorectal surgery in the scope of the Enhanced Recovery After Surgery® program?". The research took place between 12/02/2019 and 12/12/2019 through the boolean research in the following electronic databases: CINAHL Complete, MEDLINE Complete, Nursing & Allied Health Collection: Comprehensive, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cochrane Methodology Register, Library, Information Science & Technology Abstracts, MedicLatina, and in the b-ON repository with the MeSH descriptors "nursing", "colorectal" and the key-word "enhanced". Results We selected 13 articles that showed adaptation and complementarity with the nursing care ensured by the nurse coordinator of the program and stomatherapist nursing. In the preoperative period, instruction and person optimization stand out as an intervention, in the intraoperative period, a minimally invasive approach with multimodal pain management, and in the postoperative, a precocious return to feeding, rehabilitation, and telephone follow-up at the time of the hospital discharge. Conclusion The nurses perform a crucial role to the adoption and support of the suggested clinical practices of the program verifying a positive impact in patients submitted to colorectal surgery.

Estudio observacional prospectivo unicéntrico sobre el efecto de la prehabilitación trimodal en cirugía colorrectal / A single-center prospective observational study on the effect of trimodal prehabilitation in colorectal surgery

INTRODUCCIÓN: Se ha diseñado un protocolo de prehabilitación trimodal con el objetivo de valorar si contribuye a disminuir la morbilidad postoperatoria, valorar el efecto de la prehabilitación en la estancia hospitalaria global y analizar la evolución de la capacidad funcional antes y después de cirugía. MÉTODOS: Estudio observacional unicéntrico con pacientes con cáncer colorrectal intervenidos quirúrgicamente con intención curativa después de un protocolo de prehabilitación trimodal. Se recoge morbilidad postoperatoria según el Comprehensive Complication Index y estancia hospitalaria, y se compara con una matriz histórica. También se recoge capacidad funcional antes y después de la aplicación del protocolo de prehabilitación. RESULTADOS: En comparación con la población histórica se consigue disminuir el Comprehensive Complication Index global de forma estadísticamente significativa de 13,2 a 11,5. Desglosando por tipo de morbilidad, todas disminuyen en porcentaje sin conseguir significación (infección espacio quirúrgico del 11,7 al 8,4%; infección nosocomial del 15,8 al 10%, y morbilidad médica del 8,6 al 4,2%). La estancia hospitalaria global pasa de 6 a 4 días y el porcentaje de pacientes que se preparan en casa disminuye de forma estadísticamente significativa en ambos casos. CONCLUSIONES: La prehabilitación trimodal puede contribuir a disminuir la morbilidad postoperatoria y la estancia hospitalaria global de los pacientes intervenidos de neoplasia colorrectal

INTRODUCTION: A trimodal prehabilitation protocol was designed with the aim to evaluate whether it contributes to reducing postoperative morbidity, to evaluate the effect of prehabilitation on overall hospital stay, and to analyze the evolution of functional capacity before and after surgery. METHODS: A single-center observational study of patients with colorectal cancer who underwent surgery with curative intent after a trimodal prehabilitation protocol. We collected data for postoperative morbidity according to the Comprehensive Complication Index and hospital stay, which were compared with a historical matrix. Functional capacity data were also collected before and after the application of the prehabilitation protocol. RESULTS: Compared to the historical population, the overall Comprehensive Complication Index was reduced from 13.2 to 11.5, which was statistically significant. Analyzed by morbidity type, all decreased in percentage, although without achieving significance (surgical site infection from 11.7% to 8.4%, nosocomial infection 15.8 to 10% and medical morbidity 8.6% to 4.2%). The overall hospital stay went from 6 to 4 days, and the decrease in the percentage of patients who prepared at home was statistically significant in both cases. CONCLUSIONS: Trimodal prehabilitation can contribute to lowering the postoperative morbidity and overall hospital stay of patients undergoing colorectal cancer surgery

Physical Activity and Outcomes in Colorectal Surgery: A Pilot Prospective Cohort Study.

BACKGROUND: Mobilization after surgery is recommended to reduce the risk of adverse effects and to improve recovery. The aim of this study was to examine the associations between perioperative physical activity and postoperative outcomes in colorectal surgery. METHODS: The daily number of footsteps was recorded from preoperative day 5 to postoperative day 3 in a prospective cohort of patients using wrist accelerometers. Timed Up and Go Test (TUGT), 6 Min Walking Test (6MWT), and peak expiratory flow (PEF) were assessed preoperatively. ROC curves were used to assess the performance of physical activity as a diagnostic test of complications and prolonged length of stay (LOS) of more than 5 days. RESULTS: A total of 50 patients were included. Patients with complications were significantly older (67 years) than those without complications (53 years, p = 0.020). PEF was significantly lower in the group with complications (mean flow 294.3 vs. 363.6 L/min, p = 0.038) while there was no difference between groups for the other two tests (TUGT and 6MWT). The tests had no capacity to discriminate the occurrence of complications and prolonged LOS, except the 6MWT for LOS (AUC = 0.746, p = 0.004, 95% CI: 0.604-0.889). There was no difference in the mean number of preoperative footsteps, but patients with complications walked significantly less postoperatively (mean daily footsteps 1,101 vs. 1,243, p = 0.018). CONCLUSIONS: Colorectal surgery patients with complications were elderly, had decreased PEF, and walked less postoperatively. The 6MWT could be used preoperatively to discriminate patients with potentially increased LOS and foster mobilisation strategies.

A mobile device application (app) to improve adherence to an enhanced recovery program for colorectal surgery: a randomized controlled trial.

BACKGROUND: Increased adherence with enhanced recovery pathways (ERP) is associated with improved outcomes. However, adherence to postoperative elements that rely on patient participation remains suboptimal. Mobile device apps may improve delivery of health education material and have the potential to foster behavior change and improve patient compliance. The objective of this study was to estimate the extent to which a novel mobile device app affects adherence to an ERP for colorectal surgery in comparison to standard written education. METHODS: This was a superiority, parallel-group, assessor-blind, sham-controlled randomized trial involving 97 patients undergoing colorectal resection. Participants were randomly assigned with a 1:1 ratio into one of two groups: (1) iPad including a novel mobile device app for postoperative education and self-assessment of recovery, or (2) iPad without the app. The primary outcome measure was mean adherence (%) to a bundle of five postoperative ERP elements requiring patient participation: mobilization, gastrointestinal motility stimulation, breathing exercises, and consumption of oral liquids and nutritional drinks. RESULTS: In the intervention group, app usage was high (94% completed surveys on POD0, 82% on POD1, 72% on POD2). Mean overall adherence to the bundle on the two first postoperative days was similar between groups: 59% (95% CI 52-66%) in the intervention group and 62% (95% CI 56-68%) in the control group [Adjusted mean difference 2.4% (95% CI - 5 to 10%) p = 0.53]. CONCLUSIONS: In this randomized trial, access to a mobile health application did not improve adherence to a well-established enhanced recovery pathway in colorectal surgery patients, when compared to standard written patient education. Future research should evaluate the impact of applications integrating novel behavioral change techniques, particularly in contexts where adherence is low.

Factors associated with failure of Enhanced Recovery After Surgery (ERAS) in colorectal and gastric surgery.

Background: The Enhanced Recovery After Surgery (ERAS) pathway is widely applied in the perioperative period of stomach and colorectal surgery, and can decrease the length of hospital stay of the patients without compromising the safety of the patients. However, some patients are removed from this pathway for various reasons. Here we found some factors that taking the patients out from the procedures. Methods: A retrospective analysis of collected data of 550 patients over a 3-year period was conducted, with 292 in the ERAS group and 258 in the conventional care group. Then various basic elements were analyzed to explore the reasons for the failure to complete the ERAS program. Results: Total length of hospital stay after surgery was significantly shorter in the ERAS group, and a similar incidence of complication rates were observed in the two groups. In this study, the significant factors that associated with complications were advanced age (OR 2.18; p = .031), history of abdominal surgery (OR 2.03; p = .04), incomplete gastrointestinal obstruction (OR 3.42; p < .001), laparoscopic surgery (OR 0.39; p = .004) and intraoperative neostomy (OR 2.37; p = .006). Conclusions: We found that advanced age (>80 years old), history of abdominal surgery, gastrointestinal obstruction and stoma formation were the risk factors. We anticipated to design a risk assessment system upon the high-risk patients from the present ERAS pathway, and make a modified ERAS pathway for those patients.

Implementation of an Enhanced Recovery After Surgery program in elective colorectal surgery: a prospective cohort study / Implantação de um programa de recuperação aprimorada após cirurgia colorretal eletiva: um estudo prospectivo de coorte

ABSTRACT Objective: To evaluate the results of an Enhanced Recovery After Surgery (ERAS) protocol in elective colorectal surgery compared to the historical cohort of this hospital with standard care, in terms of hospital Length Of Stay (LOS), 30 days readmissions rate and 3-5 Clavien-Dindo Complications (CDC). Methodology: Data were collected from consecutive patients during 2 time periods, before (135 patients from hospital database) and after implementation of an ERAS protocol (121 with prospective follow up). Multivariate lineal or logistic regressions were used to assess the impact of ERAS program, adjusting by gender, age, laparoscopy and 3-5 CDC. Results: The two groups were homogeneous in terms of demographic and surgery details, with the exception of the operative approach, with increased use of laparoscopy in the ERAS group. The ERAS protocol decreased LOS (9.8 ± 3.7 vs. 11 ± 3.8, p = 0.018) without increasing 30 days readmission rate or the number of severe CDC. In a multivariate analysis, age and 3-5 CDC were independently associated with a longer LOS while male gender, ERAS protocol and laparoscopic surgery with a decreased LOS. 3-5 CDC increased readmissions (OR = 3.5, 95% CI 1.2-10.2) while laparoscopic surgery decreased them (OR = 0.2, 95% CI 0.1-0.8). ERAS improved compliance with secondary variables in a statistically significant way: more laparoscopic surgery; more regional analgesia in the intraoperative period; earlier adherence to ambulation; faster onset of oral liquid diet and analgesia by mouth; and lower requirements of opioids. Conclusions: ERAS protocol and laparoscopic surgery decreased LOS without increasing 30 days readmission rate. Severe CDC increased LOS and readmissions.

RESUMO Objetivo: Avaliar os resultados de um protocolo de recuperação aprimorada após a cirurgia (enhanced recovery after surgery [ERAS]) em cirurgia colorretal eletiva em comparação com a coorte histórica deste hospital, que recebeu o tratamento padrão, em termos de hospitalização, taxa de readmissão de 30 dias e graus 3 a 5 na escala de complicações cirúrgicas de Clavien-Dindo (CCD). Metodologia: Os dados foram coletados de pacientes consecutivos em dois períodos de tempo: antes (135 pacientes do banco de dados do hospital) e depois da implementação de um protocolo ERAS (121 pacientes com acompanhamento prospectivo). Regressões lineares ou logísticas multivariadas foram usadas para avaliar o impacto do protocolo ERAS, ajustando por sexo, idade, uso de laparoscopia e graus 3 a 5 na escala CCD. Resultados: Os dois grupos foram homogêneos em termos de características demográficas e cirúrgicas, com exceção da abordagem operatória, com o aumento do uso de laparoscopia no grupo ERAS. O protocolo ERAS diminuiu o tempo de internação (9,8 ± 3,7 vs. 11 ± 3,8; p = 0,018) sem aumentar a taxa de readmissão de 30 dias ou a severidade na escala CCD. Na análise multivariada, a idade e os graus 3 a 5 na escala CCD foram independentemente associados a uma hospitalização mais longa, enquanto o sexo masculino, o protocolo ERAS e a cirurgia laparoscópica foram independentemente associados a uma hospitalização mais curta. Graus 3 a 5 na escala CCD foram associados a um aumento nas readmissões (OR = 3,5; IC 95%: 1,2-10,2), enquanto a cirurgia laparoscópica foi associada a uma diminuição nesse número (OR = 0,2; IC 95%: 0,1-0,8). O ERAS melhorou a adesão às variáveis secundárias de uma forma estatisticamente significativa: aumento no número de cirurgias laparoscópicas; maior uso de analgesia regional no período intraoperatório; adesão precoce à deambulação; início mais rápido da dieta líquida oral e analgesia por via oral; finalmente, menor uso de opioides. Conclusões: O protocolo ERAS e a cirurgia laparoscópica diminuíram o tempo de internação sem aumentar a taxa de readmissão de 30 dias. Um grau severo na escala CCD aumentou a hospitalização e readmissões.

A systematic review of the intervention components, adherence and outcomes of enhanced recovery programmes in older patients undergoing elective colorectal surgery.

BACKGROUND: Enhanced recovery programmes (ERPs) aim to attenuate the surgical stress response and accelerate recovery after surgery, but are not specifically designed for older patients. The objective of this study was to review the components, adherence and outcomes of ERPs in older patients (≥65 years) undergoing elective colorectal surgery. METHODS: Pubmed, Embase and Cinahl were searched between 2000 and 2017 for randomised and non-randomised controlled trials, before-after studies, and observational studies. The methodological quality of the studies was evaluated using the MINORS quality assessment. The review was performed and reported according to the PRISMA guidelines. RESULTS: Twenty-one studies, including 3495 ERP patients aged ≥65 years, were identified. The ERPs consisted of a median of 13 intervention components. Adherence rates were reported in 9 studies and were the highest (≥80%) for pre-admission counselling, no bowel preparation, limited pre-operative fasting, antithrombotic and antimicrobial prophylaxis, no nasogastric tube, active warming, and limited intra-operative fluids. The median post-operative length of stay was 6 days. The median post-operative morbidity rate (Clavien-Dindo I-IV) was 23.5% in-hospital and 29.8% at 30 days. The in-hospital post-operative mortality rate was 0% in most studies and amounted to a median of 1.4% at 30 days. The median 30-day readmission rate was 4.9% and the median reoperation rate was 5.0%. CONCLUSIONS: ERPs in older patients were in accordance with the ERP consensus guidelines. Although the number of intervention components applied increased over time, outcomes in earlier and later studies remained comparable. Adherence rates were under-reported. Future studies should explore adherence and age-related factors, such as frailty profile, that could influence adherence. TRIAL REGISTRATION: PROSPERO 2018 CRD42018084756 .

Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Colorectal Surgery: The Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol (POWER) Study.

Importance: Enhanced Recovery After Surgery (ERAS) care has been reported to be associated with improvements in outcomes after colorectal surgery compared with traditional care. Objective: To determine the association between ERAS protocols and outcomes in patients undergoing elective colorectal surgery. Design, Setting, and Participants: The Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol (POWER) Study is a multicenter, prospective cohort study of 2084 consecutive adults scheduled for elective colorectal surgery who received or did not receive care in a self-declared ERAS center. Patients were recruited from 80 Spanish centers between September 15 and December 15, 2017. All patients included in this analysis had 1 month of follow-up. Exposures: Colorectal surgery and perioperative management were the exposures. Twenty-two individual ERAS items were assessed in all patients, regardless of whether they were included in an established ERAS protocol. Main Outcomes and Measures: The primary study outcome was moderate to severe postoperative complications within 30 days after surgery. Secondary outcomes included ERAS adherence, mortality, readmissions, reoperation rates, and hospital length of stay. Results: Between September 15 and December 15, 2017, 2084 patients were included in the study. Of these, 1286 individuals (61.7%) were men; mean age was 68 years (interquartile range [IQR], 59-77). A total of 879 patients (42.2%) presented with postoperative complications and 566 patients (27.2%) developed moderate to severe complications. The number of patients with moderate or severe complications was lower in the ERAS group (25.2% vs 30.3%; odds ratio [OR], 0.77; 95% CI, 0.63-0.94; P = .01). The overall rate of adherence to the ERAS protocol was 63.6% (IQR, 54.5%-77.3%), and the rate for patients from hospitals self-declared as ERAS was 72.7% (IQR, 59.1%-81.8%) vs non-ERAS institutions, which was 59.1% (IQR, 50.0%-63.6%; P < .001). Adherence quartiles among patients receiving the highest and lowest ERAS components showed that the patients with the highest adherence rates had fewer moderate to severe complications (OR, 0.34; 95% CI, 0.25-0.46; P < .001), overall complications (OR, 0.33; 95% CI, 0.26-0.43; P < .001), and mortality (OR, 0.27; 95% CI, 0.07-0.97; P = .06) compared with those who had the lowest adherence rates. Conclusions and Relevance: An increase in ERAS adherence appears to be associated with a decrease in postoperative complications.

IMPLEMENTATION OF ENHANCED RECOVERY AFTER COLORECTAL SURGERY (ERAS) PROTOCOL: INITIAL RESULTS OF THE FIRST BRAZILIAN EXPERIENCE.

BACKGROUND: Guidelines for enhanced recovery after surgery have their bases in colonic surgery, through the first protocols published in 2012. Since then, this practice has spread throughout the world, mainly due to improvements in surgical outcomes associated with resource savings. AIM: To analyze the first prospective results after the implementation of the guidelines. METHODS: Were retrospectively analyzed 48 patients operated in the institution prior to the standardization. This group was then compared with a series of 25 patients operated consecutively after the guidelines were implemented. RESULTS: With a 68.6% compliance rate, hospital length of stay (p=0.002), use of abdominal drains (p<0.001) and mechanical bowel preparation (p<0.001) were reduced. Mortality rates, anastomotic fistula, abdominal abscesses and reoperations were also reduced, but without statistical significance. CONCLUSION: Enhanced recovery after surgery protocols benefit patients care, resulting in better outcomes and possibly resource savings. Even with some limitations, its implementation is feasible in the Brazilian Public Health System.

Construct Validity and Responsiveness of the Abdominal Surgery Impact Scale in the Context of Recovery After Colorectal Surgery.

BACKGROUND: The Abdominal Surgery Impact Scale is a patient-reported outcome measure that evaluates quality of life after abdominal surgery. Evidence supporting its measurement properties is limited. OBJECTIVE: This study aimed to contribute evidence for the construct validity and responsiveness of the Abdominal Surgery Impact Scale as a measure of recovery after colorectal surgery in the context of an enhanced recovery pathway. DESIGN: This is an observational validation study designed according to the Consensus-based Standards for the Selection of Health Measurement Instruments checklist. SETTING: This study was conducted at a university-affiliated tertiary hospital. PATIENTS: Included were 100 consecutive patients undergoing colorectal surgery (mean age, 65; 57% male). INTERVENTION: There were no interventions. MAIN OUTCOME MEASURES: Construct validity was assessed at 2 days and 2 and 4 weeks after surgery by testing the hypotheses that Abdominal Surgery Impact Scale scores were higher 1) in patients without vs with postoperative complications, 2) with higher preoperative physical status vs lower, 3) without vs with postoperative stoma, 4) in men vs women, 5) with shorter time to readiness for discharge (≤4 days) vs longer, and 6) with shorter length of stay (≤4 days) vs longer. To test responsiveness, we hypothesized that scores would be higher 1) preoperatively vs 2 days postoperatively, 2) at 2 weeks vs 2 days postoperatively, and 3) at 4 weeks vs 2 weeks postoperatively. RESULTS: The data supported 3 of the 6 hypotheses (hypotheses 1, 5, and 6) tested for construct validity at all time points. Two of the 3 hypotheses tested for responsiveness (hypotheses 1 and 2) were supported. LIMITATIONS: This study was limited by the risk of selection bias due to the use of secondary data from a randomized controlled trial. CONCLUSIONS: The Abdominal Surgery Impact Scale was responsive to the expected trajectory of recovery up to 2 weeks after surgery, but did not discriminate between all groups expected to have different recovery trajectories. There remains a need for the development of recovery-specific, patient-reported outcome measures with adequate measurement properties. See Video Abstract at http://links.lww.com/DCR/A814.

Implementation of enhanced recovery after colorectal surgery (eras) protocol: initial results of the first brazilian experience / Implementação do protocolo de recuperação otimizada após cirurgia colorretal (eras): resultados iniciais da primeira experiência brasileira

ABSTRACT Background: Guidelines for enhanced recovery after surgery have their bases in colonic surgery, through the first protocols published in 2012. Since then, this practice has spread throughout the world, mainly due to improvements in surgical outcomes associated with resource savings. Aim: To analyze the first prospective results after the implementation of the guidelines. Methods: Were retrospectively analyzed 48 patients operated in the institution prior to the standardization. This group was then compared with a series of 25 patients operated consecutively after the guidelines were implemented. Results: With a 68.6% compliance rate, hospital length of stay (p=0.002), use of abdominal drains (p<0.001) and mechanical bowel preparation (p<0.001) were reduced. Mortality rates, anastomotic fistula, abdominal abscesses and reoperations were also reduced, but without statistical significance. Conclusion: Enhanced recovery after surgery protocols benefit patients care, resulting in better outcomes and possibly resource savings. Even with some limitations, its implementation is feasible in the Brazilian Public Health System.

RESUMO Racional: Os protocolos de recuperação otimizada após as operações têm as suas bases na cirurgia colônica, através das primeiras diretrizes publicadas em 2012. Desde então, tal prática difundiu-se pelo mundo, principalmente em virtude de melhorias nos resultados cirúrgicos associadas à economia de recursos. Objetivo: Apresentar os primeiros resultados prospectivos após a implementação das novas medidas. Métodos: Foram analisados de forma retrospectiva 48 pacientes operados na instituição previamente à aplicação do protocolo. Esse grupo foi então comparado com uma série de 25 pacientes operados de forma consecutiva após a implementação das diretrizes. Resultados: Com taxa de adesão de 68.6% às medidas propostas, observou-se redução do tempo de internação hospitalar (p=0.002), do uso de drenos abdominais (p<0.001) e do preparo mecânico do cólon (p<0.001). As taxas de mortalidade, de fístula da anastomose, de abscessos abdominais e de reoperações também foram reduzidas, porém sem significância estatística. Conclusão: A adesão às medidas recomendadas no protocolo é benéfica para pacientes e equipe de assistência, acarretando em melhores resultados e possível economia de recursos. Mesmo com algumas limitações, a sua implementação é factível no Sistema Único de Saúde Brasileiro.

Pacientes em tratamento cirúrgico por doenças colorretais crônicas: proposição e implementação de protocolo de atendimento psicológico / Patients in surgical treatment for chronic colorectal diseases: proposition and implementation of a psychological care protocol

Trata-se de estudo de desenho misto, do tipo sequencial explanatório, cuja etapa quantitativa descritiva e longitudinal objetivou propor um Protocolo Psicológico para Pacientes com Doenças Colorretais Crônicas no Perioperatório; e na etapa qualitativa exploratória avaliar a implementação deste protocolo psicológico (CAAE 58356416.2.0000.5393 CEP/EERP-USP). Na etapa quantitativa aplicou-se questionários de Miniexame do Estado Mental (MEEM); sociodemográfico, clínico e terapêutico e de investigação das demandas psicológicas, validados para este estudo, com participação de 30 pacientes com doenças colorretais crônicas em primeiro tratamento cirúrgico. Na análise estatística descritiva predominou faixa etária acima de 51 anos (63,2%); sexo masculino (60,0%); quatro anos de estudo (33,3%) e casado (60,0%); aposentado (43,3%); renda até dois salários mínimos (33,3%); neoplasia colorretal (60,0%); menos de um ano de tratamento (63,3%); e estomização (43,3%); e mediante análise de conteúdo dedutivo, as demandas psicológicas no perioperatório foram vinculadas às informações sobre cirurgia, estomização e equipamento coletor (96,7%) e cuidados pós-operatórios (64,7%) e necessidade de atendimento psicológico (93,3%); e uso de estratégias de enfrentamento focadas no problema e na emoção, busca de suporte social e práticas religiosas/pensamento fantasioso, que subsidiaram a proposição do protocolo de atendimento psicológico para esta clientela. As demandas psicológicas foram relacionadas à obtenção de conhecimento no pré-operatório sobre cirurgia e suas consequências; expectativas de resultados com a cirurgia e atendimento psicológico; e no pós-operatório, aos resultados da cirurgia; às perspectivas futuras e ao atendimento psicológico, vinculadas às intervenções Vínculo e Ensino da equipe interdisciplinar. Este protocolo foi estruturado em 10 eixos: identificação; avaliação do estado mental; apoio social; demandas pré-operatórias; demandas pós-operatórias; estratégias de enfrentamento; entendimento da condição clínica; síntese do diagnóstico psicológico; intervenções/abordagens psicoterapêuticas estabelecidas; e avaliação da intervenção psicológica. Na etapa qualitativa foi realizada a implementação deste protocolo psicológico, com participação de 16 participantes, com representatividade sociodemográfica, clínica e terapêutica semelhante ao da etapa quantitativa e a interpretação dos dados foi realizada com Análise Temática, fundamentado no referencial da Psicologia Hospitalar. As demandas psicológicas foram interpretadas em quatro temas: "Demora para tratamento no sistema de saúde"; "Dúvidas sobre diagnóstico/tratamento/bolsinha"; e "Expectativas sobre cirurgia e estomização" que constituíram os desafios no itinerário terapêutico, gerando sofrimento físico e psicoemocional; e "Os aspectos psicológicos da cirurgia e da estomização na vida do paciente" para o pós-operatório mediato, que dimensionaram a importância da intervenção suporte psicológico no favorecimento do conhecimento do paciente sobre sua condição de saúde e na assistência prestada pela equipe interdisciplinar. A intervenção psicológica favoreceu a manutenção da esperança, o enfrentamento dos sentimentos conflituosos, do adoecimento e do tratamento cirúrgico, estimulando a proatividade do paciente na busca de adaptação ao adoecimento, às repercussões terapêuticas e ao seguimento ambulatorial especializado e na retomada de sua vida. Concluiu-se que este protocolo psicológico apresentou viabilidade assistencial, com definição do papel do psicólogo neste contexto de assistência hospitalar, diminuindo a lacuna de produção sobre a temática. Os resultados deste estudo contribuirão na melhoria da assistência interdisciplinar de pacientes com doenças colorretais crônicas no perioperatório, agregando-se a intervenção psicológica para o atendimento das demandas prioritárias desta clientela

This is a mixed design study, typified as sequential explanatory, whose descriptive and longitudinal quantitative stage aimed to propose a Psychological Protocol for Patients with Chronic Colorectal Diseases in the Perioperative; and, in the exploratory qualitative stage, it aimed to evaluate the implementation of this psychological protocol (CAAE 58356416.2.0000.5393 CEP/EERP-USP). In the quantitative stage, we applied Mini Mental State Examination (MMSE); sociodemographic, clinical and therapeutic questionnaires, as well as others related to research and psychological demands, validated for this study, with the participation of 30 patients with chronic colorectal diseases in the first surgical treatment. In the descriptive statistical analysis, there was a predominance of the age group above 51 years (63.2%); male gender (60.0%); four years of study (33.3%) and married (60.0%); retired (43.3%); income up to two minimum wages (33.3%); colorectal neoplasm (60.0%); less than one year of treatment (63.3%); and ostomy (43.3%); and, through deductive content analysis, the perioperative psychological demands were linked to information on surgery, ostomy and collecting equipment (96.7%), postoperative care (64.7%) and need for psychological care (93.3%); and use of coping strategies focused on the problem and emotion, search for social support and religious practices/fantasy thinking, which supported the proposition of the psychological care protocol for this clientele. The psychological demands were related to the acquisition of preoperative knowledge about surgery and its consequences; expectations of outcomes with surgery and psychological care; and, in the postoperative, they were related to the results of the surgery; future perspectives and psychological care, linked to the interdisciplinary team Teaching and Bonding interventions. This protocol was structured in 10 axes: identification; mental state evaluation; social support; preoperative demands; postoperative demands; coping strategies; understanding of the clinical condition; synthesis of psychological diagnosis; established psychotherapeutic interventions/approaches; and psychological intervention evaluation. In the qualitative stage, we performed the implementation of this psychological protocol, with the participation of 16 participants, with sociodemographic, clinical and therapeutic representations similar to the quantitative stage, and the interpretation of the data was performed with Thematic Analysis, based on the Hospital Psychology framework. The psychological demands were interpreted in four themes: "Delay for treatment in the health system"; "Questions about diagnosis/treatment/bag"; and "Expectations about surgery and ostomy", which constituted the challenges in the therapeutic path, generating physical and psycho-emotional suffering; and "The psychological aspects of surgery and ostomy in the patient's life" for the mediate postoperative period, which dimensioned the importance of the psychological support intervention in favoring the patient's knowledge about his health condition and the care provided by the interdisciplinary team. The psychological intervention favored the maintenance of hope, the confrontation of conflicting feelings, the illness and surgical treatment, thereby stimulating the patient's proactivity in the search for adaptation to the disease, the therapeutic repercussions and the specialized outpatient follow-up, besides the resumption of life. We can conclude that this psychological protocol showed health care viability, with definition of the role of the psychologist in this context of hospital care, reducing the production gap on this topic. The results of this study will contribute to the improvement of interdisciplinary care of patients with perioperative chronic colorectal diseases, adding the psychological intervention to meet the priority demands of this clientele

Early oral feeding after colorectal surgery: A mixed methods study of knowledge translation.

AIM: Evidence-based guidelines recommend early oral feeding (EOF) as prescription of an unrestricted diet within 24 hours after colorectal surgery. The present study aimed to understand local postoperative feeding practices after colorectal surgery; identify barriers to EOF implementation; select, tailor and implement stakeholder engagement strategies to facilitate EOF uptake; and evaluate changes to practice. METHODS: A longitudinal, mixed methods study was undertaken, guided by the knowledge-to-action framework. Phase 1 assessed the nature of the problem using postoperative diet Audits 1 and 2. In Phase 2, staff interviews identified barriers to EOF implementation. Results from Phases 1 and 2 were fed back to inform Phase 3 strategies. Knowledge uptake was monitored in Audits 3 and 4. Phase 4 evaluated outcomes from Audit 5. RESULTS: In Phase 1, median time to commencement of full diet was postoperative Days 4 and 3 in Audits 1 and 2, respectively. Phase 2 identified EOF barriers, including disparities in diet upgrade practices and variable understanding of hospital diets. In Phase 3, planned strategies were implemented to improve EOF (i) educational session describing local hospital diets; (ii) consultant decision to prescribe a full diet on operation notes; and (iii) educational sessions with nursing staff describing changes to EOF practice. In Phase 4, median time to commencement of full diet improved to postoperative Day 0. Patients prescribed a full diet on operation notes increased from 0% to 82%. CONCLUSIONS: The present study successfully identified and overcame local barriers to improve EOF practices to align with guideline recommendations.

A Retrospective Cohort Study to Determine Predictive Factors for Abdominal Wound Disruption Following Colorectal Surgery.

Abdominal wound disruption (AWD) is a postoperative complication that increases length of hospital stay, mortality, and cost. A retrospective cohort study was conducted to identify predictors of AWD, defined in the National Surgical Quality Improvement Program User Guide as a spontaneous reopening of a previously surgically closed (midline) wound that occurs within 30 days after index elective surgery in patients undergoing colorectal surgery. Data from the American College of Surgeons National Surgical Quality Improvement Program (2006-2012) were searched, supplemented by institutional review board-approved chart review. Patients were identified using Current Procedural Terminology codes for open and laparoscopic abdominal colorectal procedures. Data were collected to predefined worksheets and entered into a statistical analysis program and included demographics; comorbidities; pre- and postoperative laboratory tests including white blood count, blood glucose, and albumin levels; date and type of procedure; wound classification; postoperative complication rate; type of access; time to disruption; surgical site infection (SSI); and use of the SSI intervention/prevention bundle. The Wilcoxon rank sum test was utilized to compare independent continuous variables between the groups, and Fisher's exact test was utilized to compare categorical variables. Variables with a P value <.2 at univariate logistic regression were included in multivariate logistic regression analysis. Time-to-event variables were compared using Cox regression analysis. Of the 690 patients included in the study, 16 (2.3%) developed an AWD. Mean age was 61.9 ± 15.3 years and 61.3 ± 15.0 years in AWD and non-AWD groups, respectively (P = .704). AWD occurred more frequently in men than women (75% vs. 50%; P = .040) and in patients who did compared to those who did not develop a deep incisional SSI (12.5% vs. 2%; P = .044). Preoperative albumin level was significantly lower in AWD (3.2 ± 0.8 vs. 3.8 ± 0.7; P = .006), as well as the proportion of post-bundle implementation (18.75% vs. 65.7%; P = .041). No significant differences were observed for any of the other variables examined. Per multivariate analysis, male gender (P = .05), absence of SSI bundle (P = .026), and hypoalbuminemia (P = .01) were independent predictors of AWD after elective colorectal resections. Time to AWD was significantly shorter in patients without SSI (P <.001). Results indicate implementation of the SSI bundle decreased AWD rates. Further prospective studies are needed to confirm these findings.

Acute kidney injury following implementation of an enhanced recovery after surgery (ERAS) protocol in colorectal surgery.

PURPOSE: Fluid management within Enhanced Recovery After Surgery (ERAS) protocols is designed to maintain a euvolemic state avoiding the negative sequelae of hypervolemia or hypovolemia. We sought to determine the effect of a recent ERAS protocol implementation on kidney function and on the incidence of postoperative acute kidney injury (AKI). METHODS: A total of 132 elective colorectal resections performed using our ERAS protocol were compared to a propensity-matched group prior to ERAS implementation. Fluid balance, urine output, creatinine, and blood urea nitrogen (BUN) were recorded for all patients, and the incidence of AKI was determined according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. RESULTS: Implementation of our ERAS protocol decreased average postoperative length of hospital stay (5.5 vs 7.7 days, p < 0.0001) and time to return of bowel function (2.5 vs 4.1 days, p < 0.0001). The rate of postoperative AKI increased following implementation of the protocol (11.4 vs 2.3%, p < 0.0001). However, by the time of discharge, the average creatinine of ERAS patients who had experienced AKI had returned to their preoperative baseline values (p = 0.9037). Significant univariate predictors of AKI in ERAS patients were longer operative times (p < 0.01) and the diagnosis of diverticulitis (p < 0.01). Within our ERAS patients, AKI was associated with a prolonged postoperative length of hospital stay (p < 0.01). CONCLUSIONS: Despite the proven benefits of the Enhanced Recovery After Surgery (ERAS) protocols, care should be taken during protocol implementation to monitor for and to prevent acute kidney injury.

Enhanced Recovery After Surgery as an auditing framework for identifying improvements to perioperative nutrition care of older surgical patients.

Older patients are at increased risk of malnutrition and reduced physical function. Using Enhanced Recovery After Surgery (ERAS) guidelines as an auditing framework, this study aimed to determine adherence of nutrition care to perioperative best practice in older patients. A single researcher retrieved data via chart review. Seventy-five consenting patients ≥65 years (median 72 (range 65-95) years, 61% male) admitted postoperatively to general surgical wards were recruited. Sixty per cent had a primary diagnosis of cancer and 51% underwent colorectal resection. Seventeen per cent and 4% of patients met fasting targets of 2-4 h for fluid and 6-8 h for food, respectively. Fifty-five per cent were upgraded to full diet by first postoperative day. Nil received preoperative carbohydrate loading. Minimally invasive surgery (p = 0.01) and no anastomosis formation (p = 0.05) were associated with receiving ERAS-concordant nutrition care. This study highlights areas for improvement in perioperative nutrition care of older patients at our facility.