Influences on length of stay in an enhanced recovery programme after colonic surgery

Aim Enhanced recovery after surgery (ERAS) programmes have been shown to accelerate and enhance functional recovery after colonic surgery. We analysed prospectively collected data to investigate potentially modifiable factors that may influence the length of stay (LOS) in the ERAS setting at a single institution. Method Between October 2005 and November 2008, prospective data were collected on consecutive patients who underwent elective colonic surgery without a stoma. Patients with rectal cancer, those unable to participate in preoperative ERAS components because of their inability to communicate effectively in English, those with cognitive impairment and those with an American Society of Anesthesiologists (ASA) grade of ≥4 were excluded. Statistical analyses were performed using the Mann–Whitney U‐test and Cox regression modelling. Results A total of 100 (79 malignancies) patients underwent elective colon resection during the study period. There were 57 right‐sided, 41 left‐sided and two total colectomies. The median age of the patients was 67.5 (range 31–92) years and the median day stay was 4 (range 3–46) days. Factors with significant correlations for reduced LOS were female gender, the surgeon, operative severity, high‐dependency unit (HDU) admission and incision type favouring laparoscopic and transverse approaches. Age, operation site, indication for surgery and body mass index were not significant predictors of hospital stay. Gender, operative severity, HDU admission and surgeon did not have any independent correlation with LOS; in contrast to the ASA score and the type of incision, which did. Conclusion Lower ASA score, transverse incision laparotomy and laparoscopy correlated independently with reduced postoperative LOS within the ERAS setting.     

Requirement for postoperative imaging in an enhanced recovery programme

Aim Enhanced recovery after surgery (ERAS) produces benefits to patients by reducing the length of hospital stay and morbidity. Its effect on nursing and physiotherapy workload has been studied, but the demand upon radiology is unclear. We aimed to determine radiology use to understand possible hidden expenditure not included in existing ERAS cost‐effectiveness analyses. Method Two‐hundred and sixty‐five patients from a prospective multidimensional ERAS database were retrospectively assessed for postoperative radiology use. All had undergone colorectal surgery within an established ERAS programme from 2008 to 2009, with all data prospectively recorded. Laparoscopy was offered for all primary colon and rectal resections. All adverse events, including gut dysfunction, surgical site infection and reoperation, were assessed. All radiology within 30 days of surgery was recorded. Results Radiology data were absent in 12 patients, leaving 253 for analysis. Postoperative radiology was used in 71 (28%) patients, and 41 (16%) had CT of the abdomen and pelvis (A/P) within 30 days of surgery. In 33 (13%) patients this was required during the primary admission, including 30% of patients with any postoperative adverse event. Nine (27%; 3.6% of the whole cohort) of the 33 patients required reoperation. No patient required interventional radiology. The median time to CT (A/P) during primary admission was 5 (interquartile range, 3–8) days. Eight (3%) patients had CT (A/P) after readmission with one reoperation. Forty (16%) patients underwent plain radiology (chest or abdominal) and six (2%) had abdominal ultrasound. Using general estimates of CT and plain radiology total costs, these data suggest an overall radiology cost of over £22 000, amounting to a radiology cost of £90 per ERAS patient. Conclusion Postoperative radiology is required in a significant proportion of ERAS patients, potentially reflecting a low threshold to investigate in the presence of an adverse event. Very few require subsequent intervention. Radiology costs incurred with ERAS should be considered in future economic analyses.     

A cohort study of results following elective colonic and rectal resection within an enhanced recovery programme

Objective  The use of laparoscopic surgery coupled with an enhanced recovery programme (ERP) has resulted in hospital stays of 4 or less days for colonic and 6 days following rectal resection, in previously reported small selected groups of patients. This report analyses an unselected cohort to determine if such benefits are reproducible.
Method   Consecutive patients undergoing elective colonic or rectal surgery at a single centre between January 2002 and January 2006 were followed. All were included in the ERP and underwent either laparoscopic or open surgery.
Results   The study group comprised 241 patients (mean age of 67 ± standard deviation 14 years and 49% male sex distribution) who underwent elective colorectal resection within the context of an ERP. One hundred and fifty-one (62.7%) patients had malignant disease. Overall, 191 (79.3%) patients underwent a laparoscopic procedure and the remaining underwent an open operation. Postoperative stay was shorter in patients undergoing laparoscopic vs open, colonic surgery (4 days vs 6 days, P  = 0.002). A nonsignificant trend towards reduced postoperative stay was observed for patients undergoing laparoscopic vs open, rectal surgery (6 days vs 9 days, P  = 0.088). Patients undergoing laparoscopic colectomy demonstrated significantly lower 30-day mortality rates than those undergoing traditional colectomy (3/131 vs 3/39, P  = 0.049).
Conclusion  Laparoscopic colonic surgery in the context of an ERP offers reduced hospital stay and may confer a survival advantage over traditional techniques. These results confirm that previously reported benefits of laparoscopic surgery are reproducible within an unselected population.     

Factors predicting deviation from an enhanced recovery programme and delayed discharge after laparoscopic colorectal surgery

Aim The study aimed to identify factors that predict postoperative deviation from an enhanced recovery programme (ERP) and/or delayed discharge following colorectal surgery. Method Data were prospectively collected from all patients undergoing elective laparoscopic colorectal resection between January 2006 and December 2009. They included Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) variables, body mass index (BMI), sex, preoperative serum albumin, pathology, conversion from a laparoscopic to an open approach and postoperative length of hospital stay. Results There were 176 patients (90 women) of mean age 68 years. Fifteen (9%) operations were converted from laparoscopic to open. The remainder were completed laparoscopically. Fifty‐five (31%) deviated from the ERP, with most failing multiple elements. The most common reason was failure to mobilize, which often occurred in conjunction with paralytic ileus or analgesic failure. Factors independently predicting ERP deviation on multivariate analysis were pathology and intra‐operative complications. The median length of stay was 5 days. Sixty‐four (36%) patients had a prolonged length of stay that was predicted by age, number of procedures and ERP deviation. Conclusion Pathology and intra‐operative complications are independent predictors of ERP deviation. Prolonged length of stay can be predicted by age, multiple procedures and ERP deviation. Failure to mobilize should be considered as a red flag sign prompting further investigation following colorectal resection.     

Deviation and failure of enhanced recovery after surgery following laparoscopic colorectal surgery: early prediction model

Aim Enhanced recovery after surgery (ERAS) programmes are well established, but deviation from the postoperative elements may result in delayed discharge. Early identification of such patients may allow remedial action to be taken. The aims of this study were to investigate factors associated with delayed discharge and to produce a predictive scoring system for ERAS failure. Method A retrospective review was carried out of case notes of patients who underwent elective laparoscopic colorectal resection and ERAS at Yeovil District Hospital between 2002 and 2009. Univariate and multivariate analyses were performed and binary logistic regression was used to model a predictive scoring system. Results In all, 385 patient records were reviewed with a median length of stay of 6 days; 122 (31%) patients stayed longer than 1 week (delayed discharge) and 159 (41%) deviated in up to two postoperative ERAS factors. Patient demographic factors were not predictive of delayed discharge. Deviation from ERAS factors at the end of the first postoperative day, including continued intravenous fluid infusion, lack of functioning epidural, inability to mobilize, vomiting requiring nasogastric tube insertion and re‐insertion of urinary catheter, were strongly associated with delayed discharge. A five‐element predictive scoring system for ERAS failure and delayed discharge was formulated. Conclusion Enhanced recovery failure and delayed discharge after laparoscopic colorectal surgery can be predicted by the early deviation from postoperative factors of an ERAS programme.     

Minimally invasive surgical wound infections: laparoscopic surgery decreases morbidity of surgical site infections and decreases the cost of wound care

Aim The morbidity of surgical site infections (SSIs) were compared in patients who underwent open (OS) vs laparoscopic (LS) colorectal surgery. Method Data from 603 consecutive LS patients and 2246 consecutive OS patients were prospectively recorded. Morbidity of SSIs was assessed by the need for emergency department (ED) evaluation, subsequent hospital re‐admission and re‐operation. The cost of wound care was measured by the need for home healthcare, wound vacuum assisted closure (VAC) or independent patient wound care. Results SSIs were identified in 5.8% (n = 25) of LS patients and 4.8% (n = 65) of OS patients. ED evaluation for the infection was needed in 24% of the LS group and 42% of the OS group. Hospital re‐admission was needed in one LS patient and in 52% OS patients. No LS patient needed re‐operation compared with 12% of OS patients. HHC ($162/dressing change) was required in 63% of the OS group compared with 8% of LS group. A home wound VAC system ($107/day) was utilized in 12% of the OS patients but in none of the LS patients. Dressing changes were managed independently by the patient in 92% of the LS compared with 37% of the OS patients. Conclusion Laparoscopic colorectal surgery patients experience less morbidity when they develop SSIs incurring less cost compared with open colorectal surgery patients.     

The evolution of analgesia in an ‘accelerated’ recovery programme for resectional laparoscopic colorectal surgery with anastomosis

Objective The study set out to analyse the outcomes of an evolving accelerated recovery programme after laparoscopic colorectal resection (LCR). Method The results of a prospective electronic database (March 2000 – April 2008) were analysed. Results There were 353 consecutive patients undergoing ‘three port’ high anterior resection (AR) (237 without covering stoma) and 166 a right hemicolectomy (RHC). One hundred thirty‐eight had postoperative analgesia using paracetamol IV and oral analgesia (IVP); 27 (16.3%) received additional parenteral morphine and were excluded. Patient controlled morphine analgesia (PCA) was used in 138. Transversus abdominis plane (TAP) blocks, supplemented by IV paracetamol and oral analgesia were used in the last 50 patients. The time to the resumption of diet was significantly reduced with TAP analgesia (median 12 h) and IVP (median 12 h) compared with PCA median (36 h) (χ² = 143; 4df: P < 0.001). The postoperative hospital stay was significantly reduced with TAP analgisia (median 2 days) and IVP (median 3 days) compared with PCA (median 5 days); χ² = 73; 2df: P < 0.001. Seventeen (34%) TAP and nine (6.5%) IVP patients were discharged within 24 h of surgery compared with no patient in the PCA group. Ninety‐three per cent of PCA, 35% IVP and 10% TAP patients were discharged in more than 3 days. The movement towards ‘accelerated recovery’ was not associated with any increased risk of urinary retention, return to theatre, readmission and/or 30 day mortality. Conclusion Laparoscopic surgery utilizing IV paracetamol and TAP blocks for postoperative analgesia aids safe effective ‘accelerated recovery’ in an unselected patient population undergoing right hemicolectomy and high anterior resection. Routine epidural anaesthesia is unnecessary for LCR. Morphine PCA is associated with delayed recovery.     

Enhanced recovery after surgery care to reduce surgical site wound infection and postoperative complications for patients undergoing liver surgery

This study comprehensively assessed the effect of enhanced recovery after surgery (ERAS) on wound infection and postoperative complications in patients undergoing liver surgery. The PubMed, EMBASE, MEDLINE, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, and Wanfang electronic databases were searched to collect published studies on the use of ERAS in liver surgery until December 2022. Literature selection was performed independently by two investigators according to the inclusion and exclusion criteria, and quality evaluation and data extraction were performed. RevMan 5.4 software was used in this study. Compared with the control group, the ERAS group showed a significantly lower incidence of postoperative wound infection (odds ratio [OR]: 0.59, 95% confidence interval [CI]: 0.41–0.84, P = .004) and overall postoperative complication rate (OR: 0.43, 95% CI: 0.33–0.57, P < .001) and significantly shorter postoperative hospital stay (mean difference: −2.30, 95% CI: −2.92 to −1.68, P < .001). Therefore, ERAS was safe and feasible when applied to liver resection, reducing the incidence of wound infection and total postoperative complications, and shortening the length of hospital stay. However, further studies are required to investigate the impact of ERAS protocols on clinical outcomes.     

加速康复外科联合益生菌对结直肠癌患者术后肠道菌群变化的影响

［摘要］ 目的 探讨加速康复外科联合益生菌对结直肠癌患者术后肠道菌群变化的影响。方法 前瞻性纳入2016年5月至2018年5月江门市中心医院胃肠外科收治的结直肠癌患者126例,将入组患者分为对照组（59例,单纯ERAS组）和实验组（67例,ERAS联合益生菌治疗组）。比较两组患者术后肠道菌群不同菌属数量的变化及菌群紊乱的分度,比较两组患者术后肠源性感染相关并发症的发生率。结果 两组患者术前均出现不同程度的菌群失调（P>0.05）,对照组患者术后以Ⅱ°菌群失调居多,而实验组患者术后主要表现为Ⅰ°的菌群失调（P=0.014）。术后实验组双歧杆菌、乳酸杆菌计数总量均高于对照组（P<0.001）。对照组术后出现腹泻、腹腔感染、吻合口漏的发生率比实验组高,但只有腹泻的发生率两组差异有统计学意义,腹腔感染和吻合口漏统计学差异不明显。两组患者术后均无出现脓毒血症。结论 结直肠癌患者围手术期予以益生菌治疗,可改善肠道微生态环境,保护肠道黏膜屏障,加速患者术后康复。     

规范化开展加速康复外科几个关键问题

加速康复外科（enhanced recovery after surgery,ERAS）的发展已有18年的历史,在我国的应用已有10年的初步经验。临床研究和应用结果显示,ERAS不仅仅具有缩短住院时间的优势,而且还具有减轻应激反应和疼痛,减少并发症,促进病人快速康复的优势。ERAS是一个集成创新模式,需要包括医院行政管理部门等多学科的参与,需要改变传统的临床路径。需要加大针对术后肠麻痹及肠功能康复的研究,努力实现ERAS共识与指南的临床转化。     

Implementation of an enhanced recovery protocol in pediatric colorectal surgery

Purpose

Enhanced recovery protocols (ERPs) have been shown to improve outcomes in adult surgical populations. Our purpose was to compare outcomes before and after implementation of an ERP in children undergoing elective colorectal surgery.

Case controlled study of the hospital stay and return to full activity following laparoscopic and open colorectal surgery before and after the introduction of an enhanced recovery programme

Aim The short‐term benefits of laparoscopic surgery are well established and in particular within an enhanced recovery programme. Early return to activity is to be expected but has not been quantified widely. The aim of this study was to measure the hospital stay and return to full activity following laparoscopic colorectal surgery and compare this with a matched group of patients undergoing open colorectal resections before and after the introduction of an enhanced recovery programme. Method Retrospective analysis of all laparoscopic colorectal operations performed between January 2003 and June 2007 on an intention to treat basis compared with a matched group of patients undergoing elective open colorectal surgery at the same institution. Results The median hospital stay following 179 laparoscopic colorectal resections was 6 days whilst following 144 conventional open operations it was 8 days. Following the introduction of an enhanced recovery programme the hospital stay fell from 7 to 5 days and from 9 to 7 days for laparoscopic and open groups respectively. The median return to full activity from surgery for laparoscopic patients was 13 days in comparison to 56 days for patients undergoing open colorectal surgery. Conclusions Following laparoscopic colorectal resection, patients can be expected to have a hospital stay of under a week and return to their usual activities as early as a week after discharge from hospital and < 2 weeks from surgery in comparison to patients undergoing open surgery who take 8 weeks or more to recover.     

加速康复外科在妇科腔镜手术中的应用体会

目的:探讨加速康复外科(enhanced recovery after surgery,ERAS)策略用于妇科腔镜手术中的安全性与有效性。方法:将拟行腹腔镜妇科手术的200例患者随机分为ERAS组与对照组。ERAS组围手术期采用ERAS策略处理,对照组采用传统围手术期方案处理。术后2 h、6 h、12 h、24 h采用视觉模拟评分法观察两组患者疼痛程度,对比分析两组术后肛门首次排气时间、术后恶心呕吐发生率、术后住院时间、住院总花费及其他并发症发生情况。结果:与对照组相比,ERAS组术后2 h、6 h、12 h疼痛评分及术后恶心呕吐发生率明显降低(P0.05);术后肛门首次排气时间缩短(P0.05);术后住院时间、住院总费用减少(P0.05)。两组患者术后其他并发症发生率差异无统计学意义。结论:ERAS策略可安全地用于妇科腔镜手术,能有效促进术后恢复、缩短住院时间、降低医疗费用。     

Prevalence of MRSA colonization in an adult urban Indian population undergoing orthopaedic surgery

IntroductionOrthopaedic surgery is technically demanding, implant dependant and expensive. Infection translates into a prolonged morbidity and long-term use of antibiotics. The most common organism involved in osteo-articular infections is Staphylococcus aureus, and colonizes the anterior nares of 25–30% of the population. Carriers are at higher risk for staphylococcal infections after invasive medical or surgical procedures. Prevalence of methicillin resistant Staphylococcus aureus (MRSA) has not been assessed in patients admitted for orthopaedic surgery in the Indian setting.AimTo assess the preoperative prevalence of MRSA colonization in adult patients undergoing orthopaedic surgery in urban India.Materials and methodsThis is a retrospective analysis of patients from 2009 to 2013. A total of 1550 patients admitted for orthopaedic surgery were preoperatively screened with nasal and axillary swabs for MRSA. Swab-positive patients were treated with intranasal mupirocin ointment for 3 days followed by a repeat swab. A record was made of hospitalization in the year prior to surgery and the occurrence of surgical site infection (SSI).ResultsA total of 690 males and 860 females had been screened for MRSA using an inexpensive kit costing 500 Indian rupees. For MRSA, 7/1550 (0.45%) nasal swabs were positive. No patient since 2009 has had a SSI with MRSA.ConclusionMRSA screening prior to orthopaedic surgery is a valuable and cost effective preoperative investigation even though the incidence is low. Mupirocin is effective in clearing MRSA from the nares and maybe used for 3 days to obtain elimination of the bacteria.