Background: Traditionally, patients fasted 8h before elective operations to minimize risk of aspiration. Recently, this has been challenged in Enhanced Recovery After Surgery (ERAS) protocols, which ...suggest the avoidance of preoperative fasting and promote carbohydrate loading up to 2h preoperatively. While there are increasing randomized controlled trial (RCT) data evaluating the use of preoperative carbohydrate loading, synthesis of data pertaining specifically to colorectal surgery has yet to be performed. This meta-analysis aimed to compare patients receiving preoperative carbohydrate loading to those receiving a control before colorectal surgery. Methods: MEDLINE, Embase, and CENTRAL were searched. Articles were eligible for inclusion if they were RCTs comparing patients undergoing colorectal surgery receiving and not receiving preoperative carbohydrate loading. Primary outcomes were changes in blood glucose and insulin levels. Secondary outcomes included length of stay (LOS), time to first flatus and stool, and postoperative morbidity. A pairwise meta-analysis using inverse variance random effects was performed. Results: The search yielded 3656 citations, from which 12 RCTs were included. In total, 387 patients given preoperative carbohydrate loading (47.2% female, mean age 62.0 yr) and 371 controls (49.4% female, mean age 61.1 yr) were included. There was no significant difference in postoperative blood glucose and insulin levels between groups. Patients receiving preoperative carbohydrate loading experienced a shorter time to first flatus (standardized mean difference SMD -0.48 d, 95% confidence interval CI -0.84 to -0.12, p = 0.008) and stool (SMD -0.50 d, 95% CI -0.86 to -0.14, p = 0.007). LOS was shorter in the preoperative carbohydrate loading group (SMD -0.51 d, 95% Cl -0.88 to -0.14, p = 0.007). There was no difference in postoperative morbidity between the groups. Conclusion: Preoperative carbohydrate loading does not significantly impact postoperative glycemic control in patients undergoing colorectal surgery; however, it may allow for a shorter LOS and faster return of bowel function. It merits inclusion within colorectal ERAS protocols.
Abstract Introduction Stoma formation delays discharge after colorectal surgery. Stoma education is widely recommended, but little data are available regarding whether educational interventions are ...effective. The aim of this prospective study was to investigate whether an enhanced recovery after surgery (ERAS) programme with dedicated ERAS and stoma nurse specialists focusing on counselling and stoma education can reduce the length of hospital stay, re-admission, and stoma-related complications and improve health-related quality of life (HRQoL) compared to current stoma education in a traditional standard care pathway. Methods In a single-center study 122 adult patients eligible for laparoscopic or open colorectal resection who received a planned stoma were treated in either the ERAS program with extended stoma education (n = 61) or standard care with current stoma education (n = 61). The primary endpoint was total postoperative hospital stay. Secondary endpoints were postoperative hospital stay, major or minor morbidity, early stoma-related complications, health-related quality of life, re-admission rate, and mortality. HRQoL was measured by the generic 15D instrument. Results Total hospital stay was significantly shorter in the ERAS group with education than the standard care group (median range, 6 days 2–21 days vs. 9 days 5–45 days; p < 0.001). Regarding overall major and minor morbidity, re-admission rate, HRQoL, stoma-related complications and 30-day mortality, the two treatment groups exhibited similar outcomes. Conclusion Patients receiving a planned stoma can be included in an ERAS program. Pre-operative and postoperative stoma education in an enhanced recovery programme is associated with a significantly shorter hospital stay without any difference in re-admission rate or early stoma-related complications.
To examine the impact of The National Training Program for Lapco on the rate of laparoscopic surgery and clinical outcomes of cases performed by Lapco surgeons after completion of training.
Lapco ...provided competency-based supervised clinical training for specialist colorectal surgeons in England.
We compared the rate of laparoscopic surgery, mortality, and morbidity for colorectal cancer resections by Lapco delegates and non-Lapco surgeons in 3-year periods preceding and following Lapco using difference in differences analysis. The changes in the rate of post-Lapco laparoscopic surgery with the Lapco sign-off competency assessment and in-training global assessment scores were examined using risk-adjusted cumulative sum to determine their predictive clinical validity with predefined competent scores of 3 and 5 respectively.
One hundred eight Lapco delegates performed 4586 elective colo-rectal resections pre-Lapco and 5115 post-Lapco while non-Lapco surgeons performed 72,930 matched cases. Lapco delegates had a 37.8% increase in laparoscopic surgery which was greater than non-Lapco surgeons by 20.9% 95% confidence interval (CI), 18.5-23.3, P < 0.001) with a relative decrease in 30-day mortality by -1.6% (95% CI, -3.4 to -0.2, P = 0.039) and 90-day mortality by -2.3% (95% CI, -4.3 to -0.4, P = 0.018). The change point of risk-adjusted cumulative sum was 3.12 for competency assessment tool and 4.74 for global assessment score whereas laparoscopic rate increased from 44% to 66% and 40% to 56%, respectively.
Lapco increased the rate of laparoscopic colorectal cancer surgery and reduced mortality and morbidity in England. In-training competency assessment tools predicted clinical performance after training.
Background
The transversus abdominis plane (TAP) block is an important non-narcotic adjunct for post-operative pain control in abdominal surgery. Surgeons can use laparoscopic guidance for TAP block ...placement (LTAP), however, direct comparisons to conventional ultrasound-guided TAP (UTAPs) have been lacking. The aim of this study is to determine if surgeon placed LTAPs were non-inferior to anesthesia placed UTAPs for post-operative pain control in laparoscopic colorectal surgery.
Methods
This was a prospective, randomized, patient and observer blinded parallel-arm non-inferiority trial conducted at a single tertiary academic center between 2016 and 2018 on adult patients undergoing laparoscopic colorectal surgery. Narcotic consumption and pain scores were compared for LTAP vs. UTAP for 48 h post-operatively.
Results
60 patients completed the trial (31 UTAP, 29 LTAP) of which 25 patients were female (15 UTAP, 10 LTAP) and the mean ages (SD) were 60.0 (13.6) and 61.5 (14.3) in the UTAP and LTAP groups, respectively. There was no significant difference in post-operative narcotic consumption between UTAP and LTAP at the time of PACU discharge (median IQR milligrams of morphine, 1.8 0–4.5 UTAP vs. 0 0–8.7 LTAP
P
= .32), 6 h post-operatively (5.4 1.8–17.1 UTAP vs. 3.6 0–12.6 LTAP
P
= .28), at 12 h post-operatively (9.0 3.6–29.4 UTAP vs. 7.2 0.9–22.5 LTAP
P
= .51), at 24 h post-operatively (9.0 3.6–29.4 UTAP vs. 7.2 0.9–22.5 LTAP
P
= .63), and 48 h post-operatively (39.9 7.5–70.2 UTAP vs. 22.2 7.5–63.8 LTAP P = .41). Patient-reported pain scores as well as pre-, intra-, and post-operative course were similar between groups. Non-inferiority criteria were met at all post-op time points up to and including 24 h but not at 48 h.
Conclusions
Surgeon-delivered LTAPs are safe, effective, and non-inferior to anesthesia-administered UTAPs in the immediate post-operative period.
Trial registry
The trial was registered at clinicaltrials.gov Identifier NCT03577912.
Despite a significant improvement with enhanced recovery programmes (ERP), gastro-intestinal (GI) functions that are impaired after colorectal resection and postoperative ileus (POI) remain a ...significant issue. In the literature, there is little evidence of the distinction between the treatment assessed within or outside ERP. The purpose was to evaluate the efficiency of treatments to reduce POI and improve GI function recovery within ERP. A search was performed in PubMed and Scopus on 20 September 2019. The studies were included if they compared the effect of the administration of a treatment aiming to treat or prevent POI or improve the early functional outcomes of colorectal surgery within an ERP. The main outcome measures were the occurrence of postoperative ileus, time to first flatus and time to first bowel movement. Treatments that were assessed at least three times were included in a meta-analysis. Among the analysed studies, 28 met the eligibility criteria. Six of them focused on chewing-gum and were only randomized controlled trials (RCT) and 8 of them focused on Alvimopan but none of them were RCT. The other measures were assessed in less than 3 studies over RCTs (n = 11) or retrospective studies (n = 2). In the meta-analysis, chewing gum had no significant effect on the endpoints and Alvimopan allowed a significant reduction of the occurrence of POI. Chewing-gum was not effective on GI function recovery in ERP but Alvimopan and the other measures were not sufficiently studies to draw conclusion. Randomised controlled trials are needed.Systematic review registration number CRD42020167339.
Background
Despite there being a considerable amount of published studies on robotic colorectal surgery (RCS) over the last few years, there is a lack of evidence regarding RCS training pathways. ...This study examines the short-term clinical outcomes of an international RCS training programme (the European Academy of Robotic Colorectal Surgery—EARCS).
Methods
Consecutive cases from 26 European colorectal units who conducted RCS between 2014 and 2018 were included in this study. The baseline characteristics and short-term outcomes of cases performed by EARCS delegates during training were analysed and compared with cases performed by EARCS graduates and proctors.
Results
Data from 1130 RCS procedures were collected and classified into three cohort groups (323 training, 626 graduates and 181 proctors). The training cases conversion rate was 2.2% and R1 resection rate was 1.5%. The three groups were similar in terms of baseline characteristics with the exception of malignant cases and rectal resections performed. With the exception of operative time, blood loss and hospital stay (training vs. graduate vs. proctor: operative time 302, 265, 255 min,
p
< 0.001; blood loss 50, 50, 30 ml,
p
< 0.001; hospital stay 7, 6, 6 days,
p
= 0.003), all remaining short-term outcomes (conversion, 30-day reoperation, 30-day readmission, 30-day mortality, clinical anastomotic leak, complications, R1 resection and lymph node yield) were comparable between the three groups.
Conclusions
Colorectal surgeons learning how to perform RCS under the EARCS-structured training pathway can safely achieve short-term clinical outcomes comparable to their trainers and overcome the learning process in a way that minimises patient harm.
Intraoperative lung-protective ventilation, including low tidal volume and positive end-expiratory pressure, reduces postoperative pulmonary complications. However, the effect and specific alveolar ...recruitment maneuver method are controversial. We investigated whether the intraoperative intermittent recruitment maneuver further reduced postoperative pulmonary complications while using a lung-protective ventilation strategy. Adult patients undergoing elective laparoscopic colorectal surgery were randomly allocated to the recruitment or control groups. Intraoperative ventilation was adjusted to maintain a tidal volume of 6-8 mL kg-1 and positive end-expiratory pressure of 5 cmH2O in both groups. The alveolar recruitment maneuver was applied at three time points (at the start and end of the pneumoperitoneum, and immediately before extubation) by maintaining a continuous pressure of 30 cmH2O for 30 s in the recruitment group. Clinical and radiological evidence of postoperative pulmonary complications was investigated within 7 days postoperatively. A total of 125 patients were included in the analysis. The overall incidence of postoperative pulmonary complications was not significantly different between the recruitment and control groups (28.1% vs. 31.1%, P = 0.711), while the mean ± standard deviation intraoperative peak inspiratory pressure was significantly lower in the recruitment group (10.7 ± 3.2 vs. 13.5 ± 3.0 cmH2O at the time of CO2 gas-out, P < 0.001; 9.8 ± 2.3 vs. 12.5 ± 3.0 cmH2O at the time of recovery, P < 0.001). The alveolar recruitment maneuver with a pressure of 30 cmH2O for 30 s did not further reduce postoperative pulmonary complications when a low tidal volume and 5 cmH2O positive end-expiratory pressure were applied to patients undergoing laparoscopic colorectal surgery and was not associated with any significant adverse events. However, the alveolar recruitment maneuver significantly reduced intraoperative peak inspiratory pressure. Further study is needed to validate the beneficial effect of the alveolar recruitment maneuver in patients at increased risk of postoperative pulmonary complications. Trial registration: Clinicaltrials.gov (NCT03681236).
Large laterally spreading lesions (LSL) in the colon and rectum can be safely and effectively removed by endoscopic mucosal resection (EMR). However, many patients still undergo surgery. Endoscopic ...treatment may be more cost effective. We compared the costs of endoscopic versus surgical management of large LSL.
We performed a prospective, observational, multicenter study of consecutive patients referred to 1 of 7 academic hospitals in Australia for the management of large LSL (≥ 20 mm) from January 2010 to December 2013. We collected data on numbers of patients undergoing EMR, actual endoscopic management costs (index colonoscopy, hospital stay, adverse events, and first surveillance colonoscopy), characteristics of patients and lesions, outcomes, and adverse events, and findings from follow-up examinations 14 days, 4-6 months, and 16-18 months after treatment. We compared data from patients who underwent EMR with those from a model in which all patients underwent surgery without any complications. Event-specific costs, based on Australian refined diagnosis-related group codes, were used to estimate average cost per patient.
EMR was performed on 1489 lesions (mean size, 36 mm) in 1353 patients (mean age, 67 years; 52.1% male). Total costs involved in the endoscopic management of large LSL were US $6,316,593 and total inpatient hospitalization length of stay was 1180 days. The total cost predicted for the surgical management group was US $16,601,502, with a total inpatient hospitalization length of stay of 4986 days. Endoscopic management produced a potential total cost saving of US $10,284,909; the mean cost difference per patient was US $7602 (95% confidence interval, $8458-$9220; P < .001). Inpatient hospitalization length of stay was reduced by 2.81 nights per patient (95% confidence interval, 2.69-2.94; P < .001).
In a large multicenter study, endoscopic management of large LSL by EMR was significantly more cost-effective than surgery. Endoscopic management by EMR at an appropriately experienced and resourced tertiary center should be considered the first line of therapy for most patients with this disorder. This approach is likely to deliver substantial overall health expenditure savings. ClinicalTrials.gov, Number: NCT01368289.
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