Background
Laparoscopic surgery and enhanced recovery after surgery (ERAS) programs were two major improvements for the management of colorectal diseases. The purpose of this systemic review was to ...examine whether laparoscopic colorectal surgery still improved short-term postoperative outcomes in comparison with open surgery when both groups of patients received ERAS programs.
Methods
PubMed, Embase, the Cochrane Central Register of Controlled Trials, and reference lists of the identified studies were searched to identify randomized clinical trials that compared laparoscopic with open surgery in patients undergoing colorectal resection in the context of ERAS programs. The outcome measures were analyzed, and the quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.
Results
Five randomized clinical trials encompassing 598 patients were included in the final analysis. Two of them were multicenter trials. The ERAS programs implemented in the five included trials cannot be classified as optimal ERAS programs, but suboptimal ERAS programs. Laparoscopic colorectal surgery significantly reduced total hospital stay (weighted mean difference (WMD) −1.92 days; 95 % confidence interval (CI) −2.61–−1.23 days;
P
< 0.00001) and number of complications (relative risk (RR) 0.78; 95 % CI 0.66–0.94;
P
= 0.007) compared with open surgery in the setting of ERAS programs. No significant differences were found between groups for primary hospital stay, number of patients with complications, readmission rates, and mortality. The quality of evidence for all outcomes was low-to-moderate on the GRADE scale, and none had high quality.
Conclusions
Laparoscopic colorectal resection significantly reduced total hospital stay and number of complications when compared with open surgery in the setting of suboptimal ERAS programs, but the benefits of laparoscopic colorectal resection remain to be proved within optimal ERAS programs.
Intraperitoneal drains are often placed during emergency colorectal surgery. However, there is a lack of evidence supporting their use. This study aimed to describe the efficacy and safety of ...intraperitoneal drain placement after emergency colorectal surgery.
COMPlicAted intra-abdominal collectionS after colorectal Surgery (COMPASS) is a prospective, international, cohort study into which consecutive adult patients undergoing emergency colorectal surgery were enrolled (from 3 February 2020 to 8 March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included rate and time-to-diagnosis of postoperative intraperitoneal collections, rate of surgical site infections (SSIs), time to discharge and 30-day major postoperative complications (Clavien-Dindo III-V). Multivariable logistic and Cox proportional hazards regressions were used to estimate the independent association of the outcomes with drain placement.
Some 725 patients (median age 68.0 years; 349 48.1% women) from 22 countries were included. The drain insertion rate was 53.7% (389 patients). Following multivariable adjustment, drains were not significantly associated with reduced rates (odds ratio OR = 1.56, 95% CI: 0.48-5.02, p = 0.457) or earlier detection (hazard ratio HR = 1.07, 95% CI: 0.61-1.90, p = 0.805) of collections. Drains were not significantly associated with worse major postoperative complications (OR = 1.26, 95% CI: 0.67-2.36, p = 0.478), delayed hospital discharge (HR = 1.11, 95% CI: 0.91-1.36, p = 0.303) or increased risk of SSIs (OR = 1.61, 95% CI: 0.87-2.99, p = 0.128).
This is the first study investigating placement of intraperitoneal drains following emergency colorectal surgery. The safety and clinical benefit of drains remain uncertain. Equipoise exists for randomized trials to define the safety and efficacy of drains in emergency colorectal surgery.
Aim Although there are numerous studies on the efficacy of enhanced recovery after surgery (ERAS) protocols in reducing length of stay, the long‐term compliance to such protocols in routine clinical ...practice has not been well documented. The aim of this study was to review the published literature on compliance to ERAS in patients undergoing colorectal surgery in routine clinical practice.
Method Medline, Embase and PubMed databases were searched to identify studies that focused on compliance to ERAS protocols during routine clinical practice. Fourteen studies fulfilled the inclusion criteria and a total of 19 perioperative ERAS modalities were identified across these studies.
Results None of the studies used all 19 ERAS modalities within their ERAS protocols. Compliance to the various modalities varied considerably between studies and, in general, was poorest during the postoperative period. The use of epidural had the highest compliance (between 67 and 100%), whereas the use of transverse incisions (25%) had the lowest compliance. Length of stay in hospital ranged from 2 to 13 days. Higher compliance was associated with a reduced length of hospital stay. However, reduced length of hospital stay was associated with a high rate of readmission.
Conclusion There is significant variation in the components of, as well as in compliance to, ERAS protocols in daily practice. This may contribute to the observed variation between the studies in length of hospital stay. A standardized and practically feasible ERAS protocol should be established in order to improve the implementation and optimal outcome.
Structured Abstract Background Alvimopan’s goal is to minimize postoperative ileus and optimize outcomes; however, evidence in laparoscopic surgery is lacking. Our goal was to evaluate the benefit of ...Alvimopan in laparoscopic colorectal surgery with an enhanced recovery pathway(ERP). Methods Laparoscopic colorectal cases were stratified into Alvimopan and control cohorts, then case-matched for comparability. All followed an identical ERP. The main outcomes were length of stay, complications, readmissions, and costs in the Alvimopan and control groups. Results 321 patients were analyzed in each cohort. Operative times were comparable(p=0.08). Postoperatively, complication rates were similar (p=0.29), with no difference in ileus(p=1.00). The length of stay(3.69 vs. 3.49 days;p=0.16), readmission(2.8% vs. 3.7%;p=0.66) and reoperation rates(2.2% vs. 1.6%;p=0.77) were comparable for Alvimopan and controls, respectively. Total costs were similar($14,932.47 Alvimopan vs. $14,846.56 controls; p=0.90), but the additional costs in the Alvimopan group could translate to savings of $27,577 in the cohort. Conclusions Alvimopan added no benefit in patient outcomes in laparoscopic colorectal surgery with an ERP. These results could drive a change in current practice. Controlled studies are warranted to define the cost/ benefit in clinical practice.
Background and Objective
The impact of surgical indication on compliance with enhanced recovery program (ERP) and on outcomes has never been assessed. This study aims to assess the impact of surgical ...indication (malignant vs benign) on postoperative outcomes and ERP compliance.
Methods
A multicenter nationwide database was analyzed. Patients who underwent colorectal surgery for benign disease and those who underwent colorectal surgery for cancer were compared. Inclusion criteria were elective colorectal resection with anastomosis. ERP components, postoperative morbidity, and hospital length of hospital stay data were collected.
Results
Among the 6472 patients registered in the database between October 2012 and June 2018, 4528 patients were included; 2647 in the malignant group and 1881 in the benign group. The ERP compliance over 70% was not different between groups. Postoperative morbidity rate was higher in the malignant group (22.5% vs 19.3%; P = .009) but not confirmed in multivariate analysis. Patients in the malignant group were more often readmitted after discharge, 6.6% vs 4.6% (P = .004). The mean LOS was 6.3 ± 5.0 days in the malignant group and 5.4 ± 4.7 days in the benign group (P < .001).
Conclusions
Indication for colorectal surgery did not significantly influence peri‐operative management and postoperative major complications, in patients managed within an enhanced recovery program.
Enhanced recovery after surgery (ERAS) is a multimodal perioperative care pathway designed to attenuate the stress response during the patients' journey through a surgical procedure to facilitate the ...maintenance of preoperative bodily compositions and organ function and in doing so achieve early recovery. The key factors that keep patients in hospital after uncomplicated major abdominal surgery include the need for parenteral analgesia, intravenous fluids secondary to persistent gut dysfunction, and bed rest caused by lack of mobility. The elements of the ERAS pathways are aimed to address these issues and the interventions that facilitate early recovery cover all three phases of the perioperative period during the patients' journey. They also provide clear guidance to all members of the clinical team.
Underrepresentation of highly ranked women in academic surgery is recognized.
Our objective was to examine whether sex differences exist in faculty representation, academic rank, and publication ...productivity among colorectal faculty in fellowship programs.
American Society of Colon and Rectal Surgeons fellowship program faculty were identified. Bibliometric data were obtained for each faculty member, including Hirsch index, the Hirsch index divided by research career duration, and number of publications. Linear mixed-effect regression models were constructed to determine the association between the Hirsch index and the Hirsch index divided by research career duration and sex, when controlling for institutional measures. A subset analysis of academic faculty examined the association between academic rank, sex, and Hirsch index and the Hirsch index divided by research career duration.
Colorectal fellowship programs, defined as academic, satellite-academic, and nonacademic, were evaluated.
Three hundred fifty-eight faculty members were examined across 55 training programs; 22% (n = 77) were women and 78% (n = 281) were men. Sixty-one percent (n = 220) practiced in an academic setting, 23% (n = 84) in a satellite-academic setting, and 15% (n = 54) in a nonacademic setting. There was no difference in median number of publications between sexes (15 vs 10, p = 0.33); men, however, had longer careers (18 vs 11 years, p < 0.001). When controlling for confounders, there was no difference in the Hirsch index (p = 0.42) or the Hirsch index divided by research career duration (p = 0.73) between sexes. Academic rank was significantly associated with Hirsch index and the Hirsch index divided by research career duration (p < 0.001) after controlling for sex.
Our assessment of association between publication productivity and academic rank was only possible in the subset of academic faculty. In addition, this study is limited by its retrospective nature.
We found no difference in median number of publications between men and women. When controlling for possible confounders, sex was not a significant predictor of a faculty member's publication productivity, as measured by the Hirsch index or the Hirsch index divided by research career duration; academic rank, however, was.
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