Enhanced recovery in colorectal surgery: a multicentre study

José M Ramírez, Juan A Blasco, José V Roig, Sergio Maeso-Martínez, José E Casal, Fernando Esteban, Daniel Callejo Lic, Spanish working group on fast track surgery, Emilio Maseda, Rafael Uña, Damián García-Olmo, Carlos Moreno, Marina Manzanera, Francisco A Quezada, Telesfora Sempere, Eva Llacer, Carlos Maristany, Arantxa Muñoz, Albert Navarro, Javier Cerdán, Gonzalo Sanz, Pedro Moral, Fernando Esteban, Pablo Royo, Vicente Aguilella, Julia Guillen, Tomás Ruiz, José Cuartero, Mariano Martínez, José M Ramírez, Enrique Moncada, Manuel Núñez, Luis C Luna, José E Casal, Roger Cabezali, Carlos Emparan, Pablo Soriano, Javier Isla, Antonio Arroyo, Alessandro Garcea, Pilar Serrano, José L Muñoz, Elena Miranda, José V Roig, Francisco Villalba, Antonio Salvador, Alfonso Garcia-Fabrique, Luis M Jiménez, Elena Monge, Irene Hidalgo, Emilio Del Valle, Morales Rafael, José Noguera, Xavier Viñas, Enric Macarulla, Victor Murga, Ana Pedregosa, Juan A Blasco, Sergio Maeso-Martínez, Daniel Callejo, José M Ramírez, Juan A Blasco, José V Roig, Sergio Maeso-Martínez, José E Casal, Fernando Esteban, Daniel Callejo Lic, Spanish working group on fast track surgery, Emilio Maseda, Rafael Uña, Damián García-Olmo, Carlos Moreno, Marina Manzanera, Francisco A Quezada, Telesfora Sempere, Eva Llacer, Carlos Maristany, Arantxa Muñoz, Albert Navarro, Javier Cerdán, Gonzalo Sanz, Pedro Moral, Fernando Esteban, Pablo Royo, Vicente Aguilella, Julia Guillen, Tomás Ruiz, José Cuartero, Mariano Martínez, José M Ramírez, Enrique Moncada, Manuel Núñez, Luis C Luna, José E Casal, Roger Cabezali, Carlos Emparan, Pablo Soriano, Javier Isla, Antonio Arroyo, Alessandro Garcea, Pilar Serrano, José L Muñoz, Elena Miranda, José V Roig, Francisco Villalba, Antonio Salvador, Alfonso Garcia-Fabrique, Luis M Jiménez, Elena Monge, Irene Hidalgo, Emilio Del Valle, Morales Rafael, José Noguera, Xavier Viñas, Enric Macarulla, Victor Murga, Ana Pedregosa, Juan A Blasco, Sergio Maeso-Martínez, Daniel Callejo

Abstract

Background: Major colorectal surgery usually requires a hospital stay of more than 12 days. Inadequate pain management, intestinal dysfunction and immobilisation are the main factors associated with delay in recovery. The present work assesses the short and medium term results achieved by an enhanced recovery program based on previously published protocols.

Methods: This prospective study, performed at 12 Spanish hospitals in 2008 and 2009, involved 300 patients. All patients underwent elective colorectal resection for cancer following an enhanced recovery program. The main elements of this program were: preoperative advice, no colon preparation, provision of carbohydrate-rich drinks one day prior and on the morning of surgery, goal directed fluid administration, body temperature control during surgery, avoiding drainages and nasogastric tubes, early mobilisation, and the taking of oral fluids in the early postoperative period. Perioperative morbidity and mortality data were collected and the length of hospital stay and protocol compliance recorded.

Results: The median age of the patients was 68 years. Fifty-two % of the patients were women. The distribution of patients by ASA class was: I 10%, II 50% and III 40%. Sixty-four % of interventions were laparoscopic; 15% required conversion to laparotomy. The majority of patients underwent sigmoidectomy or right hemicolectomy. The overall compliance to protocol was approximately 65%, but varied widely in its different components. The median length of postoperative hospital stay was 6 days. Some 3% of patients were readmitted to hospital after discharge; some 7% required repeat surgery during their initial hospitalisation or after readmission. The most common complications were surgical (24%), followed by septic (11%) or other medical complications (10%). Three patients (1%) died during follow-up. Some 31% of patients suffered symptoms that delayed their discharge, the most common being vomiting or nausea (12%), dyspnoea (7%) and fever (5%).

Conclusion: The following of this enhanced recovery program posed no risk to patients in terms of morbidity, mortality and shortened the length of their hospital stay. Overall compliance to protocol was 65%. The following of this program was of benefit to patients and reduces costs by shortening the length of hospital stay. The implantation of such programmes is therefore highly recommended.

Figures

Figure 1
Figure 1
Length of postoperative stay of patients who underwent colon surgery within the context of the present enhanced recovery program.

References

    1. Schoetz DJ Jr, Bockler M, Rosenblatt MS, Malhotra S, Roberts PL, Murray JJ, Coller JA, Rusin LC. "Ideal" length of stay after colectomy: whose ideal? Dis Colon Rectum. 1997;40:806–810. doi: 10.1007/BF02055437.
    1. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78:606–617.
    1. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183:630–641. doi: 10.1016/S0002-9610(02)00866-8.
    1. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care. Lancet. 2003;362:1225–1230. doi: 10.1016/S0140-6736(03)14546-1.
    1. Anderson AD, McNaught CE, MacFie J, Tring I, Barker P, Mitchell CJ. Randomized clinical trial of multimodal optimization and standard perioperative surgical care. Br J Surg. 2003;90:1497–1504. doi: 10.1002/bjs.4371.
    1. Delaney CP, Fazio VW, Senagore AJ, Robinson B, Halverson AL, Remzi FH. 'Fast track' postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg. 2001;88:1533–1538. doi: 10.1046/j.0007-1323.2001.01905.x.
    1. Kehlet H, Mogensen T. Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg. 1999;86:227–230. doi: 10.1046/j.1365-2168.1999.01023.x.
    1. Stephen AE, Berger DL. Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection. Surgery. 2003;133:277–282. doi: 10.1067/msy.2003.19.
    1. Delaney CP, Zutshi M, Senagore AJ, Remzi FH, Hammel J, Fazio VW. Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Dis Colon Rectum. 2003;46:851–859. doi: 10.1007/s10350-004-6672-4.
    1. Gatt M, Anderson AD, Reddy BS, Hayward-Sampson P, Tring IC, MacFie J. Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection. Br J Surg. 2005;92:1354–1362. doi: 10.1002/bjs.5187.
    1. Khoo CK, Vickery CJ, Forsyth N, Vinall NS, Eyre-Brook IA. A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Ann Surg. 2007;245:867–872. doi: 10.1097/01.sla.0000259219.08209.36.
    1. Maessen J, Dejong CH, Hausel J, Nygren J, Lassen K, Andersen J, Kessels AG, Revhaug A, Kehlet H, Ljungqvist O. et al.A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg. 2007;94:224–231. doi: 10.1002/bjs.5468.
    1. Daltroy LH, Morlino CI, Eaton HM, Poss R, Liang MH. Preoperative education for total hip and knee replacement patients. Arthritis Care Res. 1998;11:469–478. doi: 10.1002/art.1790110607.
    1. Klafta JM, Roizen MF. Current understanding of patients' attitudes toward and preparation for anesthesia: a review. Anesth Analg. 1996;83:1314–1321. doi: 10.1097/00000539-199612000-00031.
    1. Burke P, Mealy K, Gillen P, Joyce W, Traynor O, Hyland J. Requirement for bowel preparation in colorectal surgery. Br J Surg. 1994;81:907–910. doi: 10.1002/bjs.1800810639.
    1. Nygren J, Soop M, Thorell A, Sree NK, Ljungqvist O. Preoperative oral carbohydrates and postoperative insulin resistance. Clin Nutr. 1999;18:117–120. doi: 10.1016/S0261-5614(99)80063-6.
    1. Conway DH, Mayall R, bdul-Latif MS, Gilligan S, Tackaberry C. Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Anaesthesia. 2002;57:845–849. doi: 10.1046/j.1365-2044.2002.02708.x.
    1. Gan TJ, Soppitt A, Maroof M, el-Moalem H, Robertson KM, Moretti E, Dwane P, Glass PS. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology. 2002;97:820–826. doi: 10.1097/00000542-200210000-00012.
    1. Mowatt G, Houston G, Hernandez R, de VR, Fraser C, Cuthbertson B, Vale L. Systematic review of the clinical effectiveness and cost-effectiveness of oesophageal Doppler monitoring in critically ill and high-risk surgical patients. Health Technol Assess. 2009;13:1–118.
    1. Noblett SE, Snowden CP, Shenton BK, Horgan AF. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg. 2006;93:1069–1076. doi: 10.1002/bjs.5454.
    1. Wakeling HG, McFall MR, Jenkins CS, Woods WG, Miles WF, Barclay GR, Fleming SC. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005;95:634–642. doi: 10.1093/bja/aei223.
    1. Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg. 1995;221:469–476. doi: 10.1097/00000658-199505000-00004.
    1. Merad F, Yahchouchi E, Hay JM, Fingerhut A, Laborde Y, Langlois-Zantain O. Prophylactic abdominal drainage after elective colonic resection and suprapromontory anastomosis: a multicenter study controlled by randomization. French Associations for Surgical Research. Arch Surg. 1998;133:309–314. doi: 10.1001/archsurg.133.3.309.
    1. Urbach DR, Kennedy ED, Cohen MM. Colon and rectal anastomoses do not require routine drainage: a systematic review and meta-analysis. Ann Surg. 1999;229:174–180. doi: 10.1097/00000658-199902000-00003.
    1. Carr CS, Ling KD, Boulos P, Singer M. Randomised trial of safety and efficacy of immediate postoperative enteral feeding in patients undergoing gastrointestinal resection. BMJ. 1996;312:869–871.
    1. Di Fronzo LA, Cymerman J, O'Connell TX. Factors affecting early postoperative feeding following elective open colon resection. Arch Surg. 1999;134:941–945. doi: 10.1001/archsurg.134.9.941.
    1. Schwenk W, Gunther N, Wendling P, Schmid M, Probst W, Kipfmuller K, Rumstadt B, Walz MK, Engemann R, Junghans T. "Fast-track" rehabilitation for elective colonic surgery in Germany--prospective observational data from a multi-centre quality assurance programme. Int J Colorectal Dis. 2008;23:93–99. doi: 10.1007/s00384-007-0374-z.
    1. Braumann C, Guenther N, Wendling P, Engemann R, Germer CT, Probst W, Mayer HP, Rehnisch B, Schmid M, Nagel K, Schwenk W. Fast-Track Colon II Quality Assurance Group. Multimodal perioperative rehabilitation in elective conventional resection of colonic cancer: results from the German Multicenter Quality Assurance Program 'Fast-Track Colon II'. Dig Surg. 2009;26:123–9. doi: 10.1159/000206149.
    1. Rodríguez-Cuellar E, Ruiz López P, Romero Simó M, Landa García JI, Roig Vila JV, Ortiz Hurtado H. Analysis of the quality of surgical treatment of colorectal cancer, in 2008. A national study. Cir Esp. 2010;88:238–46.

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