Laparoscopic rectal resections and fast-track surgery: what can be expected?

doi:10.1016/j.amjsurg.2008.11.009

The American Journal of Surgery

Volume 197, Issue 3, March 2009, Pages 408-412

https://doi.org/10.1016/j.amjsurg.2008.11.009 Get rights and content

Abstract

Background

We present the results of combining protocols of standardized laparoscopic rectal resection (LRR) and perioperative fast track care.

Methods

Patients undergoing LRRs were identified from a prospectively maintained, institutional review board–approved database. Perioperative fast track care and laparoscopic operations were performed according to a standardized system.

Results

Thirty-seven patients were included. Conversion was performed in 2 males (5%). The mean operative time was 184 minutes (range 109 to 410 minutes). The mean hospital stay was 3.0 days (range 1 to 8 days) with 90% of patients discharged less than 5 days after surgery. No anastomotic leaks or mortality occurred and the in-hospital complications rate was 8%. Readmission occurred in 3 patients (8%). No specimen had involved distal or circumferential resection margins.

Conclusions

LRRs can be performed safely and effectively for rectal pathologies. Laparoscopy in conjunction with modern perioperative care provides rapid recovery with efficient use of hospital resources.

Section snippets

Methods

Prior approval for this study was obtained from the institutional review board (IRB), and our patients operated with laparoscopic access for rectal and rectosigmoid pathologies were entered prospectively into an IRB-approved database from August 2005 through November 2007. The database is registered in the National Library of Medicine (http://ClinicalTials.gov NCT #: NCT00622557). Only patients undergoing low anterior resections either as total mesorectal excision (TME) or partial mesorectal

Results

Thirty-seven patients were identified during the study period who underwent LRR for the following indications: malignancy (carcinoma in the rectum, or rectosigmoid junction) in 17 (46%), rectal polyp in 4 (11%), inflammatory disease (diverticulitis with phlegmon, abscess, or fistula) in 14 (38%), and for Crohn's proctitis and left colonic ischemia in 1 patient each (Table 1). Five (14%) patients had a diverting loop ileostomy to protect a coloanal anastomosis. Conversion was performed in 2

Comments

The combination of laparoscopic surgery and fast-track perioperative care pathways has dramatically reduced patient recovery time after surgery. Hospital stays of 1 to 4 days for more than 90% of the patients after rectal surgery can be expected as documented in this study. While similar LOS has been described after open segmental colon resection,¹⁴ rectal surgery has traditionally been associated with hospital stays from 7 days to 20 days.2, 15, 16, 17

The use of fast-track programs have

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Cited by (38)

The influence of peri-operative factors for accelerated discharge following laparoscopic colorectal surgery when combined with an enhanced recovery after surgery (ERAS) pathway
2016, International Journal of Surgery
Citation Excerpt :
Enhanced Recovery After Surgery (ERAS) is cost-effective with reduced morbidity and accelerated discharge [4–9], and has become an integral part of LCS in many units. Yet despite recent reports having shown that the introduction of ERAS into an established laparoscopic practice improves short-term outcomes [10,11], there is no randomized evidence to confirm its benefit in laparoscopic surgery. Its role in further reducing in-hospital morbidity and length of stay (LOS) remains, therefore, contentious [12,13].
Laparoscopic surgery is well established in the modern management of colorectal disease. More recently, enhanced recovery after surgery (ERAS) protocols have been introduced to further promote accelerated discharge and faster recovery. However, not all patients are suitable for early discharge. The purpose of this study was to evaluate the early outcomes of patients undergoing such a regime to determine which peri-operative factors may predict safe accelerated discharge.
Data were prospectively collected on consecutive patients undergoing laparoscopic colorectal surgery. All patients followed the institution's ERAS protocol and were discharged once specific criteria were fulfilled. Clinical characteristics and outcomes were compared between patients who were discharged before and after 72 h post-surgery. Thereafter, the peri-operative factors that were associated with delayed discharge were determined using a binary logistic model.
Three hundred patients were included in the analysis. The most common operation was laparoscopic anterior resection (n = 123, 41%). Mean length of stay was 4.8 days (standard deviation 5.9), with 185 (62%) patients discharged within 72 h. Ten (3%) patients had a post-operative complication. Three independent predictors of delayed discharge were identified; BMI (OR 1.06, 95%CI 1.01–1.11), operation length (OR 0.99, 95%CI 0.98–0.99) and complications (OR 16.26, 95%CI 4.88–54.08).
A combined approach of laparoscopic surgery and ERAS leads to reduced length of stay. This enables more than 60% of patients to be discharged within 72 h. Increased BMI, duration of operation and complications post-operatively independently predict a longer length of stay.
Spinal analgesia for laparoscopic colonic resection using an enhanced recovery after surgery programme: Better analgesia, but no benefits on postoperative recovery: A randomized controlled trial
2012, British Journal of Anaesthesia
Citation Excerpt :
In reality, the two approaches are still used separately; while laparoscopy for colonic resection is rapidly adopted by many surgeons, surgical care in many units still remains very traditional.23 24 Recently, a randomized study has demonstrated a significant advantage by implementing the ERAS programme together with laparoscopy.17–22 The 33 h difference in overall time to recovery was due to better tolerance of early dietary intake in the group receiving the two interventions.25
This study was undertaken to determine the impact of an intrathecal mixture of bupivacaine and morphine, when compared with systemic morphine, on the quality of postoperative analgesia and other outcomes in the context of the enhanced recovery after surgery (ERAS) programme for laparoscopic colonic resection.
Fifty patients undergoing general anaesthesia were randomly allocated to receive either a spinal mixture of bupivacaine and morphine followed by oral oxycodone (spinal group) or patient-controlled analgesia (PCA group). The primary outcome was consumption of opioids during the first three postoperative days. Secondary outcomes were pain scores, return of bowel function and dietary intake, readiness to hospital discharge, and length of hospital stay.
Postoperative opioid consumption in the spinal group was significantly less over the first three postoperative days (P<0.001). The quality of analgesia at rest in the first 24 h was better in the spinal group (P<0.005). Excessive sedation and respiratory depression were reported in two elderly patients with spinal analgesia. There were no differences between the two groups in other outcomes (return of bowel function and dietary intake, readiness to hospital discharge, and length of hospital stay).
When ERAS programme is used for laparoscopic colonic resection, an intrathecal mixture of bupivacaine and morphine was associated with less postoperative opioid consumption, but has no other advantages over systemic opioids.
Towards optimizing perioperative colorectal care: Outcomes for 1,000 consecutive laparoscopic colon procedures using enhanced recovery pathways
2012, American Journal of Surgery
Learning curves and efficiency concerns have slowed the integration of laparoscopy into colorectal practice. We evaluated our experience with laparoscopic colorectal (LC) surgery using enhanced recovery pathways (ERPs).
One thousand consecutive LC procedures performed by 2 surgeons over a 5-year period using previously published, standardized ERPs were assessed.
The mean age was 59, and the mean body mass index was 29.5. Procedures included segmental colectomy (54%), proctectomy (19%), total colectomy (11%), ostomy (5%), and other procedures (11%). Diagnoses included malignancy (41%), diverticulitis (16%), inflammatory bowel disease (13%), and other (30%). The mean operative time was 151 minutes, and the mean blood loss was 55 mL. Conversion to an open surgery occurred in 5.8%, whereas 2.3% were performed using a hand-assist procedure. The mean hospital stay was 4.1 days (median 3), with a 6% readmission rate. Complications (20%) included mortality (0.3%), wound infection (4%), and anastomotic leak (1.4%).
LC surgery with ERP offers excellent outcomes with efficient use of resources.
Enhanced recovery pathways optimize health outcomes and resource utilization: A meta-analysis of randomized controlled trials in colorectal surgery
2011, Surgery
Citation Excerpt :
Patients >70 years of age52,53 and patients with relevant baseline morbidity12 (American Society of Anesthesiology grade III and higher) also benefited from ERP, again demonstrating a marked reduction in morbidity and duration of stay. The positive impact of ERP on patients’ recovery seen for segmental colectomies was confirmed for minor procedures, such as ileostomy closure,54 as well as for more complex procedures, namely, reoperative pelvic surgery,12 rectal operations,55 and proctocolectomy with ileoanal reconstruction.56 Concerns about early readmissions, delays in diagnosis of complications, and increased nursing workload are frequently voiced when considering the implementation of ERP.
Health care systems provide care to increasingly complex and elderly patients. Colorectal surgery is a prime example, with high volumes of major procedures, significant morbidity, prolonged hospital stays, and unplanned readmissions. This situation is exacerbated by an exponential rise in costs that threatens the stability of health care systems. Enhanced recovery pathways (ERP) have been proposed as a means to reduce morbidity and improve effectiveness of care. We have reviewed the evidence supporting the implementation of ERP in clinical practice.
Medline, Embase, and the Cochrane library were searched for randomized, controlled trials comparing ERP with traditional care in colorectal surgery. Systematic reviews and papers on ERP based on data published in major surgical and anesthesiology journals were critically reviewed by international contributors, experienced in the development and implementation of ERP.
A random-effect Bayesian meta-analysis was performed, including 6 randomized, controlled trials totalizing 452 patients. For patients adhering to ERP, length of stay decreased by 2.5 days (95% credible interval [CrI] −3.92 to −1.11), whereas 30-day morbidity was halved (relative risk, 0.52; 95% CrI, 0.36–0.73) and readmission was not increased (relative risk, 0.59; 95% CrI, 0.14–1.43) when compared with patients undergoing traditional care.
Adherence to ERP achieves a reproducible improvement in the quality of care by enabling standardization of health care processes. Thus, while accelerating recovery and safely reducing hospital stay, ERPs optimize utilization of health care resources. ERPs can and should be routinely used in care after colorectal and other major gastrointestinal procedures.
Perioperative fast track program in intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) after cytoreductive surgery in advanced ovarian cancer
2011, European Journal of Surgical Oncology
Citation Excerpt :
Fast track surgery is a comprehensive approach, designed to accelerate recovery, reduce morbidity and shorten convalescence to ultimately improve outcomes and reduce costs.32 The introduction of Fast track programs achieves good results in postoperative outcomes in many surgical pathologies.34–41 For instance, nephrectomy 42; radical prostatectomy43; knee and hip prosthesis44; abdominal aortic aneurysm36; bariatric surgery45,46 and lung resections47 can all be carried out with a mean hospital admittance of less than 4 days and others such as antireflux surgery; suprarenalectomy; cholecystectomy; thyroidectomy; etc, are already carried out in many hospitals in ambulatory care.48,49
Diffuse peritoneal dissemination in advanced ovarian cancer can be treated using optimal effort surgery involving peritonectomy procedures and the administration of hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC).
To report on our experience in the treatment of advanced ovarian cancer using peritonectomy procedures and HIPEC through the fast track program.
From September 2008 until May 2010, forty-six patients with primary advanced (stage III-C) or recurrent ovarian cancer have been included in the fast track protocol if they had optimal cytoreduction CC-0 or CC-1 accompanied by HIPEC and there had no more than one digestive anastomosis.
The mean peritoneal cancer index (PCI) was 12.35 (3–21). The median operation time was 380 min (200–540). Optimal surgery CC-0 was achieved in 38 of the 46 patients and CC-1 in the remaining 8. Mean postoperative hospital stay was 6.94 ± 1.56 days (3–11). Major morbidity rates were 15.3%. Paralytic ileus was the most frequent of these. There was no mortality related to the procedure.
Surgery with peritonectomy procedures and HIPEC in advanced ovarian carcinoma is possible under fast track surgery programs in patients with low volume peritoneal carcinomatosis. Prospective and randomized studies are needed.
Implementation of an Enhanced Recovery After Surgery program in elective colorectal surgery: a prospective cohort study
2019, Journal of Coloproctology
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).
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.
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.
ERAS protocol and laparoscopic surgery decreased LOS without increasing 30 days readmission rate. Severe CDC increased LOS and readmissions.
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).
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.
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.
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.

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The Midwest Surgical AssociationLaparoscopic rectal resections and fast-track surgery: what can be expected?

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Comments

Lancet

Am J Surg

Laparoscopic rectal resection with anal sphincter preservation for rectal cancer: long-term outcome

Surg Endosc

Laparoscopic resection for rectal cancer: a prospective analysis of thirty-month follow-up outcomes in 312 patients

Surg Endosc

Laparoscopic surgery in rectal cancer: a prospective analysis of patient survival and outcome

Dis Colon Rectum

Long-term results of laparoscopic colorectal cancer resection Long-term results of laparoscopic colorectal cancer resection

Cochrane Database Syst Rev

Randomized trial of laparoscopic assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASSIC trial group

J Clin Oncol

Laparoscopic versus open total mesorectal excision for rectal cancer

Cochrane Database Syst Rev

Results of a standardized technique and postoperative care plan for laparoscopic sigmoid colectomyA 30-month experience

Dis Colon Rectum

Case matched comparison of clinical and financial outcome after laparoscopic or open colectomy

Ann Surg

The Midwest Surgical Association
Laparoscopic rectal resections and fast-track surgery: what can be expected?