Enhanced recovery after surgery provides patients with optimal means to counteract or minimize the deleterious effects of surgery. This concept can be adapted to suit a specific surgical procedure (i.e., colorectal surgery) and comes in the form of a program or a clinical pathway covering the pre-, intra- and postoperative periods. The purpose of these Expert Panel Guidelines was firstly to assess the impact of each parameter typically included in the fast-track programs on six foreseeable consequences of colorectal surgery: surgical stress, postoperative ileus, fluid and electrolyte imbalances, decreased postoperative mobility, sleep disorders and postoperative complications; secondly, to validate the value of each parameter in terms of efficacy criteria for success of rapid rehabilitation programs. Two primary endpoints were selected to evaluate the impact of each parameter: the duration of hospital stay and rate of postoperative complications. For some of the parameters, the lack of information in the literature forced the experts to assess the parameter using different criteria (i.e., the duration of postoperative ileus or quality of analgesia); improvement in endpoints favored the implementation of a rapid rehabilitation program. After analysis of the literature, 19 parameters were identified as potentially impacting at least one of the foreseeable consequences of colorectal surgery. GRADE(®) methodology was applied to determine a level of evidence and the strength of recommendation regarding each parameter. After synthesis of the work of experts on the 19 parameters using GRADE(®) methodology, the organizing committee reached 35 formal recommendations. The recommendations were submitted and amended by a group of reviewers. After three rounds of Delphi quotes, strong agreement was obtained for 28 recommendations (80%) and weak agreement for seven recommendations. Consensus was reached among anesthesiologists and surgeons on a number of tactics that are insufficiently applied in current rehabilitation programs in colorectal surgery such as: pre-operative intake of carbohydrates; optimization of intra-operative volume control; resumption of oral feeding within 24 hours; gum chewing after surgery; getting the patient out of bed and walking on D1. The panel also clarified the value and place of such approaches as: patient information; pre-operative immunonutrition; laparoscopic surgery; antibiotic prophylaxis; prevention of hypothermia; systematic medication to prevent nausea and vomiting; morphine-sparing analgesia techniques; indications and techniques for bladder catheterization. The panel also confirmed the futility of other methods such as: bowel preparation for colon surgery; maintaining a nasogastric tube; surgical drainage for colorectal surgery.
Background: Tumour extension beyond the mesorectal plane (ymrT4) occurs in 5-10 per cent of patients with rectal cancer and 10 per cent of patients develop locally recurrent rectal cancer (LRRC) after primary surgery. There is global variation in healthcare delivery for these conditions. Methods: An international benchmark trial of the management of ymrT4 tumours and LRRC was undertaken in France and Australia between 2015 and 2017. Heterogeneity in management and operative decision-making were analysed by comparison of surgical resection rates, blinded intercountry reading of pelvic MRI, quality-of-life assessment and qualitative evaluations. Results: Among 154 patients (97 in France and 57 in Australia), 31⋅8 per cent had ymrT4 disease and 68⋅2 per cent LRRC. The surgical resection rates were 88 and 79 per cent in France and Australia respectively (P = 0⋅112). The concordance in operative planning was low (= 0⋅314); the rate of pelvic exenteration was lower in France than Australia both in clinical practice (36 of 78 versus 34 of 40; P < 0⋅001) and in theoretical conditions (10 of 25 versus 50 of 57; P = 0⋅002). The R0 resection rate was lower in France than Australia for LRRC (25 of 49 versus 18 of 21; P = 0⋅007) but not for ymrT4 tumours (21 of 26 versus 15 of 15; P = 0⋅139). Morbidity rates were similar. Patients who underwent non-exenterative procedures had higher scores on the mental functioning subscale at 12 months (P = 0⋅047), and a lower level of distress at 6 months (P = 0⋅049). Qualitative analysis highlighted five categories of psychosocial factors influencing treatment decisions: patient, strategy, specialist, organization and culture. Conclusion: This international benchmark trial has highlighted the differences in worldwide treatment of locally advanced and LRRC. Standardized care should improve outcomes for these patients.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.