Laparoscopic colorectal surgery and Enhanced Recovery After Surgery (ERAS) program

Abstract

There is increasing evidence that minimally invasive techniques associated with Enhanced Recovery After Surgery (ERAS) protocols reduce surgery-related stress and promote faster recovery after major colorectal surgery. As a single tertiary referral center for colorectal surgery, our aim was to analyze the effects of our ERAS protocol on a heterogeneous population undergoing laparoscopic colorectal surgery.Prospectively collected data from 283 patients undergoing laparoscopic colorectal resection at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust, between March 2014 and March 2018 were retrospectively analyzed. Patients' adherence to pre-, intra-, and postoperative ERAS protocol items together with surgical short-term outcomes such as morbidity, mortality, length of hospital stay, and readmission rate was considered.The study protocol was approved by the Ethics Committee of Azienda Ospedaliera Universitaria Integrata di Verona (CRINF-1034 CESC).During the study period, 200 patients met the inclusion criteria and were enrolled in the ERAS protocol. In this series, 34% of patients were aged 70 years or older. Rectal resections represented 26% of all cases, with stoma formation performed in 14.5% of patients. Despite such procedural heterogeneity, good short-term results were obtained: by postoperative day (POD) 2, 58.5% of patients had full return of bowel function, while 63.5% and 88% achieved regular soft diet intake and autonomous walking, respectively. Median (range) length of hospital stay was 5.5 days (2-40) with 71% of patients being discharged by POD 6. No postoperative mortality was recorded, and the rate of major complications was 3.5%. During the study period, 6 patients required redo surgery (3%) and 5 patients required rehospitalization within 30 days (2.5%).This study analyzing the results of the fast-track program in our first 200 cases confirms the feasibility and safety of ERAS protocol application within a heterogeneous population undergoing laparoscopic colonic and rectal resection for benign and malignant diseases.

Impact of age on feasibility and short-term outcomes of ERAS after laparoscopic colorectal resection

“…Good results in early mobilization were achieved independently from age thanks to an optimal pain management. In our experience, one of the key aspects in post-operative pain management was the use of transversus abdominis pain (TAP) block that proved to reduce significantly the use of opioid analgesics and to ensure an optimal pain control[13,30], without the adverse effects of epidural analgesia, such as vasodilatation and hypotension. Limiting the side effects of opioids and epidural seems of particular benefit in elderly that are more sensitive to sedation and blood pressure variations.…”

“…Exclusion criteria were: inflammatory bowel disease (IBD), familial adenomatous polyposis (FAP), palliative surgery, body mass index above 35 kg/m 2 , American Society of Anaesthesiologists (ASA) physical status above 3, coagulopathy, impaired kidney function, uncontrolled diabetes, severe cardiovascular impairment or chronic obstructive pulmonary disease, psychiatric disorders, drug and alcohol addiction, duration of anesthesia above 6 h and denied consent. Reasons for pre-operative and intra-operative exclusion criteria have been previously described in detail[13]. Informed consent was obtained from all the patients for the surgical procedure proposed and the protocol was approved by the local Ethics Committee.…”

“…The objective of the ERP was to provide all the items to all patients as far as possible. Surgical approach, anesthesiologic management, post-operative analgesia and post-operative care according to ERAS items were previously described in detail[13,14].…”

Effect of the Enhanced Recovery After Surgery protocol After Colorectal Cancer Surgery

“…This ERAS protocol is effective in reducing postoperative complications, improve recovery, and shorten the length of stay in patients after colorectal surgery [ 4 - 6 ]. It is reported that this ERAS protocol is effective not only in elective open colorectal surgery [ 7 ], but also in laparoscopic surgery [ 8 ], emergency surgery [ 9 ], and elderly patient surgery [ 10 ]. The ERAS protocol can be considered to reduce postoperative complication by reducing the systemic inflammatory response after colorectal surgery, but few studies have proven the relationship between the ERAS protocol and inflammatory markers (C-reactive protein, interleukin-6, neutrophil-lymphocyte ratio, and so on) [ 11 ].…”

Análisis clínico e impacto económico de la implantación de una vía clínica de recuperación intensificada en cirugía bariátrica

“…Por ello, la seguridad y la viabilidad de los programas ERAS están ampliamente aceptadas desde la experiencia acumulada en cirugía colorrectal (117,188), incluso en la población de pacientes ancianos en la que, aunque los datos son más escasos, parece que se obtiene la misma eficacia en cuanto a estancia hospitalaria y complicaciones (189)(190)(191)(192).…”