Modified enhanced recovery after surgery protocols are beneficial for postoperative recovery for patients undergoing emergency surgery for obstructive colorectal cancer

Abstract

Enhanced recovery after surgery (ERAS) is acknowledged to reduce perioperative stress in several surgical diseases. Here, we investigated whether modified ERAS is associated with beneficial effects in the setting of emergency colorectal surgery.We retrospectively evaluated the medical records of 839 consecutive patients with obstructive colorectal cancer undergoing surgical intervention at 4 institutes. Among them, 356 cases were managed with a multidisciplinary team approach to care (modified ERAS protocols), and the remaining 483 cases were treated based on traditional protocols. According to modified ERAS or traditional care, propensity score (PS) matching was performed to adjust biases in patient selection. The primary outcome was gastrointestinal function recovery. Secondary outcomes included postoperative complications and length of hospital stay.Modified ERAS was associated with postoperative gastrointestinal function recovery, including time to first flatus (P = .002), first defecation (P = .008), and prolonged ileus (P = .016). According to the Clavien–Dindo classification, fewer total episodes of grade II or higher postoperative complications were observed in patients cared for with modified ERAS than in patients with traditional care (P = .002). Median (interquartile range) postoperative hospital stay in the modified ERAS group was 6 (3–22) days versus 9 (7–27) days in the traditional care group (P < .001). Furthermore, the interval from operation to postoperative chemotherapy (d) was significantly shorter in the modified ERAS group (35.6 ± 11.5 vs 47.6 ± 23.8, P < .001).The modified ERAS was safe and associated with clinical benefits, including fast recovery of bowel function, reduced postoperative complications, and shorter hospital stay for patients with obstructive colorectal cancer.

Enhanced recovery after surgery in emergency colorectal surgery: Review of literature and current practices

“…There were four cohort studies comparing ERAS program to conventional care in emergency colorectal surgery[8,10-12]. Three of them[8,11,12] focused on ERAS program in obstructing colorectal cancer, whereas the other[10] covered various emergency abdominal surgeries including colorectal resection for acute colorectal manifestations. All studies used a “modified” ERAS protocol in their institutes (Table 1).…”

“…The latest study, published by Shang et al[12] in 2018, was a multicenter study from China. During the study period of 8 years, 839 consecutive patients with acutely obstructed colorectal cancer underwent emergency resection in 4 hospitals.…”

“…Although the methods of ERAS intervention and the number of ERAS items applied in the aforementioned studies may be various[8,10-12], it appears that an ERAS program can safely be applicable to emergency colorectal surgery with similar beneficial effects of that shown in an elective setting such as a reduction in postoperative complication and length of hospitalization – without a significant difference in 30-d mortality and readmission rate. Study characteristics and clinical outcomes of the four published trials comparing ERAS vs non-ERAS in emergency colorectal surgery are summarized in Table 2.…”

“…In the ERAS society’s recommended guidelines for perioperative care in an elective setting in 2013, there are 20 and 21 ERAS items for colonic surgery and rectal surgery, respectively[4,5]. Most of the protocol items were used in emergency colorectal surgery with some modification[8,10-12]. Obviously, some preoperative ERAS items such as nutritional support, carbohydrate loading and “full” optimization of medical conditions are impossible to achieve in an emergency basis.…”

Clinical benefit of oral lactulose for postoperative care of pateints with complicated appendicitis using propensity score matching analysis

“…Postoperative intestinal recovery serves as the main focus of abdominal surgery [11, 12]. Postoperative ileus detention might lead to oral nutrition delay, prolonged hospital stay, even with hospital readmission [13].…”