Feasibility of a tailored ERAS programme in octogenarian patients undergoing minimally invasive surgery for colorectal cancer

Abstract

Background

The enhanced recovery after surgery (ERAS) is nowadays a widely accepted multimodal programme of care in colorectal surgery, but still there is some reluctance in its application to very elderly patients.

Aim

The aim of this study is to investigate short-term outcomes of laparoscopic resection for colorectal cancer in octogenarian patients within the ERAS programme.

Methods

Data on 162 consecutive patients aged ≥ 80 years receiving elective minimally invasive colorectal resections within ERAS programme were collected in a multicentre, retrospective database in the period 2008–2017 in Italy. Univariate and multivariate analyses were performed to assess possible risk factors for poor clinical outcomes.

Results

The postoperative minor morbidity rate (Clavien–Dindo 1 and 2) was 25.9%. The incidence of postoperative major morbidity rate (severe medical and surgical complications defined as Clavien–Dindo 3 and 4) accounted 6.1% and only 1.8% had an anastomotic leakage. Reoperation rate was 5.5%, perioperative 30-day mortality was 1.8%, and 30-day readmission rate was 6.8%. On average, patients were released after 6 days. A univariate analysis showed that possible risk factors for severe medical complications were: low preoperative albumin level, high Charlson Age Comorbidity Index Score and number of days in the intensive care unit (ICU); risk factors for severe surgical complications were: low preoperative albumin level; risk factors for late hospital discharge were: multivisceral resections, number of days in ICU and body mass index (BMI) > 25 kg/m². The multivariate analysis confirmed a low level of preoperative albumin and a longer ICU stay as independent risk factors for both postoperative severe surgical complications and late hospital discharge.

Discussion

The minimal invasive nature of the laparoscopic approach together with a multimodal analgesia therapy, the early resumption to oral diet and mobilisation could minimize the surgical stress and play an essential role in order to reduce medical morbidity in high-risk patients.

Conclusion

Colorectal surgery within ERAS programme in octogenarians is a safe and flexible treatment in high-volume centres.

Appendices

Appendix 1: surgical technique

Right colectomy

Authors started with the separation of the omentum from the transverse colon, mesentery using a medial to lateral approach. The hepatic flexure was taken down with different energy devices. The right paracolic gutter was divided along the Toldt’s line with blunt dissection until the third portion of the duodenum was clearly visible. The ileocolic and right colic vessels were divided and sectioned at their origin between clips, performing a complete mesocolic excision10. An intracorporeal anastomosis was accomplished with 60 mm laparoscopic linear staple loads. No drain was usually placed in the abdomen.

Transverse resection

The intervention consisted in three types of procedures:

• Segmentary resection of the splenic flexure, defined as a resection of the colon from the last third of the transverse colon to the first third of the descending colon. An intracorporeal mechanical latero-lateral colo-colic anastomosis was performed.

• Extended left colectomy, defined as a resection of the colon from the last third of the transverse colon to the colorectal junction. An intracorporeal mechanical end-to-end colorectal anastomosis was performed.

• Extended right colectomy, defined as a resection of the colon from the last ileal limp to the first third of the descending colon. An intracorporeal mechanical latero-lateral ileo-colic anastomosis was performed.

Left colectomy and rectal resection

Left colon mobilization was started by a medial to lateral interruption of the gastrocolic and splenocolic ligaments followed by separation of the plane between Gerota’s and Toldt’s fascias. Left paracolic gutter was dissected along the Toldt’s line with blunt dissection up to middle rectum with Waldeyer nerve-sparing fascia dissection. Section of the inferior mesenteric vessels was always performed between metallic clips, 2 cm from the aortic plane in order to preserve hypogastric nerves. After circumferential dissection, the middle rectum was divided using a 60mm laparoscopic linear stapler. An intracorporeal circular end-to-end anastomosis was achieved inserting the stapler transanally. A hydropneumatic test was performed to check the integrity of the anastomosis and any leaks identified were sutured by interrupted stitches. A perianastomotic drain tube was placed in the pelvis.

Appendix 2

Fast-track protocol

Item	Study protocol
Dedicated preoperative counselling	Anaesthesiologic, cardiologic and surgical counselling according to ESA guidelines
Preoperative optimisation; smoking/alcohol cessation; physical exercise	Improving daily aerobic activity
	Nutritional supplementation
Avoidance of preoperative bowel preparation	Only for rectal resection: two rectal enemas the evening before surgery
Preoperative fasting and carbohydrate treatment	Solids allowed up to 6 h prior surgery
	Clear fluids up to 2 h prior surgery
	Carbohydrates oral loading
Avoidance of long- or short-acting premedication anaesthetics	Premedication with Midazolam 20 mcg/kg
Prophylaxis against thromboembolism	Compression stockings
	Allen stirrups
	LMWH according to Caprini score
Antimicrobial prophylaxis and skin preparation	Cefazoline 2 g and Metronidazole 500 mg, 60 min before surgery
	Two other infusions of metronidazole 500 mg are administered in the first 24 h
Multi-modal anaesthetic protocol	Laryngeal mask airway device or orotracheal intubation
	US-guided quadratus lomborum block or TAP block
	Injection of local anaesthetics on the region of surgical wounds
PONV prophylaxis	Premedication with desametasone 8 mg + metoclopramide 10 mg + ondansetron 4 mg + ranitidine 50 mg
Laparoscopy and modifications of surgical access	Laparoscopic approach always initially performed
Avoidance of nasogastric intubation	Orogastric tube placed at the beginning of surgery, removed at the end of the procedure
Prevention of intraoperative hypothermia	Warming device (Bair Hugger)
	Warmed intravenous fluids
Perioperative fluid management	Colloids avoided, if possible, in order to prevent coagulopathy
	0.5–1 ml/kg/h infusion, starting 2 h after surgery, stopped after 24 h
Avoidance of abdominal drainage	Abdominal drain/s often placed
Urinary drainage for 1–2 days	Bladder catheter left in place for 24 h if operative time is > 120 min
Prevention of postoperative ileus	If TAP block/quadratus lomborum block applied, if thoracic epidural analgesia notapplied
	Encouraging moderate coffee assumption
Multi-modal postoperative analgesia	Multimodal analgesia with TAP block
	Intravenous infusion of drugs other than opioids
	Injection of local anaesthetics on the region of surgical wounds
Perioperative nutritional care	Nutritional screening highly recommended considering BMI and albumin level
	Preoperative oral nutrition support intake frequently necessary
	Start oral feeding 1 day after surgery with semi-liquid diet (2 days after surgery in case of ICU stay)
Postoperative glucose control	A judiciously glycemic control is applied
	Personalized food intake, according to comorbidities
Early mobilisation	Mobilization assistance and physiokinesitherapy
	Familial support in early mobilisation
Prevention of cognitive impairment (not included in ERAS items)	Avoid any communicative barrier (i.e. scientifical words)
	Avoid postoperative sedative drugs
	A caregiver should be encouraged to participate in the pre-/postoperative p