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Enhanced Recovery Program following Colorectal Resection in the Elderly Patient

Abstract

Background

The enhanced recovery program (ERP) aims to reduce the metabolic response to surgery, hastening recovery and shortening hospital stay. Concerns exist regarding morbidity and hospital stay in elderly patients. The present study aimed to compare the outcomes and compliance of elderly patients managed by an ERP protocol with a younger group.

Methods

A review was performed of a prospective database of patients undergoing colorectal resection managed under the ERP protocol between 2005 and 2010. Patients were grouped into <80 years and ≥80 years, and perioperative data were collated. The postoperative outcomes were compared with the goals set out by the ERP protocol.

Results

A total of 688 patients were included, 558 were <80 years (median: 66 years; range: 17–79 years) and 130 were ≥80 years (median: 83 years; range: 80–95 years). Some 96% of operations were planned laparoscopically. Median total length of hospital stay was 6 days (range: 1–108 days) for the <80 year group and 8 days (range: 1–167 days; P 0.363) for the elderly group, with a 30 day readmission rate of 8.6% for the population and no significant differences between groups. The 30 day mortality was 5%, with a significant difference between the two groups (P < 0.0001). Differences in protocol adherence were identified in the discontinuation of intravenous fluids, catheter removal, and early mobilization.

Conclusions

An enhanced recovery program is feasible for colorectal surgery patients ≥80 years of age, with similar compliance as the younger group to some aspects of the protocol and an acceptable readmission rate. Attention to improving compliance in the postoperative phase is necessary, particularly in such high-risk patients, as such improvement may reduce the morbidity and mortality.

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References

  1. Bardram L, Funch-Jensen P, Jensen P et al (1995) Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Lancet 345:763–764

    PubMed  CAS  Article  Google Scholar 

  2. Gatt M, Anderson AD, Reddy RS et al (2005) Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection. Br J Surg 92:1354–1362

    PubMed  CAS  Article  Google Scholar 

  3. Wind J, Polle SW, Fung Kon Jin PH (2006) Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 93:800–809

    PubMed  CAS  Article  Google Scholar 

  4. Bradshaw BG, Liu SS, Thirlby RC (1998) Standardized perioperative care protocols and reduced length of stay after colon surgery. J Am Coll Surg 186:501–506

    PubMed  CAS  Article  Google Scholar 

  5. Basse L, Hjort Jakobsen D, Billesbolle P et al (2000) A clinical pathway to accelerate recovery after colonic resection. Ann Surg 232:51–57

    PubMed  CAS  Article  Google Scholar 

  6. Basse L, Thorbol JE, Lossl K et al (2004) Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum 47:271–277

    PubMed  Article  Google Scholar 

  7. Adamina M, Kehlet H, Tomlinson GA et al (2011) Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery 149:830–840

    PubMed  Article  Google Scholar 

  8. King PM, Blazeby JM, Ewings P et al (2006) Randomised clinical trial comparing laparoscopic and open surgery for colorectal cancer within an enhanced recovery programme. Br J Surg 93:300–308

    PubMed  CAS  Article  Google Scholar 

  9. Vlug MS, Wind J, van der Zaag E et al (2009) Systematic review of laparoscopic vs open colonic surgery within an enhanced recovery programme. Colorectal Dis 11:335–343

    PubMed  CAS  Article  Google Scholar 

  10. Vlug MS, Wind J, Hollman MW et al. (2011) Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg May 18. doi:10.1097/SLA.0b013e31821fdlce

  11. Arora NS, Rochester DF (1982) Respiratory muscle strength and maxiaml voluntary ventilation in undernourished patients. Am Rev Respir Dis 126:5–8

    PubMed  CAS  Google Scholar 

  12. Giner M, Laviano A, Meguid MM et al (1996) In 1995 a correlation between malnutrition and poor outcome in critically ill patients still exists. Nutrition 12:23–29

    PubMed  CAS  Article  Google Scholar 

  13. Hill GL (1994) Impact of nutritional support on the clinical outcome of the surgical patient. Clin Nutr 13:331–340

    PubMed  CAS  Article  Google Scholar 

  14. Fazio V, Tekkis P, Remzi F et al (2004) Assessment of operative risk in colorectal cancer surgery: the Cleveland clinic foundation colorectal cancer model. Dis Colon Rectum 47:2015–2024

    PubMed  Article  Google Scholar 

  15. Colorectal Cancer Collaborative Group (2000) Surgery for colorectal cancer in elderly patients: a systematic review. Lancet 356:968–974

    Article  Google Scholar 

  16. Bardram L, Funch-Jensen P, Kehlet H (2000) Rapid rehabilitation in elderly patients after laparoscopic colonic resection. Br J Surg 87:1540–1545

    PubMed  CAS  Article  Google Scholar 

  17. Hendry PO, Hausel J, Nygren J et al (2009) Determinants of outcome after colorectal resection within an enhanced recovery programme. Br J Surg 96:197–205

    PubMed  CAS  Article  Google Scholar 

  18. Ergina PL, Gold SL, Meakins JL (1993) Perioperative care of the elderly patient. World J Surg 17:192–198. doi:10.1007/BF01658926

    PubMed  CAS  Article  Google Scholar 

  19. Smith JJ, Lee J, Burke C et al (2002) Major colorectal cancer resection should not be denied to the elderly. Eur J Surg Oncol 28:661–666

    PubMed  CAS  Article  Google Scholar 

  20. Chiappa A, Zbar AP, Bertani E et al (2001) Surgical outcomes for colorectal cancer patients including the elderly. Hepatogastroenterology 48:440–444

    PubMed  CAS  Google Scholar 

  21. Gouvas N, Tan E, Windsor A et al (2009) Fast-track vs standard care in colorectal surgery: a meta-analysis update. Int J Colorectal Dis 24:1119–1131

    PubMed  Article  Google Scholar 

  22. Scharfenberg M, Raue W, Junghans T et al (2007) “Fast-track” rehabilitation after colonic surgery in elderly patients—is it feasible? Int J Colorectal Dis 22:1469–1474

    PubMed  CAS  Article  Google Scholar 

  23. Naef M, Kasemodel GK, Mouton WG et al (2010) Outcome of colorectal cancer surgery in the fast-track era with special regard to elderly patients. Int Surg 95:153–159

    PubMed  Google Scholar 

  24. Nascimbeni R, Di Fabio F, Di Betta E et al (2009) The changing impact of age on colorectal cancer surgery. A trend analysis. Colorectal Dis 11:13–18

    PubMed  CAS  Article  Google Scholar 

  25. Dimick JB, Cowan JA Jr, Upchurch GR et al (2003) Hospital volume and surgical outcomes for elderly patients with colorectal cancer in the United States. J Surg Res 114:50–56

    PubMed  Article  Google Scholar 

  26. Seshadri PA, Mamazza J, Schlachta CM et al (2001) Laparoscopic colorectal resection in octogenarians. Surg Endosc 15:802–805

    PubMed  CAS  Article  Google Scholar 

  27. Tekkis PP, Senagore AJ, Delaney CP (2005) Conversion rates in laparosopic colorectal surgery: a predictive model with 1253 patients. Surg Endosc 19:47–54

    PubMed  CAS  Article  Google Scholar 

  28. Cima RR, Hassan I, Poola VP et al (2010) Failure of institutionally derived predictive models of conversion in laparoscopic colorectal surgery to predict conversion outcomes in an independent data set of 998 laparoscopic colorectal procedures. Ann Surg 251:652–658

    PubMed  Article  Google Scholar 

  29. Maessen JM, Dejong CH, Kessels AG, Enhanced Recovery After Surgery (ERAS) Group et al (2008) Length of stay: an inappropriate readout of the success of enhanced recovery programs. World J Surg 32:971–975. doi:10.1007/s00268-007-9404-9

    PubMed  CAS  Article  Google Scholar 

  30. Walter CJ, Collin J, Dumville JC et al (2009) Enhanced recovery in colorectal resections: a systematic review and meta-analysis. Colorectal Dis 11:344–353

    PubMed  CAS  Article  Google Scholar 

  31. Spanjersberg WR, Reurings J, Keus F et al (2011) Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev 16:CD007635

    Google Scholar 

  32. Hemandas AK, Abdelrahman T, Flashman KG et al (2010) Laparoscopic colorectal surgery produces better outcomes for high risk cancer patients compared to open surgery. Ann Surg 252:84–89

    PubMed  Article  Google Scholar 

  33. Andersen J, Hjort-Jakobsen D, Christiansen PS et al (2007) Readmission rates after a planned hospital stay of 2 vs 3 days in fast-track colonic surgery. Br J Surg 94:890–893

    PubMed  CAS  Article  Google Scholar 

  34. Marusch F, Koch A, Schmidt U et al (2005) The impact of the risk factor “age” on the early postoperative results of surgery for colorectal carcinoma and its significance for perioperative management. World J Surg 29:1013–1021. doi:10.1007/s00268-005-7711-6

    PubMed  Article  Google Scholar 

  35. Schwenk W, Gunther N, Wendling P et al (2008) “Fast-track” rehabilitation for elective colonic surgery in Germany—prospective observational data from a multi-centre quality assurance programme. Int J Colorectal Dis 23:93–99

    PubMed  CAS  Article  Google Scholar 

  36. Heriot AG, Tekkis PP, Smith JJ et al (2006) Prediction of postoperative mortality in elderly patients with colorectal cancer. Dis Colon Rectum 49:816–824

    PubMed  Article  Google Scholar 

  37. Maessen J, Dejong CHC, Hausel J et al (2007) A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg 94:224–231

    PubMed  CAS  Article  Google Scholar 

  38. Gustafsson UO, Hausel J, Thorell A, for the Enhanced Recovery After Surgery Study Group et al (2011) Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 146:571–577

    PubMed  Article  Google Scholar 

  39. Shrikhande SV, Shetty GS, Singh K et al (2009) Is early feeding after major gastrointestinal surgery a fashion or an advance? Evidence-based review of literature. J Cancer Res Ther 5:232–239

    PubMed  Article  Google Scholar 

  40. Andersen HK, Lewis SJ, Thomas S (2006) Early enteral nutrition within 24 h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database Syst Rev 18:CD004080

    Google Scholar 

  41. Marderstein EL, Delaney CP (2008) Management of postoperative ileus: focus on alvimopan. Ther Clin Risk Manag 4:965–973

    PubMed  CAS  Google Scholar 

  42. Obokhare ID, Champagne B, Stein SL et al (2011) The effect of alvimopan on recovery after laparoscopic segmental colectomy. Dis Colon Rectum 54:743–746

    PubMed  Article  Google Scholar 

  43. Lees N, Hamilton M, Rhodes A (2009) Clinical review: goal-directed therapy in high risk surgical patients. Crit Care 13:231

    PubMed  Article  Google Scholar 

  44. Rhodes A, Cecconi M, Hamilton M et al (2010) Goal-directed therapy in high-risk surgical patients: a 15-year follow-up study. Intensive Care Med 36:1327–1332

    PubMed  Article  Google Scholar 

  45. Zaouter C, Kaneva P, Carli F (2009) Less urinary tract infection by earlier removal of bladder catheter in surgical patients receiving thoracic epidural analgesia. Reg Anesth Pain Med 34:542–548

    PubMed  Article  Google Scholar 

  46. Zafiropoulos B, Alison JA, McCarren B (2004) Physiological responses to the early mobilisation of the intubated, ventilated abdominal surgery patient. Aust J Physiother 50:95–100

    PubMed  Google Scholar 

  47. Browning L, Denehy L, Scholes RL (2007) The quantity of early upright mobilisation performed following upper abdominal surgery is low: an observational study. Aust J Physiother 53:47–52

    PubMed  Article  Google Scholar 

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Acknowledgments

The authors acknowledge Jane B. Hendricks and Louis Cross for their assistance with collating the database.

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Correspondence to Nikhil Pawa.

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Pawa, N., Cathcart, P.L., Arulampalam, T.H.A. et al. Enhanced Recovery Program following Colorectal Resection in the Elderly Patient. World J Surg 36, 415–423 (2012). https://doi.org/10.1007/s00268-011-1328-8

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Keywords

  • Young Group
  • Epidural Analgesia
  • Elderly Group
  • Readmission Rate
  • Colorectal Resection