Abstract
Background
Enhanced Recovery After Surgery (E.R.A.S.) programs are now widely accepted in colonic laparoscopic resections because of faster recovery and less perioperative complications. The aim of this study was to assess safety and feasibility of discharging patients operated on by laparoscopic colectomy on postoperative day 2, so long as the first flatus has passed and in the absence of complication-related symptoms.
Methods
This study was a non-inferiority, open-label, single-center, prospective, randomized study comparing “Ultra” to Classic E.R.A.S. with discharge on POD 2 and 4, respectively. Seven hundred and sixty-five patients with resectable non-metastatic colonic cancer were analyzed: 384 patients were assigned to “Ultra” E.R.A.S. and 381 to Classic E.R.A.S. Primary end-point was mortality; secondary end-points were morbidity, readmission and reoperation rate. Limitations are: it is a single-center experience; it is not double-blind, with the intrinsic risk of intentional or unconscious bias; exclusion criteria because of “non-compliance” may be considered arbitrary.
Results
Mortality was 0.89 % in “Ultra” E.R.A.S. group and 0.59 % in Classic E.R.A.S. (p = 0.571). Morbidity was 34.1 % for “Ultra” E.R.A.S. arm and 35.4 % for Classic E.R.A.S. (p = 0.753). Readmissions were 5.6 % for “Ultra” E.R.A.S. and 5.9 % for Classic E.R.A.S. (p = 0.359). Reoperation rate was 3.8 % for “Ultra” ERAS and 4.7 % for Classic E.R.A.S. (p = 0.713). Multivariate regression analyses using Cox’s proportional hazard model showed that mortality (primary end-point), morbidity, reoperation and readmission (secondary end-points) were not significantly influenced by the two different perioperative regimens; conversely, the global cost of “Ultra” E.R.A.S. regimen was more economically effective.
Conclusion
“Ultra” E.R.A.S. showed to be safe, actual and effective; discharge on postoperative day 2 after the first flatus passage, in the absence of complication-related symptoms, should be actively considered in a modern, multidisciplinary, multimodal laparoscopic management of colonic cancer.
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References
Kehlet H (1997) Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 78(5):606–617
Lovely JK, Maxson PM, Jacob AK, Cima RR, Horlocker TT, Hebl JR, Harmsen WS, Huebner M, Larson DW (2012) Casematched series of enhanced versus standard recovery pathway in minimally invasive colorectal surgery. Br J Surg 99:120–126
Ramírez JM, Blasco JA, Roig JV, Maeso-Martínez S, Casal JE, Esteban F, Lic DC (2011) Spanish working group on fast track surgery. Enhanced recovery in colorectal surgery: a multicentre study. BMC Surg. 11:9
Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, MacFie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobom DN, Fearon K, Ljungqvist O (2012) Guidelines for perioperative care in elective colonic surgery: enhanced Recovery After Surgery (ERAS) Society recommendations. Clin. Nutr. 31:783–800
Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, MacFie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O (2013) Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS) society recommendations. World J Surg 37:259–284
Wilmore DW (2002) From Cuthbertson to fast-track surgery: 70 years of progress in reducing stress in surgical patients. Ann Surg 236:643–648
Kehlet H (2006) Surgical stress and postoperative outcome—from here to where? Reg Anesth Pain Med 31:47–52
Svanfeldt M, Thorell A, Hausel J et al (2007) Randomized clinical trial of the effect of preoperative oral carbohydrate treatment on postoperative wholebody protein and glucose kinetics. Br J Surg 94:1342–1350
Grocott MP, Mythen MG, Gan TJ (2005) Perioperative fluid management and clinical outcomes in adults. Anesth Analg 100:1093–1106
Holte K, Kehlet H (2006) Fluid therapy and surgical outcomes in elective surgery: a need for reassessment in fast-track surgery. J Am Coll Surg 202:971–989
Wong PF, Kumar S, Bohra A et al (2007) Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery. Br J Surg 94:421–426
Holte K, Kehlet H (2002) Epidural anaesthesia and analgesia—effects on surgical stress responses and implications for postoperative nutrition. Clin Nutr 21:199–206
Kehlet H (2005) Preventive measures to minimize or avoid postoperative ileus. Semin Colon Rectal Surg 16:203–206
Sylla P, Kirman I, Whelan RL (2005) Immunological advantages of advanced laparoscopy. Surg Clin North Am 85:1–18 (VII)
Kehlet H, Kennedy RH (2006) Laparoscopic colonic surgery—mission accomplished or work in progress? Colorectal Dis 8:514–517
Basse L, Jakobsen DH, Bardram L et al (2005) Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study. Ann Surg 241:416–423
Holte K, Kehlet H (2002) Perioperative single-dose glucocorticoid administration: pathophysiologic effects and clinical implications. J Am Coll Surg 195:694–712
Gan TJ, Meyer TA, Apfel CC et al (2007) Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and vomiting. Anesth Analg 105:1615–1628
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 (4):CD004080. doi:10.1002/14651858.CD004080.pub2
Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C et al (2009) Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 144(10):961–969
Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The Clavien–Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187–196. doi:10.1097/SLA.0b013e3181b13ca2
Wind J, Polle SW, Fung Kon Jin PH, Dejong CH, von Meyenfeldt MF, Ubbink DT, Gouma DJ, Bemelman WA (2006) Laparoscopy and/or fast track multimodal management versus Standard Care (LAFA) Study Group; Enhanced Recovery after Surgery (ERAS) Group. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 93:800–809
Walter CJ, Collin J, Dumville JC, Drew PJ, Monson JR (2009) Enhanced recovery in colorectal resections: a systematic review and meta-analysis. Colorectal Dis 11:344–353
Gouvas N, Tan E, Windsor A, Xynos E, Tekkis PP (2009) Fast-track vs standard care in colorectal surgery: a meta-analysis update. Int J Colorectal Dis 24:1119–1131
Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN (2010) The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 29:434–440
Kehlet H, Wilmore DW (2008) Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 248:189–198
Authors contribution
Dr. Gianluca Garulli and Dr. Luca Maria Siani contributed to concept and study design; acquisition of data; analysis and interpretation; drafting the article and critical revision; final approval of the version to be published. Dr. Andrea Lucchi contributed to acquisition of data; analysis and interpretation; drafting the article and critical revision; final approval of the version to be published. Dr. Pierluigi Berti and Carlo Gabbianelli helped with acquisition of data; analysis and interpretation; drafting the article and critical revision; final approval of the version to be published.
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The authors Gianluca Garulli, Andrea Lucchi, Pierluigi Berti, Carlo Gabbianelli and Luca Maria Siani declare no conflict of interest or any financial support to disclose.
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Garulli, G., Lucchi, A., Berti, P. et al. “Ultra” E.R.A.S. in laparoscopic colectomy for cancer: discharge after the first flatus? A prospective, randomized trial. Surg Endosc 31, 1806–1813 (2017). https://doi.org/10.1007/s00464-016-5177-2
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DOI: https://doi.org/10.1007/s00464-016-5177-2