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Enhanced Recovery Program for Colorectal Surgery: a Focus on Elderly Patients Over 75 Years Old

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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

An enhanced recovery after surgery (ERAS) protocol can effectively improve perioperative outcomes in surgical patients by reducing complication rates and hospital stay. However, its application in elderly patients has yielded contradictory results. The aim of this study was to evaluate surgical outcomes in a cohort of elderly patients undergoing colorectal resection in our unit before and after the introduction of ERAS.

Methods

From 328 patients undergoing colorectal surgery in our unit over a 2-year period (2015–2016), 114 patients ≥ 75 years of age were selected. The patients were categorized according to perioperative treatment as pre-ERAS and ERAS patients (respectively, 53 vs 61 patients), and the groups were compared for statistical purposes. Outcome measures included length of hospital stay, recovery of bowel functions, oral feeding, postoperative complications, and readmissions. Compliance with the ERAS protocol was also measured.

Results

Groups were homogeneous for all the clinical-surgical variables, with the sole exception of the Charlson index, which was more severe in the ERAS group (p = 0.012). Compared with control patients, ERAS patients reported improved functional recovery (time to first flatus, stool, and oral feeding; p < 0.001). Hospital stay was reduced in ERAS patients overall and by side of resection, excluding rectal procedures. No differences were observed regarding postoperative complications. Of note, an optimal adherence to the protocol was reported, with 79% of items respected.

Conclusions

ERAS can be considered safe in elderly patients undergoing colorectal surgery with a high comorbidity index, providing a reduction in hospital stay and improving short-term postoperative outcomes. Finally, the protocol application was feasible, with a high adherence to the items in this subset of patients.

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References

  1. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183:630–641.

    Article  PubMed  Google Scholar 

  2. Kehlet H, Wilmore DW. Fast-track surgery. Br J Surg 2005; 92:3–4.

    Article  CAS  PubMed  Google Scholar 

  3. Gatt M, Anderson AD, Reddy BS, Hayward-Sampson P, Tring IC, MacFie J. Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection. Br J Surg 2005; 92:1354–1362.

    Article  CAS  PubMed  Google Scholar 

  4. Khoo CK, Vickery CJ, Forsyth N,Vinall NS, Eyre-Brook IA. A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Ann Surg 2007; 245:867–872.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Delaney CP, Zutshi M, Senagore AJ, Remzi FH, Hammel J, Fazio VW. Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Dis Colon Rectum 2003; 46:851–859.

    Article  PubMed  Google Scholar 

  6. Anderson AD, McNaught CE, MacFie J, Tring I, Barker P, Mitchell CJ. Randomized clinical trial of multimodal optimization and standard perioperative surgical care. Br J Surg 2003; 90:1497–1504.

    Article  CAS  PubMed  Google Scholar 

  7. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg 2017; 152:292–298.

    Article  PubMed  Google Scholar 

  8. 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; Enhanced Recovery After Surgery (ERAS) Society, for Perioperative Care; European Society for Clinical Nutrition and Metabolism (ESPEN); International Association for Surgical Metabolism and Nutrition (IASMEN). Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg 2013; 37:259–84.

    Article  CAS  PubMed  Google Scholar 

  9. Pawa N, Cathcart PL, Arulampalam THA, Tutton MG, Motson RW. Enhanced recovery program following colorectal resection in elderly patient. World J Surg 2012; 36:415–423

    Article  PubMed  Google Scholar 

  10. Rumstadt B, Guenther N, Wendling P, Engemann R, Germer CT, Schmid M, Kipfmueller K, Walz MK, Schwenk W. Multimodal perioperative rehabilitation for colonic surgery in the elderly. World J Surg 2009; 33:1757–63.

    Article  CAS  PubMed  Google Scholar 

  11. Gonzalez-Ayora S, Pastor C, Guadalajara H, Ramirez JM, Royo P, Redondo E, Arroyo A, Moya P, Garcia-Olmo D. Enhanced recovery care after colorectal surgery in elderly patients. Compliance and outcomes of a multicenter study from the Spanish working group on ERAS. Int J Colorectal Dis. 2016 Sep;31(9):1625–31

    Article  PubMed  PubMed Central  Google Scholar 

  12. Feroci F, Lenzi E, Baraghini M, Garzi A, Vannucchi A, Cantafio S, Scatizzi M. Fast-track surgery in real life: how patient factors influence outcomes and compliance with an enhanced recovery clinical pathway after colorectal surgery. Surg Laparosc Endosc Percutan Tech 2013; 23:259–65.

    Article  PubMed  Google Scholar 

  13. von Elm E, Altman DG, Egger M Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 2007; 370:1453–1457. http://www.oncoguida.it/html/ente/policlinico_agostino_gemelli_823330.asp

    Article  Google Scholar 

  14. http://www.oncoguida.it/html/ente/policlinico_agostino_gemelli_823330.asp

  15. Beetsa G, Sebag-Montefioreb D, Andritschc E, Arnold D, Beishon M, Crul M, Dekker JW, Delgado Bolton R, Fléjou JF, Grisold W, Henning G, Laghi A, Lovey J, Negrouk A, Pereira P, Roca P, Saarto T, Seufferlein T, Taylor C, Ugolini G, Velde CV, Herck BV, Yared W, Costa A, Naredi P. ECCO Essential Requirements for Quality Cancer Care: ColorectalCancer. A critical review. Critical Reviews in Oncology/Hematology 2017; 110:81–93.

    Article  Google Scholar 

  16. Rinninella E, Persiani R, D'Ugo D, Pennestrì F, Cicchetti A, Di Brino E, Cintoni M, Miggiano GAD, Gasbarrini A, Mele MC. NutriCatt protocol in the Enhanced Recovery After Surgery (ERAS) program for colorectal surgery: The nutritional support improves clinical and cost-effectiveness outcomes. Nutrition 2018;50:74–81.

    Article  PubMed  Google Scholar 

  17. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240:205–213.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods 2007; 39: 175–191

    Article  Google Scholar 

  19. World Health Organisation. Health statistics and information systems, Definition of an older or elderly person. http://www.who.int/healthinfo/survey/ageingdefnolder/en/.

  20. Keller DS, Lawrence JK, Nobel T, Delaney CP. Optimizing cost and short-term outcomes for elderly patients in laparoscopic colonic surgery. Surg Endosc 2013; 27:4463–8.

    Article  PubMed  Google Scholar 

  21. Stewart BT, Stitz RW, Lumley JW. Laparoscopically assisted colorectal surgery in the elderly. Br J Surg 1999; 86:938–41.

    Article  CAS  PubMed  Google Scholar 

  22. Joseph B, Pandit V, Sadoun M, Zangbar B, Fain MJ, Friese RS, , Rhee P. Frailty in surgery. J Trauma Acute Care Surg 2014; 76:1151–6.

    Article  PubMed  Google Scholar 

  23. Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol 1994; 47:1245–51.

    Article  CAS  PubMed  Google Scholar 

  24. Lorenzon L, Costa G, Massa G, Frezza B, Stella F, Balducci G. The impact of frailty syndrome and risk scores on emergency cholecystectomy patients. Surg Today 2017; 47:74–83.

    Article  PubMed  Google Scholar 

  25. Heriot AG, Tekkis PP, Smith JJ , Cohen CR, Montgomery A, Audisio RA, Thompson MR, Stamatakis JD. et al. Prediction of postoperative mortality in elderly patients with colorectal cancer. Dis Colon Rectum 2006; 29:816–824.

    Article  Google Scholar 

  26. Ballesta Lopez C, Cid JA, Poves I, Bettónica C, Villegas L, Memon MA. Laparoscopic surgery in the elderly patient. Surg Endosc 2003; 17:333–7.

    Article  CAS  PubMed  Google Scholar 

  27. Schwandner O, Schiedeck TH, Bruch HP. Advanced age – indication or contraindication for laparoscopic colorectal surgery? Dis Colon Rectum 1999; 42:356–362.

    Article  CAS  PubMed  Google Scholar 

  28. Seshadri PA, Mamazza J, Schlachta CM, Cadeddu MO, Poulin EC. Laparoscopic colorectal resection in octogenarians. Surg Endosc 2001; 15:802–805.

    Article  CAS  PubMed  Google Scholar 

  29. Mutch MG. Laparoscopic colectomy in the elderly: when is too old? Clin Colon Rectal Surg 2006; 19:33–39.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Grailey K, Markar SR, Karthikesalingam A Aboud R, Ziprin P, Faiz O. Laparoscopic versus open colorectal resection in the elderly population. Surg Endosc 2013; 27:19–30.

    Article  Google Scholar 

  31. Schreurs WH, van der Ploeg TJ, Bemelman WA, Houdijk AP. Adherence to enhanced recovery after surgery and length of stay after colonic resection. Colorectal Dis 2013; 15:1019–1025.

    Article  PubMed  Google Scholar 

  32. Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 2011; 146:571–577.

    Article  PubMed  Google Scholar 

  33. Ahmed J, Khan S, Gatt M, Kallam R, MacFie J. Compliance with enhanced recovery programmes in electivecolorectal surgery. Br J Surg 2010; 97:754–8.

    Article  CAS  PubMed  Google Scholar 

  34. Cakir H, van Stijn MF, Lopes Cardozo AM, Langenhorst BL, Schreurs WH, van der Ploeg TJ, Bemelman WA, Houdijk AP. Adherence to Enhanced Recovery After Surgery and length of stay after colonic resection. Colorectal Dis 2013; 15:1019–25.

    Article  CAS  PubMed  Google Scholar 

  35. Bagnall NM, Malietzis G, Kennedy RH, Athanasiou T, Faiz O, Darzi A. A systematic review of enhanced recovery care after colorectal surgery in elderly patients. Colorectal Dis 2014; 16:947–56.

    Article  CAS  PubMed  Google Scholar 

  36. Wang Q, Suo J, Jiang J, Wang C, Zhao YQ, Cao X. Effectiveness of fast-track rehabilitation vs conventional care in laparoscopic colorectal resection for elderly patients: a randomized trial. Colorectal Dis 2012; 14:1009–13.

  37. Jia Y, Jin G, Guo S, Gu B, Jin Z, Gao X, Li Z. Fast-track surgery decreases the incidence of postoperative delirium and other complications in elderly patients with colorectal carcinoma. Langenbecks Arch Surg 2014; 399:77–84.

    Article  PubMed  Google Scholar 

  38. Braga M, Pecorelli N, Scatizzi M, Borghi F, Missana G, Radrizzani D, On behalf of the PeriOperative Italian SocietyEnhanced Recovery Program in High-Risk Patients Undergoing Colorectal Surgery: Results from the PeriOperative Italian Society Registry. World J Surg 2017; 41:860–867.

    Article  PubMed  Google Scholar 

  39. Baek SJ, Kim SH, Kim SY, Shin JW, Kim J. The safety of a “fast-track” program after laparoscopic colorectal surgery is comparable in older patients as in younger patients. Surg Endosc 2013; 27:1225–1232

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Dipartimento Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, UOC di Chirurgia Generale, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy

    Maria Carmen Lirosi, Flavio Tirelli, Alberto Biondi, Cristina Larotonda, Laura Lorenzon, Domenico D’Ugo & Roberto Persiani

  2. Dipartimento Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, UOC di Nutrizione Clinica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Roma, Italy

    Maria Cristina Mele

  3. Università Cattolica del Sacro Cuore, Milano, Italy

    Maria Cristina Mele, Domenico D’Ugo, Antonio Gasbarrini & Roberto Persiani

  4. Dipartimento Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, UOC di Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy

    Antonio Gasbarrini

Authors
  1. Maria Carmen Lirosi
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  2. Flavio Tirelli
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  3. Alberto Biondi
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  4. Maria Cristina Mele
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  5. Cristina Larotonda
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  6. Laura Lorenzon
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  7. Domenico D’Ugo
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  8. Antonio Gasbarrini
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  9. Roberto Persiani
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Contributions

1. Conception and design: all authors.

2. Provision of study materials or patients: Maria Carmen Lirosi, Cristina Larotonda, and Flavio Tirelli.

3. Collection and assembly of data: Maria Carmen Lirosi, Cristina Larotonda, Flavio Tirelli, and Laura Lorenzon.

4. Data analysis and interpretation: Maria Carmen Lirosi, Cristina Larotonda, Flavio Tirelli, and Laura Lorenzon.

5. Manuscript writing: Maria Carmen Lirosi, Cristina Larotonda, Flavio Tirelli, Laura Lorenzon, and Alberto Biondi.

6. Final approval of the manuscript: all authors.

Corresponding author

Correspondence to Flavio Tirelli.

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The authors declare that they have no conflict of interest.

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Lirosi, M.C., Tirelli, F., Biondi, A. et al. Enhanced Recovery Program for Colorectal Surgery: a Focus on Elderly Patients Over 75 Years Old. J Gastrointest Surg 23, 587–594 (2019). https://doi.org/10.1007/s11605-018-3943-2

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  • DOI: https://doi.org/10.1007/s11605-018-3943-2

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