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Over the past decade, evolution of perioperative care in the field of colonic surgery has seen the development of Enhanced Recovery After Surgery (ERAS) or ‘fast-track' programmes.1–3These programmes incorporate a multidisciplinary approach to perioperative care and combine evidence-based practices into a multimodal perioperative care pathway that aims to reduce surgical stress and accelerate postoperative recovery with decreased hospital stay, reduced morbidity and shortened convalescence.The development of ERAS programmes has focused on optimising individual components of perioperative care including patient education, anaesthesia, fluid management, analgesia, nutrition and ambulation.4,5 This has led to changes in many traditional aspects of surgical care, such as preoperative bowel preparation, the use of nasogastric tubes, placement of drains, enforced bed rest, and graduated diets which have been shown to be unnecessary or even harmful.6In December 2005, the senior author (AGH) initiated an ERAS programme for colonic surgery at the Manukau Surgery Centre (MSC), an elective surgical unit of Counties Manukau District Health Board (CMDHB) in Auckland, New Zealand.7,8 This programme incorporated strategies of perioperative care based on ERAS principles and used a coordinated approach in conjunction with surgical, anaesthetic and nursing staff.This programme has since become the standard of care for patients undergoing elective colonic resection at CMDHB. This paper reviews the senior author's experience of elective colectomy conducted within the ERAS programme and reports operative and clinical outcomes.Methods Patients—Using a prospectively maintained database of patients undergoing surgery within the fast-track programme, we reviewed consecutive patients who underwent elective colectomy by the senior author within the ERAS programme at MSC since it was established in December 2005. Table 1. Components of Enhanced Recovery After Surgery (ERAS) programme Preoperative Preoperative assessment in a dedicated outpatient session Education with written information given and specific daily milestones discussed Preoperative discharge planning and social situation explored Nutritional assessment Careful medical assessment and optimisation Ward visit/meet nursing staff Patients admitted to hospital on morning of surgery Avoidance of prolonged preoperative fasting – nil by mouth for only 2 hours preinduction Carbohydrate loading – two 200mL PreOp® drinks on the morning of surgery Avoidance of mechanical bowel prep Intraoperative Epidural anaesthesia – mid or low thoracic Short acting anaesthetic agents Prevention of hypothermia, active warming blanket Conservative fluid regimen – 1500mL crystalloid and 500mL colloid unless otherwise indicated as per ERAS anaesthetic protocol Prophylactic antiemetics at induction Intravenous dexamethasone (8mg) at induction10 Transverse incision for right-sided open cases if appropriate; selective use of laparoscopy for left-sided cases Avoidance of drains/nasogastric tubes Postoperative Structured nursing pathway All intravenous fluid stopped when patient arrives on ward Vasopressors in preference to intravenous fluids to treat epidural-related hypotension Early oral feeding with supplementation – started on day of operation Prophylactic antiemetics Opioid sparing analgesia/nonsteroidal anti-inflammatory drugs Early removal of urinary catheter – on postoperative day 1 Timed removal of epidural – on postoperative day 2 Early mobilisation with nursing and/or physiotherapy input Discharge criteria defined: – Tolerating adequate oral intake and passing flatus – Adequate analgesia on oral medication – Adequate and safe mobility – Follow-up in surgical outpatient clinic within 7 days of discharge Exclusion criteria for this ERAS programme were patients with serious comorbidities (American Society of Anesthesiologists [ASA] score 4 or 5), those needing a stoma, rectal lesions (defined as <15cm from the anal verge), and those unable to participate in the preoperative education and goal setting components of ERAS because of cognitive impairment or a significant language barrier. Perioperative care—Patients managed within the ERAS programme received structured perioperative care as outlined in Table 1.8,9 This focused on better patient education, optimisation of preoperative status, avoidance of unnecessary physiological stressors, early oral feeding and early mobilisation. Discharge planning was discussed with patients preoperatively with establishment of daily milestones. Patients were planned for discharge on postoperative day 3 once discharge criteria were met. Outcomes—Age, gender, ASA score, Colorectal Physiological and Operative Severity score for the enUmeration of Mortality and morbidity (Cr-POSSUM),11 indication for surgery, stage of disease, operation type and technique were recorded for all patients. Postoperative complications up to 30 days after surgery were recorded using predefined criteria and graded using the Clavien-Dindo classification system.12,13 In patients with multiple complications, the highest complication grade is reported in the final analysis. The day of discharge was recorded as well as readmissions, defined as return to hospital within 30 days postoperatively requiring a hospital stay of 24 hours or more. Total hospital stay was calculated based on day stay of index admission plus hospital stay on readmission. Results are reported as mean (standard deviation) or median (range) as appropriate. Results Between December 2005 and March 2012, 100 patients underwent elective colectomy by the senior author at MSC within the ERAS programme. A further 78 patients undergoing colonic resection over the same time period were excluded from the ERAS programme due to the formation of a stoma, significant co-morbidities requiring monitoring in an intensive care unit postoperatively, or emergency resection. Baseline characteristics for the included patients are shown in Table 2. The median age of patients was 70 years (range 16–92) with 52 patients being female. Most patients had an ASA score of 2 (55 patients) and the overall median Cr-POSSUM score was 17 (range 13–25). The most common indication for surgery was malignancy (81 cases) with the majority of patients having stage II (39 cases) or stage III (24 cases) disease. Fifty-two patients underwent right-sided colectomy, 45 patients had a left-sided colectomy and 3 patients underwent subtotal colectomy. Seventeen cases were hand-assisted laparoscopic left/sigmoid colectomies while the remainder of operations were performed open. The median day of discharge was 3 days (range 2–60) and 75 patients were discharged by day 5 after surgery (Table 3). Median total hospital stay was 4 days (range 2–60) which included 21 readmissions. Table 4 summarises reasons for readmission, day of readmission and their duration. Twelve readmissions were after postoperative day 8 and the median length of stay during readmission was 4 days (range 1–28) with 16 patients readmitted for 7 days or less. Fifty-three patients developed a complication within 30 days postoperatively with 45 patients having minor (grade I-II) complications and 8 patients having major (grade III-V) complications (Table 3). Four patients had an anastomotic leak which required reoperation. The rate of complications in patients discharged by day 3 and day 5 was 44% and 41%, respectively. Table 2. Patient characteristics Variables n=100 Age, median [range] 70 [16–92] Gender Male Female 48 52 ASA score I II III IV Cr-POSSUM, median [range] 16 55 28 1 17 [13–25] Indication for surgery Malignancy Diverticular disease Non-malignant polyp Other* 81 13 4 2 AJCC stage^ I II III IV 7 39 24 6 Operation Right-sided colectomy Left-sided colectomy Subtotal colectomy 52 45 3 Surgical technique Open Hand-assisted laparoscopic 83 17 Operation time (minutes), mean [SD] 103 [32] AJCC, American Joint Committee on Cancer; ASA, American Society of Anesthesiologists; Cr-POSSUM, Colorectal Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity; SD, standard deviation. * Inflammatory appendiceal mass (n=1), mucinous neoplasm of appendix (n=1) with no malignancy on final histology ^ Five patients for whom the indication for surgery was malignancy were not able to be staged according the AJCC colorectal cancer staging system for the following reasons: 2 patients with malignant polyps resected on colonoscopy had no residual malignancy on histology after surgery, 1 patient had a right hemicolectomy for carcinoid tumour of the appendix with the final histology showing no residual carcinoid, 1 patient had metastatic melanoma to the caecum and small bowel, and 1 patient had pseudomyxoma peritonei following a right hemicolectomy for mucinous adenocarcinoma of the appendix. Table 3. Hospital stay and postoperative complications Variables n=100 Discharge day, median [IQR] 3 [3–6] Total Hospital stay, median [IQR] 4 [3–7] Readmission 21 Complication Yes No 53 47 Complication grade* I II III IV V 3 42 3 5 0 Minor complication (Grade I–II) 45 Major complication (Grade III–V) 8 Complication aetiology Wound Urinary tract infection Urinary retention Ileus Anastomotic leak Abdominal/pelvic collection Cardiorespiratory Other† 17 7 3 4 4 1 10 7 IQR, interquartile range * Complication grade definitions:12,13 Grade I: any deviation from the normal postoperative course without the need for pharmacologic treatment or surgical, endoscopic, and radiological interventions. Grade II: requiring pharmacologic treatment with drugs other than such allowed for grade I complications. Blood transfusions and total parenteral nutrition are also included. Grade III: requiring surgical, endoscopic, or radiological intervention. Grade IV: life-threatening complication (including central nervous system complications) requiring intermediate care/intensive care unit-management. Grade V: death of a patient. † Complications classified as other: stapleline bleed (n=2), constipation, abdominal pain, bladder leak, urinoma and deconditioning. Table 4. Readmissions Reason for readmission Day of readmission (day after surgery) Duration of readmission (days) Wound infection/dehiscence (n=6) 6 6 6 9 11 30 3 20 28 2 4 6 Abdominal pain (n=2) 4 7 2 6 Constipation (n=2) 10 21 3 2 Deconditioning (n=2) 15 24 8 7 Stress ulcers in oesophagus and duodenum 4 4 Ileus 5 3 Anastomotic leak 5 4 Diarrhoea 6 3 Pleural effusion/empyema 8 21 Small bowel obstruction 9

Summary

Abstract

Aim

In 2005, the senior author (AGH) initiated an Enhanced Recovery After Surgery (ERAS) or fast-track programme for elective colonic surgery at the Manukau Surgery Centre aimed at improving perioperative care. We reviewed the senior authors experience of elective colectomy conducted within the ERAS programme and evaluated clinical outcomes.

Method

Using a prospectively maintained database, consecutive patients who underwent elective colonic resection by the senior author within the ERAS programme at the Manukau Surgery Centre between December 2005 and March 2012 were reviewed. Demographic and operative data were recorded and clinical outcomes including complications, hospital stay and readmissions were evaluated for 30 days postoperatively.

Results

100 consecutive patients were reviewed. The median age of patients was 70 years (range: 16-92) and the most common indication for surgery was malignancy (81 cases). Right-sided colectomy was performed in 52 cases while 45 patients had a left-sided colectomy and 3 patients underwent subtotal colectomy. The median day to discharge was 3 days while total hospital stay was 4 days which incorporated 21 readmissions for mostly minor complications. Major complications occurred in only 8 patients and included 4 anastomotic leaks.

Conclusion

In one surgeons experience, elective colectomy performed within an optimised perioperative care environment achieves shorter hospital stay with a low rate of major complications.

Author Information

Primal P Singh, Research Fellow, Department of Surgery, South Auckland Clinical School, Middlemore Hospital, University of Auckland; Andrew G Hill, Professor and Colorectal Surgeon, Head of South Auckland Clinical School, Department of Surgery, Middlemore Hospital, University of Auckland

Acknowledgements

Primal Singh is a recipient of the Auckland Medical Research Foundation Ruth Spencer Medical Research Fellowship.

Correspondence

Dr Primal P Singh, Department of Surgery, South Auckland Clinical School, University of Auckland, Private Bag 93311, Middlemore Hospital, Otahuhu, Auckland 1640, New Zealand. Fax: +64 9 276 0066

Correspondence Email

dr.parrysingh@gmail.com

Competing Interests

Nil.

Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008;248:189-98.Soop M, Nygren J, Ljungqvist O. Optimizing perioperative management of patients undergoing colorectal surgery: what is new? Current opinion in critical care. 2006;12:166-70.Zargar-Shoshtari K, Hill AG. Optimization of perioperative care for colonic surgery: a review of the evidence. ANZ J Surg. 2008;78:13-23.Lassen K, Soop M, Nygren J, et al. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg. 2009;144:961-9.Fearon KC, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005;24:466-77.Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183:630-41.Vather R, Shoshtari KZ, Ducat C, Hill AG. Towards a 3-day hospital stay for right hemicolectomy. N Z Med J. 2006;119:U1826.Zargar-Shoshtari K, Connolly AB, Israel LH, Hill AG. Fast-track surgery may reduce complications following major colonic surgery. Dis Colon Rectum. 2008;51:1633-40.Kahokehr AA, Sammour T, Sahakian V, et al. Influences on length of stay in an enhanced recovery programme after colonic surgery. Colorectal Dis. 2011;13:594-9.Zargar-Shoshtari K, Sammour T, Kahokehr A, et al. Randomized clinical trial of the effect of glucocorticoids on peritoneal inflammation and postoperative recovery after colectomy. Br J Surg. 2009;96:1253-61.Tekkis PP, Prytherch DR, Kocher HM, et al. Development of a dedicated risk-adjustment scoring system for colorectal surgery (colorectal POSSUM). Br J Surg. 2004;91:1174-82.Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187-96.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;240:205-13.Vather R, Zargar-Shoshtari K, Adegbola S, Hill AG. Comparison of the possum, P-POSSUM and Cr-POSSUM scoring systems as predictors of postoperative mortality in patients undergoing major colorectal surgery. ANZ J Surg. 2006;76:812-6.Delaney CP, Fazio VW, Senagore AJ, et al. 'Fast track' postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg. 2001;88:1533-8.Kahokehr A, Sammour T, Shoshtari KZ, et al. Intraperitoneal local anesthetic improves recovery after colon resection: a double-blinded randomized controlled trial. Ann Surg. 2011;254:28-38.Singh PP, Srinivasa S, Bambarawana S, et al. Perioperative use of statins in elective colectomy. Dis Colon Rectum. 2012;55:205-10.Andersen J, Hjort-Jakobsen D, Christiansen PS, Kehlet H. Readmission rates after a planned hospital stay of 2 versus 3 days in fast-track colonic surgery. Br J Surg. 2007;94:890-3.Basse L, Jakobsen DH, Bardram L, et al. Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study. Ann Surg. 2005;241:416-23.Basse L, Thorbol JE, Lossl K, Kehlet H. Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum. 2004;47:271-7.Kariv Y, Delaney CP, Senagore AJ, et al. Clinical outcomes and cost analysis of a \"fast track\" postoperative care pathway for ileal pouch-anal anastomosis: a case control study. Dis Colon Rectum. 2007;50:137-46.Sammour T, Zargar-Shoshtari K, Bhat A, et al. A programme of Enhanced Recovery After Surgery (ERAS) is a cost-effective intervention in elective colonic surgery. N Z Med J. 2010;123:61-70.

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Over the past decade, evolution of perioperative care in the field of colonic surgery has seen the development of Enhanced Recovery After Surgery (ERAS) or ‘fast-track' programmes.1–3These programmes incorporate a multidisciplinary approach to perioperative care and combine evidence-based practices into a multimodal perioperative care pathway that aims to reduce surgical stress and accelerate postoperative recovery with decreased hospital stay, reduced morbidity and shortened convalescence.The development of ERAS programmes has focused on optimising individual components of perioperative care including patient education, anaesthesia, fluid management, analgesia, nutrition and ambulation.4,5 This has led to changes in many traditional aspects of surgical care, such as preoperative bowel preparation, the use of nasogastric tubes, placement of drains, enforced bed rest, and graduated diets which have been shown to be unnecessary or even harmful.6In December 2005, the senior author (AGH) initiated an ERAS programme for colonic surgery at the Manukau Surgery Centre (MSC), an elective surgical unit of Counties Manukau District Health Board (CMDHB) in Auckland, New Zealand.7,8 This programme incorporated strategies of perioperative care based on ERAS principles and used a coordinated approach in conjunction with surgical, anaesthetic and nursing staff.This programme has since become the standard of care for patients undergoing elective colonic resection at CMDHB. This paper reviews the senior author's experience of elective colectomy conducted within the ERAS programme and reports operative and clinical outcomes.Methods Patients—Using a prospectively maintained database of patients undergoing surgery within the fast-track programme, we reviewed consecutive patients who underwent elective colectomy by the senior author within the ERAS programme at MSC since it was established in December 2005. Table 1. Components of Enhanced Recovery After Surgery (ERAS) programme Preoperative Preoperative assessment in a dedicated outpatient session Education with written information given and specific daily milestones discussed Preoperative discharge planning and social situation explored Nutritional assessment Careful medical assessment and optimisation Ward visit/meet nursing staff Patients admitted to hospital on morning of surgery Avoidance of prolonged preoperative fasting – nil by mouth for only 2 hours preinduction Carbohydrate loading – two 200mL PreOp® drinks on the morning of surgery Avoidance of mechanical bowel prep Intraoperative Epidural anaesthesia – mid or low thoracic Short acting anaesthetic agents Prevention of hypothermia, active warming blanket Conservative fluid regimen – 1500mL crystalloid and 500mL colloid unless otherwise indicated as per ERAS anaesthetic protocol Prophylactic antiemetics at induction Intravenous dexamethasone (8mg) at induction10 Transverse incision for right-sided open cases if appropriate; selective use of laparoscopy for left-sided cases Avoidance of drains/nasogastric tubes Postoperative Structured nursing pathway All intravenous fluid stopped when patient arrives on ward Vasopressors in preference to intravenous fluids to treat epidural-related hypotension Early oral feeding with supplementation – started on day of operation Prophylactic antiemetics Opioid sparing analgesia/nonsteroidal anti-inflammatory drugs Early removal of urinary catheter – on postoperative day 1 Timed removal of epidural – on postoperative day 2 Early mobilisation with nursing and/or physiotherapy input Discharge criteria defined: – Tolerating adequate oral intake and passing flatus – Adequate analgesia on oral medication – Adequate and safe mobility – Follow-up in surgical outpatient clinic within 7 days of discharge Exclusion criteria for this ERAS programme were patients with serious comorbidities (American Society of Anesthesiologists [ASA] score 4 or 5), those needing a stoma, rectal lesions (defined as <15cm from the anal verge), and those unable to participate in the preoperative education and goal setting components of ERAS because of cognitive impairment or a significant language barrier. Perioperative care—Patients managed within the ERAS programme received structured perioperative care as outlined in Table 1.8,9 This focused on better patient education, optimisation of preoperative status, avoidance of unnecessary physiological stressors, early oral feeding and early mobilisation. Discharge planning was discussed with patients preoperatively with establishment of daily milestones. Patients were planned for discharge on postoperative day 3 once discharge criteria were met. Outcomes—Age, gender, ASA score, Colorectal Physiological and Operative Severity score for the enUmeration of Mortality and morbidity (Cr-POSSUM),11 indication for surgery, stage of disease, operation type and technique were recorded for all patients. Postoperative complications up to 30 days after surgery were recorded using predefined criteria and graded using the Clavien-Dindo classification system.12,13 In patients with multiple complications, the highest complication grade is reported in the final analysis. The day of discharge was recorded as well as readmissions, defined as return to hospital within 30 days postoperatively requiring a hospital stay of 24 hours or more. Total hospital stay was calculated based on day stay of index admission plus hospital stay on readmission. Results are reported as mean (standard deviation) or median (range) as appropriate. Results Between December 2005 and March 2012, 100 patients underwent elective colectomy by the senior author at MSC within the ERAS programme. A further 78 patients undergoing colonic resection over the same time period were excluded from the ERAS programme due to the formation of a stoma, significant co-morbidities requiring monitoring in an intensive care unit postoperatively, or emergency resection. Baseline characteristics for the included patients are shown in Table 2. The median age of patients was 70 years (range 16–92) with 52 patients being female. Most patients had an ASA score of 2 (55 patients) and the overall median Cr-POSSUM score was 17 (range 13–25). The most common indication for surgery was malignancy (81 cases) with the majority of patients having stage II (39 cases) or stage III (24 cases) disease. Fifty-two patients underwent right-sided colectomy, 45 patients had a left-sided colectomy and 3 patients underwent subtotal colectomy. Seventeen cases were hand-assisted laparoscopic left/sigmoid colectomies while the remainder of operations were performed open. The median day of discharge was 3 days (range 2–60) and 75 patients were discharged by day 5 after surgery (Table 3). Median total hospital stay was 4 days (range 2–60) which included 21 readmissions. Table 4 summarises reasons for readmission, day of readmission and their duration. Twelve readmissions were after postoperative day 8 and the median length of stay during readmission was 4 days (range 1–28) with 16 patients readmitted for 7 days or less. Fifty-three patients developed a complication within 30 days postoperatively with 45 patients having minor (grade I-II) complications and 8 patients having major (grade III-V) complications (Table 3). Four patients had an anastomotic leak which required reoperation. The rate of complications in patients discharged by day 3 and day 5 was 44% and 41%, respectively. Table 2. Patient characteristics Variables n=100 Age, median [range] 70 [16–92] Gender Male Female 48 52 ASA score I II III IV Cr-POSSUM, median [range] 16 55 28 1 17 [13–25] Indication for surgery Malignancy Diverticular disease Non-malignant polyp Other* 81 13 4 2 AJCC stage^ I II III IV 7 39 24 6 Operation Right-sided colectomy Left-sided colectomy Subtotal colectomy 52 45 3 Surgical technique Open Hand-assisted laparoscopic 83 17 Operation time (minutes), mean [SD] 103 [32] AJCC, American Joint Committee on Cancer; ASA, American Society of Anesthesiologists; Cr-POSSUM, Colorectal Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity; SD, standard deviation. * Inflammatory appendiceal mass (n=1), mucinous neoplasm of appendix (n=1) with no malignancy on final histology ^ Five patients for whom the indication for surgery was malignancy were not able to be staged according the AJCC colorectal cancer staging system for the following reasons: 2 patients with malignant polyps resected on colonoscopy had no residual malignancy on histology after surgery, 1 patient had a right hemicolectomy for carcinoid tumour of the appendix with the final histology showing no residual carcinoid, 1 patient had metastatic melanoma to the caecum and small bowel, and 1 patient had pseudomyxoma peritonei following a right hemicolectomy for mucinous adenocarcinoma of the appendix. Table 3. Hospital stay and postoperative complications Variables n=100 Discharge day, median [IQR] 3 [3–6] Total Hospital stay, median [IQR] 4 [3–7] Readmission 21 Complication Yes No 53 47 Complication grade* I II III IV V 3 42 3 5 0 Minor complication (Grade I–II) 45 Major complication (Grade III–V) 8 Complication aetiology Wound Urinary tract infection Urinary retention Ileus Anastomotic leak Abdominal/pelvic collection Cardiorespiratory Other† 17 7 3 4 4 1 10 7 IQR, interquartile range * Complication grade definitions:12,13 Grade I: any deviation from the normal postoperative course without the need for pharmacologic treatment or surgical, endoscopic, and radiological interventions. Grade II: requiring pharmacologic treatment with drugs other than such allowed for grade I complications. Blood transfusions and total parenteral nutrition are also included. Grade III: requiring surgical, endoscopic, or radiological intervention. Grade IV: life-threatening complication (including central nervous system complications) requiring intermediate care/intensive care unit-management. Grade V: death of a patient. † Complications classified as other: stapleline bleed (n=2), constipation, abdominal pain, bladder leak, urinoma and deconditioning. Table 4. Readmissions Reason for readmission Day of readmission (day after surgery) Duration of readmission (days) Wound infection/dehiscence (n=6) 6 6 6 9 11 30 3 20 28 2 4 6 Abdominal pain (n=2) 4 7 2 6 Constipation (n=2) 10 21 3 2 Deconditioning (n=2) 15 24 8 7 Stress ulcers in oesophagus and duodenum 4 4 Ileus 5 3 Anastomotic leak 5 4 Diarrhoea 6 3 Pleural effusion/empyema 8 21 Small bowel obstruction 9

Summary

Abstract

Aim

In 2005, the senior author (AGH) initiated an Enhanced Recovery After Surgery (ERAS) or fast-track programme for elective colonic surgery at the Manukau Surgery Centre aimed at improving perioperative care. We reviewed the senior authors experience of elective colectomy conducted within the ERAS programme and evaluated clinical outcomes.

Method

Using a prospectively maintained database, consecutive patients who underwent elective colonic resection by the senior author within the ERAS programme at the Manukau Surgery Centre between December 2005 and March 2012 were reviewed. Demographic and operative data were recorded and clinical outcomes including complications, hospital stay and readmissions were evaluated for 30 days postoperatively.

Results

100 consecutive patients were reviewed. The median age of patients was 70 years (range: 16-92) and the most common indication for surgery was malignancy (81 cases). Right-sided colectomy was performed in 52 cases while 45 patients had a left-sided colectomy and 3 patients underwent subtotal colectomy. The median day to discharge was 3 days while total hospital stay was 4 days which incorporated 21 readmissions for mostly minor complications. Major complications occurred in only 8 patients and included 4 anastomotic leaks.

Conclusion

In one surgeons experience, elective colectomy performed within an optimised perioperative care environment achieves shorter hospital stay with a low rate of major complications.

Author Information

Primal P Singh, Research Fellow, Department of Surgery, South Auckland Clinical School, Middlemore Hospital, University of Auckland; Andrew G Hill, Professor and Colorectal Surgeon, Head of South Auckland Clinical School, Department of Surgery, Middlemore Hospital, University of Auckland

Acknowledgements

Primal Singh is a recipient of the Auckland Medical Research Foundation Ruth Spencer Medical Research Fellowship.

Correspondence

Dr Primal P Singh, Department of Surgery, South Auckland Clinical School, University of Auckland, Private Bag 93311, Middlemore Hospital, Otahuhu, Auckland 1640, New Zealand. Fax: +64 9 276 0066

Correspondence Email

dr.parrysingh@gmail.com

Competing Interests

Nil.

Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008;248:189-98.Soop M, Nygren J, Ljungqvist O. Optimizing perioperative management of patients undergoing colorectal surgery: what is new? Current opinion in critical care. 2006;12:166-70.Zargar-Shoshtari K, Hill AG. Optimization of perioperative care for colonic surgery: a review of the evidence. ANZ J Surg. 2008;78:13-23.Lassen K, Soop M, Nygren J, et al. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg. 2009;144:961-9.Fearon KC, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005;24:466-77.Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183:630-41.Vather R, Shoshtari KZ, Ducat C, Hill AG. Towards a 3-day hospital stay for right hemicolectomy. N Z Med J. 2006;119:U1826.Zargar-Shoshtari K, Connolly AB, Israel LH, Hill AG. Fast-track surgery may reduce complications following major colonic surgery. Dis Colon Rectum. 2008;51:1633-40.Kahokehr AA, Sammour T, Sahakian V, et al. Influences on length of stay in an enhanced recovery programme after colonic surgery. Colorectal Dis. 2011;13:594-9.Zargar-Shoshtari K, Sammour T, Kahokehr A, et al. Randomized clinical trial of the effect of glucocorticoids on peritoneal inflammation and postoperative recovery after colectomy. Br J Surg. 2009;96:1253-61.Tekkis PP, Prytherch DR, Kocher HM, et al. Development of a dedicated risk-adjustment scoring system for colorectal surgery (colorectal POSSUM). Br J Surg. 2004;91:1174-82.Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187-96.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;240:205-13.Vather R, Zargar-Shoshtari K, Adegbola S, Hill AG. Comparison of the possum, P-POSSUM and Cr-POSSUM scoring systems as predictors of postoperative mortality in patients undergoing major colorectal surgery. ANZ J Surg. 2006;76:812-6.Delaney CP, Fazio VW, Senagore AJ, et al. 'Fast track' postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg. 2001;88:1533-8.Kahokehr A, Sammour T, Shoshtari KZ, et al. Intraperitoneal local anesthetic improves recovery after colon resection: a double-blinded randomized controlled trial. Ann Surg. 2011;254:28-38.Singh PP, Srinivasa S, Bambarawana S, et al. Perioperative use of statins in elective colectomy. Dis Colon Rectum. 2012;55:205-10.Andersen J, Hjort-Jakobsen D, Christiansen PS, Kehlet H. Readmission rates after a planned hospital stay of 2 versus 3 days in fast-track colonic surgery. Br J Surg. 2007;94:890-3.Basse L, Jakobsen DH, Bardram L, et al. Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study. Ann Surg. 2005;241:416-23.Basse L, Thorbol JE, Lossl K, Kehlet H. Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum. 2004;47:271-7.Kariv Y, Delaney CP, Senagore AJ, et al. Clinical outcomes and cost analysis of a \"fast track\" postoperative care pathway for ileal pouch-anal anastomosis: a case control study. Dis Colon Rectum. 2007;50:137-46.Sammour T, Zargar-Shoshtari K, Bhat A, et al. A programme of Enhanced Recovery After Surgery (ERAS) is a cost-effective intervention in elective colonic surgery. N Z Med J. 2010;123:61-70.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Over the past decade, evolution of perioperative care in the field of colonic surgery has seen the development of Enhanced Recovery After Surgery (ERAS) or ‘fast-track' programmes.1–3These programmes incorporate a multidisciplinary approach to perioperative care and combine evidence-based practices into a multimodal perioperative care pathway that aims to reduce surgical stress and accelerate postoperative recovery with decreased hospital stay, reduced morbidity and shortened convalescence.The development of ERAS programmes has focused on optimising individual components of perioperative care including patient education, anaesthesia, fluid management, analgesia, nutrition and ambulation.4,5 This has led to changes in many traditional aspects of surgical care, such as preoperative bowel preparation, the use of nasogastric tubes, placement of drains, enforced bed rest, and graduated diets which have been shown to be unnecessary or even harmful.6In December 2005, the senior author (AGH) initiated an ERAS programme for colonic surgery at the Manukau Surgery Centre (MSC), an elective surgical unit of Counties Manukau District Health Board (CMDHB) in Auckland, New Zealand.7,8 This programme incorporated strategies of perioperative care based on ERAS principles and used a coordinated approach in conjunction with surgical, anaesthetic and nursing staff.This programme has since become the standard of care for patients undergoing elective colonic resection at CMDHB. This paper reviews the senior author's experience of elective colectomy conducted within the ERAS programme and reports operative and clinical outcomes.Methods Patients—Using a prospectively maintained database of patients undergoing surgery within the fast-track programme, we reviewed consecutive patients who underwent elective colectomy by the senior author within the ERAS programme at MSC since it was established in December 2005. Table 1. Components of Enhanced Recovery After Surgery (ERAS) programme Preoperative Preoperative assessment in a dedicated outpatient session Education with written information given and specific daily milestones discussed Preoperative discharge planning and social situation explored Nutritional assessment Careful medical assessment and optimisation Ward visit/meet nursing staff Patients admitted to hospital on morning of surgery Avoidance of prolonged preoperative fasting – nil by mouth for only 2 hours preinduction Carbohydrate loading – two 200mL PreOp® drinks on the morning of surgery Avoidance of mechanical bowel prep Intraoperative Epidural anaesthesia – mid or low thoracic Short acting anaesthetic agents Prevention of hypothermia, active warming blanket Conservative fluid regimen – 1500mL crystalloid and 500mL colloid unless otherwise indicated as per ERAS anaesthetic protocol Prophylactic antiemetics at induction Intravenous dexamethasone (8mg) at induction10 Transverse incision for right-sided open cases if appropriate; selective use of laparoscopy for left-sided cases Avoidance of drains/nasogastric tubes Postoperative Structured nursing pathway All intravenous fluid stopped when patient arrives on ward Vasopressors in preference to intravenous fluids to treat epidural-related hypotension Early oral feeding with supplementation – started on day of operation Prophylactic antiemetics Opioid sparing analgesia/nonsteroidal anti-inflammatory drugs Early removal of urinary catheter – on postoperative day 1 Timed removal of epidural – on postoperative day 2 Early mobilisation with nursing and/or physiotherapy input Discharge criteria defined: – Tolerating adequate oral intake and passing flatus – Adequate analgesia on oral medication – Adequate and safe mobility – Follow-up in surgical outpatient clinic within 7 days of discharge Exclusion criteria for this ERAS programme were patients with serious comorbidities (American Society of Anesthesiologists [ASA] score 4 or 5), those needing a stoma, rectal lesions (defined as <15cm from the anal verge), and those unable to participate in the preoperative education and goal setting components of ERAS because of cognitive impairment or a significant language barrier. Perioperative care—Patients managed within the ERAS programme received structured perioperative care as outlined in Table 1.8,9 This focused on better patient education, optimisation of preoperative status, avoidance of unnecessary physiological stressors, early oral feeding and early mobilisation. Discharge planning was discussed with patients preoperatively with establishment of daily milestones. Patients were planned for discharge on postoperative day 3 once discharge criteria were met. Outcomes—Age, gender, ASA score, Colorectal Physiological and Operative Severity score for the enUmeration of Mortality and morbidity (Cr-POSSUM),11 indication for surgery, stage of disease, operation type and technique were recorded for all patients. Postoperative complications up to 30 days after surgery were recorded using predefined criteria and graded using the Clavien-Dindo classification system.12,13 In patients with multiple complications, the highest complication grade is reported in the final analysis. The day of discharge was recorded as well as readmissions, defined as return to hospital within 30 days postoperatively requiring a hospital stay of 24 hours or more. Total hospital stay was calculated based on day stay of index admission plus hospital stay on readmission. Results are reported as mean (standard deviation) or median (range) as appropriate. Results Between December 2005 and March 2012, 100 patients underwent elective colectomy by the senior author at MSC within the ERAS programme. A further 78 patients undergoing colonic resection over the same time period were excluded from the ERAS programme due to the formation of a stoma, significant co-morbidities requiring monitoring in an intensive care unit postoperatively, or emergency resection. Baseline characteristics for the included patients are shown in Table 2. The median age of patients was 70 years (range 16–92) with 52 patients being female. Most patients had an ASA score of 2 (55 patients) and the overall median Cr-POSSUM score was 17 (range 13–25). The most common indication for surgery was malignancy (81 cases) with the majority of patients having stage II (39 cases) or stage III (24 cases) disease. Fifty-two patients underwent right-sided colectomy, 45 patients had a left-sided colectomy and 3 patients underwent subtotal colectomy. Seventeen cases were hand-assisted laparoscopic left/sigmoid colectomies while the remainder of operations were performed open. The median day of discharge was 3 days (range 2–60) and 75 patients were discharged by day 5 after surgery (Table 3). Median total hospital stay was 4 days (range 2–60) which included 21 readmissions. Table 4 summarises reasons for readmission, day of readmission and their duration. Twelve readmissions were after postoperative day 8 and the median length of stay during readmission was 4 days (range 1–28) with 16 patients readmitted for 7 days or less. Fifty-three patients developed a complication within 30 days postoperatively with 45 patients having minor (grade I-II) complications and 8 patients having major (grade III-V) complications (Table 3). Four patients had an anastomotic leak which required reoperation. The rate of complications in patients discharged by day 3 and day 5 was 44% and 41%, respectively. Table 2. Patient characteristics Variables n=100 Age, median [range] 70 [16–92] Gender Male Female 48 52 ASA score I II III IV Cr-POSSUM, median [range] 16 55 28 1 17 [13–25] Indication for surgery Malignancy Diverticular disease Non-malignant polyp Other* 81 13 4 2 AJCC stage^ I II III IV 7 39 24 6 Operation Right-sided colectomy Left-sided colectomy Subtotal colectomy 52 45 3 Surgical technique Open Hand-assisted laparoscopic 83 17 Operation time (minutes), mean [SD] 103 [32] AJCC, American Joint Committee on Cancer; ASA, American Society of Anesthesiologists; Cr-POSSUM, Colorectal Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity; SD, standard deviation. * Inflammatory appendiceal mass (n=1), mucinous neoplasm of appendix (n=1) with no malignancy on final histology ^ Five patients for whom the indication for surgery was malignancy were not able to be staged according the AJCC colorectal cancer staging system for the following reasons: 2 patients with malignant polyps resected on colonoscopy had no residual malignancy on histology after surgery, 1 patient had a right hemicolectomy for carcinoid tumour of the appendix with the final histology showing no residual carcinoid, 1 patient had metastatic melanoma to the caecum and small bowel, and 1 patient had pseudomyxoma peritonei following a right hemicolectomy for mucinous adenocarcinoma of the appendix. Table 3. Hospital stay and postoperative complications Variables n=100 Discharge day, median [IQR] 3 [3–6] Total Hospital stay, median [IQR] 4 [3–7] Readmission 21 Complication Yes No 53 47 Complication grade* I II III IV V 3 42 3 5 0 Minor complication (Grade I–II) 45 Major complication (Grade III–V) 8 Complication aetiology Wound Urinary tract infection Urinary retention Ileus Anastomotic leak Abdominal/pelvic collection Cardiorespiratory Other† 17 7 3 4 4 1 10 7 IQR, interquartile range * Complication grade definitions:12,13 Grade I: any deviation from the normal postoperative course without the need for pharmacologic treatment or surgical, endoscopic, and radiological interventions. Grade II: requiring pharmacologic treatment with drugs other than such allowed for grade I complications. Blood transfusions and total parenteral nutrition are also included. Grade III: requiring surgical, endoscopic, or radiological intervention. Grade IV: life-threatening complication (including central nervous system complications) requiring intermediate care/intensive care unit-management. Grade V: death of a patient. † Complications classified as other: stapleline bleed (n=2), constipation, abdominal pain, bladder leak, urinoma and deconditioning. Table 4. Readmissions Reason for readmission Day of readmission (day after surgery) Duration of readmission (days) Wound infection/dehiscence (n=6) 6 6 6 9 11 30 3 20 28 2 4 6 Abdominal pain (n=2) 4 7 2 6 Constipation (n=2) 10 21 3 2 Deconditioning (n=2) 15 24 8 7 Stress ulcers in oesophagus and duodenum 4 4 Ileus 5 3 Anastomotic leak 5 4 Diarrhoea 6 3 Pleural effusion/empyema 8 21 Small bowel obstruction 9

Summary

Abstract

Aim

In 2005, the senior author (AGH) initiated an Enhanced Recovery After Surgery (ERAS) or fast-track programme for elective colonic surgery at the Manukau Surgery Centre aimed at improving perioperative care. We reviewed the senior authors experience of elective colectomy conducted within the ERAS programme and evaluated clinical outcomes.

Method

Using a prospectively maintained database, consecutive patients who underwent elective colonic resection by the senior author within the ERAS programme at the Manukau Surgery Centre between December 2005 and March 2012 were reviewed. Demographic and operative data were recorded and clinical outcomes including complications, hospital stay and readmissions were evaluated for 30 days postoperatively.

Results

100 consecutive patients were reviewed. The median age of patients was 70 years (range: 16-92) and the most common indication for surgery was malignancy (81 cases). Right-sided colectomy was performed in 52 cases while 45 patients had a left-sided colectomy and 3 patients underwent subtotal colectomy. The median day to discharge was 3 days while total hospital stay was 4 days which incorporated 21 readmissions for mostly minor complications. Major complications occurred in only 8 patients and included 4 anastomotic leaks.

Conclusion

In one surgeons experience, elective colectomy performed within an optimised perioperative care environment achieves shorter hospital stay with a low rate of major complications.

Author Information

Primal P Singh, Research Fellow, Department of Surgery, South Auckland Clinical School, Middlemore Hospital, University of Auckland; Andrew G Hill, Professor and Colorectal Surgeon, Head of South Auckland Clinical School, Department of Surgery, Middlemore Hospital, University of Auckland

Acknowledgements

Primal Singh is a recipient of the Auckland Medical Research Foundation Ruth Spencer Medical Research Fellowship.

Correspondence

Dr Primal P Singh, Department of Surgery, South Auckland Clinical School, University of Auckland, Private Bag 93311, Middlemore Hospital, Otahuhu, Auckland 1640, New Zealand. Fax: +64 9 276 0066

Correspondence Email

dr.parrysingh@gmail.com

Competing Interests

Nil.

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