Enhanced Recovery in Colorectal Surgery Joint Hospital Surgical

Enhanced Recovery in Colorectal Surgery Joint Hospital Surgical Grand Round 24. 10. 2015 By Chau Pui Ling, Bonnie

Introduction Concept of fast track surgery since 1990 s by Kehlet 1 Evidence based and multidisciplinary approach Reduce stress Reduced morbidity Maintain postoperative physiological function Faster recovery Enhanced mobilisation Shorter hospital stay 1. Wilmore, D. W. , & Kehlet, H. (2001). Management of patients in fast track surgery. BMJ: British Medical Journal (International Edition), 322(7284), 473

ERAS • ERAS(Enhanced recovery after surgery) society first established ERAS protocol in colorectal surgery in 2005 • Latest version published in 2013 - colonic and rectal surgery 2, 3 • More and more types of surgeries now included in ERAS- gastrectomy, radical cystectomy and pancreaticoduodenectomy 2. Gustafsson, U. , Scott, M. , Schwenk, W. , Demartines, N. , Roulin, D. , Francis, N. , &. . . Ljungqvist, O. (2013). Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World Journal Of Surgery, 37(2), 259 -284. doi: 10. 1007/s 00268 -012 -1772 -0 3. Nygren, J. , Thacker, J. , Carli, F. , Fearon, K. , Norderval, S. , Lobo, D. , &. . . Ramirez, J. (2012). Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS^®) Society recommendations. Clinical Nutrition, 31(6), 801 -816. doi: 10. 1016/j. clnu. 2012. 08. 012

Content 1. Look into the ERAS pathway in colorectal surgery in elective setting 2. Selected individual componentsa) Preoperative: i) Bowel Preparation ii) Preoperative Fasting and Carbohydrate Loading b) Intraoperative: i) Laparoscopic and Modification of Surgical Access ii) Perioperative Analgesia 3. ERAS pathway as a whole 4. Conclusion and take home message

Postoperative Preoperative Intraoperative Diagram adopted from www. intechopen. com

Preoperative Bowel Preparation Cochrane review 20114 20 trials included No statistically significant difference in wound infection (SSI) and anastomotic leakage rates comparing groups of no bowel preparation and those who received mechanical bowel preparation For rectal surgery further evaluation is needed, so as the case of laparoscopic surgery ERAS society recommendation: No routine mechanical bowel preparation; however, further studies are needed for evaluation in rectal surgery with defunctioning ileostomy 4. Güenaga, K. F. (2011). Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Of Systematic Reviews, (9), doi: 10. 1002/14651858. CD 001544. pub 4

Preoperative Bowel Preparation (2) What’s new? Recent retrospective analysis published in Annals of Surgery 8/2015 by American College of Surgeons National Surgical Quality Improvement Program ( ACS NSQIP) 5 Combined bowel preparation with mechanical cleansing and oral antibiotics resulted in significantly lower rates of incidence of incisional surgical site infection, anastomotic leakage and hospital readmission 5. Kiran, R. P. , Murray, A. A. , Chiuzan, C. , Estrada, D. , & Forde, K. (2015). Combined Preoperative Mechanical Bowel Preparation With Oral Antibiotics Significantly Reduces Surgical Site Infection, Anastomotic Leak, and Ileus After Colorectal Surgery. Annals Of Surgery, 262(3), 416 -425. doi: 10. 1097/SLA. 0000001416

Preoperative Bowel Preparation (3)

Preoperative Bowel Preparation (4)

Preoperative Bowel Preparation (5)

Postoperative Preoperative Intraoperative Diagram adopted from www. intechopen. com

Preoperative Fasting and Carbohydrate Loading § Meta-analysis published in 20136 § 21 randomised studies with 1685 patients, including those undergoing major abdominal surgery, laparoscopic cholecystectomy, hernia repair, thyroidectomy and orthopedic surgery. § Results showed no overall difference in length of hospital stay between patients receiving preoperative carbohydrate treatment and placebo. § However in subgroup analysis including patients who received preoperative carbohydrate treatment prior to major open abdominal surgery, length of stay is significantly reduced by 1 day (p=0. 007) § No reported aspiration pneumonitis § No increase in complications 6. Awad, S. , Varadhan, K. K. , Ljungqvist, O. , & Lobo, D. N. (2013). A meta-analysis of randomised controlled trials on preoperative oral carbohydrate treatment in elective surgery. Clinical Nutrition, 32(1), 34 -44. doi: 10. 1016/j. clnu. 2012. 10. 011

Preoperative Fasting and Carbohydrate Loading (2)

Preoperative Fasting and Carbohydrate Loading (3) ERAS recommendation: Clear fluids allowed up to 2 hours and solids up to 6 hours prior to induction of anaesthesia. Preoperative carbohydrate treatment should be used routinely Giving fluid containing high concentration of complex carbohydrates can enable patients to undergo surgery in a metabolically fed state Reduced postoperative thirst, hunger and anxiety

Laparoscopic and Modification of Surgical Access § LAFA trial in 2011 § LAFA trial is a RCT 7 with 9 Dutch hospitals comprising 427 patients from age 40 -80, randomized into 4 treatment groups (laparoscopic/fast track, lap/standard, open/ FT, open/standard), only colectomy patients included § Results showed Lap/ FT care resulted in significantly faster recovery after colonic surgery than all other combinations in terms of shorter total hospital stay by a median of 1 day. § Overall morbidity, complications and mortality did not differ significantly 7. Vlug, M. S. , Wind, J. , Hollmann, M. W. , Ubbink, D. T. , Cense, H. A. , Engel, A. F. , &. . . Bemelman, W. A. (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). Annals Of Surgery, 254(6), 868 -875. doi: 10. 1097/SLA. 0 b 013 e 31821 fd 1 ce

LAFA-Trial

LAFA Trial (2)

Laparoscopy and Modification of Surgical Access (2) ERAS recommendation: Laparoscopic surgery for colonic resections is recommended if expertise is available Reduced postoperative complications, pain and hospital stay without compromising oncological outcomes

Postoperative Preoperative Intraoperative Diagram adopted from www. intechopen. com

Perioperative Analgesia ERAS recommendation: In open surgery: Thoracic epidural analgesia with low dose local anaesthetic and opioids should be used In laparoscopic surgery: In alternative to TEA is a carefully administered spinal analgesia with a low dose long acting opioid; opioids should be avoided to prevent PONV and ileus

Perioperative Analgesia (2) § RCT on epidural vs patient controlled analgesia for laparoscopic colorectal surgery in ERP- Annals of surgery 4/201510 § 128 patients from a single center randomised to PCA/ EDA Medical recovery was shorter by median of 1 day in PCA group compared to EDA group (4 days vs 5 days), but did not reach statistical significance § Subgroup analysis excluding patients with major complications showed that medical recovery was achieved in significantly shorter time in PCA group compared to EDA group § Overall hospital stay similar 10. Hübner, M. , Blanc, C. , Roulin, D. , Winiker, M. , Gander, S. , & Demartines, N. (2015). Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway. Annals Of Surgery, 261(4), 648 -653. doi: 10. 1097/SLA. 0000000838

Meta-analysis of ERAS § Meta-analysis of 16 RCTs published in 12/201311 § ERAS reduced overall morbidity rates with decreased nonsurgical complications and shortened hospital stay (mean LOS 5. 8 days in ERAS vs 8 days in standard group) without increasing readmission rates § 16 RCTs, no of items applied ranged from 4 to 13, most frequently applied items included early feeding, no routine nasogastric tubes, early mobilisation, no preoperative fasting and epidural anaesthesia 11. Greco, M. , Capretti, G. , Beretta, L. , Gemma, M. , Pecorelli, N. , & Braga, M. (2014). Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World Journal Of Surgery, 38(6), 1531 -1541. doi: 10. 1007/s 00268 -013 -2416 -8

Impact of Compliance of ERAS § Retrospective review of a prospectively entered international database of 1509 colonic and 843 rectal resections between 2008 to 2013 in 6 countries 12 12. The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection: Results From an International Registry. (2015). Annals Of Surgery, 261(6), 1153 -1159. doi: 10. 1097/SLA. 0000001029

Impact of Compliance of ERAS (2)

Compliance and Length of Stay % Compliance Median LOS OR/95% CI/ P <50% 8 days ( IQR 6 -10) 75 -90% - OR=0. 94/ 95%% CI 0. 90 -0. 98/ P=0. 012 >90% 6 days (IQR 4 -8) OR= 0. 88/ 95% CI 0. 82 -0. 92/ P<0. 001 -

Compliance and Complications Rate % Compliance Complications Rate OR/95% CI/P <50% 47. 8% (120/251 cases) - 75 -90% 41. 3% (251/614 cases) OR=0. 85/ 95%CI 1. 40 -1. 64/ P<0. 001 >90% 33. 3% (100/300 cases) OR=0. 69/ 95%CI 0. 50 -0. 89/ P<0. 001

Conclusion 1. Some of the items have already been adopted in standard caremaintenance of normothermia, antimicrobial prophylaxis 2. However, idea of ERAS in terms of evidence based medicine is fundamental for modern medicine 3. Laparoscopic surgery, preoperative carbohydrate loading are shown to be effective in promoting early recovery 4. Methods of analgesia, bowel preparation may need further studies for evaluation 5. Increasing compliance may lead to improved efficacy

Reference Wilmore, D. W. , & Kehlet, H. (2001). Management of patients in fast track surgery. BMJ: British Medical Journal (International Edition), 322(7284), 473 ●Gustafsson, U. , Scott, M. , Schwenk, W. , Demartines, N. , Roulin, D. , Francis, N. , &. . . Ljungqvist, O. (2013). Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World Journal Of Surgery, 37(2), 259 -284. doi: 10. 1007/s 00268 -012 -1772 -0 ●Kiran, R. P. , Murray, A. A. , Chiuzan, C. , Estrada, D. , & Forde, K. (2015). Combined Preoperative Mechanical Bowel Preparation With Oral Antibiotics Significantly Reduces Surgical Site Infection, Anastomotic Leak, and Ileus After Colorectal Surgery. Annals Of Surgery, 262(3), 416 -425. doi: 10. 1097/SLA. 000000141 ●Güenaga, K. F. (2011). Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Of Systematic Reviews, (9), doi: 10. 1002/14651858. CD 001544. pub ●Awad, S. , Varadhan, K. K. , Ljungqvist, O. , & Lobo, D. N. (2013). A meta-analysis of randomised controlled trials on preoperative oral carbohydrate treatment in elective surgery. Clinical Nutrition, 32(1), 34 -44. doi: 10. 1016/j. clnu. 2012. 10. 011 ●Vlug, M. S. , Wind, J. , Hollmann, M. W. , Ubbink, D. T. , Cense, H. A. , Engel, A. F. , &. . . Bemelman, W. A. (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). Annals Of Surgery, 254(6), 868 -875. doi: 10. 1097/SLA. 0 b 013 e 31821 fd 1 ce ●Kennedy, R. H. , Francis, A. , Dutton, S. , Love, S. , Pearson, S. , Blazeby, J. M. , &. . . Kerr, D. J. (2012). En. ROL: a multicentre randomised trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme. BMC Cancer, 12181. doi: 10. 1186/1471 -2407 -12 -18 ●Greco, M. , Capretti, G. , Beretta, L. , Gemma, M. , Pecorelli, N. , & Braga, M. (2014). Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World Journal Of Surgery, 38(6), 1531 -1541. doi: 10. 1007/s 00268 -013 -2416 -8 ●The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection: Results From an International Registry. (2015). Annals Of Surgery, 261(6), 1153 -1159. doi: 10. 1097/SLA. 0000001029 ●Hübner, M. , Blanc, C. , Roulin, D. , Winiker, M. , Gander, S. , & Demartines, N. (2015). Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway. Annals Of Surgery, 261(4), 648 -653. doi: 10. 1097/SLA. 0000000838 ●

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