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International Journal of Colorectal Disease

Published in:

01-05-2011 | Original Article

A simplified rehabilitation program for patients undergoing elective colonic surgery—randomized controlled clinical trial

Authors: Leonardo Maciel da Fonseca, Magda Maria Profeta da Luz, Antônio Lacerda-Filho, Maria Isabel Toulson Davisson Correia, Rodrigo Gomes da Silva

Published in: International Journal of Colorectal Disease | Issue 5/2011

Abstract

Background

We have proposed a simplified perioperative rehabilitation program for elective colonic surgery that is focused on early oral nutrition and that could reduce hospital stay and postoperative ileus time without raising complications and readmission rates.

Patients and methods

Fifty-four patients admitted for elective colonic surgery were prospectively randomized into two groups: (1) an early feeding group (EFG)—on the first postoperative day, patients initially received a oral liquid diet and were advanced to a regular diet within the next 24 h as tolerated and at their discretion; (2) a traditional care group—patients were managed by nothing per orus until the elimination of the first flatus and then submitted to an oral liquid diet, followed by a regular diet within the next 24 h as described for the EFG. All patients followed a well-defined, simplified rehabilitation program.

Results

Patients' baseline characteristics were similar in the two groups. Hospital stay was significantly lower in the EFG (4.0 [±3.7] versus 7.6 [±8.1] days; p = 0.000). Diet tolerance and progression were similar between groups. Time to first flatus after surgery was significantly lower in the EFG (1.5 [±0.5] versus 2.0 [±0.7] days; p = 0.019). Complication and readmission rates were similar in both groups.

Conclusions

Early oral nutrition associated with a simplified perioperative rehabilitation program reduces postoperative length of hospital stay and ileus time after elective colonic resection without increasing rates of complications or readmissions.

Sagar S, Harland P, Shields R (1979) Early postoperative feeding with elemental diet. Br Med J 1(6159):293–295PubMedCrossRef

Hartsell PA, Frazee RC, Harrison JB, Smith RW (1997) Early postoperative feeding after elective colorectal surgery. Arch Surg 132(5):518–520, discussion 520–511PubMed

Beier-Holgersen R, Boesby S (1996) Influence of postoperative enteral nutrition on postsurgical infections. Gut 39(6):833–835PubMedCrossRef

Ortiz H, Armendariz P, Yarnoz C (1996) Is early postoperative feeding feasible in elective colon and rectal surgery? Int J Colorectal Dis 11(3):119–121PubMedCrossRef

Stewart BT, Woods RJ, Collopy BT, Fink RJ, Mackay JR, Keck JO (1998) Early feeding after elective open colorectal resections: a prospective randomized trial. Aust N Z J Surg 68(2):125–128PubMedCrossRef

Reissman P, Teoh TA, Cohen SM, Weiss EG, Nogueras JJ, Wexner SD (1995) Is early oral feeding safe after elective colorectal surgery? A prospective randomized trial. Ann Surg 222(1):73–77PubMedCrossRef

Carr CS, Ling KD, Boulos P, Singer M (1996) Randomised trial of safety and efficacy of immediate postoperative enteral feeding in patients undergoing gastrointestinal resection. BMJ 312(7035):869–871PubMed

Kehlet H, Mogensen T (1999) Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg 86(2):227–230. doi:10.1046/j.1365-2168.1999.01023.x PubMedCrossRef

Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, Nygren J, Hausel J, Soop M, Andersen J, Kehlet H (2005) Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 24(3):466–477. doi:10.1016/j.clnu.2005.02.002 PubMedCrossRef

10.

Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, von Meyenfeldt MF, Fearon KC, Revhaug A, Norderval S, Ljungqvist O, Lobo DN, Dejong CH (2009) Consensus review of optimal perioperative care in colorectal surgery: enhanced recovery after surgery (eras) group recommendations. Arch Surg 144(10):961–969. doi:10.1001/archsurg.2009.170 PubMedCrossRef

11.

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(10):1119–1131. doi:10.1007/s00384-009-0703-5 PubMedCrossRef

12.

Eskicioglu C, Forbes SS, Aarts MA, Okrainec A, McLeod RS (2009) Enhanced recovery after surgery (eras) programs for patients having colorectal surgery: a meta-analysis of randomized trials. J Gastrointest Surg 13(12):2321–2329. doi:10.1007/s11605-009-0927-2 PubMedCrossRef

13.

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. doi:10.1016/j.clnu.2010.01.004 PubMedCrossRef

14.

Kehlet H, Buchler MW, Beart RW Jr, Billingham RP, Williamson R (2006) Care after colonic operation–is it evidence-based? Results from a multinational survey in Europe and the United States. J Am Coll Surg 202(1):45–54. doi:10.1016/j.jamcollsurg.2005.08.006 PubMedCrossRef

15.

Lassen K, Hannemann P, Ljungqvist O, Fearon K, Dejong CH, von Meyenfeldt MF, Hausel J, Nygren J, Andersen J, Revhaug A (2005) Patterns in current perioperative practice: survey of colorectal surgeons in five Northern European countries. BMJ 330(7505):1420–1421. doi:10.1136/bmj.38478.568067.AE PubMedCrossRef

16.

Maessen J, Dejong CH, Hausel J, Nygren J, Lassen K, Andersen J, Kessels AG, Revhaug A, Kehlet H, Ljungqvist O, Fearon KC, von Meyenfeldt MF (2007) A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg 94(2):224–231. doi:10.1002/bjs.5468 PubMedCrossRef

17.

Kehlet H, Wilmore DW (2008) Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 248(2):189–198. doi:10.1097/SLA.0b013e31817f2c1a PubMedCrossRef

18.

Zargar-Shoshtari K, Connolly AB, Israel LH, Hill AG (2008) Fast-track surgery may reduce complications following major colonic surgery. Dis Colon Rectum 51(11):1633–1640. doi:10.1007/s10350-008-9386-1 PubMedCrossRef

19.

Wichmann MW, Eben R, Angele MK, Brandenburg F, Goetz AE, Jauch KW (2007) Fast-track rehabilitation in elective colorectal surgery patients: a prospective clinical and immunological single-centre study. ANZ J Surg 77(7):502–507. doi:10.1111/j.1445-2197.2007.04138.x PubMedCrossRef

20.

Scharfenberg M, Raue W, Junghans T, Schwenk W (2007) “Fast-track” rehabilitation after colonic surgery in elderly patients—is it feasible? Int J Colorectal Dis 22(12):1469–1474. doi:10.1007/s00384-007-0317-8 PubMedCrossRef

21.

Schwenk W, Gunther N, Wendling P, Schmid M, Probst W, Kipfmuller K, Rumstadt B, Walz MK, Engemann R, Junghans T (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(1):93–99. doi:10.1007/s00384-007-0374-z PubMedCrossRef

22.

Jakobsen DH, Sonne E, Andreasen J, Kehlet H (2006) Convalescence after colonic surgery with fast-track vs conventional care. Colorectal Dis 8(8):683–687. doi:10.1111/j.1463-1318.2006.00995.x PubMedCrossRef

23.

Raue W, Haase O, Junghans T, Scharfenberg M, Muller JM, Schwenk W (2004) ‘Fast-track’ multimodal rehabilitation program improves outcome after laparoscopic sigmoidectomy: a controlled prospective evaluation. Surg Endosc 18(10):1463–1468. doi:10.1007/s00464-003-9238-y PubMedCrossRef

24.

Klein J (2008) Multimodal multidisciplinary standardization of perioperative care: still a long way to go. Curr Opin Anaesthesiol 21(2):187–190. doi:10.1097/ACO.0b013e3282f70042 PubMedCrossRef

25.

Polle SW, Wind J, Fuhring JW, Hofland J, Gouma DJ, Bemelman WA (2007) Implementation of a fast-track perioperative care program: what are the difficulties? Dig Surg 24(6):441–449. doi:10.1159/000108327 PubMedCrossRef

26.

Kehlet H (2008) Fast-track colorectal surgery. Lancet 371(9615):791–793. doi:10.1016/S0140-6736(08)60357-8 PubMedCrossRef

27.

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

28.

DiFronzo LA, Yamin N, Patel K, O’Connell TX (2003) Benefits of early feeding and early hospital discharge in elderly patients undergoing open colon resection. J Am Coll Surg 197(5):747–752. doi:10.1016/S1072-7515(03)00794-4 PubMedCrossRef

29.

Di Fronzo LA, Cymerman J, O’Connell TX (1999) Factors affecting early postoperative feeding following elective open colon resection. Arch Surg 134(9):941–945, discussion 945–946PubMedCrossRef

30.

Feo CV, Romanini B, Sortini D, Ragazzi R, Zamboni P, Pansini GC, Liboni A (2004) Early oral feeding after colorectal resection: a randomized controlled study. ANZ J Surg 74(5):298–301. doi:10.1111/j.1445-1433.2004.02985.x PubMedCrossRef

31.

Bisgaard T, Kehlet H (2002) Early oral feeding after elective abdominal surgery—what are the issues? Nutrition 18(11–12):944–948PubMedCrossRef

32.

Delaney CP, Zutshi M, Senagore AJ, Remzi FH, Hammel J, Fazio VW (2003) 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 46(7):851–859. doi:10.1097/01.DCR.0000075209.09377.00 PubMedCrossRef

33.

Gatt M, Anderson AD, Reddy BS, Hayward-Sampson P, Tring IC, MacFie J (2005) Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection. Br J Surg 92(11):1354–1362. doi:10.1002/bjs.5187 PubMedCrossRef

34.

Khoo CK, Vickery CJ, Forsyth N, Vinall NS, Eyre-Brook IA (2007) A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Ann Surg 245(6):867–872. doi:10.1097/01.sla.0000259219.08209.36 PubMedCrossRef

35.

Anderson AD, McNaught CE, MacFie J, Tring I, Barker P, Mitchell CJ (2003) Randomized clinical trial of multimodal optimization and standard perioperative surgical care. Br J Surg 90(12):1497–1504. doi:10.1002/bjs.4371 PubMedCrossRef

36.

Muller S, Zalunardo MP, Hubner M, Clavien PA, Demartines N (2009) A fast-track program reduces complications and length of hospital stay after open colonic surgery. Gastroenterology 136(3):842–847. doi:10.1053/j.gastro.2008.10.030 PubMedCrossRef

37.

Serclova Z, Dytrych P, Marvan J, Nova K, Hankeova Z, Ryska O, Slegrova Z, Buresova L, Travnikova L, Antos F (2009) Fast-track in open intestinal surgery: prospective randomized study (clinical trials gov identifier no. Nct00123456). Clin Nutr 28(6):618–624. doi:10.1016/j.clnu.2009.05.009 PubMedCrossRef

38.

Lewis SJ, Andersen HK, Thomas S (2009) Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding: a systematic review and meta-analysis. J Gastrointest Surg 13(3):569–575. doi:10.1007/s11605-008-0592-x PubMedCrossRef

39.

Holte K, Kehlet H (2000) Postoperative ileus: a preventable event. Br J Surg 87(11):1480–1493. doi:10.1046/j.1365-2168.2000.01595.x PubMedCrossRef

40.

MacKay G, Ihedioha U, McConnachie A, Serpell M, Molloy RG, O’Dwyer PJ (2007) Laparoscopic colonic resection in fast-track patients does not enhance short-term recovery after elective surgery. Colorectal Dis 9(4):368–372. doi:10.1111/j.1463-1318.2006.01123.x PubMedCrossRef

41.

Basse L, Jakobsen DH, Bardram L, Billesbolle P, Lund C, Mogensen T, Rosenberg J, Kehlet H (2005) Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study. Ann Surg 241(3):416–423PubMedCrossRef

42.

Basse L, Thorbol JE, Lossl K, Kehlet H (2004) Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum 47(3):271–277. doi:10.1007/s10350-003-0055-0, discussion 277–278PubMedCrossRef

Title: A simplified rehabilitation program for patients undergoing elective colonic surgery—randomized controlled clinical trial
Authors: Leonardo Maciel da Fonseca
Magda Maria Profeta da Luz
Antônio Lacerda-Filho
Maria Isabel Toulson Davisson Correia
Rodrigo Gomes da Silva
Publication date: 01-05-2011
Publisher: Springer-Verlag
Published in: International Journal of Colorectal Disease / Issue 5/2011
Print ISSN: 0179-1958
Electronic ISSN: 1432-1262
DOI: https://doi.org/10.1007/s00384-010-1089-0

At a glance: The STEP trials

Springer Medicine

A simplified rehabilitation program for patients undergoing elective colonic surgery—randomized controlled clinical trial

Abstract

Background

Patients and methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Patients and methods

Results

Conclusions

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