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01-12-2020 | Enterostomy | Original Article

Is an enhanced recovery program (ERP) after rectal surgery as feasible as after colonic surgery? A multicentre Francophone study of 870 rectal resections

Authors: J. Veziant, K. Poirot, A. Mulliez, B. Pereira, K. Slim, The Francophone Group for Enhanced Recovery After Surgery (GRACE)

Published in: Langenbeck's Archives of Surgery | Issue 8/2020

Abstract

Background

Enhanced recovery program (ERP) is well-established in colorectal surgery. Rectal surgery (RS) is known to be associated with high morbidity and prolonged hospital stay, which might explain why ERPs are less applied in this specific group of patients. The aim of this large-scale study was to assess the feasibility of an ERP in RS compared with colonic surgery.

Methods

This study was a retrospective analysis of a prospective database including 3740 patients eligible for colorectal resection from February 2014 to January 2017 in 75 European Francophone centres. Patients were divided into two groups (colon group C vs. rectum group R). The main endpoint was compliance with ERP components. A subgroup analysis was performed in patients for whom a defunctioning stoma (DS) was required after RS.

Results

A total of 3740 patients were included. There were 2870 patients in group C and 870 patients in group R. The overall compliance rate for ERPs was 81.71% in group C and 79.09% in group R. Patients were significantly less mobilized within 24 h in group R. Specific recommendations for RS concerning bowel preparation and abdominal drainage were significantly less implemented. Overall morbidity was significantly higher in group R. Mean length of stay (LOS) was significantly shorter in group C. In the sub-group analysis, a DS was significantly associated with fewer compliance with early mobilization and early feeding, leading to significantly longer LOS (group R).

Conclusion

ERP is safe and effective in RS, despite the well-known higher morbidity and LOS compared with colonic surgery. DS could be a limiting factor in ERP implementation after RS.

Ni X, Jia D, Chen Y, Wang L, Suo J (2019) Is the Enhanced Recovery After Surgery (ERAS) program effective and safe in laparoscopic colorectal cancer surgery? A meta-analysis of randomized controlled trials. J Gastrointest Surg 23:1502–1512. https://doi.org/10.1007/s11605-019-04170-8CrossRefPubMed

Nygren J, Thacker J, Carli F, Fearon KCH, Norderval S, Lobo DN, Ljungqvist O, Soop M, Ramirez J, 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) (2013) Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS(®)) Society recommendations. World J Surg 37:285–305. https://doi.org/10.1007/s00268-012-1787-6CrossRefPubMed

Stottmeier S, Harling H, Wille-Jørgensen P, Balleby L, Kehlet H (2012) Postoperative morbidity after fast-track laparoscopic resection of rectal cancer. Colorectal Dis 14:769–775. https://doi.org/10.1111/j.1463-1318.2011.02767.xCrossRefPubMed

Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J, Enhanced Recovery After Surgery Study Group (2011) Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 146:571–577. https://doi.org/10.1001/archsurg.2010.309CrossRefPubMed

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 J Surg 38:1531–1541. https://doi.org/10.1007/s00268-013-2416-8CrossRefPubMed

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

Braga M, Gianotti L, Radaelli G, Vignali A, Mari G, Gentilini O, di Carlo V (1999) Perioperative immunonutrition in patients undergoing cancer surgery: results of a randomized double-blind phase 3 trial. Arch Surg 134:428–433. https://doi.org/10.1001/archsurg.134.4.428CrossRefPubMed

Smedley F, Bowling T, James M, Stokes E, Goodger C, O’Connor O et al (2004) Randomized clinical trial of the effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care. Br J Surg 91:983–990. https://doi.org/10.1002/bjs.4578CrossRefPubMed

Finco C, Magnanini P, Sarzo G, Vecchiato M, Luongo B, Savastano S, Bortoliero M, Barison P, Merigliano S (2007) Prospective randomized study on perioperative enteral immunonutrition in laparoscopic colorectal surgery. Surg Endosc 21:1175–1179. https://doi.org/10.1007/s00464-007-9238-4CrossRefPubMed

10.

Maurice-Szamburski A, Auquier P, Viarre-Oreal V, Cuvillon P, Carles M, Ripart J, Honore S, Triglia T, Loundou A, Leone M, Bruder N, PremedX Study Investigators (2015) Effect of sedative premedication on patient experience after general anesthesia: a randomized clinical trial. JAMA 313:916–925. https://doi.org/10.1001/jama.2015.1108CrossRefPubMed

11.

Blanc M-C, Slim K, Beyer-Berjot L (2020) Best practices in bowel preparation for colorectal surgery: a 2020 overview. Expert Rev Gastroenterol Hepatol 14:681–688. https://doi.org/10.1080/17474124.2020.1775581CrossRefPubMed

12.

Smith I, Kranke P, Murat I, Smith A, O’Sullivan G, Søreide E et al (2011) Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 28:556–569. https://doi.org/10.1097/EJA.0b013e3283495ba1CrossRefPubMed

13.

Awad S, Varadhan KK, Ljungqvist O, Lobo DN (2013) A meta-analysis of randomised controlled trials on preoperative oral carbohydrate treatment in elective surgery. Clin Nutr 32:34–44. https://doi.org/10.1016/j.clnu.2012.10.011CrossRefPubMed

14.

Deijen CL, Vasmel JE, de Lange-de Klerk ESM, Cuesta MA, Coene P-PLO, Lange JF et al (2017) Ten-year outcomes of a randomised trial of laparoscopic versus open surgery for colon cancer. Surg Endosc 31:2607–2615. https://doi.org/10.1007/s00464-016-5270-6CrossRefPubMed

15.

Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF, Gerhards MF, van Wagensveld B, van der Zaag E, van Geloven A, Sprangers MA, Cuesta MA, Bemelman WA, LAFA study group (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). Ann Surg 254:868–875. https://doi.org/10.1097/SLA.0b013e31821fd1ceCrossRefPubMed

16.

Breukink S, Pierie J, Wiggers T Laparoscopic versus open total mesorectal excision for rectal cancer. Cochrane Database Syst Rev 2006:CD005200. https://doi.org/10.1002/14651858.CD005200.pub2

17.

Messager M, Sabbagh C, Denost Q, Regimbeau JM, Laurent C, Rullier E, Sa Cunha A, Mariette C (2015) Is there still a need for prophylactic intra-abdominal drainage in elective major gastro-intestinal surgery? J Visc Surg 152:305–313. https://doi.org/10.1016/j.jviscsurg.2015.09.008CrossRefPubMed

18.

Peeters KCMJ, Tollenaar RAEM, Marijnen CAM, Klein Kranenbarg E, Steup WH, Wiggers T et al (2005) Risk factors for anastomotic failure after total mesorectal excision of rectal cancer. Br J Surg 92:211–216. https://doi.org/10.1002/bjs.4806CrossRefPubMed

19.

Nelson RL, Gladman E, Barbateskovic M Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst Rev 2014:CD001181. https://doi.org/10.1002/14651858.CD001181.pub4.

20.

Sessler DI (2016) Perioperative thermoregulation and heat balance. Lancet 387:2655–2664. https://doi.org/10.1016/S0140-6736(15)00981-2CrossRefPubMed

21.

Corcoran T, Rhodes JEJ, Clarke S, Myles PS, Ho KM (2012) Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesth Analg 114:640–651. https://doi.org/10.1213/ANE.0b013e318240d6ebCrossRefPubMed

22.

Kranke P, Eberhart LHJ (2011) Possibilities and limitations in the pharmacological management of postoperative nausea and vomiting. Eur J Anaesthesiol 28:758–765. https://doi.org/10.1097/EJA.0b013e32834a4e1eCrossRefPubMed

23.

Srinivasa S, Kahokehr AA, Yu T-C, Hill AG (2011) Preoperative glucocorticoid use in major abdominal surgery: systematic review and meta-analysis of randomized trials. Ann Surg 254:183–191. https://doi.org/10.1097/SLA.0b013e3182261118CrossRefPubMed

24.

Castelino T, Fiore JF, Niculiseanu P, Landry T, Augustin B, Feldman LS (2016) The effect of early mobilization protocols on postoperative outcomes following abdominal and thoracic surgery: a systematic review. Surgery 159:991–1003. https://doi.org/10.1016/j.surg.2015.11.029CrossRefPubMed

25.

Andersen HK, Lewis SJ, Thomas S Early enteral nutrition within 24h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database Syst Rev 2006:CD004080. https://doi.org/10.1002/14651858.CD004080.pub2.

26.

Grass F, Slieker J, Frauche P, Solà J, Blanc C, Demartines N, Hübner M (2017) Postoperative urinary retention in colorectal surgery within an enhanced recovery pathway. J Surg Res 207:70–76. https://doi.org/10.1016/j.jss.2016.08.089CrossRefPubMed

27.

Schreiber A, Aydil E, Walschus U, Glitsch A, Patrzyk M, Heidecke C-D, Schulze T (2019) Early removal of urinary drainage in patients receiving epidural analgesia after colorectal surgery within an ERAS protocol is feasible. Langenbecks Arch Surg 404:853–863. https://doi.org/10.1007/s00423-019-01834-6CrossRefPubMed

28.

Alfonsi P, Slim K, Chauvin M, Mariani P, Faucheron JL, Fletcher D, Working Group of Société française d’anesthésie et réanimation (SFAR), Société française de chirurgie digestive (SFCD) (2014) French guidelines for enhanced recovery after elective colorectal surgery. J Visc Surg 151:65–79. https://doi.org/10.1016/j.jviscsurg.2013.10.006CrossRefPubMed

29.

Jouve P, Bazin J-E, Petit A, Minville V, Gerard A, Buc E, Dupre A, Kwiatkowski F, Constantin JM, Futier E (2013) Epidural versus continuous preperitoneal analgesia during fast-track open colorectal surgery: a randomized controlled trial. Anesthesiology 118:622–630. https://doi.org/10.1097/ALN.0b013e3182800d94CrossRefPubMed

30.

Marret E, Remy C, Bonnet F, Postoperative Pain Forum Group (2007) Meta-analysis of epidural analgesia versus parenteral opioid analgesia after colorectal surgery. Br J Surg 94:665–673. https://doi.org/10.1002/bjs.5825CrossRefPubMed

31.

Gorissen KJ, Benning D, Berghmans T, Snoeijs MG, Sosef MN, Hulsewe KWE, Luyer MDP (2012) Risk of anastomotic leakage with non-steroidal anti-inflammatory drugs in colorectal surgery. Br J Surg 99:721–727. https://doi.org/10.1002/bjs.8691CrossRefPubMed

32.

Sammour T, Chandra R, Moore JW (2016) Extended venous thromboembolism prophylaxis after colorectal cancer surgery: the current state of the evidence. J Thromb Thrombolysis 42:27–32. https://doi.org/10.1007/s11239-015-1300-9CrossRefPubMed

33.

Pędziwiatr M, Pisarska M, Kisielewski M, Major P, Mydlowska A, Rubinkiewicz M, Winiarski M, Budzyński A (2016) ERAS protocol in laparoscopic surgery for colonic versus rectal carcinoma: are there differences in short-term outcomes? Med Oncol 33:56. https://doi.org/10.1007/s12032-016-0772-6CrossRefPubMedPubMedCentral

34.

ERAS Compliance Group (2015) The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry. Ann Surg 261:1153–1159. https://doi.org/10.1097/SLA.0000000000001029CrossRef

35.

Kennedy RH, Francis EA, Wharton R, Blazeby JM, Quirke P, West NP, Dutton SJ (2014) Multicenter randomized controlled trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme: EnROL. J Clin Oncol 32:1804–1811. https://doi.org/10.1200/JCO.2013.54.3694CrossRefPubMed

36.

van Zelm R, Coeckelberghs E, Sermeus W, De Buck van Overstraeten A, Weimann A, Seys D et al (2017) Variation in care for surgical patients with colorectal cancer: protocol adherence in 12 European hospitals. Int J Colorectal Dis 32:1471–1478. https://doi.org/10.1007/s00384-017-2863-zCrossRefPubMed

37.

Slim K (2010) Gaps between evidence-based guidelines and the daily surgical practices. J Visc Surg 147:e337–e339. https://doi.org/10.1016/j.jviscsurg.2010.10.007CrossRefPubMed

38.

Carthey J, Walker S, Deelchand V, Vincent C, Griffiths WH (2011) Breaking the rules: understanding non-compliance with policies and guidelines. BMJ 343:d5283. https://doi.org/10.1136/bmj.d5283CrossRefPubMed

39.

Feroci F, Lenzi E, Baraghini M, Garzi A, Vannucchi A, Cantafio S, Scatizzi M (2013) Fast-track colorectal surgery: protocol adherence influences postoperative outcomes. Int J Colorectal Dis 28:103–109. https://doi.org/10.1007/s00384-012-1569-5CrossRefPubMed

40.

Gumbau V, García-Armengol J, Salvador-Martínez A, Ivorra P, García-Coret MJ, García-Rodríguez V, Roig JV (2015) Impact of a diverting stoma in an enhanced recovery programme for rectal cancer. Cir Esp 93:18–22. https://doi.org/10.1016/j.ciresp.2014.03.016CrossRefPubMed

41.

Fiore JF, Castelino T, Pecorelli N, Niculiseanu P, Balvardi S, Hershorn O et al (2017) Ensuring early mobilization within an enhanced recovery program for colorectal surgery: a randomized controlled trial. Ann Surg 266:223–231. https://doi.org/10.1097/SLA.0000000000002114CrossRefPubMed

42.

Hughes MJ, Cunningham W, Yalamarthi S (2020) The effect of preoperative stoma training for patients undergoing colorectal surgery in an enhanced recovery programme. Ann R Coll Surg Engl 102:180–184. https://doi.org/10.1308/rcsann.2019.0145CrossRefPubMed

43.

Younis J, Salerno G, Fanto D, Hadjipavlou M, Chellar D, Trickett JP (2012) Focused preoperative patient stoma education, prior to ileostomy formation after anterior resection, contributes to a reduction in delayed discharge within the enhanced recovery programme. Int J Colorectal Dis 27:43–47. https://doi.org/10.1007/s00384-011-1252-2CrossRef

44.

Faiz O, Haji A, Burns E, Bottle A, Kennedy R, Aylin P (2011) Hospital stay amongst patients undergoing major elective colorectal surgery: predicting prolonged stay and readmissions in NHS hospitals. Colorectal Dis 13:816–822. https://doi.org/10.1111/j.1463-1318.2010.02277.xCrossRefPubMed

45.

Hignett S, Parmar CD, Lewis W, Makin CA, Walsh CJ (2011) Ileostomy formation does not prolong hospital length of stay after open anterior resection when performed within an enhanced recovery programme. Colorectal Dis 13:1180–1183. https://doi.org/10.1111/j.1463-1318.2010.02381.xCrossRefPubMed

46.

Slim K, Reymond T, Joris J, Paul S, Pereira B, Cotte E (2020) Intolerance to early oral feeding in enhanced recovery after colorectal surgery: an early red flag? Colorectal Dis 22:95–101. https://doi.org/10.1111/codi.14785CrossRefPubMed

47.

Keane C, Savage S, McFarlane K, Seigne R, Robertson G, Eglinton T (2012) Enhanced recovery after surgery versus conventional care in colonic and rectal surgery. ANZ J Surg 82:697–703. https://doi.org/10.1111/j.1445-2197.2012.06139.xCrossRefPubMed

48.

Cintorino D, Ricotta C, Bonsignore P, Di Francesco F, Li Petri S, Pagano D et al (2018) Preliminary report on introduction of enhanced recovery after surgery protocol for laparoscopic rectal resection: a single-center experience. J Laparoendosc Adv Surg Tech A 28:1437–1442. https://doi.org/10.1089/lap.2018.0234CrossRefPubMed

49.

Vignali A, Elmore U, Cossu A, Lemma M, Calì B, de Nardi P, Rosati R (2016) Enhanced recovery after surgery (ERAS) pathway vs traditional care in laparoscopic rectal resection: a single-center experience. Tech Coloproctol 20:559–566. https://doi.org/10.1007/s10151-016-1497-4CrossRefPubMed

50.

De Crignis L, Slim K, Cotte E, Meillat H, Dupré A (2020) Impact of surgical indication on patient outcomes and compliance with enhanced recovery program for colorectal surgery: A Francophone multicenter retrospective analysis. J Surg Oncol. https://doi.org/10.1002/jso.26097

51.

Schwenk W, Neudecker J, Raue W, Haase O, Müller JM (2006) “Fast-track” rehabilitation after rectal cancer resection. Int J Colorectal Dis 21:547–553. https://doi.org/10.1007/s00384-005-0056-7CrossRefPubMed

52.

Branagan G, Richardson L, Shetty A, Chave HS (2010) An enhanced recovery programme reduces length of stay after rectal surgery. Int J Colorectal Dis 25:1359–1362. https://doi.org/10.1007/s00384-010-1032-4CrossRefPubMed

Title: Is an enhanced recovery program (ERP) after rectal surgery as feasible as after colonic surgery? A multicentre Francophone study of 870 rectal resections
Authors: J. Veziant
K. Poirot
A. Mulliez
B. Pereira
K. Slim
The Francophone Group for Enhanced Recovery After Surgery (GRACE)
Publication date: 01-12-2020
Publisher: Springer Berlin Heidelberg
Keywords: Enterostomy
Rectal Extirpation
Enterostomy
Rectal Extirpation
Published in: Langenbeck's Archives of Surgery / Issue 8/2020
Print ISSN: 1435-2443
Electronic ISSN: 1435-2451
DOI: https://doi.org/10.1007/s00423-020-02001-y

At a glance: The STEP trials

Springer Medicine

Is an enhanced recovery program (ERP) after rectal surgery as feasible as after colonic surgery? A multicentre Francophone study of 870 rectal resections

Abstract

Background

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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