A retrospective observational study of enhanced recovery after surgery in older patients undergoing elective colorectal surgery

Enhanced recovery programs (ERPs) in colorectal surgery have demonstrated beneficial effects on postoperative complications, return of bowel function, length of stay, and costs, without increasing readmissions or mortality. However, ERPs were not specifically designed for older patients and feasibility in older patients has been questioned.; The aim of this study was to assess ERP adherence and outcomes in older patients and to identify risk factors for postoperative complications and prolonged length of stay.; Retrospective analysis of consecutive patients (≥70 years) undergoing elective colorectal resection in a tertiary referral hospital in 2017.; Ninety-six patients were included. Adherence rates were above 80% in 18 of 21 ERP interventions considered. The lowest adherence rates were noted for preoperative carbohydrate loading and cessation of intravenous fluids. Postoperative complications (Clavien-Dindo ≥2) and prolonged postoperative length of stay (>75th percentile) were observed in 39.6% and 26.3%, respectively. Median length of stay was 7 days. The 30-day mortality, readmission and reoperation rates were 2.1%, 12.6% and 8.3%, respectively. Multivariable analysis indicated that polypharmacy and site of surgery were independent risk factors for postoperative complications, while higher age, American Society of Anesthesiologists class and preoperative radiotherapy were independent risk factors for prolonged postoperative length of stay.; ERP adherence in older patients undergoing colorectal resection is high and ERP is therefore considered feasible. Postoperative complications and prolonged postoperative length of stay are common, so at risk patients should be targeted with tailored geriatric interventions

Quadratus Lumborum Block Versus Perioperative Intravenous Lidocaine for Postoperative Pain Control in Patients Undergoing Laparoscopic Colorectal Surgery:A Prospective, Randomized, Double-blind Controlled Clinical Trial

OBJECTIVE: To investigate the comparative analgesic efficacy of systemic lidocaine and quadratus lumborum (QL) block in laparoscopic colorectal surgery.BACKGROUND: Although epidural analgesia is the standard to control pain in patients undergoing open colorectal surgery, optimal analgesic management in laparoscopic surgery is less well-defined. There is need for effective and efficient alternatives to epidural analgesia for pain management in patients undergoing laparoscopic colorectal surgery.METHODS: A total of 125 patients undergoing laparoscopic colorectal surgery were included in this randomized, double-blind controlled clinical trial. Patients randomly received an intravenous infusion with placebo plus a QL-block with placebo, a QL-block with ropivacaine 0.25% plus intravenous placebo, or intravenous lidocaine plus a QL-block with placebo. Postoperatively, all patients received patient-controlled intravenous anesthesia (PCIA) with morphine. Primary outcome parameter was the opioid consumption during the first 24 hours postoperatively. Secondary endpoints included severity of postoperative pain, time to return of intestinal function, incidence of postoperative nausea and vomiting, and length of hospital stay.RESULTS: The QL-block was not superior to systemic lidocaine for the reduction of morphine requirements in the first 24 hours postoperatively {QL-group: 37.5 (28.4) mg [mean (standard deviation)] vs lidocaine group: 40.2 (25) mg, P = 0.15}. For the majority of secondary outcome parameters, no significant differences were found between the groups. Morphine consumption in the postanesthesia care unit, the number of PCIA-boli demanded by the patient, and the number of PCIA-boli delivered by the PCIA-pump during the first 24 hours postoperatively were lower in the placebo group.CONCLUSIONS: In our trial, the QL-block did not provide superior postoperative analgesia when compared to systemic lidocaine in laparoscopic colorectal surgery.TRIAL REGISTRATION: Eudra CT: 2014-001499-73; 31/7/2014.</p

Matrix metalloproteinase-9 in relation to patients with complications after colorectal surgery: a systematic review

Purpose: Anastomotic leakage (AL) is the most severe complication following colorectal resection and is associated with increased mortality. The main group of enzymes responsible for collagen and protein degradation in the extracellular matrix is matrix metalloproteinases. The literature is conflicting regarding anastomotic leakage and the degradation of extracellular collagen by matrix metalloproteinase-9 (MMP-9). In this systematic review, the

A prospective european trial comparing laparotomy, laparoscopy, robotic-assisted, and transanal total mesorectal excision procedures in high-risk patients with rectal cancer: the RESET trial

Objective: To compare total mesorectal excision (TME) techniques combined with sphincter-sparing procedure in high-risk patients (HRPs). Background: TME is the standard treatment for rectal cancer, but can be challenging in HRPs. The available surgical approaches must be compared, especially in HRPs. Methods: Prospective, observational, multicenter trial to compare laparotomy (OTME), laparoscopy (LTME), robotic-assisted surgery (RTME), and transanal surgery (TaTME) in HRPs. The composite primary outcome included circumferential radial margin (CRM) 1mm, TME grade II-III, and absence of Clavien-Dindo grade III-IV complications. Three propensity score analyses were performed (LTME vs. RTME, RTME vs. TaTME, LTME vs. TaTME). Results: 1078 HRPs (75% of men, median body mass index of 27 kg/m2, 50% of tumors in the lower third of the rectum) underwent surgery. The RTME and TaTME groups included patients with more advanced and lower tumors and coloanal anastomosis (P<0.001). Operative time was longer for RTME surgery (P<0.001). Conversion rate was similar for minimally invasive procedures (4.5%). The global R0 resection rate was 96% without difference among techniques. The primary outcome rates were 82.4%, 64.3%, 74.7%, and 80.3% for LTME, OTME, RTME, and TaTME, respectively. None achieved the expected success rate (85%), and propensity score analyses found no differences. Operative results were similar between high- and low-volume inclusion centers only for RTME. Conclusions: The RESET trial yielded high-quality results despite focusing on HRPs. Minimally invasive procedures showed similar sphincter-sparing procedure outcomes, but LTME included patients with more favorable tumors. Oncologic and functional outcomes will be evaluated at 2 years (ClinicalTrials.gov, ID: NCT03574493).Conflicts of Interest and Source of Funding: RESET was endorsed by the European Society of Coloproctology (ESCP). Financial support was provided by Intuitive Surgical, Aubonne, Switzerland. RESET was designed and conducted independently at the Montpellier Cancer Institute. The funding institutions had no influence on the design or conduct of the study. PR received research and education grants from Intuitive Surgical. The other authors declare no other conflict of interest

Stoma-free survival after anastomotic leak following rectal cancer resection: worldwide cohort of 2470 patients

Background: the optimal treatment of anastomotic leak after rectal cancer resection is unclear. this worldwide cohort study aimed to provide an overview of four treatment strategies applied. Methods: Patients from 216 centres and 45 countries with anastomotic leak after rectal cancer resection between 2014 and 2018 were included. treatment was categorized as salvage surgery, faecal diversion with passive or active (vacuum) drainage, and no primary/secondary faecal diversion. The primary outcome was 1-year stoma-free survival. In addition, passive and active drainage were compared using propensity score matching (2 : 1). results: Of 2470 evaluable patients, 388 (16.0 per cent) underwent salvage surgery, 1524 (62.0 per cent) passive drainage, 278 (11.0 per cent) active drainage, and 280 (11.0 per cent) had no faecal diversion. one-year stoma-free survival rates were 13.7, 48.3, 48.2, and 65.4 per cent respectively. propensity score matching resulted in 556 patients with passive and 278 with active drainage. there was no statistically significant difference between these groups in 1-year stoma-free survival (OR 0.95, 95 per cent c.i. 0.66 to 1.33), with a risk difference of -1.1 (95 per cent c.i. -9.0 to 7.0) per cent. after active drainage, more patients required secondary salvage surgery (OR 2.32, 1.49 to 3.59), prolonged hospital admission (an additional 6 (95 per cent c.i. 2 to 10) days), and ICU admission (OR 1.41, 1.02 to 1.94). Mean duration of leak healing did not differ significantly (an additional 12 (-28 to 52) days). Conclusion: Primary salvage surgery or omission of faecal diversion likely correspond to the most severe and least severe leaks respectively. In patients with diverted leaks, stoma-free survival did not differ statistically between passive and active drainage, although the increased risk of secondary salvage surgery and ICU admission suggests residual confounding

Stoma-free survival after anastomotic leak following rectal cancer resection: worldwide cohort of 2470 patients

Background: The optimal treatment of anastomotic leak after rectal cancer resection is unclear. This worldwide cohort study aimed to provide an overview of four treatment strategies applied. Methods: Patients from 216 centres and 45 countries with anastomotic leak after rectal cancer resection between 2014 and 2018 were included. Treatment was categorized as salvage surgery, faecal diversion with passive or active (vacuum) drainage, and no primary/ secondary faecal diversion. The primary outcome was 1-year stoma-free survival. In addition, passive and active drainage were compared using propensity score matching (2 : 1). Results: Of 2470 evaluable patients, 388 (16.0 per cent) underwent salvage surgery, 1524 (62.0 per cent) passive drainage, 278 (11.0 per cent) active drainage, and 280 (11.0 per cent) had no faecal diversion. One-year stoma-free survival rates were 13.7, 48.3, 48.2, and 65.4 per cent respectively. Propensity score matching resulted in 556 patients with passive and 278 with active drainage. There was no statistically significant difference between these groups in 1-year stoma-free survival (OR 0.95, 95 per cent c.i. 0.66 to 1.33), with a risk difference of ¿1.1 (95 per cent c.i. ¿9.0 to 7.0) per cent. After active drainage, more patients required secondary salvage surgery (OR 2.32, 1.49 to 3.59), prolonged hospital admission (an additional 6 (95 per cent c.i. 2 to 10) days), and ICU admission (OR 1.41, 1.02 to 1.94). Mean duration of leak healing did not differ significantly (an additional 12 (¿28 to 52) days). Conclusion: Primary salvage surgery or omission of faecal diversion likely correspond to the most severe and least severe leaks respectively. In patients with diverted leaks, stoma-free survival did not differ statistically between passive and active drainage, although the increased risk of secondary salvage surgery and ICU admission suggests residual confounding