Prospective Cohort Study

Importance Enhanced Recovery After Surgery (ERAS) is a paradigm shift in perioperative care, resulting in substantial improvements in clinical outcomes and cost savings. Observations Enhanced Recovery After Surgery is a multimodal, multidisciplinary approach to the care of the surgical patient. Enhanced Recovery After Surgery process implementation involves a team consisting of surgeons, anesthetists, an ERAS coordinator (often a nurse or a physician assistant), and staff from units that care for the surgical patient. The care protocol is based on published evidence. The ERAS Society, an international nonprofit professional society that promotes, develops, and implements ERAS programs, publishes updated guidelines for many operations, such as evidence-based modern care changes from overnight fasting to carbohydrate drinks 2 hours before surgery, minimally invasive approaches instead of large incisions, management of fluids to seek balance rather than large volumes of intravenous fluids, avoidance of or early removal of drains and tubes, early mobilization, and serving of drinks and food the day of the operation. Enhanced Recovery After Surgery protocols have resulted in shorter length of hospital stay by 30% to 50% and similar reductions in complications, while readmissions and costs are reduced. The elements of the protocol reduce the stress of the operation to retain anabolic homeostasis. The ERAS Society conducts structured implementation programs that are currently in use in more than 20 countries. Local ERAS teams from hospitals are trained to implement ERAS processes. Audit of process compliance and patient outcomes are important features. Enhanced Recovery After Surgery started mainly with colorectal surgery but has been shown to improve outcomes in almost all major surgical specialties. Conclusions and Relevance Enhanced Recovery After Surgery is an evidence-based care improvement process for surgical patients. Implementation of ERAS programs results in major improvements in clinical outcomes and cost, making ERAS an important example of value-based care applied to surgery.

Enhanced Recovery After Surgery: A Review

[Crohn's disease].

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

/pdf/guidelines-for-perioperative-care-in-elective-colonic-1wl593eui2.pdf

Guidelines for perioperative care in elective colonic surgery: Enhanced recovery after surgery (ERAS®) society recommendations

Epidemiology and Natural History of Inflammatory Bowel Diseases

Background:Ileal pouch anal anastomosis (IPAA) is the treatment of choice for chronic, medically refractory mucosal ulcerative colitis, indeterminate colitis, familial adenomatous polyposis (FAP), and a select group of patients with Crohn's disease.Aim:We report outcomes, complications, and quality

Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients.

Purpose Laparoscopy is the approach of choice for the majority of colorectal disorders that require a minimally invasive abdominal operation. As the emphasis on minimizing the technique continues, natural orifice surgery is quickly evolving. The authors utilized an embryologic natural orifice, the umbilicus, as sole access to the abdomen to perform a colorectal procedure. Herein, we present our initial experience of single-port laparoscopic colorectal surgery using a Uni-X™ Single-Port Access Laparoscopic System (Pnavel Systems, Morganville, New Jersey, USA) with a multi-channel cannula and specially designed curved laparoscopic instrumentation.



Method  The abdomen was approached through a 3.5 cm incision via the umbilicus and a single-port access device was utilized to perform a right hemicolectomy on a patient with an unresectable caecal polyp and a body mass index of 35. Ligation of the ileocolic artery was done with a LigaSure Device™ (Covidien Ltd, Norwalk, Connecticut, USA), and was followed by colonic mobilization, extraction and extracorporeal ileocolic anastomosis.



Results  The total operative time was 115 min with minimal blood loss. Hospital stay was 4 days with no undue sequelae.



Conclusion  Single-port laparoscopic surgery may allow common colorectal laparoscopic operations to be performed entirely through the patient’s umbilicus and enable an essentially scarless procedure. Additional experience and continued investigation are warranted.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1463-1318.2008.01660.x

Single-port laparoscopy in colorectal surgery

Background:
A combination of factors has emphasized the need to reduce postoperative stay after surgery. Multimodal care plans may shorten hospital stay, but have been associated with high readmission rates and are generally reserved for straightforward, non-complicated colonic (not rectal) resections. This study evaluated a ‘fast track’ protocol in patients undergoing major colonic and rectal surgery.

Methods:
Sixty consecutive patients (median age 44·5 (range 13–70) years) underwent major procedures over a 6-week period on one colorectal service. Nasogastric tubes and epidural anaesthesia were not used. Patients participated in a protocol of early diet and early ambulation, and were discharged after meeting defined criteria.

Results:
Fifty-eight patients (97 per cent) were deemed suitable for the ‘fast track’ approach at the time of surgery and stayed for a mean(s.d.) of 4·3(1·6) days after operation. Patients in diagnosis-related group (DRG) 148 (colorectal resection with co-morbidity; n = 40) stayed for 4·6(1·7) days, which was longer than those in DRG 149 (without co-morbidity; n = 18) who stayed 3·5(0·8) days (P = 0·01). Three patients (5 per cent) required a nasogastric tube for vomiting. There were no readmissions directly attributable to ‘fast track’ failure, although four patients (7 per cent) were readmitted within 30 days of operation for other reasons. Eight poorly compliant patients stayed for 5·1(1·1) days (P = 0·02 versus compliant patients). ‘Fast track’ patients had a shorter length of stay than patients receiving traditional care on other colorectal services during the same time period (compared by DRG 148, DRG 149 and for all patients) (P < 0·0001).

Conclusion:
The ‘fast track’ protocol allows patients with high levels of co-morbidity undergoing complex colorectal and reoperative pelvic surgery to benefit from a rapid recovery and early discharge from hospital. The approach is safe and has low readmission rates. © 2001 British Journal of Surgery Society Ltd

‘Fast track’ postoperative management protocol for patients with high co‐morbidity undergoing complex abdominal and pelvic colorectal surgery

The occurrence of strictures as a complication of Crohn's disease is a significant clinical problem. No specific antifibrotic therapies are available. This systematic review comprehensively addresses the pathogenesis, epidemiology, prediction, diagnosis and therapy of this disease complication. We also provide specific recommendations for clinical practice and summarise areas that require future investigation.

https://gut.bmj.com/content/gutjnl/62/7/1072.full.pdf

Crohn's disease complicated by strictures: a systematic review

Objective:Using meta-analytical techniques, the study compared postoperative adverse events and functional outcomes of stapled versus hand-sewn ileal pouch-anal anastomosis (IPAA) following restorative proctocolectomy.Background:The choice of mucosectomy and hand-sewn versus stapled pouch-anal anast

Feza H. Remzi

Papers

Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients.

Single-port laparoscopy in colorectal surgery

‘Fast track’ postoperative management protocol for patients with high co‐morbidity undergoing complex abdominal and pelvic colorectal surgery

Crohn's disease complicated by strictures: a systematic review

A Comparison of Hand-Sewn Versus Stapled Ileal Pouch Anal Anastomosis (IPAA) Following Proctocolectomy: A Meta-Analysis of 4183 Patients