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

Importance The use of narcotics among patients with Crohn disease (CD) is endemic. Objective To evaluate the association between preoperative use of narcotics and postoperative outcomes in patients with CD. Design, Setting, and Participants Patients undergoing abdominal surgery for CD at a tertiary referral center between January 1998 and June 2014 were identified from an institutional prospectively maintained CD database. Main Outcomes and Measures Primary end points were overall morbidity, postoperative hospital length of stay, and readmission. Univariate and multivariate analyses were used to assess possible associations between postoperative outcomes and demographic and clinical variables, including preoperative narcotic use. Results Of the 1331 patients included, the mean age for patients who had at least 1 pharmacy claim for narcotics within 1 month before surgery was 41.5 years and 41.1 years for patients without a pharmacy claim. Of 1461 abdominal operations for CD, 267 (18.3%) were performed on patients receiving preoperative narcotics. Patients receiving narcotics were more likely to have a current smoking habit ( P P  = .046) and undergoing treatment with biologics ( P  = .04). Patients with preoperative narcotic use had a longer mean (SD) length of stay (11.2 [8.9] vs 7.7 [5.5]; P P P  = .04) and prolonged hospital stay (estimate = 2.91; SE = 0.44; P Conclusions and Relevance Preoperative use of narcotics in patients undergoing abdominal surgery for CD is associated with worse postoperative outcomes. Before starting regular narcotic use, patients with CD should be considered for surgical intervention.

Association of Preoperative Narcotic Use With Postoperative Complications and Prolonged Length of Hospital Stay in Patients With Crohn Disease.

Recent developments in adhesion prevention have led to the introduction of a sodium hyaluranate-based bioresorbable membrane into clinical practice. Its application has been regarded as safe and efficient. We present three cases of postoperative acute aseptic peritonitis without an obvious etiology, which might have been related to this bioresorbable membrane during recent surgery. Surgeons should be aware of this kind of a complication that might be attributed to this product.

An unusual complication after hyaluronate-based bioresorbable membrane (Seprafilm) application.

Laparoscopic sigmoidectomy for diverticulitis is widely accepted, using either endolinear staplers or traditional linear staplers under direct vision through the extraction site to transect the rectum. The aim of this study was to assess modifiable factors affecting perioperative morbidity after elective laparoscopic sigmoidectomy for diverticulitis. Potential associations between perioperative morbidity and demographic, disease-related, and treatment-related factors were assessed on all consecutive patients included in a prospectively collected database undergoing elective laparoscopic sigmoidectomy for diverticulitis between 1992 and 2013. Rectal transection with a linear stapler under direct vision through the extraction site was considered compatible with laparoscopic technique. There were two deaths out of 1059 patients (0.19 %). Conversion rate was 13.1 %, overall morbidity 28 %, and anastomotic leak 3.7 %. Independent factors associated with morbidity in an intent-to-treat analysis were ASA 3 (OR 1.53, p = 0.006), conversion (OR 1.71, p = 0.015), and rectal transection without endolinear stapling (traditional linear stapler: OR 1.75, p = 0.003; surgical knife: OR 2.09, p = 0.002). The same factors along with complicated diverticulitis (OR 1.56, p = 0.013) were independently associated with overall morbidity among laparoscopically completed cases. BMI ≥ 35 (OR 2.3, p = 0.017), complicated diverticulitis (OR 2.37, p = 0.002), and rectal transection with a traditional linear stapler (OR 2.19, p = 0.018) were independently associated with abdomino-pelvic infections, both in an intent-to-treat analysis and among laparoscopically completed cases. The number of endolinear stapler firings was not associated with morbidity. Most factors associated with morbidity of laparoscopic sigmoidectomy for diverticulitis cannot be easily modified. With the limitation of a retrospective analysis, modifiable factors to minimize morbidity are laparoscopic completion and endolinear stapling.

Is there anything we can modify among factors associated with morbidity following elective laparoscopic sigmoidectomy for diverticulitis

Background There are no published studies on the impact of visceral adipose tissue (VAT) change on outcomes of restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA). The aim of this historic cohort study was to evaluate the impact of excessive VAT gain on the outcomes of inflammatory bowel disease (IBD) patients with IPAA. Methods We evaluated all eligible patients with at least two sequential CT scans after pouch construction from our prospectively maintained Pouchitis Registry between 2002 and 2014. The visceral fat area (VFA) was measured on CT images. The study group comprised patients with a significant VAT gain (> 15%), and the control group was those without. The adverse outcomes of the pouch were defined as the new development of chronic pouch inflammation (chronic pouchitis, chronic cuffitis or Crohn's disease of the pouch), anastomotic sinus and the combination of above (the composite adverse outcome) or pouch failure, after the inception CT. Results Of 1564 patients in the Registry, 59 (3.8%) with at least 2 CT scans after pouch surgery were included. Twenty-nine patients (49.2%) were in the study group, and 30 (50.8%) were in the control group. The median duration from the inception to the latest CT was 552 (range: 31-2598) days for the entire cohort. We compared the frequency of new chronic pouch inflammation (13.8% vs 3.3%, P = 0.195), new pouch sinus (10.3% vs 0%, P = 0.112), composite adverse pouch outcome (24.1% vs 3.3%, P = 0.026) or pouch failure (10.3% vs 6.7%, P = 0.671) between the two groups. Kaplan-Meier plot for time-to-pouch failure between the pouch patients with or without excessive body mass index (BMI) gain (> 10%) showed statistical difference (P = 0.011). Limited stepwise multivariate analysis showed that excessive VAT gain (odds ratio = 12.608, 95% confidence interval: 1.190-133.538, P = 0.035) was an independent risk factor for the adverse pouch comes. Conclusions In this cohort of ileal pouch patients, excessive VAT gain as well as gain in BMI after pouch construction was found to be associated with poor long-term outcomes.

Postoperative excessive gain in visceral adipose tissue as well as body mass index are associated with adverse outcomes of an ileal pouch

BACKGROUND This study aimed to compare perioperative outcomes of patients undergoing robotic, laparoscopic, and open colectomy using a procedure-targeted database. METHODS Retrospective review of patients undergoing elective colectomy in 2013 was conducted using the procedure-targeted database of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Robotic, laparoscopic, and open groups were matched (1:1:1) based on age, gender, body mass index, surgical procedure, diagnosis and ASA classification. Demographics, comorbidities, and short-term (30 day) outcomes were compared. RESULTS Out of 12 790 patients, 387 fulfilled criteria per group after matching. Univariate comparison showed operating time was longer (P < 0.001) and hospital stay was shorter (P < 0.001) in the robotic group. Morbidity (P < 0.001), superficial SSI (P < 0.001), bleeding requiring transfusion (P < 0.001), ventilator dependency (P = 0.003), and ileus (P < 0.001) rates were lower in the robotic group. After adjusting for confounders, outcomes were comparable between the groups except hospital stay which was shorter in the robotic group (P < 0.001). CONCLUSIONS ACS-NSQIP data demonstrated several short-term advantages of robotic surgery compared with laparoscopic and open surgery.

Feza H. Remzi

Papers

Association of Preoperative Narcotic Use With Postoperative Complications and Prolonged Length of Hospital Stay in Patients With Crohn Disease.

An unusual complication after hyaluronate-based bioresorbable membrane (Seprafilm) application.

Is there anything we can modify among factors associated with morbidity following elective laparoscopic sigmoidectomy for diverticulitis

Postoperative excessive gain in visceral adipose tissue as well as body mass index are associated with adverse outcomes of an ileal pouch

Robotic, laparoscopic, and open colectomy: a case-matched comparison from the ACS-NSQIP.