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

Treating common benign anal diseases has evolved towards more outpatient procedures with better outcome. However, minimizing post-procedure morbidities such as pain and the avoidance incontinence remain the most significant concerns. We introduce some controversies and highlight the developments in current surgical practice for the treatment of common anal problems.

Controversies in the treatment of common anal problems

Dear Editor: Patients with ulcerative colitis (UC) are at risk for the development of dysplasia or cancer with cumulative incidence rates of 2% by 10 years, 8% by 20 years, and 18% by 30 years in a meta-analysis. Reported risk factors for dysplasia or cancer are long duration of colitis, severe and extensive colitis, concomitant primary sclerosing cholangitis, family history of colorectal cancer (CRC), and early age of UC diagnosis. Surveillance colonoscopy with biopsy, the current gold standard, has been shown to reduce mortality of CRC associated with UC. The presence of multi-focal low-grade dysplasia (LGD), flat dysplasia, dysplasia-associated mass or lesion, and high-grade dysplasia (HGD) or CRC warrants colectomy in patients with UC. Restorative proctocolectomy (RPC) with ileal pouch–anal anastomosis (IPAA) is the definitive surgical treatment for patients with UC-associated neoplasia. Total proctocolectomy does not completely abolish the risk for CRC in UC patents. The risk for neoplasia the analtransitional zone (ATZ), and rarely in the pouch body, may still persist in a small subset of patients. Our recent study of 3,203 patients with RPC for UC found cumulative incidences for pouch neoplasia at 5, 10, 15, 20, and 25 years were 0.9%, 1.3%, 1.9%, 4.2%, and 5.1%, respectively. Multivariable analysis showed that the risk factor associated with pouch neoplasia was preoperative diagnosis of UC-associated cancer or dysplasia, with an adjusted hazard ratio of 13.43. Therefore, surveillance is indicated in patients at risk. However, surveillance pouch endoscopy with biopsy can still miss the diagnosis of adenocarcinoma at the dysplasia stage. Of 36 cases with pouch adenocarcinoma reported in the literature, 20 had routine surveillance endoscopy and only three cases had a histologic diagnosis of dysplasia before cancer. In our clinical practice, we have encountered cases in which pouch cancer was detected on surveillance endoscopy without prior endoscopic and histologic evidence of dysplasia. Of our 11 cases of pouch adenocarcinoma, three (27.3%) had no visible lesions on pouchoscopy at the time of cancer diagnosis. Currently, there is no consensus on the need or interval of surveillance pouchoscopy in patients with IPAA. On the other hand, it is clear that the current gold standard of cancer surveillance, i.e., endoscopy with biopsy can miss early diagnosis of cancer. Sampling error or subhistologic changes of carcinogenesis devoid of morphologic detection E. C. Obusez : B. Shen Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA

Adenocarcinoma in the ileal pouch: early detection and potential role of fecal DNA methylated markers in surveillance.

Background: Although tissue eosinophilia in mucosal biopsy specimens from the ileal pouch in patients treated with restorative proctocolectomy is frequently seen, its clinical significance has not been investigated. The aim of this study was to assess whether tissue eosinophilia was associated with disease status of ileal pouches.



Methods: Hematoxylin and eosin slides of pouch and afferent limb biopsy specimens from 106 patients randomly selected from the Pouchitis Database were evaluated by 2 gastrointestinal pathologists. Of 106 patients, 81 had corresponding mucosal biopsy specimens of the afferent limb that were available for review. Tissue eosinophil infiltration was evaluated in a semiquantitative fashion with scores ranging from 0–3. Univariate and multivariate analyses were performed to assess the association between eosinophil scores and demographic, clinical, endoscopic, and histologic features.



Results: Multivariate analyses showed that tissue eosinophilia of the pouch and afferent limb was not associated with chronic inflammatory conditions of the pouch and the presence of concurrent autoimmune-mediated disorders. Tissue eosinophil score of the pouch was significantly higher than that in the corresponding afferent limb in the same patient population (P = 0.043). A high tissue eosinophil score in the afferent limb was associated with non-use nonsteroidal antiinflammatory drug use (odds ratio = 3.5; 95% confidence interval [CI]: 1.2, 10.4) and high endoscopic inflammation scores in the afferent limb (odds ratio = 1.6; 95% CI: 1.1, 2.2). Similar associations were not found in pouch biopsy specimens.



Conclusions: Tissue eosinophilia in the pouch was more prominent than that in the afferent limb in patients with restorative proctocolectomy. Tissue eosinophilia in the pouch and afferent limb appeared to be associated with different risk factors. These findings suggest that luminal factors in different topographical locations of the pouch may contribute to eosinophil-mediated inflammation at these sites.



(Inflamm Bowel Dis 2008)

Evaluation of tissue eosinophilia in the pouch and afferent limb in patients with restorative proctocolectomy

The modern era of ileal pouch anal anastomosis began just over 20 years ago. Several areas remain controversial, including patient selection, surgical technique, use of a temporary diverting ileostomy, aging sphincters, complications, and postoperative management. This article reviews current controversies concerning ileal pouch anal anastomoses and our approach to managing patients who undergo this complicated procedure. (J WOCN 2001;28:32-6.)

Feza H. Remzi

Papers

Controversies in the treatment of common anal problems

Adenocarcinoma in the ileal pouch: early detection and potential role of fecal DNA methylated markers in surveillance.

Evaluation of tissue eosinophilia in the pouch and afferent limb in patients with restorative proctocolectomy

The ileal pouch anal anastomosis: Past, present, and future

Surgical management of patients with ulcerative colitis during pregnancy: maternal and fetal outcomes.