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Department of Digestive Surgical Oncology, Institute Paoli-Calmettes, Marseille, France
© 2024 The Korean Society of Coloproctology
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Conflict of interest
No potential conflict of interest relevant to this article was reported.
Funding
None.
Author contributions
Conceptualization: HM, CdC, BL; Data curation: VW, MD, JS; Formal analysis: HM; Writing–original draft: HM, VW, MD; Writing–review & editing: CdC, BL, JS. All authors read and approved the final manuscript.
Phase | ERAS |
|
---|---|---|
Before | After | |
Preoperative phase | ||
Information | Standard information | Specific information with nurse and informed consent |
Immunonutrition | Yes | Yes |
Bowel preparation | Not systematic | No |
Limited fasting | Fasting at midnight the day before | Last meal 6 hr before surgery |
Clear liquids until 2 hr before surgery | ||
Carbohydrate loading | No | 400 mL the evening before surgery and 2 hr before surgery |
Premedication | Alprazolam 0.5 mg the evening before | Only for anxiety |
Perioperative phase | ||
Antibioprophylaxis | Yes | Yes |
Zero fluid balanced | No | Yes |
Corticosteroid | No | Dexamethasone 8 mg at induction |
Prevention of PONV | Nonsystematic | Prophylactic use of ondansetron 4 mg |
Normothermia | Yes | Yes |
Locoregional analgesia | Nonsystematic | TAP block or incisional infiltration (lidocaine) |
Abdominal drain | Nonsystematic | Nonsystematic |
Postoperative phase | ||
Nasogastric tube | 24 hr postoperation for right colectomy | No |
Thromboprophylaxis | Yes | Yes |
Opioid-sparing multimodal analgesia | No (systematic patient-controlled morphine pump) | Ketoprofen 100 mg×2/day for 2 days |
Paracetamol 1,000 mg + opium 25 mg×4/day | ||
Opioid 5 mg only if VAS >4 | ||
Removal of IV fluid | After resumption of transit and normal feeding | On POD 1 in the absence of PONV |
Early feeding | Progressive after resumption of transit | Semisolid meal on the evening of the intervention |
Normal diet on POD 1 | ||
Early mobilization | No | Out of bed 1 hr on POD 0 |
Walking and chair >4 hr/day from POD 1 | ||
Urinary catheter | Systematic and removal on POD 2 | Removal on POD1 |
Postdischarge | Dedicated emergency telephone number | Logbook containing postoperative instructions for early detection of POCs at home |
No systematic blood test apart from platelet counts during anticoagulant treatment | Telephone interviews on days 1, 7, and 30 after discharge to record all medical problems and to ensure patient’s satisfaction with return home and nursing care | |
No systematic blood test |
Characteristic | Standard group (n=136) | ERAS group (n=136) | P-value |
---|---|---|---|
Sex | 0.47 | ||
Male | 70 (51.5) | 76 (55.9) | |
Female | 66 (48.5) | 60 (44.1) | |
Age (yr) | 68.3±12.4 | 67.8±13.6 | 0.75 |
ASA physical status | 0.35 | ||
I, II | 91 (66.9) | 99 (72.8) | |
III, IV | 45 (33.1) | 37 (27.2) | |
Comorbidity | |||
Diabetes mellitus | 15 (11.0) | 19 (14.0) | 0.45 |
Pulmonary | 13 (9.6) | 29 (21.3) | <0.01 |
Cardiac | 17 (12.5) | 12 (8.8) | 0.34 |
Tobacco use | 41 (30.1) | 56 (41.2) | 0.05 |
Body mass index (kg/m2) | 25.6±4.3 | 25.9±5.0 | 0.62 |
Malnutrition | 14 (10.3) | 26 (19.1) | 0.04 |
Preoperative anemia | 51 (37.5) | 43 (31.6) | 0.33 |
Neoadjuvant chemotherapy | 20 (14.7) | 34 (25.0) | 0.04 |
Surgical procedure | 0.66 | ||
Right colectomy | 79 (58.1) | 86 (63.2) | |
Left colectomy | 57 (41.9) | 50 (36.8) | |
Surgical approach | <0.01 | ||
Robotic | 0 (0) | 37 (27.2) | |
Laparoscopy | 136 (100) | 99 (72.8) | |
Conversion | 10 (7.4) | 9 (6.7) | >0.99 |
Length of stay (day) | |||
Initial | 12.2±7.7 | 8.8±5.7 | <0.01 |
Total | 13.1±8.7 | 11.4±6.7 | 0.04 |
ICU admission | 51 (37.5) | 43 (31.6) | 0.37 |
90-day Clavien-Dindo grade | <0.01 | ||
I | 66 (48.5) | 64 (47.1) | |
II | 43 (31.6) | 27 (19.9) | |
III | 17 (12.5) | 43 (31.6) | |
IV | 9 (6.7) | 1 (0.7) | |
V | 1 (0.7) | 1 (0.7) | |
Life-threatening complication | 9 (6.7) | 1 (0.7) | 0.01 |
Reoperation | 20 (14.7) | 32 (23.5) | 0.08 |
Indication for adjuvant chemotherapy | 53 (39.0) | 23 (16.9) | <0.01 |
Adjuvant chemotherapy performed | 40/53 (75.5) | 22/23 (95.7) | 0.05 |
1-yr Mortality | 10 (7.4) | 2 (1.5) | 0.03 |
Characteristic | Standard group (n=14) | ERAS group (n=21) | P-value |
---|---|---|---|
Proportion in the overall population | 14/380 (3.7) | 21/660 (3.2) | 0.84 |
Type of complication | >0.99 | ||
Abscess | 3 (21.4) | 7 (33.3) | |
Anastomotic leakage | 11 (78.6) | 14 (66.7) | |
Type of surgery | >0.99 | ||
Left colectomy | 7 (50.0) | 12 (57.1) | |
Right colectomy | 7 (50.0) | 9 (42.9) | |
Time of diagnostic | 0.25 | ||
Initial stay | 12 (85.7) | 15 (71.4) | |
Readmission | 2 (14.3) | 6 (28.6) | |
Diagnostic delay (day) | 5.3±1.9 | 3.8±1.2 | 0.06 |
Diagnostic CT scan | 14 (100) | 16 (76.2) | 0.06 |
Treatment | 0.49 | ||
Antibiotic alone | 0 (0) | 3 (14.3) | |
Radiological drainage | 2 (14.3) | 3 (14.3) | |
Surgical treatment | 12 (85.7) | 16 (76.2) | |
Time to surgery (day) | 7.1±4.2 | 4.1±1.9 | 0.07 |
Surgical approach during reoperation | <0.01 | ||
Laparotomy | 11/12 (91.7) | 2/16 (12.5) | |
Laparoscopy | 1/12 (8.3) | 12/16 (75.0) | |
Conversion to open | 0/12 (0) | 2/16 (12.5) | |
Surgical procedure | <0.01 | ||
Take-down anastomosis + end stoma | 7/12 (58.3) | 6/16 (37.5) | |
Suture + diverting stoma | 1/12 (8.4) | 10/16 (62.5) | |
Peritoneal lavage and drainage | 4/12 (33.3) | 0/16 (0) | |
ICU admission | 7 (50.0) | 10 (47.6) | 0.89 |
ICU stay (day) | 13.9±7.9 | 6.4±3.6 | |
Associated complication | 9 (64.3) | 7 (33.3) | 0.07 |
Ionic and/or renal disorders | 5 (35.7) | 2 (9.5) | |
Delirium | 3 (21.4) | 1 (4.8) | |
Transfusion | 4 (28.6) | 4 (19) | |
Cardiac decompensation | 1 (7.1) | 0 (0) | |
Aspiration pneumonia | 1 (7.1) | 0 (0) | |
Respiratory distress | 2 (14.3) | 1 (4.8) | |
Hemodynamic instability | 3 (21.4) | 1 (4.8) | |
90-day Morbidity (Clavien-Dindo grade) | 0.03 | ||
II | 0 (0) | 3 (14.3) | |
III | 8 (57.1) | 17 (80.9) | |
IV | 6 (42.9) | 1 (4.8) | |
Comprehensive Complication Index | 43.1±12.8 | 33.1±6.0 | 0.03 |
Length of stay (day) | |||
Initial | 23.3±12.5 | 10.9±7.9 | <0.01 |
During readmission | 6.0±7.3 | 10.2±7.3 | 0.18 |
Total | 25.1±11.5 | 14.8±7.4 | <0.01 |
Stoma closure | 6/8 (75.0) | 15/16 (93.8) | 0.24 |
Time to stoma closure (wk) | 17.8±5.3 | 13.1±4.6 | 0.08 |
Indication for adjuvant chemotherapy | 5 (35.7) | 8 (38.1) | >0.99 |
Adjuvant chemotherapy performed | 1/5 (20.0) | 8/8 (100) | <0.01 |
1-yr Mortality | 0 (0) | 0 (0) | - |
Characteristic | Standard group (n=47) | ERAS group (n=49) | P-value |
---|---|---|---|
Proportion in the overall population | 47/380 (12.4) | 49/660 (7.4) | 0.01 |
Type of surgery | 0.13 | ||
Left colectomy | 13 (27.7) | 7 (14.3) | |
Right colectomy | 34 (72.3) | 42 (85.7) | |
Time of diagnosis (day) | 3.8±1.3 | 2.9±0.9 | <0.01 |
Initial stay | 46 (97.9) | 45 (91.8) | |
Readmission | 1 (2.1) | 4 (8.2) | |
Diagnostic CT scan | 20 (42.6) | 20 (40.8) | >0.99 |
Time to CT scan (day) | 6.3±3.1 | 4.0±1.6 | <0.01 |
Maintenance of postoperative NGT | 21 (44.7) | 3 (6.1) | <0.01 |
Insertion of NGT | 27 (57.4) | 34 (69.4) | 0.20 |
NGT duration (day) | 4.5±2.2 | 3.4±1.4 | 0.13 |
Recovery time (day) | 8.5±4.4 | 6.6±2.6 | 0.02 |
Infusion duration (day) | 7.7±4.6 | 6.1±3.1 | 0.07 |
First gas (day) | 4.9±2.1 | 3.3±2.1 | <0.01 |
First feces (day) | 6.7±2.4 | 5.2±2.4 | <0.01 |
ICU admission | 5 (10.6) | 3 (6.1) | 0.48 |
Length of stay (day) | |||
Initial | 13.3±6.9 | 9.5±3.8 | <0.01 |
During readmission | 6.0 | 4.6±2.6 | - |
Total | 13.5±7.0 | 10.0±3.3 | <0.01 |
Associated complication | 17 (36.2) | 6 (12.2) | <0.01 |
Ionic and/or renal disorder | 12 (25.5) | 4 (8.2) | |
Confusion | 4 (8.5) | 1 (2.0) | |
Cardiac decompensation | 2 (4.3) | 1 (2.0) | |
Aspiration pneumonia | 4 (8.5) | 3 (6.1) | |
90-day Morbidity (Clavien-Dindo grade) | 0.38 | ||
I–II | 44 (93.6) | 47 (96.0) | |
III | 1 (2.1) | 1 (2.0) | |
IV | 2 (4.3) | 0 (0) | |
V | 0 (0) | 1 (2.0) | |
Comprehensive Complication Index | 17.7±10.4 | 14.2±13.9 | <0.01 |
Indication for adjuvant chemotherapy | 27 (57.4) | 24 (49.0) | 0.41 |
Adjuvant chemotherapy performed | 23/27 (85.2) | 22/24 (91.7) | 0.67 |
1-yr Mortality | 4 (8.5) | 1 (2.0) | 0.20 |
Characteristic | Standard group (n=15) | ERAS group (n=26) | P-value |
---|---|---|---|
Proportion in the overall population | 15/380 (3.9) | 26/660 (3.9) | >0.99 |
Delay surgery-readmission (day) | 17.9±10.5 | 10.4±8.9 | 0.01 |
Delay discharge-readmission (day) | 9.7±8.9 | 5.6±6.4 | 0.17 |
Initial LOS before readmission (day) | 10.1±6.9 | 7.2±5.3 | 0.01 |
LOS during readmission (day) | 8.3±12.9 | 8.2±6.7 | 0.35 |
POC during initial stay | 10 (66.7) | 10 (38.5) | 0.11 |
ICU admission | 5 (33.3) | 3 (11.5) | 0.12 |
Total LOS (day) | 18.3±13.1 | 15.4±8.0 | 0.57 |
Main cause of readmission | - | ||
Dehydration | 1 (6.7) | 2 (7.7) | |
Parietal abscess or hematoma | 4 (26.7) | 4 (15.4) | |
Ileus | 2 (13.3) | 4 (15.4) | |
Intestinal bleeding | 2 (13.3) | 3 (11.5) | |
Intra-abdominal abscess | 5 (33.3) | 4 (15.4) | |
Anastomotic leakage | 1 (6.7) | 4 (15.4) | |
Acute urinary retention | 0 (0) | 1 (3.8) | |
Clostridium difficile colitis | 0 (0) | 1 (3.8) | |
Chyloperitoneum | 0 (0) | 1 (3.8) | |
Ascites | 0 (0) | 1 (3.8) | |
Clavien-Dindo grade during readmission | 0.37 | ||
I–II | 7 (46.7) | 11 (42.3) | |
III | 7 (46.7) | 15 (57.7) | |
IV | 1 (6.7) | 0 (0) | |
Indication for adjuvant chemotherapy | 7 (46.7) | 11 (42.3) | >0.99 |
Adjuvant chemotherapy performed | 6/7 (85.7) | 11/11 (100) | 0.39 |
1-yr Mortality | 3 (20.0) | 0 (0) | - |
ERAS, Enhanced Recovery After Surgery; PONV, postoperative nausea and vomiting; TAP, transverse abdominal plane; VAS, visual analog scale; IV, intravenous; POD: postoperative day; POC, postoperative complication.
Values are presented as number (%), mean±standard deviation, or mean. ERAS, Enhanced Recovery After Surgery; ASA, American Society of Anesthesiologists; ICU, intensive care unit.
Values are presented as number (%) or mean±standard deviation. ERAS, Enhanced Recovery After Surgery; CT, computed tomography; ICU, intensive care unit.
Values are presented as number (%) or mean±standard deviation. ERAS, Enhanced Recovery After Surgery; CT, computed tomography; NGT, nasogastric tube; ICU, intensive care unit.
Values are presented as number (%) or mean±standard deviation. Percentages may not total 100 due to rounding. ERAS, Enhanced Recovery After Surgery; LOS, length of stay; POC, postoperative complication; ICU, intensive care unit.