Skip to main content
SpringerLink
Log in

Impact of laparoscopy on adherence to an enhanced recovery pathway and readiness for discharge in elective colorectal surgery: Results from the PeriOperative Italian Society registry

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Introduction

Previous studies reported that laparoscopic surgery (LPS) improved postoperative outcomes in patients undergoing colorectal surgery within an enhanced recovery program (ERP). However, the effect of minimally invasive surgery on each ERP item has not been clarified, yet. The aim of this study is to assess the impact of LPS on adherence to ERP items and recovery as measured by time to readiness for discharge (TRD).

Methods

Prospectively collected data entered in an electronic Italian registry specifically designed for ERP were reviewed. Patients undergoing elective colorectal surgery were divided into three groups: successful laparoscopy, conversion to open surgery, primary open surgery. Adherence to 19 ERP elements and postoperative outcomes were compared among groups. Multivariate regression analysis was used to identify whether LPS had an independent role to improve ERP adherence and postoperative outcomes.

Results

714 patients (successful LPS 531, converted 42, open 141) underwent elective colorectal surgery within an ERP. Epidural analgesia was used in the 75.1% of open group patients versus 49.9% of LPS group patients (p = 0.012). After surgery, oral feeding recovery, i.v. fluids suspension, removal of both urinary and epidural catheters occurred earlier in the LPS group both in the overall series and in uneventful patients only. Mean TRD and length of hospital stay were significantly shorter in the LPS group (p < 0.001 for both). Overall morbidity rate was 18.7% in the LPS group versus 32.6% in the open group (p = 0.001). At multivariate analysis, LPS was significantly associated to an increased adherence to postoperative ERP items, a shorter TRD, and a reduced overall morbidity, whereas rectal surgery and new stoma formation impaired postoperative recovery.

Conclusions

The present study showed that a successful laparoscopic procedure had an independent role to increase the adherence to postoperative ERP and to improve short-term postoperative outcome.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ (2011) Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev 16(2):CD007635

    Google Scholar 

  2. Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN (2010) The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 29:434–440

    Article  PubMed  Google Scholar 

  3. Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M (2014) Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg 38:1531–1541

    Article  PubMed  Google Scholar 

  4. Sammour T, Zargar-Shoshtari K, Bhat A, Kahokehr A, Hill AG (2010) A programme of enhanced recovery after surgery (ERAS) is a cost-effective intervention in elective colonic surgery. NZ Med J 123:61–70

    Google Scholar 

  5. Roulin D, Donadini A, Gander S, Griesser AC, Blanc C, Hübner M, Schäfer M, Demartines N (2013) Cost-effectiveness of the implementation of enhanced recovery protocol for colorectal surgery. Br J Surg 100:1108–1114

    Article  CAS  PubMed  Google Scholar 

  6. Muller S, Zalunardo MP, Hubner M, Clavien PA, Demartines N, Zurich Fast Track Study Group (2009) A fast-track program reduces complications and length of stay after open colonic surgery. Gastroenterology 136:842–847

    Article  PubMed  Google Scholar 

  7. Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, Nygren J, Hausel J, Soop M, Andersen J, Kehlet H (2005) Enhanced recovery after surgery:a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 24:466–477

    Article  Google Scholar 

  8. Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF, Gerhards MF, van Wagensveld BA, van der Zaag ES, van Geloven AA, Sprangers MA, Cuesta MA, Bemelman WA, LAFA study group (2011) Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery. Ann Surg 254:868–875

    Article  PubMed  Google Scholar 

  9. Zhuang CL, Huang DD, Chen FF, Zhou CJ, Zheng BS, Chen BC, Shen X, Yu Z (2015) Laparoscopic versus open colorectal surgery within enhanced recovery after surgery programs: a systematic review and meta-analysis of randomized controlled trials. Surg Endosc 29:2091–2100

    Article  PubMed  Google Scholar 

  10. Spanjersberg WR, van Sambeeck JD, Bremers A, Rosman C, van Laarhoven CJ (2015) Systematic review and meta-analysis for laparoscopic versus open colon surgery with or without an ERAS programme. Surg Endosc 29:3443–3453

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Kennedy RH, Francis EA, Wharton R, Blazeby JM, Quirke P, West NP, Dutton SJ (2014) Multicenter randomized controlled trial of conventional vs. laparoscopic surgery for colorectal cancer within an enhanced recovery program: EnROL. J Clin Oncol 32:1804–1811

    Article  PubMed  Google Scholar 

  12. Braga M, Pecorelli N, Scatizzi M, Borghi F, Missana G, Radrizzani D, PeriOperative Italian Society (2016) Enhanced recovery program in high-risk patients undergoing colorectal surgery. Results from the Perioperative Italian Society registry. World J Surg. doi:10.1007/s00268-016-3766-9

    Google Scholar 

  13. Pecorelli N, Hershorn O, Baldini G, Fiore JF, Jr., Stein BL, Liberman AS, Charlebois P, Carli F, Feldman LS. (2016) Impact of adherence to care pathway interventions on recovery following bowel resection within an established enhanced recovery program. Surg Endosc doi:10.1007/s00464-016-5169-2 [Epub ahead of print]

    Google Scholar 

  14. Fiore JF Jr, Faragher IG, Bialocerkowski A, Browning L, Denehy L (2013) Time to readiness for discharge is a valid and reliable measure of short-term recovery after colorectal surgery. World J Surg 37:2927–2934

    Article  PubMed  Google Scholar 

  15. Bozzetti F, Braga M, Gianotti L, Gavazzi C, Mariani L (2001) Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: a randomised multicentre trial. Lancet 358:1487–1492

    Article  CAS  PubMed  Google Scholar 

  16. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213

    Article  PubMed  PubMed Central  Google Scholar 

  17. Dhruva Rao PK, Howells S, Haray PN (2015) Does an enhanced recovery programme add value to laparoscopic colorectal resections? Int J Colorectal Dis 30:1473–1477

    Article  CAS  PubMed  Google Scholar 

  18. Alvarez MP, Foley KE, Zebley DM, Fassler SA (2015) Comprehensive enhanced recovery pathway significantly reduced postoperative length of stay and opioid usage in elective laparoscopic colectomy. Surg Endosc 29:2506–2511

    Article  PubMed  Google Scholar 

  19. Khreiss W, Huebner M, Cima RR, Dozois ER, Chua HK, Pemberton JH, Harmsen WS, Larson DW (2014) Improving conventional recovery with enhanced recovery in minimally invasive surgery for rectal cancer. Dis Colon Rectum 57:557–563

    Article  PubMed  Google Scholar 

  20. ERAS Compliance Group (2015) The impact of enhanced recovery protocol compliance on elective colorectal cancer resection. Results from an International Registry. Ann Surg 261:1153–1159

    Article  Google Scholar 

  21. Basse L, Jakobsen DH, Bardram L, Billesbølle P, Lund C, Mogensen T, Rosenberg J, Kehlet H (2005) Functional recovery after open versus laparoscopic colonic resection. Ann Surg 241:416–423

    Article  PubMed  PubMed Central  Google Scholar 

  22. Gatt M, Anderson AD, Reddy BS, Hayward-Sampson P, Tring IC, MacFie J (2005) Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection. Br J Surg 92:1354–1362

    Article  CAS  PubMed  Google Scholar 

  23. Haines KJ, Skinner EH, Berney S (2013) Association of postoperative pulmonary complications with delayed mobilisation following major abdominal surgery: an observational cohort study. Physiotherapy 99:119–125

    Article  CAS  PubMed  Google Scholar 

  24. Zaouter C, Kaneva P, Carli F (2009) Less urinary tract infection by earlier removal of bladder catheter in surgical patients receiving thoracic epidural analgesia. Reg Anesth Pain Med 34:542–548

    Article  PubMed  Google Scholar 

  25. Harrison OJ, Smart NJ, White P, Brigic A, Carlisle ER, Allison AS, Ockrim JB, Francis NK (2014) Operative time and outcome of enhanced recovery after surgery after laparoscopic colorectal surgery. JSLS 18:265–272

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

Members of the PeriOperative Italian Society are Luca Pellegrino MD (Department of Surgery, Cuneo Hospital), Danilo Radrizzani MD (Department of Anesthesiology, Legnano Hospital), Luigi Beretta, MD (Department of Anesthesiology, Vita-Salute University San Raffaele Hospital), Umberto Casiraghi (Department of Surgery, Vita-Salute University San Raffaele Hospital), Andrea Muratore MD (Department of Surgery, Candiolo Hospital), Michele Crespi MD (Department of Surgery, Luigi Sacco Hospital), Riccardo Iuliani MD (Department of Surgery, Cottolengo Hospital), Carlo Bima MD (Department of Surgery, Cottolengo Hospital), Hedayat Bouzari MD (Department of Surgery, Mauriziano Hospital), Andrea Pisani Ceretti MD (Department of Surgery, San Paolo Hospital).

Author information

Authors and Affiliations

  1. Department of Surgery, Vita-Salute University, San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy

    Marco Braga, Marianna Maspero & Nicolò Pecorelli

  2. Department of Surgery, Cuneo Hospital, Cuneo, Italy

    Felice Borghi

  3. Department of Surgery, Prato Hospital, Prato, Italy

    Marco Scatizzi

  4. Department of Surgery, Casa di Cura Città di Udine, Udine, Italy

    Giancarlo Missana

  5. Department of Surgery, Cantù Hospital, Cantù, Italy

    Marco Azzola Guicciardi

  6. Department of Surgery, Humanitas Hospital IRCCS, Rozzano, Italy

    Stefano Bona

  7. Department of Surgery, Careggi Hospital, University of Florence, Florence, Italy

    Ferdinando Ficari

Authors
  1. Marco Braga
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Felice Borghi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Marco Scatizzi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Giancarlo Missana
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Marco Azzola Guicciardi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Stefano Bona
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Ferdinando Ficari
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Marianna Maspero
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Nicolò Pecorelli
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

on behalf of the PeriOperative Italian Society

  • Luca Pellegrino
  • , Danilo Radrizzani
  • , Luigi Beretta
  • , Umberto Casiraghi
  • , Andrea Muratore
  • , Michele Crespi
  • , Riccardo Iuliani
  • , Carlo Bima
  • , Hedayat Bouzari
  •  & Andrea Pisani Ceretti

Corresponding author

Correspondence to Marco Braga.

Ethics declarations

Disclosures

Drs. Marco Braga, Felice Borghi, Marco Scatizzi, Giancarlo Missana, Marco Azzola Guicciardi, Stefano Bona, Ferdinando Ficari, Marianna Maspero, Nicolò Pecorelli have no conflicts of interest or financial ties to disclose.

Additional information

Members of the PeriOperative Italian Society are listed in Acknowledgement section.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 27 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Braga, M., Borghi, F., Scatizzi, M. et al. Impact of laparoscopy on adherence to an enhanced recovery pathway and readiness for discharge in elective colorectal surgery: Results from the PeriOperative Italian Society registry. Surg Endosc 31, 4393–4399 (2017). https://doi.org/10.1007/s00464-017-5486-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-017-5486-0

Keywords

Search

Navigation