Epidural and Continuous Wound Infusion in Enhanced Recovery Protocols

INTRODUCTION Colorectal surgery has been associated with a complication rate of 15–20% and mean postoperative inpatient stays of 6–11 days. The principles of enhanced recovery after surgery (ERAS) are well established and have been developed to optimise perioperative care and facilitate discharge. The purpose of this systematic review is to present an updated review of perioperative care in colorectal surgery from the available evidence and ERAS group recommendations. METHODS Systematic searches of the PubMed and Embase™ databases and the Cochrane library were conducted. A hand search of bibliographies of identified studies was conducted to identify any additional articles missed by the initial search strategy. RESULTS A total of 59 relevant studies were identified. These included six randomised controlled trials and seven clinical controlled trials that fulfilled the inclusion criteria. These studies showed reductions in duration of inpatient stays in the ERAS groups compared with more traditional care as well as reductions in morbidity and mortality rates. CONCLUSIONS Reviewing the data reveals that ERAS protocols have a role in reducing postoperative morbidity and result in an accelerated recovery following colorectal surgery. Similarly, both primary and overall hospital stays are reduced significantly. However, the available evidence suggests that ERAS protocols do not reduce hospital readmissions or mortality. These findings help to confirm that ERAS protocols should now be implemented as the standard approach for perioperative care in colorectal surgery.

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A Commonsense Patient-Centered Approach to Multimodal Analgesia Within Surgical Enhanced Recovery Protocols

Journal of Pain Research ◽

10.2147/jpr.s238772 ◽

2019 ◽

Vol Volume 12 ◽

pp. 3461-3466 ◽

Cited By ~ 5

Author(s):

Edward R Mariano ◽

Michael E Schatman

Keyword(s):

Enhanced Recovery ◽

Multimodal Analgesia ◽

Patient Centered ◽

Recovery Protocols

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Advances in flap monitoring and impact of enhanced recovery protocols

Journal of Surgical Oncology ◽

10.1002/jso.25179 ◽

2018 ◽

Vol 118 (5) ◽

pp. 758-767 ◽

Cited By ~ 10

Author(s):

Sarah J. Karinja ◽

Bernard T. Lee

Keyword(s):

Enhanced Recovery ◽

Flap Monitoring ◽

Recovery Protocols

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Meta-Analysis of Enhanced Recovery Protocols in Bariatric Surgery

Journal of Gastrointestinal Surgery ◽

10.1007/s11605-018-3709-x ◽

2018 ◽

Vol 22 (6) ◽

pp. 964-972 ◽

Cited By ~ 29

Author(s):

Ola S. Ahmed ◽

Ailín C. Rogers ◽

Jarlath C. Bolger ◽

Achille Mastrosimone ◽

William B. Robb

Keyword(s):

Bariatric Surgery ◽

Enhanced Recovery ◽

Meta Analysis ◽

Recovery Protocols

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714 UTILITY, TECHNIQUES, AND OUTCOMES FOR THORACIC DRAINAGE AFTER OESOPHAGECTOMY: A SYSTEMATIC REVIEW

Diseases of the Esophagus ◽

10.1093/dote/doab052.714 ◽

2021 ◽

Vol 34 (Supplement_1) ◽

Author(s):

Charles Bull ◽

Philip H Pucher ◽

James Gossage

Keyword(s):

Enhanced Recovery ◽

Cochrane Collaboration ◽

Patient Comfort ◽

Effusion Rate ◽

Thoracic Drainage ◽

Drain Fluid ◽

Position Type ◽

Oesophageal Surgery ◽

Recovery Protocols

Abstract The routine use of post-operative drains in surgery continues to evolve as part of modern practices. Modern enhanced recovery protocols eschew using abdominal drains due to their impact on patient comfort, mobility, and recovery. This change in practice has not applied to thoracic drainage after oesophagectomy, where one or multiple drains are routinely placed. The aim of this study was to determine the evidence for, and how best to use drains during oesophageal surgery. Methods A systematic literature search was performed in Medline, Embase and Cochrane collaboration databases until Jan 25th, 2021. All studies which compared outcomes for different types or uses of thoracic drainage, or reported outcomes directly related to chest drains in oesophageal surgery were included. Studies were collated into domains based on variations in number, position, type, removal criteria, diagnostic use and complications of drains. Methodological quality was assessed by the Newcastle-Ottawa and Jadad Scores. Results 28 studies met the inclusion criteria. Four studies compared drain numbers, three showed similar outcomes and pain reduction using one. A single study showed that another, ‘anastomotic drain’ aided diagnosis and reduced leak mortality. Transhiatal drains had less pain and similar outcomes compared to intercostal drains. Drain fluid amylase aids leak diagnosis, however, accuracy requires drains to remain for 6 days. Removal of drains with daily volumes of less than 300 mL did not impact effusion rate. Complications can arise from drains with a 7% chance of drains migrating into the lumen of a leak and a risk of drain-site metastasis. Conclusion Drain use is a small facet of oesophageal surgery that can have a significant impact on outcomes. There is no evidence for non-drain use. A single transhiatal drain reduces pain without impacting on outcomes. Drains can have a role in diagnosing and managing anastomotic leaks, however, to be accurate drains have to stay in situ for longer. This extends patients discomfort and moves away from ERP trends and other surgical specialities.

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An Expanded Preoperative Component within an Enhanced Recovery Protocol Improves Outcomes in Colorectal Surgery

The American Surgeon ◽

10.1177/000313481708300849 ◽

2017 ◽

Vol 83 (8) ◽

pp. 928-934

Author(s):

Nathan M. Johnson ◽

Sandy L. Fogel

Keyword(s):

Colorectal Surgery ◽

Length Of Stay ◽

Enhanced Recovery ◽

Statistical Significance ◽

Current Evidence ◽

P Value ◽

Postoperative Length ◽

Enhanced Recovery Protocol ◽

Recovery Protocols ◽

Colorectal Procedures

Enhanced Recovery Protocols (ERPs) have been shown to lead to quicker recovery in colorectal surgery, with reduced postoperative length of stay (LOS). ERPs could potentially be improved with an expanded preoperative component reflecting current evidence. We hypothesize that an ERP with an expanded preoperative component will reduce LOS consistent with or exceeding that seen with traditional ERPs. Our ERP was implemented in June of 2014. Data was collected for two full years from July 2014 through June 2016. The protocol was employed in colorectal cases, both elective and emergent. Data from ERP cases were compared with contemporaneous controls that did not go through the ERP. Patients who underwent colorectal procedures and participated in the ERP with the expanded preoperative component had an average LOS of 5.33 days, whereas controls stayed for an average of 7.93 days (P value, <0.01). ERP cases also experienced fewer read-missions and complications, although statistical significance could not be established. The results demonstrate that an ERP with an enhanced preoperative component significantly reduces LOS and potentially decreases the rate of readmissions and total complications.

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