Prehabilitation in patients undergoing colorectal surgery fails to confer reduction in overall morbidity: Results of a single-center, single-blinded, randomized controlled trial

Objective Patients undergoing major surgery are prone to a functional decline due to the impairment of muscle, cardiorespiratory and neurological function as a response to surgical stress. Currently, there are solely weak recommendations in the ERAS protocol regarding the role of preoperative physical activity and prehabilitation in patients undergoing colorectal surgery. Studies in heterogenous cohorts showed contradictory results regarding the impact of prehabilitation on the reduction of postoperative complications. This randomized controlled trial assesses the impact of prehabilitation on postoperative complications in patients undergoing colorectal surgery within an ERAS protocol. Methods Between July 2016 and June 2019, a single-center, single-blinded , randomized controlled trial designed to test whether physiotherapeutic prehabilitation vs. normal physical activities prior to colorectal surgery may decrease morbidity within a stringent ERAS protocol was carried out. The primary endpoint was postoperative complications assessed by Comprehensive Complications Index (CCI®). Primary and secondary endpoints for both groups were analyzed and compared. Results A total of 107 patients (54 in the pERACS and 53 in the control cohort) were included in the study and randomized. Dropout rate was 4.5% (n = 5). Mean age (SD) in the control cohort was 65 (29–86) and 66 (24–90) years in pERACS cohort. The pERACS cohort contained more female patients (40% vs. 55%, p = 0.123) and a higher percentage of colorectal adenocarcinoma (32% vs. 23%, p = 0.384) although not significant. Almost all patients underwent minimally invasive surgery in both cohorts (96% vs 98%, p = 1.000). There was no between-cohort difference in the primary outcome measure 30-day Comprehensive Complications Index (15 [0 – 49] vs. 18 [0 – 43], p = 0.059). Secondary outcome as complications assessed according to Clavien-Dindo, length of hospital stay, reoperation rate and mortality showed no difference between both cohorts. Conclusion Routine physiotherapeutic prehabilitation cannot be recommended for patients undergoing colorectal surgery within an ERAS protocol (Grade A recommendation). To eliminate other confounders like geographical difference or difference in surgical technique, further multicenter RCTs are needed.

“Micro Hand S” Surgical Robot vs Laparoscopic Gastrectomy for Gastric Cancer: Comparison of Short-Term Outcomes

Background Expensive cost of surgery has limited the use of surgical robot in China. The emergence of “Micro Hand S” surgical robot provides more choices for surgical treatment. Our study was to evaluate the safety and feasibility of “Micro Hand S” surgical robotic gastrectomy for gastric cancer. Methods Perioperative data of 75 patients who underwent “Micro Hand S” surgical robotic gastrectomy (RG) or laparoscopic gastrectomy (LG) at the Department of General Surgery, Third Xiangya Hospital, Central South University from June 2017 to January 2019 were collected to compare the short-term outcomes between the two groups. Results No statistically significant difference was found in baseline characteristics between the two groups (P > 0.05). RG group had longer operation time (P < 0.01). The harvested lymph nodes were comparable between the two groups (P = 0.084). There were five positive margins in the LG group, and the R0 resection rate was comparable between the two groups (P = 0.247). 16 complications occurred in the RG group according to the Clavien-Dindo classification system, 6 in grade I, and 10 in grade II. 68 complications happened in the LG group, 22 in grade I, 44 in grade II, 1 in grade IIIa and 1 in grade IVa. The comprehensive complications index (CCI) was similar between the two groups (P = 0.895). Intraoperative blood loss, surgical resection, reconstruction of the digestive tract intraoperative blood transfusion, Chemoradiotherapy, pathological type, degree of differentiation, proximal resection margin, time of first flatus, time of liquid diet, time of abdominal drainage tube extraction, and hospital stay for RG and LG were similar too (P > 0.05). Conclusion “Micro Hand S” surgical robotic gastrectomy is safe and feasible. Keywords Surgical robot; Gastric cancer; Gastrectomy; Safety; Feasibility

P162 ENHANCED RECOVERY PROTOCOL COMPLIANCE AND CLINICAL OUTCOMES IN ESOPHAGECTOMY FOR CANCER: DESIGN OF A MEASURING INSTRUMENT

Objectives Success of an enhanced recovery program (ERP) is not easily measured/quantified. Can a newly developed measuring instrument help to determine compliance and thus success of an ERP? Methods From the introduction of our ERP (May 2017), 200 consecutive potential curative esophagectomies for cancer were reviewed. A newly developed instrument with 12 prospectively recorded benchmarks was used to measure compliance. Each patient was scored for all benchmarks, reflecting how well the protocol-timeline was followed. A mean score of ≥70% of all benchmarks in a patient is considered compliant with the ERP-protocol. Results Sixty-three percent (125/200) of the patients were compliant (Fig1A). Compliance to the ERP showed significant beneficial effects on clinical outcomes: the comprehensive complications index was significantly lower in the compliant group compared to the not-compliant group: 22.6 versus 43.3; p<0.0001. This resulted in a significant lower median (IQR) length of stay between both groups: 9 (8-10) days versus 14 (11-22) days; p<0.0001. Some of the benchmarks showed a direct relation to individual complications, e.g. the percentage of pneumonias is correlated to the benchmark ‘active mobilization on postoperative day1’ (Fig1B) Conclusion Higher compliance to the ERP protocol helps to reduce postoperative complications and thus shortens the postoperative hospital stay.

O18 TREATMENT OF ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY (TENTACLE STUDY)

Aim The aim of this study is to investigate which factors contribute to anastomotic leakage severity and to compose an evidence based anastomotic leakage severity score. Secondly, we aim to investigate which anastomotic leakage characteristics are associated with success of different anastomotic leakage treatments and to compare the effectiveness of different initial anastomotic leakage treatments for anastomotic leakage classified according to severity and leakage characteristics. Background Anastomotic leakage occurs in 0%-30% after esophagectomy for cancer. It is a severe complication with mortality rates approximately ranging from 2%-12%. In addition, it is associated with a prolonged ICU treatment and hospital stay. Anastomotic leakage severity is currently graded according to how it is treated (grade I: conservative treatment, grade II: endoscopic/radiologic intervention and grade III: surgical intervention). However, this scoring system cannot be used to guide decision making when anastomotic leakage is diagnosed in a clinical setting. Factors that may influence the severity of the anastomotic leakage are (amongst others) location of the anastomosis, estimated surface of the defect, estimated circumference of the defect, extent of contamination, degree of sepsis and time from diagnosis until therapy. However, little is known about to what extent these and other factors contribute to anastomotic leakage severity. In addition, there is a paucity of data on what leakage characteristics dictate the success of a specific treatment. Methods We will perform an international multicenter retrospective cohort study. All adult patients with anastomotic leakage according to the ECCG definition after esophagectomy and gastric conduit reconstruction for esophageal cancer are suitable for inclusion. We aim to include at least 1000 patients. The primary outcome parameter is 90-day mortality. Secondary outcome parameters are in-hospital mortality, 30-day mortality, 180-day mortality, comprehensive complications index, total number of reinterventions, hospital and ICU length of stay and hospital related costs. Results Data collection will take place from April 2019 until December 2019. Study results are expected in June 2020. Conclusion We hypothesize that we will be able to identify factors that influence the severity of the anastomotic leakage and to compose a leakage severity score. Furthermore, we expect to identify leakage characteristics dictating the success of a specific treatment.