Accelerated 23-h enhanced recovery protocol for colon surgery: the CHASE-study

Abstract

The introduction of the Enhanced Recovery After Surgery (ERAS) program has radically improved postoperative outcomes in colorectal surgery. Optimization of ERAS program to an accelerated recovery program may further improve these said outcomes. This single-center, prospective study investigated the feasibility and safety of a 23-h accelerated enhanced recovery protocol (ERP) for colorectal cancer patients (ASA I–II) undergoing elective laparoscopic surgery. The 23-h accelerated ERP consisted of adjustments in pre-, peri- and postoperative care; this was called the CHASE-protocol. This group was compared to a retrospective cohort of colorectal cancer patients who received standard ERAS care. Patients were discharged within 23 h after surgery if they met the discharge criteria. Primary outcome was the rate of the successful discharge within 23 h. Successful discharge within the CHASE-cohort was realized in 33 out of the 41 included patients (80.5%). Compared to the retrospective cohort (n = 75), length of stay was significantly shorter in the CHASE-cohort (p = 0.000), and the readmission rate was higher (p = 0.051). Complication rate was similar, severe complications were observed less frequently in the CHASE-cohort (4.9% vs. 8.0%). Findings from this study support the feasibility and safety of the accelerated 23-h accelerated ERP with the CHASE-protocol in selected patients.

Same-day discharge (SDD) vs standard enhanced recovery after surgery (ERAS) protocols for major colorectal surgery: a systematic review

“… Preoperative selection based on clinical and social factors. SDD offered only if patient lived within proximity of the hospital (< 10 miles) Tweed et al (2022) [ 32 ] Pre-operative: - Dedicated preoperative counselling - Baseline assessment with physical examination, electrocardiogram on indication and standard laboratory work-up - Nutritional screening by dietician - Fasting 6 h prior to surgery for solid food and 2 h prior to surgery for liquids - Oral carbohydrate loading for non-diabetic patients at least 2 h prior to surgery - Bowel preparation with bisacodyl (2 tablets of 5 mg the night before surgery and 1 tablet the morning of surgery) for patients scheduled for left-sided colon surgery - Preoperative analgesia with 1000 mg Paracetamol and 600 mg Gabapentin (300 mg if glomerular filtration rate < 60 ml/min or age > 70 years) Intraoperative: - Spinal anaesthesia (Prilocaine)* prior to induction of general anaesthesia - Use of short-acting total intravenous anaesthesia (propofol, remifentanil and ketamine) - Restrictive fluid management with continuous perfusion of Ringer Lactate 3 ml/kg/h - Deep neuromuscular blockade (Rocuronium bromide perfusion) - Lung protective ventilation (Total Volume 6–8 ml/kg; minimum FiO2 and optimal PEEP) - Adequate temperature regulation with forced air warming and core temperature monitoring - Starting intra-abdominal pressure at 12 mmHg with a gradual decrease to 8 mmHg - Minimally invasive surgery with intracorporal anastomosis - Extraction of specimen through a suprapubic Pfannenstiel incision, no additional mini-laparotomy performed Post-operative – directly: - Postoperative pain management consisted of Paracetamol (4 × 1000 mg), Meloxicam (1 × 7.5 mg daily for 3 days). If indicated, 5–20 mg Oxynorm (per os) or opioids in the form of Piritramide (intravenously) were given - Intake and gastro-intestinal motility were stimulated by offering an ice lolly on the recovery ward - Mobilisation was actively stimulated - If an urinary catheter was placed; this was removed before 10:00 PM on the surgical ward POD 1: - Routine physical examination by the ward physician - Evaluation of recovery and readiness for discharge - Expectation management regarding postoperative recovery and provision of an information booklet about postoperative recovery *Initially, patients received a combination of spinal anaesthesia with bupivacaine-glucose and morphine intrathecally prior to general anaesthesia.…”

“…1 ) and were deemed to be methodologically robust. Three studies, by de Azevedo et al [ 27 ], Popeskou et al [ 31 ], and Tweed et al [ 32 ], had moderate risks of bias, mainly due to missing data and selection of participants.…”

“… McKenna et al (2020) [ 30 ] Not stated Not stated Overall readmission: P = 0.04 Discharged POD 0–1: 43 (4.8%) Discharged POD 2: 349 (5.1%) Discharged POD 3–5: 1670 (5.8%) Overall complication rate not stated The post discharge rate of anastomotic leak in the early discharge group was only 1%, and this was similar to the anastomotic leak rate in the intermediate (1%) and standard (1%) discharge groups. The rate of both ileus (early: 2%, intermediate: 2%, standard: 2%) were similar across the 3 discharge groups, as were other postoperative complications Not stated Not stated Popeskou et al (2022) [ 31 ] 30-day mortality SDD: 0 (0%) Control:2 (0.3%) Not stated 30-day readmission rate: SDD: 4 (7.8%) - 1 SBIO from adhesions - 1 extraction site wound abscess - 1 nausea - 1 superficial abdominal pain Control: 72 (9.2%) Not stated 100% adherence rate Not stated Levy et al (2009) [ 33 ] Not stated Median post-operative stay P = 0.01 SDD: 0.95 days (IQR 0.95–0.96) Control: 3.2 days (IQR 2.4–3.9) 0 0 Not stated All patients were satisfied with the service; all ten would request to follow the same pathway again if required, and all would recommend it to other patients Tweed et al (2022) [ 32 ] 30 day mortality SDD: 0% Control:0% Median primary length of hospital stay P = 0.000 SDD (out of 41): LOS 1 day: 33 (80.5%) LOS 2 days: 6 (14.9%) LOS 3 days: 2 (4.9%) Control: LOS 1 day: 0 LOS 2 days: 9 (12%) LOS 3 days: 38 (50.7%) LOS > 3 days: 28 (37.3%) 30-day readmission rate: P = 0.051 SDD (out of 41 pts): 7 (17.1%) - 1 Anastomotic leak - 1 Trocal hernia - 2 Rectal blood loss - 1 Ileus - 1 Pneumonia - 1 Dizziness Control: 4 (5.3%) - 1 Anastomotic leak - 1 Ileus - 1 Biliary pancreatitis - 1 Abscess Patients discharged < 23 h (out of 33 patients): 6 (18.2%) P = 0.565 SDD (out of 41 pts): 13 (31.7%) ...…”

“…SDD protocols did not lead to increased 30-day readmission rates compared to standard ERAS. Six studies, by Bednarski et al [ 23 ], Brandt et al [ 24 ], Lee et al [ 29 ], Popeskou et al [ 31 ], Tweed et al [ 32 ], and Levy et al [ 33 ], reported no significant differences in 30-day readmission rates between both groups. The remaining two studies did not publish readmission rate data for the control group but reported a 30-day readmission rate of 6.8% and 0% in the SDD group [ 27 , 33 ].…”

“…Of the five single-arm studies, three studies, by Gignoux et al [ 22 ], Dobradin et al [ 28 ] and Gignoux et al [ 35 ] reported mean LOS, which ranged from 10 h 24 min [ 35 ] to 21 h 47 min [ 28 ]. Four comparative studies, by Bednarski et al [ 23 ], Lee et al [ 29 ], Levy et al [ 33 ], Tweed et al [ 32 ] reported mean or median LOS, showing significantly reduced LOS in the SDD group compared to the control group. Bednarski et al demonstrated that SDD reduced the LOS by 25.6 h as compared to standard ERAS (28.2 h vs 53.8 h, P = 0.002) [ 23 ].…”