Surgical Stress Reduction in Elderly Patients Undergoing Elective Colorectal Laparoscopic Surgery within an ERAS Protocol

Abstract

ERAS program applied to colorectal laparoscopic surgery is well known to reduce hospitalization improving short terms outcomes and minimizing the Surgical Stress Response. However its effectiveness in elderly population is yet to be demonstrated. The primary aim of this study is to compare the level of immune and nutritional serum indexes across surgery in patients aged over 70 years old undergoing elective colorectal laparoscopic surgery within an ERAS protocol or according to a Standard program. 83 patients undergoing colorectal laparoscopic surgery were enrolled and randomized in two groups (ERAS Group 40, Standard Group 43) within a larger randomized trial on a general population. Surgical stress parameters were collected preoperatively, 1, 3 and 5 days after surgery. Nutritional parameters were collected preoperatively, 1 and 5 days after surgery. Short Term Outcomes were also prospectively assessed. IL-6 levels were lower in the EG on 1, 3, and 5 days post-operatively (p 0.05). IL-6 levels in the Enhanced group returned to pre operative level 3 days after surgery. C-reactive protein level was lower in the Enhanced group on day 1, 3, and 5 (p 0.05). There was no difference in Cortisol and Prolactin levels between groups. Prealbumin serum level was higher on day 5 (p 0.05) compared to standard group. Postoperative outcomes in terms of normal bowel function and length of hospital stay were significantly improved in the ERAS group. Colorectal laparoscopic surgery within an ERAS prototcol in elderly patients affects Surgical Stress Response, decreasing IL-6 and CRP levels postoperatively and improving Prealbumin post operative synthesis.

C‐reactive protein as a marker of the surgical stress reduction within an ERAS protocol (Enhanced Recovery After Surgery) in colorectal surgery: A prospective cohort study

“…These results are consistent with findings from other centers . In other words, laparoscopic surgery appears to be associated with a reduction in the postoperative SIR, as evidenced by circulating concentration of CRP following colorectal surgery, and is likely to reduce the surgical stress response as part of an ERAS protocol . However, several studies have reported no differences in postoperative serum CRP when those undergoing laparoscopic colorectal surgery were compared with those undergoing open procedures .…”

“…These results are consistent with findings from other medical centres that conclude that the ERAS protocol decrease the SIR to surgery. 4,5,7,25,26 There is a statistically significant difference in the CRP values between patients operated by laparoscopy versus those operated by open surgery in POD1 and POD2, but not in POD3. The increase in laparoscopic surgery in the ERAS group may be one of the causes that has reduced the values of CRP in that group.…”

“…This includes: mechanical bowel preparation; avoidance of nasogastric tubes and drains; the preoperative fasting and carbohydrate loading; the early postoperative enteral nutrition; and the early mobilization. No studies have examined the impact of ERAS protocols as a whole versus standard perioperative care on the postoperative SIR in colorectal surgery, without the inclusion of a laparoscopic surgery versus open surgery arm, making the assessment of the impact of ERAS protocols difficult . It is important to conduct a larger study in order to objectively collect evidence of the effect of individual components of ERAS protocols in reducing the stress response following colorectal surgery.…”

“…Hospitalization and surgery affect the normal homeostasis. This process is called Surgical Stress Response or Systemic Inflammatory Response (SIR) to surgery and involves both immune and neuro‐endocrine systems . One of the markers of SIR is C‐reactive protein (CRP).…”

“…systems. 7,8 One of the markers of SIR is C-reactive protein (CRP). It is used to detect postoperative complications resulting from surgical injury and as a useful tool to ensure a safe early discharge following colorectal surgery.…”