OBJECTIVES: To describe a consensus review of optimal perioperative care in colorectal surgery and to provide consensus recommendations for each item of an evidence-based protocol for optimal perioperative care. DATA SOURCES: For every item of the perioperative treatment pathway, available English-language literature has been examined. STUDY SELECTION: Particular attention was paid to meta-analyses, randomized controlled trials, and systematic reviews. DATA EXTRACTION: A consensus recommendation for each protocol item was reached after critical appraisal of the literature by the group. DATA SYNTHESIS: For most protocol items, recommendations are based on good-quality trials or meta-analyses of such trials. CONCLUSIONS: The Enhanced Recovery After Surgery (ERAS) Group presents a comprehensive evidence-based consensus review of perioperative care for colorectal surgery. It is based on the evidence available for each element of the multimodal perioperative care pathway.

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Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations.

The aims of severe perioperative bleeding management are three-fold. First, preoperative identification by anamesis and laboratory testing of those patients for whom the perioperative bleeding risk may be increased. Second, implementation of strategies for correcting preoperative anaemia and stabilisation of the macro- and microcirculations in order to optimise the patient’s tolerance to bleeding. Third, targeted procoagulant interventions to reduce the amount of bleeding, morbidity, mortality and costs. The purpose of these guidelines is to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthetists throughout Europe to integrate this knowledge into daily patient care wherever possible. The Guidelines Committee of the European Society of Anaesthesiology (ESA) formed a task force with members of scientific subcommittees and individual expert members of the ESA. Electronic databases were searched without language restrictions from the year 2000 until 2012. These searches produced 20 664 abstracts. Relevant systematic reviews with meta-analyses, randomised controlled trials, cohort studies, case-control studies and cross-sectional surveys were selected. At the suggestion of the ESA Guideline Committee, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was initially used to assess the level of evidence and to grade recommendations. During the process of guideline development, the official position of the ESA changed to favour the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. This report includes general recommendations as well as specific recommendations in various fields of surgical interventions. The final draft guideline was posted on the ESA website for four weeks and the link was sent to all ESA members. Comments were collated and the guidelines amended as appropriate. When the final draft was complete, the Guidelines Committee and ESA Board ratified the guidelines.

https://epub.ub.uni-muenchen.de/24023/1/oa_24023.pdf

Management of severe perioperative bleeding Guidelines from the European Society of Anaesthesiology

Purpose Preoperative short-term radiotherapy improves local control in patients treated with total mesorectal excision (TME). This study was performed to assess the presence and magnitude of long-term side effects of preoperative 5 × 5 Gy radiotherapy and TME. Also, hospital treatment was recorded for diseases possibly related to late side effects of rectal cancer treatment. Patients and Methods Long-term morbidity was assessed in patients from the prospective randomized TME trial, which investigated the efficacy of 5 × 5 Gy before TME surgery for mobile rectal cancer. Dutch patients without recurrent disease were sent a questionnaire. Results Results were obtained from 597 patients, with a median follow-up of 5.1 years. Stoma function, urinary function, and hospital treatment rates did not differ significantly between the treatment arms. However, irradiated patients, compared with nonirradiated patients, reported increased rates of fecal incontinence (62% v 38%, respectively; P < .001), pad wearing as a ...

https://ascopubs.org/doi/pdf/10.1200/JCO.2005.14.779

Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer : Increased bowel dysfunction in irradiated patients - A dutch colorectal cancer group study

BACKGROUND: Complications from major surgery are undesirable, common, and potentially avoidable. The long-term consequences of short-term surgical complications have recently been recognized to have a profound influence on longevity and quality of life in survivors. In the past 30 years, there have been a number of studies conducted attempting to reduce surgical mortality and morbidity by deliberately and preemptively manipulating perioperative hemodynamics. Early studies had a high control-group mortality rate and were criticized for this as being unrepresentative of current practice and raised opposition to its implementation as routine care. We performed this review to update this body of literature and to examine the effect of changes in current practice and quality of care to see whether the conclusions from previous quantitative analyses of this field remain valid. METHODS: Randomized clinical trials evaluating the use of preemptive hemodynamic intervention to improve surgical outcome were identified using multiple methods. Electronic databases (MEDLINE, EMBASE, and the Cochrane Controlled Clinical Trials register) were screened for potential trials, reference lists of identified trials were examined, and additional sources were sought from experts and industry representatives. Identified studies that fulfilled the entry criteria were examined in full and subjected to quantifiable analysis, subgroup analysis, and sensitivity analysis where possible. RESULTS: There were 29 studies identified, 23 of which reported surgical complications. In total, the 29 trials involved 4805 patients with an overall mortality of 7.6%. The use of preemptive hemodynamic intervention significantly reduced mortality (pooled odds ratio [95% confidence interval] of 0.48 [0.33-0.78]; P = 0.0002) and surgical complications (odds ratio 0.43 [0.34-0.53]; P < 0.0001). Subgroup analysis showed significant reductions in mortality for studies using a pulmonary artery catheter, supranormal resuscitation targets, studies using cardiac index or oxygen delivery as goals, and the use of fluids and inotropes as opposed to fluids alone. By contrast, there was a significant reduction in morbidity for each of the 4 subgroups analyzed. CONCLUSION: The use of a preemptive strategy of hemodynamic monitoring and coupled therapy reduces surgical mortality and morbidity.

A Systematic Review and Meta-Analysis on the Use of Preemptive Hemodynamic Intervention to Improve Postoperative Outcomes in Moderate and High-Risk Surgical Patients

Objective: The aim of this study was to develop and validate a scoring system for bowel dysfunction after low anterior resection (LAR) for rectal cancer, on the basis of symptoms and impact on quality of life (QoL). Background: LAR for rectal cancer often results in severe bowel dysfunction (LAR syndrome [LARS]) with incontinence, urgency, and frequent bowel movements. Several studies have investigated functional outcome, but the terminology is inconsistent hereby complicating comparison of results. Methods: Questionnaires regarding bowel function was sent to all 1143 LAR patients eligible for inclusion identified in the national Colorectal Cancer Database. Associations between items and QoL were computed by binomial regression analyses. The important items were selected and regression analysis was performed to find the adjusted risk ratios. Individual score values were designated items to form the LARS score, which was divided into “no LARS,” “minor LARS,” and “major LARS.” Validity was tested by receiver operating characteristic (ROC) curve and Spearman’s rank correlation and discriminant validity was tested by Student t tests. Results: A total of 961 patients returned completed questionnaires. The 5 most important items were “incontinence for flatus,” “incontinence for liquid stools,” “frequency,” “clustering,” and “urgency.” The range (0‐42) was divided into 0 to 20 (no LARS), 21 to 29 (minor LARS), and 30 to 42 (major LARS). The score showed good correlation and a high sensitivity (72.54%) and specificity (82.52%) for major LARS. Discriminant validity showed significant differences between groups with and without radiotherapy (P < 0.0001), tumor height more or less than 5 cm (P < 0.0001), and total mesorectal excision/ partial mesorectal excision (P = 0.0163). Conclusions: We have constructed a valid and reliable LARS score correlated to QoL—a simple tool for quick clinical evaluation of the severity of LARS. (Ann Surg 2012;255:922‐928)

Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer.

Background Occult hypovolaemia is a key factor in the aetiology of postoperative morbidity and may not be detected by routine heart rate and arterial pressure measurements. Intraoperative gut hypoperfusion during major surgery is associated with increased morbidity and postoperative hospital stay. We assessed whether using intraoperative oesophageal Doppler guided fluid management to minimize hypovolaemia would reduce postoperative hospital stay and the time before return of gut function after colorectal surgery. Methods This single centre, blinded, prospective controlled trial randomized 128 consecutive consenting patients undergoing colorectal resection to oesophageal Doppler guided or central venous pressure (CVP)-based (conventional) intraoperative fluid management. The intervention group patients followed a dynamic oesophageal Doppler guided fluid protocol whereas control patients were managed using routine cardiovascular monitoring aiming for a CVP between 12 and 15 mm Hg. Results The median postoperative stay in the Doppler guided fluid group was 10 vs 11.5 days in the control group P Conclusions Intraoperative oesophageal Doppler guided fluid management was associated with a 1.5-day median reduction in postoperative hospital stay. Patients recovered gut function significantly faster and suffered significantly less gastrointestinal and overall morbidity.

Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery

Introduction Colonoscopic surveillance after colorectal cancer resection is widely practised despite little evidence that it improves survival. The optimum protocol for colonoscopic follow-up after colorectal cancer resection has not yet been elucidated. We audited the outcome of an empirical colonoscopic follow-up programme in a cohort of patients who underwent colorectal resection with a minimum of five years follow-up to establish patterns of metachronous neoplasia and suitable surveillance intervals.



Methods  The colonoscopic records, biopsy results and follow-up details of patients diagnosed with colorectal cancer between June1990 and June1996 were reviewed. The number and type of metachronous neoplastic lesions diagnosed was recorded. Rates of development of new neoplasms were estimated by calculating the time from operation to their first discovery. Factors predictive of further development of polyps or cancer were sought. Results were compared to published reports of intensive follow-up programmes.



Results  Seven hundred and ninety-eight patients underwent colorectal resection with curative intent during the study period. 226 patients had one or more follow-up colonoscopies (mean time post resection 48.8 months). In total 352 colonoscopies, encompassing 1437 patient years of surveillance, were performed. Nine metachronous cancers in eight patients, five of which were asymptomatic were diagnosed by colonoscopy at a mean of 63 months. Three asymptomatic recurrences were diagnosed but all were inoperable. 70 (31%) patients had adenomatous polyps diagnosed after a mean time from operation of 34 months for simple adenomatous polyps and 21 months for those with advanced features. Patients with multiple polyps or advanced polyps at the initial colonoscopy were more likely to form subsequent polyps. Only 5.8% of patients with a single adenoma or a normal colon formed an advanced adenoma over the next 36 months of surveillance.



Conclusion  The results of an empirical colonoscopic follow-up programme compared favourably to the results of the intensive programmes reported in the literature. Most patients are at very low risk of developing significant colonic pathology over the first five years after resection. Colonoscopic surveillance intervals need not be less than five years unless the patient has multiple adenomas or advanced adenomas at the first colonoscopy. Three yearly surveillance intervals are most probably adequate in these individuals.

Colonoscopic surveillance after curative colorectal resection: Results of an empirical surveillance programme

Objective To determine the contribution of total mesorectal excision (TME), short-course pre-operative radiotherapy (SCRT), the level of the anastomosis and other putative contributory factors to the incidence and degree of faecal incontinence after anterior resection of the rectum.



Patients and methods  Survivors of anterior resection of the rectum performed between February 1996 and February 2001, with a functioning anastomosis, were asked to complete a telephone questionnaire regarding their current bowel habit. Faecal incontinence was scored using the St. Mark's Incontinence Score.



Results  The median age of 124 patients who completed the questionnaire was 76 years. Of these, 104 patients had neoplastic disease, 66 (53%) patients exhibited some degree of incontinence, median St. Marks' Score 6, interquartile range 3–10. There was a significant association between the anastomotic level, and the St. Mark's Score (P < 0.0001, linear regression). Male sex (P = 0.047), SCRT (P = 0.0014) and an anastomotic leak (P = 0.038) were associated with significantly higher incontinence scores. Age, splenic flexure mobilization, TME, anastomotic configuration or use of a temporary stoma had no detectable independent effect on incontinence scores.



Conclusions  Poor functional outcome following anterior resection was associated with a low anastomosis, SCRT or an anastomotic leak. The finding that SCRT was a predictor of postoperative incontinence emphasizes the need for stringent patient selection for this treatment modality.

W. F. A. Miles

Papers

Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery

Colonoscopic surveillance after curative colorectal resection: Results of an empirical surveillance programme

Pre-operative short-course radiotherapy is associated with faecal incontinence after anterior resection.