Alan Horgan

Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection

Protocolized fluid administration using oesophageal Doppler monitoring may improve the postoperative outcome in patients undergoing surgery.

Pre‐operative oral carbohydrate loading in colorectal surgery: a randomized controlled trial

Objectiveu2002 Surgery induces a catabolic response with stress hormone release and insulin resistance. The aim of this study was to assess the effect of pre‐operative carbohydrate administration on grip strength, gastrointestinal function and hospital stay following elective colorectal surgery.

Tumour cell dissemination following endoscopic stent insertion

This study examined whether colonoscopy or endoscopic stent insertion increases levels of carcinoembryonic antigen (CEA) and/or cytokeratin (CK) 20 mRNA expression in the peripheral circulation of patients with colorectal cancer.

Preoperative Intensive, Community-Based vs. Traditional Stoma Education: A Randomized, Controlled Trial

PURPOSEConventional practice in colorectal surgery involves stoma education being imparted postoperatively. Proficiency in stoma management often delays patients’ discharge following colorectal surgery. The aim of this randomized, controlled trial was to compare preoperative intensive, community-based stoma education with conventional postoperative stoma education after elective colorectal surgery.METHODSForty-two elective colorectal patients requiring a stoma were randomized into an intensive preoperative teaching (study) or postoperative (control) group. Intervention for the study group included two preoperative visits in the community during which patients were taught with audiovisual aids to use and change the stoma pouching system. Goal-directed postoperative stoma education was standardized for both groups. Outcomes measured included time to stoma proficiency, postoperative hospital stay, unplanned stoma-related interventions in the community within six weeks of discharge, and preoperative and postoperative hospital anxiety and depression scores. Cost-effectiveness of the intervention was also evaluated.RESULTSAll outcomes measured were improved in the study group, including time to stoma proficiency(5.5 vs. 9 days; P = 0.0005), hospital stay (8 vs. 10 days; Pn = 0.029), and unplanned stoma-related community interventions per patient (median 0 vs. 0.5; P = 0.0309). No adverse effects of the intervention were noted. The average cost saving per patient was £1,119 (

Rectoanal inhibitory reflex following low stapled anterior resection of the rectum

2,104) for the study group compared with the control group.CONCLUSIONSStoma education is more effective if undertaken in the preoperative setting. It results in shorter times to stoma proficiency and earlier discharge from the hospital. It also reduces stoma-related interventions in the community and has no adverse effects on patient well-being.

A prospective case-matched comparison of clinical and financial outcomes of open versus laparoscopic colorectal resection.

The rectoanal inhibitory reflex plays an important role in the normal mechanisms of anorectal continence. Anterior resection abolishes the reflex, but whether it recovers, particularly after inverted stapled anastomosis, is not clear. Anal manometry was performed on patients undergoing low anterior resection for carcinoma. Maximum anal resting pressure and the rectoanal inhibitory reflex were assessed preoperatively and up to two years postoperatively. The reflex was present in 43 of 46 patients (93 percent) preoperatively, in 8 of 45 patients (18 percent) on the 10th postoperative day, and in 6 of 29 patients (21 percent) between six months and one year following surgery. Twenty patients were studied more than two years postoperatively, and in 17 (85 percent) the reflex was demonstrated. In the majority of low anterior resection patients, the rectoanal inhibitory reflex is abolished by surgery, remains absent throughout the first year, and has recovered by the end of the second postoperative year. This may be important in the recovery of anorectal function in these patients.

Perioperative fluid management: Consensus statement from the enhanced recovery partnership

BackgroundWe aimed to assess the clinical outcomes and costs associated with laparoscopic resection within an elective colorectal practice.MethodOver a 12-month period data were prospectively collected on patients undergoing elective colorectal resection under the care of a single consultant surgeon. Thirty patients undergoing laparoscopic colorectal resection were case-matched by type of resection, disease process, and, where appropriate, cancer stage to patients having open surgery. A cost analysis was carried out incorporating cost of surgical bed stay, theater time, and specific equipment costs.ResultsIn the 30 patients having laparoscopic resection, a conversion rate of 13% was observed. Surgery was performed for colorectal cancer in 83% of patients, and 53% of resections were rectal. No significant differences were found in age (65 versus 69 years, p = 0.415), BMI (27.4 versus 26.1, p = 0.527), POSSUM physiology score (16 versus 16.5, p = 0.102), American Society of Anesthesiologists (ASA) grade (2 versus 2, p = 0.171), or length of theater time (160 min versus 160 min, p = 0.233) between the laparoscopic and open patients. Hospital stay was reduced in the laparoscopic group (5 versus 9 days, p < 0.001). Average cost of surgical equipment used for a laparoscopic resection was greater than for open surgery (£912.39 versus £276.41, p = 0.001). Cost of hospital stay was significantly less (£1259.75 versus £2267.55, p < 0.001). Cost of operating room time was similar for the two groups (£2066.63 versus £1945.07, p = 0.152). Overall no significant cost difference could be found between open and laparoscopic resection (£4560.9 versus £4348.45, p = 0.976). More postoperative complications were seen in the open resection group (14 versus 4, p < 0.001).ConclusionsIntraoperative equipment costs are greater for laparoscopic resection than for open surgery. However, benefits can be seen in terms of quicker recovery and shorter hospital stay. Laparoscopic surgery is a financially viable alternative to open resection in selected patients.

Consensus views on implementation and measurement of enhanced recovery after surgery in England: Delphi study.

Enhanced Recovery (ER) after Surgery (or Fast Track) is a bundle of ‘best evidence based practices’ delivered by a multi-professional health care team, with the intention of helping patients recover faster after surgery [1]. Professor Henrik Kehlet, a surgeon from Denmark, pioneered the concept more than a decade ago but practitioners in the UK remained sceptical of his amazing results and adoption in the National Health Service (NHS) had been slow [1,2]. The Enhanced Recovery Partnership Programme (ERPP) was set up by the Department of Health in England in May 2009, to encourage the widespread adoption of ER with the aim of improving recovery from major surgery [1,3]. The Programme initially concentrated on elective major surgery in four specialities (Colorectal, Musculoskeletal, Gynaecology and Urology). Audit of ER practice by the early adopters demonstrated greater than 80% compliance with the majority of elements recommended by the ERPP. However, perioperative fluid management including the administration of pre-operative carbohydrate drinks and individualised goal directed fluid management guided by advanced haemodynamic monitoring (e.g. Oesophageal Doppler) had lower levels of compliance [3]. A pilot study using Commissioning for Quality and Innovation (CQUIN) to encourage practice change showed a dramatic improvement in outcomes in North Central London with very high levels of compliance with the ERPP recommended principles of perioperative fluid management, in particular goal directed fluid management [4]. n nThe National Programme has evolved into the Enhanced Recovery Partnership (ERP), and the most recent guide published by the ERP includes evidence of widespread adoption of ER in the NHS in England and achievement of stated goals i.e. reduced length of hospital stay after surgery resulting in more operations being performed despite fewer bed days, no increase in readmissions and high levels of patient satisfaction [5]. Perioperative fluid management is at the heart of Enhanced Recovery and the use of intra-operative fluid management technology, such as Oesophageal Doppler, is supported by the ERP in line with the National Institute of Clinical Excellence (NICE) Guidance (MTG3), the NHS Operating Framework 2012–13 and the Department of Health Innovation Health and Wealth Review 2011 [5-7]. Despite concordance in the guidelines, the veracity of the evidence has been challenged [8,9]. n nThe ERP thought it was timely to produce a consensus statement from the National Clinical Leads and Specialist Advisors within the specific context of Enhanced Recovery and, for the purpose of widespread dissemination, the general principles and key recommendations outlined in the latest guide are reiterated in this article [5]. Of note, no particular evidence based methodology was used aside from seeking unanimous agreement from the authors. A practical and pragmatic set of guidelines and recommendations was the aim. The conclusions do align with the GIFTASUP guidelines and NICE guidance where established EBM methodologies were utilised [6,8,10]. In making this consensus statement we agree that larger, more definitive studies of perioperative fluid management and, in particular, the relative contribution of haemodynamic monitoring compared with fluid restriction would be welcomed [11,12]. However, to be useful, such studies must be conducted in the context of a fully implemented Enhanced Recovery Program.

Comparison of Fresh-Frozen Cadaver and High-Fidelity Virtual Reality Simulator as Methods of Laparoscopic Training

Objective The Department of Healths Enhanced Recovery Partnership Programme (ERPP) started a spread and adoption scheme of Enhanced Recovery After Surgery (ERAS) throughout England. In preparation for widespread adoption the ERPP wished to obtain expert consensus on appropriate outcome measures for ERAS, emerging techniques being widely adopted and proposed methods for the continued development and sustainability of ERAS in the National Health Service. The aim of this study was to interrogate expert opinion and define areas of consensus on these issues. Design A Delphi technique using three rounds of reiterative questionnaires was used to obtain consensus. Participants Experts were chosen from teams with experience of delivering a successful ERAS programme across different surgical specialties and across various disciplines. Setting The first two rounds of the questionnaire were completed online and a final, third round was undertaken in a meeting using interactive voting. Results 86 experts took part in this study. Consensus statements agreed that patient experience data should be recorded, analysed and reviewed at regular ERAS meetings. Recent developments in regional analgesia, the increased use of intraoperative monitoring for fluid management and cardio-pulmonary exercise testing were the main emerging techniques identified. National standards for those outcome measures would be welcomed. To sustain success in ERAS, the experts highlighted clinical champions and the presence of a dedicated ERAS facilitator as essential elements. For future networking, a unanimous agreement was achieved on the formation a national network to facilitate spread and adoption of ERAS and to promote research and education across surgery. Conclusions Consensus was achieved on regular measurement and review of patient experience in ERAS. Agreement was reached on the role of regional analgesia and the use of oesophageal Doppler for intraoperative goal-directed fluid therapy. In order to facilitate the further spread and adoption of best practices and to promote research and education, an ERAS-UK network was recommended.

Analysis of laboratory-based laparoscopic colorectal surgery workshops within the English National Training Programme

BackgroundThe aim of this study was to compare fresh-frozen cadavers (FFC) with a high-fidelity virtual reality simulator (VRS) as training tools in minimal access surgery for complex and relatively simple procedures.MethodsA prospective comparative face validity study between FFC and VRS (LAP Mentor™) was performed. Surgeons were recruited to perform tasks on both FFC and VRS appropriately paired to their experience level. Group A (senior) performed a laparoscopic sigmoid colectomy, Group B (intermediate) performed a laparoscopic incisional hernia repair, and Group C (junior) performed basic laparoscopic tasks (BLT) (camera manipulation, hand-eye coordination, tissue dissection and hand-transferring skills). Each subject completed a 5-point Likert-type questionnaire rating the training modalities in nine domains. Data were analysed using nonparametric tests.ResultsForty-five surgeons were recruited to participate (15 per skill group). Median scores for subjects in Group A were significantly higher for evaluation of FFC in all nine domains compared to VRS (pxa0<xa00.01). Group B scored FFC significantly better (pxa0<xa00.05) in all domains except task replication (pxa0=xa00.06). Group C scored FFC significantly better (pxa0<xa00.01) in eight domains but not on performance feedback (pxa0=xa00.09). When compared across groups, juniors accepted VRS as a training model more than did intermediate and senior groups on most domains (pxa0<xa00.01) except team work.ConclusionsFresh-frozen cadaver is perceived as a significantly overall better model for laparoscopic training than the high-fidelity VRS by all training grades, irrespective of the complexity of the operative procedure performed. VRS is still useful when training junior trainees in BLT.