N. K. Francis

Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS ® ) Society Recommendations

BackgroundThis review aims to present a consensus for optimal perioperative care in colonic surgery and to provide graded recommendations for items for an evidenced-based enhanced perioperative protocol.MethodsStudies were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group.ResultsFor most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (quality of evidence and recommendations according to the GRADE system).ConclusionsBased on the evidence available for each item of the multimodal perioperative care pathway, the Enhanced Recovery After Surgery (ERAS) Society, International Association for Surgical Metabolism and Nutrition (IASMEN) and European Society for Clinical Nutrition and Metabolism (ESPEN) present a comprehensive evidence-based consensus review of perioperative care for colonic surgery.

Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations☆

BACKGROUND This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide graded recommendations for items for an evidenced-based enhanced perioperative protocol. METHODS Studies were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group. RESULTS For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (quality of evidence and recommendations according to the GRADE system). CONCLUSIONS Based on the evidence available for each item of the multimodal perioperative-care pathway, the Enhanced Recovery After Surgery (ERAS) Society, International Association for Surgical Metabolism and Nutrition (IASMEN) and European Society for Clinical Nutrition and Metabolism (ESPEN) present a comprehensive evidence-based consensus review of perioperative care for colonic surgery.

Deviation and failure of enhanced recovery after surgery following laparoscopic colorectal surgery: early prediction model

Aim  Enhanced recovery after surgery (ERAS) programmes are well established, but deviation from the postoperative elements may result in delayed discharge. Early identification of such patients may allow remedial action to be taken. The aims of this study were to investigate factors associated with delayed discharge and to produce a predictive scoring system for ERAS failure.

First international training and assessment consensus workshop on transanal total mesorectal excision (taTME)

The interest and adoption of transanal total mesorectal excision (taTME) is growing rapidly worldwide. This new technique has arisen thanks to advances in minimally invasive surgery and transanal approaches. The ultimate goal of the procedure is to improve clinical, oncological and functional outcomes of rectal excision by obtaining a meticulous TME resection in cancer cases, whilst avoiding injury to surrounding pelvic structures. Transanal TME is a complex procedure and demands excellent, prerequisite surgical skills in order to complete the operation in a safe and efficient manner. The ‘‘bottom-up’’ approach also reveals a completely new viewpoint of the pelvic anatomy for most surgeons. The combination of complexity and unfamiliarity has triggered the occurrence of adverse events, such as urethral injuries [1, 2], which were rarely encountered previously in conventional laparoscopic or open resections. Uptake of a new operation is also associated with a proficiency-gain curve during which there is increased morbidity and mortality [3]. These adverse outcomes during the introduction and dissemination of taTME must be honestly reported, properly analysed and addressed accordingly. Only then can we avoid a ‘‘dip’’ in the adoption curve we saw early on in the laparoscopic experience due to port site metastasis.

Factors predicting 30-day readmission after laparoscopic colorectal cancer surgery within an enhanced recovery programme.

Hospital readmission within 30 days of surgery has become a marker of poor quality patient care. This study aimed to investigate factors predictive of 30‐day readmission after laparoscopic colorectal cancer surgery within an enhanced recovery after surgery (ERAS) programme.

Manual of fast track recovery for colorectal surgery

This book brings together everything you need to know about enhanced recovery and more. Its clear layout and concise style enable it to be used both as a manual and as a reference text. It would be a suitable read for all members of the multidisciplinary team. The title suggests a purely colorectal focus. However, this is misleading as most of the contents refers to the general concept of enhanced recovery and only Chapter 7 focuses purely on colorectal surgery. I would therefore recommend this book as a resource for any surgical specialty looking to implement an enhanced recovery programme. Despite the extensive reference lists at the end of each chapter, a limitation of this text is that it only includes research up to 2010. Since advances in enhanced recovery are continuous, there are already a number of key studies that have been published in the past two years and are therefore missing from the book. Furthermore, in an era of patient-centred care, perhaps greater focus could have been given to enhanced recovery from the patient’s perspective.

Operative Time and Outcome of Enhanced Recovery After Surgery After Laparoscopic Colorectal Surgery

Background and Objectives: Combining laparoscopy and enhanced recovery provides benefit to short-term outcomes after colorectal surgery. Advances in training and techniques have allowed surgeons to operate on cases that are technically challenging and associated with prolonged operative time. Laparoscopic techniques improve the outcome of enhanced recovery after colorectal surgery; however, there are no specifications on the effect of prolonged operations on the outcome. The objective was to elucidate the impact of prolonged surgery and blood loss on the outcome of enhanced recovery after surgery after laparoscopic colorectal surgery. Methods: Four-hundred patients who underwent elective colorectal resection on enhanced recovery after surgery in Yeovil District Hospital between 2002 and 2009 were retrospectively reviewed. Delayed discharge was defined as a prolonged length of stay beyond the mean in this series (≥8 days). Results: Three-hundred eighty-five patients were included. Median operative time was 180 minutes with a median blood loss of 100 mL. Conversion was not associated with a prolonged length of stay. Operative time and blood loss correlated with length of stay in a stepwise fashion. There were 2 cutoff points of operative time at 160 minutes and 300 minutes (5 hours), where risk of prolonged stay increased significantly (odds ratio [OR] = 2.02; 95% confidence interval [CI], 1.05–3.90; P = .027), and blood loss of >500 mL (OR = 3.114; 95% CI, 1.501–6.462, P = .002). Conclusions: Total operative timing impacts negatively on the outcome of enhanced recovery after laparoscopic colorectal resections with increased risk of delayed discharge seen after ∼2.5 hours and 5-hour duration.

Consensus on structured training curriculum for transanal total mesorectal excision (TaTME)

BackgroundThe interest and adoption of transanal total mesorectal excision (TaTME) is growing amongst the colorectal surgical community, but there is no clear guidance on the optimal training framework to ensure safe practice for this novel operation. The aim of this study was to establish a consensus on a detailed structured training curriculum for TaTME.MethodsA consensus process to agree on the framework of the TaTME training curriculum was conducted, seeking views of 207 surgeons across 18 different countries, including 52 international experts in the field of TaTME. The process consisted of surveying potential learners of this technique, an international experts workshop and a final expert’s consensus to draw an agreement on essential elements of the curriculum.ResultsAppropriate case selection was strongly recommended, and TaTME should be offered to patients with mid and low rectal cancers, but not proximal rectal cancers. Pre-requisites to learn TaTME should include completion of training and accreditation in laparoscopic colorectal surgery, with prior experience in transanal surgery. Ideally, two surgeons should undergo training together in centres with high volume for rectal cancer surgery. Mentorship and multidisciplinary training were the two most important aspects of the curriculum, which should also include online modules and simulated training for purse-string suturing. Mentors should have performed at least 20 TaTME cases and be experienced in laparoscopic training. Reviewing the specimens’ quality, clinical outcome data and entering data into a registry were recommended. Assessment should be an integral part of the curriculum using Global Assessment Scales, as formative assessment to promote learning and competency assessment tool as summative assessment.ConclusionsA detailed framework for a structured TaTME training curriculum has been proposed. It encompasses various training modalities and assessment, as well as having the potential to provide quality control and future research initiatives for this novel technique.

Development and evaluation of a cadaveric training curriculum for low rectal cancer surgery in the English LOREC National Development Programme.

The National Development Programme for Low Rectal Cancer in England (LOREC) was commissioned in response to wide variation in the outcome of patients with low rectal cancer. One of the aims of LOREC was to enhance surgical techniques in managing low rectal cancer. This study reports on the development and evaluation of a novel national technical skills cadaveric training curriculum in extralevator abdominoperineal excision.

Objective assessment of technique in laparoscopic colorectal surgery: What are the existing tools?

Assessment can improve the effectiveness of surgical training and enable valid judgments of competence. Laparoscopic colon resection surgery is now taught within surgical residency programs, and assessment tools are increasingly used to stimulate formative feedback and enhance learning. Formal assessment of technical performance in laparoscopic colon resection has been successfully applied at the specialist level in the English “LAPCO” National Training Program. Objective assessment tools need to be developed for training and assessment in laparoscopic rectal cancer resection surgery. Simulation may have a future role in assessment and accreditation in laparoscopic colorectal surgery; however, existing virtual reality models are not ready to be used for assessment of this advanced surgery.