Stig Norderval

Consensus Review of Optimal Perioperative Care in Colorectal Surgery: Enhanced Recovery After Surgery (ERAS) Group Recommendations

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.

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

BackgroundThis review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery, and to provide graded recommendations for items for an evidenced-based enhanced recovery protocol.MethodsStudies were selected with particular attention paid to meta-analyses, randomized 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 (evidence grade: high or moderate).ConclusionsBased on the evidence available for each item of the multimodal perioperative care pathway, the Enhanced Recovery After Surgery (ERAS) Society, European Society for Clinical Nutrition and Metabolism (ESPEN) and International Association for Surgical Metabolism and Nutrition (IASMEN) present a comprehensive evidence-based consensus review of perioperative care for rectal surgery.

The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection Results From an International Registry

BACKGROUND The ERAS (enhanced recovery after surgery) care has been shown in randomized clinical trials to improve outcome after colorectal surgery compared to traditional care. The impact of different levels of compliance and specific elements, particularly out with a trial setting, is poorly understood. OBJECTIVE This study evaluated the individual impact of specific patient factors and perioperative enhanced recovery protocol compliance on postoperative outcome after elective primary colorectal cancer resection. METHODS The international, multicenter ERAS registry data, collected between November 2008 and March 2013, was reviewed. Patient demographics, disease characteristics, and perioperative ERAS protocol compliance were assessed. Linear regression was undertaken for primary admission duration and logistic regression for the development of any postoperative complication. FINDINGS A total of 1509 colonic and 843 rectal resections were undertaken in 13 centers from 6 countries. Median length of stay for colorectal resections was 6 days, with readmissions in 216 (9.2%), complications in 948 (40%), and reoperation in 167 (7.1%) of 2352 patients. Laparoscopic surgery was associated with reduced complications [odds ratio (OR) = 0.68; P < 0.001] and length of stay (OR = 0.83, P < 0.001). Increasing ERAS compliance was correlated with fewer complications (OR = 0.69, P < 0.001) and shorter primary hospital admission (OR = 0.88, P < 0.001). Shorter hospital stay was associated with preoperative carbohydrate and fluid loading (OR = 0.89, P = 0.001), and totally intravenous anesthesia (OR = 0.86, P < 0.001); longer stay was associated with intraoperative epidural analgesia (OR = 1.07, P = 0.019). Reduced postoperative complications were associated with restrictive perioperative intravenous fluids (OR = 0.35, P < 0.001). CONCLUSIONS This analysis has demonstrated that in a large, international cohort of patients, increasing compliance with an ERAS program and the use of laparoscopic surgery independently improve outcome.

Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery, and to provide graded recommendations for items for an evidenced-based enhanced recovery protocol. METHODS Studies were selected with particular attention paid to meta-analyses, randomized 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 (evidence grade: high or moderate). CONCLUSIONS Based on the evidence available for each item of the multimodal perioperative care pathway, the Enhanced Recovery After Surgery (ERAS) Society, European Society for Clinical Nutrition and Metabolism (ESPEN) and International Association for Surgical Metabolism and Nutrition (IASMEN) present a comprehensive evidence-based consensus review of perioperative care for rectal surgery.

Anal Incontinence After Obstetric Sphincter Tears: Outcome of Anatomic Primary Repairs

PURPOSEObstetric sphincter tears lead to anal incontinence in 40 to 60 percent of affected women. Primary repair is usually performed without identifying the internal anal sphincter. Since 1999 digestive surgeons have participated in the primary repair of such tears at our hospital. The intention was to perform separate repair of the internal and external anal sphincter in cases of combined tears to achieve a lower incontinence rate than is usually reported after conventional primary repair. The aim of the present study was to evaluate our results after anatomic primary repair.METHODA follow-up study was undertaken after all primary repairs performed in 1999 and 2000. It included anal ultrasonography manometry and an assessment of incontinence (Wexner score).RESULTSA total of 74 women sustained obstetric sphincter tears during the study period, and 71 (96 percent) were assessed after a median of 27 months (range, 14–39 months). Nine women declined investigation with ultrasonography/manometry. Incontinence was present in 22 women (31 percent), of whom 17 had gas incontinence only. The symptoms were mild (Wexner score 1–2) in 11 women (50 percent). None of 17 women with normal ultrasonography results were incontinent versus 20 of 45 with pathologic ultrasonographic results (P = 0.001). The mean sphincter length, squeeze pressure, and resting pressure were significantly higher in women with Wexner scores of 0–2 vs. women with a score of more than 2. Sphincter length was inversely correlated with the degree of incontinence (P < 0.001).CONCLUSIONSThe incontinence rate after anatomic primary repair is low compared with the last decade’s reported results after conventional primary repair. A short anal sphincter after repair is associated with a poorer outcome.

Anal incontinence after obstetric sphincter tears: incidence in a Norwegian county

Background.  Anal sphincter tears during vaginal delivery are a major cause of anal incontinence. We wanted to assess the incidence in a Norwegian county where primary repairs are performed in four hospitals using similar per‐ and postoperative protocol for the treatment of such injuries.

Correlation between anal sphincter defects and anal incontinence following obstetric sphincter tears: assessment using scoring systems for sonographic classification of defects

To determine if there is a correlation between the sonographic extent of anal sphincter defects revealed by three‐dimensional endoanal sonography (EAUS) and the degree of anal incontinence following primary repair of obstetric sphincter tears.

Three‐dimensional endoanal ultrasonography: intraobserver and interobserver agreement using scoring systems for classification of anal sphincter defects

To determine the degree of intraobserver and interobserver agreement for an experienced and an inexperienced sonologist using two scoring systems for ultrasonographic assessment of anal sphincter defects.

Introducing an asymmetric cleft lift technique as a uniform procedure for pilonidal sinus surgery.

Background and Aims: Asymmetric techniques for surgery in pilonidal sinus disease (PSD) have been reported to provide better results than simple excision and closure in the midline. The aim of this retrospective study was to evaluate the results after introducing the Bascom asymmetric cleft lift procedure in our hospital on a day care basis. Material and Methods: From a total of 33 patients operated from April 2002 to September 2004 with the Bascom asymmetric cleft lift technique, we were able to contact 29 who were invited to a follow up study. Eighteen (62%) of these patients accepted a consultation in the outpatient clinic while 11 (38%) were interviewed by phone. Results: At follow up mean 17 (range 10–27) months after the operation 24 (83%) of the wounds were healed while recurrences were present in 5 (17%) of the patients. In two of the patients with recurrences errors in the procedures were identified. Further results related to pre-, per- and postoperative conditions are discussed in this paper. Conclusion: Early results after surgery for PSD with the Bascom asymmetric cleft-lift technique are promising. The technique has now become our standard procedure for treating chronic, symptomatic PSD.

Long-term results after anterior sphincteroplasty for anal incontinence.

Objective: To assess the long term incontinence and quality of life (Qol) results after elective anterior sphincteroplasty for anal incontinence. Materials and Methods: Short and long term follow-up included respectively 28 and 25 of the 29 patients who were operated between 1989 and 1998 in our institution. Qol was assessed with gastro intestinal quality of life index (GIQLI). Incontinence was graded according to Parks score supplied with St Marks score at long term follow-up. Results: 21 (73%) patients had a history of obstetric sphincter tears. Mean age at operation was 45 years (range 6–77). Median time from operation to short term follow-up was 26 months (mean 38 months, range 2–113) and 84 months (mean 105, range 74–185) to long term follow-up. At short term follow-up 19 of 28 patients (68%) were continent for stool compared with nine of 25 patients (36%) at long term follow-up. Nine of 17 (53%) who were continent for stool at short term follow-up remained continent for stool at long term follow-up. Patients with a history of obstetric sphincter tear had less severe incontinence at long term follow-up compared to women with other causes of incontinence (St. Marks score 8 and 16 respectively, p = 0,015). Patients with no incontinence or gas incontinence only, had higher quality of life score at both follow-ups than those who where incontinent for stool (p = 0,007 and p = 0,014 respectively). Conclusion: More than half of the patients remained continent for stool at long term follow-up. Continence for stool was associated with high Qol score.