Enhanced recovery after liver surgery. Cost-effectiveness of Enhanced Recovery Versus Conventional Perioperative Management for Colorectal Surgery Randomized clinical trial on enhanced recovery versus standard care following open liver resection Enhanced Recovery Program following Colorectal Resection in the Elderly Patient Intravenous Lidocaine Versus Thoracic Epidural Analgesia: A Randomized Controlled Trial in Patients Undergoing Laparoscopic Colorectal Surgery Using an Enhanced Recovery Program Anti-inflammatory Effects of Enhanced Recovery Programs on Early-Stage Colorectal Cancer Surgery Enhanced recovery in major colorectal surgery: safety and efficacy in an unselected surgical population at a UK district general hospital. Multicenter randomized controlled trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme: EnROL. Ensuring Early Mobilization Within an Enhanced Recovery Program for Colorectal Surgery: A Randomized Controlled Trial A mobile device application (app) to improve adherence to an enhanced recovery program for colorectal surgery: a randomized controlled trial Alvimopan Provides Additional Improvement in Outcomes and Cost Savings in Enhanced Recovery Colorectal Surgery Discharge within 24 to 72 hours of colorectal surgery is associated with low readmission rates when using Enhanced Recovery Pathways. Short-Term Outcomes of Laparoscopy Combined with Enhanced Recovery Pathway after Ileocecal Resection for Crohn’s Disease: a Case-Matched Analysis Predicting who will fail early discharge after laparoscopic colorectal surgery with an established enhanced recovery pathway Post-discharge follow-up using text messaging within an enhanced recovery program after colorectal surgery. Optimizing cost and short-term outcomes for elderly patients in laparoscopic colonic surgery Impact of adherence to care pathway interventions on recovery following bowel resection within an established enhanced recovery program Transversus abdominis plane blocks and enhanced recovery pathways: making the 23-h hospital stay a realistic goal after laparoscopic colorectal surgery Focused preoperative patient stoma education, prior to ileostomy formation after anterior resection, contributes to a reduction in delayed discharge within the enhanced recovery programme The benefit of an enhanced recovery programme following elective laparoscopic sigmoid colectomy An enhanced recovery pathway decreases duration of stay after esophagectomy. Prospective study of colorectal enhanced recovery after surgery in a community hospital. Laparoscopy within a fast-track program enhances the short-term results after elective surgery for resectable colorectal cancer
INTRODUCTION In a majority of cases , enhanced recovery after surgery program ( ERP ) leads to a reduced rate of postoperative complications and shortened hospital stays following digestive surgery . The program 's preoperative , perioperative and postoperative measures are implemented by the members of a motivated multidisciplinary team . Having shown its merits in digestive surgery , ERP would be particularly useful in liver surgery due to the elevated rates of morbidity and mortality this type of operation continues to entail . The objective of this review was to evaluate the efficacy of ERP  in liver surgery . METHOD This is a systematic narrative review of the literature on the efficacy of ERP  in liver surgery by laparotomy or laparoscopy . RESULTS Notwithst and ing a number of studies ( n=30 : 5 r and omized trials , 14 cohort studies and 11 meta-analyses ) less sizable than with regard to digestive surgery in general and colorectal surgery in particular , analysis of the literature confirms that in liver surgery , ERP is associated with an overall decrease in complications by 30 to 60 % , but without improvement in the rates of hospital readmission and postoperative mortality . All of the studies report a reduction in average length of stay ( ALOS ) by 2.3 days and in functional recovery , a more objective indicator than ALOS , by 2.5 days . As of now , the economic impact of the ERP programs in liver surgery is neither positive nor negative , the above-mentioned savings being counterbalanced by heightened costs for material and equipment . Laparoscopic surgery is independently associated with better outcomes in terms of complications , functional recovery and ALOS ; that is why it is important to incorporate this surgical approach in ERP as often as possible . Given a lack of robust evidence , Prehabilitation , which is a preoperative optimization process leading to improved functional reserve , has yet to be assigned a place in ERP programs pertaining to liver surgery . Possible roadblocks to application of an ERP program can be overcome through coordination by a team leader , a motivated multidisciplinary team , training courses and dedicated teaching sessions . CONCLUSION ERP is a care improvement process that has a major play to play in organization of liver surgery , and its large-scale application is to be recommended Objective : To determine the cost-effectiveness of enhanced recovery pathways ( ERPs ) versus conventional care for patients undergoing elective colorectal surgery . Background : ERPs for colorectal surgery are clinical ly effective , but their cost-effectiveness is unknown . Methods : A multi-institutional prospect i ve cohort cost-effectiveness analysis was performed . Adult patients undergoing elective colorectal resection at 2 university-affiliated institutions from October 2012 to October 2013 were enrolled . One center used an ERP , whereas the other did not . Postoperative outcomes were recorded up to 60 days . Total costs were reported in 2013 Canadian dollars . Effectiveness was measured using the SF-6D , a health utility measure vali date d for postoperative recovery . Uncertainty was expressed using bootstrapped estimates ( 10,000 repetitions ) . Results : A total of 180 patients were included  ( conventional care : n = 95 ; ERP : n = 95 ) . There were no differences in patient characteristics except for a higher proportion of laparoscopy in the ERP group . Mean length of stay was shorter in the ERP group ( 6.5 vs 9.8 days ; P = 0.017 ) , but there were no differences in complications or readmissions . Patients in the ERP group returned to work quicker and had less caregiver burden . There was no difference in quality of life between the 2 groups . The cost of the ERP program was $ 153 per patient . Overall societal costs were lower in the ERP group ( mean difference = −2985 ; 95 % confidence interval , −5753 to −373 ) . The ERP had a greater than 99 % probability of cost-effectiveness . The results were insensitive to a range of assumptions and subgroups . Conclusions : Enhanced recovery is cost-effective compared with conventional perioperative management for elective colorectal resection Enhanced recovery programmes ( ERPs ) have been shown to reduce length of hospital stay ( LOS ) and complications in colorectal surgery . Whether ERPs have the same benefits in open liver resection surgery is unclear , and r and omized clinical trials are lacking Background The enhanced recovery program ( ERP ) aims to reduce the metabolic response to surgery , hastening recovery and shortening hospital stay . Concerns exist regarding morbidity and hospital stay in elderly patients . The present study aim ed to compare the outcomes and compliance of elderly patients managed by an ERP protocol with a younger group . Methods A review was performed of a prospect i ve data base of patients undergoing colorectal resection managed under the ERP protocol between 2005 and 2010 . Patients were grouped into < 80 years and ≥80 years , and perioperative data were collated . The postoperative outcomes were compared with the goals set out by the ERP protocol . Results A total of 688 patients were included , 558 were < 80 years ( median : 66 years ; range : 17–79 years ) and 130 were ≥80 years ( median : 83 years ; range : 80–95 years ) . Some 96 % of operations were planned laparoscopically . Median total length of hospital stay was 6 days ( range : 1–108 days ) for the < 80 year group and 8 days ( range : 1–167 days ; P 0.363 ) for the elderly group , with a 30 day readmission rate of 8.6 % for the population and no significant differences between groups . The 30 day mortality was 5 % , with a significant difference between the two groups ( P < 0.0001 ) . Differences in protocol adherence were identified in the discontinuation of intravenous fluids , catheter removal , and early mobilization . Conclusions An enhanced recovery program is feasible for colorectal surgery patients ≥80 years of age , with similar compliance as the younger group to some aspects of the protocol and an acceptable readmission rate . Attention to improving compliance in the postoperative phase is necessary , particularly in such high-risk patients , as such improvement may reduce the morbidity and mortality Background and Objective : Laparoscopy , thoracic epidural analgesia , and enhanced recovery program ( ERP ) have been shown to be the major elements to facilitate the postoperative recovery strategy in open colorectal surgery . This study compared the effect of intraoperative and postoperative intravenous ( IV ) lidocaine infusion with thoracic epidural analgesia on postoperative restoration of bowel function in patients undergoing laparoscopic colorectal resection using an ERP . Methods : Sixty patients scheduled for elective laparoscopic colorectal surgery were prospect ively r and omized to receive either thoracic epidural analgesia ( TEA group ) or IV lidocaine infusion ( IL group ) ( 1 mg/kg per hour ) with patient-controlled analgesia morphine for the first 48 hours after surgery . All patients received a similar ERP . The primary outcome was time to return of bowel function . Postoperative pain intensity , time out of bed , dietary intake , duration of hospital stay , and postoperative complications were also recorded . Results : Mean times and SD ( 95 % confidence interval ) to first flatus ( TEA , 24 [ SD , 11 ] [ 19 - 29 ] hrs vs IL , 27 [ SD , 12 ] [ 22 - 32 ] hrs ) and to bowel movements ( TEA , 44 ±19 [ 35 - 52 ] hrs vs IL , 43 [ SD , 20 ] [ 34 - 51 ] hrs ) were similar in both groups ( P = 0.887 ) . Thoracic epidural analgesia provided better analgesia in patients undergoing rectal surgery . Time out of bed and dietary intake were similar . Patients in the TEA and IL groups were discharged on median day 3 ( interquartile range , 3 - 4 days ) , P = 0.744 . Sixty percent of patients in both groups left the hospital on day 3 . Conclusions : Intraoperative and postoperative IV infusion of lidocaine in patients undergoing laparoscopic colorectal resection using an ERP had a similar impact on bowel function compared with thoracic epidural analgesia Background Postoperative ileus ( POI ) is observed in 20–30 % of patients undergoing colorectal cancer surgery , despite enhanced recovery programs ( ERPs ) . Cyclooxygenase (COX)-2 is identified as a key enzyme in POI , but other arachidonic acid pathway enzymes have received little attention despite their potential as selective targets to prevent POI . The objectives were to compare the expression of arachidonic acid metabolism ( AAM ) enzymes ( 1 ) between patients who underwent colorectal cancer surgery and followed an ERP or not ( NERP ) , ( 2 ) and between ERP patients who experimented POI or not and ( 3 ) to determine the ability of antagonists of these pathways to modulate contractile activity of colonic muscle . Methods This was a translational study . Main outcome measures were gastrointestinal motility recovery data , mRNA expressions of key enzymes involved in AAM ( RT-qPCR ) and ex vivo motility values of the circular colon muscle . Twenty-eight prospect ively included ERP patients were compared to eleven retrospectively included NERP patients that underwent colorectal cancer surgery . Results ERP  reduced colonic mucosal COX-2 , microsomal prostagl and in E synthase ( mPGES1 ) and hematopoietic prostagl and in D synthase ( HPGDS ) mRNA expression . mPGES1 and HPGDS mRNA expression were significantly associated with ERP compliance ( respectively , r2 = 0.25 , p = 0.002 and r2 = 0.6 , p < 0.001 ) . In muscularis propria , HPGDS mRNA expression was correlated with GI motility recovery ( p = 0.002 ) . The pharmacological inhibition of mPGES1 increased spontaneous ex vivo contractile activity in circular muscle ( p = 0.03 ) . Conclusion The effects of ERP on GI recovery are correlated with the compliance of ERP and could be mediated at least in part by mPGES1 , HPGDS and COX-2 . Furthermore , mPGES1 shows promise as a therapeutic target to further reduce POI duration among ERP patients BACKGROUND Enhanced Recovery Programmes ( ERPs ) have been shown to benefit recovery following major surgery in selected centres and patient groups , but their wider applicability requires continued evaluation . The aims of this study were to assess the outcomes of the first 400 consecutive , non-selected patients , undergoing major elective colorectal surgery within an Enhanced Recovery programme at a UK District General hospital and to examine the effects of patient risk factors and operative approach on outcomes . METHODS Since September 2005 all patients undergoing major elective colon and rectal surgery at our hospital have been treated within an ERP and their data recorded prospect ively on a data base . Safety and efficacy outcomes for the first 400 patients were compared using SPSS v14.0 with both a retrospective , pre-ERP group ; and according to patient risk factors and operative approaches . RESULTS Median length of stays ( LOS ) reduced from 9 days ( IQR 7 - 11 ) to 6 days ( IQR 5 - 10 ) after introduction of the ERP ( p < 0.001 ) . No statistically significant differences in LOS were observed between elderly ( ≥80 years ) and younger patients or between different BMI groups . American Society of Anesthesiologists ( ASA ) grade 3 patients demonstrated significantly longer median LOS than those with ASA grade s 1 and 2 . Patients undergoing laparoscopic surgery  had median LOS of 6 days ( IQR 4 - 8 ) compared to 7 days ( IQR 5 - 10 ) for open procedures ( p < 0.001 ) . No differences in morbidity or mortality were observed between the groups . CONCLUSIONS Unselected application of an ERP in our unit has been associated with reductions in post-operative LOS . The ERP was safe and effective when applied to all our study patients independent of age and BMI . Despite LOS being longer in ASA grade 3 patients , application of the ERP to this higher risk group was not associated with significantly increased morbidity or mortality . Laparoscopic surgery result ed in additional modest reductions in LOS compared to open surgery within the ERP PURPOSE Laparoscopic resection and a multimodal approach known as an enhanced recovery program ( ERP ) have been major changes in colorectal perioperative care that have improved clinical outcomes for colorectal cancer resection . EnROL ( Enhanced Recovery Open Versus Laparoscopic ) is a multicenter r and omized controlled trial examining whether the benefits of laparoscopy still exist when open surgery is optimized within an ERP . PATIENTS AND METHODS Adults with colorectal cancer suitable for elective resection were r and omly assigned at a ratio of 1:1 to  laparoscopic or open surgery within an ERP , stratified by center , cancer site ( colon v rectum ) , and age group ( < 66 v 66 - 75 v > 75 years ) using minimization . The primary outcome was physical fatigue at 1 month postsurgery . Secondary outcomes included hospital stay , complications , other patient-reported outcomes ( PROs ) , and physical function . Patients and outcome assessors were blinded until 7 days postsurgery or discharge if earlier . Central independent and blinded pathologic assessment of surgical quality was undertaken . RESULTS A total of 204 patients ( laparoscopy , n=103 ; open surgery , n=101 ) were recruited from 12 UK centers from July 2008 to April 2012 .  One-month physical fatigue scores were similar in both groups ( mean : laparoscopy , 12.28 ; 95 % CI , 11.37 to 13.19 v open surgery , 12.05 ; 95 % CI , 11.14 to 12.96 ; adjusted mean difference , -0.23 ; 95 % CI , -1.52 to 1.07 ) . Median total hospital stay was significantly shorter after laparoscopic surgery ( median : laparoscopy , 5 ; interquartile range [ IQR ] , 4 to 9 v open surgery , 7 ; IQR , 5 to 11 days ; P=.033 ) . There were no differences in other secondary outcomes or in specimen quality after central pathologic review . CONCLUSION In patients treated by experienced surgeons within an ERP , physical fatigue and other PROs were similar in both groups , but laparoscopic surgery significantly reduced length of hospital stay Objective : To estimate the extent to which the addition of staff-directed facilitation of early mobilization to an Enhanced Recovery Program ( ERP ) impacts recovery after colorectal surgery , compared with usual care . Summary Background Data : Early mobilization is considered an important component of ERPs but , despite guidelines recommendations , adherence remains quite low . The value of dedicating specific re sources ( eg , staff time ) to increase early mobilization is unknown . Methods : This r and omized trial involved 99 colorectal surgery patients in an established ERP ( median age 63 , 57 % male , 80 % laparoscopic ) r and omized 1:1 to usual care  ( including preoperative education about early mobilization with postoperative daily targets ) or facilitated mobilization [ staff dedicated to assist transfers and walking from postoperative days ( PODs ) 0–3 ] . Primary outcome was the proportion of patients returning to preoperative functional walking capacity ( 6-min walk test ) at 4 weeks after surgery . We also explored the association of the intervention with in-hospital mobilization , time to achieve discharge criteria , time to recover gastrointestinal function , 30-day comprehensive complication index , and patient-reported outcome measures . Results : In the facilitated mobilization group , adherence to mobilization targets was greater on POD0 [ OR 4.7 ( 95 % CI 1.8–11.9 ) ] , POD1 [ OR 6.5 ( 95 % CI 2.3–18.3 ) ] , and POD2 [ OR 3.7 ( 95 % CI 1.2–11.3 ) ] . Step count was at least 2-fold greater on POD1 [ mean difference 843.3 steps ( 95 % CI 219.5–1467.1 ) ] and POD2 [ mean difference 1099.4 steps ( 95 % CI 282.7–1916.1 ) ] There was no between-group difference in recovery of walking capacity at 4 weeks after surgery [ OR 0.77 ( 95 % CI 0.30–1.97 ) ] . Other outcome measures were also not different between groups . Conclusions : In an ERP for colorectal surgery , staff-directed facilitation of early mobilization increased out-of-bed activities during hospital stay but did not improve outcomes . This study does not support the value of allocating additional re sources to ensure early mobilization in ERPs . Trial Registration : Clinical Trials.gov Identifier : Background Increased adherence with enhanced recovery pathways ( ERP ) is associated with improved outcomes . However , adherence to postoperative elements that rely on patient participation remains suboptimal . Mobile device apps may improve delivery of health education material and have the potential to foster behavior change and improve patient compliance . The objective of this study was to estimate the extent to which a novel mobile device app affects adherence to an ERP for colorectal surgery in comparison to st and ard written education . Methods This was a superiority , parallel-group , assessor-blind , sham-controlled r and omized trial involving 97 patients undergoing colorectal resection . Participants were r and omly assigned with a 1:1 ratio into one of two groups : ( 1 ) iPad including a novel mobile device app for postoperative education and self- assessment of recovery , or ( 2 ) iPad without the app . The primary outcome measure was mean adherence ( % ) to a bundle of five postoperative ERP elements requiring patient participation : mobilization , gastrointestinal motility stimulation , breathing exercises , and consumption of oral liquids and nutritional drinks . Results In the intervention group , app usage was high ( 94 % completed surveys on POD0 , 82 % on POD1 , 72 % on POD2 ) . Mean overall adherence to the bundle on the two first postoperative days was similar between groups : 59 % ( 95 % CI 52–66 % ) in the intervention group and 62 % ( 95 % CI 56–68 % ) in the control group [ Adjusted mean difference 2.4 % ( 95 % CI − 5 to 10 % ) p = 0.53 ] . Conclusions In this r and omized trial , access to a mobile health application did not improve adherence to a well-established enhanced recovery pathway in colorectal surgery patients , when compared to st and ard written patient education . Future research should evaluate the impact of applications integrating novel behavioral change techniques , particularly in context s where adherence is low Objective : To examine the impact of alvimopan on outcomes and costs in a rigorous enhanced recovery colorectal surgery protocol . Background : Postoperative ileus remains a major source of morbidity and costs in colorectal surgery . Alvimopan has been shown to reduce incidence of postoperative ileus in enhanced recovery colorectal surgery ; however , data are equivocal regarding its benefit in reducing length of stay and costs . Methods : Patients undergoing major elective enhanced recovery colorectal surgery were identified from a prospect ively-collected data base ( 2010–2013 ) . Multivariable analyses were employed to compare outcomes and hospital costs among patients who had alvimopan versus no alvimopan  by adjusting for demographic , clinical , and treatment characteristics . Results : A total of 660 patients were included ; 197 patients received alvimopan and 463 patients had no alvimopan .  In unadjusted analysis , the alvimopan group had a faster return of bowel function , shorter length of stay , and lower rates of ileus , Foley re-insertion , and urinary tract infection ( all P < 0.01 ) . After adjustment , alvimopan was associated with a faster return of bowel function by 0.6 day ( P = 0.0006 ) , and lower incidence of postoperative ileus ( odds ratio 0.23 , P = 0.0002 ) . With adjustment , alvimopan was associated with a shorter length of stay by 1.6 days ( P = 0.002 ) , and a hospital cost savings of $ 1492 per patient ( P = 0.01 ) . Conclusions : Alvimopan administration as an element of enhanced recovery colorectal surgery is associated with faster return of bowel function , lower incidence of postoperative ileus , shorter hospitalization , and a significant cost savings . These results suggest that alvimopan is cost-effective in the setting of enhanced recovery colorectal surgery protocol s , and should therefore be considered in these programs BACKGROUND Enhanced Recovery Pathways ( ERPs ) have demonstrated reduced hospital length of stay and improved outcomes after colorectal surgery . Concerns exist about increases in readmission rates . Laparoscopic colorectal surgery with an ERP can permit earlier discharge without compromising safety or increasing readmission rates . STUDY DESIGN A review of a prospect i ve data base was performed for major elective colorectal procedures by a single surgeon . All patients followed a st and ardized ERP and discharge criteria . Patients were categorized by approach and day of discharge ( DoD ) of ≤ 1 , ≤ 2 , ≤ 3 , ≤ 7 , and > 7 days . Main outcomes measures were length of stay and 30-day readmission rates in each group . RESULTS Eight hundred and six cases ( 609 laparoscopic , 197 open ) were identified during a 64-month period . Mean age was similar for the laparoscopic ( 59.1 years ) and open ( 58.3 years ) groups . Mean overall DoD was at 5 days ( ± 4.8 days ) ; by approach , the mean laparoscopic DoD was at 3.9 days and open DoD was at 8.4 days . Twenty-nine percent were discharged within 48 hours ( 38 % laparoscopic and 8 % open ) and 50 % were discharged within 72 hours ( 62 % laparoscopic and 19 % open ) . Only 8.9 % of all patients ( n = 72 ) were readmitted ( 7.2 % laparoscopic , 14.2 % open ) . The cumulative readmission rate for laparoscopic patients in early DoD groups postoperative days 1 , 2 , and 3 were 0.2 % , 1.6 % , and 3.4 % , respectively . CONCLUSIONS Combining laparoscopy with an ERP optimizes patient care in colorectal surgery . The combination permits early discharge ; 38 % were discharged within 2 days and 62 % within 3 days of surgery , with low readmission rates . These results support that early DoD is possible without compromising patient safety or increasing readmission rates . This might be a marker for low readmission rate , and suggests that readmission rate alone might not be an adequate marker of quality Background Laparoscopy combined with an enhanced recovery pathway ( ERP ) is widely considered to be the first-choice option for patients with colorectal cancer . However , no previous reports have focused on patients with Crohn ’s disease ( CD ) treated by laparoscopy and ERP . Methods Twenty patients with CD underwent laparoscopic ileocecal resection with an ERP at two institutions . The ERP protocol included no bowel preparation nor fasting , no nasogastric tube , no abdominal drains , early removal of urinary catheter , early solid dietary intake and mobilization , opioid-sparing analgesia and restrictive fluid management . This group was compared with a matched historical control group of 70 CD patients who underwent laparoscopic ileocecal resection treated with conventional care .  Results Compliance with the  ERP was high ( ≥80 % ) for all items except no drain placement . A significantly earlier return of bowel function ( time to first flatus and stool ) was observed in the ERP group . Mean postoperative and total length of stay were significantly shorter in the ERP group . Postoperative complications were similar in both groups . Conclusions This is the first reported experience of laparoscopy with ERP in CD patients and suggests that optimized perioperative care combined with minimally invasive techniques may lead to further improvements in surgical outcomes for CD patients Background Despite using laparoscopy and enhanced recovery pathways ( ERP ) , some patients are not ready for early discharge . The goal of this study was to identify predictors for patients who might fail early discharge , so that any defined factors might be addressed and optimized . Methods A prospect ively maintained data base was review ed for major elective laparoscopic colorectal surgical procedures . Cases were divided into day of discharge groups : ≤3 days and > 4 days . All followed a st and ardized ERP . Demographic and clinical data were compared using Student ’s paired t tests or Fisher ’s exact test , with p value < 0.05 statistically significant . Regression analysis was performed to identify significant variables . Results There were 275 ≤3 days patients and 273 > 4 days patients . There were significant differences between groups in body mass index ( p = 0.0123 ) , comorbidities ( p = 0.0062 ) , ASA class ( p = 0.0014 ) , operation time ( p < 0.001 ) , postoperative complications ( p < 0.001 ) , and 30-day reoperation rate ( p = 0.0004 ) . There were no significant differences for intraoperative complications ( p = 0.724 ) , readmissions ( p = 0.187 ) , or mortality rate ( p = 1.00 ) . Significantly more patients were discharged directly home in the ≤3-days cohort . Using logistic regression , every hour of operating time increased the risk of length of stay > 4 days by 2.35 % . Conclusions Elective colorectal surgery patients with longer operation times and more comorbidities are more likely to fail early discharge . These patients should have different expectations of the ERP , as an expected 1- to 3-day stay may not be achievable . By identifying patients at risk for failing early discharge , re sources and postoperative support can be better allocated and patients better informed about likely recovery INTRODUCTION Enhanced recovery after surgery programs ( ERP ) often lead to early discharge and return to home . In terms of risk management , extended surveillance is recommended . Surveillance using text messages ( TM ) has been vali date d for minor operations in ambulatory surgery . The goal of this study was to evaluate the feasibility of home surveillance by TM after colorectal surgery within an ERP . METHODS This prospect i ve multicenter study involved the University hospitals of Clermont-Ferr and , Grenoble , Marseille and Lyon Sud between November 2014 and September 2015 . All patients underwent colorectal surgery within an ERP . Post-discharge , patients received TM ( 4 simple questions with regard to pain , bowel movements , temperature and phlebitis ) on days 1 , 3 and 5 . If there was abnormal or lack of response , an automatic alert was sent to the attending physician via Internet and the patient was contacted immediately . RESULTS One hundred and eleven patients were included . Responses were obtained within a median of 12 ( 1 - 422 ) minutes , and 90 % of patients answered all TM . There were 48 alerts : 56 % because of pain and 40 % due to absence of response to the TM . Alerts led to in-hospital care for 4 % of patients including three re-hospitalizations and two unplanned re-operations . The median satisfaction score ( 85 % of patients responded ) was 5 on a scale of 1 to 5 . CONCLUSION This study suggests the possibility , as for ambulatory surgery , to use test messaging for post-discharge home surveillance for patients undergoing colorectal surgery within an ERP Background Elderly patients often are regarded as high-risk for major abdominal surgery because of a lack of functional reserve and associated medical comorbidities . The goal of this study was to compare the cost of care and short-term outcomes of elderly and nonelderly patients undergoing laparoscopic colectomy .  Our hypothesis was that elderly patients managed with  laparoscopic colorectal surgery and an enhanced recovery protocol ( ERP ) can realize the same benefits of lower hospital length of stay ( LOS ) without increasing hospital costs or readmission rates . Methods Review of a prospect i ve data base identified all patients that underwent an elective laparoscopic colectomy from 2009 to 2012 . Patients were stratified into elderly ( ≥70 years old ) and nonelderly ( < 70 years old ) cohorts . The main outcome measures were discharge disposition , hospital costs , hospital LOS , and 30-day readmission rates between the laparoscopic and open groups . Results A total of 302 nonelderly ( 66 % ) and 153 elderly ( 34 % ) patients were included in the analysis . The elderly cohort had significantly higher comorbidities than the nonelderly group . There were no mortalities . Operative variables ( procedure time , blood loss , and intraoperative complications ) were similar . At discharge , significantly more elderly patients required temporary nursing or home care . There were no significant differences in short-term outcomes of LOS , 30-day readmission rates , or costs for the episode of care between the two groups . Conclusions Combining laparoscopic colectomy with an ERP is cost-effective and results in similar short-term outcomes for the elderly and nonelderly patients . Despite higher comorbidities , elderly patients realized the same benefits of shorter LOS with similar hospital costs and readmission rates Introduction Guidelines recommend incorporation of more than 20 perioperative interventions within an enhanced recovery program ( ERP ) . However , the impact of overall adherence to the pathway and the relative contribution of each intervention are unclear . The aim of this study was to estimate the extent to which adherence to ERP elements is associated with outcomes and identify key ERP elements predicting successful recovery following bowel resection . Methods Prospect ively collected data entered in a registry specifically design ed for ERPs were review ed . Patients undergoing elective bowel resection between 2012 and 2014 were treated within an ERP comprising 23 care elements . Primary outcome was successful recovery defined as the absence of complications , discharge by postoperative day 4 and no readmission . Secondary outcomes were length of hospital stay ( LOS ) , 30-day morbidity , and severity ( Comprehensive complication index , CCI , 0–100 ) . Regression analyses were adjusted for potential confounders . Results A total of 347 patients were included in the study .  Median primary LOS was 4 days ( IQR 3–7 ) . Patients were adherent to median 18 ( IQR 16–20 ) elements . A total of 156 ( 45 % ) patients had successful recovery . Morbidity occurred in 175 ( 50 % ) patients with median CCI 8.6 ( IQR 0–22.6 ) . There was a positive association between adherence and successful recovery ( OR 1.39 for every additional element , p < 0.001 ) , LOS ( 11 % reduction for every additional element , p < 0.001 ) , 30-day postoperative morbidity ( OR 0.78 , p < 0.001 ) , and the CCI ( 17 % reduction , p < 0.001 ) . Laparoscopy ( OR 4.32 , p < 0.001 ) , early mobilization out of bed ( OR 2.25 , p = 0.021 ) , and early termination of IV fluid infusion ( OR 2.00 , p = 0.013 ) significantly predicted successful recovery . These factors were also associated with reduced morbidity and complication severity . Conclusions Increased adherence to ERP interventions was associated with successful early recovery and a reduction in postoperative morbidity and complication severity . In an established ERP where overall adherence was high , laparoscopic approach , perioperative fluid management , and patient mobilization remain key elements associated with improved outcomes Background Although enhanced recovery pathways ( ERPs ) may permit early recovery and discharge after laparoscopic colorectal surgery ( LC ) , most publications report that the mean hospital stay is 4 and 6 days . This study evaluates the addition of a transversus abdominis plane ( TAP ) block to the st and ard ERP . Methods In this study , 35 consecutive elective patients received a TAP block at the end of LC . The patients were matched by operation , diagnosis , age , gender , and body mass index ( BMI ) with 35 recent cases and followed in a prospect i ve institutional review board (IRB)-approved data base . All the patients were managed with a st and ardized ERP . The surgeon placed TAP blocks under laparoscopic guidance that infiltrated 15 ml of 0.5 % Marcaine on both sides of the abdomen . Results The cases included 8 low pelvic anastomoses , 4 proctectomies with or without an ileal pouch anal anastomosis , 5 sigmoid/left colectomies , 13 ileocolic/right colectomies , 1 total colectomy , and 5 others . The mean age was 59 years for the TAP group and 64.1 years for the control group ( p = 0.21 ) . The mean hospital stay was 2 days for the TAP patients and 3 days for the control patients ( p = 0.000013 ) . Of the 35 TAP patients , 13 went home on postoperative day ( POD ) 1 ( 37 % ) , 12 on POD 2 ( 34 % ) , 8 on POD 3 ( 23 % ) , and the remainder on POD 4 . Of the 35 control patients , 1 went home on POD 1 ( 3 % ) , 10 on POD 2 ( 29 % ) , 10 on POD 3 ( 29 % ) , 11 on POD 4 ( 31 % ) , and the remainder on POD 5 to 8 . The TAP patients required fewer narcotics postoperatively than the control patients ( respective mean morphine equivalents , 31.08 vs. 85.41 ; p = 0.01 ) . Discussion A bilateral TAP block significantly improved the results of an established ERP for patients undergoing LC . Surgeon-administered TAP blocks may be an economical and efficient method for improving the results of LC Purpose Stoma formation is a well-known cause for delayed discharge  following colorectal surgery . This has been addressed by the enhanced recovery programme ( ERP ) preoperatively through stoma counselling sessions . These aim to promote independent stoma management post-operatively , thus expediting hospital discharge . We compared the numbers of patients with prolonged hospital stay secondary to delayed independent stoma management prior to and following the introduction of an enhanced recovery programme with preoperative stoma education . Methods Data collection on patients undergoing anterior resection with the formation of a loop ileostomy was carried out retrospectively prior to ERP ( January 2006 to August 2008 ) and prospect ively following the introduction of  ERP  ( September 2008 to October 2010 ) . Comparisons were made in patients with prolonged hospital stay ( defined as hospital stay of more than 5 days ) secondary to stoma management . Results Two hundred forty patients underwent elective anterior resection with the formation of a loop ileostomy , 120 prior ERP  and 120 post-ERP . Average length of hospital stay was 14 days before ERP introduction , with a range of 7–25 days . The mean length of stay amongst the ERP patients was 8 days ( p = 0.17 ) , ranging from 3 to 17 days . Twenty-one patients in the pre-ERP group ( 17.5 % ) experienced postponed hospital discharge due to a delay in independent stoma management , compared to one patient experiencing such a delay after the introduction of ERP ( 0.8 % , p < 0.0001 ) . Conclusions Delayed discharge secondary to independent stoma management can be significantly reduced with preoperative stoma management teaching as part of an enhanced recovery programme Background Enhanced recovery programmes ( ERPs ) have demonstrated reduced morbidity and length of hospital stay in patients undergoing open elective colorectal resections . The application of laparoscopic techniques to colorectal surgery is associated with shorter length of stay and morbidity compared to open resections . In the setting of laparoscopic surgery , it is unclear whether there is an additive effect on length of stay and morbidity by combining these . The current study addresses the benefit of an ERP ( RAPID protocol ) in a cohort of matched patients undergoing laparoscopic sigmoid colon resection Material s and methods Consecutive patients over a 40-month period who underwent laparoscopic sigmoid colon resection  were assigned either to the RAPID protocol ( group 1 ) or traditional post operative care ( group 2 ) in a non-r and omised manner . Analysis was on an “ intention to treat ” basis . Primary and secondary endpoints were identified ; primary endpoints included length of hospital stay and readmission rate . Secondary endpoints included morbidity and mortality rate . Results Seventy-three consecutive patients were included . Group 1 included 37 patients . Group 2 included 36 patients .  Median length of hospital stay in groups 1 and 2 was 5 and 8 days , respectively ( p = 0.01 ) . Readmission rate in groups 1 and 2 was 8.1 % and 8.3 % , respectively ( p = 0.98 ) . Morbidity rate in groups 1 and 2 was 30 % and 22 % , respectively ( p = 0.61 ) ; there was one mortality in each group . Conclusion The application of the ERP ( RAPID ) to patients undergoing laparoscopic sigmoid colon resection results in a significant improvement in length of hospital stay , with comparable morbidity and readmission rates PURPOSE Enhanced recovery pathways ( ERP ) decrease morbidity and duration of stay after colorectal surgery . There is little information about their role in complex procedures , such as esophagectomy . The purpose of this study was to determine the impact of an ERP on duration of stay , complications , and readmissions after esophagectomy . METHODS Patients undergoing esophagectomy for cancer or high- grade dysplasia from June 2009 to December 2011 were identified from a prospect ively maintained data base . Beginning in June 2010 , all patients were enrolled in a 7-day multidisciplinary ERP including written patient education with daily treatment plan , indications for intensive care admission , early structured mobilization , and diet and drain management . Short-term ( 30-day ) outcomes were compared for patients undergoing esophagectomy pre- and post-pathway . Data are expressed as median values [ interquartile range ] . RESULTS We identified 106 patients ; 47 underwent esophagectomy before ERP implementation and 59 after . Patients were similar with respect to age , gender , diagnosis , and operative time .  Hospital stay was shorter in the ERP group ( 8 [ 7 - 17 ] vs 10 [ 9 - 17 ] days ; P = .01 ) . There were no differences in rates of complications ( 59 % vs 62 % ) or readmissions ( 6 % vs 5 % ) . CONCLUSION Implementation of a multidisciplinary ERP for esophagectomy was associated with decreased duration of stay , without an increase in complications or readmissions IMPORTANCE Enhanced recovery after surgery ( ERAS ) colorectal programs have shown to be successful at reducing length of stay in many international and academic centers ; however , their efficacy in a community hospital setting remains unclear . OBJECTIVE To determine if favorable results could be reproduced in a community hospital setting using our ERAS program , which was developed using core ERAS guidelines with the goal of accelerated recovery while also addressing other important outcomes affecting patient experience and safety . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve study of ERAS program , a multidisciplinary effort involving anesthesia , preadmission staff , nursing , and surgery staff at a community hospital . The program was initiated in 2010 and was in full practice by 2011 . We assessed practice patterns and patient outcomes for all elective colon and rectal resection cases performed in 2009 ( prior to ERAS implementation ) , 2011 , and 2012 . MAIN OUTCOMES AND MEASURES Laparoscopic approach , narcotic use , length of stay , 30-day readmission , ileus ( defined as reinsertion of nasogastric tube ) , and intra-abdominal infection and association between colorectal cancer ( CRC ) diagnosis and these outcomes . RESULTS From 2009 to 2012 , the use of laparoscopy increased from 57.4 % to 88.8 % ( P < .001 ) . Length of stay decreased significantly ( 6.7 days vs 3.7 days , P < .001 ) , without an increase in 30-day readmission rate ( 17.6 % vs 12.5 % , P = .49 ) . Use of patient-controlled narcotic analgesia and duration of use decreased ( 63.2 % of patients vs 15 % , P < .001 ; 67.8 hours vs 47.1 hours , P = .02 ) . Ileus rate decreased from 13.2 % to 2.5 % ( P = .02 ) . Intra-abdominal infection decreased from 7.4 % to 2.5 % ( P = .24 ) . When comparing laparoscopic cases alone , similar results were observed . Following regression analysis , there were no statistically significant differences between CRC diagnosis and LOS , 30-day readmission rates , ileus , and intra-abdominal infection ( all P 's > .05 ) . Length of stay reductions result ed in an estimated cost savings of $ 3202 per patient ( 2011 ) and $ 4803 per patient ( 2012 ) . CONCLUSIONS AND RELEVANCE Implementation of this patient care-directed enhanced recovery program is feasible in a community hospital setting , and it is associated with decreased LOS without increased readmission or morbidity , as well as significant decreases in narcotic use and cost . Improved outcomes are independent of the laparoscopic approach and CRC diagnosis Background Whether laparoscopic colorectal resection improved recovery within an enhanced recovery program was investigated . Methods This study was design ed as a query of a prospect ively maintained colorectal data base to identify 350 patients who underwent elective colorectal resection with primary anastomosis for colorectal cancer between January 1 , 2005 and December 31 , 2009 . Patients were categorized into two groups ( laparoscopic and open resection ) , and demographic , treatment , and outcome variables were independently review ed for accuracy . A detailed fast-track protocol was prepared and distributed to all patients , department doctors , and nurses to st and ardize the treatment . Results A total of 209 patients underwent laparoscopic-assisted colorectal resection , and 141 had open surgery .  There was no difference between the two groups in terms of age , sex , BMI , ASA , comorbidity , previous abdominal surgery , preoperative chemoradiotherapy , cancer site , and AJCC 2002 staging . Twenty-three patients in the laparoscopic group required conversion to an open procedure due to hemorrhage , tumor extension , or technical difficulties . Laparoscopic patients had earlier tolerance of diet , bowel movement , flatus and stool canalization , mobilization , suction drain removal , and interruption of analgesic drug administration . Length of postoperative stay was shorter ( 4 vs. 7 days , p = 0.0004 ) and fewer postoperative nonsurgical complications ( 3 vs. 13 % p = 0.009 ) were registered for the laparoscopic group . Conclusions This study suggests that within an enhanced recovery program , laparoscopic resection may provide the best short-term clinical outcomes for patients with resectable colorectal cancer
The present systematic review suggests that ERPs in colorectal and pancreas surgery are associated with cost savings compared to conventional perioperative management .
Enhanced recovery programs ( ERPs ) have been shown to improve postoperative outcomes after abdominal surgery .
This study aim ed to review the current literature to assess if ERPs in colorectal , pancreas , and liver surgery induce cost savings .