Management and 1-year outcomes of anastomotic leakage after elective colorectal surgery.

PURPOSE: To analyze different types of management and one-year outcomes of anastomotic leakage (AL) after elective colorectal resection. METHODS: All patients with anastomotic leakage after elective colorectal surgery with anastomosis (76/1,546; 4.9%), with the exclusion of cases with proximal diverting stoma, were followed-up for at least one year. Primary endpoints were as follows: composite outcome of one-year mortality and/or unplanned intensive care unit (ICU) admission and additional morbidity rates. Secondary endpoints were as follows: length of stay (LOS), one-year persistent stoma rate, and rate of return to intended oncologic therapy (RIOT). RESULTS: One-year mortality rate was 10.5% and unplanned ICU admission rate was 30.3%. Risk factors of the composite outcome included age (aOR = 1.08 per 1-year increase, p = 0.002) and anastomotic breakdown with end stoma at reoperation (aOR = 2.77, p = 0.007). Additional morbidity rate was 52.6%: risk factors included open versus laparoscopic reoperation (aOR = 4.38, p = 0.03) and ICU admission (aOR = 3.63, p = 0.05). Median (IQR) overall LOS was 20 days (14-26), higher in the subgroup of patients reoperated without stoma. At 1 year, a stoma persisted in 32.0% of patients, higher in the open (41.2%) versus laparoscopic (12.5%) reoperation group (p = 0.04). Only 4 out of 18 patients (22.2%) were able to RIOT. CONCLUSION: Mortality and/or unplanned ICU admission rates after AL are influenced by increasing age and by anastomotic breakdown at reoperation; additional morbidity rates are influenced by unplanned ICU admission and by laparoscopic approach to reoperation, the latter also reducing permanent stoma and failure to RIOT rates. TRIAL REGISTRATION: ClinicalTrials.gov # NCT03560180.

Transversus abdominis plane (TAP) block versus thoracic epidural analgesia (TEA) in laparoscopic colon surgery in the ERAS program.

AIM: The enhanced recovery after surgery (ERAS) pathway and laparoscopic approach had been proven beneficial for patients and should now be considered as a standard of care in colorectal surgery. Multimodal analgesia is the gold standard in the ERAS program with the use of thoracic epidural analgesia (TEA). Few data are available on Transversus abdominis plane (TAP) blocks in laparoscopic colorectal surgery and ERAS pathway. The aim of this study is to evaluate the efficacy of TAP block compared to TEA in the management of postoperative pain and the impact on the recurrence of postoperative nausea, vomiting and ileus in laparoscopic colorectal surgery in the ERAS program. METHOD: From October 2014 to October 2016, 182 patients underwent elective colon surgical interventions in enhanced recovery after surgery pathway. The patients were divided into two groups: Group 1 (n = 92) and Group 2 (n = 91) who received TEA and TAP block, respectively, with a standardized postoperative analgesic regimen consisting of regular 1 g of paracetamol every 8 h and a rescue dose with intravenous non-steroidal anti-inflammatory drugs infusion for both groups. RESULTS: No differences were observed in baseline patient characteristics, clinical variables and surgical procedures between the two groups, as well as in the postoperative complications rate (p = 0.515) in accordance with Clavien-Dindo classification, 90-day mortality (p = 0.319), hospital stay (p = 0.469) and 30-day readmission rate (p = 0.711). Patients in the TAP block group showed lower postoperative nausea and vomiting rates (p = 0.025), as well as lower ileus (p = 0.031) and paraesthesia rates (p = 0.024). No differences were found in urinary retention (p = 0.157). Despite the "opioid-free" analgesia protocol in the TAP block group, pain intensity was comparable between the two groups (p = 0.651). CONCLUSION: TAP block combined with an opioid-sparing analgesia in the setting of the laparoscopic colorectal surgery and ERAS program is feasible and effective in postoperative pain control.

E.R.A.S. pathway in colorectal surgery in elderly: Our experience: A retrospective cohort study.

AIM: Numerous geriatric patients develop colorectal disease. Elderly patients are often considered high-risk surgical candidates. Enhanced recovery after surgery (E.R.A.S.) has been proven to be beneficial for patients. The aim of the study was to evaluate the results of an ERAS protocol in older patients that underwent colorectal surgery compared to younger patients. METHOD: In the period between January 2010 to December 2015 a total of 589 patients underwent elective colorectal surgical interventions treated within the E.R.A.S pathway: 211 patients younger than 65 years, 175 patients aged from 66 years to 75 years, and 203 patients older than 75 years. End point of interest were postoperative complications, 90-day mortality, length of hospital stay and readmission within 30 days. RESULTS: Significant differences between the three groups were observed for comorbidities (p:0.001); in particular older patients had significantly more diabetes, renal, cardiac, and respiratory diseases, ASA (p < 0.001), presence of malignancy (p < 0.001). However there were not differences between the groups in surgical procedures (p = 0.095), operative time (p = 0.823), anastomotic leakage (p = 0.960), hospital stay (p = 0.081), readmission rate (p = 0.904), 90-days mortality (p = 0.183) and morbidity (p = 0.973) in accordance with Clavien-Dindo classification. Multivariate logistic regression analysis showed that advanced age in E.R.A.S. pathway is not a predictive factor of morbidity, readmission within 30 days and 90-day mortality. CONCLUSION: There was no significant difference in morbidity, 90-day mortality, length of stay or readmission rate in patients aged over 75 years compared with younger patients. Old age does not represent a contraindication to the implementation of the E.R.A.S protocol in patients that underwent colorectal surgery. WHAT DOES THIS PAPER ADD TO THE EXISTING LITERATURE?: In the literature there are not many studies that address the impact of older age in the treatment of colorectal disease in an ERAS program. The aging of the population raises new questions in the management of the colorectal surgery in the elderly. ERAS pathway has been proven to be beneficial for patients, which results in a reduction of postoperative morbidity. Compared to what is reported in the literature this study confirms that ERAS program in colorectal surgery can be applied in older patients with no significant difference in morbidity, 90-day mortality, length of stay or readmission rate compared with younger.