Is ERAS in laparoscopic surgery for colorectal cancer changing risk factors for delayed recovery?

There is evidence that implementation of enhanced recovery after surgery (ERAS) protocols into colorectal surgery reduces complication rate and improves postoperative recovery. However, most published papers on ERAS outcomes and length of stay in hospital (LOS) include patients undergoing open resections. The aim of this pilot study was to determine the factors affecting recovery and LOS in patients after laparoscopic colorectal surgery for cancer combined with ERAS protocol. One hundred and forty-three consecutive patients undergoing elective laparoscopic resection were prospectively evaluated. They were divided into two subgroups depending on their reaching the targeted length of stay—LOS (75 patients in group 1—≤4 days, 68 patients in group 2—>4 days). A univariate and multivariate logistic regression analysis was performed to assess for factors (demographics, perioperative parameters, complications and compliance with the ERAS protocol) independently associated with LOS of 4 days or longer. The median LOS in the entire group was 4 days. The postoperative complication rate was higher (18.7 vs. 36.7 %), and the compliance with ERAS protocol was lower (91.2 vs. 76.7 %) in group 2. There was an association between the pre- and postoperative compliance and the subsequent complications. In uni- and multivariate analysis, the lack of balanced fluid therapy (OR 3.87), lack of early mobilization (OR 20.74), prolonged urinary catheterization (OR 4.58) and use of drainage (OR 2.86) were significantly associated with prolonged LOS. Neither traditional patient risk factors nor the stage of the cancer was predictive of the duration of hospital stay. Instead, compliance with the ERAS protocol seems to influence recovery and LOS when applied to laparoscopic colorectal cancer surgery

Optimising the Bariatric Perioperative Journey

Aim To evaluate whether bariatric surgery can be made more cost-effective and to improve early and long-term outcomes Methods The bariatric procedure offered at Counties Manukau District Health Board (CMDHB), Auckland, is laparoscopic sleeve gastrectomy (LSG). Therefore this thesis deals solely with surgical recovery and outcomes after LSG. To determine the current status of LSG at CMDHB, a retrospective review describing the outcomes of the first 400 patients to have LSG at our institution was performed, the results of which would be used to measure the effect of clinical interventions described in later chapters. The thesis was then divided into two distinct phases. The first phase was to determine whether optimised and standardised perioperative care would lead to improved surgical recovery, improved clinical outcomes and reduced perioperative costs. Implementation of an Enhanced Recovery After Surgery (ERAS) programme was hypothesised to be an effective way to achieve this. A bariatric ERAS programme was therefore formulated by performing an extensive review of the literature evaluating perioperative care interventions in major abdominal surgery. In this review, prehabilitation was identified as an intervention which could be investigated in later chapters as a means to improve surgical recovery. Once formulated, the ERAS programme was evaluated within a randomised controlled trial. The second phase of the thesis was to determine whether improved exercise behaviour would lead to improved surgical outcomes. A prospective study was first performed to describe the long-term efficacy of LSG at our institution in order to determine the extent to which outcomes could be improved. A systematic review was then performed to determine whether a text-message intervention could be used to improve exercise adherence in order to optimise preoperative exercise behaviour. The efficacy of text-messages and preoperative exercise were then investigated within a randomised controlled trial