Review ArticleOptimizing outcomes of colorectal surgery – The current perspectives
Introduction
The march in the surgery has enabled us to think beyond life and limb preservation.1 Patient reported outcomes (PRO) are the driving force behind this development2, 3, 4 and modifications will make the unwanted adverse events as ‘never events’.5, 6
Traditionally, colorectal surgery is associated with a 20–25% risk of complications and 7–10 days of hospital stay. Modifications of PRO's at several substeps will lead to speedier recovery and decreased length of stay in hospital (LOSH). There are various guidelines available in the literature in this regard, namely the Enhanced Recovery After Surgery (ERAS), European Society for Clinical Nutrition and Metabolism (ESPEN) Guidelines, and International Association for Surgical Metabolism and Nutrition (IASMEN) Guidelines, which target speedier recovery after surgery.7, 8, 9, 10 There are several modifications and revision of the ERAS guidelines over the years.11, 12, 13
The various substeps of the patient care, which have an influence on the PRO, are briefly outlined.
- 1.
Preadmission information, education, and counseling:
Surgical scars leave a permanent impact on the mind of the patient.14 Every patient planned for a surgical procedure is having an element of anxiety and fear for undergoing the operative procedure. Detailed information about the procedure, its usual outcome, and preoperative psychological counseling of the patient have shown to hasten the postoperative recovery and decrease LOSH.15, 16, 17, 18 Detailed ‘Informed Consent’ is essential to make patients and their relatives aware of the available options for treatment and their possible complications, so that they can opt for the best for themselves. Informed Consent bridges the gap between the surgeon and the patient and also clears the misconceptions19 and is an effective tool for patient education.
- 2.
Preoperative optimization:
The preoperative physical conditioning, called the prehab, is considered as a factor, which influences faster recovery and improves surgical outcomes.20, 21, 22, 23, 24, 25, 26 Physical conditioning can be in the form of physical or yoga exercises, which stimulates a state of natural stress response. Such patients who are preconditioned with prehab or yoga exercises do better when subjected to the surgical stress.27, 28, 29, 30
Ethanol abuse and smoking also makes patient vulnerable to the undesired side effects like bleeding, wound infections, and cardiopulmonary complications.31, 32, 33 A minimum of 1 month of abstinence is advised.
- 3.
Preoperative mechanical bowel preparation:
Mechanical bowel preparation (MBP) used to be the routine before any major abdominal surgery. It is a well-supported fact that MBP is associated with adverse physiological effects attributed to dehydration,34 is distressing for the patient, and is associated with prolonged ileus after major colorectal surgery. A recent study suggested that the routine use of MBP is not necessary before major abdominal surgery and does not affect the mortality rates, anastomotic leak, reoperation rates, and wound infections.35 MBP of patients posted for laparoscopic colorectal surgery is also a matter of debate. Though laparoscopic colectomy can be safely done without MBP, situations needing intraoperative colonoscopy to localize small tumors make MBP necessary.
- 4.
Preoperative fasting and carbohydrate treatment:
A recent meta-analysis showed that fasting from midnight has no role in reducing the gastric contents or raising the pH of stomach juices as compared with patients who were allowed to take clear fluids until 2 h before anesthesia.36, 37 National & European Anesthesia Society recommends intake of clear fluid until 2 h before induction of anesthesia.38, 39, 40, 41 This may be modified in patient suffering from morbid obesity and uncontrolled diabetes.
Carbohydrate pretreatment results in less postoperative losses of nitrogen and protein,42, 43 as well as better maintained lean body mass and muscle strength.44, 45, 46
Such preconditioning provides patient those extra bit of calories and muscular strength to mobilize early and a successful speedy recovery (Table 1).
- 5.
Preoperative medications:
Walker and Smith47 concluded that patients receiving oral anxiolytic within 12 h before surgery showed impairment in psychomotor function postoperatively, which reduces the patient's ability to mobilize, eat, and drink. Postoperative fatigue and sleep disturbances affects the patient's health-related quality of life (HrQol) for up to 3 months. They have been specifically linked to neuro-immuno-humoral peritoneal axis.48, 49
Failure to mobilize early postoperatively is the single, most important factor responsible for prolonged hospital stay. The role of prehab and physical or yoga exercises comes into play, as an accustomed patient will take less time to mobilize.27, 28, 29, 30 Thus administration of sedatives for anxiolytics given by oral route is best avoided.
- 6.
Thromboprophylaxis:
Patients undergoing major abdominal or colorectal cancer surgery, especially pelvic surgery, should receive mechanical thromboprophylaxis with well-fitted compression stockings, because these have shown to significantly decrease incidence of DVT postoperatively.50
At-risk individuals are those with51 the following characteristics:
- •
Malignant disease
- •
Previous pelvic surgery
- •
Patients on corticosteroids
- •
Patients with extensive comorbidities like DM, hyperlipidemia, and hypothyroidism
- •
Hypercoagulable state
Pharmacological thromboprophylaxis with LMWH or unfractionated heparin is indicated in these high-risk group patients. Kwon et al.52 demonstrated that pharmacological prophylaxis reduces the prevalence of symptomatic venous thromboembolism from 1.8% to 1.1% and also reduced overall cancer mortality. Once-daily LMWH is as effective as twice-daily administration.53, 54
- 7.
Antimicrobial prophylaxis and skin preparation:
The use of antibiotic prophylaxis for patient undergoing colorectal surgery reduces the risk of surgical site infections.55 The best time for administration is 30–60 min before the incision is made.56 Repeated dose of antibiotics is also beneficial in prolonged procedures.57 The spectrum of antibiotic administered should cover both aerobic and anaerobic bacteria.
A study comparing different types of skin-cleansing agents showed that overall incidence of surgical site infection was 40% lower in a chlorhexidine vs betadine skin preparation group.58
The preferred method of part preparation/hair removal is hair clipping as compared to shaving with razors, although the timing of hair removal does not seem to affect the outcome.
- 8.
Standard anesthesia protocol:
The 3-key elements in which an anesthetist plays a role and can affect surgical outcomes are as follows:
Recognition of the importance of these components has led to the description of a “Trimodal Approach” for optimizing outcomes in laparoscopic surgery.59
The use of epidural analgesia has proven to be superior to opioids-based analgesia in terms of several important outcomes,60 including pain,61 PONV,62 and complications. Patient-controlled analgesia may be equally effective.59
Targeted fluid delivery approach is preferred against physiological measures,63 which guide perioperative fluid replacement. Once euvolemia has been established, mean arterial blood pressure should be maintained using vasopressors to avoid salt and water overload.64
- 9.
Postoperative nausea and vomiting (PONV):
The incidence of PONV is 20–25% in all surgical patients and is a leading cause of patient dissatisfaction and delayed discharge from the hospital. The etiology of PONV is multifactorial and depends upon the following:
- •
Patient factors – female patients, nonsmokers, and patients with history of motion sickness.
- •
Anesthesia factors – volatile anesthesia agents, nitrous oxide, and IV opioids.
- •
Surgical factors – major abdominal surgery like colorectal surgery.
Many guidelines are available like APFEL score, which stratify patients into low- to high-risk group of PONV and directs antiemetic prophylaxis.65 Recently, the concept of multimodal approach to tackle PONV is widely accepted. This combines pharmacological and nonpharmacological measures.66
- •
Nonpharmacological measures are as follows:
- ∘
Avoidance of emetogenic stimuli, such as inhalational anesthetics
- ∘
Use of propofol for induction and maintenance of anesthesia
- ∘
Carbohydrate loading
- ∘
Adequate hydration
- ∘
Use of high inspired oxygen during anesthesia67, 68
- ∘
- •
Pharmacological measures are as follows:
- ∘
Use of regional anesthetic techniques, such as epidurals and transverse abdominis plane (TAP) blocks, lead to reduced use of postoperative opioids69
- ∘
Use of NSAID as an alternative to opioids
- ∘
Different classes of antiemetics in use, based on the types of receptors they act on, are chlorogenic, dopaminergic, serotonergic, and histaminergic.
The potency of antiemetic effect is enhanced if > 2 antiemetics are used in combination.70
- 10.
Modification of surgical access:
Minimally invasive surgery has proved its worth in minimizing the surgical stress response with equivalent outcomes as compared to open surgery. It is now recommended for many complex procedures,71 and the indications are expanding. Minimally invasive colonic resection improves recovery.72, 73, 74, 75, 76, 77 Laparoscopic surgery has equivalent cancer outcomes as compared to the traditional open surgery.78, 79, 80, 81, 82 A recent laparoscopic and fast track multimodal management vs standard care (LAFA) study from a multicenter RCT, randomized between laparoscopic and open segmental colectomy within Dutch centers [74], reported a 2-day less LOSH in Laparoscopic Surgery group as compared to Open Surgery group. Buchanan et al.83 also reported that the conversion rate in elective colorectal surgery for laparoscopic approach is <10%, and in >9% of patients posted for surgery of the colorectal cancer, minimally invasive approach can be utilized. Speedy recovery is also dependent on the wound length.84, 85
- 11.
Nasogastric decompression by Ryles’ tube:
Routine use of nasogastric (NG) intubation has been linked to high incidence of pulmonary complications like atelectasis and pneumonia.86 A meta-analysis of RCT on the use of nasogastric decompression after abdominal surgery87 suggested that there is no rationale for routine NG decompression during elective surgery, it only serves to evacuate the air that gets trapped in the stomach during ventilation.
- 12.
Preventing intraoperative hypothermia:
Maintaining a normal core temperature of the patient is very important. Patients who become hypothermic (core temp. <36 °C) have been shown to have higher rates of wound infection,87, 88 morbid cardiac events,89 bleeding,90 and increase in oxygen consumption.91
Maintenance of core body temperature during procedure can be achieved by air warming blankets, heating mattresses, or recirculating water garments92; active warming should also continue in the postoperative period until the patient's core temperature is >36 °C.93 Use of prewarmed fluid for IV administration is also helpful.91
- 13.
Perioperative fluid management:
It is very important to achieve a state of physiological euvolemia in a patient undergoing major abdominal surgery for the following reasons:
- •
Intravascular hypovolemia can lead to a decrease in cardiac output, hypoperfusion of the vital organ, and bowel with resultant increase in rate of complications.
- •
Fluid overload leads to bowel edema and increased interstitial lung water.87
Laparoscopic surgery has a decrease in compartmental fluid shifts and SIRS phenomenon, thereby reducing the fluid requirement; but due to the head down position and pneumoperitoneum, cardiac output may reduce. Thus, targeted individualized fluid delivery is most appropriate.94, 95
The dynamic variables like arterial waveform analysis and CVP may guide fluid therapy.96, 97, 98
Balanced crystalloids have been shown to be superior to 0.9% saline for the maintenance of electrolyte balance.99
- 14.
Drainage of peritoneal cavity:
Traditionally, drainage of the peritoneal cavity is done to prevent accumulation of fluid in the bed of dissection, infection, and anastomotic breakdown. Recent RCTs have tested the efficacy of tube drainage of peritoneal cavity post major abdominal surgery and did not demonstrate any beneficial effects on clinical or radiological anastomotic dehiscence, wound infection, reoperation, extra-abdominal complications, or mortality.100, 101
It may be concluded that peritoneal drainage is not associated with any advantage or disadvantage but many drainage systems impair early mobilization.
- 15.
Urinary drainage:
Urinary catheterization is done during major abdominal surgery, mainly to monitor urine output and to prevent urinary retention post surgery. Alpert et al.102 concluded that intraoperative urine output was not a predictor of renal function. Only a brief duration of transurethral catheter drainage is desirable because increasing duration of urinary catheterization is associated with increased risk of UTI.
The prevalence of UTI significantly reduces with early removal (POD-1 vs POD-4) of urinary catheter (2% vs 14%).103
- 16.
Prevention of postoperative ileus:
Prolonged ileus is a major cause of delayed discharge from the hospital and prolonged LOSH after major abdominal surgery. The interventions that are deemed to be successful in decreasing the duration of ileus are as follows:
- •
Use of epidural analgesia as compared to IV opoid analgesia62, 104
- •
Avoiding fluid overloading in the perioperative period105, 106
- •
Avoidance of nasogastric decompression107
- •
Laparoscopic vs open approach – laparoscopic-assisted colonic resection leads to faster return of bowel activity, as well as resumption of oral diet compared with open surgery75, 77
- •
Perioperative use of chewing gum has a positive effect on postoperative duration of ileus108
- 17.
Postoperative analgesia:
The features of optimal analgesia in the postoperative period are as follows:
- •
It should provide a good pain relief
- •
Allow early mobilization
- •
Allow early return of gut function and oral feeding
- •
Should not cause any complication109
Understanding of the bimolecular basis of surgical convalescence110, 111 involved in postoperative pain has led to targeted approach to breakdown the cascade of inflammatory response112 and thereby minimizing their ill-effects.
The optimal analgesia for speedy recovery achieved by multimodal anesthesia technique is as follows:
- -
Combining regional analgesia or local anesthetics and avoiding parenteral opioids.
- -
IV paracetamol forms an important component of multimodal analgesia regimen and can be given as 1 g four times a day.
No other medications have been recommended for routine use.
- 18.
Postoperative nutritional care:
Low BMI does not appear to be independent risk factors for complications or prolonged LOSH.113 Regardless of the BMI, consumption of energy and protein is often low in the preoperative phase in patients to undergo colonic surgery. Thus, addition of oral supplements can improve overall intake to reach nutritional goals.114, 115, 116 Soop et al.117 suggested that combination of preoperative oral treatment of carbohydrates, epidural analgesia, and early enteral nutrition should be the aim.
The optimal time duration for preoperative nutritional supplement in a malnourished patient planned for colorectal surgery is 7–10 days preoperatively and this leads to decreased incidence of infectious complication and anastomotic leak.118 RCTs of the early enteral feeding vs nil by mouth show that early feeding reduces the risk of infection and LOSH and is not associated with an increased risk of anastomotic dehiscence.119, 120, 121
- 19.
Postoperative control of glucose:
Postoperative period is usually associated with increased insulin resistance, which can lead to hyperglycemia. Persistent hyperglycemia has been associated with increased risk of complications and mortality after major abdominal surgery.122, 123 Factors that affect insulin action or insulin resistance are124,125 as follows:
- •
Bowel preparation prolonging preoperative fasting
- •
Preoperative carbohydrate treatment instead of overnight fasting
Any reduction in hyperglycemia, regardless of the degree or level, improves patient outcome.117
- 20.
Early mobilization:
Early mobilization reduces the chances of chest complications and also counteracts insulin resistance.13 It may also improve muscle strength along with adequate nutritional support.126
Conversely, prolonged bed rest leads to several negative effects.127 LAFA trial77 supported the fact that mobilization on postoperative day 1, 2, and 3 is associated with speedy recovery.
Smart et al.128 suggested that failure to mobilize was the most common reason for delayed recovery and was associated with prolonged LOSH.
Factors responsible for immobilization include the following:
- -
Inadequate control of pain
- -
Continuous IV fluid replacement
- -
Indwelling urinary catheter
- -
Lack of patient motivation
- -
Preexisting comorbidities
- 21.
Audit:
It is a known fact that quality audit improves healthcare practice.129
Auditing is usually discussed under the following 3 domains:
- a)
Measuring PROs, readmission rates, and complications
- b)
Determining functional recovery and patient experience
- c)
Measuring compliance with or deviation from standard protocols
In the LAFA study, overall compliance to ERAS item of 60% was reported in laparoscopic and open colonic surgery.
There are several tools to audit compliance and outcomes, e.g. ERAS society interactive audit and data collection system (www.erassociety.org).
- 22.
Yoga exercise:
Yoga has several positive effects. It can contribute in the prehab of the patient, leads to a speedy recovery, enhances the postoperative recovery, and mobilizes and decreases LOSH. A regular yoga exercise also reduces the risk of pulmonary and infectious complications.27, 28, 29, 30
Section snippets
Conclusions
Modification of patient care at various substeps results in speedy recovery after colorectal surgery, faster convalescence, with a resultant decrease in LOSH, and early resumption of daily responsibilities. There is a need for regular update of knowledge base and continuous training of the surgical care providers for persistent better outcomes. Various components of patient care need to be optimized for desired, speedier recovery.
A strict compliance with time-tested guidelines in a suitable
Conflicts of interest
The authors have none to declare.
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