Guidelines for perioperative care in elective rectal ...

1 Guidelines for perioperative care in elective rectal /pelvic surgery : EnhancedRecovery After surgery (ERAS ) Society recommendationsqJ. Nygrena,j,*,k, J. Thackerb,k, F. Carlic,k, Fearond,k, S. Nordervale,k, Lobof,k, O. Ljungqvistg,k,M. Sooph,k, J. Ramirezi,kaDepartment of surgery , Ersta Hospital, Karolinska Institutet, Stockholm, SwedenbDepartment of surgery , Duke University, Durham, NC, USAcDepartment of Anaesthesia, McGill University, Montreal, Quebec, CanadadDepartment of Clinical surgery , School of Clinical Sciences and Community Health, University of Edinburgh, Royal Infirmary, Edinburgh, UKeDepartment of Gastroenterological surgery , University Hospital of North Norway, Troms , NorwayfDivision of Gastrointestinal surgery , Nottingham Digestive Diseases Centre National Institute for Health Research Biomedical Research Unit, Nottingham University Hospitals,Queen s Medical Centre, Nottingham, UKgDepartment of surgery , Orebro University Hospital, Orebro, SwedenhSouth Auckland Clinical School University of Auckland, Department of surgery Middlemore Hospital, Auckland.

2 New ZealandiDepartment of Colorectal surgery , Hospital Cl nico Universitario Lozano Blesa, Zaragoza, SpainjDepartment of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Swedenarticle infoArticle history:Received 14 August 2012 Accepted 19 August 2012 Keywords:ColorectalRectalPelvicSurgeryEn hanced recoveryPerioperative caresummaryBackground:This review aims to present a consensus for optimal perioperative care in rectal /pelvicsurgery, and to provide graded recommendations for items for an evidenced-based enhanced :Studies were selected with particular attention paid to meta-analyses, randomized controlledtrials and large prospective cohorts. For each item of the perioperative treatment pathway, availableEnglish-language literature was examined, reviewed and graded. A consensus recommendation wasreached after critical appraisal of the literature by the :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).

3 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 andMetabolism (ESPEN) and International Association for Surgical Metabolism and Nutrition (IASMEN)present a comprehensive evidence-based consensus review of perioperative care for rectal surgery . 2012 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights IntroductionUntil quite recently, patients undergoing colorectal resectionwere counseled to accept a 20e25% risk of complications anda7e10-day postoperative stay in hospital. As studies throughoutthe 1980e1990s showed, length of stay in hospital (LOSH) andcomplication rates improved even if a single component of carewas this, the idea of incorporating many of theseelements into a comprehensive perioperative care Recovery After surgery (ERAS ) is a dynamic culmi-nation of evidence based upon perioperative care elements.

4 Thestrongest evidence for ERAS implementation is in the care ofpatients undergoing open colonic resection. Many interventionspreviously shown to benefit outcomes in this population have nowqThe Guidelines are published as a joint effort between the Enhanced RecoveryAfter surgery (ERAS) Society, for perioperative Care, The European Society forClinical Nutrition and Metabolism (ESPEN) and The International Association forSurgical Metabolism and Nutrition (IASMEN) and copyrights for this publication isshared between the three societies. The Guidelines are published jointly in WorldJournal of surgery (IASMEN) and Clinical Nutrition (ESPEN), and will also beavailable on the ESPEN ( ) and ERAS Society websites ( ).*Corresponding author. Department of surgery , Ersta Hospital, KarolinskaInstitutet, Stockholm, Sweden. Tel.: 46 87146542; fax: 46 Nygren).kOn behalf of the ERAS Society, the European Society for Clinical Nutrition andMetabolism and the International Association for Surgical Nutrition lists available atSciVerse ScienceDirectClinical Nutritionjournal homepage: $esee front matter 2012 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism.

5 All rights Nutrition 31 (2012) 801e816been successfully applied to laparoscopic colon resections, as wellas to other surgical specialties such as urology, orthopedics, studying the application of ERAS principles tocolonic resections have acknowledged the difference betweenintra-abdominal large-bowel resections and pelvic surgery . Pelvicintestinal resections are fraught with higher complication rates,longer LOSH, and unique complications not seen in abdominalsurgery. Because of this and a need to address the more commonlower-bowel resections, the authors of ERAS studies have excludedpatients undergoing rectal resection or treated pelvic resections asa subgroup. In several studies, rectal resections are included in theoverall analysis of an ERAS protocol or component implementa-tion, only to be excluded or discounted as a special consideration the present work, the authors have specifically considered theapplication of ERAS principles to a special population of rectalresection patients.

6 We define pelvic bowel procedures to includeresections of the last 12e15 cm of the large bowel as measuredfrom the anus, and/or those resections defined intraoperatively tobe below the pelvic reflection. Through the application of thesedefinitions, we have included resections that encompass theincreased: difficulty of pelvic surgery compared with segmentalcolonic resections; operative times and use of retraction known toincrease perioperative morbidity; risk to the pelvic structures ( ,hypogastric nerves, ureters). Although all indications for pelvicresections were included in the literature search, mention ofspecific recommendations relative to the diagnosis is made ifappropriate. For example, the use of laparoscopy for pelvic bowelmalignancy is not as readily applied outside of a trial as opposed tocommonly accepted laparoscopic resection for pelvic inflammatorybowel recognition of the aspects of pelvic bowel surgery that areknown to be more difficult and moribund than abdominal surgery ,we critically reviewed and graded the evidence.

7 These guidelinesare a literature review with summary expert opinion regarding theapplication of ERAS principles to rectal resection. Many (but notall) ERAS protocol elements, as defined in colonic resection, havebeen applied successfully to rectal 1is an over-view of the individual components of ERAS for colonic resectionwith explanations as to the applicability in rectal resection. Whilepractical, a discussion of application of the individual elementsmay not be as important as the consideration of a paradigm true focus of ERAS, whether the application of interventions isto rectal resection or orthopedics, is the understanding andprevention of the causative factors of perioperative stress and lossof homeostasis. By considering the specific stress factors associ-ated with rectal resection during our review of the literature, wehave created Guidelines to shift the paradigm of care of rectalresection patients and stimulate more studies to further this effort(Table 2).

8 2. Literature searchThe authors met in April 2011, and the topics for inclusion wereagreed and allocated. The principal literature search utilisedMEDLINE, Embase and Cochrane databases to identify relevantarticles published between January 1966 and January 2012. MedicalSubject Headings terms were used, as well as the accompanyingentry terms for the patient group, interventions and outcomes. Theselected key words were rectum , perioperative care , enhancedrecovery and fasttrack . There was no language lists of all eligible articles were checked for otherrelevant studies. Conference proceedings were not searched. Expertcontributions came from within the ERAS Society Working Party onSystematic Study selectionTitles and abstracts were screened by individual reviewers toidentify potentially relevant articles. Discrepancies in judgementwere resolved by the senior author and during committee meetingsof the ERAS Society Working Party on Systematic Reviews.

9 Reviews,case series, non-randomised and randomised control studies,meta-analyses and systematic reviews were considered for eachindividual Quality assessment and data analysesThe methodological quality of the included studies wasassessed using the Cochrane strength of evidenceand conclusions were assessed and agreed by all authors in May2012. Quality of evidence and recommendations were evaluatedaccording to the Grading of Recommendations, Assessment,Development and Evaluation (GRADE) fromthe GRADE Guidelines ,4the recommendations are given asfollows: strong recommendations indicate that the panel isconfident that the desirable effects of adherence to a recommen-dation outweigh the undesirable effects . Weak recommenda-tions indicate that the desirable effects of adherence toa recommendation probably outweigh the undesirable effects, butthe panel is less confident.

10 Recommendations were based onquality of evidence ( high , moderate , low , very low ) but alsoon the balance between desirable and undesirable effects; and onvalues and latter implies that, in some cases,strong recommendations could be reached from low-quality dataandvice Evidence base and recommendationseERAS Preoperative counsellingPreoperative counselling targeting expectations about surgicaland anaesthetic procedures may diminish fear and anxiety andenhance postoperative recovery and , leaflets or multimedia information containing expla-nations of the procedure along with tasks that the patient should beencouraged to fulfil may improve perioperative feeding, earlypostoperative mobilisation, pain control, and respiratory physio-therapy; and hence reduce the prevalence of , the patient should meet with the surgeon, anaesthetistand nurse. Patients destined for a diverting or permanent stomashould have a preadmission nursing visit regarding enterostomaltherapy to better prepare them for the procedure and to reducepostoperative and recommendation: patients should receiveroutine dedicated preoperative level: grade: Preoperative optimisationPreoperative optimisation is a crucial step in major abdominalsurgery and physiological preparation for surgery is evaluation should be used to identify medical condi-tions and risk factors for postoperative morbidity and of anaemia, diabetes mellitus (DM) and hypertensionJ.