Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1621_Библиотеки_им_академика_М_И_Перельмана.pdf
23
Randomized Studies
To date, as relevant to our population, extended prophylaxis has only been studied in
RCTs for abdominal pelvic cancer [8, 25–27]. These studies, which are presented in
Table 3.3, conrmed that extended prophylaxis is efcacious in decreasing 30-day
VTE for abdominopelvic cancer patients. The main caveat/limitation of these three
studies is that they all used routine imaging to detect the DVTs, and detection of PE’s
was clinical. This strategy was used because in order to adequately power a study based
on clinical VTE rates, as many as 3000 patients may need to be enrolled which is essen-
tially cost-prohibitive. This is likely why so few randomized studies exist on this topic
overall, and why this has not yet been studied in the IBD surgical population.
Table 3.3 Relevant RCTs evaluating extended VTE chemoprophylaxis after abdominal surgery
First author
(year)
Patients studied Intervention N VTE rates
Secondary
outcome
Quality of
evidence
Bergqvist
(2002) [8]
Major
abdominopelvic
cancer surgery
Inpatient
enoxaparin
only vs.
enoxaparin
for 28-days
332 Routine
venography
12% vs.
4.8%,
p=0.02
Bleeding:
4.8% vs.
6.1%,
p=NS
Moderate
Rasmussen
(2006) [25]
Major
abdominal
surgery
Dalteparin
7-days vs.
28days
343 Routine
venography
16.3% vs.
7.3%,
p=0.01
(NNT=12)
Major
bleeding:
1.8% vs.
0.5%
a
Moderate
Kakkar
(2010) [26]
Major
abdominopelvic
cancer surgery
Bemiparin
8-days vs.
28day
625 Routine
venography
4.6% vs.
0.8%,
p=0.01
Major
bleeding:
0.6% vs.
0.3%
a
Minor
bleeding:
0.3% vs.
0.3%
a
Moderate
Vedovati
(2014) [27]
Laparoscopic
colorectal
cancer surgery
SQH 1-week
vs. 4weeks
225 Routine
Ultrasound
30-days:
9.7% vs. 0,
p=0.001;
90-days:
9.7% vs.
0.9%,
p=0.005;
relative risk
reduction
91%
Major
bleeding
(30-days):
0.9% vs.
0.9%
a
Moderate
SQH subcutaneous heparin, NNT number needed to treat
a
p-value not reported
3 Extended Venous Thromboembolism Prophylaxis After Surgery forInammatory…
24
Some argue that one does not need to give prophylaxis to prevent clinically silent
VTEs. On the other hand, one cannot predict when a clinically silent VTE will
become symptomatic, and in the worst case result in a patient dying. Studies have
proven that extended prophylaxis is both efcacious for preventing VTEs and safe
in terms of bleeding. These results have been conrmed by several meta-analyses
[28, 29].
Guidelines Recommendations forExtended VTE
Chemoprophylaxis after Surgery forIBD
As of 2012, the American College of Chest Physicians (ACCP) Prophylaxis
Guidelines for non-orthopedic surgery recommended that highest-risk patients
(VTE risk ~6%) who have cancer receive 4 weeks of chemoprophylaxis. As of
2018, the American Society of Colorectal Surgeons Clinical Practice Guidelines
Committee recommended that extended prophylaxis be considered for surgical IBD
patients [2]. Thus extended chemoprophylaxis can now be considered part of the
standard of care for IBD patients.
Outcomes ofExtended VTE Chemoprophylaxis
Risk ofBleeding
The risk of bleeding secondary to VTE chemoprophylaxis is low. In a retrospective
study of 974 IBD patients, the rate of major postoperative bleeding in patients who
had VTE chemoprophylaxis was 0.4%, vs. 0%, p=NS in those with no prophylaxis,
whereas the rate of minor bleeding was 5.4% vs. 0%, p=NS [30], with and without
prophylaxis, respectively. According to the ACCP VTE Prophylaxis Guidelines for
non-orthopedic surgery, which are drawn from a wide-variety of operations, the risk
of major bleeding with the use of any postoperative chemoprophylaxis is approxi-
mately double compared to those without any chemoprophylaxis, however as seen
above the absolute rates remain small [1]. In addition, there was no difference in
wound hematoma and major bleeding requiring reoperation between the use of low
molecular weight heparin (LMWH) and unfractionated heparin (UFH) [1]. Bleeding
rates reported from RCTs are shown in Table 3.3. In summary, patients should be risk-
stratied for both risk of VTE and the risk of bleeding from chemoprophylaxis [1].
Cost-Effectiveness
Currently, there is minimal data regarding the cost-effectiveness of extended VTE
chemoprophylaxis for IBD patients underwent surgery. However, there is some evi-
dence suggesting the use of extended VTE chemoprophylaxis in major abdominal
and pelvic surgery is indeed cost-effective. In a decision analysis model of pelvic
C. H. A. Lee and S. D. Holubar
25
surgery patients, from a healthcare system perspective, the use of UFH for one
month is the most effective and least costly (mean cost of $1,611) strategy in pre-
venting postoperative VTE, whereas LMWH for 1 month is equally effective but
more expensive (mean cost of $2,197) [31]. Furthermore, 2 cost-effective analyses
demonstrated that the use of LMWH for extended VTE chemoprophylaxis would be
cost-effective only when the probability of VTE exceed 2.4% and 2.1% respec-
tively, rates which are below the typical rate seen in IBD patients postoperatively
[32, 33]. In contrast, based on results from a decision model constructed to compare
the use of UFH, LMWH, and 325mg of aspirin versus no extended prophylaxis
after cancer surgery, UFH was found to be the most cost-effective, potentially sav-
ing $30 million per year in the United States; however, the decision-analysis sug-
gested that aspirin could be considered as an alternative strategy when compliance
is low (i.e. fear of self- injection) [34]. Given wider availability of lower cost generic
LMWH since that study (2010), a more recent cost-minimization decision analysis
suggests that using LMWH as extended therapy is cost-effective in the current cost
environment [35].
Recommendation Based onData
We recommend that IBD patients undergoing major colorectal surgery be managed
with extended VTE chemoprophylaxis with LMWH for 28days post-operatively
(moderate evidence quality; strong recommendation).
Personal View ofData
Despite a present lack of level 1 evidence for post-operative IBD patients, the short-
and long-term risks of VTE far outweigh the risks of extended chemoprophylaxis.
For actively inamed IBD patients undergoing major abdominopelvic surgery, eval-
uation begins with a screening lower extremity duplex, and upper extremity duplex
if a PICC line if present, for the majority of emergency, transferred, or hospitalized
patients. Prior to the induction of anesthesia, we conrm VTE chemoprophylaxis
with either SQH 5000units or enoxaparin 40mg and the application of sequential
compression boots as part of the preoperative checklist; for malnourished, under-
weight patients below 60 kg of body weight, we dose-adjust to 30 mg of
enoxaparin.
Postoperatively, chemoprophylaxis is integrated into the colorectal post- operative
order-sets as a hard-stop in the electronic medical record. If a patient is not receiving
risk-stratied chemoprophylaxis, then the healthcare provider must document the
reason, also as a hard-stop. Sequential compression devices are continued postop-
eratively until the patient is fully ambulatory. Patients are encouraged to ambulate
on the day of surgery and as much as possible thereafter.
The SQH or enoxaparin is continued until hospital discharge. After major
abdominopelvic operations for IBD (not including ileostomy closures), we
3 Extended Venous Thromboembolism Prophylaxis After Surgery forInammatory…
26
recommend extending the VTE chemoprophylaxis with enoxaparin for a total of
28days after discharge. In the circumstance of insurance denials, or unaffordable
insurance co-pays/out-of-pocket expense, we rst ask the Care Managers for
their assistance is cost-reduction mechanism such as coupons; a minority will
need to seek charity funding. Although low-dose aspirin may be an alternative in
general surgery patients at high-risk of VTE when LMWH or UFH are contrain-
dicated or unavailable, the efcacy for extended prophylaxis has not yet been
studied [1, 36].
There are multiple caveats regarding the use of LMWH.The rst is that LMWH is
associated with a lower rate of heparin induced thrombosis and thrombocytopenia
(HITT). Prophylactic dose LMWH does not need to be held for 24h before surgery, as
this practice is associated with an increased risk of VTE [3]. Also, LMWH cannot be
given 12h before or after an epidural catheter insertion or removal. LMWH is also
contraindicated in those with renal dysfunction (i.e. creatinine clearance <30 cc/mL),
those at increased risk of perioperative bleeding, and in those with heparin allergies and
HITT.Finally, two surgical adages to remember: “It is easier to treat bleeding that to
treat clotting”, and “prophylactic heparin does not cause bleeding, surgeons cause
bleeding”.
References
1. Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, Samama CM.Prevention
of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of throm-
bosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines. Chest. 2012;141:e227S–e77S.
2. Fleming F, Gaertner W, Ternent CA, Finlayson E, Herzig D, Paquette IM, Feingold DL, Steele
SR.The American Society of Colon and Rectal Surgeons Clinical Practice Guideline for the
Prevention of Venous Thromboembolic Disease in Colorectal Surgery. Dis Colon Rectum.
2018;61:14–20.
3. Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT.Regional
anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society
of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition). Reg
Anesth Pain Med. 2018;43:263–309.
4. Gu J, Stocchi L, Gorgun E, Remzi FH.Risk factors associated with portomesenteric venous
thrombosis in patients undergoing restorative proctocolectomy for medically refractory ulcer-
ative colitis. Color Dis. 2016;18:393–9.
5. Katsanos AH, Katsanos KH, Kosmidou M, Giannopoulos S, Kyritsis AP, Tsianos EV.Cerebral
sinus venous thrombosis in inammatory bowel diseases. QJM. 2013;106:401–13.
6. Wallaert JB, De Martino RR, Marsicovetere PS, Goodney PP, Finlayson SR, Murray JJ,
Holubar SD. Venous thromboembolism after surgery for inammatory bowel disease: are
there modiable risk factors? Data from ACS NSQIP.Dis Colon Rectum. 2012;55:1138–44.
7. Group ES.Efcacy and safety of enoxaparin versus unfractionated heparin for prevention of
deep vein thrombosis in elective cancer surgery: a double-blind randomized multicentre trial
with venographic assessment. ENOXACAN Study Group. Br J Surg. 1997;84:1099–103.
8. Bergqvist D, Agnelli G, Cohen AT, Eldor A, Nilsson PE, Le Moigne-Amrani A, Dietrich-Neto
F, Investigators EI.Duration of prophylaxis against venous thromboembolism with enoxaparin
after surgery for cancer. N Engl J Med. 2002;346:975–80.
9. McLeod RS, Geerts WH, Sniderman KW, Greenwood C, Gregoire RC, Taylor BM, Silverman
RE, Atkinson KG, Burnstein M, Marshall JC, Burul CJ, Anderson DR, Ross T, Wilson SR,
Barton P.Subcutaneous heparin versus low-molecular-weight heparin as thromboprophylaxis
C. H. A. Lee and S. D. Holubar
27
in patients undergoing colorectal surgery: results of the Canadian colorectal DVT prophylaxis
trial: a randomized, double-blind trial. Ann Surg. 2001;233:438–44.
10. Lee CHA, Aiello A, Stocchi L, Lipman J, Shawki S, Hull T, Steele S, Holubar S. P781
Dening the economic burden of venous thromboembolism after surgery for inammatory
bowel disease in the USA: a national inpatient sample study. J Crohn’s Colitis. 2019;13(Suppl
1):S511–2. https://doi.org/10.1093/ecco-jcc/jjy222.905.
11. Zaghiyan KN, Sax HC, Miraor E, Cossman D, Wagner W, Mirocha J, Gewertz B, Fleshner P,
Cedars-Sinai DVTSG.Timing of chemical thromboprophylaxis and deep vein thrombosis in
major colorectal surgery: a randomized clinical trial. Ann Surg. 2016;264:632–9.
12. Greaves SW, Holubar SD. Preoperative hospitalization is independently associated with
increased risk for venous thromboembolism in patients undergoing colorectal surgery: a national
surgical quality improvement program database study. Dis Colon Rectum. 2015;58:782–91.
13. Aziz FRA.Patients who are transferred from other hospitals have higher incidence of DVT.J
Vasc Surg Venous Lymphat Disord. 2013;1:102–3.
14. Caprini JA, Arcelus JI, Hasty JH, Tamhane AC, Fabrega F. Clinical assessment of
venous thromboembolic risk in surgical patients. Semin Thromb Hemost. 1991;17(Suppl
3):304–12.
15. Rogers SO Jr, Kilaru RK, Hosokawa P, Henderson WG, Zinner MJ, Khuri SF.Multivariable
predictors of postoperative venous thromboembolic events after general and vascular surgery:
results from the patient safety in surgery study. J Am Coll Surg. 2007;204:1211–21.
16. Obi AT, Pannucci CJ, Nackashi A, Abdullah N, Alvarez R, Bahl V, Wakeeld TW, Henke
PK.Validation of the Caprini venous thromboembolism risk assessment model in critically Ill
surgical patients. JAMA Surg. 2015;150:941–8.
17. Gross ME, Vogler SA, Mone MC, Sheng X, Sklow B.The importance of extended postopera-
tive venous thromboembolism prophylaxis in IBD: a National Surgical Quality Improvement
Program Analysis. Dis Colon Rectum. 2014;57:482–9.
18. Benlice C, Holubar S, Gorgun E, Stocchi L, Lipman J, Kalady M, Champagne BJ, Steele
S. The importance of extended VTE prophylaxis in patients with IBD: nomogram-based
assessment from the ACS-NSQIP Cohort. 2018:S25.
19. Holubar S, Lee CHA, Feinberg A, Lavryk O, Stocchi L, Rieder F, Regeuiro M, Hull T, Steele
S. P160 Hypercoagulability in patients undergoing abdominopelvic surgery for inammatory
bowel disease: insights from thromboelastography. J Crohn’s Colitis. 2019;13(1):S168–9.
https://doi.org/10.1093/ecco-jcc/jjy222.284.
20. Wilson MZ, Connelly TM, Tinsley A, Hollenbeak CS, Koltun WA, Messaris E. Ulcerative
colitis is associated with an increased risk of venous thromboembolism in the postoperative
period: the results of a matched cohort analysis. Ann Surg. 2015;261:1160–6.
21. Brady MT, Patts GJ, Rosen A, Kasotakis G, Siracuse JJ, Sachs T, Kuhnen A, Kunitake
H.Postoperative venous thromboembolism in patients undergoing abdominal surgery for IBD:
a common but rarely addressed problem. Dis Colon Rectum. 2017;60:61–7.
22. McKenna NP, Behm KT, Ubl DS, Glasgow AE, Mathis KL, Pemberton JH, Habermann EB,
Cima RR.Analysis of postoperative venous thromboembolism in patients with chronic ulcer-
ative colitis: is it the disease or the operation? Dis Colon Rectum. 2017;60:714–22.
23. Ali F, Al-Kindi SG, Blank JJ, Peterson CY, Ludwig KA, Ridol TJ.Elevated venous thrombo-
embolism risk following colectomy for IBD Is equal to those for colorectal cancer for ninety
days after surgery. Dis Colon Rectum. 2018;61:375–81.
24. Holubar SD.Prophylaxis of postoperative complications. In: Gan TJ, Thacker JK, Miller TE,
Scott MJ, Holubar SD, editors. Enhanced recovery for major abdominopelvic surgery. West
Islip, NY: Professional Communications Inc.; 2016.
25. Rasmussen MS, Jorgensen LN, Wille-Jorgensen P, Nielsen JD, Horn A, Mohn AC, Somod L,
Olsen B, Investigators F. Prolonged prophylaxis with dalteparin to prevent late thromboem-
bolic complications in patients undergoing major abdominal surgery: a multicenter random-
ized open-label study. J Thromb Haemost. 2006;4:2384–90.
26. Kakkar VV, Balibrea JL, Martinez-Gonzalez J, Prandoni P, Group CS.Extended prophylaxis
with bemiparin for the prevention of venous thromboembolism after abdominal or pelvic sur-
gery for cancer: the CANBESURE randomized study. J Thromb Haemost. 2010;8:1223–9.
3 Extended Venous Thromboembolism Prophylaxis After Surgery forInammatory…
28
27. Vedovati MC, Becattini C, Rondelli F, Boncompagni M, Camporese G, Balzarotti R, Mariani
E, Flamini O, Pucciarelli S, Donini A, Agnelli G. A randomized study on 1-week versus
4-week prophylaxis for venous thromboembolism after laparoscopic surgery for colorectal
cancer. Ann Surg. 2014;259:665–9.
28. Rasmussen MS, Jorgensen LN, Wille-Jorgensen P. Prolonged thromboprophylaxis with low
molecular weight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev.
2009:CD004318.
29. Fagarasanu A, Alotaibi GS, Hrimiuc R, Lee AY, Wu C.Role of extended thromboprophylaxis
after abdominal and pelvic surgery in cancer patients: a systematic review and meta-analysis.
Ann Surg Oncol. 2016;23:1422–30.
30. Ra G, Thanabalan R, Ratneswaran S, Nguyen GC. Predictors and safety of venous throm-
boembolism prophylaxis among hospitalized inammatory bowel disease patients. J Crohns
Colitis. 2013;7:e479–85.
31. Teoh D, Berchuck A, Alvarez Secord A, Lee PS, Lowery WJ, Sfakianos GP, Valea FA, Myers
ER, Havrilesky LJ.Cost comparison of strategies for the management of venous thromboem-
bolic event risk following laparotomy for ovarian cancer. Gynecol Oncol. 2011;122:467–72.
32. Iannuzzi JC, Rickles AS, Kelly KN, Fleming FJ, Dolan JG, Monson JR, Noyes K.Dening
high risk: cost-effectiveness of extended-duration thromboprophylaxis following major onco-
logic abdominal surgery. J Gastrointest Surg. 2014;18:60–8.
33. Trepanier M, Alhassan N, Sabapathy C, Liberman S, Charlebois P, Stein B, Feldman LS, Lee
L.Cost-effectiveness of extended thromboprophylaxis in patients undergoing colorectal sur-
gery from a Canandian healthcare system perspective. 2018:P52.
34. Bradley CT, Brasel KJ, Miller JJ, Pappas SG.Cost-effectiveness of prolonged thromboprophy-
laxis after cancer surgery. Ann Surg Oncol. 2010;17:31–9.
35. Holubar S, Dulai P, Piazik B, Finlayson S, Udeh B. Extended enoxaparin venous thrombo-
embolism prophylaxis after surgery for inammatory bowel disease: a cost-based decision
analysis. ECCO. 2018;2018:P768.
36. Smith M, Wakam G, Wakeeld T, Obi A. New trends in anticoagulation therapy. Surg Clin
North Am. 2018;98:219–38.
C. H. A. Lee and S. D. Holubar
29
© Springer Nature Switzerland AG 2019
N. Hyman et al. (eds.), Mastery of IBD Surgery,
https://doi.org/10.1007/978-3-030-16755-4_4
L. M. Cannon (*)
Section of Colon and Rectal Surgery, Department of General Surgery, University of Chicago
Medicine, Chicago, IL, USA
e-mail: lcannon@surgery.bsd.uchicago.edu
4
The Use ofEnhanced Recovery Pathways
inPatients Undergoing Surgery
forInflammatory Bowel Disease
LisaMarieCannon
Introduction
First described in the 1990s by Henrik Kehlet, perioperative care protocols have
replaced traditional inpatient convalescence standards in colorectal surgery [1]. At
their core, they aim to standardize the care process with evidence-based recommen-
dations for the pre-, intra-, and postoperative phases of care as well as the patient’s
transition home. These protocols function under several names, including fast-track
pathway, accelerated care program, enhanced recovery pathway (ERP), and the
Enhanced Recovery After Surgery (ERAS) program. Herein the author refers to this
care paradigm exclusively as an enhanced recovery pathway.
Though they vary slightly across institutions, the key components of the multi-
modal ERP include preadmission counseling, minimizing preoperative fasting, car-
bohydrate loading, multimodal opioid sparing analgesia, avoidance of excess uid
administration, antibiotic prophylaxis, prophylaxis against post-operative nausea
and vomiting and venous thromboembolism, early discontinuation of urinary cath-
eter, early oral feeding, early ambulation, and dened discharge criteria with daily
discharge planning. ERPs require that patients become active participants in their
care. Informed patients who understand the benets of an ERP are more likely to be
compliant with elements that require a motivated patient, such as early ambulation
and readiness for discharge. Lack of consensus about process standardization,
increased number of protocol elements, and lack of commitment on behalf of the
team stakeholders can all affect protocol adherence.
ERPs within colorectal surgery have repeatedly demonstrated a reduction in
length of stay and complications without increasing readmission rate through
multiple institutional studies, meta-analysis, and a Cochrane review [2]. Further,
30
they result in increased patient satisfaction particularly through improved pain-
control, and are cost-effective [3]. Given that the ERP framework aims to reduce
surgical stress and minimize physiologic disturbance, utilization of a minimally
invasive approach is a natural extension of an ERP. A minimally invasive
approach is known to be synergistic with ERPs in reducing morbidity and length
of stay [4–7]
.
Currently, enhanced recovery pathways are demonstrated to be efcacious for
patients with benign or malignant conditions undergoing colorectal surgery. While
a minimally invasive approach is known to be benecial in patients with Crohn’s
disease or ulcerative colitis undergoing intestinal resection, little has been reported
on the use of enhanced recovery protocols in this population [8–12]
.
Using the PICO format, inammatory bowel disease (IBD) patients undergo-
ing surgery and receiving perioperative management on a dened enhanced recov-
ery protocol were compared to those receiving conventional perioperative care
(Table 4.1). The outcomes evaluated were length of stay, morbidity, and
readmission.
Search Strategy
A systematic literature search was performed of MEDLINE and PubMed to identify
English language publications related to utilization of enhanced recovery protocols
in IBD in adults published from January 2000 through June 2018. Combinations of
key words were constructed and applied to these databases. The search strategy
used in MEDLINE included both MeSH subject headings when possible and/or
keyword mapping alias operator commands for the terms ‘inammatory bowel dis-
ease’ or ‘ulcerative colitis’ or ‘Crohn’s,’ AND ‘enhanced recovery,’ ‘ERAS,’ ‘fast-
track, or ‘accelerated care.’ Similar combinations were then applied to PubMed.
The biographies of all the original articles were then explored for any additional
germane publications. Case reports, letters, systematic reviews, and duplicate arti-
cles were excluded.
Because the above search yielded only six relevant studies [13–18], a similar
search was performed that was limited to ‘colorectal,’ AND ‘enhanced recovery,’
‘ERAS,’ ‘fast-track, or ‘accelerated care,’ AND ‘conventional care’ within the same
time-frame in adult patients, and then further limited to ‘length of stay,’ AND ‘post-
operative complications.’ Further limiting by ‘readmission’ was too restrictive and
this limit was lifted. These studies were then individually assessed to determine if
they contained any IBD patients in their study population, and in this manner a fur-
ther seven studies were identied [3, 19–24].
Table 4.1 PICO table
P (Patients)
I (Intervention) C (Comparator)
O (Outcomes)
IBD patients requiring
surgery
Enhanced recovery
protocol
Conventional
care
Length of stay
30-day readmission
30-day morbidity
L. M. Cannon
31
Results
Thirteen English language studies were identied. Using the GRADE system
approach to developing practice guidelines, all 13 studies were rated either low or
very low quality; reasons for this included small sample size, allocation conceal-
ment, surgeon bias, lack of blinding, and lack of reporting on important metrics
such as surgical approach, conversion rate, level of adherence to the ERP protocol,
or 30-day readmission rate. Most studies did not provide important IBD-specic
demographic information such as preoperative use of biologic therapy, steroids, or
immune modulation. Some studies did not describe utilizing dened discharge cri-
teria or otherwise discuss discharge readiness even though this parameter is known
to inuence one of the outcomes of interest, length of stay [25]. There is partial
indirectness of study outcomes in regard to IBD in the studies that include other
disease populations such as neoplasia or diverticulitis patients. Some studies
employed a ‘before and after’ format of their study populations, recognizing that it
is difcult to simultaneously conduct two postoperative care paradigms on the
same surgical ward with the same nursing staff; but this does introduce bias. Most
of the included studies had more than one of these limitations. Two studies did not
have a comparator group [13, 15], and in one study the comparator group was not
conventional care, but a different disease population— neoplasia— employing the
same ERP.In this study only the IBD arm was considered in the data [14]. These
studies are summarized in Table4.2. One study patient population from Thiele
appears to be entirely included within a more recent study from the same institu-
tion by Shah [3, 17].
The studies are heterogeneous in regard to the specic components of the path-
way, with use of mechanical or oral antibiotic bowel preparation and use of epidural
or other neuraxial anesthesia being the most variable. Discussion of the use of
mechanical and/or oral antibiotic bowel preparation is a controversial and evolving
topic and outside the scope of this chapter; but recent evidence highlights the impor-
tance of oral antibiotics as adjunct therapy in reducing surgical site infection [26].
Studies that employed thoracic epidural anesthesia also had increased or exclusive
utilization of an open approach; this is consistent with data that does not support the
use of epidural anesthesia after laparoscopy in the setting of an enhanced recovery
program [27, 28]. Almost all studies included only elective colorectal resections.
All studies adhered to well-established practice parameters for antibiotic prophy-
laxis and venous thromboembolic prophylaxis. Avoidance of fasting generally
meant allowance of clears until 2h prior to induction of anesthesia. Carbohydrate
loading was accomplished through a variety of beverages. Opioid-sparing multi-
modal analgesia usually included a non-steroidal anti-inammatory medication and
acetaminophen.
There are a total of 3463 intestinal surgeries represented by these studies. Of
these 2249 were placed on an enhanced recovery protocol, and 2140 are presumed
unique cases. Of these 2140 intestinal surgeries, only 28.9% were performed with a
stated indication as IBD. This relatively low proportion sets the framework by
which any IBD-specic recommendation must be considered. 71% of the
4 The Use ofEnhanced Recovery Pathways inPatients Undergoing Surgery…
32
Table 4.2 Evidence on enhanced recovery pathways in inammatory bowel disease
a
Study (period)
N
%
IBD
% Minimally invasive
approach
(% Conversion) LOS
Dened discharge
criteria
30-day
Readmission
30-day
Morbidity
Andersen etal. [13]
(’00–’03)
+ epidural, restrictive uid regimen, early mobilization, early PO, early urinary catheter removal,
MMA, MagOx
IBD ileocolic
resections on ERP
32
b
100 0 Mean 3.0day
(Range 2–20)
Yes 6% 25%
c
Dai etal. [14]
(’12–’15)
Pre-op education, no bowel prep, avoidance of fasting, minimally invasive preferred,
Restrictive uid regimen, early mobilization, early PO, early urinary catheter removal, MMA
IBD patients on ERP 259 100 52.5
(10.4)
7.9±5.3day NR NR 34.2%
Delaney etal. [15] Pre-op education, avoidance of fasting, early mobilization, early PO, early urinary catheter removal, MMA
Colorectal surgery on
ERP
1000 13.2 100
(5.8)
Mean 4.1±3.2day Yes 6% 20.3%
Delaney etal. [19] 64 Pre-op education, early mobilization, early PO
Colorectal surgery on
ERP
31 54.8 0 5.2±2.5day NS Yes 9.7%
e
NS 22%
e
NS
Conventional care 33 78.8 0 5.8±3day 18.2%
e
30%
e
Keane etal. [20]
(‘07–‘09)
240 Pre-op education, ± bowel prep, avoidance of fasting, carbohydrate loading, ± epidural, early HLIV,
Early mobilization, early PO, early urinary catheter removal
Colorectal surgery on
ERP
80 12.5 NR Median 6day
(Range 1–63)
p 0.0004 Yes 21.3% NS 40.0% NS
Conventional care 160 4.4 NR Median 7day
(Range 3–125)
11.9% 42.5%
Lee etal. [21]
(’12–’13)
190 Pre-op education, prehabilitation, ± bowel prep, avoidance of fasting, carbohydrate loading,
± epidural, avoid overhydration, early mobilization, early PO, early urinary catheter removal, MMA
Colorectal surgery on
ERP
95 12.6 75
(NR)
Mean
5.7±5.5day
p 0.007 NR 13%
d
NS 40%
d
NS
Conventional care 95 8.4 45
(NR)
Mean
9.4±11.8day
11%
d
43%
d
L. M. Cannon