Seminars in Colon & Rectal Surgery RSS feed: Current Issue. Seminars in Colon and Rectal Surgery offers a comprehensive and coordinated review of a single, timely topic related to the diagnosis and treatment of proctologic diseases. Each issue is an organized compendium of practical information that serves as a lasting reference for colorectal surgeons, general surgeons, surgeons in training and their colleagues in medicine with an interest in colorectal disorders. 2010 Topics March Pelvic Floor Evaluation Tracy Hull June Reducing Morbidity Warren Enker http://www.seminarscolonrectalsurgery.com/?rss=yesElsevier Inc.en © 2010 Elsevier Inc. All rights reserved. Seminars in Colon & Rectal Surgery1043-1489213September 2010 © 2010 Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.seminarscolonrectalsurgery.com/article/PIIS1043148910000394/abstract?rss=yesThis edition of Seminars in Colorectal Surgery is devoted to understanding the evolution, evidence, and implementation of enhanced recovery or “fast track” pathways. I hope this overview is comprehensive and provides trainees, surgeons, and additional support staff with a fundamental understanding of why improved recovery programs have gained momentum at institutions around the globe.IntroductionBradley J. Champagne10.1053/j.scrs.2010.05.001Seminars in Colon & Rectal Surgery 21, 3 (2010)2010-09-01Seminars in Colon & Rectal Surgery2010-09-01213S1043-1489(10)X0004-5Enhanced ("Fast Track") Peri-Operative Pathways131132http://www.seminarscolonrectalsurgery.com/article/PIIS1043148910000400/abstract?rss=yesThe primary goal of fast track protocols is to enhance postoperative recovery by decreasing morbidity, mortality, length of stay, and return to full function. An important component of limiting postoperative morbidity and mortality is evaluating and assessing preoperative risk. The underlying medical conditions of patients as well as their functional status form a big component of preoperative risk, which in turn is a determinant of postoperative outcomes. The preoperative history and physical examination form the backbone of preoperative risk assessment. This will direct which further tests are necessary to complete the preoperative evaluation. The underlying conditions that pose the greatest risk include cardiovascular disease, pulmonary disease, diabetes mellitus, underlying immunosuppression, incident infections, and functional status. There are various disease-specific risk assessment tools and indexes that help to risk-stratify patients in each disease category. Based on these indexes, several algorithms have been developed to help determine what preoperative testing is required, if any. The accurate evaluation and assessment of preoperative risk will ensure that patients are optimized before surgery to decrease the incidence of postoperative morbidity and mortality, and thereby enhance recovery.Preoperative Risk Evaluation and AssessmentJonathan A. Laryea10.1053/j.scrs.2010.05.002Seminars in Colon & Rectal Surgery 21, 3 (2010)2010-09-01Seminars in Colon & Rectal Surgery2010-09-01213S1043-1489(10)X0004-5Enhanced ("Fast Track") Peri-Operative Pathways133138http://www.seminarscolonrectalsurgery.com/article/PIIS1043148910000412/abstract?rss=yesLaparoscopic surgery has become a widely accepted standard of care for various intra-abdominal procedures, particularly colectomy. The creation of pneumoperitoneum has the potential to alter normal homeostatic mechanisms, but in general alters physiology to a lesser degree than open surgery, which translates into improvements in postoperative recovery. In addition, there are important variations in the immunologic response to laparoscopic surgery in comparison with open surgery. While all the innumerable interactions that occur both at the local site of surgery and systemically are still being elucidated, it does seem that these differences may have implications in terms of oncologic outcomes.Physiology, Immunologic and Metabolic Responses to Laparoscopic SurgeryAmanda S. Ayers, Sang W. Lee10.1053/j.scrs.2010.05.003Seminars in Colon & Rectal Surgery 21, 3 (2010)2010-09-01Seminars in Colon & Rectal Surgery2010-09-01213S1043-1489(10)X0004-5Enhanced ("Fast Track") Peri-Operative Pathways139143http://www.seminarscolonrectalsurgery.com/article/PIIS1043148910000424/abstract?rss=yesMechanical and antibiotic bowel preparation is a time tested procedure that when done appropriately, significantly reduces the risk of infectious complications of colorectal surgical procedures, surgical site infections, and anastomotic dehiscence. Currently, a 3-tier regimen, which includes preoperative mechanical cleansing to reduce the fecal load, preoperative nonabsorbed oral antimicrobials effective against both aerobic and anaerobic bacteria, and perioperative parenteral antibiotics is most commonly used in the US. The vast majority of surgeons in the US today consider this approach as the cornerstone of elective colorectal surgery. However, randomized clinical trials from several countries have concluded that the role of mechanical and antibiotic bowel preparation should be re-evaluated. To date, there have been numerous randomized clinical trials comparing preoperative mechanical preparation to no preparation in patients undergoing elective colorectal surgery. When combined in meta-analyses, however, there is no statistically significant evidence that patients benefit from either mechanical or antibiotic bowel preparation. The data are overwhelming that the dogma regarding bowel preparation before elective colorectal surgery should be abandoned.Bowel Preparation Before Elective Colorectal Surgery: What is the EvidenceC. Neal Ellis10.1053/j.scrs.2010.05.004Seminars in Colon & Rectal Surgery 21, 3 (2010)2010-09-01Seminars in Colon & Rectal Surgery2010-09-01213S1043-1489(10)X0004-5Enhanced ("Fast Track") Peri-Operative Pathways144147http://www.seminarscolonrectalsurgery.com/article/PIIS1043148910000436/abstract?rss=yesThe National Surgical Quality Improvement Program is a validated, outcomes-based program that strives to improve the quality of surgical care nationwide. One approach to improve surgical outcomes is by reduction of adverse events, such as venous thromboembolism and surgical site infections. In this article, preventative measures with thromboprophylaxis and antibiotics are reviewed. Routine thromboprophylaxis for the hospitalized patient is recommended based on risk stratification. Mechanical, pharmacologic, or alternative interventions may be required. In addition, there are published guidelines for judicious use of antibiotics in the surgical setting. We discuss the optimal choice, administration, and duration of antibiotics with recommendations specific to colorectal patients. In the National Surgical Quality Improvement Program era, widespread implementation and adherence to both thromboprophylaxis and antibiotics need to be optimized.Deep Venous Thrombosis Prophylaxis and Antibiotics in the National Surgical Quality Improvement Program EraRenee Huang, Edward C. Lee10.1053/j.scrs.2010.05.005Seminars in Colon & Rectal Surgery 21, 3 (2010)2010-09-01Seminars in Colon & Rectal Surgery2010-09-01213S1043-1489(10)X0004-5Enhanced ("Fast Track") Peri-Operative Pathways148152http://www.seminarscolonrectalsurgery.com/article/PIIS1043148910000448/abstract?rss=yesAll patients develop postoperative ileus (POI) after major abdominal surgery, with approximately 10% developing a more severe form of prolonged ileus. POI represents the single largest factor influencing length of stay after abdominal surgery and has the great implications for patients and resource use in health care. New methods to treat and decrease the duration of POI are therefore of great importance. Up to the year 2000, several pharmacologic agents had been studied to prevent POI, however none of these agents were effective enough to become part of routine established practice. Over the past decade, significant progress has been made treating POI pharmacologically. This article outlines the different pharmacologic options that exist for POI, with emphasis on the research during the past decade and future perspectives.Role of Pharmacologic Agents in Treating Postoperative IleusKnut Magne Augestad, Fabien Leblanc, Conor P. Delaney10.1053/j.scrs.2010.05.006Seminars in Colon & Rectal Surgery 21, 3 (2010)2010-09-01Seminars in Colon & Rectal Surgery2010-09-01213S1043-1489(10)X0004-5Enhanced ("Fast Track") Peri-Operative Pathways153159http://www.seminarscolonrectalsurgery.com/article/PIIS104314891000045X/abstract?rss=yesWith the introduction of enhanced surgical recovery programs there has been a rekindled interest over recent years in the optimal surgical fluid regimen. The historical debate between liberal vs restrictive fluid regimens has been re-evaluated and the idea of individualized goal-directed therapy has been introduced and subjected to a number of randomized controlled trials. While untreated hypovolemia can be detrimental to patients, fluid overload can be just as (if not more) hazardous. By tailoring fluid administration to an individual patient's needs using a treatment algorithm based on closely monitored flow variables, postoperative recovery can be improved with reduced morbidity, less gastrointestinal dysfunction, and reduced hospital stay.Perioperative Fluid ManagementSophie E. Noblett, Alan F. Horgan10.1053/j.scrs.2010.05.007Seminars in Colon & Rectal Surgery 21, 3 (2010)2010-09-01Seminars in Colon & Rectal Surgery2010-09-01213S1043-1489(10)X0004-5Enhanced ("Fast Track") Peri-Operative Pathways160164http://www.seminarscolonrectalsurgery.com/article/PIIS1043148910000461/abstract?rss=yesEffective anesthesia and postoperative pain management are key elements for both optimal perioperative patient care and satisfaction and an accelerated recovery after ambulatory or inpatient colorectal surgery. A major concern for patients undergoing surgery continues to be pain control both during and after the operation. Although recent advances have been made in the development of new analgesics, treatment strategies, and delivery systems, providing effective pain control can still be a challenge. This is especially true in the setting of accelerated recovery programs that aim for early ambulation, earlier hospital discharge, and a more rapid return to the activities of daily living. We review the common methods of anesthesia and pain management for both ambulatory and major abdominal surgery and describe how, when properly chosen and implemented, the result is better patient care and expedited operative recovery.Anesthesia and Pain ManagementAmy Lightner, Mitchell Lin, James Yoo10.1053/j.scrs.2010.05.008Seminars in Colon & Rectal Surgery 21, 3 (2010)2010-09-01Seminars in Colon & Rectal Surgery2010-09-01213S1043-1489(10)X0004-5Enhanced ("Fast Track") Peri-Operative Pathways165169http://www.seminarscolonrectalsurgery.com/article/PIIS1043148910000473/abstract?rss=yesPerioperative outcomes after colorectal surgery can be significantly improved with fast-track recovery techniques by attenuating surgical stress responses and reducing postoperative organ dysfunction. Significant improvements in postoperative ileus and hospital length of stay can be achieved when fast-track programs are compared with traditional care for open surgery. However, whether the fast-track protocol is conducted with laparoscopic methods or open surgery, these protocols require multidisciplinary cooperation and continuous quality assurance to achieve optimal results.Outcomes of Fast-Track Pathways for Open and Laparoscopic SurgeryTimothy M. Geiger, Graham MacKay, Rocco Ricciardi10.1053/j.scrs.2010.05.009Seminars in Colon & Rectal Surgery 21, 3 (2010)2010-09-01Seminars in Colon & Rectal Surgery2010-09-01213S1043-1489(10)X0004-5Enhanced ("Fast Track") Peri-Operative Pathways170175http://www.seminarscolonrectalsurgery.com/article/PIIS1043148910000485/abstract?rss=yesThe fundamental impact of a colectomy enhanced recovery pathway is the increased efficiency provided by guidelines defining the sequencing and timing of interventions. The applicability of the pathway across a broad range of disease pathology and diverse patient populations must be considered and its value assessed across the entire episode of care. The major hurdle that limits the value proposition of an enhanced recovery pathway is successful implementation and maintenance of such pathways across all members participating in patient care. Increasing understanding of the surgical stress response will help us continue to create components within enhanced recovery pathways that will reduce morbidity and effectively reduce cost in management of colorectal patients.The Economics of Enhanced Recovery PathwaysTheodor Asgeirsson, Anthony J. Senagore10.1053/j.scrs.2010.05.010Seminars in Colon & Rectal Surgery 21, 3 (2010)2010-09-01Seminars in Colon & Rectal Surgery2010-09-01213S1043-1489(10)X0004-5Enhanced ("Fast Track") Peri-Operative Pathways176179http://www.seminarscolonrectalsurgery.com/article/PIIS1043148910000497/abstract?rss=yesAlthough significant evidence exists detailing the benefits of enhanced recovery pathways, adoption rates have been slow for most surgeons and hospitals. Creating and implementing an enhanced recovery pathway is a significant undertaking with notable obstacles. Copious and sometimes conflicting data make determining which elements to incorporate into a care pathway difficult. The assessment of preimplementation complication and readmission rates is important to evaluate potential benefits or risks of the program to a patient population. A multidisciplinary team must be educated and committed to ensure the success of the program. Finally, both practitioners and patients must be reeducated, and preconceptions about postoperative recovery must be overcome to create a successful program.Incorporating Enhanced Care Pathways into Colorectal PracticeSharon L. Stein10.1053/j.scrs.2010.05.011Seminars in Colon & Rectal Surgery 21, 3 (2010)2010-09-01Seminars in Colon & Rectal Surgery2010-09-01213S1043-1489(10)X0004-5Enhanced ("Fast Track") Peri-Operative Pathways180183