Early rehabilitation programs after laparoscopic colorectal surgery: Evidence and criticism

doi:10.3748/wjg.v19.i46.8543

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Dec 14, 2013 (publication date) through Jan 1, 2025

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World Journal of Gastroenterology

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World J Gastroenterol. Dec 14, 2013; 19(46): 8543-8551
Published online Dec 14, 2013. doi: 10.3748/wjg.v19.i46.8543

Table 1 Previous representative studies of colonic surgery with early rehabilitation programs

Ref.	Country	Study design	Inclusion period	Patients (n)	Operations	Approach	LOS (d)		Readmissions		Morbidity		Mortality
Ref.	Country	Study design	Inclusion period	Patients (n)	Operations	Approach	ERP	CC	ERP	CC	ERP	CC	ERP	CC
Anderson et al[3], 2003	United Kingdom	RCT	ND	25 (ERP: 14, CC: 11)Cancer: 18 (72)ERP: 11, CC: 7	RH: 14 (ERP: 9, CC: 5)LH: 11 (ERP: 5, CC: 6)	ND	3 (2-7)	7 (4-10)^a	0 (0)	0 (0)	4 (29)	5 (45)	0 (0)	1 (9)
Gatt et al[4], 2005	United Kingdom	RCT	ND	39 (ERP: 19, CC: 20)Cancer: 27 (69)ERP: 12, CC: 15	RH: 10 (ERP: 5, CC: 5)AR: 15 (ERP: 5, CC: 10)Others: 14 (ERP: 9, CC: 5)	ND	5 (4-9)	7.5 (6-10)^a	1 (5)	4 (20)	9 (47)	15 (75)	1 (5)	0 (0)
Khoo et al[5], 2007	United Kingdom	RCT	2003-2004	70 (ERP: 35, CC: 35)Cancer: 70 (100)	Colonic: 47 (ERP: 22, CC: 25)Rectal: 23 (ERP: 13, CC: 10)	Open	5 (3-37)	7 (4-63)^a	3 (9)	1 (3)	9 (26)	16 (46)	0 (0)	2 (6)
Muller et al[6], 2009	Switzerland	RCT	2004-2006	151 (ERP: 76, CC: 75)Cancer: 131 (87)ERP: 67, CC: 64	RH: 48 (ERP: 26, CC: 22)AR/LH: 101(ERP: 30, CC: 51)	Open	5 (2-30)	9 (6-30)^a	3 (4)	2 (3)	16 (21)	37 (49)^a	0 (0)	0 (0)
Serclova et al[7], 2009	Czech	RCT	2005-2007	103 (ERP: 51, CC: 52)Cancer: 7 (7)ERP: 3, CC: 4IBD: 89 (86)ERP: 46, CC: 43	Simple:(ERP: 47.1%, CC: 61.5)Multiple:(ERP: 29.4%, CC: 21.2)	Open	7 (5-11)	9 (7-22)^a	0 (0)	0 (0)	11 (22)	25 (48)^a	0 (0)	0 (0)
Lee et al[13], 2011	South Korea	RCT	2007-2009	100 (ERP: 46, CC: 54)Cancer: 100 (100)	RH: 38 (ERP: 17, CC: 21)LH: 15 (ERP: 5, CC: 10)AR: 47 (ERP: 24, CC: 23)	Lap	7 (6-8)	8 (7-9)	0 (0)	0 (0)	6 (11)	14 (20)	0 (0)	0 (0)
Vlug et al[9], 2011	Netherlands	RCT	200 -2009	400 (ERP: 193, CC: 207)Cancer: 400 (100)	RH: 179 (ERP: 80, CC: 99)LH: 221 (ERP: 120, CC: 101)	Open/lap	Open: 7 (5-11)Lap: 5 (4-8)	Open: 7 (6-13)Lap: 6 (4.5-9.5)^a	13 (7)	14 (7)	125 (65)	132 (64)	6 (3)	4 (2)
Wang et al[26], 2012	China	RCT	2006-2009	78 (ERP: 40, CC: 38)Cancer: 78 (100)	RH: 13 (ERP: 7, CC: 6)Sig: 34 (ERP: 18, CC:16)AR: 25 (ERP: 13, CC: 12)	Lap	5.5 (5-6)	7.0 (6-8)^a	ND	ND	2 (5)	8 (21)	0 (0)	0 (0)

^aP < 0.05 vs early rehabilitation program (ERP) group. LOS: Length of hospital stay; CC: Conventional care; RCT: Randomized controlled trial; RH: Right hemicolectomy; LH: Left hemicolectomy; SB: Small bowel; AR: Anterior resection; IBD: Inflammatory bowel disease; Lap: Laparoscopic; LAR: Low anterior resection; APR: Abdominoperineal resection; Sig: Sigmoidectomy; ND: Not documented. Continuous data are given as median (range) or mean ± SD.

Table 2 Summary of previous studies that evaluated early rehabilitation programs after laparoscopic rectal surgery

Ref.	Country	Study design	Inclusion period	Patients (n)	Operations	Clinical effectiveness (LOS and complications)
Lindsetmo et al[22], 2009	United States	Prospective cohort study	2005-2007	37Cancer: 17 (46)Polyp: 4 (11)Others: 16 (43)	SPS: 37 (100)Diverting ileostomy: 7 (19)	Mean LOS: 3.0 d (range 1-8 d)Overall complications: 6 (16)UTI: 1; SSI: 2Readmission < 30 d: 3 (8)
Chen et al[27], 2011	Taiwan	Prospective cohort study	2007-2009	80Cancer: 76 (95)Benign: 4 (5)	APR: 15 (19)SPS: 65 (81)Diverting ileostomy: 32 (49)	Mean LOS: 5.0d (range 3-22)Overall complications: 11 (14)AL: 1; pelvic abscess 2; ileus: 1Readmission < 30 d: 7 (9)
Stottmeier et al[28], 2012	Denmark	Prospective cohort study	2006-2009	102Cancer: 102 (100)	APR: 19 (19)Hartmann: 6 (6)SPS: 77 (75)Diverting colostomy: 38 (37)Diverting ileostomy: 3 (3)	Median LOS: 5 d (range 2-42 d)Overall complications: 25 (25)AL: 3; intra-abdominal abscess: 3Readmission < 30 d: 15 (15)
Huibers et al[29], 2012	Nether-lands	Retrospective case-control study	2004-2009	76 (ERP: 43, CC: 33)Cancer: 76 (100)	APR: 24 (32)ERP: 16 (37)CC: 8 (24)SPS: 52 (68)ERP: 27 (63)CC: 25 (76)	Median LOS: (P = 0.042)ERP: 7 d (range 2-83 d)CC: 10 d (range 4-74 d)Overall complications:ERP: 17 (40)AL: 5; intra-abdominal abscess: 7CC: 9 (27)AL: 4; intra-abdominal abscess: 3Readmission < 30 d: (P = 0.421)ERP: 5 (12)CC: 6 (18)
Lee et al[30], 2013	South Korea	RCT	2007-2011	98 (ERP: 52, CC: 46)Cancer 98 (100)	SPS: 98 (100)Diverting ileostomy: 98 (100)	Median recovery time¹: (P = 0.47)ERP: 137 h (range 107-188 h)CC: 146.5 h (range 115-183 h)Overall complications: (P = 0.054)ERP: 22 (42)AL: 1; POI: 15; acute voiding difficulty: 9CC: 11 (24)AL: 1; POI: 6; acute voiding difficulty: 2Readmission < 30 d: 0 (0)

¹Defined by tolerable diet for 24 h, safe ambulation, analgesic-free and afebrile without complication. LOS: Length of hospital stay; SPS: Sphincter preserving surgery; UTI: Urinary tract infection; SSI: Surgical site infection; APR: Abdominoperineal resection; AL: anastomosis leakage; ERP: Early rehabilitation program; CC: Conventional care; RCT: Randomized controlled trial; POI: Postoperative ileus.

Table 3 Protocols used in previous studies for evaluating early rehabilitation programs after laparoscopic rectal surgery

Protocols	*Lindsetmo et al[22], 2009*	*Chen et al[27], 2011*	*Stottmeier et al[28], 2012*	*Huibers et al[29], 2012*	*Lee et al[30], 2013*
Preoperative stage
General considerations	Patient education	Patient education and ERP explanation	Thorough informationEstablishing a contract	ND	Operative risk assessmentCounseling, informed consent
Oral bowel preparation	Yes	Yes	No (enema for left-sided tumors)	No (2 enemas)	Yes
NPO	ND	8 h before surgery	Fluid until 2 h before surgery	2 h before surgery	8 h before surgery
Oral carbohydrate solution	No	No	No	Yes	No
Epidural analgesia	No	No	Yes	Yes	No
Prophylactic antibiotics	ND	Single dose	Single dose (ampicillin + metronidazole + gentamicin)	Single dose (cefalozine + metronidazole)	ND
DVT prophylaxis	ND	ND	LMWH 2 h before surgeryCompression stockings	LMWH until discharge	ND
Perioperative stage
Operation approach	Laparoscopic	Laparoscopic	Laparoscopic	Laparoscopic	Laparoscopic
Anesthesia	ND	Short-acting anesthetics	Propofol, remifentanyl and muscle relaxant	ND	ND
Fluid	ND	Perioperative fluid restriction	Avoid both hypovolemia and fluid overload	ND	ND
Urinary drainage	Urethral catheter	Urethral catheter	Suprapubic or urethral catheter	Urethral catheter	Urethral catheter
Nasogastric tube	Yes (orogastric tube, removed before extubation)	No	No	No	No
Intra-abdominal drain	Rarely	Yes	No	Yes (one)	Yes (one)
Postoperative stage
Pain control	IV PCA (12-18 h)KetorolacOral analgesia	Oral NSAIDs immediatelyafter surgeryOpioid for 1 d if needed	Epidural analgesiaParacetamol, ibuprofenOpioid if needed	Epidural analgesiaParacetamol, diclofenacOpioid avoided	IV PCA till POD 2
Sipping water	Immediately after surgery	Immediately after surgery	Immediately after surgery	Immediately after surgery	Immediately after surgery
Oral food intake	POD 1	POD 1	Evening of the day of surgery	Liquid diet in the evening	Semi-fluid diet, POD 1
Removal of urinary catheter	POD 1	POD 1	Immediately after surgery	POD 2	POD 3
Removal of intra- abdominal drain	No drain	POD 4	No drain	POD 2	ND
Mobilization	As soon as possible	Immediately after surgery	Two hours after surgery	POD 1	POD 1
Regular laxatives	ND	Sennoside	MgSO4 1 g two dimes daily	MgO	MgO
Routine discharge	ND	POD 5	POD 3	ND	ND
Discharge criteria	Tolerance of fluids and solid diet, adequate oral analgesia, passage of flatus or stool, adequate home support	No fever, no tachycardia, successful passage of flatus/stool, tolerance for 3 meals/d, comfort in taking oral non-opioid analgesics, independent ambulation, adequate self-care ability	Adequate bladder and bowel function, ability to drink, eat, walk without problems, manageable pain	No remaining lines or catheters, toleration of solid food, passage of stool, controllable pain, self-care ability	ND (Recovery: tolerance of diet for 24 h, analgesic-free, safe ambulation, afebrile status without major complications)

ERP: Early rehabilitation program; DVT: Deep vein thrombosis; LMWH: Low-molecular-weight heparin; NSAID: Non-steroidal anti-inflammatory drug; PCA: Patient-controlled analgesia; POD: Postoperative day; ND: Not described.

Citation: Kim DW, Kang SB, Lee SY, Oh HK, In MH. Early rehabilitation programs after laparoscopic colorectal surgery: Evidence and criticism. World J Gastroenterol 2013; 19(46): 8543-8551
URL: https://www.wjgnet.com/1007-9327/full/v19/i46/8543.htm
DOI: https://dx.doi.org/10.3748/wjg.v19.i46.8543