Laparoscopic rectal resections without epidural catheters - does it work?

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Mohamad El-Ahmar, Franziska Koch, Anja Köhler, Lutz Moikow, Matthias Ristig, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1789554/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Aug, 2022 Read the published version in International Journal of Colorectal Disease → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose: Placement of an epidural catheter (EC) in colorectal resections is still recommended as a valid measure to achieve a low level of pain. However, EC is associated with increased invasiveness, and with an increased risk of bladder emptying disorders and a decrease of blood pressure, which all relate to delayed mobilization. Preliminary data show that EC placement may not be necessary in laparoscopic colon resections. The aim of this prospective study was to investigate how omission of EC placement influences short-term postoperative outcomes in laparoscopic rectal resections. Methods : All laparoscopic rectal resections occurring between 2013-2020 were prospectively examined. Resections from 01/2013-02/2018 (group A) were compared with resections from 03/2018-12/2020 (group B; after internal change of the perioperative pain regime). In addition to EC placement, the other target parameters of our study were urinary catheter placement during the inpatient stay, postoperative pain >3 days on a numerical rating scale (NRS), mobilization in the first 5 postoperative days, time until the first postoperative bowel movement, postoperative complications according to Clavien-Dindo, Intermediate care unit stay (IMC stay) in days and hospital length of stay in days. Results : In the entire study period, 221 laparoscopic rectal resections were performed: 122 in group A, and 99 resections in group B. The frequency of EC placement and urinary catheter placement, postoperative IMC stay, and hospital length of stay, were significantly lower in group B (p<0.05). The postoperative mobilization of patients in group B was possible more quickly. There were no differences in the level of pain, time until the first postoperative bowel movement, and postoperative complications according to Clavien-Dindo. Conclusion : Omission of EC placement in laparoscopic rectal resections led to faster mobilization, a shorter IMC stay, and a shorter hospital stay without increasing the pain level. Postoperative complications did not change when an EC was not placed. Therefore, routine EC placement in laparoscopic rectal resections is unnecessary. convalescence epidural catheters laparoscopy rectal resections Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Introduction With medical advances, colorectal surgery has changed in recent years. Laparoscopy, in particular, has become an established procedure in rectal surgery. According to data from Helios clinics, one of the largest private hospital operators in Europe, the proportion of rectal resections that are accessed laparoscopically has been continuously increasing since 2016. Specifically, internal Helios data show that the proportion of laparoscopic rectal resections in 2016 was 32.80%, increasing to 49.34% in 2021 [1]. Furthermore, perioperative medicine is also currently on an international upswing and is gaining more attention thanks to the ERAS® (Enhanced Recovery After Surgery) concept. The advantages of this multimodal and minimally invasive treatment method have been described in multiple studies in recent years [2-11]. The placement of an epidural catheter (EC) has been seen as an important part of modern perioperative management, and was implemented as a global standard as a result of this fast-track recovery regime. However, EC placement is associated with increased invasiveness, which is characterized by an increased rate of bladder emptying disorders, circulatory depression, and the associated reduced mobility [12-14]. A number of international studies have meanwhile shown that EC placement does not offer any advantages in laparoscopic colon resections and is therefore unnecessary [15-19]. The extent to which these results can also be applied to the placement of EC in laparoscopic rectum resections cannot be conclusively determined at present. The aim of this prospective study was to evaluate the changes the omission of EC placement induces in the postoperative short-term outcomes of laparoscopic rectal resections Methods In this prospective analysis, all laparoscopic rectal resections from 01/2013-02/2018 (group A) were analyzed and compared with the laparoscopic rectal resections from 03/2018-12/2020 (group B). From group A, 122 patients could be included in this study; EC placement was standard in this group (EC placement in 80.3% of the cases). From group B, 99 patients could be included in this study. At the start of the group B period we changed our internal standard operating procedures (SOPs) and standard EC placement was no longer performed (EC placement in 7.1% of the cases). Relevant patient-related preoperative data were collected in both groups; this included patient age and gender. The preoperative classification of the surgical risk was based on the recommendations of the American Society of Anesthesiologists Classification (ASA classification). In addition, disease-specific data were documented. This included the extent of resection, the height localization of the tumors, and the classification of the tumor stage according to the Union for International Cancer Control (UICC) [20-23]. A distinction was made between the following tumor localizations: Upper third of rectum: 12 – 16 cm. Mid-rectum: 6 – < 12cm. Lower third of rectum: < 6 cm. The extent of resection was limited to the following 3 interventions: High anterior rectal resection with partial mesorectal excision (tumors of the upper third of the rectum). Low anterior rectal resection with complete mesorectal excision (tumors of the middle and lower third of the rectum). Abdomino-perineal rectal extirpation (tumors with sphincter involvement/preoperative incontinence). EC was always placed between the thoracic vertebrae 9 and 10 as part of the anesthesia induction. The analgesia used for this procedure consisted of a combination of ropivacaine 0.2% and sufentanil 0.75 µg/ml, at a flow rate of 8 ml/h. A bolus administration was also possible at 6 ml/h. The blocking time after bolus administration was 8 hours. In addition to EC placement, the other target parameters of our study were: Urinary catheter placement during the inpatient stay. Postoperative pain >3 days on a numerical rating scale (NRS). Mobilization in the first 5 postoperative days. Time until the first postoperative bowel movement. Postoperative complications according to Clavien-Dindo. Intermediate care unit stay (IMC stay) in days. Hospital length of stay in days. All urinary catheter placements that became necessary during the inpatient stay were recorded. No distinction was made as to when the placement of a urinary catheter became necessary during the inpatient stay. Postoperative pain was recorded twice daily by a nurse using the numerical rating scale (NRS). Group B patients (without EC placement) received intraoperatively a modified transversus abdominis plane block (TAP block) as a local anesthetic, with application of 2 x 75 mg ropivacaine. Postoperative pain therapy was carried out according to the WHO grading scheme. The basic analgesia consisted of metamizol 500 mg 4 x 1 tablet, and oxycodone 20 mg 2 x 1 tablet, daily. Piritramide was also available to the patients as an on-demand medication, up to 9 times a day as a subcutaneous injection. In addition, all patients received concomitant medication with Movicol sachets 2 x 1 sachet daily, and rescue medication against potential postoperative nausea. To compare the two groups, the percentage of postoperative days with a pain score > 3 in the first 5 postoperative days was documented. Regarding postoperative mobilization, four variables were available for comparing the two groups. In the first 5 postoperative days, a distinction was made between: no mobilization; mobilization to the edge of the bed; mobilization at room level; and mobilization on the ward floor. The mobilization took place with the help of physiotherapists, until independent mobilization on the ward floor was possible. All patients were informed of the usefulness of rapid mobilization during a pre-hospital discussion. Complications were classified according to Clavien-Dindo [24]. The length of postoperative IMC stay and the length of hospital stay were recorded in days. Emergency procedures and primarily open rectal resections were excluded from this study. To compare the position of the distribution of a metric variable from two independent groups, the Shapiro-Wilk test was first used to check whether the data in the groups were normally distributed. If the assumption of normal distribution was not rejected (p-value ³ 0.1), the comparison was performed using the t-test. If the assumption of normal distribution was rejected, the Mann-Whitney-U test was used. To compare frequency distributions of a categorical variable from independent groups, the chi-square test or Fisher's exact test (if the expected cell frequencies were less than five) were used. Results In the entire study period, 221 laparoscopic rectal resections were performed. Of these, 122 resections were carried out in the period from 01/2013-02/2018 (group A), and 99 resections were carried out in the period from 03/2018-12/2020 (group B). The median age in group A was 67 years (min. 40 years; max. 89 years), and in group B 66 years (min. 34 years; max. 88 years) (p = 0.723). Regarding gender, 83 patients (68%) in group A and 62 patients (62.6%) in group B were male (p=0.400). In terms of preoperative classification of the surgical risk, 49.2% of patients in group A and 52.5% in group B were classified as ASA level 3 (p=0.001). The detailed results are summarized in Figure 1 and Table 1. Specific results of group A patients Thirty (24.6%) rectal tumors were localized in the upper, 76 (62.3%) in the middle, and 16 (13.1%) in the lower third of the rectum, based on preoperative staging. This was followed by high anterior rectal resection in 27 cases (22.1%), and low anterior rectal resection in 79 cases (64.8%). In 16 cases (13.1%) an abdomino-perineal rectal extirpation was performed. A protective ileostomy was constructed in all patients with a low anterior rectal resection. In all abdomino-perineal rectal extirpations, an end descending colostomy was consecutively constructed. The detailed group A patient characteristics are presented in Table 1. As part of the perioperative pain therapy, EC was placed in 80.3% of cases in group A (Fig. 2). In addition, in 97.5% of these cases a urinary catheter placement was necessary during inpatient stay (Fig. 3). These urinary catheters were placed either intraoperatively or in the postoperative phase due to urinary retention. A total of 116 patients (95.1%) from this group had a postoperative stay in the IMC ward. The median IMC stay of all patients in group A was 1 day (min. 0 day; max. 38 days). On the day of surgery, 52 patients (42.6%) reported pain >3 according to the NRS. On the first postoperative day, a pain score >3 was documented in 34 patients (27.9%). On the second postoperative day, the number of patients with a pain score >3 decreased to 17 patients (13.9%). From the third to the fifth postoperative day, a maximum of seven patients (5.8%) reported a pain score of >3 (Fig. 4). The mobilization of patients on the ward floor on the first postoperative day was possible in five cases (4.1%), whereas no mobilization was possible on the first postoperative day in 49 cases (40.2%). Mobilization on the ward floor was possible on the second postoperative day in 28 patients (23%), with 14 cases (11.5%) remaining unable to mobilize. The number of patients who were mobile on the ward floor continued to increase from the third postoperative day [57 patients (46.7%)] to the fifth postoperative day [91 patients (74.6%)]. Mobilization was still not possible in eight cases (6.6%) on the third postoperative day, as well as on the fifth postoperative day ((Fig. 5 – 9). The median time until the first bowel movement was 2 days in group A (min. 1 day; max. 8 days). With regard to postoperative complications, 76 cases (62.3%) showed no postoperative complications during inpatient stay. In ten cases each there was a complication grade 1, 2 and 4a (each 8.2% of the cases), and one patient had a grade 5 complication (0.8%) (Fig. 10). Finally, the median length of hospital stay for patients in group A was 10 days (min. 4 days; max. 40 days). The detailed outcomes of group A patients are shown in Table 2. Specific results of group B patients Preoperative staging revealed 21 (21.2%) rectal tumors in the upper, 48 (48.5%) in the middle, and 30 (30.3%) in the lower third of the rectum. Accordingly, in 21 cases (21.2%) a high anterior rectal resection was performed, and in 61 cases (61.6%) a low anterior rectal resection was performed. In 17 cases (17.2%) an abdomino-perineal rectal extirpation was performed. Regarding the respective tumor location (p=0.877) and the consecutive extent of resection (p=0.645), no significant differences compared to group A were observed. The detailed group B patient characteristics are shown in Table 1. In 92.9% of group B cases no EC was placed (p<0.001 compared to group A). In the remaining 7.1% of cases with EC placement an abdomino-perineal rectal extirpation was always performed (Fig. 2). Twenty-five patients (25.3%) of this group had a postoperative stay in the IMC ward. The median length of the IMC stay of all patients in group B was 0 days (min. 0 days; max. 19 days) (p<0.001 compared to group A). In group B, a urinary catheter placement was necessary in a total of 35 cases (35.4%) (p<0.001 compared to group A). In seven patients with abdomino-perineal rectum extirpations, the urinary catheter placement was routinely performed in addition to EC placement (Fig. 3). On the day of surgery, 49 patients (49.5%) reported a pain level >3 according to the NRS. A pain score >3 was documented on the first postoperative day in 23 patients (23.2%). On the second postoperative day the number of patients with a pain score >3 decreased to 13 patients (13.1%). From the third to the fifth postoperative day, ten patients reported a pain score of >3 (10.1%). No significant difference in terms of postoperative pain was observed between the two groups (p=0.285) (Fig. 4). The mobilization of patients on the ward floor on the first postoperative day was possible in 55 cases (55.5%), whereas no mobilization was possible on the first postoperative day in five cases (5.1%). On the second postoperative day mobilization on the ward floor was possible in 72 patients (72.7%). In the further postoperative course, the number of patients who were mobile on the ward floor increased continuously: on the third postoperative day 87 patients (87.9%), on the fourth postoperative day 92 patients (93%), and on the fifth postoperative day 94 patients (95%) were mobile on the ward floor. In two cases there was no mobilization on the ward floor on either the fourth or the fifth postoperative day. A significant difference in terms of mobilization was observed compared to group A (p<0.001) (Fig. 5 – 9). The median time until the first bowel movement was 2 days in group B (min. 1 day; max. 7 days). Sixty-four patients (64.6%) in group B showed no postoperative complications during their inpatient stay. There was a grade 1 complication in seven patients (7.1%) and a grade 2 complication in 12 patients (12.1%); in three cases (3%) there was a grade 3a complication, and in six cases (6.0%) a grade 3b complication; three patients (3%) developed a grade 4a complication and one (1%) patient a grade 4b complication; and three patients (3%) had a grade 5 complication. There was no significant difference in postoperative complications between groups A and B (p=0.608) (Fig. 10). Finally, the median length of hospital stay for patients in group B was 7 days (min. 3 days; max. 36 days) (p=<0.001 compared to group A). The detailed outcomes of group B patients are shown in Table 2. Discussion According to a Germany-wide analysis from 2019, colorectal resection is still one of the most frequently performed visceral surgical operations among all inpatients [25]. Laparoscopy, in particular, has been established as the standard procedure in colorectal surgery. According to our own internal data, the proportion of laparoscopic rectal resections has been steadily increasing over the last years, from 32.80% in 2016 to 49.34% in 2021 [1]. With the progress of perioperative medicine through multimodal treatment concepts such as ERAS® (Enhanced Recovery After Surgery), postoperative morbidity has also decreased, and the length of hospital stay has shortened [2-11]. The advantages of these multimodal treatment concepts are well known [2-11]. During the postoperative course, EC placement continues to play a major role regarding postoperative pain and the associated possibility for mobilization. A positive influence on postoperative intestinal paralysis has also been ascribed to EC placement [26-31]. This is illustrated in a 2014 publication by Pöpping et al., according to which EC placement in gastrointestinal interventions led to a reduction in pulmonary and cardiac complications, a reduced stress response, and improved intestinal motility [30]. On the other hand, EC placement is associated with increased invasiveness, and, on top of system-specific risks such as catheter infection or dura perforation, has additional potential disadvantages such as an increased rate of bladder emptying disorders, circulatory depression, and the associated reduced mobility [12-14,32-33]. Meanwhile, a number of international studies have shown that EC placement does not offer any advantages in laparoscopic colon resections and is therefore unnecessary [15-19]. Whether EC placement in laparoscopic rectal resections is indeed beneficial for the patients’ short-term outcomes remains unknown. In 2019, after a Germany-wide survey of 102 hospitals, Wagner et al. reported that in 98.8% of cases of abdominal intervention, routine urinary catheters were placed in addition to the EC placement [32]. The reason for this is the blockage of the parasympathetic nervous system, which leads to a bladder emptying disorder. Moreover, the results of a study by Halabi et al. from 2014 showed that EC-induced bladder emptying disorders lead to a 1.8-fold increased risk of urinary tract infections [34]. By omitting EC placement, we achieved a significant reduction in the number of urinary catheter placements in our study; the installation of a urinary catheter was only necessary in 1/3 of the cases. This result consists of two variables; it includes the placement of urinary catheters that become necessary due to postoperative urinary retention on the one hand, and the routine placement of urinary catheters as a result of EC placement during rectal extirpation on the other. Preoperative patient education is essential to prepare for the upcoming operation and the postoperative rehabilitation phase, including the postoperative pain [35-38]. This is also reflected in our data. The waiver of EC placement was very well offset by the combination of preoperative patient training, with mental preparation of the patients for the postoperative course, including the postoperative pain and the WHO analgesia grading scheme. As a result, in our analysis, there was no significant difference between the two groups regarding postoperative pain. This is in agreement with the results of Turi et al. from 2019, who published a data analysis from 14 different Italian clinics. Similarly, to our finding, no advantage of EC placement in relation to postoperative pain could be demonstrated in that study either [39]. Due to the standard performance of all rectal resections using minimally invasive surgical techniques, our results show that routine EC placement not only has no advantages, but it clearly impairs the short-term postoperative rehabilitation phase and triggers a chain reaction. According to our data, EC placement was performed in approximately 80% of patients in group A, and was followed by a urinary catheter placement in almost all patients. Mobilization of patients with an EC on the ward floor was therefore only possible in less than 5% of the cases on the first postoperative day. In addition, in almost half of the cases in group A there was no mobilization at all on the first postoperative day. In comparison, mobilization of group B patients on the first postoperative day was possible in 55 patients (55.5%) on the ward floor. Moreover, the mobilization of group B patients increased proportionally over the days, and on the fifth postoperative day 94 (95%) of the group B patients were mobile on the ward floor. A potential reason explaining this could be the difficulty in handling the catheter, and the potential fear of the patients when handling the catheter. EC as well as urinary catheter placement were also seen by Koch et al. as an obstacle to rehabilitation in 2021 [40]. Another important aspect is the delayed convalescence period of group A, in terms of the length of postoperative IMC stay. This can probably be attributed to postoperative hypotension, which is almost always associated with EC placement. As a result, patients can become dependent on norepinephrine, making a longer IMC stay necessary. This hypothesis is supported by a study by Gramigni et al. from 2013, by Hanna et al. from 2017, and is also in agreement with results from our work [41-42]. The median IMC stay of group A patients (with EC) was 1 day. In comparison, group B patients (without EC) had a median IMC stay of 0 days (p-value <0.001). A meta-analysis with 1138 patients from 2016 by Guay et al. showed that EC placement had a significant positive effect on postoperative intestinal paralysis after colorectal resections [30]. On the other hand, a study by Khan et al. from 2013 analyzed six studies between 1999 and 2011; two of these studies also showed a positive effect of EC on postoperative stool regulation, whereas the remaining four could not demonstrate a positive effect of EC on stool regulation [19]. Our analysis also showed no difference between the two groups regarding the length of time until the first bowel movement, with patients in both groups having their first bowel movement on average 2 days after surgery. With no significant differences in the rate of postoperative complications according to Clavien-Dindo, the hospital stay of group B patients was also significantly shorter, with a median of 7 days for group B compared to a median of 10 days for group A (p-value <0.001). The shortened length of hospital stay without an increase in postoperative morbidity is also in agreement with the results reported by Wei et al. in 2020 [43]. Despite these positive observations, it is important to take a critical look at our study. For instance, possible positive effects of EC on the postoperative course, such as on postoperative nausea, were not taken into account. Moreover, in the future, it will be interesting to find out what effect the robotic rectum resection, rectum extirpation, or both, will have on EC placement. While conventional laparoscopic rectal extirpation often requires a suprasymphyseal rescue incision for deep dissection, this is completely unnecessary in the robotic surgical method. Thus, the argument of increased invasiveness of the intervention can no longer be used, which should accordingly also lead to a declining number of EC placements. Conclusion EC placement has long been the standard for colorectal resections, and is particularly recommended for rectal resections [5]. In our analysis, dispensing with EC placement from laparoscopic rectal resections led to faster mobilization of patients without increasing the level of pain, and to a significantly shorter hospital stay. More importantly, EC omission was not associated with a change in postoperative complications. In summary, according to our data, routine EC placement in laparoscopic rectal resection is not beneficial for the patients and can be dispensed with. Declarations There are no relevant financial or non-financial competing interests to report. Ethics declarations The authors declare that they have no conflicts of interest. Ethical approval Ethical approval was waived by the local Ethics Committee of the medical faculty of the university of Rostock on 10 th of January 2019 in view of the prospective nature of the study and all the procedures being performed were part of the routine care. Consent to participate Consent to participate has been obtained. Consent for publication All authors have given consent for publication. Author’s contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Mohamad El-Ahmar, Anja Köhler and Franziska Koch. Matthias Ristig and Jörg-Peter Ritz have set the target parameters and monitored the analysis. Lutz Moikow assisted in all questions regarding the epidural catheter from the anesthesiologcial point of view. Mohamad El-Ahmar wrote the manuscript. Franziska Koch and Jörg-Peter Ritz commented on previous versions of the manuscript. All authors read and approved the final manuscript Funding Declaration No funding was received for conducting this study. References Internal data query of all Helios clinics Kehlet H, Wilmore DW: Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78: 606–617 Bardram L, Funch-Jensen P, Jensen P, Crawford ME, Kehlet H.: Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Lancet 1995; 345(8952):763-4 Kehlet H: Organizing postoperative accelerated recovery programs. Reg Anesth 1996; 21:149-151 Schwenk W: Fast Track Rehabilitation in der Viszeralchirurgie. Der Chirurg 2009; 80: 690-701 Kehlet H, Joshi GP. Systematic reviews and meta-analyses of randomized controlled trials on perioperative outcomes: an urgent need for critical reappraisal. 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Pöpping DM, Elia N, Van Aken HK, Marret E, Schug SA, Kranke P, Wenk M Tramèr MR: Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials. Ann Surg. 2014 Jun;259(6):1056-67. Wagner J, Eiken B, Haubitz I, Lichthardt S, Matthes N, Löb S, Klein I, Germer CT, Wiegering A. Suprapubic bladder drainage and epidural catheters following abdominal surgery-A risk for urinary tract infections? PLoS One. 2019 Jan 23;14(1):e0209825. doi: 10.1371/journal.pone.0209825. PMID: 30673740; PMCID: PMC6343869. Vogelsang H, Lang A, Cevik B, Botteck NM, Weber TP, Herzog-Niescery J. Incidence of infection in non-tunnelled thoracic epidural catheters after major abdominal surgery. Acta Anaesthesiol Scand. 2020 Oct;64(9):1312-1318. doi: 10.1111/aas.13650. Epub 2020 Jun 25. PMID: 32521043. Halabi WJ, Kang CY, Nguyen VQ, Carmichael JC, Mills S, Stamos MJ, Pigazzi A. Epidural analgesia in laparoscopic colorectal surgery: a nationwide analysis of use and outcomes. JAMA Surg. 2014 Feb;149(2):130-6. doi: 10.1001/jamasurg.2013.3186. PMID: 24336894. Aasa A, Hovbäck M, Berterö CM. The importance of preoperative information for patient participation in colorectal surgery care. J Clin Nurs. 2013 Jun;22(11-12):1604-12. doi: 10.1111/jocn.12110. Epub 2013 Feb 28. PMID: 23445552. Sjöling M, Nordahl G, Olofsson N, Asplund K. The impact of preoperative information on state anxiety, postoperative pain and satisfaction with pain management. Patient Educ Couns. 2003 Oct;51(2):169-76. doi: 10.1016/s0738-3991(02)00191-x. PMID: 14572947. Simpson JC, Bao X, Agarwala A (2019) Pain Management in Enhanced Recovery after Surgery (ERAS) protocols. Clin Colon Rectal Surg 32(2):121–128. https://doi.org/10.1055/s-0038-1676477 Tan M, Law LS, Gan TJ. Optimizing pain management to facilitate Enhanced Recovery After Surgery pathways. Can J Anaesth 2015; 62 (02) 203-218 Turi S, Gemma M, Braga M, Monzani R, Radrizzani D, Beretta L; Perioperative Italian Society-ERAS Italian Chapter. Epidural analgesia vs systemic opioids in patients undergoing laparoscopic colorectal surgery. Int J Colorectal Dis. 2019 May;34(5):915-921. doi: 10.1007/s00384-019-03284-4. Epub 2019 Mar 29. PMID: 30927065. Koch F, Green M, Dietrich M, Moikow L, Ritz JP. Die „Big Five“ der Invasivität – Sinnhaftigkeit von Drainagen, Sonden und Kathetern in der kolorektalen Chirurgie [The "Big Five" of Invasiveness - the Usefulness of Drains, Probes and Catheters in Colorectal Surgery]. Zentralbl Chir. 2021 Oct 19. German. doi: 10.1055/a-1533-2612. Epub ahead of print. PMID: 34666401. Gramigni E, Bracco D, Carli F. Epidural analgesia and postoperative orthostatic haemodynamic changes: observational study. Eur J Anaesthesiol. 2013 Jul;30(7):398-404. doi: 10.1097/EJA.0b013e32835b162c. PMID: 23435278. Hanna MH, Jafari MD, Jafari F, Phelan MJ, Rinehart J, Sun C, Carmichael JC, Mills SD, Stamos MJ, Pigazzi A. Randomized Clinical Trial of Epidural Compared with Conventional Analgesia after Minimally Invasive Colorectal Surgery. J Am Coll Surg. 2017 Nov;225(5):622-630. doi: 10.1016/j.jamcollsurg.2017.07.1063. Epub 2017 Aug 3. PMID: 28782603. Wei IH, Pappou EP, Smith JJ, Widmar M, Nash GM, Weiser MR, Paty PB, Guillem JG, Afonso A, Garcia-Aguilar J. Monitoring an Ongoing Enhanced Recovery After Surgery (ERAS) Program: Adherence Improves Clinical Outcomes in a Comparison of Three Thousand Colorectal Cases. Clin Surg. 2020 Aug;5:2909. Epub 2020 Aug 10. PMID: 33163851; PMCID: PMC7643765. Tables Table 1: General results of Group A and B Variables Group A (n = 122) Group B (n = 99) p-Value n % n % Age (years) Min. Median Max. 40 67 89 - 34 66 88 - 0,723 Gender Male patients Female patients 62 37 - 62 37 - 0,400 ASA-Score 1 2 3 9 53 60 7,4 % 43,4 % 49,2 % 2 45 52 2,0 % 45,5 % 52,5 % 0.001 Tumor localization (height in cm) Lower third of rectum: < 6cm Mid-rectum: 6 – < 12cm Upper third of rectum: 12 – 16cm. 40 55 27 32,8 % 45,1 % 22,1 % 30 48 21 30,3 % 48,5 % 21,2 % 0.877 Extent of resection High anterior rectal resection Low anterior rectal resection Abdomino-perineal rectal extirpation 30 76 16 24,6 % 62,3 % 13,1 % 21 61 17 21,2 % 61,6 % 17,2 % 0.645 Table 2: Specific results of both groups Variable Group A (n = 122) Group B (n = 99) p-Value n % n % EC placement Yes No 98 24 80,3 % 19,7 % 7 92 7,1 % 92,9 % <0,001 Urinary catheter placement Yes No 119 3 97,5 % 2,5 % 35 64 35, 4% 64, 6 % 3 days on a numerical rating scale (NRS) 0d 1d 2d 3d 4d 5d 52 34 17 6 6 7 42,6 % 27,9 % 13,9 % 4,9% 4,9 % 5,8 % 49 23 13 3 10 1 49,5 % 23,2 % 13,1 % 3,0 % 10,1 % 1,1 % 0,285 Mobilization on the 1 st postoperative day No mobilization Edge of bed Room level Ward floor 49 48 20 5 40,2 % 39,3 % 16,4 % 4,1 % 5 26 13 55 5,1 % 26,3 % 13,1 % 55,5 % <0,001 Mobilization on the 2 nd postoperative day No mobilization Edge of bed Room level Ward floor 14 44 36 28 11,5 % 36,0 % 29,5 % 23,0 % 4 8 15 72 4.0 % 8,1 % 15,2 % 72,7% Mobilization on the 3 rd postoperative day No mobilization Edge of bed Room level Ward floor 8 29 28 57 6,5 % 23,8 % 23,0 % 46,7 % 3 4 5 87 3,0 % 4,0 % 5,1 % 87,9 % Mobilization on the 4 th postoperative day No mobilization Edge of bed Room level Ward floor 6 16 22 78 4,9 % 13,1 % 18,0 % 64,0 % 2 1 4 92 2,0 % 1,0 % 4,0 % 93 % Mobilization on the 5 th postoperative day No mobilization Edge of bed Room level Ward floor 8 6 17 91 6,6 % 5,0 % 13,9 % 74,5 % 2 1 2 94 2,0 % 1,0 % 2,0 % Time until the 1 st postoperative bowel movement Min. Median Max. 1 2 8 - 1 2 7 - 0.007 Postoperative complications according to Clavien-Dindo None Grade 1 Grade 2 Grade 3a Grade 3b Grade 4a Grade 4b Grade 5 76 10 10 6 8 10 1 1 62,3 % 8,2 % 8,2 % 4,9 % 6,6 % 8,2 % 0,8 % 0,8 % 64 7 12 3 6 3 1 3 64,6 % 7,1 % 12,1 % 3,0 % 6,0 % 3,0 % 1,0 % 3,0 % 0,608 IMC-stay in days Min. Median Max. 0 d 1 d 38 d - 0 d 0 d 19 d - <0,001 Hospital length of stay in days Min. Median Max. 4 d 10 d 40 d - 3 d 7 d 36 d - Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Aug, 2022 Read the published version in International Journal of Colorectal Disease → Version 1 posted Editorial decision: Major revision 20 Jul, 2022 Reviews received at journal 10 Jul, 2022 Reviewers agreed at journal 28 Jun, 2022 Reviewers invited by journal 28 Jun, 2022 Submission checks completed at journal 28 Jun, 2022 Editor assigned by journal 28 Jun, 2022 First submitted to journal 23 Jun, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1789554","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":116889432,"identity":"f15b1872-d87a-45cf-ac5a-5391abc43a31","order_by":0,"name":"Mohamad 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1","display":"","copyAsset":false,"role":"figure","size":100299,"visible":true,"origin":"","legend":"\u003cp\u003eMain results of the study\u0026nbsp;\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-1789554/v1/6e7d07d5e670bf9d88d95ad3.png"},{"id":23483964,"identity":"893bf135-493c-4770-8bc5-ba37bd252738","added_by":"auto","created_at":"2022-07-05 19:12:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":10264,"visible":true,"origin":"","legend":"\u003cp\u003ePercentage of EC placement\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-1789554/v1/392440394529ae57cca9ed46.png"},{"id":23484445,"identity":"8b1abac6-8886-4cfd-aa66-fca84269a1f1","added_by":"auto","created_at":"2022-07-05 19:23:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":10667,"visible":true,"origin":"","legend":"\u003cp\u003ePercentage of urinary catheter placement\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-1789554/v1/216cc6bc1c57869b59d831c5.png"},{"id":23483966,"identity":"f5d5021d-87a5-4771-b317-3942094d68bd","added_by":"auto","created_at":"2022-07-05 19:12:59","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":13201,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePostoperative pain \u0026gt;3 days on a numerical rating scale (NRS)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-1789554/v1/99691a2a73d8509f5c5ccbcf.png"},{"id":23484364,"identity":"19dbab56-e469-4c59-bb7b-3b83fde7b811","added_by":"auto","created_at":"2022-07-05 19:18:00","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":13338,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMobilization on the 1\u003c/em\u003e\u003csup\u003e\u003cem\u003est\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e postoperative day\u003c/em\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-1789554/v1/ecf4c0a2e37ec9ea1d1d581a.png"},{"id":23483973,"identity":"2390f406-ece6-418c-9c8e-8c41cda93dd9","added_by":"auto","created_at":"2022-07-05 19:13:00","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":12666,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMobilization on the 2\u003c/em\u003e\u003csup\u003e\u003cem\u003end\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e postoperative day\u003c/em\u003e\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-1789554/v1/a4c1c3391262a2e27dbe7c92.png"},{"id":23484366,"identity":"d6091f68-ac33-4198-9d59-14f8b89a10ac","added_by":"auto","created_at":"2022-07-05 19:18:00","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":12818,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMobilization on the 3\u003c/em\u003e\u003csup\u003e\u003cem\u003erd\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e postoperative day\u003c/em\u003e\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-1789554/v1/06092e221eb443315ac69dae.png"},{"id":23483967,"identity":"56b1633a-1303-42cd-87e3-685b50c66474","added_by":"auto","created_at":"2022-07-05 19:13:00","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":13526,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMobilization on the 4\u003c/em\u003e\u003csup\u003e\u003cem\u003eth\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e postoperative day\u003c/em\u003e\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-1789554/v1/52565e3b40e2851f89e7dd9f.png"},{"id":23483968,"identity":"d24d565b-3bfc-44e3-9ca6-746a40c8c485","added_by":"auto","created_at":"2022-07-05 19:13:00","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":13455,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMobilization on the 5\u003c/em\u003e\u003csup\u003e\u003cem\u003eth\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e postoperative day\u003c/em\u003e\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-1789554/v1/a3d213f539ccd42d781a9693.png"},{"id":23483971,"identity":"24fb715a-1870-448a-a52b-c02e495c3189","added_by":"auto","created_at":"2022-07-05 19:13:00","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":13113,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePostoperative complications according to Clavien-Dindo\u0026nbsp;\u003c/em\u003e\u003c/p\u003e","description":"","filename":"10.png","url":"https://assets-eu.researchsquare.com/files/rs-1789554/v1/e785c0e8ae3bcaa483ece8db.png"},{"id":53295748,"identity":"95e7d3c2-e981-4181-ae29-a96f08eab190","added_by":"auto","created_at":"2024-03-23 06:42:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":500939,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1789554/v1/3546ae8d-d6cb-4fe3-98a7-e014b13a354b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Laparoscopic rectal resections without epidural catheters - does it work?","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWith medical advances, colorectal surgery has changed in recent years. Laparoscopy, in particular, has become an\u0026nbsp;established procedure\u0026nbsp;in rectal surgery. According to data from Helios clinics, one of the largest private hospital operators in Europe, the proportion of rectal resections that are accessed laparoscopically has been continuously increasing since 2016. Specifically, internal Helios data show that the proportion of laparoscopic rectal resections\u0026nbsp;in 2016 was\u0026nbsp;32.80%, increasing to 49.34% in 2021 [1].\u003c/p\u003e\n\u003cp\u003eFurthermore, perioperative medicine is also currently on an international upswing and is gaining more attention thanks to the ERAS\u0026reg; (Enhanced Recovery After Surgery) concept. The advantages of this multimodal and minimally invasive treatment method have been described in multiple studies in recent years [2-11]. The placement of an epidural catheter (EC) has been seen as an important part of modern perioperative management, and was implemented as a global standard as a result of this fast-track recovery regime. However, EC placement is associated with increased invasiveness, which is characterized by an increased rate of bladder emptying disorders, circulatory depression, and the associated reduced mobility [12-14]. A number of international studies have meanwhile shown that EC placement does not offer any advantages in laparoscopic colon resections and is therefore unnecessary [15-19]. The extent to which these results can also be applied to the placement of EC in laparoscopic rectum resections cannot be conclusively determined at present.\u003c/p\u003e\n\u003cp\u003eThe aim of this prospective study was to evaluate the changes the omission of EC placement induces in the postoperative short-term outcomes of laparoscopic rectal resections\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eIn this prospective analysis, all laparoscopic rectal resections from 01/2013-02/2018 (group A) were analyzed and compared with\u0026nbsp;the laparoscopic rectal resections from 03/2018-12/2020 (group B).\u003c/p\u003e\n\u003cp\u003eFrom group A, 122 patients could be included in this study; EC placement was standard in this group (EC placement in 80.3% of the cases). From group B,\u0026nbsp;99 patients\u0026nbsp;could be included in this study. At the start of the group B period we changed our internal standard operating procedures (SOPs) and standard EC placement was no longer performed (EC placement in 7.1% of the cases). Relevant patient-related preoperative data were collected in both\u0026nbsp;groups; this included patient age and\u0026nbsp;gender. The preoperative classification of the surgical risk was based on the recommendations of the American Society of Anesthesiologists Classification (ASA classification). In addition, disease-specific data were documented. This included the extent of resection, the height localization of the tumors,\u0026nbsp;and\u0026nbsp;the classification of the tumor stage according to the Union for International Cancer Control (UICC) [20-23]. A distinction was made between the following tumor localizations:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eUpper third of rectum: 12 \u0026ndash; 16 cm.\u003c/li\u003e\n \u003cli\u003eMid-rectum: 6 \u0026ndash; \u0026lt; 12cm.\u003c/li\u003e\n \u003cli\u003eLower third of rectum: \u0026lt; 6 cm.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u0026nbsp;The extent of resection was limited to the following 3 interventions:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eHigh anterior rectal resection with partial mesorectal excision (tumors of the upper third of the rectum).\u003c/li\u003e\n \u003cli\u003eLow anterior rectal resection with complete mesorectal excision (tumors of the middle and lower third of the rectum).\u003c/li\u003e\n \u003cli\u003eAbdomino-perineal rectal extirpation (tumors with sphincter involvement/preoperative incontinence).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eEC was always placed between the thoracic vertebrae 9 and 10 as part of the anesthesia induction. The analgesia used for this procedure consisted of a combination of ropivacaine 0.2% and sufentanil 0.75 \u0026micro;g/ml, at a flow rate of 8 ml/h. A bolus administration was also possible at 6 ml/h. The blocking time after\u0026nbsp;bolus administration was\u0026nbsp;8 hours.\u003c/p\u003e\n\u003cp\u003eIn addition to EC placement, the other target parameters of our study were:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eUrinary catheter placement during the inpatient stay.\u003c/li\u003e\n \u003cli\u003ePostoperative pain \u0026gt;3 days on a numerical rating scale (NRS).\u003c/li\u003e\n \u003cli\u003eMobilization in the first 5 postoperative days.\u003c/li\u003e\n \u003cli\u003eTime until the first postoperative bowel movement.\u003c/li\u003e\n \u003cli\u003ePostoperative complications according to Clavien-Dindo.\u003c/li\u003e\n \u003cli\u003eIntermediate care unit stay (IMC stay) in days.\u003c/li\u003e\n \u003cli\u003eHospital length of stay in days.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAll urinary catheter placements that became necessary during the inpatient stay were recorded. No distinction was made as to when the placement of a urinary catheter became necessary during the inpatient stay.\u003c/p\u003e\n\u003cp\u003ePostoperative pain was recorded twice daily by a nurse using the numerical rating scale (NRS). Group B patients (without EC placement) received intraoperatively a modified transversus abdominis plane block (TAP block) as a local anesthetic, with\u0026nbsp;application of 2\u0026nbsp;x 75 mg ropivacaine. Postoperative pain therapy was carried out according to the\u0026nbsp;WHO grading scheme. The basic analgesia consisted of metamizol 500 mg 4 x 1 tablet, and oxycodone 20 mg 2 x 1 tablet, daily. Piritramide was also available to the patients as an on-demand medication, up to 9 times a day as a subcutaneous injection. In addition, all patients received concomitant medication with Movicol sachets 2 x 1 sachet daily, and rescue medication against potential postoperative nausea. To compare the two groups, the percentage of postoperative days with a pain score \u0026gt; 3 in the first 5 postoperative days was documented.\u003c/p\u003e\n\u003cp\u003eRegarding postoperative mobilization, four variables were available for comparing\u0026nbsp;the two groups. In the first\u0026nbsp;5 postoperative days, a distinction was made between: no mobilization; mobilization to the edge of the bed; mobilization at room level;\u0026nbsp;and mobilization on the ward floor.\u0026nbsp;The mobilization took place with the help of physiotherapists, until independent mobilization on the ward floor was possible. All patients were informed of the usefulness of rapid mobilization during a pre-hospital discussion.\u003c/p\u003e\n\u003cp\u003eComplications were classified according to\u0026nbsp;Clavien-Dindo [24]. The length of\u0026nbsp;postoperative IMC stay and the length of hospital stay were recorded in days. Emergency procedures and primarily open rectal resections were excluded from this study.\u003c/p\u003e\n\u003cp\u003eTo compare the position of the distribution of a metric variable from two independent groups, the Shapiro-Wilk test was first used to check whether the data in the groups were normally distributed. If the assumption of normal distribution was not rejected (p-value \u0026sup3; 0.1), the comparison was performed using the t-test. If the assumption of normal distribution was rejected, the Mann-Whitney-U test was used. To compare frequency distributions of a categorical variable from independent groups, the chi-square test or Fisher\u0026apos;s exact test (if the expected cell frequencies were less than five) were used.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn the entire study period, 221 laparoscopic rectal resections were performed. Of these, 122 resections were carried out in the period from 01/2013-02/2018 (group A), and 99 resections were carried out in the period from 03/2018-12/2020 (group B). The median age\u0026nbsp;in group A was 67 years (min. 40 years; max. 89 years), and in group B 66 years (min. 34 years; max. 88 years) (p = 0.723). Regarding gender, 83 patients (68%) in group A and 62\u0026nbsp;patients (62.6%) in group B were male (p=0.400). In terms of preoperative classification of the surgical risk, 49.2% of\u0026nbsp;patients in group A and 52.5% in group B were classified as ASA level 3 (p=0.001).\u0026nbsp;The detailed results are summarized in Figure 1 and Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSpecific results of group A patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThirty (24.6%) rectal tumors were localized in the upper, 76 (62.3%) in the middle, and 16 (13.1%) in the lower third of the rectum, based on preoperative staging. This was followed by high anterior rectal resection in 27 cases (22.1%), and low anterior rectal resection in 79 cases (64.8%). In 16 cases (13.1%) an abdomino-perineal rectal extirpation was performed. A protective ileostomy was constructed in all patients with a low anterior rectal resection. In all abdomino-perineal rectal extirpations, an end descending colostomy was consecutively constructed. The detailed group A patient characteristics are presented in Table 1. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs part of the perioperative pain therapy, EC was placed in 80.3% of cases in group A (Fig. 2). In addition, in 97.5% of these cases a urinary catheter placement was necessary during inpatient stay (Fig. 3). These urinary catheters were placed either intraoperatively or in the postoperative phase due to urinary retention. A total of\u0026nbsp;116 patients (95.1%)\u0026nbsp;from this group had a postoperative stay\u0026nbsp;in the IMC ward. The median IMC stay of all patients in\u0026nbsp;group A was 1 day (min. 0 day; max. 38 days).\u003c/p\u003e\n\u003cp\u003eOn the day of surgery, 52 patients (42.6%) reported pain \u0026gt;3 according to the\u0026nbsp;NRS. On the first postoperative day,\u0026nbsp;a pain score \u0026gt;3 was documented in 34 patients (27.9%). On the second postoperative day, the number of patients with a pain score \u0026gt;3 decreased to 17\u0026nbsp;patients (13.9%). From the third to the fifth postoperative day, a maximum of\u0026nbsp;seven patients (5.8%) reported a pain score of \u0026gt;3 (Fig. 4).\u003c/p\u003e\n\u003cp\u003eThe mobilization of patients on the ward floor on the first postoperative day was possible in five cases (4.1%), whereas\u0026nbsp;no mobilization was possible on the first postoperative day in\u0026nbsp;49 cases (40.2%). Mobilization\u0026nbsp;on the ward floor was possible on the second postoperative day in 28 patients (23%),\u0026nbsp;with 14 cases (11.5%) remaining unable to mobilize. The number of patients who were mobile on the ward floor continued to increase from the third postoperative day [57 patients\u0026nbsp;(46.7%)] to the fifth postoperative day [91 patients (74.6%)]. Mobilization was still not possible in eight cases (6.6%) on the third postoperative day, as well as on the fifth postoperative day ((Fig. 5 \u0026ndash; 9).\u003c/p\u003e\n\u003cp\u003eThe median time until the first bowel movement was 2 days in group A (min. 1 day; max. 8 days).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWith regard to postoperative complications, 76 cases (62.3%) showed no postoperative complications during\u0026nbsp;inpatient stay. In ten cases each there\u0026nbsp;was a complication grade 1, 2 and 4a (each 8.2% of the cases), and one patient had a grade 5 complication\u0026nbsp;(0.8%)\u0026nbsp;(Fig. 10).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, the median length of hospital stay for\u0026nbsp;patients in group A was 10 days (min. 4 days; max. 40 days).\u0026nbsp;The detailed outcomes of group A patients are shown in Table 2.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSpecific results of group B patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePreoperative staging revealed 21 (21.2%) rectal tumors in the upper, 48 (48.5%) in the middle,\u0026nbsp;and 30\u0026nbsp;(30.3%) in the lower third of the rectum. Accordingly, in 21 cases (21.2%) a high anterior rectal resection was performed, and in 61 cases (61.6%) a low anterior rectal resection was performed.\u0026nbsp;In 17 cases (17.2%) an abdomino-perineal rectal extirpation was performed. Regarding the respective tumor location (p=0.877) and the consecutive extent of resection (p=0.645), no significant differences compared to group A were observed. The detailed group B patient characteristics are shown in Table 1.\u003c/p\u003e\n\u003cp\u003eIn 92.9% of group B cases no EC was placed (p\u0026lt;0.001 compared to group A). In the remaining 7.1% of cases with EC placement an abdomino-perineal rectal extirpation was always performed (Fig. 2). Twenty-five patients (25.3%) of this group had a postoperative stay\u0026nbsp;in the IMC ward. The median length of the IMC stay of all patients in group B was 0 days (min. 0 days; max. 19 days) (p\u0026lt;0.001 compared to group A).\u003c/p\u003e\n\u003cp\u003eIn group B, a urinary catheter placement was necessary in a total of 35 cases (35.4%) (p\u0026lt;0.001 compared to group A). In seven patients with abdomino-perineal rectum extirpations, the urinary catheter placement was routinely performed in addition to EC placement (Fig. 3).\u003c/p\u003e\n\u003cp\u003eOn the day of surgery, 49 patients (49.5%) reported a pain level \u0026gt;3 according to the NRS. A pain score \u0026gt;3 was documented on the first postoperative day in 23 patients (23.2%). On the second postoperative day the number of patients with a pain score \u0026gt;3 decreased to 13\u0026nbsp;patients (13.1%). From the third to the fifth postoperative day, ten patients reported a pain score of \u0026gt;3 (10.1%). No significant difference in terms of postoperative pain was observed between the two groups (p=0.285) (Fig. 4).\u003c/p\u003e\n\u003cp\u003eThe mobilization of patients on the ward floor on the first postoperative day was possible in 55 cases (55.5%), whereas\u0026nbsp;no mobilization was possible on the first postoperative day in\u0026nbsp;five cases (5.1%).\u0026nbsp;On the second postoperative day mobilization\u0026nbsp;on the ward floor was possible in 72 patients (72.7%). In the further postoperative course, the number of patients who were mobile on the ward floor increased continuously: on the third postoperative day 87 patients (87.9%), on the fourth postoperative day\u0026nbsp;92 patients (93%), and on the fifth postoperative day 94 patients (95%) were mobile on the ward floor. In\u0026nbsp;two cases\u0026nbsp;there was no mobilization\u0026nbsp;on the ward floor on either the fourth or the fifth postoperative day. A significant\u0026nbsp;difference in terms of mobilization was observed compared to group\u0026nbsp;A (p\u0026lt;0.001)\u0026nbsp;(Fig. 5 \u0026ndash; 9).\u003c/p\u003e\n\u003cp\u003eThe median time until the first bowel movement was 2 days in group B (min. 1 day; max. 7 days).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSixty-four patients (64.6%) in group B showed no postoperative complications during their inpatient stay. There was a grade 1 complication\u0026nbsp;in\u0026nbsp;seven patients (7.1%) and a grade 2 complication\u0026nbsp;in 12 patients (12.1%); in three cases (3%) there was a grade 3a complication, and in six cases (6.0%) a grade 3b complication; three patients (3%) developed a grade 4a complication\u0026nbsp;and\u0026nbsp;one (1%) patient a grade 4b complication; and three\u0026nbsp;patients (3%) had a grade 5 complication. There was no significant difference in postoperative complications between groups A and B (p=0.608) (Fig. 10).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, the median length of hospital stay for patients in group B was 7 days (min. 3 days; max. 36 days) (p=\u0026lt;0.001 compared to group A). The detailed outcomes of group B patients are shown in Table 2.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAccording to a Germany-wide analysis from 2019, colorectal resection is still one of the most frequently performed visceral surgical operations among all inpatients [25]. Laparoscopy,\u0026nbsp;in particular, has been established\u0026nbsp;as the standard procedure in colorectal surgery. According to our own internal data, the proportion of laparoscopic rectal resections has been steadily\u0026nbsp;increasing over the last years,\u0026nbsp;from 32.80% in 2016 to 49.34% in 2021 [1]. With the progress of perioperative medicine through multimodal treatment concepts such as ERAS\u0026reg; (Enhanced Recovery After Surgery), postoperative morbidity has also decreased, and the length of hospital stay has shortened [2-11].\u003c/p\u003e\n\u003cp\u003eThe advantages of these multimodal treatment concepts are well known [2-11]. During the postoperative course, EC placement continues to play a major role regarding postoperative pain and the associated possibility for mobilization. A positive influence on postoperative intestinal paralysis has also been ascribed to EC placement [26-31]. This is illustrated in a 2014 publication by P\u0026ouml;pping et al., according to which EC placement in gastrointestinal interventions led to a reduction in pulmonary and cardiac complications, a reduced stress response,\u0026nbsp;and improved intestinal motility [30].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn the other hand, EC placement is associated with increased invasiveness, and, on top of system-specific risks such as catheter infection or dura perforation, has additional potential disadvantages such as an increased rate of bladder emptying disorders, circulatory depression,\u0026nbsp;and\u0026nbsp;the associated reduced mobility [12-14,32-33]. Meanwhile, a number of international studies have shown that EC placement does not offer any advantages in laparoscopic colon resections and is therefore unnecessary [15-19]. Whether EC placement in laparoscopic rectal resections is indeed beneficial for the patients\u0026rsquo; short-term outcomes remains unknown.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn 2019, after a Germany-wide survey of 102 hospitals, Wagner et al.\u0026nbsp;reported that in 98.8% of cases of abdominal intervention, routine urinary catheters were placed in addition to the EC\u0026nbsp;placement [32]. The reason for this is the blockage of the parasympathetic nervous system, which leads to a bladder emptying disorder. Moreover, the results of a study by Halabi et al. from 2014 showed that EC-induced bladder emptying disorders lead to a 1.8-fold increased risk of urinary tract infections [34]. By omitting EC placement, we achieved a significant reduction in the number of urinary catheter placements in our study; the installation of a urinary catheter was only necessary in 1/3 of the cases. This result consists of two variables; it includes the placement of urinary catheters that become necessary due to postoperative urinary retention on the one hand, and the routine placement of urinary catheters as a result of EC placement during rectal extirpation on the other.\u003c/p\u003e\n\u003cp\u003ePreoperative patient education is essential to prepare for the upcoming operation and the postoperative rehabilitation phase, including\u0026nbsp;the postoperative pain [35-38]. This is also reflected in our data. The waiver of EC placement was very well offset by the combination of preoperative patient training, with mental preparation of the patients for the postoperative course, including the postoperative pain and the WHO analgesia grading scheme. As a result, in our analysis, there was no significant difference\u0026nbsp;between the two groups\u0026nbsp;regarding postoperative pain. This is in agreement with the results of Turi et al.\u0026nbsp;from 2019, who published a data analysis from 14 different Italian clinics.\u0026nbsp;Similarly, to our finding, no advantage of EC placement in relation to postoperative pain could be demonstrated in that study either [39].\u003c/p\u003e\n\u003cp\u003eDue to the standard performance of all rectal resections using minimally invasive surgical techniques, our results show that routine EC placement not only has no advantages, but it clearly impairs the short-term postoperative rehabilitation phase and triggers a chain reaction. According to our data, EC placement was performed in approximately 80% of patients in group A, and was followed by a urinary catheter placement in almost all\u0026nbsp;patients. Mobilization of\u0026nbsp;patients with an EC on the ward floor was therefore only possible in less than 5% of the cases on the first postoperative day. In addition, in almost half of the cases in group A there was no mobilization at all on the first postoperative day. In comparison, mobilization of group B patients on the first postoperative day was possible in 55 patients (55.5%) on the ward floor. Moreover, the mobilization of group B patients increased proportionally over the days, and on the fifth postoperative day 94 (95%) of the group B patients were mobile on the ward floor. A potential reason explaining this could be the difficulty in handling the catheter, and the potential fear of the patients when handling the catheter. EC as well as urinary catheter placement were also seen by Koch et al.\u0026nbsp;as\u0026nbsp;an obstacle\u0026nbsp;to rehabilitation in 2021 [40].\u003c/p\u003e\n\u003cp\u003eAnother important aspect is the delayed convalescence period of group A, in terms of the length of postoperative IMC stay. This can probably be\u0026nbsp;attributed to\u0026nbsp;postoperative hypotension, which is almost always associated with EC placement. As a result, patients can become dependent on norepinephrine, making a longer IMC stay necessary. This hypothesis is supported by a study by Gramigni et al.\u0026nbsp;from 2013, by Hanna et al.\u0026nbsp;from 2017,\u0026nbsp;and is also in agreement with results from our work [41-42]. The median IMC stay of group A patients (with EC) was 1 day. In comparison, group B patients (without EC) had a median IMC stay of 0 days (p-value \u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003eA meta-analysis with 1138 patients from 2016 by Guay et al.\u0026nbsp;showed that\u0026nbsp;EC placement had a significant positive effect on postoperative intestinal paralysis after colorectal resections [30]. On the other hand, a study by Khan et al. from 2013 analyzed six studies between 1999 and 2011; two of these studies also showed a positive effect of EC on postoperative stool regulation, whereas the remaining four could not demonstrate a positive effect of EC on stool regulation [19]. Our analysis also showed no difference between the two groups regarding the length of time until the first bowel movement, with patients in both groups having their first bowel movement on average 2 days after surgery.\u003c/p\u003e\n\u003cp\u003eWith no significant differences in the rate of postoperative complications according to Clavien-Dindo, the hospital stay of group B patients was also significantly shorter,\u0026nbsp;with a median of 7 days for group B compared to a median of 10 days for group A (p-value \u0026lt;0.001). The shortened length of hospital stay without an increase in postoperative morbidity is also in agreement with the results reported by Wei et al.\u0026nbsp;in 2020 [43].\u003c/p\u003e\n\u003cp\u003eDespite these positive observations, it is important to take a critical look at our study. For instance, possible positive effects of EC on the postoperative course, such as on postoperative nausea, were not taken into account. Moreover, in the future, it will be interesting to find out what effect the robotic rectum resection, rectum extirpation, or both, will have on EC placement. While conventional laparoscopic rectal extirpation often requires a suprasymphyseal rescue incision for deep dissection, this is completely unnecessary in the robotic surgical method. Thus, the argument of increased invasiveness of the intervention can no longer be used, which should accordingly also lead to a declining number of EC placements.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEC placement has long been the standard for colorectal resections, and is particularly recommended for rectal resections [5]. In our analysis, dispensing with EC placement from laparoscopic rectal resections led to faster mobilization of patients without increasing the level of pain, and to a significantly shorter hospital stay. More importantly, EC omission was not associated with a change in postoperative complications. In summary, according to our data, routine EC placement in laparoscopic rectal resection is not beneficial for the patients and can be dispensed with.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThere are no relevant financial or non-financial competing interests to report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was waived by the local Ethics Committee of the medical faculty of the university of Rostock on 10\u003csup\u003eth\u003c/sup\u003e of January 2019 in view of the prospective nature of the study and all the procedures being performed were part of the routine care. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent to participate has been obtained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have given consent for publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Mohamad El-Ahmar, Anja K\u0026ouml;hler and Franziska Koch. Matthias Ristig and J\u0026ouml;rg-Peter Ritz have set the target parameters and monitored the analysis. Lutz Moikow assisted in all questions regarding the epidural catheter from the anesthesiologcial point of view. Mohamad El-Ahmar wrote the manuscript. Franziska Koch and J\u0026ouml;rg-Peter Ritz commented on previous versions of the manuscript. All authors read and approved the final manuscript\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for conducting this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eInternal data query of all Helios clinics \u003c/li\u003e\n\u003cli\u003eKehlet H, Wilmore DW: Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78: 606\u0026ndash;617 \u003c/li\u003e\n\u003cli\u003eBardram L, Funch-Jensen P, Jensen P, Crawford ME, Kehlet H.: Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Lancet 1995; 345(8952):763-4 \u003c/li\u003e\n\u003cli\u003eKehlet H: Organizing postoperative accelerated recovery programs. Reg Anesth 1996; 21:149-151 \u003c/li\u003e\n\u003cli\u003eSchwenk W: Fast Track Rehabilitation in der Viszeralchirurgie. Der Chirurg 2009; 80: 690-701\u003c/li\u003e\n\u003cli\u003eKehlet H, Joshi GP. Systematic reviews and meta-analyses of randomized controlled trials on perioperative outcomes: an urgent need for critical reappraisal. Anesth Analg. 2015;121(4):1104\u0026ndash;1107.\u003c/li\u003e\n\u003cli\u003eKoch F, Green M, Dietrich M, Moikow L, Pontau F, Ulmer S, Dietrich N, Ritz JP. Perioperatives Management \u0026ndash; Aufgaben und Bedeutung von speziell geschulten Pflegekr\u0026auml;ften [Perioperative Management - Tasks and Significance of Specially Trained Nursing Staff]. Zentralbl Chir. 2021 Jun;146(3):260-268. German. doi: 10.1055/a-1393-6892. Epub 2021 Jun 21. PMID: 34154006.\u003c/li\u003e\n\u003cli\u003eCavallaro P, Bordeianou L. Implementation of an ERAS Pathway in Colorectal Surgery. Clin Colon Rectal Surg. 2019 Mar;32(2):102-108. doi: 10.1055/s-0038-1676474. Epub 2019 Feb 28. PMID: 30833858; PMCID: PMC6395097.\u003c/li\u003e\n\u003cli\u003eSimpson JC, Bao X, Agarwala A. Pain Management in Enhanced Recovery after Surgery (ERAS) Protocols. Clin Colon Rectal Surg. 2019 Mar;32(2):121-128. doi: 10.1055/s-0038-1676477. Epub 2019 Feb 28. PMID: 30833861; PMCID: PMC6395101.\u003c/li\u003e\n\u003cli\u003eBan KA, Berian JR, Ko CY. Does Implementation of Enhanced Recovery after Surgery (ERAS) Protocols in Colorectal Surgery Improve Patient Outcomes? Clin Colon Rectal Surg. 2019 Mar;32(2):109-113. doi: 10.1055/s-0038-1676475. Epub 2019 Feb 28. PMID: 30833859; PMCID: PMC6395090.\u003c/li\u003e\n\u003cli\u003eNi X, Jia D, Chen Y, Wang L, Suo J. Is the Enhanced Recovery After Surgery (ERAS) Program Effective and Safe in Laparoscopic Colorectal Cancer Surgery? A Meta-Analysis of Randomized Controlled Trials. J Gastrointest Surg. 2019 Jul;23(7):1502-1512. doi: 10.1007/s11605-019-04170-8. Epub 2019 Mar 11. PMID: 30859422.\u003c/li\u003e\n\u003cli\u003eCooper GM, Stride PC: Dural puncture. Blood patch not always benign. BMJ. 1993 May 15; 306(6888): 1339.\u003c/li\u003e\n\u003cli\u003eScherer R, Schmutzler M, Giebler R et al. Complications related to thoracic epidural analgesia: a prospective study in 1071 surgical patients. Acta Anaestheiol Scand. 1993 May; 37(4): 370-4.\u003c/li\u003e\n\u003cli\u003eAuroy Y, Narchi P, Messiah A et al. Serious complications related to regional anaesthesia: results of a prospective survey in France. Anaestheiology. 1997 Sep; 87(3): 479-86.\u003c/li\u003e\n\u003cli\u003eGustafsson, U.O., Scott, M.J., Hubner, M. et al. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS\u003csup\u003e\u0026reg;\u003c/sup\u003e) Society Recommendations: 2018. World J Surg 43,\u003cstrong\u003e \u003c/strong\u003e659\u0026ndash;695 (2019). https://doi.org/10.1007/s00268-018-4844-y\u003c/li\u003e\n\u003cli\u003eLjungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017 Mar 1;152(3):292-298. doi: 10.1001/jamasurg.2016.4952. PMID: 28097305.\u003c/li\u003e\n\u003cli\u003eCarmichael, Joseph C. M.D.1; Keller, Deborah S. M.S., M.D.2; Baldini, Gabriele M.D.3; Bordeianou, Liliana M.D.4; Weiss, Eric M.D.5; Lee, Lawrence M.D., Ph.D.6; Boutros, Marylise M.D.6; McClane, James M.D.7; Feldman, Liane S. M.D.6; Steele, Scott R. M.D.8 Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons, Diseases of the Colon \u0026amp; Rectum: August 2017 - Volume 60 - Issue 8 - p 761-784 doi: 10.1097/DCR.0000000000000883\u003c/li\u003e\n\u003cli\u003eBona S, Molteni M, Rosati R, Elmore U, Bagnoli P, Monzani R, Caravaca M, Montorsi M. Introducing an enhanced recovery after surgery program in colorectal surgery: A single center experience. World J Gastroenterol 2014; 20(46): 17578-17587 [PMID: 25516673 DOI: 10.3748/wjg.v20.i46.17578]\u003c/li\u003e\n\u003cli\u003eKhan SA, Khokhar HA, Nasr AR, Carton E, El-Masry S. Effect of epidural analgesia on bowel function in laparoscopic colorectal surgery: a systematic review and meta-analysis. Surg Endosc. 2013 Jul;27(7):2581-91. doi: 10.1007/s00464-013-2794-x. Epub 2013 Feb 7. 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Norstein, Editors. 1997, Springer: Berlin Heidelberg New York. p. 405-45. \u003c/li\u003e\n\u003cli\u003eUICC, \u003cem\u003eTNM Classification of Malignant Tumours\u003c/em\u003e. 6th Edition ed, ed. L.H. Sobin and C. Wittekind. 2002, New York: John Wiley \u0026amp; Sons. \u003c/li\u003e\n\u003cli\u003eDindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004 Aug;240(2):205-13. doi: 10.1097/01.sla.0000133083.54934.ae. PMID: 15273542; PMCID: PMC1360123.\u003c/li\u003e\n\u003cli\u003eBaum P, Diers J, Lichthardt S, Kastner C, Schlegel N, Germer CT, Wiegering A. Mortality and Complications Following Visceral Surgery: A Nationwide Analysis Based on the Diagnostic Categories Used in German Hospital Invoicing Data. Dtsch Arztebl Int. 2019 Nov 1;116(44):739-746. doi: 10.3238/arztebl.2019.0739. PMID: 31774053; PMCID: PMC6912125.\u003c/li\u003e\n\u003cli\u003eRodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, Sage D, Futter M, Saville G, Clark T, MacMahon S: Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ, 2000 Dec 16; 321(7275):1493. \u003c/li\u003e\n\u003cli\u003eBallantyne JC, Carr DB, Chalmers TC, Dear KB, Angelillo IF, Mosteller F: Postoperative patient-controlled analgesia: meta-analyses of initial randomized control trials. J Clin Anesth. 1993 May-Jun; 5(3):182-93 \u003c/li\u003e\n\u003cli\u003eBlock BM, Liu SS, Rowlingson AJ et al. Efficacy of postoperative epidural analgesia: a meta- analysis. JAMA 2003; 290:2455\u0026ndash;2463 \u003c/li\u003e\n\u003cli\u003eJorgensen H, Wetterslev J, Moiniche S, Dahl JB.: Epidural local anaesthetics versus opioid-based analgesic regimens on postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery. Cochrane Database Syst Rev 2000(4):CD001893 \u003c/li\u003e\n\u003cli\u003eGuay J, Nishimori M, Kopp SL. Epidural Local Anesthetics Versus Opioid-Based Analgesic Regimens for Postoperative Gastrointestinal Paralysis, Vomiting, and Pain After Abdominal Surgery: A Cochrane Review. Anesth Analg. 2016 Dec;123(6):1591-1602. doi: 10.1213/ANE.0000000000001628. PMID: 27870743.\u003c/li\u003e\n\u003cli\u003eP\u0026ouml;pping DM, Elia N, Van Aken HK, Marret E, Schug SA, Kranke P, Wenk M Tram\u0026egrave;r MR: Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials. Ann Surg. 2014 Jun;259(6):1056-67.\u003c/li\u003e\n\u003cli\u003eWagner J, Eiken B, Haubitz I, Lichthardt S, Matthes N, L\u0026ouml;b S, Klein I, Germer CT, Wiegering A. Suprapubic bladder drainage and epidural catheters following abdominal surgery-A risk for urinary tract infections? PLoS One. 2019 Jan 23;14(1):e0209825. doi: 10.1371/journal.pone.0209825. PMID: 30673740; PMCID: PMC6343869.\u003c/li\u003e\n\u003cli\u003eVogelsang H, Lang A, Cevik B, Botteck NM, Weber TP, Herzog-Niescery J. Incidence of infection in non-tunnelled thoracic epidural catheters after major abdominal surgery. Acta Anaesthesiol Scand. 2020 Oct;64(9):1312-1318. doi: 10.1111/aas.13650. Epub 2020 Jun 25. PMID: 32521043.\u003c/li\u003e\n\u003cli\u003eHalabi WJ, Kang CY, Nguyen VQ, Carmichael JC, Mills S, Stamos MJ, Pigazzi A. Epidural analgesia in laparoscopic colorectal surgery: a nationwide analysis of use and outcomes. JAMA Surg. 2014 Feb;149(2):130-6. doi: 10.1001/jamasurg.2013.3186. PMID: 24336894.\u003c/li\u003e\n\u003cli\u003eAasa A, Hovb\u0026auml;ck M, Berter\u0026ouml; CM. The importance of preoperative information for patient participation in colorectal surgery care. J Clin Nurs. 2013 Jun;22(11-12):1604-12. doi: 10.1111/jocn.12110. Epub 2013 Feb 28. PMID: 23445552.\u003c/li\u003e\n\u003cli\u003eSj\u0026ouml;ling M, Nordahl G, Olofsson N, Asplund K. The impact of preoperative information on state anxiety, postoperative pain and satisfaction with pain management. Patient Educ Couns. 2003 Oct;51(2):169-76. doi: 10.1016/s0738-3991(02)00191-x. PMID: 14572947.\u003c/li\u003e\n\u003cli\u003eSimpson JC, Bao X, Agarwala A (2019) Pain Management in Enhanced Recovery after Surgery (ERAS) protocols. Clin Colon Rectal Surg 32(2):121\u0026ndash;128. https://doi.org/10.1055/s-0038-1676477\u003c/li\u003e\n\u003cli\u003eTan M, Law LS, Gan TJ. Optimizing pain management to facilitate Enhanced Recovery After Surgery pathways. Can J Anaesth 2015; 62 (02) 203-218\u003c/li\u003e\n\u003cli\u003eTuri S, Gemma M, Braga M, Monzani R, Radrizzani D, Beretta L; Perioperative Italian Society-ERAS Italian Chapter. Epidural analgesia vs systemic opioids in patients undergoing laparoscopic colorectal surgery. Int J Colorectal Dis. 2019 May;34(5):915-921. doi: 10.1007/s00384-019-03284-4. Epub 2019 Mar 29. PMID: 30927065.\u003c/li\u003e\n\u003cli\u003eKoch F, Green M, Dietrich M, Moikow L, Ritz JP. Die \u0026bdquo;Big Five\u0026ldquo; der Invasivit\u0026auml;t \u0026ndash; Sinnhaftigkeit von Drainagen, Sonden und Kathetern in der kolorektalen Chirurgie [The \u0026quot;Big Five\u0026quot; of Invasiveness - the Usefulness of Drains, Probes and Catheters in Colorectal Surgery]. Zentralbl Chir. 2021 Oct 19. German. doi: 10.1055/a-1533-2612. Epub ahead of print. PMID: 34666401.\u003c/li\u003e\n\u003cli\u003eGramigni E, Bracco D, Carli F. Epidural analgesia and postoperative orthostatic haemodynamic changes: observational study. Eur J Anaesthesiol. 2013 Jul;30(7):398-404. doi: 10.1097/EJA.0b013e32835b162c. PMID: 23435278.\u003c/li\u003e\n\u003cli\u003eHanna MH, Jafari MD, Jafari F, Phelan MJ, Rinehart J, Sun C, Carmichael JC, Mills SD, Stamos MJ, Pigazzi A. Randomized Clinical Trial of Epidural Compared with Conventional Analgesia after Minimally Invasive Colorectal Surgery. J Am Coll Surg. 2017 Nov;225(5):622-630. doi: 10.1016/j.jamcollsurg.2017.07.1063. Epub 2017 Aug 3. PMID: 28782603.\u003c/li\u003e\n\u003cli\u003eWei IH, Pappou EP, Smith JJ, Widmar M, Nash GM, Weiser MR, Paty PB, Guillem JG, Afonso A, Garcia-Aguilar J. Monitoring an Ongoing Enhanced Recovery After Surgery (ERAS) Program: Adherence Improves Clinical Outcomes in a Comparison of Three Thousand Colorectal Cases. Clin Surg. 2020 Aug;5:2909. Epub 2020 Aug 10. PMID: 33163851; PMCID: PMC7643765.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: General results of Group A and B\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" width=\"18.049490538573508%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" width=\"35.22561863173217%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 21.7363%;\" width=\"19.213973799126638%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup A\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 122)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 20.6387%;\" width=\"17.758369723435226%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup B\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 99)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 7.7187%;\" width=\"9.75254730713246%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 6.3926%;\" width=\"25.984251968503937%\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.4824%;\" width=\"25.984251968503937%\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3516%;\" width=\"22.440944881889763%\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.1484%;\" width=\"25.590551181102363%\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.049490538573508%\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.22561863173217%\"\u003e\n \u003cp\u003eMin.\u003c/p\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003cp\u003eMax.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.3926%;\" width=\"9.606986899563319%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.4824%;\" width=\"9.606986899563319%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3516%;\" width=\"8.296943231441048%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.1484%;\" width=\"9.461426491994178%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.7187%;\" width=\"9.75254730713246%\"\u003e\n \u003cp\u003e0,723\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.049490538573508%\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.22561863173217%\"\u003e\n \u003cp\u003eMale patients\u003c/p\u003e\n \u003cp\u003eFemale patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.3926%;\" width=\"9.606986899563319%\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.4824%;\" width=\"9.606986899563319%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3516%;\" width=\"8.296943231441048%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.1484%;\" width=\"9.461426491994178%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.7187%;\" width=\"9.75254730713246%\"\u003e\n \u003cp\u003e0,400\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.049490538573508%\"\u003e\n \u003cp\u003eASA-Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.22561863173217%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.3926%;\" width=\"9.606986899563319%\"\u003e\n \u003cp\u003e9\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.4824%;\" width=\"9.606986899563319%\"\u003e\n \u003cp\u003e7,4 %\u003c/p\u003e\n \u003cp\u003e43,4 %\u003c/p\u003e\n \u003cp\u003e49,2 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3516%;\" width=\"8.296943231441048%\"\u003e\n \u003cp\u003e2\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e45\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.1484%;\" width=\"9.461426491994178%\"\u003e\n \u003cp\u003e2,0 %\u003c/p\u003e\n \u003cp\u003e45,5 %\u003c/p\u003e\n \u003cp\u003e52,5 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.7187%;\" width=\"9.75254730713246%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.049490538573508%\"\u003e\n \u003cp\u003eTumor localization (height in cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.22561863173217%\"\u003e\n \u003cp\u003eLower third of\u0026nbsp;rectum: \u0026lt; 6cm\u003c/p\u003e\n \u003cp\u003eMid-rectum: 6 \u0026ndash; \u0026lt; 12cm\u003c/p\u003e\n \u003cp\u003eUpper third of\u0026nbsp;rectum: 12 \u0026ndash; 16cm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.3926%;\" width=\"9.606986899563319%\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.4824%;\" width=\"9.606986899563319%\"\u003e\n \u003cp\u003e32,8 %\u003c/p\u003e\n \u003cp\u003e45,1 %\u003c/p\u003e\n \u003cp\u003e22,1 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3516%;\" width=\"8.296943231441048%\"\u003e\n \u003cp\u003e30\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e48\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e21\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.1484%;\" width=\"9.461426491994178%\"\u003e\n \u003cp\u003e30,3 %\u003c/p\u003e\n \u003cp\u003e48,5 %\u003c/p\u003e\n \u003cp\u003e21,2 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.7187%;\" width=\"9.75254730713246%\"\u003e\n \u003cp\u003e0.877\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.049490538573508%\"\u003e\n \u003cp\u003eExtent of resection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.22561863173217%\"\u003e\n \u003cp\u003eHigh anterior rectal resection\u003c/p\u003e\n \u003cp\u003eLow anterior rectal resection\u003c/p\u003e\n \u003cp\u003eAbdomino-perineal rectal extirpation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.3926%;\" width=\"9.606986899563319%\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.4824%;\" width=\"9.606986899563319%\"\u003e\n \u003cp\u003e24,6 %\u003c/p\u003e\n \u003cp\u003e62,3 %\u003c/p\u003e\n \u003cp\u003e13,1 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3516%;\" width=\"8.296943231441048%\"\u003e\n \u003cp\u003e21\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e61\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.1484%;\" width=\"9.461426491994178%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e21,2 %\u003c/p\u003e\n \u003cp\u003e61,6 %\u003c/p\u003e\n \u003cp\u003e17,2 %\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.7187%;\" width=\"9.75254730713246%\"\u003e\n \u003cp\u003e0.645\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 2: Specific results of both groups\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" width=\"30.983606557377048%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" width=\"16.885245901639344%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 19.4727%;\" width=\"20.983606557377048%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup A\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 122)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.2773%;\" width=\"21.311475409836067%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup B\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 99)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" width=\"9.836065573770492%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 10.3594%;\" width=\"22.48062015503876%\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4727%;\" width=\"27.131782945736433%\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5566%;\" width=\"21.705426356589147%\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.1934%;\" width=\"28.68217054263566%\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.983606557377048%\"\u003e\n \u003cp\u003eEC placement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.885245901639344%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3594%;\" width=\"9.508196721311476%\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4727%;\" width=\"11.475409836065573%\"\u003e\n \u003cp\u003e80,3 %\u003c/p\u003e\n \u003cp\u003e19,7 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5566%;\" width=\"9.180327868852459%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.1934%;\" width=\"12.131147540983607%\"\u003e\n \u003cp\u003e7,1 %\u003c/p\u003e\n \u003cp\u003e92,9 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.836065573770492%\"\u003e\n \u003cp\u003e\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.983606557377048%\"\u003e\n \u003cp\u003eUrinary catheter placement\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.885245901639344%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3594%;\" width=\"9.508196721311476%\"\u003e\n \u003cp\u003e119\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4727%;\" width=\"11.475409836065573%\"\u003e\n \u003cp\u003e97,5 %\u003c/p\u003e\n \u003cp\u003e2,5 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5566%;\" width=\"9.180327868852459%\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.1934%;\" width=\"12.131147540983607%\"\u003e\n \u003cp\u003e35, 4%\u003c/p\u003e\n \u003cp\u003e64, 6 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.836065573770492%\"\u003e\n \u003cp\u003e\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.983606557377048%\"\u003e\n \u003cp\u003ePostoperative pain\u0026nbsp;\u0026gt;3 days on a numerical rating scale (NRS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.885245901639344%\"\u003e\n \u003cp\u003e0d\u003c/p\u003e\n \u003cp\u003e1d\u003c/p\u003e\n \u003cp\u003e2d\u003c/p\u003e\n \u003cp\u003e3d\u003c/p\u003e\n \u003cp\u003e4d\u003c/p\u003e\n \u003cp\u003e5d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3594%;\" width=\"9.508196721311476%\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4727%;\" width=\"11.475409836065573%\"\u003e\n \u003cp\u003e42,6 %\u003c/p\u003e\n \u003cp\u003e27,9 %\u003c/p\u003e\n \u003cp\u003e13,9 %\u003c/p\u003e\n \u003cp\u003e4,9%\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4,9 %\u003c/p\u003e\n \u003cp\u003e5,8 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5566%;\" width=\"9.180327868852459%\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.1934%;\" width=\"12.131147540983607%\"\u003e\n \u003cp\u003e49,5 %\u003c/p\u003e\n \u003cp\u003e23,2 %\u003c/p\u003e\n \u003cp\u003e13,1 %\u003c/p\u003e\n \u003cp\u003e3,0 %\u003c/p\u003e\n \u003cp\u003e10,1 %\u003c/p\u003e\n \u003cp\u003e1,1 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.836065573770492%\"\u003e\n \u003cp\u003e0,285\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.983606557377048%\"\u003e\n \u003cp\u003eMobilization on the 1\u003csup\u003est\u003c/sup\u003e postoperative day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.885245901639344%\"\u003e\n \u003cp\u003eNo mobilization\u003c/p\u003e\n \u003cp\u003eEdge of bed\u003c/p\u003e\n \u003cp\u003eRoom level\u003c/p\u003e\n \u003cp\u003eWard floor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3594%;\" width=\"9.508196721311476%\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4727%;\" width=\"11.475409836065573%\"\u003e\n \u003cp\u003e40,2 %\u003c/p\u003e\n \u003cp\u003e39,3 %\u003c/p\u003e\n \u003cp\u003e16,4 %\u003c/p\u003e\n \u003cp\u003e4,1 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5566%;\" width=\"9.180327868852459%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.1934%;\" width=\"12.131147540983607%\"\u003e\n \u003cp\u003e5,1 %\u003c/p\u003e\n \u003cp\u003e26,3 %\u003c/p\u003e\n \u003cp\u003e13,1 %\u003c/p\u003e\n \u003cp\u003e55,5 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" width=\"9.836065573770492%\"\u003e\n \u003cp\u003e\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.36363636363637%\"\u003e\n \u003cp\u003eMobilization on the 2\u003csup\u003end\u003c/sup\u003e postoperative day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.727272727272727%\"\u003e\n \u003cp\u003eNo mobilization\u003c/p\u003e\n \u003cp\u003eEdge of bed\u003c/p\u003e\n \u003cp\u003eRoom level\u003c/p\u003e\n \u003cp\u003eWard floor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3594%;\" width=\"10.545454545454545%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4727%;\" width=\"12.727272727272727%\"\u003e\n \u003cp\u003e11,5 %\u003c/p\u003e\n \u003cp\u003e36,0 %\u003c/p\u003e\n \u003cp\u003e29,5 %\u003c/p\u003e\n \u003cp\u003e23,0 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5566%;\" width=\"10.181818181818182%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.1934%;\" width=\"13.454545454545455%\"\u003e\n \u003cp\u003e4.0 %\u003c/p\u003e\n \u003cp\u003e8,1 %\u003c/p\u003e\n \u003cp\u003e15,2 %\u003c/p\u003e\n \u003cp\u003e72,7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.36363636363637%\"\u003e\n \u003cp\u003eMobilization on the 3\u003csup\u003erd\u003c/sup\u003e postoperative day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.727272727272727%\"\u003e\n \u003cp\u003eNo mobilization\u003c/p\u003e\n \u003cp\u003eEdge of bed\u003c/p\u003e\n \u003cp\u003eRoom level\u003c/p\u003e\n \u003cp\u003eWard floor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3594%;\" width=\"10.545454545454545%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4727%;\" width=\"12.727272727272727%\"\u003e\n \u003cp\u003e6,5 %\u003c/p\u003e\n \u003cp\u003e23,8 %\u003c/p\u003e\n \u003cp\u003e23,0 %\u003c/p\u003e\n \u003cp\u003e46,7 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5566%;\" width=\"10.181818181818182%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.1934%;\" width=\"13.454545454545455%\"\u003e\n \u003cp\u003e3,0 %\u003c/p\u003e\n \u003cp\u003e4,0 %\u003c/p\u003e\n \u003cp\u003e5,1 %\u003c/p\u003e\n \u003cp\u003e87,9 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.36363636363637%\"\u003e\n \u003cp\u003eMobilization on the 4\u003csup\u003eth\u003c/sup\u003e postoperative day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.727272727272727%\"\u003e\n \u003cp\u003eNo mobilization\u003c/p\u003e\n \u003cp\u003eEdge of bed\u003c/p\u003e\n \u003cp\u003eRoom level\u003c/p\u003e\n \u003cp\u003eWard floor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3594%;\" width=\"10.545454545454545%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4727%;\" width=\"12.727272727272727%\"\u003e\n \u003cp\u003e4,9 %\u003c/p\u003e\n \u003cp\u003e13,1 %\u003c/p\u003e\n \u003cp\u003e18,0 %\u003c/p\u003e\n \u003cp\u003e64,0 %\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5566%;\" width=\"10.181818181818182%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.1934%;\" width=\"13.454545454545455%\"\u003e\n \u003cp\u003e2,0 %\u003c/p\u003e\n \u003cp\u003e1,0 %\u003c/p\u003e\n \u003cp\u003e4,0 %\u003c/p\u003e\n \u003cp\u003e93 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.36363636363637%\"\u003e\n \u003cp\u003eMobilization on the 5\u003csup\u003eth\u003c/sup\u003e postoperative day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.727272727272727%\"\u003e\n \u003cp\u003eNo mobilization\u003c/p\u003e\n \u003cp\u003eEdge of bed\u003c/p\u003e\n \u003cp\u003eRoom level\u003c/p\u003e\n \u003cp\u003eWard floor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3594%;\" width=\"10.545454545454545%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4727%;\" width=\"12.727272727272727%\"\u003e\n \u003cp\u003e6,6 %\u003c/p\u003e\n \u003cp\u003e5,0 %\u003c/p\u003e\n \u003cp\u003e13,9 %\u003c/p\u003e\n \u003cp\u003e74,5 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5566%;\" width=\"10.181818181818182%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.1934%;\" width=\"13.454545454545455%\"\u003e\n \u003cp\u003e2,0 %\u003c/p\u003e\n \u003cp\u003e1,0 %\u003c/p\u003e\n \u003cp\u003e2,0 %\u003c/p\u003e\n \u003col\u003e\n \u003cli\u003e\u0026nbsp;\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.983606557377048%\"\u003e\n \u003cp\u003eTime until the 1\u003csup\u003est\u003c/sup\u003e postoperative bowel movement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.885245901639344%\"\u003e\n \u003cp\u003eMin.\u003c/p\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003cp\u003eMax.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3594%;\" width=\"9.508196721311476%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4727%;\" width=\"11.475409836065573%\"\u003e\n \u003cp\u003e-\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5566%;\" width=\"9.180327868852459%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.1934%;\" width=\"12.131147540983607%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.836065573770492%\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.983606557377048%\"\u003e\n \u003cp\u003ePostoperative complications according to\u0026nbsp;Clavien-Dindo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.885245901639344%\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003cp\u003eGrade 1\u003c/p\u003e\n \u003cp\u003eGrade 2\u003c/p\u003e\n \u003cp\u003eGrade 3a\u003c/p\u003e\n \u003cp\u003eGrade 3b\u003c/p\u003e\n \u003cp\u003eGrade 4a\u003c/p\u003e\n \u003cp\u003eGrade 4b\u003c/p\u003e\n \u003cp\u003eGrade 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3594%;\" width=\"9.508196721311476%\"\u003e\n 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style=\"width: 16.1934%;\" width=\"12.131147540983607%\"\u003e\n \u003cp\u003e64,6 %\u003c/p\u003e\n \u003cp\u003e7,1 %\u003c/p\u003e\n \u003cp\u003e12,1 %\u003c/p\u003e\n \u003cp\u003e3,0 %\u003c/p\u003e\n \u003cp\u003e6,0 %\u003c/p\u003e\n \u003cp\u003e3,0 %\u003c/p\u003e\n \u003cp\u003e1,0 %\u003c/p\u003e\n \u003cp\u003e3,0 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.836065573770492%\"\u003e\n \u003cp\u003e0,608\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.983606557377048%\"\u003e\n \u003cp\u003eIMC-stay in days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.885245901639344%\"\u003e\n \u003cp\u003eMin.\u003c/p\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003cp\u003eMax.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3594%;\" width=\"9.508196721311476%\"\u003e\n \u003cp\u003e0 d\u003c/p\u003e\n \u003cp\u003e1 d\u003c/p\u003e\n \u003cp\u003e38 d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4727%;\" width=\"11.475409836065573%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5566%;\" width=\"9.180327868852459%\"\u003e\n \u003cp\u003e0 d\u003c/p\u003e\n \u003cp\u003e0 d\u003c/p\u003e\n \u003cp\u003e19 d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.1934%;\" width=\"12.131147540983607%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" width=\"9.836065573770492%\"\u003e\n \u003cp\u003e\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.36363636363637%\"\u003e\n \u003cp\u003eHospital length of stay in days\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.727272727272727%\"\u003e\n \u003cp\u003eMin.\u003c/p\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003cp\u003eMax.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3594%;\" width=\"10.545454545454545%\"\u003e\n \u003cp\u003e4 d\u003c/p\u003e\n \u003cp\u003e10 d\u003c/p\u003e\n \u003cp\u003e40 d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4727%;\" width=\"12.727272727272727%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.5566%;\" width=\"10.181818181818182%\"\u003e\n \u003cp\u003e3 d\u003c/p\u003e\n \u003cp\u003e7 d\u003c/p\u003e\n \u003cp\u003e36 d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.1934%;\" width=\"13.454545454545455%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-colorectal-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcd","sideBox":"Learn more about [International Journal of Colorectal Disease](http://link.springer.com/journal/384)","snPcode":"384","submissionUrl":"https://submission.nature.com/new-submission/384/3","title":"International Journal of Colorectal Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"convalescence, epidural catheters, laparoscopy, rectal resections","lastPublishedDoi":"10.21203/rs.3.rs-1789554/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1789554/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePurpose:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e \u003c/em\u003ePlacement of an epidural catheter (EC) in colorectal resections is still recommended as a valid measure to achieve a low level of pain. However, EC is associated with increased invasiveness, and with an increased risk of bladder emptying disorders and a decrease of blood pressure, which all relate to delayed mobilization. Preliminary data show that EC placement may not be necessary in laparoscopic colon resections. The aim of this prospective study was to investigate how omission of EC placement influences short-term postoperative outcomes in laparoscopic rectal resections.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMethods\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e: \u003c/em\u003eAll laparoscopic rectal resections occurring between 2013-2020 were prospectively examined. Resections from 01/2013-02/2018 (group A) were compared with resections from 03/2018-12/2020 (group B; after internal change of the perioperative pain regime). \u0026nbsp;In addition to EC placement, the other target parameters of our study were urinary catheter placement during the inpatient stay, postoperative pain \u0026gt;3 days on a numerical rating scale (NRS), mobilization in the first 5 postoperative days, time until the first postoperative bowel movement, postoperative complications according to Clavien-Dindo, Intermediate care unit stay (IMC stay) in days and hospital length of stay in days.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eResults\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e: \u003c/em\u003eIn the entire study period, 221 laparoscopic rectal resections were performed: 122 in group A, and 99 resections in group B. The frequency of EC placement and urinary catheter placement, postoperative IMC stay, and hospital length of stay, were significantly lower in group B (p\u0026lt;0.05). The postoperative mobilization of patients in group B was possible more quickly. There were no differences in the level of pain, time until the first postoperative bowel movement, and postoperative complications according to Clavien-Dindo.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConclusion\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e: \u003c/em\u003eOmission of EC placement in laparoscopic rectal resections led to faster mobilization, a shorter IMC stay, and a shorter hospital stay without increasing the pain level. Postoperative complications did not change when an EC was not placed. Therefore, routine EC placement in laparoscopic rectal resections is unnecessary.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Laparoscopic rectal resections without epidural catheters - does it work?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-07-05 19:12:58","doi":"10.21203/rs.3.rs-1789554/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-07-20T15:17:07+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-07-10T15:39:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"b4648ece-0c51-4eb5-a3eb-e8cdb1c676d9","date":"2022-06-29T03:58:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-06-28T18:43:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-06-28T05:46:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-06-28T05:46:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Colorectal Disease","date":"2022-06-23T20:07:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-colorectal-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcd","sideBox":"Learn more about [International Journal of Colorectal Disease](http://link.springer.com/journal/384)","snPcode":"384","submissionUrl":"https://submission.nature.com/new-submission/384/3","title":"International Journal of Colorectal Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"854ebf7f-8d13-4e18-b07e-9a6819dc8326","owner":[],"postedDate":"July 5th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-03-23T06:42:28+00:00","versionOfRecord":{"articleIdentity":"rs-1789554","link":"https://doi.org/10.1007/s00384-022-04242-3","journal":{"identity":"international-journal-of-colorectal-disease","isVorOnly":false,"title":"International Journal of Colorectal Disease"},"publishedOn":"2022-08-24 06:42:28","publishedOnDateReadable":"August 24th, 2022"},"versionCreatedAt":"2022-07-05 19:12:58","video":"","vorDoi":"10.1007/s00384-022-04242-3","vorDoiUrl":"https://doi.org/10.1007/s00384-022-04242-3","workflowStages":[]},"version":"v1","identity":"rs-1789554","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1789554","identity":"rs-1789554","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}