**ERAS (Enhanced Recovery after Surgery) in Colorectal Surgery**

Raúl Sánchez-Jiménez, Alberto Blanco Álvarez, Jacobo Trebol López, Antonio Sánchez Jiménez, Fernando Gutiérrez Conde and José Antonio Carmona Sáez

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/57136

**1. Introduction**

Evidence-based medicine has led to an extensive investigation and development of new therapies and programs to improve the care of the surgical patient, both in the postoperative and in the pre-operative period, known as enhanced recovery after surgery (ERAS) programs, "fast-track" programs or multimodal rehabilitation programs.

#### **1.1. Definition**

ERAS programs are evidenced-based protocols designed to standardize and optimize perioperative medical care in order to reduce surgical trauma, perioperative physiological stress and organ dysfunction related to elective procedures [1]. In addition, improved out‐ comes, decreased hospital length of stay and faster patient recovery to normal life are expected to be obtained. Other advantages of this philosophy are the reduction of clinical complications and the health costs together with and increase of patient satisfaction. A diagram with all the core principles of an ERAS program can be seen on Figure 1.

This approach could not be understood and implemented without the participation and commitment of a multidisciplinary team including surgeons, anesthesiologists, nursing staff and hospital administration. Moreover, it is important to make the patient and their families a partner in their care and give them join responsibility for the recovery.

These kinds of programs are not exclusive of a type of surgery or surgical procedure since they can be applied to different specialties (digestive, vascular, thoracic, etc.), different procedures

(colon resection, pancreatic procedures, etc.) or different approaches (laparoscopic or open procedures).

Surgeons learned over the years that surgery was an aggression and that the bigger the procedure was, the bigger the aggression emerged. For example, surgeons understood that patients undergoing major open colorectal surgery suffered prolonged rehabilitation with profound changes in endocrine, metabolic, neural and pulmonary function during the postoperative period. However, the scientific interest was not focused on how to control these

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489

In digestive surgery there were some inviolable principles that were transferred between generation of surgeons over a long period of time. Senior clinicians had strong principles and

**•** Preoperative prolonged fasting is necessary to empty the bowel, prevent intraoperative

**•** Mechanical bowel preparation is imperative in colorectal surgery to prevent intraoperative contamination and the passage of faeces through a suture line while it is healing. This

**•** Systematic use of nasogastric tubes is imperative to empty stomach and prevent its content

**•** Postoperative period is a "resting time" in which surgeons are expecting spontaneous

The majority of these paradigms were only based on clinical experience instead of the scientific evidence and, subsequently, they were passed down from masters to disciples, who preserved them as a non-questionable tradition. However, stepwise, published studies have dispelled these and other "truths" and the evidence has taught us that some of them may be unnecessary and maybe they can contribute to postoperative functional deterioration. For example, the return of bowel function is essential for postoperative recovery and this is influenced nega‐ tively by several perioperative factors such as preoperative fasting and bowel mechanical preparation, opioid analgesic, fluid overload, immobilization and postoperative prolonged fasting. Thus, several reviews and meta-analyses have focused in the absence of benefits in routinely mechanical bowel preparation, routine nasogastric decompression or prolonged

In 1990's, several revolutionary changes were seen: in the field of anesthesia the development of regional anesthetic techniques and new drugs to control pain and sedation; and in the field of surgery the widespread use of minimally invasive (laparoscopic) techniques. As a result, a great improvement in postoperative recovery and earlier return of patients to normal function were achieved. Moreover, it was thought that a minimally invasive approach, with reduced operative trauma, conducted to an earlier return of bowel function and allowed for early oral tolerance. The next step was the thinking that some of the improvements seen were simply

**•** Extended periods of bed rest are recommended to facilitate abdominal wall healing.

contamination and the early passage of bowel content through an anastomosis.

they were assumed as a dogma. We will highlight some of them:

passage could increase leaking and dehiscence risk or infections.

**•** Drains usage is essential in all kind of digestive procedures.

to come into the bowel protecting sutures.

due to overall changes in perioperative care attitudes.

patient recovery.

postoperative fasting [3].

changes.

In this chapter we will focus on ERAS protocols applied to colorectal surgery.

#### **1.3. Background**

Patients undergoing major open colorectal surgery traditionally undergo prolonged rehabili‐ tation and complication rates even as high as 30% have been reported after this procedure [2].

**Figure 1.** Core principles of an ERAS program applied to digestive tract surgery.

Surgeons learned over the years that surgery was an aggression and that the bigger the procedure was, the bigger the aggression emerged. For example, surgeons understood that patients undergoing major open colorectal surgery suffered prolonged rehabilitation with profound changes in endocrine, metabolic, neural and pulmonary function during the postoperative period. However, the scientific interest was not focused on how to control these changes.

In digestive surgery there were some inviolable principles that were transferred between generation of surgeons over a long period of time. Senior clinicians had strong principles and they were assumed as a dogma. We will highlight some of them:


(colon resection, pancreatic procedures, etc.) or different approaches (laparoscopic or open

Patients undergoing major open colorectal surgery traditionally undergo prolonged rehabili‐ tation and complication rates even as high as 30% have been reported after this procedure [2].

In this chapter we will focus on ERAS protocols applied to colorectal surgery.

**Figure 1.** Core principles of an ERAS program applied to digestive tract surgery.

procedures).

488 Colorectal Cancer - Surgery, Diagnostics and Treatment

**1.3. Background**


The majority of these paradigms were only based on clinical experience instead of the scientific evidence and, subsequently, they were passed down from masters to disciples, who preserved them as a non-questionable tradition. However, stepwise, published studies have dispelled these and other "truths" and the evidence has taught us that some of them may be unnecessary and maybe they can contribute to postoperative functional deterioration. For example, the return of bowel function is essential for postoperative recovery and this is influenced nega‐ tively by several perioperative factors such as preoperative fasting and bowel mechanical preparation, opioid analgesic, fluid overload, immobilization and postoperative prolonged fasting. Thus, several reviews and meta-analyses have focused in the absence of benefits in routinely mechanical bowel preparation, routine nasogastric decompression or prolonged postoperative fasting [3].

In 1990's, several revolutionary changes were seen: in the field of anesthesia the development of regional anesthetic techniques and new drugs to control pain and sedation; and in the field of surgery the widespread use of minimally invasive (laparoscopic) techniques. As a result, a great improvement in postoperative recovery and earlier return of patients to normal function were achieved. Moreover, it was thought that a minimally invasive approach, with reduced operative trauma, conducted to an earlier return of bowel function and allowed for early oral tolerance. The next step was the thinking that some of the improvements seen were simply due to overall changes in perioperative care attitudes.

In the late 1990´s, based on those findings, the "fast track" concept to major abdominal surgery was pioneered by Professor Henrik Kehlet and a solid doctrine concerning perioperative care was born. He was a researcher surgeon interested in perioperative medicine, from the Hvidovre University Hospital in Denmark. Kehlet and colleages were investigating in combined pain relief, early feeding and mobilization since 1995 [4], observing that no more complications were seen and that patients even could be discharged earlier [3]. The concept of a "multimodal" approach was first published in 1997 [4] and subsequently prospective studies appeared [5]. The aims of Kehlet´s study were to reduce postoperative morbidity and mortality and to promote a faster recovery through a multimodal approach, thus minimizing the impact of the factors that lead to surgical stress. On the other hand, in the study of Basse *et al* the multimodal rehabilitation program significantly reduced the postoperative hospital stay in high-risk patients undergoing colonic resection (two days compared to more than 10 days in some historical series) and it might also reduce postoperative ileus and cardiopulmo‐ nary complications [5].

The overall metabolic changes in the stress response involve protein and fat catabolism to provide energy. Protein from skeletal muscle and glycerol from fat breakdown are utilised in glucogenogenesis in the liver. In addition surgery induces hormonal, haematological and inmunological changes and activate the sympathetic nervous system (stimulated by hypoten‐ sion, hypoxaemia or metabolic acidosis, pain, anxiety and distress, autonomic and afferent nerves and directly hypothalamus) [10]. The initial stimulus for this response comes from cytokines, especially IL-6 and TNF, release by leucocytes and endotelial cells present at the site of injury and they are the principal mediators of the response in the acute-phase. Postoperative levels of these cytokines are correlated with the magnitude of the surgery and the presence of complications. On the other hand, leucocytes are key effector cells in the response to surgery, they mobilize quickly to devitalizated or injured tissue to begin repair and prevent secondary microbial invasion. A few minutes after the start of surgery an ACTH, vasopresine, cortisol, catecholamines, aldosterone and glucagon release occur pretending to provide to the disabled organism energy, to retain liquid and salt, and supporting the cardiovascular homeostasis [11].

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A randomized controlled trial has shown that Multimodal Rehabilitation programs attenuate the response to the surgical stress as it demonstrates a significant descent of IL-1, IL-6, TNF-

Summarizing, the stress response to surgery increase the levels of ACTH, cortisol, GH, IGF1, ADH and glucagon, reduce the insulin, mobilizes glycogen (by glycogenolysis and skeletal

**•** Exhaustion of energy supplies and loss of lean muscle mass, leading to weakness of both

The response to the surgical trauma is protective since his final target is the survival of the disabled organism. It depends on a delicate balance between pro-inflammatory and antiinflammatory mechanisms; nevertheless, it is known that it can be harmful when this balance is altered. Thus, if the pro-inflammatory component predominates, a Systemic Inflammatory Response Syndrome (SIRS) could be induced; on the other hand patients can suffer the effects derived from the inmunosupresion as infections or tumor progression if predominates anti-

muscle breakdown) and promotes formation of acute phase proteins and lipolysis.

This response also generates adverse effects; some of the most important are:

**•** Splanchnic vasoconstriction wich may impact intestinal anastomoses healing.

α and INF-gamma levels in the postoperative period.

peripheral and respiratory muscle if it is severe.

**•** Hypercoagulability (risk of Deep Vein Thrombosis).

**•** Impaired wound healing and increased risk of infections.

**•** Increased myocardial oxygen demand.

**•** Sodium and water retention.

inflammatory components.

**•** Hypoxaemia.

During the following decade published studies in this issue grew exponentially. Subsequently, cohort studies, controlled trials and several reviews and meta-analyses were published. It is important to highlight those from Wind [6], Goubas [7], and the meta-analyses directed by Cochrane Collaborative Group in 2011 that will be analyzed in the following chapter´s sections [8]. Moreover, an ERAS Society was officially founded in 2010 as a natural evolution of the ERAS Study Group. This group started its works in 2001 trying to change from tradition to best-practice because there was a great discrepancy between the existing practices and those which were already known to be best practice based on the existing literature. More informa‐ tion is provided in the official website http://www.erassociety.org/.

To summarize, we can conclude that published results and their meta-analyses have shown the benefits of this package of measures, so that evidence-based medicine supports the ERAS concept. Nevertheless, recent surveys have demonstrated slow adaptation and implementa‐ tion of the fast-track methodology. In this setting, it has been shown by Kehlet *et al* in an international multicenter study based on 1,082 patients who had undergone elective colonic operations that strategies that could contribute to improved recovery and reduce complica‐ tions were not been applied and that major improvements in outcomes and reduction of costs could be obtained applying ERAS methodology [9].

Little by little, ERAS implementation and application in the clinical setting continued growing in the following years until the present. Nowadays ERAS protocols, with little modifications to adapt them to each center´s functioning, are been applied in a great number of colorectal units worldwide. The information communicated in different conventions and published makes us think that ERAS has changed from a promising "published" issue to a real application in the clinical practice.

#### **1.4. The stress response to surgery**

Surgeons have shown interest in metabolic and endocrine response to the surgical trauma long time ago. Such interest has increased by the recognition that to modulate this response to the surgical aggression might reduce the postoperative morbidity and mortality.

The overall metabolic changes in the stress response involve protein and fat catabolism to provide energy. Protein from skeletal muscle and glycerol from fat breakdown are utilised in glucogenogenesis in the liver. In addition surgery induces hormonal, haematological and inmunological changes and activate the sympathetic nervous system (stimulated by hypoten‐ sion, hypoxaemia or metabolic acidosis, pain, anxiety and distress, autonomic and afferent nerves and directly hypothalamus) [10]. The initial stimulus for this response comes from cytokines, especially IL-6 and TNF, release by leucocytes and endotelial cells present at the site of injury and they are the principal mediators of the response in the acute-phase. Postoperative levels of these cytokines are correlated with the magnitude of the surgery and the presence of complications. On the other hand, leucocytes are key effector cells in the response to surgery, they mobilize quickly to devitalizated or injured tissue to begin repair and prevent secondary microbial invasion. A few minutes after the start of surgery an ACTH, vasopresine, cortisol, catecholamines, aldosterone and glucagon release occur pretending to provide to the disabled organism energy, to retain liquid and salt, and supporting the cardiovascular homeostasis [11].

A randomized controlled trial has shown that Multimodal Rehabilitation programs attenuate the response to the surgical stress as it demonstrates a significant descent of IL-1, IL-6, TNFα and INF-gamma levels in the postoperative period.

Summarizing, the stress response to surgery increase the levels of ACTH, cortisol, GH, IGF1, ADH and glucagon, reduce the insulin, mobilizes glycogen (by glycogenolysis and skeletal muscle breakdown) and promotes formation of acute phase proteins and lipolysis.

This response also generates adverse effects; some of the most important are:


In the late 1990´s, based on those findings, the "fast track" concept to major abdominal surgery was pioneered by Professor Henrik Kehlet and a solid doctrine concerning perioperative care was born. He was a researcher surgeon interested in perioperative medicine, from the Hvidovre University Hospital in Denmark. Kehlet and colleages were investigating in combined pain relief, early feeding and mobilization since 1995 [4], observing that no more complications were seen and that patients even could be discharged earlier [3]. The concept of a "multimodal" approach was first published in 1997 [4] and subsequently prospective studies appeared [5]. The aims of Kehlet´s study were to reduce postoperative morbidity and mortality and to promote a faster recovery through a multimodal approach, thus minimizing the impact of the factors that lead to surgical stress. On the other hand, in the study of Basse *et al* the multimodal rehabilitation program significantly reduced the postoperative hospital stay in high-risk patients undergoing colonic resection (two days compared to more than 10 days in some historical series) and it might also reduce postoperative ileus and cardiopulmo‐

During the following decade published studies in this issue grew exponentially. Subsequently, cohort studies, controlled trials and several reviews and meta-analyses were published. It is important to highlight those from Wind [6], Goubas [7], and the meta-analyses directed by Cochrane Collaborative Group in 2011 that will be analyzed in the following chapter´s sections [8]. Moreover, an ERAS Society was officially founded in 2010 as a natural evolution of the ERAS Study Group. This group started its works in 2001 trying to change from tradition to best-practice because there was a great discrepancy between the existing practices and those which were already known to be best practice based on the existing literature. More informa‐

To summarize, we can conclude that published results and their meta-analyses have shown the benefits of this package of measures, so that evidence-based medicine supports the ERAS concept. Nevertheless, recent surveys have demonstrated slow adaptation and implementa‐ tion of the fast-track methodology. In this setting, it has been shown by Kehlet *et al* in an international multicenter study based on 1,082 patients who had undergone elective colonic operations that strategies that could contribute to improved recovery and reduce complica‐ tions were not been applied and that major improvements in outcomes and reduction of costs

Little by little, ERAS implementation and application in the clinical setting continued growing in the following years until the present. Nowadays ERAS protocols, with little modifications to adapt them to each center´s functioning, are been applied in a great number of colorectal units worldwide. The information communicated in different conventions and published makes us think that ERAS has changed from a promising "published" issue to a real application

Surgeons have shown interest in metabolic and endocrine response to the surgical trauma long time ago. Such interest has increased by the recognition that to modulate this response to the

surgical aggression might reduce the postoperative morbidity and mortality.

tion is provided in the official website http://www.erassociety.org/.

could be obtained applying ERAS methodology [9].

nary complications [5].

490 Colorectal Cancer - Surgery, Diagnostics and Treatment

in the clinical practice.

**1.4. The stress response to surgery**


The response to the surgical trauma is protective since his final target is the survival of the disabled organism. It depends on a delicate balance between pro-inflammatory and antiinflammatory mechanisms; nevertheless, it is known that it can be harmful when this balance is altered. Thus, if the pro-inflammatory component predominates, a Systemic Inflammatory Response Syndrome (SIRS) could be induced; on the other hand patients can suffer the effects derived from the inmunosupresion as infections or tumor progression if predominates antiinflammatory components.

## **2. Aim and concerns**

The aims of ERAS programs are:


Pre-operative nutritional management: drinks and any new medication and nutritional

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493

Admission on the day of surgery: because the patient has been prepared for surgery in the pre-

**•** Fasting is required to reduce the risk of aspiration during a general anesthesia The duration of preoperative fasting should be two hours for liquids and six hours for solids (grade A

**•** Major surgery is associated with postoperative insulin-resistance. Non-diabetic patients should receive carbohydrate (CHO) loading pre-operatively because they increase glycerol deposits, reduce thirst, hunger and postoperative insulin resistance [14], reducing protein catabolism, postoperative ileus and loss of lean muscle mass. CHO has to be taken in the

Mechanical bowel preparation can cause dehydration and fluid and electrolyte abnormalities,

**•** Medication causing long-term sedation from midnight prior to surgery must not been used,

**•** Prophylaxis against thromboembolism with low-dose unfraccionated heparin or lowmolecular-weight heparin (grade A recommendation) and the use of elastic stockings or

**•** Antibiotic prophylaxis with single-dose antibiotic prophylaxis against both anaerobes and aerobes about one hour before surgery is recommended (grade A recommendation).

Changes in body temperature can lead to coagulopathy, adverse cardiac events, and decreased resistance to surgical wound infections. An upper-body forced-air heating cover should be

Mid-thoracic epidural analgesia and avoidance of fluid overload are recommended to prevent

particularly in elderly patients, increasing morbidity and post-operative ileus [16].

evening before surgery and 2 hours before anaesthetic induction [15].

in order to conserve the sleep pattern (grade A recommendation).

supplements should be given at this time.

**Pre-operative fasting and carbohydrate loading:**

*3.1.2. Pre-operative care*

recommendation) [13].

**Avoid mechanical bowel preparation:**

pneumatic compression are recommended.

used routinely (grade A recommendation).

post-operative ileus (grade A recommendation) [16], [17].

**Prevention of post-operative ileus:**

admission period.

**Medication:**

**3.2. Intraoperative**

**Normothermia:**


## **3. ERAS protocol components**

ERAS programs are composed of preoperative, intra-operative and postoperative strategies combined to form a multimodal pathway:

#### **3.1. Preoperative**

#### *3.1.1. Pre-admission*

Pre-operative optimization: it is focused on targeting areas to optimize patient comorbidities (previous or related to the presenting complaint) such as anemia, diabetic and blood pressure control, optimizing cardiovascular disease treatments, respiratory functioning,…. It is also imperative avoid smoking and alcohol consumption. Patient´s individualized Risk stratifica‐ tion is also important to make good patient information and treatment decision.

Information: It is shown that this information reduces the patient's anxiety and facilitates the compliance of the program [12].

Patients and their families should be very knowledgeable about the process. It is very impor‐ tant to make them a partner in the process and give them the responsibility for their recovery and they should be clearly informated about the perioperative care, normal course of the protocol, discharge criteria, possible complications and the outpatient follow-up after dis‐ charge. Targets like postoperative oral intake or early mobilization are given in this stage to the patient.

Patient education: including ostomy management and its appropiate localization for it.

Pre-operative nutritional management: drinks and any new medication and nutritional supplements should be given at this time.

#### *3.1.2. Pre-operative care*

**2. Aim and concerns**

The aims of ERAS programs are:

492 Colorectal Cancer - Surgery, Diagnostics and Treatment

and to avoid immobility.

as well as reduce protein cathabolism.

patients usually reach these criteria sooner.

**3. ERAS protocol components**

**3.1. Preoperative**

*3.1.1. Pre-admission*

the patient.

compliance of the program [12].

combined to form a multimodal pathway:

**•** To standardize and optimize perioperative medical care.

**•** To atenuate the stress response to surgery: metabolic, endocrine and inflamatory response

**•** Regarding hospital discharge, factors such as pain, lack of gastrointestinal function and immobility complications are the main delaying patient discharge after colorectal surgery. So ERAS objectives will be to promote pain control, to improve gastrointestinal function

**•** Despite the discharge criteria with ERAS programs are similar than in traditional care,

ERAS programs are composed of preoperative, intra-operative and postoperative strategies

Pre-operative optimization: it is focused on targeting areas to optimize patient comorbidities (previous or related to the presenting complaint) such as anemia, diabetic and blood pressure control, optimizing cardiovascular disease treatments, respiratory functioning,…. It is also imperative avoid smoking and alcohol consumption. Patient´s individualized Risk stratifica‐

Information: It is shown that this information reduces the patient's anxiety and facilitates the

Patients and their families should be very knowledgeable about the process. It is very impor‐ tant to make them a partner in the process and give them the responsibility for their recovery and they should be clearly informated about the perioperative care, normal course of the protocol, discharge criteria, possible complications and the outpatient follow-up after dis‐ charge. Targets like postoperative oral intake or early mobilization are given in this stage to

Patient education: including ostomy management and its appropiate localization for it.

tion is also important to make good patient information and treatment decision.

**•** To decrease hospital length stay and a faster patient recovery to normal life.

Admission on the day of surgery: because the patient has been prepared for surgery in the preadmission period.

#### **Pre-operative fasting and carbohydrate loading:**


#### **Avoid mechanical bowel preparation:**

Mechanical bowel preparation can cause dehydration and fluid and electrolyte abnormalities, particularly in elderly patients, increasing morbidity and post-operative ileus [16].

#### **Medication:**


#### **3.2. Intraoperative**

#### **Normothermia:**

Changes in body temperature can lead to coagulopathy, adverse cardiac events, and decreased resistance to surgical wound infections. An upper-body forced-air heating cover should be used routinely (grade A recommendation).

#### **Prevention of post-operative ileus:**

Mid-thoracic epidural analgesia and avoidance of fluid overload are recommended to prevent post-operative ileus (grade A recommendation) [16], [17].

### **Approach:**

The use of minimally invasive techniques, where possible is advisable. Laparoscopic approach is recommended if locally validated (grade A recommendation) [18]. It has been shown to reduce the length of hospital stay, initial wound complications and time to return of gastro‐ intestinal tract function in colorectal surgery. If an open procedure is required, transverse incisions should be made preferentially to reduce postoperative pain.

CI 0.26 to 0.71; P = 0.001) significantly reduced overall morbidity after colorectal resection compared with standard fluid amount and fluid therapy guided by conventional haemody‐ namic variables respectively. No significant differences were founded in mortality, cardio‐ pulmonary morbidity, wound infection, anastomotic failure, recovery of bowel function and

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495

They should be inserted only if ileus develops. They are associated with discomfort and a delay in oral intake. Nasogastric tubes should not be used routinely in the elective situations in

Drains are avoided, as there is no evidence of beneficial effect in reducing postoperative morbidity, mortality, or reduce the effect of anastomotic leakage [28],[29]. Short-term (24-hour) use of drains after low anterior resections may be advisable. They are not indicated following

The aim of their use is to reduce the dose of general anesthetic needed and the stress response to surgery. In order to reduce the release of stress hormones and post-operative insuline resistance it is very important start with the epidural analgesia before the surgery. (Grade A

Maintenance of hydration, avoiding overcharge and encouraging the discontinuation of intravenous fluid therapy as soon as possible and early commencement of oral intake,

Patients should receive continuous epidural mid-thoracic low-dose local anesthetic and opioid combinations (grade A recommendation) for approximately 48 hours following elective colonic surgery and approximately 96 hours following pelvic surgery. This provides postoperative analgesia and reduces postoperative ileus by blockade of the sympathetic nervous system. Low concentration local anesthetic mixtures reduce motor block and improve early mobilization. Intravenous analgesia is used with paracetamol and non-esteroid anti-inflam‐ matory drugs [30]. Intravenous opioids are avoided because of increase sedation, ileus and

It is very important a risk stratification of patients during surgery using the Apfel scoring system with prophylaxis given for moderate or high risk patients. Risk factors are: female sex, non-smokers, administration of opioids postoperatively, motion sickness or previous postop‐

postoperative period (grade A recommendation) [26],[27].

routine colonic resection above the peritoneal reflection.

hospital stay.

**Nasogastric tubes:**

**Surgical drains:**

**Epidural analgesia:**

recommendation).

**3.3. Postoperative**

including carbohydrate drinks.

respiratory complications.

**Nausea and vomiting:**

**Hydration:**

**Analgesia:**

#### **Peri-operative fluid management:**

Perioperative fluid management for fast-track protocols must be balanced between avoiding hypovolemia and excessive fluid administration. Overhydration has previously been common in the perioperative period, and comparisons of liberal and restrictive fluid regimes suggest that this may be detrimental.

Perioperative fluid overload can cause fluid retention and increase body weight; this is related with generalized edema (which can cause a descense in tissue oxygenation [19]), visceral edema (related with postoperative ileus), can impaire wound and anastomosis healing, can increase cardiorespiratory complications [20,21] and also thrombotic risk.

Intra-operative and post-operative fluid restriction in major colonic surgery with avoidance of hypovolaemia is safe (grade A recommendation) and reduce the time for return of gastro‐ intestinal tract function, improves healing, reduce length of hospital admission and avoid pulmonary dysfunction [21] and reduce overall postoperative complications by up to two thirds [22]. Early commencement of oral intake also allows reducing intravenous fluids sooner. Postoperative serious hypotension may best treated with vasopressors rather than large quantities of intravenous fluids.

No clear consensus exists regarding the optimal fluid (crystalloid or colloid), the fluid amount (liberal, restricted or supplemental) and the fluid administration (goal-directed fluid therapy by oesophageal Doppler-derived variables –such as stroke volume, the blood volume pumped with each beat- versus conventional haemodynamic variables) for fluid management after and during colectomy.

Fluid management can be then optimized using transesophageal monitoring of the cardiac stroke volume with goal-directed administration of fluid boluses. This methodology can improve outcome (patients recovered gut function significantly faster and suffered signifi‐ cantly less gastrointestinal and overall morbidity) in patients with significant medical comor‐ bidities allowing an earlier hospital discharge [23]. These results have been confirmed with posterior literature review that showed a reduced hospital stay, fewer complications and ICU admissions, less requirement for inotropes and faster return of normal gastro-intestinal function [24].

In the last years literature reviews and metaanalyses have been published trying to give light to these doubts: which fluid, how many and how to control the administration. We want to highlight the one from Rahbari *et al* [25]. Authors included nine randomized controlled trials, finding that restrictive fluid amount (OR 0.41 with 95% CI 0.22 to 0.77; P = 0.005) and goaldirected fluid therapy by means of oesophageal Doppler-derived variables (OR 0.43 with 955 CI 0.26 to 0.71; P = 0.001) significantly reduced overall morbidity after colorectal resection compared with standard fluid amount and fluid therapy guided by conventional haemody‐ namic variables respectively. No significant differences were founded in mortality, cardio‐ pulmonary morbidity, wound infection, anastomotic failure, recovery of bowel function and hospital stay.

#### **Nasogastric tubes:**

**Approach:**

**Peri-operative fluid management:**

494 Colorectal Cancer - Surgery, Diagnostics and Treatment

that this may be detrimental.

quantities of intravenous fluids.

during colectomy.

function [24].

The use of minimally invasive techniques, where possible is advisable. Laparoscopic approach is recommended if locally validated (grade A recommendation) [18]. It has been shown to reduce the length of hospital stay, initial wound complications and time to return of gastro‐ intestinal tract function in colorectal surgery. If an open procedure is required, transverse

Perioperative fluid management for fast-track protocols must be balanced between avoiding hypovolemia and excessive fluid administration. Overhydration has previously been common in the perioperative period, and comparisons of liberal and restrictive fluid regimes suggest

Perioperative fluid overload can cause fluid retention and increase body weight; this is related with generalized edema (which can cause a descense in tissue oxygenation [19]), visceral edema (related with postoperative ileus), can impaire wound and anastomosis healing, can

Intra-operative and post-operative fluid restriction in major colonic surgery with avoidance of hypovolaemia is safe (grade A recommendation) and reduce the time for return of gastro‐ intestinal tract function, improves healing, reduce length of hospital admission and avoid pulmonary dysfunction [21] and reduce overall postoperative complications by up to two thirds [22]. Early commencement of oral intake also allows reducing intravenous fluids sooner. Postoperative serious hypotension may best treated with vasopressors rather than large

No clear consensus exists regarding the optimal fluid (crystalloid or colloid), the fluid amount (liberal, restricted or supplemental) and the fluid administration (goal-directed fluid therapy by oesophageal Doppler-derived variables –such as stroke volume, the blood volume pumped with each beat- versus conventional haemodynamic variables) for fluid management after and

Fluid management can be then optimized using transesophageal monitoring of the cardiac stroke volume with goal-directed administration of fluid boluses. This methodology can improve outcome (patients recovered gut function significantly faster and suffered signifi‐ cantly less gastrointestinal and overall morbidity) in patients with significant medical comor‐ bidities allowing an earlier hospital discharge [23]. These results have been confirmed with posterior literature review that showed a reduced hospital stay, fewer complications and ICU admissions, less requirement for inotropes and faster return of normal gastro-intestinal

In the last years literature reviews and metaanalyses have been published trying to give light to these doubts: which fluid, how many and how to control the administration. We want to highlight the one from Rahbari *et al* [25]. Authors included nine randomized controlled trials, finding that restrictive fluid amount (OR 0.41 with 95% CI 0.22 to 0.77; P = 0.005) and goaldirected fluid therapy by means of oesophageal Doppler-derived variables (OR 0.43 with 955

incisions should be made preferentially to reduce postoperative pain.

increase cardiorespiratory complications [20,21] and also thrombotic risk.

They should be inserted only if ileus develops. They are associated with discomfort and a delay in oral intake. Nasogastric tubes should not be used routinely in the elective situations in postoperative period (grade A recommendation) [26],[27].

#### **Surgical drains:**

Drains are avoided, as there is no evidence of beneficial effect in reducing postoperative morbidity, mortality, or reduce the effect of anastomotic leakage [28],[29]. Short-term (24-hour) use of drains after low anterior resections may be advisable. They are not indicated following routine colonic resection above the peritoneal reflection.

#### **Epidural analgesia:**

The aim of their use is to reduce the dose of general anesthetic needed and the stress response to surgery. In order to reduce the release of stress hormones and post-operative insuline resistance it is very important start with the epidural analgesia before the surgery. (Grade A recommendation).

#### **3.3. Postoperative**

#### **Hydration:**

Maintenance of hydration, avoiding overcharge and encouraging the discontinuation of intravenous fluid therapy as soon as possible and early commencement of oral intake, including carbohydrate drinks.

#### **Analgesia:**

Patients should receive continuous epidural mid-thoracic low-dose local anesthetic and opioid combinations (grade A recommendation) for approximately 48 hours following elective colonic surgery and approximately 96 hours following pelvic surgery. This provides postoperative analgesia and reduces postoperative ileus by blockade of the sympathetic nervous system. Low concentration local anesthetic mixtures reduce motor block and improve early mobilization. Intravenous analgesia is used with paracetamol and non-esteroid anti-inflam‐ matory drugs [30]. Intravenous opioids are avoided because of increase sedation, ileus and respiratory complications.

#### **Nausea and vomiting:**

It is very important a risk stratification of patients during surgery using the Apfel scoring system with prophylaxis given for moderate or high risk patients. Risk factors are: female sex, non-smokers, administration of opioids postoperatively, motion sickness or previous postop‐ erative nause and vomitig [31]. Patients with two ore more risk factors should be treated. Dexamethasone or 5HT3 receptor antagonist, droperidol or metoclopramide near the end of surgery are recomended. It is preferred those medication that have a minimal post-operative hang-over and effects on gastrointesinal motility. Also short-acting anesthetic and analgesic agents should be used, avoiding long-lasting opiates where possible [32].

#### **Nutrition support:**

Early commencement of an oral intake (frequently in theater recovery) after surgery should be encouraged (grade A recommendation). Oral nutritional supplements should be prescribed (approximately 200 mL, energy dense, 2-3 times daily) from the day of surgery until normal food intake is achieved. These supplements can be continued beyond the return of normal intake if pre-operative nutritional status is poor. Early resumption of oral intake is associated with fewer wound infections and shorter hospital admissions as well.

#### **Early mobilization:**

Early mobilization should occur in accordance with pre-operative plan and is a key element of ERAS in colorectal surgery [10]. For patients to be out of bed for two hours on the day of surgery and six hours thereafter is recommended. The aim is to reduce muscle loss and improve respiratory function, reducing the risk of pneumonia, and maximizing oxygen delivery to tissues. This is also essential to reducing the risk of venous thromboembolism. The breathing exercises should be done, especially in patients with previous lung pathology and these exercises must be trained before surgery.

#### **Urinary catheter and drains:**

Urinary catheters and peritoneal drains should bre removed as soon as possible in order to reduce the incidence of urinary tract infection and because of early mobilization respectively

#### **Early discharge:**

At the end, early discharge, when the discharge criteria have been reached, is the goal of fasttrack along with the early recovery and return to normal activity.

**•** It is necessary a review of the literature and a carefully study of the hospital resources where

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**•** A systematic audit should be performed including length of stay, morbidity, mortality and hospital readmissions to allow direct comparison with other institutions and provide

**•** The program should be designed in agreement with consensus documents.

An example of an ERAS protocol in colorectal surgery can be seen on Table 1.

Optimization of the patient and education (including stoma) Preoperative studies (anesthetist and other if is required)

Hyperproteic supplement 3 times every day during the week before surgery

Pre-admission Indication for surgery, information and signed consent

the ERAS program will be implemented.

motivation for staff and patients.

**Figure 2.** Components of the ERAS protocols

Pre-operative Day before surgery

**PREOPERATIVE**

A summary of all of these commented components of the perioperative management can be seen on Figure 2.

## **4. From theory to practice — How to organize an ERAS program**


erative nause and vomitig [31]. Patients with two ore more risk factors should be treated. Dexamethasone or 5HT3 receptor antagonist, droperidol or metoclopramide near the end of surgery are recomended. It is preferred those medication that have a minimal post-operative hang-over and effects on gastrointesinal motility. Also short-acting anesthetic and analgesic

Early commencement of an oral intake (frequently in theater recovery) after surgery should be encouraged (grade A recommendation). Oral nutritional supplements should be prescribed (approximately 200 mL, energy dense, 2-3 times daily) from the day of surgery until normal food intake is achieved. These supplements can be continued beyond the return of normal intake if pre-operative nutritional status is poor. Early resumption of oral intake is associated

Early mobilization should occur in accordance with pre-operative plan and is a key element of ERAS in colorectal surgery [10]. For patients to be out of bed for two hours on the day of surgery and six hours thereafter is recommended. The aim is to reduce muscle loss and improve respiratory function, reducing the risk of pneumonia, and maximizing oxygen delivery to tissues. This is also essential to reducing the risk of venous thromboembolism. The breathing exercises should be done, especially in patients with previous lung pathology and

Urinary catheters and peritoneal drains should bre removed as soon as possible in order to reduce the incidence of urinary tract infection and because of early mobilization respectively

At the end, early discharge, when the discharge criteria have been reached, is the goal of fast-

A summary of all of these commented components of the perioperative management can be

**•** A well-educated multidisciplinary team will be needed composed by: surgeons, anesthesi‐ ologists and pain care specialists, nursing staff, physiotherapysts and occupational thera‐

**•** ERAS programs involve a selected number of individual interventions. It is necessary to implement all together, because only in this way they demonstrate a greater impact on

**4. From theory to practice — How to organize an ERAS program**

outcomes than when we implement them as individual interventions [1],[33].

agents should be used, avoiding long-lasting opiates where possible [32].

with fewer wound infections and shorter hospital admissions as well.

track along with the early recovery and return to normal activity.

these exercises must be trained before surgery.

**Urinary catheter and drains:**

pists and social workers

**Early discharge:**

seen on Figure 2.

**Nutrition support:**

496 Colorectal Cancer - Surgery, Diagnostics and Treatment

**Early mobilization:**

**Figure 2.** Components of the ERAS protocols


An example of an ERAS protocol in colorectal surgery can be seen on Table 1.



Liquid diet at least 2 L, including 600 mL of high protein/high calories

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Bland/normal diet including 600 mL of high protein/high calorie Verify if Discharge criteria have been reached by the patient

The goal of ERAS programs is an accelerated recovery and return to normal activity but it is not the only focus of the protocol [34]. Discharge criteria and time-based discharge depends

Patients and their families should feel comfortable with the discharge. In this setting they should know that they will be followed as outpatient and they could return to hospital if

Normal diet including 600 mL of high protein/high calorie Verify if Discharge criteria have been reached by the patiente

Out-patient visit after 10-14 daysRanitidine v.o. /8 h

Laxative /12h with MgO (2g / 24h) Heparine in order to protocol

Ranitidine t.d.s

Mobilisation on demand Remove epidural catheter

Postoperative day 2 See day 1 recommendations

Postoperative day 3 See day 2 recommendations

Follow-up Telephone monitoring for 48 h

**5. Discharge criteria**

required.

**Discharge criteria** Good mobilization

Adequate oral intake for liquids and solids

Patient feel comfortable with discharge

Patient know about possible complications and their detection

Gastrointestinal transit for gas Normal urinary function No wound problems Pain control No fever

**Table 1.** An ERAS protocol example in colorectal resections.

on the community support and possibility to follow-up.

Discharge criteria must be previously established (see Table 2):

**Table 2.** Discharge criteria most usually used in colorectal surgery ERAS programs.

#### **INTRAOPERATIVE**



**Table 1.** An ERAS protocol example in colorectal resections.

#### **5. Discharge criteria**

Ostomy location

expected

498 Colorectal Cancer - Surgery, Diagnostics and Treatment

Day of surgery

Surgeons Laparoscopy or transverse incisions

SpO2 > 95%

Day of surgery In seat for at least 2h in the evening

Postoperative day 1 Mobilization 6 h a day

**INTRAOPERATIVE**

**POSTOPERATIVE** Day of surgery (Recovery room)

Preoperative medication

Enemas (10 am- 10 pm) if laparoscopic approach is validated

Neomycin and Erythromycin 1g po at 1 pm- 2 pm- 9 pm

Prophylaxis for DVT at 6 pm (dose depends on the risk) Gabapentin 300 mg and ranitidine 150 mg at 10 pm

Carbohydrate loading 2 hours before surgery (400 mL) Antiseptic shower, shaved and elastic stockings


Maintenance Oxygen/air FiO2 0.6 – 0.8

Vasoconstrictive drugs if hypotension

Local anesthesia with levobupivacaine

Paracetamol 1 g/6h+/- metamizol 2g/8h

Paracetamol 1g/6h +/- metamizol 2g/8h

Nasal cannulae for SpO2 > 95%

Remove nasogastric tube at the end of surgery

Epidural analgesia according with protocol of anesthesia

Epidural analgesia according to protocol of anesthesia Metroclopramide 10 mg/8h and ondansetron 4 mg/8h

Epidural analgesia according to protocol of anesthesia

Fluids: 1.5 L Ringer lactate solution + 0.5 expander fluids x 24 hours

Suspend fluid e.v. if tolerated diet, maintaining heparine injection

Liquid diet 2 hours after surgery including 400 mL of Hyperproteic supplement

Anesthetist Normothermia: upper-body forced-air heating cover and liquid heater (37ºC) Mid-thoracic (T10) epidural analgesia with levobupivacaine

No mecanical bowel preparation, except if ileostomy or intraoperative colonoscopy is

Liquids on demand and carbohydrate loading during the evening (800 mL)


Avoid fluids overload maintaining 5cc/kg/h (Hartmann). Hb > 8.0 g/dL

Ondansetron 4 mg or droperidol 1.25 mg 30 minutes before the end Adittional dose of Augmentine 2 g if surgery takes more than 4h

Avoid surgical drains except short-term (24-hour) drains after low anterior resection

Mask with 4 l/m oxygen flow for 2h independent of saturation, after that nasal cannulae for

The goal of ERAS programs is an accelerated recovery and return to normal activity but it is not the only focus of the protocol [34]. Discharge criteria and time-based discharge depends on the community support and possibility to follow-up.

Patients and their families should feel comfortable with the discharge. In this setting they should know that they will be followed as outpatient and they could return to hospital if required.

Discharge criteria must be previously established (see Table 2):


**Table 2.** Discharge criteria most usually used in colorectal surgery ERAS programs.

## **6. Outcomes**

The expanding evidence-based medicine shows that ERAS program benefits not only all patients (including the elderly or potentially malnourished patients) but also the health service [35].

The success of this program depends on pre-operative setting of expectations including the concept of patients being partners in their care and taking part-ownership of post-operative

Best results are achieved when the whole multidisciplinary team believe and take part in the

The keys of ERAS are: patient information, preservation of gastrointestinal function, minimize

Early discharge is the goal of ERAS protocols and patients usually reach the discharge criteria

Although most of the studies tend to find a lower morbidity, there are no clear advantage in mortality and we think that more studies are needed to confirm the results and focalized in mortality and long-term results of ERAs methodology. We can conclude that at least there are no significant differences in mortality and morbidity with traditional care (ERAs methodology is not dangerous for patients and probably represents a big benefice) and ERAS are more cost-

, Jacobo Trebol López1

,

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501

and José Antonio Carmona Sáez1

program and individual interventions are implemented all together.

organ dysfunction, active pain control and to promote the patient´s autonomy.

, Fernando Gutiérrez Conde4

1 Department of General Surgery, Nuestra Señora de Sonsoles Hospital, Ávila, Spain

4 Department of General Surgery, University Hospital of Salamanca, Salamanca, Spain

[2] Kehlet H, Mogensen T. Hospital stay of 2 days after open sigmoidectomy with a mul‐

[3] Kehlet H. Multimodal approach to control postoperative pathophysiology and reha‐

2 Department of General Surgery, Santos Reyes Hospital, Burgos, Spain

[1] Kehlet H, Wilmore DW. Fast-track surgery. Br.J.Surg. 2005;92:3-4.

timodal rehabilitation programme. Br.J.Surg. 1999;86:227-230.

rehabilitation.

sooner than in traditional care.

effectiveness than traditional care.

Raúl Sánchez-Jiménez1\*, Alberto Blanco Álvarez2

\*Address all correspondence to: raulsj34@gmail.com

3 Physiotherapist, Cadiz University, Cádiz, Spain

bilitation. Br.J.Anaesth. 1997;78:606-617.

**Author details**

**References**

Antonio Sánchez Jiménez3

Patients accomplish surgery in the best condition. They have better management during and after operation and the best post-operative recovery.

Randomized trials and meta-analysis identified a significantly shorter length of stay and lower in-hospital postoperative complications (maybe secondary to the shorter length of hospital stay) [6].These advantages are mainly attributed to fluid restriction and epidural analgesia.

Other outcome improvements attributed to ERAS programs are shorter duration of postop‐ erative ileus [6], better oral intake, better pain control, less cardiopulmonary morbidity, better preservation of body mass and exercise performance [36], an improvement in grip strength (all of them suggesting an overall improvement in muscular function), earlier resumption of normal activities and a reduced need for daytime sleep [37].

Early discharge is the goal of Fast-Track protocols, and should not be offset by a higher rate of hospital readmission. However, the overall rate of readmission for patients managed with early discharge is comparable to patients with a longer median length of hospital stay [34].Regarding the economical issues, it must be pointed out that the increased cost in laparoscopic approach must be balanced with savings from a shorter length of hospital stay, lower morbidity and no differences in readmission rates.

## **7. The research initiatives**

The confirmation of the initial results should prompt the ERAS methodology embracing in other kind of major surgical procedures as gastric or pancreatic procedures.

The possibility of applying some components of fast-track programs in patients undergoing emergency colorectal surgery must be also evaluated, especially in order to reduce preopera‐ tive stress.

New drugs like Ketamina, Lidocaina, Alvimopan could have an important role in the future because of their properties in analgesia and in gastrointestinal resumption.

## **8. Summary and recommendations**

ERAS programs for colorectal surgery were developed to reduce inpatient hospital costs through improvements in preoperative, intra-operative and postoperative strategies.

The success of this program depends on pre-operative setting of expectations including the concept of patients being partners in their care and taking part-ownership of post-operative rehabilitation.

Best results are achieved when the whole multidisciplinary team believe and take part in the program and individual interventions are implemented all together.

The keys of ERAS are: patient information, preservation of gastrointestinal function, minimize organ dysfunction, active pain control and to promote the patient´s autonomy.

Early discharge is the goal of ERAS protocols and patients usually reach the discharge criteria sooner than in traditional care.

Although most of the studies tend to find a lower morbidity, there are no clear advantage in mortality and we think that more studies are needed to confirm the results and focalized in mortality and long-term results of ERAs methodology. We can conclude that at least there are no significant differences in mortality and morbidity with traditional care (ERAs methodology is not dangerous for patients and probably represents a big benefice) and ERAS are more costeffectiveness than traditional care.

## **Author details**

**6. Outcomes**

500 Colorectal Cancer - Surgery, Diagnostics and Treatment

service [35].

The expanding evidence-based medicine shows that ERAS program benefits not only all patients (including the elderly or potentially malnourished patients) but also the health

Patients accomplish surgery in the best condition. They have better management during and

Randomized trials and meta-analysis identified a significantly shorter length of stay and lower in-hospital postoperative complications (maybe secondary to the shorter length of hospital stay) [6].These advantages are mainly attributed to fluid restriction and epidural analgesia.

Other outcome improvements attributed to ERAS programs are shorter duration of postop‐ erative ileus [6], better oral intake, better pain control, less cardiopulmonary morbidity, better preservation of body mass and exercise performance [36], an improvement in grip strength (all of them suggesting an overall improvement in muscular function), earlier resumption of

Early discharge is the goal of Fast-Track protocols, and should not be offset by a higher rate of hospital readmission. However, the overall rate of readmission for patients managed with early discharge is comparable to patients with a longer median length of hospital stay [34].Regarding the economical issues, it must be pointed out that the increased cost in laparoscopic approach must be balanced with savings from a shorter length of hospital stay,

The confirmation of the initial results should prompt the ERAS methodology embracing in

The possibility of applying some components of fast-track programs in patients undergoing emergency colorectal surgery must be also evaluated, especially in order to reduce preopera‐

New drugs like Ketamina, Lidocaina, Alvimopan could have an important role in the future

ERAS programs for colorectal surgery were developed to reduce inpatient hospital costs

through improvements in preoperative, intra-operative and postoperative strategies.

other kind of major surgical procedures as gastric or pancreatic procedures.

because of their properties in analgesia and in gastrointestinal resumption.

after operation and the best post-operative recovery.

normal activities and a reduced need for daytime sleep [37].

lower morbidity and no differences in readmission rates.

**7. The research initiatives**

**8. Summary and recommendations**

tive stress.

Raúl Sánchez-Jiménez1\*, Alberto Blanco Álvarez2 , Jacobo Trebol López1 , Antonio Sánchez Jiménez3 , Fernando Gutiérrez Conde4 and José Antonio Carmona Sáez1

\*Address all correspondence to: raulsj34@gmail.com


3 Physiotherapist, Cadiz University, Cádiz, Spain

4 Department of General Surgery, University Hospital of Salamanca, Salamanca, Spain

## **References**


[4] Basse L, Hjort JD, Billesbolle P, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection. Ann.Surg. 2000;232:51-57.

[18] Lobo DN, Bostock KA, Neal KR et al. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled tri‐

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[19] Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis of selective ver‐ sus routine nasogastric decompression after elective laparotomy. Ann.Surg.

[20] Petrowsky H, Demartines N, Rousson V, Clavien PA. Evidence-based value of pro‐ phylactic drainage in gastrointestinal surgery: a systematic review and meta-analy‐

[21] Urbach DR, Kennedy ED, Cohen MM. Colon and rectal anastomoses do not require routine drainage: a systematic review and meta-analysis. Ann.Surg. 1999;229:174-180.

[23] Tiippana EM, Hamunen K, Kontinen VK, Kalso E. Do surgical patients benefit from perioperative gabapentin/pregabalin? A systematic review of efficacy and safety. An‐

[25] Leslie JB, Viscusi ER, Pergolizzi JV, Jr., Panchal SJ. Anesthetic Routines: The Anesthe‐ siologist's Role in GI Recovery and Postoperative Ileus. Adv.Prev.Med.

[26] Wilmore DW, Kehlet H. Management of patients in fast track surgery. BMJ

[27] Hendren S, Morris AM, Zhang W, Dimick J. Early discharge and hospital readmis‐

[28] Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of

[29] Basse L, Madsen JL, Kehlet H. Normal gastrointestinal transit after colonic resection using epidural analgesia, enforced oral nutrition and laxative. Br.J.Surg.

[30] Jakobsen DH, Sonne E, Andreasen J, Kehlet H. Convalescence after colonic surgery

randomized controlled trials in colorectal surgery. Surgery 2011;149:830-840.

sion after colectomy for cancer. Dis.Colon Rectum 2011;54:1362-1367.

with fast-track vs conventional care. Colorectal Dis. 2006;8:683-687.

[24] Kehlet H, Holte K. Review of postoperative ileus. Am.J.Surg. 2001;182:3S-10S.

[22] Francom M. Stop drug price increases. Am.Pharm. 1991;NS31:6, 8.

al. Lancet 2002;359:1812-1818.

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[4] Basse L, Hjort JD, Billesbolle P, Werner M, Kehlet H. A clinical pathway to accelerate

[5] Wind J, Polle SW, Fung Kon Jin PH et al. Systematic review of enhanced recovery

[6] Gouvas N, Tan E, Windsor A, Xynos E, Tekkis PP. Fast-track vs standard care in col‐ orectal surgery: a meta-analysis update. Int.J.Colorectal Dis. 2009;24:1119-1131.

[7] Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane.Database.Syst.Rev.

[8] Kehlet H, Buchler MW, Beart RW, Jr., Billingham RP, Williamson R. Care after colon‐ ic operation--is it evidence-based? Results from a multinational survey in Europe and

[9] Zutshi M, Delaney CP, Senagore AJ, Fazio VW. Shorter hospital stay associated with fastrack postoperative care pathways and laparoscopic intestinal resection are not as‐

[10] Desborough JP. The stress response to trauma and surgery. Br.J.Anaesth.

[11] Carli F, Charlebois P, Baldini G, Cachero O, Stein B. An integrated multidisciplinary approach to implementation of a fast-track program for laparoscopic colorectal sur‐

[12] Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology 2011;114:495-511.

[13] Soop M, Carlson GL, Hopkinson J et al. Randomized clinical trial of the effects of im‐ mediate enteral nutrition on metabolic responses to major colorectal surgery in an

[14] Mathur S, Plank LD, McCall JL et al. Randomized controlled trial of preoperative or‐ al carbohydrate treatment in major abdominal surgery. Br.J.Surg. 2010;97:485-494. [15] Guenaga KK, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective

[16] Kehlet H. Postoperative ileus--an update on preventive techniques.

[17] Vlug MS, Wind J, Hollmann MW et al. Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann.Surg.

enhanced recovery protocol. Br.J.Surg. 2004;91:1138-1145.

Nat.Clin.Pract.Gastroenterol.Hepatol. 2008;5:552-558.

colorectal surgery. Cochrane.Database.Syst.Rev. 2009CD001544.

sociated with increased physical activity. Colorectal Dis. 2004;6:477-480.

recovery after colonic resection. Ann.Surg. 2000;232:51-57.

programmes in colonic surgery. Br.J.Surg. 2006;93:800-809.

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2000;85:109-117.

2011;254:868-875.


**Chapter 20**

**Psychosocial Care for**

Hitoshi Okamura

**1. Introduction**

such skills.

http://dx.doi.org/10.5772/57140

**Patients with Colorectal Cancer**

Additional information is available at the end of the chapter

care providers in cancer care settings should know.

As medical care based on information disclosure has been promoted, the concept of informed consent has also come to be understood in cancer care, and its faithful practice is now required. However, reactions ranging from ordinary psychological reactions (such as discouragement and feelings of isolation, alienation, despair, etc.) to psychological changes requiring the attention of a specialist (i.e., depression) are sometimes seen when information is disclosed, especially after conveying bad news, and healthcare providers must constantly keep the psychological states of their patients in mind. In this chapter, I will first describe the usual psychological reactions that cancer patients exhibit after the disclosure of cancer-related information. Additionally, I will discuss general matters to keep in mind when delivering bad news to cancer patients. Then, I will summarize the diagno‐ sis and management of psychological distress requiring psychiatric attention that health‐

In addition, healthcare providers are expected to strive for good communication with the patient and the patient's family during the process of conveying bad news about a patient's condition and obtaining informed consent. In reality, however, training in communication skills and support skills is only rarely available, and as a result, many healthcare provid‐ ers experience stress as a result of having been unable to acquire such skills adequately. With this background in mind, I will describe the need for communication skills in cancer care and review recent literature regarding the effectiveness of training designed to improve

> © 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **Chapter 20**

## **Psychosocial Care for Patients with Colorectal Cancer**

Hitoshi Okamura

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/57140

## **1. Introduction**

As medical care based on information disclosure has been promoted, the concept of informed consent has also come to be understood in cancer care, and its faithful practice is now required. However, reactions ranging from ordinary psychological reactions (such as discouragement and feelings of isolation, alienation, despair, etc.) to psychological changes requiring the attention of a specialist (i.e., depression) are sometimes seen when information is disclosed, especially after conveying bad news, and healthcare providers must constantly keep the psychological states of their patients in mind. In this chapter, I will first describe the usual psychological reactions that cancer patients exhibit after the disclosure of cancer-related information. Additionally, I will discuss general matters to keep in mind when delivering bad news to cancer patients. Then, I will summarize the diagno‐ sis and management of psychological distress requiring psychiatric attention that health‐ care providers in cancer care settings should know.

In addition, healthcare providers are expected to strive for good communication with the patient and the patient's family during the process of conveying bad news about a patient's condition and obtaining informed consent. In reality, however, training in communication skills and support skills is only rarely available, and as a result, many healthcare provid‐ ers experience stress as a result of having been unable to acquire such skills adequately. With this background in mind, I will describe the need for communication skills in cancer care and review recent literature regarding the effectiveness of training designed to improve such skills.

© 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **2. Typical psychological reactions to information disclosure (especially bad news) (Table 1)**

that, "I have to go about my daily life living with my cancer," although it may be difficult to go about their lives with the same feeling as when they were completely healthy, it does not create a very severe obstacle to their everyday lives, and they are able to return to a living

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507

It is important to have a good understanding of the "typical" psychological reactions described

**3. General matters to keep in mind when delivering bad news to cancer**

**a.** The bad news should first be discussed with the patients themselves whenever possible. **b.** The same physician should take charge of the patient from the initial contact until the definitive treatment whenever possible. This allows for true informed consent, during which the patient can calmly decide among several choices of treatment modalities. If a situation arises where a change in the physician-in-charge is necessary, care should be

**c.** The location for discussing the bad news must be carefully chosen, providing an envi‐ ronment of privacy where the patients can fully express their feelings, as necessary. On no account should the bad news be communicated via the telephone or while passing in a corridor or in any public place. It was reported that 55% of patients who were told the news by telephone expressed negative feelings [2]. Patients and their families who are given bad news in an inconsiderate manner may never forget the thoughtlessness of the

**d.** From the initial interview, physicians should try to tell the truth consistently and should provide as much information as they have available at the time. Bad news based on

**e.** Although an accurate explanation is necessary, the patient should not be bombarded with facts with no consideration given to the patient's state. Physicians should be prepared to explain facts as clearly and as simply as necessary. Patients should not be expected to cope

**f.** Patients are sometimes told, "You have advanced cancer and there is nothing I can do. There is no effective treatment in your case." Such cruel attitudes presented by the physician causes a loss of hope, anger, resignation and a sense of alienation in patients. Physicians should recognize that they can generate either hope or despair in patients by their verbal expressions or attitude. Physicians should present other positive features, including supportive care, instead of abandoning a patient with such a statement. **g.** Breaking bad news is commonly performed in an outpatient clinic. An adequate amount of time to provide an explanation and subsequent consideration is necessary. When

pattern that is almost the same as before.

taken not to destroy patient rapport.

with everything by themselves.

unconfirmed information should not be delivered.

above that cancer patients exhibit.

**patients**

**1.** Basic principles

physician.

Bad news must be conveyed more often than good news when disclosing information during the clinical course of cancer. Here, the typical psychological reactions displayed by patients after being informed of such bad news will be explained by providing examples of reactions after having been informed of a diagnosis of cancer. First, the initial few days are characterized by not being ready to believe or by temporarily denying what they have been told, saying,: "That can't be…," or by a sense of despair, saying,: "Oh, I've got cancer…." Later, a time is reached when they sometimes say,: "My mind went blank, and it was as though it hadn't happened to me," or "I don't clearly remember what happened after I was told I had cancer. I don't remember how I got home." Thus, it is important for attending physicians to recognize that patients may not clearly remember any subsequent explanations after they have been told that they have cancer, and that even if they describe tests and treatment in great detail, the patients may not understand the explanations adequately.

A. First phase: period of early reaction / within a few days

Patients do not believe the information or temporarily deny the facts. Some patients retrospectively describe this period as, 'My mind ceased to function as if these things were not happening to me'. Others experience despair, i.e. 'I was told what I feared'.

B. Second phase: period of distress / after 1–2 weeks

Patients repeatedly develop symptoms such as anxiety, depression, insomnia, appetite loss or decreased concentration. Owing to marked anxiety and decreased concentration, patients repeatedly ask the same questions.

C. Third phase: period of adaptation / after 2 weeks–1 month, sometimes 3 months Patients face reality and begin to or try to adapt to the new situation.

**Table 1.** Psychological reactions to being given a bad news

Then, after a little while, a time comes when symptoms such as a sinking feeling, anxiety, feelings of isolation from their surroundings, difficulty sleeping, or a loss of appetite might occur repeatedly. Symptoms in the form of getting excited or upset over petty matters are also sometimes seen. There are also times when the patient's behavior may take the form of repeatedly asking the same question because patients are very anxious and their ability to concentrate has declined. As a result of these conditions, patients sometimes experience a certain degree of interference with their daily lives, because the things that they were usual‐ ly able to do have become troublesome or take longer to complete.

After 2 weeks have gone by, however, patients gradually begin to face their real problems and become able to adapt to their new reality. More specifically, they begin to gather information, saying, "There's nothing I can do about having been diagnosed with cancer. From here on, I'm going to think about how best to make things better," or they become capable of an optimistic outlook, saying, "My cancer may get better." Moreover, because they always have the feeling that, "I have to go about my daily life living with my cancer," although it may be difficult to go about their lives with the same feeling as when they were completely healthy, it does not create a very severe obstacle to their everyday lives, and they are able to return to a living pattern that is almost the same as before.

It is important to have a good understanding of the "typical" psychological reactions described above that cancer patients exhibit.

## **3. General matters to keep in mind when delivering bad news to cancer patients**

**1.** Basic principles

**2. Typical psychological reactions to information disclosure (especially bad**

Bad news must be conveyed more often than good news when disclosing information during the clinical course of cancer. Here, the typical psychological reactions displayed by patients after being informed of such bad news will be explained by providing examples of reactions after having been informed of a diagnosis of cancer. First, the initial few days are characterized by not being ready to believe or by temporarily denying what they have been told, saying,: "That can't be…," or by a sense of despair, saying,: "Oh, I've got cancer…." Later, a time is reached when they sometimes say,: "My mind went blank, and it was as though it hadn't happened to me," or "I don't clearly remember what happened after I was told I had cancer. I don't remember how I got home." Thus, it is important for attending physicians to recognize that patients may not clearly remember any subsequent explanations after they have been told that they have cancer, and that even if they describe tests and treatment in great detail, the

Patients do not believe the information or temporarily deny the facts. Some patients retrospectively describe this period as, 'My mind ceased to function as if these things were not happening to me'. Others experience despair, i.e. 'I

concentration. Owing to marked anxiety and decreased concentration, patients repeatedly ask the same questions.

Then, after a little while, a time comes when symptoms such as a sinking feeling, anxiety, feelings of isolation from their surroundings, difficulty sleeping, or a loss of appetite might occur repeatedly. Symptoms in the form of getting excited or upset over petty matters are also sometimes seen. There are also times when the patient's behavior may take the form of repeatedly asking the same question because patients are very anxious and their ability to concentrate has declined. As a result of these conditions, patients sometimes experience a certain degree of interference with their daily lives, because the things that they were usual‐

After 2 weeks have gone by, however, patients gradually begin to face their real problems and become able to adapt to their new reality. More specifically, they begin to gather information, saying, "There's nothing I can do about having been diagnosed with cancer. From here on, I'm going to think about how best to make things better," or they become capable of an optimistic outlook, saying, "My cancer may get better." Moreover, because they always have the feeling

Patients repeatedly develop symptoms such as anxiety, depression, insomnia, appetite loss or decreased

C. Third phase: period of adaptation / after 2 weeks–1 month, sometimes 3 months

ly able to do have become troublesome or take longer to complete.

Patients face reality and begin to or try to adapt to the new situation.

**Table 1.** Psychological reactions to being given a bad news

patients may not understand the explanations adequately.

A. First phase: period of early reaction / within a few days

B. Second phase: period of distress / after 1–2 weeks

**news) (Table 1)**

506 Colorectal Cancer - Surgery, Diagnostics and Treatment

was told what I feared'.


patients are very anxious, the physician-in-charge should provide a consultation with a psychiatrist. Options such as talking to patients on another occasion after completing all their duties at the outpatient clinic or offering encouragement by talking again on the telephone on the day that the bad news has been divulged can sometimes be very effective.

problems based on the DSM-III (The DSM-III is a set of comprehensive diagnostic criteria for all mental disorders that was drawn up by the American Psychiatric Association in 1980 and is widely used throughout the world in prevalence surveys, etc. The revised DSM-III-R was published in 1987, the DSM-IV in 1994, and the DSM-IV-TR in 2000). They reported that 32% of the 215 subjects met the diagnostic criteria for adjustment disorders, 6% for depression, and 4% for delirium. These 3 psychological manifestations appear to be characteristic of the psychological distress experienced by cancer patients who require psychiatric attention. Moreover, because all these psychological manifestations reduce patients' quality of life

The incidence of adjustment disorders, depression, or delirium has not been previously assessed in colorectal cancer patients. However, some reports have described the prevalence of psychological distress using various symptom rating scales. These reports are summarized in Table 2 [5-13]. The reports suggest that the prevalence of psychological distress in colorectal cancer patients is 7% - 44%. Zabora et al. [14] assessed the prevalence of psychological distress among a large sample of cancer patients and variations in distress among 14 cancer diagnoses; the overall prevalence of distress in this sample was 35.1% (colorectal cancer: 31.6%), and a

**Subjects Outcome variables Major results**

Over the 5-year trajectory, the prevalence of high overall distress ranged between 44% and 32%.

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Patients who received only surgery, as treatment, had lower levels of depression, anxiety and traumatic stress symptoms when compared with patients who received surgery and chemotherapy or surgery plus

The prevalence of anxiety and depression were determined to be 10% and 7%, respectively.

Paranoid ideation, psychoticism, interpersonal sensitivity, anxiety and depressive symptoms increased significantly over the one-year

period of the study.

radiotherapy.

Psychological distress: Brief Symptom

at six time points from 5 months to 5

during the period of 12 months after

Anxiety and depression: Psychosocial

Psychological distress: Symptom Distress

at baseline and one year after the initial

Screen for Cancer (PSSCAN) at the first visit to a clinic

Checklist (SCL-90-R)

assessment

Anxiety and depression: Hospital Anxiety and Depression Scale (HADS) Traumatic stress: Impact of Events Scale

Inventory-18 (BSI-18)

years post-diagnosis

Revised (IES-R)

treatment

(QOL), their proper diagnosis and treatment is needed.

1966 colorectal cancer survivors

114 colorectal cancer patients who received treatments

252 colorectal cancer patients referred to an outpatient clinic

144 early nonmetastatic colorectal cancer patients

**Author, Journal (year) [Reference No.]**

Dunn et al, *Psychooncology* (2012) [5]

Graa Pereira et

*Eur J Oncol Nurs* (2012) [6]

Daudt et al, *Suppor*t Care Cancer (2012)

Hyphantis et al, *J Psychosom Res* (2011) [8]

[7]

al,

greater patient burden was associated with similar rates of distress.


Derogatis et al. [4] conducted interviews with 215 inpatients and outpatients at three leading cancer centers in the eastern United States, and investigated the prevalence of psychological problems based on the DSM-III (The DSM-III is a set of comprehensive diagnostic criteria for all mental disorders that was drawn up by the American Psychiatric Association in 1980 and is widely used throughout the world in prevalence surveys, etc. The revised DSM-III-R was published in 1987, the DSM-IV in 1994, and the DSM-IV-TR in 2000). They reported that 32% of the 215 subjects met the diagnostic criteria for adjustment disorders, 6% for depression, and 4% for delirium. These 3 psychological manifestations appear to be characteristic of the psychological distress experienced by cancer patients who require psychiatric attention. Moreover, because all these psychological manifestations reduce patients' quality of life (QOL), their proper diagnosis and treatment is needed.

patients are very anxious, the physician-in-charge should provide a consultation with a psychiatrist. Options such as talking to patients on another occasion after completing all their duties at the outpatient clinic or offering encouragement by talking again on the telephone on the day that the bad news has been divulged can sometimes be very effective.

**h.** Patients may show reservation towards physicians and sometimes fear them. Therefore, some patients cannot express their feelings when they are given bad news or cannot ask physicians questions, believing that they should do what the physician has told them. However, some patients are able to be more frank when talking to nurses and may ask them questions about the news. Therefore, it is important for physicians to hear the patient's true feelings and complaints through nurses. Cooperation between physicians

**i.** The physician should not hurry to explain all the details on one occasion. Several inter‐ views with each patient are recommended to discuss the bad news in a step-by-step

**j.** The physician should put himself or herself in the patient's place and should not judge

**a.** In principle, family members should not be told the bad news before the patient has been told. Families who want the patient to be ignorant of the news may be worried that "… the patient may commit suicide because of fears or shock." However, such a risk is much lower than generally believed [3], though this risk should always be taken into consider‐

**b.** When a patient is referred to our hospital and only the family has been told the bad news at another hospital and the family strongly opposes telling the patient the truth, the family should be repeatedly encouraged to change their minds, taking as much time as necessary. In such cases, it is important not to blame the initial physicians for their old-fashioned approach, since the rapport between the patient and the physicians may be impaired. **c.** Families play a very important role in cancer treatment. When the bad news is told definitively, the explanation should ideally be given to the patient and family together. Although the patient takes priority over the family, it is very important to inform the

**d.** Families sometimes become more agitated than patients and cannot remember or understand the explanation accurately Therefore, physicians should not take it for granted that "…families will be alright when receiving bad news, because they are not patients." When necessary, families should also be supported. It is often helpful for the physician-

Derogatis et al. [4] conducted interviews with 215 inpatients and outpatients at three leading cancer centers in the eastern United States, and investigated the prevalence of psychological

and nurses is very important in this situation.

the patient's reactions prematurely.

508 Colorectal Cancer - Surgery, Diagnostics and Treatment

**2.** Approaches to speaking with family members

family of the patient's state as accurately as possible.

in-charge to ask a psychiatrist for advice.

**3.** Psychological distress requiring psychiatric attention

manner.

ation.

The incidence of adjustment disorders, depression, or delirium has not been previously assessed in colorectal cancer patients. However, some reports have described the prevalence of psychological distress using various symptom rating scales. These reports are summarized in Table 2 [5-13]. The reports suggest that the prevalence of psychological distress in colorectal cancer patients is 7% - 44%. Zabora et al. [14] assessed the prevalence of psychological distress among a large sample of cancer patients and variations in distress among 14 cancer diagnoses; the overall prevalence of distress in this sample was 35.1% (colorectal cancer: 31.6%), and a greater patient burden was associated with similar rates of distress.



**1.** Adjustment disorders

of anxiety or depression.

by the healthcare provider.

would be difficult to accept as specific mental disorders.

Adjustment disorders are the most common psychological manifestation exhibited by cancer patients, but few studies or reports have examined adjustment disorders alone. Problems with the diagnostic criteria for adjustment disorders themselves are likely to be one of the reasons for the lack of studies on this topic. The diagnostic criteria in the DSM-IV-TR state that adjustment disorders are "reactions such as anxiety and depression or behavior disorders that occur in association with psychosocial stress." The diagnosis of adjustment disorders is made when the degree of the reaction is stronger than expected or when symptoms interfere with social functions from everyday life to social activities, and such disorders are said to be a continuous condition, without any strict division from normal reactions. Thus, the criteria are vague, and the term "adjustment disorders" is used as a "wastebasket diagnosis" when there is a mood disorder but other diagnoses, including depression, do not apply. Nevertheless, the term has the advantage of being able to include a variety of psychological manifestations that

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Inadequate pain control can be listed as a primary cause of adjustment disorders. According to a study by Derogatis et al. [1], a higher percentage of cancer patients who met the diagnostic criteria for adjustment disorders had severe pain, compared with cancer patients who did not meet the criteria. Anxiety, depression, and agitation are known to readily develop when pain of unknown cause persists [15]. Clearly, understanding patients' pain, which is a typical symptom that requires symptomatic relief, and adequately controlling such pain seems to be also useful for relieving psychological distress. Moreover, feelings of difficulty breathing [16] or malaise [17], which (similar to pain) often occur in colorectal cancer patients, can have an impact on patient QOL and can be difficult to treat, and their presence appears to be a cause

These adjustment disorders should be evaluated and properly managed, but few patients are actually diagnosed correctly and treated properly [18]. One reason for this situation appears to be that healthcare providers often miss psychological manifestations. Although the issue of physicians and nurses who are not specialists in psychiatric care overlooking mild depression and anxiety symptoms occurring during the course of cancer is, to some extent, unavoidable, there seems to be a need for education regarding the diagnosis and treatment of adjustment disorders, which are the most common psychological manifestations of cancer patients.

Psychotropic drugs, such as anxiolytic agents, hypnotics, and, depending on the circumstan‐ ces, antidepressants, are often used for treatment, but it is important to make an effort to identify the cause of the adjustment disorders described above by sufficiently listening to what the patient has to say, and then eliminating the cause. To accomplish this task, supportive psychiatric care in which caregivers encourage patients to express how they are really feeling at the present time (especially feelings of fear and anxiety), that supports and empathizes with the patients, and that does not provide unrealistic information but provides assurance within the realm of reality is said to be effective. In other words, supportive psychiatric care can become a valid treatment only when the patients feel that their present suffering is understood

**Table 2.** A summary of psychological distress in colorectal cancer patients

Below, the special features of each of these psychological manifestations are summarized.

#### **1.** Adjustment disorders

**Author, Journal (year) [Reference No.]**

> 99 colorectal cancer patients

510 Colorectal Cancer - Surgery, Diagnostics and Treatment

37 colorectal cancer patients

110 colorectal cancer patients undergoing chemotherapy

1822 colorectal cancer patients

98 advanced colorectal cancer patients during chemotherapy

**Table 2.** A summary of psychological distress in colorectal cancer patients

Patel et al, *J Affect Disord* (2011) [9]

Medeiros et al, *J Gastrointest Cancer* (2010)

Alacacioglu et al, *Support Care Cancer* (2012)

[10]

[11]

[12]

Lynch et al, *Cancer* (2008)

Pugliese et al, *Health Qual Life Outcomes* (2006)

[13]

**Subjects Outcome variables Major results**

Seventeen patients (17%) were diagnosed with a current mood or anxiety disorder, 11 (11%) met criteria for a depressive disorder and 7 (7%) with a primary anxiety disorder, and one patient had a secondary diagnosis of generalized

Mild or moderate depression was diagnosed in 31.6% of the CHG patients in the first evaluation and in 38.6% at the second one. There was a higher number of patients with moderate state or trait anxiety in the CHG when compared to the CG in

The mean Beck depression scores

11.2±9.0 (range 0–44) and the mean STAI scores were 41.9±8.8 (range 22–71). 23.6% were determined as

psychological distress was low: 8.3%

at 6 and 12 months postdiagnosis, respectively. Of the143 participants who met caseness for distress at Time 1, 38% remained highly distressed at Time 2.

According to the clinical interview, 20 (20%) met criteria for adjustment disorders, 3 (3%) for phobia, and 3 (3%) for generalized anxiety

anxiety disorder.

both evaluations.

were

depressive.

and 6.7%

disorder.

The prevalence of global

Clinical interview: Composite

Psychological distress: Distress

Anxiety and depression: Hospital Anxiety and Depression Scale (HADS) within 9 weeks of receiving diagnosis

of Depression and Anxiety After surgical resection; at the beginning and at the end of the treatment in the chemotherapy group (CHG) and at the first and after 6 months of follow-up in the control

group (CG)

(BDI)

(STAI)

during chemotherapy

Inventory-18 (BSI-18) at baseline (after diagnosis),

(Time 2) postdiagnosis

before initiating treatment

Thermometer (DT)

International Diagnostic Interview (CIDI)

Anxiety and depression: Questionnaires

Depression: Beck Depression Inventory

Anxiety: State-Trait Anxiety Inventory

Psychological distress: Brief Symptom

approximately 6 (Time 1) and 12 months

Descriptive diagnosis: DSM III-R criteria

Below, the special features of each of these psychological manifestations are summarized.

Adjustment disorders are the most common psychological manifestation exhibited by cancer patients, but few studies or reports have examined adjustment disorders alone. Problems with the diagnostic criteria for adjustment disorders themselves are likely to be one of the reasons for the lack of studies on this topic. The diagnostic criteria in the DSM-IV-TR state that adjustment disorders are "reactions such as anxiety and depression or behavior disorders that occur in association with psychosocial stress." The diagnosis of adjustment disorders is made when the degree of the reaction is stronger than expected or when symptoms interfere with social functions from everyday life to social activities, and such disorders are said to be a continuous condition, without any strict division from normal reactions. Thus, the criteria are vague, and the term "adjustment disorders" is used as a "wastebasket diagnosis" when there is a mood disorder but other diagnoses, including depression, do not apply. Nevertheless, the term has the advantage of being able to include a variety of psychological manifestations that would be difficult to accept as specific mental disorders.

Inadequate pain control can be listed as a primary cause of adjustment disorders. According to a study by Derogatis et al. [1], a higher percentage of cancer patients who met the diagnostic criteria for adjustment disorders had severe pain, compared with cancer patients who did not meet the criteria. Anxiety, depression, and agitation are known to readily develop when pain of unknown cause persists [15]. Clearly, understanding patients' pain, which is a typical symptom that requires symptomatic relief, and adequately controlling such pain seems to be also useful for relieving psychological distress. Moreover, feelings of difficulty breathing [16] or malaise [17], which (similar to pain) often occur in colorectal cancer patients, can have an impact on patient QOL and can be difficult to treat, and their presence appears to be a cause of anxiety or depression.

These adjustment disorders should be evaluated and properly managed, but few patients are actually diagnosed correctly and treated properly [18]. One reason for this situation appears to be that healthcare providers often miss psychological manifestations. Although the issue of physicians and nurses who are not specialists in psychiatric care overlooking mild depression and anxiety symptoms occurring during the course of cancer is, to some extent, unavoidable, there seems to be a need for education regarding the diagnosis and treatment of adjustment disorders, which are the most common psychological manifestations of cancer patients.

Psychotropic drugs, such as anxiolytic agents, hypnotics, and, depending on the circumstan‐ ces, antidepressants, are often used for treatment, but it is important to make an effort to identify the cause of the adjustment disorders described above by sufficiently listening to what the patient has to say, and then eliminating the cause. To accomplish this task, supportive psychiatric care in which caregivers encourage patients to express how they are really feeling at the present time (especially feelings of fear and anxiety), that supports and empathizes with the patients, and that does not provide unrealistic information but provides assurance within the realm of reality is said to be effective. In other words, supportive psychiatric care can become a valid treatment only when the patients feel that their present suffering is understood by the healthcare provider.

#### **2.** Depression

Table 3 shows the diagnostic criteria for depression based on the DSM-IV-TR. A diagnosis of depression is made when either a depressed mood or a loss of interest or pleasure or both occurs, and a total of 5 or more other symptoms are present for at least 2 weeks. However, because some of the physical symptoms included among the listed symptoms of depression, such as sleep disturbance, anorexia and weight loss, a decreased ability to concentrate, and malaise, are common symptoms, especially in palliative care settings, these symptoms are often not regarded as unusual even when present, and there is a strong tendency for depression to be underestimated among cancer patients. Why is the accurate evaluation and treatment of depression important? To answer this question, a specific case is presented below.

whenever a patient desires an early death, it is essential to always keep depression in mind

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A younger age, a past history of mood disorder, a history of alcohol dependence, low social support, a poor physical condition, and inadequate pain control have been implicated as risk

In addition, caution is also necessary with regard to the fact that depression is sometimes induced as a side effect of drugs that are used to treat physical illnesses [21]. Associations with depression have also been pointed out for some β-adrenergic antagonists and benzodiazepines as well as some anticancer drugs, including vincristine and asparaginase. Steroids are widely used to treat brain edema caused by brain metastasis and for malaise and nausea, but they are

A variety of questionnaires and rating scales have become available as ways to convenient‐ ly screen for depression, and these tools have a high utility value as indicators of the presence of depression in cancer patients. However, prior to the use of these tools, healthcare providers must first take an interest in their patients' psychological distress and discuss the matter with their patients. When Chochinov et al. [22] used a 13-item short version of the depression screening scale and inquired about only a depressed mood in a study of 197 terminal-stage cancer patients, they reported that asking, "How are you feeling? Aren't you feeling depressed?" was the most useful way of screening for depression. When health‐ care providers are standing in front of a patient, after inquiring "How are you?" the healthcare provider can easily ask an additional question, "How are you feeling?" with‐ out imposing any great burden on everyday clinical practice, and this additional question seems to be a convenient and effective way of not overlooking depression that healthcare

As a general rule, depression is treated with drug therapy, primarily with antidepressants, and although it takes 1-2 weeks for them to take effect, these drugs are very effective in many cases. In the past, thirst and constipation were frequent side effects, but antidepressants with fewer side effects have been recently developed, and it seems possible to utilize them effec‐ tively. Nevertheless, the fact that some antidepressants inhibit the metabolism of anticancer drugs and affect their blood concentrations needs to be kept in mind when using them concomitantly. However, as stated above, the most important point is to evaluate accurately

Delirium is an organic mental disorder that is often seen during the early stage of cancer therapy or from an advanced to terminal stage, and it is a "consciousness" disorder that is accompanied by cognitive disorders such as psychomotor excitation manifesting as a mild clouding of consciousness, delusions, and hallucinations. Because cognition is impaired, a wide variety of accompanying psychological symptoms may develop. Classical cases of delirium are characterized by an abrupt onset of symptoms and diurnal fluctuations in symptoms (especially symptoms becoming worse during the night), as well as difficulty in focusing and maintaining attention. Sometimes, psychiatric departments are frequently

and to evaluate the patient's decision-making ability.

factors for depression in cancer patients [20].

known to be possible causes of depression.

providers can implement immediately.

whether the patient is in a depressed state.

**3.** Delirium


Depressed mood and/or loss of interest or pleasure in life activities for at least 2 weeks and at least five of the above symptoms that cause clinically significant impairment in social, work, or other important areas of functioning almost every day.

**Table 3.** Diagnostic criteria of depression

#### [Case]

The patient was a 65-year-old man who was being followed up for advanced colorectal cancer and had entered the terminal stage. Predominantly palliative care was being performed, and symptom control was fairly good. However, he gradually began to experience insomnia, and this symptom persisted. A short while later he was heard to say, "There's no point in living anymore. I want to die," and he exhibited minimal facial expressions. A hypnotic was prescribed, but the treatment was ineffective. Because the condition described above persisted, he was referred to a psychiatrist. Based on an examination, the psychiatrist concluded that the cause was depression, and when the patient was treated with a low dose of an antidepressant, he no longer made the above complaints, and his facial expression became peaceful.

It is not rare for cancer patients, particularly terminal patients, to speak of suicidal ideation (a feeling that they want to die or that there is no point in living), similar to the case described above, and more than half of such patients are reportedly in a depressed state [19]. However, since depression can be alleviated suicidal ideation can be stopped with proper treatment,

<sup>1.</sup> Depressed mood most of the day.

<sup>2.</sup> Diminished interest or pleasure in all or most activities.

whenever a patient desires an early death, it is essential to always keep depression in mind and to evaluate the patient's decision-making ability.

A younger age, a past history of mood disorder, a history of alcohol dependence, low social support, a poor physical condition, and inadequate pain control have been implicated as risk factors for depression in cancer patients [20].

In addition, caution is also necessary with regard to the fact that depression is sometimes induced as a side effect of drugs that are used to treat physical illnesses [21]. Associations with depression have also been pointed out for some β-adrenergic antagonists and benzodiazepines as well as some anticancer drugs, including vincristine and asparaginase. Steroids are widely used to treat brain edema caused by brain metastasis and for malaise and nausea, but they are known to be possible causes of depression.

A variety of questionnaires and rating scales have become available as ways to convenient‐ ly screen for depression, and these tools have a high utility value as indicators of the presence of depression in cancer patients. However, prior to the use of these tools, healthcare providers must first take an interest in their patients' psychological distress and discuss the matter with their patients. When Chochinov et al. [22] used a 13-item short version of the depression screening scale and inquired about only a depressed mood in a study of 197 terminal-stage cancer patients, they reported that asking, "How are you feeling? Aren't you feeling depressed?" was the most useful way of screening for depression. When health‐ care providers are standing in front of a patient, after inquiring "How are you?" the healthcare provider can easily ask an additional question, "How are you feeling?" with‐ out imposing any great burden on everyday clinical practice, and this additional question seems to be a convenient and effective way of not overlooking depression that healthcare providers can implement immediately.

As a general rule, depression is treated with drug therapy, primarily with antidepressants, and although it takes 1-2 weeks for them to take effect, these drugs are very effective in many cases. In the past, thirst and constipation were frequent side effects, but antidepressants with fewer side effects have been recently developed, and it seems possible to utilize them effec‐ tively. Nevertheless, the fact that some antidepressants inhibit the metabolism of anticancer drugs and affect their blood concentrations needs to be kept in mind when using them concomitantly. However, as stated above, the most important point is to evaluate accurately whether the patient is in a depressed state.

#### **3.** Delirium

**2.** Depression

1. Depressed mood most of the day.

4. Insomnia or sleeping too much.

6. Fatigue or loss of energy.

9. Recurrent thoughts of death.

every day.

[Case]

2. Diminished interest or pleasure in all or most activities.

5. Agitation or psychomotor retardation noticed by others.

8. Diminished ability to think or concentrate, or indecisiveness.

3. Significant unintentional weight loss or gain.

512 Colorectal Cancer - Surgery, Diagnostics and Treatment

7. Feelings of worthlessness or excessive guilt.

**Table 3.** Diagnostic criteria of depression

Table 3 shows the diagnostic criteria for depression based on the DSM-IV-TR. A diagnosis of depression is made when either a depressed mood or a loss of interest or pleasure or both occurs, and a total of 5 or more other symptoms are present for at least 2 weeks. However, because some of the physical symptoms included among the listed symptoms of depression, such as sleep disturbance, anorexia and weight loss, a decreased ability to concentrate, and malaise, are common symptoms, especially in palliative care settings, these symptoms are often not regarded as unusual even when present, and there is a strong tendency for depression to be underestimated among cancer patients. Why is the accurate evaluation and treatment of

Depressed mood and/or loss of interest or pleasure in life activities for at least 2 weeks and at least five of the above symptoms that cause clinically significant impairment in social, work, or other important areas of functioning almost

The patient was a 65-year-old man who was being followed up for advanced colorectal cancer and had entered the terminal stage. Predominantly palliative care was being performed, and symptom control was fairly good. However, he gradually began to experience insomnia, and this symptom persisted. A short while later he was heard to say, "There's no point in living anymore. I want to die," and he exhibited minimal facial expressions. A hypnotic was prescribed, but the treatment was ineffective. Because the condition described above persisted, he was referred to a psychiatrist. Based on an examination, the psychiatrist concluded that the cause was depression, and when the patient was treated with a low dose of an antidepressant,

he no longer made the above complaints, and his facial expression became peaceful.

It is not rare for cancer patients, particularly terminal patients, to speak of suicidal ideation (a feeling that they want to die or that there is no point in living), similar to the case described above, and more than half of such patients are reportedly in a depressed state [19]. However, since depression can be alleviated suicidal ideation can be stopped with proper treatment,

depression important? To answer this question, a specific case is presented below.

Delirium is an organic mental disorder that is often seen during the early stage of cancer therapy or from an advanced to terminal stage, and it is a "consciousness" disorder that is accompanied by cognitive disorders such as psychomotor excitation manifesting as a mild clouding of consciousness, delusions, and hallucinations. Because cognition is impaired, a wide variety of accompanying psychological symptoms may develop. Classical cases of delirium are characterized by an abrupt onset of symptoms and diurnal fluctuations in symptoms (especially symptoms becoming worse during the night), as well as difficulty in focusing and maintaining attention. Sometimes, psychiatric departments are frequently consulted, and the nature of the requests is a failure to cooperate with treatment, negativity, and suspicion of dementia. The prevalence of delirium increases as the patients' physical conditions deteriorate and they reach a stage [23], and an overall prevalence of 4%-27% has been reported for all stages.

**Possible to recover Difficult to recover**

Organ failure Brain metastasis

appropriate.

Maintenance of sleep Care of families

**Points to be paid attention to**

Antiemetic with dopamine receptor antagonistic action (e.g., metoclopramide) is

Adverse effects of morphine (dry mouth, constipation, dysuria, sleepiness) are

In case of under administration of anticancer agents or liver metastasis.

Relief of delirium symptoms Antipsychotic drug,

Relief of restlessness or agitation

Benzodiazepine is used in combination, as

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Typical cause Goal of care Drug therapy Content of care

Extrapyramidal symptom Anticholinergic effect Hepatic dysfunction Malignant syndrome

**4. Communication skills**

Electrolyte imbalance

Inflammatory reaction Recovery from delirium Antipsychotic drug,

Recovery from delirium

Care of families

Benzodiazepine is used at a minimum.

**Table 4.** Delirium causes for which recovery in response to treatment is possible or difficult

aggravated.

experience stress because they have not acquired adequate skills.

often administered antecedently.

In case of the poor general conditions.

Nothing is more important to the process of conveying bad news and obtaining informed consent than that healthcare providers strive for good communication with the patient and the patient's family. Good communication is said to have a favorable impact on physical and mental health, such as helping patients to cope with their disease, improving compliance, and bringing about the control of blood pressure and blood glucose levels, as well as pain control, and as a result of achieving a strong trusting relationship with their healthcare provider, patients are willing to engage actively in their treatment, increasing its therapeutic effect. [24]. Moreover, forging good relationships with patients also reportedly decreases the risk of burn out by healthcare providers [25]. However, in reality, training in communication skills and support skills is seldom provided, and as a result, many healthcare providers are thought to

Against this background, a training program designed to improve communication skills was conducted in the United Kingdom with 178 highly experienced oncologists as the subjects [26]. When the physicians were the subjects of the evaluation, the results reportedly showed that the physicians were able to gain self-confidence with regard to communication, and had

**Table 5.** Points regarding adverse events during the use of psychotropic drugs to treat cancer patients

Correction of daily living rhythms

Drug Anemia

Several hypotheses, including impaired neurotransmitter metabolism in the brain and an impaired sleep-wakefulness mechanism, have been proposed with regard to the pathogenetic mechanism of delirium, but nothing definite is known. The causes of delirium in cancer patients consist of direct causes, such as cancer metastasis to the brain, and indirect causes caused by electrolyte abnormalities (caution is particularly necessary in regard to hypercalce‐ mia secondary to bone metastasis), the side effects of drugs (drug-induced delirium is relatively common and is seen with narcotic analgesics, such as morphine, and drugs that have an anticholinergic action) or irradiation, and in association with multi-organ failure, infection, changes in nutritional status, etc., the incidences of which increase as a terminal stage is reached;, however, indirect causes are by far more common. Drug-induced delirium is relatively frequent and is seen with narcotic analgesics, such as morphine, and drugs that have an anticholinergic action.

An examination of the causes of delirium according to disease stage showed that single factors based on treatment (surgery, chemotherapy, etc.) are more common during stages when the patients' conditions are relatively good and that multiple factors tend to be involved in the terminal stage. Bruera et al. [23] conducted a study of the causes of delirium in terminal-stage cancer patients using peripheral blood biochemistry tests, CT examinations of the brain, and arterial blood gas analyses and reported that the cause was unknown in 56% of the cases. The factors identified were, listed in order starting with the most frequent,: drugs, sepsis, brain metastasis, hepatic or renal failure, hypercalcemia, and hyponatremia. They reported that the results showed that two thirds of the patients with a cognitive disorder died later without recovering and that the other third recovered before they died. A variety of factors in the etiology of delirium have often accumulated in terminal patients, making it difficult to identify a cause and to treat the condition.

The basic approach to treatment is to determine the cause of the delirium, and then to eliminate the cause. However, it is important to distinguish between whether recovery in response to treatment is possible or would be difficult and to decide upon an appropriate care goal (Table 4). A variety of factors in the etiology of delirium have often accumulated in terminal patients, and the identification of a cause and subsequent treatment are often difficult. When intense excitement is present or when the delirium interferes with everyday living as a result of hallucinations, delusions, etc., symptomatic drug therapy, including treatment with antipsy‐ chotic drugs, is often performed. In principle, drug therapy is the same as for the usual treatment of delirium: (1) benzodiazepine monotherapy is not used, (2) antiparkinsonian drugs are not used in combination, and (3) multiple drug combinations are not used. Table 5 contains points that should be kept in mind with regard to adverse events when using psychotropic drugs to treat cancer patients. Moreover, modifications of the patient's environment, family support, and the support and education of the staff of the hospital unit are also needed, in addition to the above.


**Table 4.** Delirium causes for which recovery in response to treatment is possible or difficult


**Table 5.** Points regarding adverse events during the use of psychotropic drugs to treat cancer patients

## **4. Communication skills**

consulted, and the nature of the requests is a failure to cooperate with treatment, negativity, and suspicion of dementia. The prevalence of delirium increases as the patients' physical conditions deteriorate and they reach a stage [23], and an overall prevalence of 4%-27% has

Several hypotheses, including impaired neurotransmitter metabolism in the brain and an impaired sleep-wakefulness mechanism, have been proposed with regard to the pathogenetic mechanism of delirium, but nothing definite is known. The causes of delirium in cancer patients consist of direct causes, such as cancer metastasis to the brain, and indirect causes caused by electrolyte abnormalities (caution is particularly necessary in regard to hypercalce‐ mia secondary to bone metastasis), the side effects of drugs (drug-induced delirium is relatively common and is seen with narcotic analgesics, such as morphine, and drugs that have an anticholinergic action) or irradiation, and in association with multi-organ failure, infection, changes in nutritional status, etc., the incidences of which increase as a terminal stage is reached;, however, indirect causes are by far more common. Drug-induced delirium is relatively frequent and is seen with narcotic analgesics, such as morphine, and drugs that have

An examination of the causes of delirium according to disease stage showed that single factors based on treatment (surgery, chemotherapy, etc.) are more common during stages when the patients' conditions are relatively good and that multiple factors tend to be involved in the terminal stage. Bruera et al. [23] conducted a study of the causes of delirium in terminal-stage cancer patients using peripheral blood biochemistry tests, CT examinations of the brain, and arterial blood gas analyses and reported that the cause was unknown in 56% of the cases. The factors identified were, listed in order starting with the most frequent,: drugs, sepsis, brain metastasis, hepatic or renal failure, hypercalcemia, and hyponatremia. They reported that the results showed that two thirds of the patients with a cognitive disorder died later without recovering and that the other third recovered before they died. A variety of factors in the etiology of delirium have often accumulated in terminal patients, making it difficult to identify

The basic approach to treatment is to determine the cause of the delirium, and then to eliminate the cause. However, it is important to distinguish between whether recovery in response to treatment is possible or would be difficult and to decide upon an appropriate care goal (Table 4). A variety of factors in the etiology of delirium have often accumulated in terminal patients, and the identification of a cause and subsequent treatment are often difficult. When intense excitement is present or when the delirium interferes with everyday living as a result of hallucinations, delusions, etc., symptomatic drug therapy, including treatment with antipsy‐ chotic drugs, is often performed. In principle, drug therapy is the same as for the usual treatment of delirium: (1) benzodiazepine monotherapy is not used, (2) antiparkinsonian drugs are not used in combination, and (3) multiple drug combinations are not used. Table 5 contains points that should be kept in mind with regard to adverse events when using psychotropic drugs to treat cancer patients. Moreover, modifications of the patient's environment, family support, and the support and education of the staff of the hospital unit are also needed, in

been reported for all stages.

514 Colorectal Cancer - Surgery, Diagnostics and Treatment

an anticholinergic action.

a cause and to treat the condition.

addition to the above.

Nothing is more important to the process of conveying bad news and obtaining informed consent than that healthcare providers strive for good communication with the patient and the patient's family. Good communication is said to have a favorable impact on physical and mental health, such as helping patients to cope with their disease, improving compliance, and bringing about the control of blood pressure and blood glucose levels, as well as pain control, and as a result of achieving a strong trusting relationship with their healthcare provider, patients are willing to engage actively in their treatment, increasing its therapeutic effect. [24]. Moreover, forging good relationships with patients also reportedly decreases the risk of burn out by healthcare providers [25]. However, in reality, training in communication skills and support skills is seldom provided, and as a result, many healthcare providers are thought to experience stress because they have not acquired adequate skills.

Against this background, a training program designed to improve communication skills was conducted in the United Kingdom with 178 highly experienced oncologists as the subjects [26]. When the physicians were the subjects of the evaluation, the results reportedly showed that the physicians were able to gain self-confidence with regard to communication, and had become able to engage in patient-centered communication, including directing their attention to patients' psychosocial aspects. This study was the first of its kind, and it was followed by the start of a succession of studies regarding the effectiveness of communication skills training (CST). The effects of CST interventions for health care professionals have been compiled and analyzed in several systematic reviews across recent decades [27-30]. These reviews have consistently concluded that CST leads to better communication behaviors among clinicians [28, 30]. A recent meta-analysis of 13 studies reported a moderate effect size of 0.54 (Cohen's d) for the impact of CST on the communication behaviors of oncology clinicians [30]. However, on the other hand, Kissane et al. [31] pointed out in the most recent review article that outcomes impacting patient satisfaction, improved adaptation, and enhanced quality of life are still lacking, and that patient benefits, such as increased treatment adherence and enhanced adaption, need to be demonstrated from CST.

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[6] Graҫa Pereira M, Figueiredo AP, Fincham FD. Anxiety, depression, traumatic stress and quality of life in colorectal cancer after different treatments: A study with Portu‐

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Thus, evaluations of training in communication skills have not yet led to any definite conclu‐ sions, but an education system and a curriculum designed to improve communication skills is definitely needed in the near future. Bad news must often be conveyed, particularly in cancer care settings, and the acquisition of such skills by healthcare providers seems to be absolutely essential.

#### **5. Conclusion**

Based on the characteristics of colorectal cancer patients, the forms of psychological distress that are said to often be encountered in cancer care settings and to require evaluation and management from the standpoint of a psychiatrist have been summarized. The necessary communication skills, which are one of the skill sets that must be acquired to engage in cancer care, have also been described. However, the people who are closely involved with such psychosocial aspects and need such skills to deal with patients in actual clinical settings are typically the attending physicians, who are oncologists, and allied healthcare professionals, rather than psychiatrists. Thus, it is paramount that all healthcare providers involved in the care of cancer patients become proficient in communication skills so that they may interact with patients and their families and so that they may always aim to provide medical care with patients' psychological aspects in mind.

#### **Author details**

Hitoshi Okamura\*

Address all correspondence to: hokamura@hiroshima-u.ac.jp

Institute of Biomedical & Health Sciences, Hiroshima University, Japan

### **References**

become able to engage in patient-centered communication, including directing their attention to patients' psychosocial aspects. This study was the first of its kind, and it was followed by the start of a succession of studies regarding the effectiveness of communication skills training (CST). The effects of CST interventions for health care professionals have been compiled and analyzed in several systematic reviews across recent decades [27-30]. These reviews have consistently concluded that CST leads to better communication behaviors among clinicians [28, 30]. A recent meta-analysis of 13 studies reported a moderate effect size of 0.54 (Cohen's d) for the impact of CST on the communication behaviors of oncology clinicians [30]. However, on the other hand, Kissane et al. [31] pointed out in the most recent review article that outcomes impacting patient satisfaction, improved adaptation, and enhanced quality of life are still lacking, and that patient benefits, such as increased treatment adherence and enhanced

Thus, evaluations of training in communication skills have not yet led to any definite conclu‐ sions, but an education system and a curriculum designed to improve communication skills is definitely needed in the near future. Bad news must often be conveyed, particularly in cancer care settings, and the acquisition of such skills by healthcare providers seems to be absolutely

Based on the characteristics of colorectal cancer patients, the forms of psychological distress that are said to often be encountered in cancer care settings and to require evaluation and management from the standpoint of a psychiatrist have been summarized. The necessary communication skills, which are one of the skill sets that must be acquired to engage in cancer care, have also been described. However, the people who are closely involved with such psychosocial aspects and need such skills to deal with patients in actual clinical settings are typically the attending physicians, who are oncologists, and allied healthcare professionals, rather than psychiatrists. Thus, it is paramount that all healthcare providers involved in the care of cancer patients become proficient in communication skills so that they may interact with patients and their families and so that they may always aim to provide medical care with

adaption, need to be demonstrated from CST.

516 Colorectal Cancer - Surgery, Diagnostics and Treatment

patients' psychological aspects in mind.

Address all correspondence to: hokamura@hiroshima-u.ac.jp

Institute of Biomedical & Health Sciences, Hiroshima University, Japan

essential.

**5. Conclusion**

**Author details**

Hitoshi Okamura\*


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## *Edited by Jim S Khan*

Colorectal cancer is one of the commonest cancers affecting individuals across the world. An improvement in survival has been attributed to multidisciplinary management, better diagnostics, improved surgical options for the primary and metastatic disease and advances in adjuvant therapy. In this book, international experts share their experience and knowledge on these different aspects in the management of colorectal cancer. An in depth analysis of screening for colorectal cancer, detailed evaluation of diagnostic modalities in staging colorectal cancer, recent advances in adjuvant therapy and principles and trends in the surgical management of colorectal cancer is provided. This will certainly prove to be an interesting and informative read for any clinician involved in the management of patients with colorectal cancer.

Photo by ThitareeSarmkasat / iStock

Colorectal Cancer - Surgery, Diagnostics and Treatment

Colorectal Cancer

Surgery, Diagnostics and Treatment

*Edited by Jim S Khan*