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Senturk M, Sungur Z. Enhanced recovery after thoracic anesthesia. Saudi J Anaesth 2021; 15:348-355. [PMID: 34764842 PMCID: PMC8579505 DOI: 10.4103/sja.sja_1182_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 11/14/2022] Open
Abstract
In recent years, the concept of “Perioperative Medicine” has been evolved to a more concrete and sophisticated approach called “Enhanced Recovery After Surgery” (ERAS). ERAS has been first introduced in colorectal surgery by a dedicated leading ERAS® society, ERAS-criteria has been subsequently extended into several types of surgery, including thoracic surgery. Anesthesiology has always been one of the most important components of the multidisciplinary perioperative approaches, which is also valid for ERAS. There are several guidelines published on the enhanced recovery after thoracic surgery (ERATS). This article focuses on the “official” ERATS protocols of a joint consensus of two different societies. Regarding thoracic anesthesia, there are some challenges to be dealt with. The first challenge, although there is a large number of studies published on thoracic anesthesia, only a very few of them have studied the overall outcome and quality of recovery; and only few of them were powered enough to provide sufficient evidence. This has led to the fact that some components of the protocol are debatable. The second challenge, the adherence to individual elements and the overall compliance are poorly reported and also hard to apply even in the best organized centers. This article explains and discusses the debatable viewpoints on the elements of the ERATS protocol published in 2019 aiming to achieve a list for the future steps required for a more effective and evidence-based ERATS protocol.
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Affiliation(s)
- Mert Senturk
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Zerrin Sungur
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
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Honaker MD, Hawes CC, Vinter DA, Montgomery A, Parker JC, Smith BE. Continuous transversus abdominis plane blocks in patients undergoing minimally invasive colorectal surgery: a randomized pilot study. Int J Colorectal Dis 2021; 36:2511-2518. [PMID: 34240275 DOI: 10.1007/s00384-021-03978-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Transversus abdominis plane (TAP) blocks are used in an attempt to decrease narcotic use and its subsequent consequences. The primary goal of this study was to see if TAP blocks decreased narcotic use in patients undergoing minimally invasive colorectal surgery. METHODS A randomized pilot study was conducted. The amount of narcotic used examined in morphine milligram equivalents (MME) was collected for the first 4 post-operative days (PODs). Demographic data, length of stay (LOS), readmission rate, and 90-day mortality was also examined. Statistical analysis of the data was performed with a p < 0.05 determined to be significant. RESULTS Eighty-eight patients were included. Forty-seven were randomized to the TAP group and 41 to the no TAP group. There was no difference in age, race, gender, indication for operation, or Charlson Comorbidity Index (p > 0.05). The median MME for each POD was similar for POD 1 (22.5 vs 37.5; p = 0.054), POD 3 (15 vs 22.5; p = 0.48), and POD 4 (22.5 vs 10.5; p = 0.42) on bivariate analysis. On POD 2, the TAP group had significantly less narcotic intake than the no TAP group (17.5 vs 30; p = 0.047). However, on multivariate analysis when controlling for other variables, there was no statistical difference between the groups. Median LOS was 3 days for both groups. Readmissions, post-operative complications, and mortality were also similar between the two groups (p > 0.05). CONCLUSION Our findings indicate that continuous TAP blocks do not decrease the amount of MME used during the first 4 post-operative days compared to patient receiving traditional pain control measures.
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Affiliation(s)
- Michael Drew Honaker
- Department of Surgical Oncology and Colorectal Surgery, Navicent Health, 800 1St Suite 240, Macon, GA, 31201, USA.
| | - Casey Chinn Hawes
- Department of Surgery, Mercer University School of Medicine, 777 Hemlock Street, Macon, GA, 31201, USA
| | - Dana Alina Vinter
- Department of Internal Medicine, Mercer University School of Medicine, 433 Cherry Street, Macon, GA, 31201, USA
| | - Anne Montgomery
- Georgia Rural Health Innovation Center, Mercer University School of Medicine, 1501 Mercer University Dr, Macon, GA, 31207, USA
| | - James Cole Parker
- Department of Surgery, Mercer University School of Medicine, 777 Hemlock Street, Macon, GA, 31201, USA
| | - Betsy Epps Smith
- Department of Internal Medicine, Mercer University School of Medicine, 433 Cherry Street, Macon, GA, 31201, USA
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Postoperative pulmonale Komplikationen nach chirurgischen Eingriffen. ANÄSTHESIE NACHRICHTEN 2021. [PMCID: PMC8720644 DOI: 10.1007/s44179-021-0039-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Comparison of Postoperative Pain and Pain Control Techniques in Uniportal - Biportal Vats and Open Surgery Patients. MARMARA MEDICAL JOURNAL 2021. [DOI: 10.5472/marumj.984215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Roy N, Parra MF, Brown ML, Sleeper LA, Carlson L, Rhodes B, Nathan M, Mistry KP, Del Nido PJ. Enhancing Recovery in Congenital Cardiac Surgery. Ann Thorac Surg 2021; 114:1754-1761. [PMID: 34710385 DOI: 10.1016/j.athoracsur.2021.09.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 09/07/2021] [Accepted: 09/09/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND The benefits of a comprehensive enhanced recovery after surgery (ERAS®) program for the congenital heart disease population are largely unknown. We evaluated adherence and outcomes following a recently implemented enhanced recovery program (ERP) in congenital cardiac surgery. METHODS Patients undergoing elective surgery for simple and moderately complex congenital cardiac surgery followed institutional ERP guidelines since 10/2018. Adherence to guidelines over a 12-month period (P2) was compared to implementation data (P1:5 months). The association of outcomes with continuous time was estimated using linear regression. RESULTS Among 559 patients (representing 40% of the cardiac surgical volume) following the ERP over a period of 17 months, no differences in patient characteristics were observed between periods, except higher incidence of prior operations in P2. Adherence to many aspects of guidelines improved from P1 to P2. Notably, operating room extubation: 27% in P2 vs.16% in P1, p=0.006; decrease in median ventilation time: 6.0-hrs (IQR 0-9.2) in P2 vs. 7.6-hrs (IQR 3.8-12.3) in P1, p=0.002. In addition, there was a reduction in opioids, reported as oral morphine equivalents (OME), most significant for intraoperative OME: 5.00 mg/kg (3.11-7.60) in P2 vs. 6.05 mg/kg (3.77-9.78) in P1, p=0.001. There was no difference in overall intensive care unit (ICU) and postoperative length of stay except in lower risk surgeries. Surgical outcomes were similar in the two periods. CONCLUSIONS An enhanced recovery program reduced the use of opioids, led to more OR extubation and reduced mechanical ventilation duration in patients undergoing congenital cardiac surgery.
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Affiliation(s)
- Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - M Fernanda Parra
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Morgan L Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Laura Carlson
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States
| | - Barbara Rhodes
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Kshitij P Mistry
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
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Thörn RMW, Stepniewski J, Hjelmqvist H, Forsberg A, Ahlstrand R, Ljungqvist O. Supervised Immediate Postoperative Mobilization After Elective Colorectal Surgery: A Feasibility Study. World J Surg 2021; 46:34-42. [PMID: 34668047 PMCID: PMC8677683 DOI: 10.1007/s00268-021-06347-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early mobilization is a significant part of the ERAS® Society guidelines, in which patients are recommended to spend 2 h out of bed on the day of surgery. However, it is not yet known how early patients can safely be mobilized after completion of colorectal surgery. The aim of this study was to evaluate the feasibility, and safety of providing almost immediate structured supervised mobilization starting 30 min post-surgery at the postoperative anesthesia care unit (PACU), and to describe reactions to this approach. METHODS This feasibility study includes 42 patients aged ≥18 years who received elective colorectal surgery at Örebro University Hospital. They underwent a structured mobilization performed by a specialized physiotherapist using a modified Surgical ICU Optimal Mobilization Score (SOMS). SOMS determines the level of mobilization at four levels from no activity to ambulating. Mobilization was considered successful at SOMS ≥ 2, corresponding to sitting on the edge of the bed as a proxy of sitting in a chair due to lack of space. RESULTS In all, 71% (n = 30) of the patients reached their highest level of mobilization between the second and third hour of arrival in the PACU. Before discharge to the ward, 43% (n = 18) could stand at the edge of the bed and 38% (n = 16) could ambulate. Symptoms that delayed advancement of mobilization were pain, somnolence, hypotension, nausea, and patient refusal. No serious adverse events occurred. CONCLUSIONS Supervised mobilization is feasible and can safely be initiated in the immediate postoperative care after colorectal surgery. Trial registration Clinical trials.gov identifier: NTC03357497.
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Affiliation(s)
- Rose-Marie W Thörn
- Department of Physiotherapy, Örebro University Hospital, Örebro, Sweden.
| | - Jan Stepniewski
- Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden
| | - Hans Hjelmqvist
- Department of Anesthesiology and Intensive Care, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anette Forsberg
- Department of Physiotherapy, Örebro University Hospital, Örebro, Sweden
| | - Rebecca Ahlstrand
- Department of Anesthesiology and Intensive Care, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Tan YY, Liaw F, Warner R, Myers S, Ghanem A. Enhanced Recovery Pathways for Flap-Based Reconstruction: Systematic Review and Meta-Analysis. Aesthetic Plast Surg 2021; 45:2096-2115. [PMID: 33821314 DOI: 10.1007/s00266-021-02233-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/11/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) pathways are known to improve patient outcomes after surgery. In recent years, there have been growing interest in ERAS for reconstructive surgery. OBJECTIVES To systematically review and summarise literature on the key components and outcomes of ERAS pathways for autologous flap-based reconstruction. DATA SOURCES Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Current Controlled Trials, World Health Organization International Clinical Trials Registry Platform and reference lists of relevant studies. INCLUSION CRITERIA All primary studies of ERAS pathways for free and pedicled flap-based reconstructions reported in the English language. OUTCOME MEASURES The primary outcome measure was length of stay. Secondary outcomes were complication rates including total flap loss, partial flap loss, unplanned reoperation within 30 days, readmission to hospital within 30 days, surgical site infections and medical complications. RESULTS Sixteen studies were included. Eleven studies describe ERAS pathways for autologous breast reconstructions and five for autologous head and neck reconstructions. Length of stay was lower in ERAS groups compared to control groups (mean reduction, 1.57 days; 95% CI, - 2.15 to - 0.99). Total flap loss, partial flap loss, unplanned reoperations, readmissions, surgical site infections and medical complication rates were similar between both groups. Compliance rates were poorly reported. CONCLUSION ERAS pathways for flap-based reconstruction reduce length of stay without increasing complication rates. ERAS pathways should be adapted to each institution according to their needs, resources and caseload. There is potential for the development of ERAS pathways for chest wall, perineum and lower limb reconstruction. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Agarwal P, Frid I, Singer J, Zalatimo O, Schirmer CM, Kimmell KT, Agarwal N. Neurosurgery perception of Enhanced Recovery After Surgery (ERAS) protocols. J Clin Neurosci 2021; 92:110-114. [PMID: 34509236 DOI: 10.1016/j.jocn.2021.07.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/08/2021] [Accepted: 07/25/2021] [Indexed: 12/19/2022]
Abstract
Enhanced Recovery After Surgery (ERAS) protocols are widespread in several fields, particularly general surgery, and attempt to deliver surgical care at a lower cost while also improving patient outcomes. However, few institutions have implemented ERAS protocols in neurosurgery. As such, a survey of neurosurgeons on the current state of ERAS in neurosurgery was conducted to provide insight on scaling the practice nationally. A 15-question survey was designed to assess the implementation of andsatisfaction with ERAS protocols at individual institutions. A total of 39 responses were collected from 38 unique institutions. 58.9%(N = 23) reported implementation of neurosurgical ERAS protocols. 52.1% (N = 12) of the responses were neurosurgeons at academic institutions withneurosurgical residency programs. Most neurosurgeons used ERAS protocolsfor spine cases (N = 23), with only 17.3% (N = 4) employing ERAS protocolsfor cranial cases. 69.5% (N = 16) of survey participants reported that thedesign and implementation of ERAS was a multidisciplinary effort acrossmany departments, including neurosurgery, anesthesia, and pharmacy.Decreased costs and intensive care unit (ICU) admission were reported tobe unanticipated benefits of ERAS implementation. Unanticipated challenges to implementation of new protocols included difficulties withelectronic medical record (EMR) integration, agreement of protocoldetails amongst stakeholders, uniform implementation of protocols by allneurosurgeons, and lack of adaptability by multidisciplinary staff. Meandepartment satisfaction with ERAS protocol implementation was 4.00 +/- 0.81 (N = 22) on a 5-point Likert scale.
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Affiliation(s)
- Prateek Agarwal
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, United States
| | - Ilya Frid
- Department of Neurosurgery and Neuroscience Institute, Geisinger Health System and Geisinger Commonwealth School of Medicine, Wilkes-Barre, PA, United States
| | - Justin Singer
- Spectrum Health Medical Group, Department of Neurosurgery, Grand Rapids, MI, United States
| | - Omar Zalatimo
- Lifebridge Health, Department of Neurosurgery, The Sandra and Malcolm Berman Brain & Spine Institute, Baltimore, MD, United States
| | - Clemens M Schirmer
- Department of Neurosurgery and Neuroscience Institute, Geisinger Health System and Geisinger Commonwealth School of Medicine, Wilkes-Barre, PA, United States; Lifebridge Health, Department of Neurosurgery, The Sandra and Malcolm Berman Brain & Spine Institute, Baltimore, MD, United States; Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Kristopher T Kimmell
- Rochester Regional Health, Department of Neurosurgery, Rochester, NY, United States
| | - Nitin Agarwal
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, United States.
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Harkouk H, Capmas P, Derridj N, Belbachir A, Nkam L, Aegerter P, Battaglia E, Tharel L, Fletcher D. Limited impact of a top-down approach to improve enhanced recovery programme in French university hospitals: a before-after retrospective survey. Perioper Med (Lond) 2021; 10:29. [PMID: 34482837 PMCID: PMC8419963 DOI: 10.1186/s13741-021-00200-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 06/08/2021] [Indexed: 11/28/2022] Open
Abstract
Background Enhanced recovery programme (ERP) after surgery needs development in Assistance Publique Hôpitaux de Paris (APHP). Methods A retrospective before-and-after study was performed in 2015 and 2017 on three surgical models (total knee arthroplasty (TKA), colectomy and hysterectomy) in 17 hospitals including 29 surgical departments. Data were collected in one control intervention (total hip arthroplasty (THA), gastrectomy and ovariectomy). In 2016, Massive Open Online Course on ERP and a day meeting information were developed by APHP. A national update on ERP was also organized by HAS and a regional professional partnership programme was started. Primary outcomes were length of stay (LOS) and complications after surgery. Data on ERP items were collected in the patients’ chart and in anaesthetist and surgeon interview. Seventy percent application rate reflects application of ERP procedure. Results 1321 patient’s files were analysed (812 in 2015 and 509 in 2017). The LOS (mean (SD)) is reduced by 1.6 day for TKA (2015, 8.7 (6.7) versus 7.1 (3.4) in 2017; p<0.001) but stable for colectomy and hysterectomy. Incidence of severe complications after surgery is unchanged in all types of surgical models. For TKA and hysterectomy respectively applied items of ERP (i.e. >70% application) increased respectively from 5 to 7 out of 17 and 16 in 2015 and 2017. For colectomy, they were stable at 6 out of 21 in 2015 and 2017. The mean application rates of ERP items stayed below 50% in all cases in 2017. The LOS was negatively correlated with ERP items’ application when data collected in 2015 and 2017 were analysed together. Conclusion ERP application did not significantly improved between 2015 and 2017 for three surgical models after an institutional information and diffusion of recommendations in 29 surgical departments of seventeen French University hospitals underlining the limit of a top-down approach.
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Affiliation(s)
- Hakim Harkouk
- Anaesthesia and Intensive Care Department, Ambroise Paré Hospital, APHP, 9 avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France.,Université Paris-Saclay, UVSQ, Inserm, LPPD, 92100, Boulogne, France
| | - Perrine Capmas
- Obstetric Gynecology Department, Bicêtre Hospital, APHP, Le Kremlin-Bicêtre, France
| | - Nawal Derridj
- Clinical Research Unit, Ambroise Paré Hospital, APHP, Boulogne-Billancourt, France
| | - Anissa Belbachir
- Anaesthesia and Intensive Care Department, Cochin Hospital, APHP, Paris, France
| | - Lionelle Nkam
- Clinical Research Unit, Ambroise Paré Hospital, APHP, Boulogne-Billancourt, France
| | - Philippe Aegerter
- GIRCI-IDF, Cellule Méthodologie, Paris, France.,Université Paris-Saclay, UVSQ, Inserm, Équipe d'Épidémiologie respiratoire intégrative, CESP - Centre de recherche en Epidémiologie et Santé des Populations U1018 INSERM UPS UVSQ, 94807, Villejuif, France
| | - Eva Battaglia
- Direction de la Politique et de la Transformation, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Laure Tharel
- Direction de la Politique et de la Transformation, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Dominique Fletcher
- Anaesthesia and Intensive Care Department, Ambroise Paré Hospital, APHP, 9 avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France. .,Université Paris-Saclay, UVSQ, Inserm, LPPD, 92100, Boulogne, France.
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Liu HR, Yang P, Han S, Zhang Y, Zhu HY. The application of enhanced recovery after surgery and negative-pressure wound therapy in the perioperative period of elderly patients with colorectal cancer. BMC Surg 2021; 21:336. [PMID: 34488699 PMCID: PMC8422616 DOI: 10.1186/s12893-021-01331-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 08/24/2021] [Indexed: 12/17/2022] Open
Abstract
Objective To Explore the perioperative application of enhanced recovery after surgery (ERAS) and negative-pressure wound therapy in the elderly patients with colorectal cancer. Methods A retrospective clinical data were studied in the patients with colorectal cancer in Department of General Surgery in Shanghai Fourth People,s Hospital (from March, 2017 to March, 2019), One hundred and fifty patients with undergoing radical surgery for colorectal cancer were divided into two groups: ERAS group (n = 76 cases, accepting ERAS management) and Conventional treatment(CT) group (n = 74 cases, accepting traditional treatment), Bleeding in operation, the time of postoperative anal flatus, number of wound dressing changing, time of wound healing, the length of postoperative hospital stay, readmission rate, postoperative complication, were compared between the two groups. Results ERAS was associated with less bleeding in operation, less Wound fat liquefaction, less wound dressing changing, less time of wound healing, less time of postoperative anal flatus compare to CT group (P < 0.05); anastomotic fistula, readmission rate is similar in two groups (P > 0.05). Conclusion The modified ERAS can be safely applied to the perioperative period of elderly colorectal cancer patients and promote recovery; negative-pressure wound therapy is helpful for wound healing and promoting rehabilitation.
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Affiliation(s)
- Han-Rong Liu
- Department of General Surgery, Shanghai Fourth People's Hospital, Affiliated to Tongji University School of Medicine, No.1297 sanmen Road, Hongkou District, Shanghai, China.
| | - Ping Yang
- Department of Internal Medicine, Shanghai Pengpu Community Health Service Center, Shanghai, China
| | - Song Han
- Department of General Surgery, Shanghai Fourth People's Hospital, Affiliated to Tongji University School of Medicine, No.1297 sanmen Road, Hongkou District, Shanghai, China
| | - Yu Zhang
- Department of General Surgery, Shanghai Fourth People's Hospital, Affiliated to Tongji University School of Medicine, No.1297 sanmen Road, Hongkou District, Shanghai, China
| | - Hui-Yin Zhu
- Department of General Surgery, Shanghai Fourth People's Hospital, Affiliated to Tongji University School of Medicine, No.1297 sanmen Road, Hongkou District, Shanghai, China
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Weibel S, Pace NL, Schaefer MS, Raj D, Schlesinger T, Meybohm P, Kienbaum P, Eberhart LHJ, Kranke P. Drugs for preventing postoperative nausea and vomiting in adults after general anesthesia: An abridged Cochrane network meta-analysis. J Evid Based Med 2021; 14:188-197. [PMID: 34043870 DOI: 10.1111/jebm.12429] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/08/2021] [Accepted: 04/10/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE In this abridged version of the recently published Cochrane review on antiemetic drugs, we summarize its most important findings and discuss the challenges and the time needed to prepare what is now the largest Cochrane review with network meta-analysis in terms of the number of included studies and pages in its full printed form. METHODS We conducted a systematic review with network meta-analyses to compare and rank single antiemetic drugs and their combinations belonging to 5HT₃-, D₂-, NK₁-receptor antagonists, corticosteroids, antihistamines, and anticholinergics used to prevent postoperative nausea and vomiting in adults after general anesthesia. RESULTS 585 studies (97 516 participants) testing 44 single drugs and 51 drug combinations were included. The studies' overall risk of bias was assessed as low in only 27% of the studies. In 282 studies, 29 out of 36 drug combinations and 10 out of 28 single drugs lowered the risk of vomiting at least 20% compared to placebo. In the ranking of treatments, combinations of drugs were generally more effective than single drugs. Single NK1 receptor antagonists were as effective as other drug combinations. Of the 10 effective single drugs, certainty of evidence was high for aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron, while moderate for fosaprepitant and droperidol. For serious adverse events (SAEs), any adverse event (AE), and drug-class specific side effects evidence for intervention effects was mostly not convincing. CONCLUSIONS There is high or moderate evidence for at least seven single drugs preventing postoperative vomiting. However, there is still considerable lack of evidence regarding safety aspects that does warrant investigation.
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Affiliation(s)
- Stephanie Weibel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Nathan L Pace
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anaesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Diana Raj
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Queen Elizabeth University Hospital, Glasgow, UK
| | - Tobias Schlesinger
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Peter Kienbaum
- Department of Anaesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Leopold H J Eberhart
- Department of Anaesthesiology & Intensive Care Medicine, Philipps-University Marburg, Marburg, Germany
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
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An overview of the evidence for enhanced recovery. SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2021.100826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Huepenbecker SP, Iniesta MD, Zorrilla-Vaca A, Ramirez PT, Cain KE, Vaughn M, Cata JP, Mena GE, Lasala J, Meyer LA. Incidence of acute kidney injury after open gynecologic surgery in an enhanced recovery after surgery pathway. Gynecol Oncol 2021; 163:191-198. [PMID: 34400005 DOI: 10.1016/j.ygyno.2021.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/06/2021] [Accepted: 08/08/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine the incidence of postoperative AKI after open gynecologic surgery within ERAS, compare AKI in pre-ERAS and ERAS cohorts, and identify factors associated with AKI. METHODS We compared postoperative AKI in patients who underwent open gynecologic surgery at one institution before and after ERAS implementation. AKI was defined as acute risk, injury, or failure by RIFLE criteria. Pre-ERAS and ERAS cohorts were matched using propensity score analysis in a 1:1 fashion using the nearest neighbor technique. Chi-squared, Fisher's Exact, and Wilcoxon rank-sum tests were used. RESULTS Among 1334 ERAS and 191 pre-ERAS patients, postoperative AKI incidence was higher in the ERAS cohort (13.1% vs 5.8%, p = .004). In 166 matched pairs, ERAS patients had higher incidence (16.9% vs 5.4%, p < .001) and odds (OR 3.54, 95% CI 1.61-7.76) of AKI. Within ERAS, AKI was associated with older age (median age 65 vs 57, p < .001), Charlson Comorbidity Index score ≥ 3 (71.4% vs 57.9%, p < .001), and higher intraoperative estimated blood loss (400 vs 225 mL, p < .001), fluid administration (net fluid balance +1535 vs 1261 mL, p < .001), and hypotension lasting >5 min (41.7% vs 30.7%, p < .001). ERAS patients with AKI had longer hospital stays (median 4 vs 3 days, p < .001) and more readmissions (19% vs. 10%, p < .001) and grade 3+ complications (26% vs. 7%, p < .001). CONCLUSIONS The incidence and odds of postoperative AKI was higher after gynecologic surgery within ERAS, and patients with AKI were more likely to have complications. Potential strategies to prevent postoperative AKI include perioperative fluid and blood pressure optimization.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrés Zorrilla-Vaca
- Department of Anesthesia and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Katherine E Cain
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Micah Vaughn
- The University of Texas Medical Branch, Galveston, TX, USA
| | - Juan P Cata
- Department of Anesthesia and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gabriel E Mena
- Department of Anesthesia and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Javier Lasala
- Department of Anesthesia and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Hendri AZ, Khalilullah SA, Aditya GA. A preliminary outcome of modified enhanced recovery protocol versus standard of care in radical cystectomy: an Indonesian experience. AFRICAN JOURNAL OF UROLOGY 2021. [DOI: 10.1186/s12301-021-00213-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
This study aimed to evaluate the outcomes of modified Enhanced Recovery After Surgery (ERAS) protocol and standard of care (SC) in bladder cancer patients who underwent radical cystectomy (RC). The length of stay and complications rates were the primary outcomes. Time functional recovery, bowel movement, mobilization, drain removal, and other perioperative outcomes were the secondary outcomes.
Methods
A cohort retrospective study was conducted to investigate the effectiveness of the modified ERAS protocol compared to SC in 61 patients who underwent RC (36 ERAS vs. 25 SC).
Results
The modified ERAS protocol was associated with shorter length of stay (9.3 ± 5.0 days vs. 12.6 ± 6.7 days, P = 0.032) and reduction in important postoperative milestones, including days to first solid diet (3.5 ± 1.6 vs. 5.5 ± 1.5, P = 0.000), days to first defecation (4.8 ± 2.4 vs. 7.2 ± 2.4, P = 0.001), days to first walking (4.7 ± 2.2 vs. 7.9 ± 2.4, P = 0.000), and days to drain removal (3.9 ± 1.3 vs. 5.9 ± 2.5 P = 0.001). Postoperative complications rates were lower in the modified ERAS groups, but the result was not statistically significant (P = 0.282). Also, there were no significant differences between transfusion requiring, intensive care monitoring, re-operation, and re-admission between groups.
Conclusion
This study demonstrated that the modified ERAS protocol for RC can accelerate postoperative recovery without any adverse effects on morbidity and mortality.
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Regenbogen SE, Cain-Nielsen AH, Syrjamaki JD, Norton EC. Clinical and Economic Outcomes of Enhanced Recovery Dissemination in Michigan Hospitals. Ann Surg 2021; 274:199-205. [PMID: 33351489 PMCID: PMC8211908 DOI: 10.1097/sla.0000000000004726] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate real-world effects of enhanced recovery protocol (ERP) dissemination on clinical and economic outcomes after colectomy. SUMMARY BACKGROUND DATA Hospitals aiming to accelerate discharge and reduce spending after surgery are increasingly adopting perioperative ERPs. Despite their efficacy in specialty institutions, most studies have lacked adequate control groups and diverse hospital settings and have considered only in-hospital costs. There remain concerns that accelerated discharge might incur unintended consequences. METHODS Retrospective, population-based cohort including patients in 72 hospitals in the Michigan Surgical Quality Collaborative clinical registry (N = 13,611) and/or Michigan Value Collaborative claims registry (N = 14,800) who underwent elective colectomy, 2012 to 2018. Marginal effects of ERP on clinical outcomes and risk-adjusted, price-standardized 90-day episode payments were evaluated using mixed-effects models to account for secular trends and hospital performance unrelated to ERP. RESULTS In 24 ERP hospitals, patients Post-ERP had significantly shorter length of stay than those Pre-ERP (5.1 vs 6.5 days, P < 0.001), lower incidence of complications (14.6% vs 16.9%, P < 0.001) and readmissions (10.4% vs 11.3%, P = 0.02), and lower episode payments ($28,550 vs $31,192, P < 0.001) and postacute care ($3,384 vs $3,909, P < 0.001). In mixed-effects adjusted analyses, these effects were significantly attenuated-ERP was associated with a marginal length of stay reduction of 0.4 days (95% confidence interval 0.2-0.6 days, P = 0.001), and no significant difference in complications, readmissions, or overall spending. CONCLUSIONS ERPs are associated with small reduction in postoperative length of hospitalization after colectomy, without unwanted increases in readmission or postacute care spending. The real-world effects across a variety of hospitals may be smaller than observed in early-adopting specialty centers.
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Affiliation(s)
- Scott E Regenbogen
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
| | - Anne H Cain-Nielsen
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - John D Syrjamaki
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
| | - Edward C Norton
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Economics, University of Michigan, Ann Arbor, Michigan
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Connolly JG, Tan KS, Mastrogiacomo B, Dycoco J, Caso R, Jones GD, McCormick PJ, Sanchez-Vega F, Irie T, Scarpa JR, Gupta HV, Adusumilli PS, Rocco G, Isbell JM, Bott MJ, Fischer GW, Jones DR, Mincer JS. Intraoperative opioid exposure, tumour genomic alterations, and survival differences in people with lung adenocarcinoma. Br J Anaesth 2021; 127:75-84. [PMID: 34147159 PMCID: PMC8258974 DOI: 10.1016/j.bja.2021.03.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/01/2021] [Accepted: 03/06/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Opioids have been linked to worse oncologic outcomes in surgical patients. Studies in certain cancer types have identified associations between survival and intra-tumoural opioid receptor gene alterations, but no study has investigated whether the tumour genome interacts with opioid exposure to affect survival. We sought to determine whether intraoperative opioid exposure is associated with recurrence-specific survival and overall survival in early-stage lung adenocarcinoma, and whether selected tumour genomics are associated with this relationship. Associations between ketamine and dexmedetomidine and outcomes were also studied. METHODS Surgical patients (N=740) with pathological stage I-III lung adenocarcinoma and next-generation sequencing data were retrospectively reviewed from a prospectively maintained database. RESULTS On multivariable analysis, ketamine administration was protective for recurrence-specific survival (hazard ratio = 0.44, 95% confidence interval 0.24-0.80; P=0.007), compared with no adjunct. Higher intraoperative oral morphine milligram equivalents were significantly associated with worse overall survival (hazard ratio=1.09/10 morphine milligram equivalents, 95% confidence interval 1.02-1.17; P=0.010). Significant interaction effects were found between morphine milligram equivalents and fraction genome altered and morphine milligram equivalents and CDKN2A, such that higher fraction genome altered or CDKN2A alterations were associated with worse overall survival at higher morphine milligram equivalents (P=0.044 and P=0.052, respectively). In contrast, alterations in the Wnt (P=0.029) and Hippo (P=0.040) oncogenic pathways were associated with improved recurrence-specific survival at higher morphine milligram equivalents, compared with unaltered pathways. CONCLUSIONS Intraoperative opioid exposure is associated with worse overall survival, whereas ketamine exposure is associated with improved recurrence-specific survival in patients with early-stage lung adenocarcinoma. This is the first study to investigate tumour-specific genomic interactions with intraoperative opioid administration to modify survival associations.
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Affiliation(s)
- James G Connolly
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kay See Tan
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brooke Mastrogiacomo
- Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph Dycoco
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Raul Caso
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gregory D Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Patrick J McCormick
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Francisco Sanchez-Vega
- Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Takeshi Irie
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Joseph R Scarpa
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Hersh V Gupta
- Dana-Farber Brigham and Women's Cancer Center, Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Prasad S Adusumilli
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Druckenmiller Center for Lung Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gaetano Rocco
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Druckenmiller Center for Lung Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James M Isbell
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Druckenmiller Center for Lung Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Matthew J Bott
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Druckenmiller Center for Lung Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gregory W Fischer
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - David R Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Druckenmiller Center for Lung Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Joshua S Mincer
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA.
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Liu L, Zhang J, Wang G, Guo C, Chen Y, Huang C, Li S. Delayed Discharge after Thoracic Surgery under the Guidance of ERAS Protocols. Thorac Cardiovasc Surg 2021; 70:405-412. [PMID: 34176111 DOI: 10.1055/s-0041-1727232] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols have been applied in thoracic surgery and are beneficial to patients. However, some issues about ERAS are still pending. METHODS A total of 1,654 patients who underwent thoracic surgery under the guidance of ERAS protocols were enrolled in this study. We set the length of postoperative stay (LOPS) as our key research indicator. Patients were divided into routine discharge group and delayed discharge group based on LOPS. Causes of delayed discharge were analyzed to improve management of postoperative recovery. RESULTS Male, old age, underlying disease (coronary artery disease, chronic kidney disease, old cerebral infarction, chronic obstructive pulmonary disease, and arrhythmia), intensive care unit (ICU) stay, type of insurance, and lower forced expiratory volume in one second (FEV1) are the independent impact factors causing delayed discharge. Increased nonchylous drainage (INCD) and prolonged air leakage were the two leading causes for delayed discharge. CONCLUSION Patients should have personalized recovery goal under the same ERAS protocols. We should accept that patients in poor general condition have a prolonged LOPS. More stringent ICU stay indications should be developed to increase postoperative patients' ERAS protocols compliance. Further research on chest tube management will make a contribution to ERAS protocols.
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Affiliation(s)
- Lei Liu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Dongcheng-qu, Beijing, People's Republic of China
| | - Jiaqi Zhang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Dongcheng-qu, Beijing, People's Republic of China
| | - Guige Wang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Dongcheng-qu, Beijing, People's Republic of China
| | - Chao Guo
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Dongcheng-qu, Beijing, People's Republic of China
| | - Yeye Chen
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Dongcheng-qu, Beijing, People's Republic of China
| | - Cheng Huang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Dongcheng-qu, Beijing, People's Republic of China
| | - Shanqing Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Dongcheng-qu, Beijing, People's Republic of China
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Li R, Wang K, Qu C, Qi W, Fang T, Yue W, Tian H. The effect of the enhanced recovery after surgery program on lung cancer surgery: a systematic review and meta-analysis. J Thorac Dis 2021; 13:3566-3586. [PMID: 34277051 PMCID: PMC8264698 DOI: 10.21037/jtd-21-433] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/14/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Lung cancer is one of the most common causes of cancer-related death worldwide. The enhanced recovery after surgery (ERAS) program is an effective evidence-based multidisciplinary protocol of perioperative care. However, the roles of ERAS in lung cancer surgery remain unclear. This systematic review and meta-analysis aimed to investigate the short-term impact of the ERAS program on lung resection surgery, especially in relation to postoperative complications. METHODS A systematic literature search of PubMed, EMBASE, and the Cochrane Library databases until October 2020 was performed to identify the studies that implemented an ERAS program in lung cancer surgery. The studies were selected and subjected to data extraction by 2 reviewers independently, which was followed by quality assessment. A random effects model was used to calculate overall effect sizes. Risk ratio (RR), risk difference (RD), and standardized mean difference (SMD) with 95% confidence interval (CI) served as the summary statistics for meta-analysis. Subgroup analysis and sensitivity analysis were subsequently performed. RESULTS A total of 21 studies with 6,480 patients were included. The meta-analysis indicated that patients in the ERAS group had a significantly reduced risk of postoperative complications (RR =0.64; 95% CI: 0.52 to 0.78) and shortened postoperative length of stay (SMD=-1.58; 95% CI: -2.38 to -0.79) with a significant heterogeneity. Subgroup analysis showed that the risks of pulmonary (RR =0.58; 95% CI: 0.45 to 0.75), cardiovascular (RR =0.73; 95% CI: 0.59 to 0.89), urinary (RR =0.53; 95% CI: 0.32 to 0.88), and surgical complications (RR =0.64; 95% CI: 0.42 to 0.97) were significantly lower in the ERAS group. No significant reduction was found in the in-hospital mortality (RD =0.00; 95% CI: -0.01 to 0.00) and readmission rate (RR =1.00; 95% CI: 0.76 to 1.32). In the qualitative review, most of the evidence reported significantly decreased hospitalization costs in the ERAS group. CONCLUSIONS The implementation of an ERAS program for surgery of lung cancer can effectively reduce risks of postoperative complications, length of stay, and costs of patients who have undergone lung cancer surgery without compromising their safety.
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Affiliation(s)
- Rongyang Li
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Kun Wang
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chenghao Qu
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Weifeng Qi
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Tao Fang
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Weiming Yue
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Hui Tian
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
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Brolet EA, Joris JL, Monseur JJ, Donneau AFH, Slim K. Impact of non-steroidal anti-inflammatory drugs on the efficiency of enhanced recovery programmes after colorectal surgery: a retrospective study of the GRACE database. Anaesth Crit Care Pain Med 2021; 40:100880. [PMID: 33965647 DOI: 10.1016/j.accpm.2021.100880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 02/28/2021] [Accepted: 02/28/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Multimodal analgesia is considered a key element of enhanced recovery programmes (ERPs) after colorectal surgery. We investigated the effects of NSAIDs, a major component of multimodal analgesia on adherence to ERP, incidence of postoperative complications, and length of hospital stay (LOS). METHODS This was a retrospective study of the GRACE database that included 8611 patients scheduled for colorectal surgery with an ERP between February 2016 and November 2019. Primary endpoints were adherence to the postoperative protocol, the rate and type of postoperative complications, and LOS. Data are median [IQR] and number (per cent). Multivariate models were used to assess the effects of NSAIDs on these variables taking into account potential confounding factors. RESULTS Data from 8258 patients were analysed and classified into four groups according to whether NSAIDs had been given intra- and/or postoperatively or not at all; 4578 patients were given NSAIDs intra- and/or postoperatively and 3680 patients received no NSAIDs. Use of NSAIDs was significantly (P<0.001) associated with improved adherence to the postoperative protocol (4.0 [3.0-4.0] vs. 3.0 [2.0-4.0] items), a reduced incidence of complications (21.1% vs. 29.2%), and a shortened LOS (5.0 [3.0-7.0] vs. 6.0 [4.0-9.0] days) compared to the no-NSAIDs group. Multivariate analyses adjusted for the confounding factors confirmed a significant (P<0.001) beneficial impact of NSAIDs on these three primary endpoints. CONCLUSION This study suggests that perioperative NSAID use results in better adherence to the postoperative protocol, fewer postoperative in-hospital complications, and shorter LOS after colorectal surgery.
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Affiliation(s)
- Etienne A Brolet
- Department of Anaesthesia and Intensive Care Medicine, CHU Liège, University of Liège, Liège, Belgium
| | - Jean L Joris
- Department of Anaesthesia and Intensive Care Medicine, CHU Liège, University of Liège, Liège, Belgium; Groupe Francophone de Réhabilitation Améliorée Après Chirurgie (GRACE, Francophone Group for Enhanced Recovery After Surgery, www.grace-asso.fr), Beaumont, France.
| | - Justine J Monseur
- Biostatistics Unit, Department of Public Health, University of Liège, Liège, Belgium
| | | | - Karem Slim
- Groupe Francophone de Réhabilitation Améliorée Après Chirurgie (GRACE, Francophone Group for Enhanced Recovery After Surgery, www.grace-asso.fr), Beaumont, France; Service of Digestive Surgery and Unit of Ambulatory Surgery, CHU Estaing, 63003 Clermont-Ferrand, France
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- Groupe Francophone de Réhabilitation Améliorée Après Chirurgie (GRACE, Francophone Group for Enhanced Recovery After Surgery, www.grace-asso.fr), Beaumont, France
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Proposal and Validation of a New Classification of Surgical Outcomes after Colorectal Resections within an Enhanced Recovery Programme. Surg Res Pract 2021; 2021:8864555. [PMID: 34056059 PMCID: PMC8131168 DOI: 10.1155/2021/8864555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 05/03/2021] [Indexed: 01/08/2023] Open
Abstract
Background Advantages of Enhanced Recovery (ER) programmes in colorectal surgery have already been demonstrated, but heterogeneity exists with respect to the choice of compared outcomes. A comprehensive classification aimed at standardizing the reporting of surgical outcomes has been proposed and validated. Method Clinical variables of 231 patients who underwent colorectal resections within an ER programme from 2013–2018 were analysed. Their outcomes have been reported according to a new classification in 5 classes and 11 subclasses. Prognostic variables have been identified. Results Seventy-nine patients (34.2%) had an optimal class 1 outcome. Almost half of the patients had an uneventful recovery after being discharged after day 4 (2a). Only two patients (0.9%) were discharged early and then readmitted for a minor ailment (2b). Total morbidity was 12.6% (3a–5). Perioperative mortality was 2.6% (5). Young age, laparoscopic resection, and years of experience with ER have been identified as independent prognostic factors towards a totally positive outcome. Conclusions The proposed outcome classification is a simple and objective tool to report the surgical outcome in clinical studies. Its implementation seems to be appropriate, in particular, in the field of ER protocols in colorectal surgery, but it can have a wider application in any other surgical subspeciality.
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Liu JY, Perez SD, Balch GG, Sullivan PS, Srinivasan JK, Staley CA, Sweeney J, Sharma J, Shaffer VO. Elderly Patients Benefit From Enhanced Recovery Protocols After Colorectal Surgery. J Surg Res 2021; 266:54-61. [PMID: 33984731 DOI: 10.1016/j.jss.2021.01.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/27/2021] [Accepted: 01/29/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Enhanced recovery protocols (ERAS) aim to decrease physiological stress response to surgery and maintain postoperative physiological function. Proponents of ERAS state these protocols decrease lengths of stay (LOS) and complication rates. Our aim was to assess whether elderly patients receive the same benefit as younger patients using ERAS protocols. METHODS We queried patients from 2015 to 2017 at our institution with Enhanced Recovery in Surgery (ERIN) variables from the targeted colectomy NSQIP database. The patients were divided into sextiles and analyzed for readmission, LOS, return of bowel function, tolerating diet, mobilization, and multimodal pain management comparing the youngest sextile to the oldest sextile. RESULTS Two hundred sixty-two patients (73% colectomies) were enrolled in ERAS. When compared with the youngest sextile (age 19-43.8), the oldest sextile (age 71.4-92.5) had similar readmission rates at 9.8% versus 9.5% (P-value = 0.87), quicker return of bowel function, average 1.9 d versus 3.7 d (P-value < 0.01), and tolerated diet quicker, average POD 2.4 d versus 5.1 d (P-value < 0.01). There was a slight decrease in the use of multimodal pain management 88% versus 100% (P-value = 0.07), but mobilization on POD1 was slightly better in the elderly at 80% versus 78% (P-value = 0.76). Elderly patients enrolled in ERAS had an average LOS of 4.9 days versus 7.8 in the younger patients (P-value = 0.08). Among elderly non-ERAS patients average LOS was 14.6 days. CONCLUSION Overall, elderly patients fared better or the same on the ERIN variables analyzed than the younger cohort. ERAS protocols are beneficial and applicable to elderly patients undergoing colorectal surgery.
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Affiliation(s)
- Jessica Y Liu
- Department of Surgery, Emory University, Atlanta, Georgia.
| | | | - Glen G Balch
- Department of Surgery, Emory University, Atlanta, Georgia
| | | | | | | | - John Sweeney
- Department of Surgery, Emory University, Atlanta, Georgia
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Fuller S, Kumar SR, Roy N, Mahle WT, Romano JC, Nelson JS, Hammel JM, Imamura M, Zhang H, Fremes SE, McHugh-Grant S, Nicolson SC. The American Association for Thoracic Surgery Congenital Cardiac Surgery Working Group 2021 consensus document on a comprehensive perioperative approach to enhanced recovery after pediatric cardiac surgery. J Thorac Cardiovasc Surg 2021; 162:931-954. [PMID: 34059337 DOI: 10.1016/j.jtcvs.2021.04.072] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - S Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, and Department of Pediatrics, Keck School of Medicine of the University of Southern California, Heart Institute, Children's Hospital Los Angeles, Los Angeles, Calif.
| | - Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, Mass
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jennifer C Romano
- Departments of Cardiac Surgery and Pediatrics, University of Michigan, CS Mott Children's Hospital, Ann Arbor, Mich
| | - Jennifer S Nelson
- Department of Cardiovascular Services, Nemours Children's Hospital, and Department of Surgery, University of Central Florida College of Medicine, Orlando, Fla
| | - James M Hammel
- Department of Cardiothoracic Surgery, Children's Hospital and Medical Center of Omaha, Omaha, Neb
| | - Michiaki Imamura
- Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sara McHugh-Grant
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Penn
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Penn
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73
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Balvardi S, Pecorelli N, Castelino T, Niculiseanu P, Alhashemi M, Liberman AS, Charlebois P, Stein B, Carli F, Mayo NE, Feldman LS, Fiore JF. Impact of Facilitation of Early Mobilization on Postoperative Pulmonary Outcomes After Colorectal Surgery: A Randomized Controlled Trial. Ann Surg 2021; 273:868-875. [PMID: 32324693 DOI: 10.1097/sla.0000000000003919] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To estimate the extent to which staff-directed facilitation of early mobilization impacts recovery of pulmonary function and 30-day postoperative pulmonary complications (PPCs) after colorectal surgery. SUMMARY BACKGROUND DATA Early mobilization after surgery is believed to improve pulmonary function and prevent PPCs; however, adherence is low. The value of allocating resources (eg, staff time) to increase early mobilization is unknown. METHODS This study involved the analysis of a priori secondary outcomes of a pragmatic, observer-blind, randomized trial. Consecutive patients undergoing colorectal surgery were randomized 1:1 to usual care (preoperative education) or facilitated mobilization (staff dedicated to assist transfers and walking during hospital stay). Forced vital capacity, forced expiratory volume in 1 second (FEV1), and peak cough flow were measured preoperatively and at 1, 2, 3 days and 4 weeks after surgery. PPCs were defined according to the European Perioperative Clinical Outcome Taskforce. RESULTS Ninety-nine patients (57% male, 80% laparoscopic, median age 63, and predicted FEV1 97%) were included in the intention-to-treat analysis (usual care 49, facilitated mobilization 50). There was no between-group difference in recovery of forced vital capacity [adjusted difference in slopes 0.002 L/d (95% CI -0.01 to 0.01)], FEV1 [-0.002 L/d (-0.01 to 0.01)] or peak cough flow [-0.002 L/min/d (-0.02 to 0.02)]. Thirty-day PPCs were also not different between groups [adjusted odds ratio 0.67 (0.23-1.99)]. CONCLUSIONS In this randomized controlled trial, staff-directed facilitation of early mobilization did not improve postoperative pulmonary function or reduce PPCs within an enhanced recovery pathway for colorectal surgery. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02131844.
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Affiliation(s)
- Saba Balvardi
- Department of Surgery, McGill University, Montreal, QC, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Nicolò Pecorelli
- Department of Surgery, McGill University, Montreal, QC, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Tanya Castelino
- Department of Surgery, McGill University, Montreal, QC, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Petru Niculiseanu
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Mohsen Alhashemi
- Department of Surgery, McGill University, Montreal, QC, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | | | | | - Barry Stein
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Franco Carli
- Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Nancy E Mayo
- Division of Clinical Epidemiology, McGill University, Montreal, QC, Canada
| | - Liane S Feldman
- Department of Surgery, McGill University, Montreal, QC, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Julio F Fiore
- Department of Surgery, McGill University, Montreal, QC, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
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Bellas-Cot.ín S, Casans-Franc..s R, Ib.í..ez C, Muguruza I, Mu..oz-Alameda LE. Implementation of an ERAS program in patients undergoing thoracic surgery at a third-level university hospital: an ambispective cohort study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2021; 73:16-24. [PMID: 33930342 PMCID: PMC9801216 DOI: 10.1016/j.bjane.2021.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 03/16/2021] [Accepted: 04/14/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To analyze the effects of an ERAS program on complication rates, readmission, and length of stay in patients undergoing pulmonary resection in a tertiary university hospital. METHODS Ambispective cohort study with a prospective arm of 50 patients undergoing thoracic surgery within an ERAS program (ERAS group) versus a retrospective arm of 50 patients undergoing surgery before the protocol was implemented (Standard group). The primary outcome was the number of patients with 30-day surgical complications. Secondary outcomes included ERAS adherence, non-surgical complications, mortality, readmission, reintervention rate, pain, and hospital length of stay. We performed a multivariate logistic analysis to study the correlation between outcomes and ERAS adherence. RESULTS In the univariate analysis, we found no difference between the two groups in terms of surgical complications (Standard 18 [36%] vs. ERAS 12 [24%], p=0.19). In the ERAS group, only the readmission rate was significantly lower (Standard 15 [30%] vs. ERAS 6 [12%], p=0.03). In the multivariate analysis, ERAS adherence was the only factor associated with a reduction in surgical complications (OR [95% CI]=0.02 [0.00, 0.59], p=0.03) and length of stay (HR [95% CI]=18.5 [4.39, 78.4], p<0.001). CONCLUSIONS The ERAS program significantly reduced the readmission rate at our hospital. Adherence to the ERAS protocol reduced surgical complications and length of stay.
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Affiliation(s)
- Soledad Bellas-Cot.ín
- Hospital Universitario Fundaci..n Jim..nez D.¡az, Department of Anaesthesiology, Madrid, Spain,Corresponding author.
| | - Rub..n Casans-Franc..s
- Hospital Universitario Infanta Elena, Department of Anaesthesiology, Valdemoro, Madrid, Spain
| | - Cristina Ib.í..ez
- Hospital Universitario Fundaci..n Jim..nez D.¡az, Department of Anaesthesiology, Madrid, Spain
| | - Ignacio Muguruza
- Hospital Universitario Fundaci..n Jim..nez D.¡az, Department of Thoracic Surgery, Madrid, Spain
| | - Luis E. Mu..oz-Alameda
- Hospital Universitario Fundaci..n Jim..nez D.¡az, Department of Anaesthesiology, Madrid, Spain
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75
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Blache G, El Hajj H, Jauffret C, Houvenaeghel G, Sabiani L, Barrou J, Masquin I, Le Saout J, Mokart D, Faucher M, Lambaudie E. Care as Usual: An Acceptable Strategy to Apply During the COVID-19 Pandemic in a French Tertiary Gynecologic Oncology Department. Front Oncol 2021; 11:653009. [PMID: 33968755 PMCID: PMC8097084 DOI: 10.3389/fonc.2021.653009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/23/2021] [Indexed: 01/08/2023] Open
Abstract
We describe and analyze a “care as usual” strategy of a French Comprehensive Cancer Center during the COVID-19 pandemic to manage surgical patients with gynecological cancer. We conducted a retrospective analysis evaluating the surgical activity in our gynecologic oncology department between January 21 and May 12, 2020. We compared the surgical activity and surgical and oncologic outcomes during the pre-lockdown period and the pandemic period. The main objective was to evaluate the impact of the COVID-19 pandemic on surgical activity. The secondary objectives were to analyze the surgical and the oncologic outcomes. We compared the surgical activity during the 8 weeks after the national lockdown (85 procedures) to the surgical activity in the 8 weeks preceding the lockdown (127 procedures). We observed a 33% decrease in activity between the two periods. The clinical and epidemiologic characteristics were similar between the two periods. There were no differences between the surgical approaches (p = 0.592), the surgical complexity (p = 0.323), the length of stay (p = 0.85), and even for the complex procedure (p = 0.96) and the perioperative (p = 0.791) and postoperative complication rates (p = 0.102). We observed a significant decrease in the time of return to intended oncological treatment (RIOT) during the lockdown period with an average of 31.9 days compared to 46.9 days in the pre-lockdown period (p = 0.003). During the COVID-19 pandemic, “care as usual” represents an acceptable strategy without impairing the oncologic outcome in a Comprehensive Cancer Center with a patient-centered clinical pathway for gynecologic oncologic surgical patients.
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Affiliation(s)
- Guillaume Blache
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Houssein El Hajj
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Camille Jauffret
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Gilles Houvenaeghel
- Department of surgical oncology, Institut Paoli-Calmettes and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, France
| | - Laura Sabiani
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Julien Barrou
- Department of surgical oncology, Institut Paoli-Calmettes and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, France
| | - Isabelle Masquin
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Jérémy Le Saout
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Djamel Mokart
- Department of Anesthesiology and Critical Care, Paoli Calmettes Institute, Marseille, France
| | - Marion Faucher
- Department of Anesthesiology and Critical Care, Paoli Calmettes Institute, Marseille, France
| | - Eric Lambaudie
- Department of surgical oncology, Institut Paoli-Calmettes and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, France
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Ye K, Zhong Z, Zhu L, Ren J, Xiao M, Liu W, Xiong W. Modified transperitoneal versus retroperitoneal laparoscopic radical nephroureterectomy in the management of upper urinary tract urothelial carcinoma: Best practice in a single center with updated results. J Int Med Res 2021; 48:300060520928788. [PMID: 32538682 PMCID: PMC7297496 DOI: 10.1177/0300060520928788] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective Radical nephroureterectomy remains the gold standard for the surgical treatment of upper urinary tract urothelial carcinoma (UTUC). Based on previous research, we prospectively compared the advantages of transperitoneal laparoscopic radical nephroureterectomy (TLNU) with a three-port technique in a single position versus retroperitoneal laparoscopic radical nephroureterectomy (RLNU). Methods We evaluated 48 patients diagnosed with UTUC at our institution from January 2015 to October 2019. The patients underwent either TLNU (n = 24) or RLNU (n = 24). We randomly assigned the patients to each technique group based on their body mass index because our experience has shown that the body mass index is the main interfering factor for this surgery. The baseline characteristics and perioperative outcomes were compared between the groups. Results We found no significant differences in the baseline characteristics, time until recovery of intestinal function, or postoperative hospital stay between the two groups. However, the TLNU group had a shorter operation time and better postoperative pain control than the RLNU group. Conclusion Modified TLNU is associated with a shorter operative time and less severe postoperative pain compared with RLNU. Both techniques are safe and reliable with adequate management, and their therapeutic effects are comparable in other aspects.
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Affiliation(s)
- Kun Ye
- Department of Urology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.,Uro-Oncology Institute of Central South University, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhaohui Zhong
- Department of Urology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.,Uro-Oncology Institute of Central South University, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Liang Zhu
- Department of Urology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.,Uro-Oncology Institute of Central South University, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jiannan Ren
- Department of Urology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.,Uro-Oncology Institute of Central South University, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ming Xiao
- Department of Urology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.,Uro-Oncology Institute of Central South University, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wentao Liu
- Department of Urology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.,Uro-Oncology Institute of Central South University, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wei Xiong
- Department of Urology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.,Uro-Oncology Institute of Central South University, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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77
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Elango M, Papalois V. Working towards an ERAS Protocol for Pancreatic Transplantation: A Narrative Review. J Clin Med 2021; 10:1418. [PMID: 33915899 PMCID: PMC8036565 DOI: 10.3390/jcm10071418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/24/2021] [Accepted: 03/27/2021] [Indexed: 12/11/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) initially started in the early 2000s as a series of protocols to improve the perioperative care of surgical patients. They aimed to increase patient satisfaction while reducing postoperative complications and postoperative length of stay. Despite these protocols being widely adopted in many fields of surgery, they are yet to be adopted in pancreatic transplantation: a high-risk surgery with often prolonged length of postoperative stay and high rate of complications. We have analysed the literature in pancreatic and transplantation surgery to identify the necessary preoperative, intra-operative and postoperative components of an ERAS pathway in pancreas transplantation.
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Affiliation(s)
- Madhivanan Elango
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK;
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78
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Licina A, Silvers A, Laughlin H, Russell J, Wan C. Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components. BMC Anesthesiol 2021; 21:74. [PMID: 33691620 PMCID: PMC7944908 DOI: 10.1186/s12871-021-01281-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 02/16/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Enhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on available evidence. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review. METHODS We included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies in adults and pediatric patients evaluating any one of the 22 pre-defined components. Our primary outcomes included all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). Following databases (1990 onwards) were searched: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two authors screened the citations, full-text articles, and extracted data. A narrative synthesis was provided. We constructed Evidence Profile (EP) tables for each component of the pathway, where appropriate information was available. Due to clinical and methodological heterogeneity, we did not conduct a meta-analyses. GRADE system was used to classify confidence in cumulative evidence for each component of the pathway. RESULTS We identified 5423 relevant studies excluding duplicates as relating to the 22 pre-defined components of enhanced recovery in spinal surgery. We included 664 studies in the systematic review. We identified specific evidence within the context of spinal surgery for 14/22 proposed components. Evidence was summarized in EP tables where suitable. We performed thematic synthesis without EP for 6/22 elements. We identified appropriate societal guidelines for the remainder of the components. CONCLUSIONS We identified the following components with high quality of evidence as per GRADE system: pre-emptive analgesia, peri-operative blood conservation (antifibrinolytic use), surgical site preparation and antibiotic prophylaxis. There was moderate level of evidence for implementation of prehabilitation, minimally invasive surgery, multimodal perioperative analgesia, intravenous lignocaine and ketamine use as well as early mobilization. This review allows for the first formalized evidence-based unified protocol in the field of ERSS. Further studies validating the multimodal ERSS framework are essential to guide the future evolution of care in patients undergoing spinal surgery.
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Affiliation(s)
- Ana Licina
- Austin Health, 145 Studley Road, Heidelberg, Victoria 3084 Australia
| | - Andrew Silvers
- Monash Health, Clayton, Australia, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria Australia
| | | | - Jeremy Russell
- Department of Neurosurgery, Austin Health, Melbourne, Victoria, Australia
| | - Crispin Wan
- Royal Hobart Hospital, Hobart, Tasmania, Australia
- St Vincent’s Hospital, Melbourne, Australia
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79
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Wang C, Lai Y, Li P, Su J, Che G. Influence of enhanced recovery after surgery (ERAS) on patients receiving lung resection: a retrospective study of 1749 cases. BMC Surg 2021; 21:115. [PMID: 33676488 PMCID: PMC7936477 DOI: 10.1186/s12893-020-00960-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 11/12/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The study aimed to evaluate the outcomes following the implementation of enhanced recovery after surgery (ERAS) for patients undergoing lung cancer surgery. METHOD A retrospective cohort study involving 1749 patients with lung cancer undergoing pulmonary resection was conducted. The patients were divided into two time period groups for analysis (routine pathway and ERAS pathway). Logistic regression analysis was performed to assess the risks of developing postoperative pulmonary complications. RESULTS Among the 1749 patients, 691 were stratified into the ERAS group, and 1058 in to the routine group. The ERAS group presented with shorter postoperative in-hospital length of stay (LOS) (4.0 vs 6.0, P < 0.001), total LOS (10.0 vs. 13.0 days, P < 0.001), and lower total in-hospital costs (P < 0.001), including material (P < 0.001) and drug expenses (P < 0.001). Furthermore, the ERAS group also presented with a lower occurrence of postoperative pulmonary complications (PPCs) than the routine group (15.2% vs. 19.5%, P = 0.022). Likewise, a significantly lower occurrence of pneumonia (8.4% vs. 14.2%, P < 0.001) and atelectasis (5.9% vs. 9.8%, P = 0.004) was found in the ERAS group. Regarding the binary logistic regression, the ERAS intervention was the sole independent factor for the occurrence of PPCs (OR: 0.601, 95% CI 0.434-0.824, P = 0.002). In addition, age (OR: 1.032, 95% CI 1.018-1.046), COPD (OR: 1.792, 95% CI 1.196-2.686), and FEV1 (OR: 0.205, 95% CI 0.125-0.339) were also independent predictors of PPCs. CONCLUSION Implementation of an ERAS pathway shows improved postoperative outcomes, including shortened LOS, lower in-hospital costs, and reduced occurrence of PPCs, providing benefits to the postoperative recovery of patients with lung cancer undergoing surgical treatment.
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Affiliation(s)
- Chunmei Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Yutian Lai
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Pengfei Li
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Jianhuan Su
- Rehabilitation Department, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Guowei Che
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
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Mattson J, Thayer M, Mott SL, Lyons YA, Hardy-Fairbanks A, Hill EK. Multimodal perioperative pain protocol for gynecologic laparotomy is associated with reduced hospital length of stay. J Obstet Gynaecol Res 2021; 47:1082-1089. [PMID: 33559303 DOI: 10.1111/jog.14640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/07/2020] [Accepted: 12/17/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The primary objective was to evaluate the impact of a multimodal perioperative pain regimen on length of hospital stay for patients undergoing laparotomy with a gynecologic oncologist. METHODS We compared 52 patients who underwent laparotomy with a gynecologic oncologist at a single institution between 2017 and 2018, after implementation of a multimodal perioperative pain regimen, to a historic cohort of 94 patients (2016-2017). The multimodal pain regimen included pre- and post-operative administration of oral acetaminophen, gabapentin, and celecoxib, in addition to standard narcotics and optional epidural analgesia. Demographic, surgical, and post-operative data were collected. RESULTS On multivariable analysis, bowel resection, stage, surgery length, age, and cohort group were retained as significant independent predictors of length of stay. Patients undergoing laparotomy prior to the pain protocol had a length of stay 1.26 times longer than patients during the post-implementation period (p < 0.01). For complex surgical patients, this translated into a reduction in length of hospital stay of 1.73 days. There was a significant reduction in pain scale score on post-operative day zero from 5 to 3 (p = 0.02) and a non-significant overall reduction of post-operative morphine equivalents, with similar adverse outcomes. CONCLUSION Implementation of a multimodal perioperative pain regimen in patients undergoing gynecologic oncology laparotomy was associated with a significant reduction of length of hospital stay and improved patient-perceived pain, even in the absence of a complete Enhanced Recovery After Surgery (ERAS) protocol.
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Affiliation(s)
- Jordan Mattson
- Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, Minnesota, USA
| | - MacKenzie Thayer
- Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sarah L Mott
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Yasmin A Lyons
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Abbey Hardy-Fairbanks
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Emily K Hill
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Kim KK, Krause M, Brandes IF, Khanna AK, Bartels K. Transesophageal echocardiography for perioperative management in thoracic surgery. Curr Opin Anaesthesiol 2021; 34:7-12. [PMID: 33315644 DOI: 10.1097/aco.0000000000000947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW Perioperative transesophageal echocardiography (TEE) is most often employed during cardiac surgery. This review will summarize some of the recent findings relevant to TEE utilization during thoracic surgical procedures. RECENT FINDINGS Hemodynamic monitoring is a key component of goal-directed fluid therapy, which is also becoming more common for management of thoracic surgical procedures. Although usually not required for the anesthetic management of common thoracic surgeries, TEE is frequently used during lung transplantation and pulmonary thromboendarterectomy. Few clinical studies support current practice patterns, and most recommendations are based on expert opinion. SUMMARY Currently, routine use of TEE in thoracic surgery is often limited to specific high-risk patients and/or procedures. As in other perioperative settings, TEE may be utilized to elucidate the reasons for acute hemodynamic instability without apparent cause. Contraindications to TEE apply and have to be taken into consideration before performing a TEE on a thoracic surgical patient.
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Affiliation(s)
- Kevin K Kim
- Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Martin Krause
- Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Ivo F Brandes
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University, School of Medicine, Winston-Salem, North Carolina, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Karsten Bartels
- Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado, USA
- Outcomes Research Consortium, Cleveland, OH, USA
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Abstract
INTRODUCTION Perioperative enhanced recovery after surgery (ERAS) concepts or fast-track are supposed to accelerate recovery after surgery, reduce postoperative complications and shorten the hospital stay when compared to traditional perioperative treatment. METHODS Electronic search of the PubMed database to identify systematic reviews with meta-analysis (SR) comparing ERAS and traditional treatment. RESULTS The presented SR investigated 70 randomized controlled studies (RCT) with 12,986 patients and 93 non-RCT (24,335 patients) concerning abdominal, thoracic and vascular as well as orthopedic surgery. The complication rates were decreased under ERAS following colorectal esophageal, liver and pulmonary resections as well as after implantation of hip endoprostheses. Pulmonary complications were reduced after ERAS esophageal, gastric and pulmonary resections. The first bowel movements occurred earlier after ERAS colorectal resections and delayed gastric emptying was less often observed after ERAS pancreatic resection. Following ERAS fast-track esophageal resection, anastomotic leakage was diagnosed less often as well as surgical complications after ERAS pulmonary resection. The ERAS in all studies concerning orthopedic surgery and trials investigating implantation of a hip endoprosthesis or knee endoprosthesis reduced the risk for postoperative blood transfusions. Regardless of the type of surgery, ERAS shortened hospital stay without increasing readmissions. CONCLUSION Numerous clinical trials have confirmed that ERAS reduces postoperative morbidity, shortens hospital stay and accelerates recovery without increasing readmission rates following most surgical operations.
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Zhou Q, Cai M, Gou J, Ning N. Effect of Postoperative High-Concentration Oxygen on Recovery After Thyroid Surgery: A Prospective, Open, Randomized, Controlled Study. Front Endocrinol (Lausanne) 2021; 12:595571. [PMID: 34290666 PMCID: PMC8287853 DOI: 10.3389/fendo.2021.595571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 06/21/2021] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To investigate the effectiveness of high-concentration oxygen on the improvement of throat symptoms and voice changes after thyroid surgery and its protection of the parathyroid function. METHODS A total of 600 patients undergoing thyroid surgery who met the inclusion criteria were randomly divided into the experimental group (n = 300) and the control group (n = 300) by using a random number generator. The patients in the experimental group underwent high-oxygen treatment [FiO280 (8 L/min)] for 6 continuous hours after returning to the ward after surgery. The patients in the control group underwent low-oxygen treatment [FiO230 (2 L/min)] for 6 continuous hours after returning to the ward after surgery. RESULTS The postoperative incision pain score of patients in the experimental group was significantly better than that in the control group at 6 h (1.07 ± 0.80 VS 1.23 ± 0.95, P=0.031) and 12 h (1.08 ± 0.64 VS 1.20 ± 0.73, P=0.041). The postoperative throat pain score of the patients in the experimental group was significantly better than that of the control group at 6 h (1.40 ± 0.85 VS 1.59 ± 0.97, P=0.011) and 12 h (1.40 ± 0.85 VS 1.59 ± 0.97, P=0.019). The PONV score of the patients in the experimental group was significantly better than that of the control group at 12 h (0.09 ± 0.19 VS 0.14 ± 0.37, P=0.024). The Voice Handicap Index score of the patients in the experimental group was significantly better than that of the control group at 24 h (2.89 ± 5.92 VS 4.10 ± 6.31, P=0.017), 36 h (2.46 ± 5.06 VS 3.43 ± 5.97, P=0.035), and 48 h (2.46 ± 5.06 VS 3.43 ± 5.97, P=0.032). CONCLUSION High-concentration oxygen can alleviate PONV and pain after thyroid surgery, with less severe voice changes potentially. However, its effects on swallowing function, and parathyroid function need to be further verified. CLINICAL TRIAL REGISTRATION NUMBER ChiCTR-IOR-17012765 (China Clinical Trial Registry clinical trial registration center [http://www.chictr.org.cn/index.aspx).
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Affiliation(s)
- Qian Zhou
- Department of Thyroid Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Ming Cai
- Department of Thyroid Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Juxiang Gou
- Department of Thyroid Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
- *Correspondence: Ning Ning, ; Juxiang Gou,
| | - Ning Ning
- West China School of Nursing, Sichuan University/Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Ning Ning, ; Juxiang Gou,
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Croasdale DR, Su EM, Olutola OE, Polito CP, Ata A, Keenan M, Valerian BT, David Chismark A, Canete JJ, Lee EC. The Effect of an Enhanced Recovery Program on Elective Right Hemicolectomies for Crohn's Disease vs. Colon Cancer: A Retrospective Cohort Analysis. Am Surg 2020; 88:120-125. [PMID: 33356439 DOI: 10.1177/0003134820982573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols are widely employed in colorectal surgery, successful in reducing postoperative morbidities and hospital length of stay (LOS). However, ERAS effects on the inflammatory bowel disease population remain unclear. This study examines the postoperative course of both Crohn's disease (CD) and colon cancer (CC) patients after elective right hemicolectomies and compares the effectiveness of ERAS protocol. METHODS A retrospective analysis was performed on patients with CD and CC undergoing elective right hemicolectomies and ileocecectomies from January 2014 through June 2016 (pre-ERAS) and January 2017 through April 2019 (post-ERAS) from a single tertiary care center. Patient demographics and perioperative variables were examined, including prolonged postoperative ileus (PPOI), hospital LOS, and 30-day readmission. RESULTS 98 CC patients and 91 CD patients met the inclusion criteria. The pre-ERAS CC and post-ERAS CC cohorts were significantly different: post-ERAS had fewer patients with congestive heart failure and chronic obstructive pulmonary disease and had higher albumin levels. The pre-ERAS CC cohort had significantly longer operative durations and higher rates of concomitant procedures than the post-ERAS CC cohort. Both patients with CC and CD had a reduction in LOS with implementation of ERAS, decreasing by 2.24 days (P = .002) and 1.21 days (P = .038), respectively. There was a reduction in rates of organ space infections with CD (pre .132, post .00, P = .007). There was a trend towards an increased rate of PPOI with CD (Pre .079, Post .226, P = .062). DISCUSSION The ERAS protocol significantly reduced LOS for both groups, without increasing 30-day readmission rates or other morbidities.
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Affiliation(s)
| | | | | | - Caroline P Polito
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Ashar Ata
- Department of Surgery, 138207Albany Medical Center, Albany, NY, USA
| | - Megan Keenan
- Department of Surgery, 138207Albany Medical Center, Albany, NY, USA
| | - Brian T Valerian
- Department of Surgery, 138207Albany Medical Center, Albany, NY, USA
| | - A David Chismark
- Department of Surgery, 138207Albany Medical Center, Albany, NY, USA
| | | | - Edward C Lee
- Department of Surgery, 138207Albany Medical Center, Albany, NY, USA
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85
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Joliat GR, Hübner M, Roulin D, Demartines N. Cost Analysis of Enhanced Recovery Programs in Colorectal, Pancreatic, and Hepatic Surgery: A Systematic Review. World J Surg 2020; 44:647-655. [PMID: 31664495 DOI: 10.1007/s00268-019-05252-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Enhanced recovery programs (ERPs) have been shown to improve postoperative outcomes after abdominal surgery. This study aimed to review the current literature to assess if ERPs in colorectal, pancreas, and liver surgery induce cost savings. METHODS A systematic review was performed including prospective and retrospective studies comparing conventional management versus ERP in terms of costs. All kinds of ERP were considered (fast-track, ERAS®, or home-made protocols). Studies with no mention of a clear protocol and no reporting of protocol compliance were excluded. RESULTS Thirty-seven articles out of 144 identified records were scrutinized as full articles. Final analysis included 16 studies. In colorectal surgery, two studies were prospective (1 randomized controlled trial, RCT) and six retrospective, totaling 1277 non-ERP patients and 2078 ERP patients. Three of the eight studies showed no difference in cost savings between the two groups. The meta-analysis found a mean cost reduction of USD3010 (95% CI: 5370-650, p = 0.01) in favor of ERP. Among the five included studies in pancreas surgery (all retrospective, 552 non-ERP vs. 348 ERP patients), the mean cost reduction in favor of the ERP group was USD7020 (95% CI: 11,600-2430, p = 0.003). In liver surgery, only three studies (two retrospective and 1 RCT, 180 non-ERP vs. 197 ERP patients) were found, which precluded a sound cost analysis. CONCLUSIONS The present systematic review suggests that ERPs in colorectal and pancreas surgery are associated with cost savings compared to conventional perioperative management. Cost data in liver surgery are scarce.
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Affiliation(s)
- Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Didier Roulin
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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86
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Piccioni F, Droghetti A, Bertani A, Coccia C, Corcione A, Corsico AG, Crisci R, Curcio C, Del Naja C, Feltracco P, Fontana D, Gonfiotti A, Lopez C, Massullo D, Nosotti M, Ragazzi R, Rispoli M, Romagnoli S, Scala R, Scudeller L, Taurchini M, Tognella S, Umari M, Valenza F, Petrini F. Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic surgery (PACTS) part 1: preadmission and preoperative care. Perioper Med (Lond) 2020; 9:37. [PMID: 33292657 PMCID: PMC7704118 DOI: 10.1186/s13741-020-00168-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 11/03/2020] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care. METHODS A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task Force criteria. RESULTS Recommendations for preoperative care focus on risk assessment, patient preparation (prehabilitation), and the choice of procedure (open thoracotomy vs. video-assisted thoracic surgery). CONCLUSIONS These recommendations should help pulmonologists to improve preoperative management in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.
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Affiliation(s)
- Federico Piccioni
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, via Venezian 1, 20133, Milan, Italy.
| | | | - Alessandro Bertani
- Division of Thoracic Surgery and Lung Transplantation, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS ISMETT - UPMC, Palermo, Italy
| | - Cecilia Coccia
- Department of Anesthesia and Critical Care Medicine, National Cancer Institute "Regina Elena"-IRCCS, Rome, Italy
| | - Antonio Corcione
- Department of Critical Care Area Monaldi Hospital, Ospedali dei Colli, Naples, Italy
| | - Angelo Guido Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Roberto Crisci
- Department of Thoracic Surgery, University of L'Aquila, L'Aquila, Italy
| | - Carlo Curcio
- Thoracic Surgery, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Carlo Del Naja
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG, Italy
| | - Paolo Feltracco
- Department of Medicine, Anaesthesia and Intensive Care, University Hospital of Padova, Padua, Italy
| | - Diego Fontana
- Thoracic Surgery Unit - San Giovanni Bosco Hospital - Torino, Turin, Italy
| | | | - Camillo Lopez
- Thoracic Surgery Unit, V Fazzi Hospital, Lecce, Italy
| | - Domenico Massullo
- Anesthesiology and Intensive Care Unit, Azienda Ospedaliero Universitaria S. Andrea, Rome, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Riccardo Ragazzi
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria Sant'Anna, Ferrara, Italy
| | - Marco Rispoli
- Anesthesia and Intensive Care, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Stefano Romagnoli
- Department of Health Science, Section of Anesthesia and Critical Care, University of Florence, Florence, Italy
- Department of Anesthesia and Critical Care, Careggi University Hospital, Florence, Italy
| | - Raffaele Scala
- Pneumology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Luigia Scudeller
- Clinical Epidemiology Unit, Scientific Direction, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Marco Taurchini
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG, Italy
| | - Silvia Tognella
- Respiratory Unit, Orlandi General Hospital, Bussolengo, Verona, Italy
| | - Marzia Umari
- Combined Department of Emergency, Urgency and Admission, Cattinara University Hospital, Trieste, Italy
| | - Franco Valenza
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
- Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
| | - Flavia Petrini
- Department of Anaesthesia, Perioperative Medicine, Pain Therapy, RRS and Critical Care Area - DEA ASL2 Abruzzo, Chieti University Hospital, Chieti, Italy
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Baos S, Rogers CA, Abbadi R, Alzetani A, Casali G, Chauhan N, Collett L, Culliford L, de Jesus SE, Edwards M, Goddard N, Lamb J, McKeon H, Molyneux M, Stokes EA, Wordsworth S, Gibbison B, Pufulete M. Effectiveness, cost-effectiveness and safety of gabapentin versus placebo as an adjunct to multimodal pain regimens in surgical patients: protocol of a placebo controlled randomised controlled trial with blinding (GAP study). BMJ Open 2020; 10:e041176. [PMID: 33444208 PMCID: PMC7682449 DOI: 10.1136/bmjopen-2020-041176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Gabapentin is an antiepileptic drug currently licensed to treat epilepsy and neuropathic pain but has been used off-label to treat acute postoperative pain. The GAP study will compare the effectiveness, cost-effectiveness and safety of gabapentin as an adjunct to standard multimodal analgesia versus placebo for the management of pain after major surgery. METHODS AND ANALYSIS The GAP study is a multicentre, double-blind, randomised controlled trial in patients aged 18 years and over, undergoing different types of major surgery (cardiac, thoracic or abdominal). Patients will be randomised in a 1:1 ratio to receive either gabapentin (600 mg just before surgery and 600 mg/day for 2 days after surgery) or placebo in addition to usual pain management for each type of surgery. Patients will be followed up daily until hospital discharge and then at 4 weeks and 4 months after surgery. The primary outcome is length of hospital stay following surgery. Secondary outcomes include pain, total opioid use, adverse health events, health related quality of life and costs. ETHICS AND DISSEMINATION This study has been approved by the Research Ethics Committee . Findings will be shared with participating hospitals and disseminated to the academic community through peer-reviewed publications and presentation at national and international meetings. Patients will be informed of the results through patient organisations and participant newsletters. TRIAL REGISTRATION NUMBER ISRCTN63614165.
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Affiliation(s)
- Sarah Baos
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Chris A Rogers
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Reyad Abbadi
- Department of Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Aiman Alzetani
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Gianluca Casali
- Department of Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Nilesh Chauhan
- Department of Anaesthesia, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Laura Collett
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Lucy Culliford
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Samantha E de Jesus
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mark Edwards
- Department of Anaesthesia, University Hospital Southampton NHS FoundationTrust, Southampton, UK
- Acute, Critical & Perioperative Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - Nicholas Goddard
- Department of Anaesthesia, University Hospital Southampton NHS FoundationTrust, Southampton, UK
| | - Jennifer Lamb
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Holly McKeon
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mat Molyneux
- Department of Anaesthesia, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | | - Sarah Wordsworth
- Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Ben Gibbison
- Department of Anaesthesia, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Maria Pufulete
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, UK
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88
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Weibel S, Schaefer MS, Raj D, Rücker G, Pace NL, Schlesinger T, Meybohm P, Kienbaum P, Eberhart LHJ, Kranke P. Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: an abridged Cochrane network meta-analysis. Anaesthesia 2020; 76:962-973. [PMID: 33170514 DOI: 10.1111/anae.15295] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
Postoperative nausea and vomiting is a common adverse effect of anaesthesia. Although dozens of different anti-emetics are available for clinical practice, there is currently no comparative ranking of efficacy and safety of these drugs to inform clinical practice. We performed a systematic review with network meta-analyses to compare, and rank in terms of efficacy and safety, single anti-emetic drugs and their combinations, including 5-hydroxytryptamine3 , dopamine-2 and neurokinin-1 receptor antagonists; corticosteroids; antihistamines; and anticholinergics used to prevent postoperative nausea and vomiting in adults after general anaesthesia. We systematically searched for placebo-controlled and head-to-head randomised controlled trials up to November 2017 (updated in April 2020). We assessed how trustworthy the evidence was using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Confidence In Network Meta-Analysis (CINeMA) approaches for vomiting within 24 h postoperatively, serious adverse events, any adverse event and drug class-specific side-effects. We included 585 trials (97,516 participants, 83% women) testing 44 single drugs and 51 drug combinations. The studies' overall risk of bias was assessed as low in only 27% of the studies. In 282 trials, 29 out of 36 drug combinations and 10 out of 28 single drugs lowered the risk of vomiting at least 20% compared with placebo. In the ranking of treatments, combinations of drugs were generally more effective than single drugs. Single neurokinin-1 receptor antagonists were as effective as other drug combinations. Out of the 10 effective single drugs, certainty of evidence was high for aprepitant, with risk ratio (95%CI) 0.26 (0.18-0.38); ramosetron, 0.44 (0.32-0.59); granisetron, 0.45 (0.38-0.54); dexamethasone, 0.51 (0.44-0.57); and ondansetron, 0.55 (0.51-0.60). It was moderate for fosaprepitant, 0.06 (0.02-0.21) and droperidol, 0.61 (0.54-0.69). Granisetron and amisulpride are likely to have little or no increase in any adverse event compared with placebo, while dimenhydrinate and scopolamine may increase the number of patients with any adverse event compared with placebo. So far, there is no convincing evidence that other single drugs effect the incidence of serious, or any, adverse events when compared with placebo. Among drug class specific side-effects, evidence for single drugs is mostly not convincing. There is convincing evidence regarding the prophylactic effect of at least seven single drugs for postoperative vomiting such that future studies investigating these drugs will probably not change the estimated beneficial effect. However, there is still considerable lack of evidence regarding safety aspects that does warrant investigation.
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Affiliation(s)
- S Weibel
- Department of Anaesthesia and Critical Care, University of Wuerzburg, Wuerzburg, Germany
| | - M S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Department of Anaesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - D Raj
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Queen Elizabeth University Hospital, Glasgow, UK
| | - G Rücker
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - N L Pace
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - T Schlesinger
- Department of Anaesthesia and Critical Care, University of Wuerzburg, Wuerzburg, Germany
| | - P Meybohm
- Department of Anaesthesia and Critical Care, University of Wuerzburg, Wuerzburg, Germany
| | - P Kienbaum
- Department of Anaesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - L H J Eberhart
- Department of Anaesthesiology and Intensive Care Medicine, Philipps-University Marburg, Marburg, Germany
| | - P Kranke
- Department of Anaesthesia and Critical Care, University of Wuerzburg, Wuerzburg, Germany
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Feng D, Tang Y, Yang Y, Han P, Wei W. Intracorporeal versus extracorporeal urinary diversion after robotic-assisted radical cystectomy: evidence from a systematic review and pooled analysis of observational studies. MINERVA UROL NEFROL 2020; 72:519-530. [DOI: 10.23736/s0393-2249.20.03829-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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90
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An AHRQ national quality improvement project for implementation of enhanced recovery after surgery. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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91
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Piccioni F, Droghetti A, Bertani A, Coccia C, Corcione A, Corsico AG, Crisci R, Curcio C, Del Naja C, Feltracco P, Fontana D, Gonfiotti A, Lopez C, Massullo D, Nosotti M, Ragazzi R, Rispoli M, Romagnoli S, Scala R, Scudeller L, Taurchini M, Tognella S, Umari M, Valenza F, Petrini F. Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care. Perioper Med (Lond) 2020; 9:31. [PMID: 33106758 PMCID: PMC7582032 DOI: 10.1186/s13741-020-00159-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 09/22/2020] [Indexed: 02/08/2023] Open
Abstract
Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients. Methods A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria. Results Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis. Conclusions These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.
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Affiliation(s)
- Federico Piccioni
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Alessandro Bertani
- Division of Thoracic Surgery and Lung Transplantation, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS ISMETT - UPMC, Palermo, Italy
| | - Cecilia Coccia
- Department of Anesthesia and Critical Care Medicine, National Cancer Institute "Regina Elena"-IRCCS, Rome, Italy
| | - Antonio Corcione
- Department of Critical Care Area Monaldi Hospital, Ospedali dei Colli, Naples, Italy
| | - Angelo Guido Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Roberto Crisci
- Department of Thoracic Surgery, University of L'Aquila, L'Aquila, Italy
| | - Carlo Curcio
- Thoracic Surgery, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Carlo Del Naja
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG Italy
| | - Paolo Feltracco
- Department of Medicine, Anaesthesia and Intensive Care, University Hospital of Padova, Padova, Italy
| | - Diego Fontana
- Thoracic Surgery Unit - San Giovanni Bosco Hospital, Turin, Italy
| | | | - Camillo Lopez
- Thoracic Surgery Unit, 'V Fazzi' Hospital, Lecce, Italy
| | - Domenico Massullo
- Anesthesiology and Intensive Care Unit, Azienda Ospedaliero Universitaria S. Andrea, Rome, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Riccardo Ragazzi
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria Sant'Anna, Ferrara, Italy
| | - Marco Rispoli
- Anesthesia and Intensive Care, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Stefano Romagnoli
- Department of Health Science, Section of Anesthesia and Critical Care, University of Florence, Florence, Italy.,Department of Anesthesia and Critical Care, Careggi University Hospital, Florence, Italy
| | - Raffaele Scala
- Pneumology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Luigia Scudeller
- Clinical Epidemiology Unit, Scientific Direction, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Marco Taurchini
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG Italy
| | - Silvia Tognella
- Respiratory Unit, Orlandi General Hospital, Bussolengo, Verona, Italy
| | - Marzia Umari
- Combined Department of Emergency, Urgency and Admission, Cattinara University Hospital, Trieste, Italy
| | - Franco Valenza
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
| | - Flavia Petrini
- Department of Anaesthesia, Perioperative Medicine, Pain Therapy, RRS and Critical Care Area - DEA ASL2 Abruzzo, Chieti University Hospital, Chieti, Italy
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Zhang D, Sun K, Wang T, Wu G, Wang J, Cui Y, Wu J. Systematic Review and Meta-Analysis of the Efficacy and Safety of Enhanced Recovery After Surgery vs. Conventional Recovery After Surgery on Perioperative Outcomes of Radical Cystectomy. Front Oncol 2020; 10:541390. [PMID: 33072572 PMCID: PMC7538712 DOI: 10.3389/fonc.2020.541390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/13/2020] [Indexed: 12/31/2022] Open
Abstract
Background and objective: Radical cystectomy has been characterized as the most difficult operation in urology because of the complex surgical procedures and postoperative complications. Enhanced recovery after surgery (ERAS), which reduces the incidence of perioperative complications, has been widely used in clinical surgery. Herein, we performed a meta-analysis to evaluate the efficacy and safety of ERAS vs. conventional recovery after surgery (CRAS) on perioperative outcomes of radical cystectomy. Methods: We performed a systematic search of randomized controlled trials (RCTs) in the following databases: Medline, Embase, and the Cochrane Controlled Trials Register, based on the PICOS strategy. The reference lists of the retrieved studies were further surveyed for relevant publications. Results: Our search yielded seven RCTs containing 813 patients. The ERAS group was found to have better performance in the following parameters: length of hospital stay [mean difference (MD) = -1.12, 95% confidence interval (CI): -1.80 to -0.45, P = 0.001], time to first flatus (MD = -0.70, 95% CI: -0.98 to 0.41, P < 0.00001), and time to regular diet (MD = -0.12, 95% CI: -1.76 to -0.28, P = 0.007). However, there were no significant differences between the two groups in major complications [odds ratio (OR) = 0.91, 95% CI: 0.63 to 1.34, P = 0.64], readmission (OR = 1.15, 95% CI: 0.65 to 2.01, P = 0.63), ileus (OR = 0.75, 95% CI: 0.44 to 1.28, P = 0.29), wound infection (OR = 0.56, 95% CI: 0.31 to 1.01, P = 0.05), mortality (OR = 0.69, 95% CI: 0.24 to 1.99, P = 0.49), or time to first bowel movement (MD = -0.55, 95% CI: -1.62 to 0.53, P = 0.32). Conclusion: ERAS reduced the length of hospital stay, time to first flatus, and time to regular diet after cystectomy. Compared to CRAS protocols, ERAS protocols do not increase the risk of adverse events.
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Affiliation(s)
- Dongxu Zhang
- Department of Urology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Kai Sun
- Department of Urology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Tianqi Wang
- Department of Urology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Gang Wu
- Department of Urology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Jipeng Wang
- Department of Urology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Yuanshan Cui
- Department of Urology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
- Department of Urology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jitao Wu
- Department of Urology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
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93
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Unnecessary Blood Transfusion Prolongs Length of Hospital Stay of Patients Who Undergo Free Fibular Flap Reconstruction of Mandibulofacial Defects: A Propensity Score-Matched Study. J Oral Maxillofac Surg 2020; 78:2316-2327. [PMID: 32866482 DOI: 10.1016/j.joms.2020.07.213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/25/2020] [Accepted: 07/22/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE Blood transfusion is usually a common clinical practice in flap transfer surgery because of its invasive hemorrhagic nature. Although intraoperative restrictive transfusion policy was suggested in vascularized fibular flap reconstruction, its clinical evidence was still insufficient. Therefore, our study aimed to investigate the influence of intraoperative blood transfusion on length of stay (LOS) after vascularized fibular flap reconstruction. PATIENTS AND METHODS Patients who underwent vascularized fibular flap reconstruction of mandibulofacial defects between 2012 and 2018 were reviewed. Univariate and multivariate analyses were performed to identify factors that influenced LOS. The identified factors and other perioperative factors that may influence transfusion decision were included in propensity score matching to explore the independent impact of intraoperative blood transfusion on LOS. RESULTS About 375 patients were included, and the median LOS was 14.00 (12.00, 19.00) days in our study. Multivariate analysis suggested that duration of surgery, fluid infusion speed for more than 24 hours on operative day, intraoperative blood transfusion, and postoperative complication were associated with prolonged LOS (P < .05). Propensity score matching was performed, and the difference of LOS between the matched transfused and nontransfused group was statistically significant (15.00 [12.75, 20.00] vs 14.00 [11.75, 16.25]; P < .001). The comparison between the matched and unmatched transfused patients indicated that the former has less radiotherapy history, blood loss, and higher preoperative hemoglobin (P ≤ .001). CONCLUSIONS Intraoperative blood transfusion is independently associated with prolonged LOS in patients without preoperative anemia, radiotherapy history, or intraoperative massive hemorrhage who undergo vascularized fibular flap reconstruction. Efforts should be made to avoid unnecessary intraoperative blood transfusion, and our results support consideration of a restrictive transfusion policy in these patients.
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94
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Hartman A, Leonard D, Trefois C, Remue C, Bachmann R, Abbes Orabi N, Lupu I, Robu B, Steyaert A, Kartheuser A. Good compliance to enhanced recovery program improves outcome after colorectal surgery. Surg Endosc 2020; 35:4214-4221. [DOI: 10.1007/s00464-020-07903-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/17/2020] [Indexed: 12/29/2022]
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95
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Song BM, Kadhim M, Shanmugam JP, King AG, Heffernan MJ. Enhanced Recovery After Pediatric Scoliosis Surgery: Key Components and Current Practice. Orthopedics 2020; 43:e338-e344. [PMID: 32745223 DOI: 10.3928/01477447-20200721-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/09/2019] [Indexed: 02/03/2023]
Abstract
With the goal of safety and efficiency in health care delivery, enhanced recovery protocols (ERPs) continue to gain traction throughout various surgical disciplines, including in pediatric scoliosis surgery. The growing body of literature reporting decreased length of stay and cost with no change in readmissions or complications has brought these protocols to the forefront. The key components of ERPs include preoperative patient counseling, perioperative pain management, and early patient mobilization. In this review, the authors aim to describe the foundational history and major components of ERPs following pediatric spine deformity surgery. [Orthopedics. 2020;43(5):e338-e344.].
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96
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Porserud A, Karlsson P, Rydwik E, Aly M, Henningsohn L, Nygren-Bonnier M, Hagströmer M. The CanMoRe trial - evaluating the effects of an exercise intervention after robotic-assisted radical cystectomy for urinary bladder cancer: the study protocol of a randomised controlled trial. BMC Cancer 2020; 20:805. [PMID: 32842975 PMCID: PMC7448437 DOI: 10.1186/s12885-020-07140-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/06/2020] [Indexed: 01/30/2023] Open
Abstract
Background Patients who have undergone radical cystectomy for urinary bladder cancer are not sufficiently physically active and therefore may suffer complications leading to readmissions. A physical rehabilitation programme early postoperatively might prevent or at least alleviate these potential complications and improve physical function. The main aim of the CanMoRe trial is to evaluate the impact of a standardised and individually adapted exercise intervention in primary health care to improve physical function (primary outcome) and habitual physical activity, health-related quality of life, fatigue, psychological wellbeing and readmissions due to complications in patients undergoing robotic-assisted radical cystectomy for urinary bladder cancer. Methods In total, 120 patients will be included and assigned to either intervention or control arm of the study. All patients will receive preoperative information on the importance of early mobilisation and during the hospital stay they will follow a standard protocol for enhanced mobilisation. The intervention group will be given a referral to a physiotherapist in primary health care close to their home. Within the third week after discharge, the intervention group will begin 12 weeks of biweekly exercise. The exercise programme includes aerobic and strengthening exercises. The control group will receive oral and written information about a home-based exercise programme. Physical function will serve as the primary outcome and will be measured using the Six-minute walk test. Secondary outcomes are gait speed, handgrip strength, leg strength, habitual physical activity, health-related quality of life, fatigue, psychological wellbeing and readmissions due to complications. The measurements will be conducted at discharge (i.e. baseline), post-intervention and 1 year after surgery. To evaluate the effects of the intervention mixed or linear regression models according to the intention to treat procedure will be used. Discussion This proposed randomised controlled trial has the potential to provide new knowledge within rehabilitation after radical cystectomy for urinary bladder cancer. The programme should be easy to apply to other patient groups undergoing abdominal surgery for cancer and has the potential to change the health care chain for these patients. Trial registration ClinicalTrials.gov. Clinical trial registration number NCT03998579. First posted June 26, 2019.
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Affiliation(s)
- Andrea Porserud
- Department of Neurobiology, Care sciences and Society, Division of Physiotherapy, Karolinska Institutet, Stockholm, Sweden. .,Allied Health Professionals Function, Medical unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden.
| | - Patrik Karlsson
- Department of Neurobiology, Care sciences and Society, Division of Physiotherapy, Karolinska Institutet, Stockholm, Sweden.,Allied Health Professionals Function, Medical unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden
| | - Elisabeth Rydwik
- Department of Neurobiology, Care sciences and Society, Division of Physiotherapy, Karolinska Institutet, Stockholm, Sweden.,Allied Health Professionals Function, Medical unit Ageing, Health and Function, Karolinska University Hospital, Stockholm, Sweden
| | - Markus Aly
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Patient Area Pelvic Cancer, Prostate Cancer Patient Flow, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Lars Henningsohn
- Department of Clinical Science, Intervention and Technology, CLINTEC, Division of Urology, Karolinska Institutet, Stockholm, Sweden
| | - Malin Nygren-Bonnier
- Department of Neurobiology, Care sciences and Society, Division of Physiotherapy, Karolinska Institutet, Stockholm, Sweden.,Allied Health Professionals Function, Medical unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Hagströmer
- Department of Neurobiology, Care sciences and Society, Division of Physiotherapy, Karolinska Institutet, Stockholm, Sweden.,Allied Health Professionals Function, Medical unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden.,Region Stockholm, Academic Primary Health Care Centre, Stockholm, Sweden
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97
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Sultan P, Sharawi N, Blake L, Carvalho B. Enhanced recovery after caesarean delivery versus standard care studies: a systematic review of interventions and outcomes. Int J Obstet Anesth 2020; 43:72-86. [DOI: 10.1016/j.ijoa.2020.03.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/11/2020] [Accepted: 03/20/2020] [Indexed: 12/16/2022]
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98
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Feng D, Liu S, Lu Y, Wei W, Han P. Clinical efficacy and safety of enhanced recovery after surgery for patients treated with radical cystectomy and ileal urinary diversion: a systematic review and meta-analysis of randomized controlled trials. Transl Androl Urol 2020; 9:1743-1753. [PMID: 32944535 PMCID: PMC7475686 DOI: 10.21037/tau-19-941] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The aim of this study was to evaluate the effect of enhanced recovery after surgery (ERAS) on perioperative outcomes in patients undergoing radical cystectomy (RC) and ileal urinary diversion (IUD). We performed a literature search of PubMed, Web of Science, EMBASE, the Cochrane Library and three main Chinese databases (WANFANG, CNKI and VIP) in December 2019 without language restrictions. Two reviewers independently selected studies, evaluated methodological quality and extracted data using Cochrane Collaboration’s tools. Efficacy was assessed by the time to first flatus, first bowel movement, and hospitalization time. Safety was assessed by 30-day readmission and complications after surgery. Our searches identified 6 studies, including 628 patients. A total of 323 (51%) patients took ERAS. We observed that ERAS reduced the time to first flatus [standard mean difference (SMD): −1.65, 95% CI: −2.63 to −0.68, P=0.0009], first bowel movement (SMD: −1.14, 95% CI: −1.78 to −0.50, P=0.0005), and hospitalization time (MD: −4.09, 95% CI: −6.34 to −1.85, P=0.0004). We did not detect significant difference in terms of 30-day readmission [relative risk (RR): 1.33, 95% CI: 0.61–2.88, P=0.48] and postoperative complications (RR: 0.91, 95% CI: 0.65–1.26, P=0.56) between ERAS and conventional recovery after surgery (CRAS). Our findings indicated that ERAS protocols throughout the perioperative period of RC with IUD might reduce hospitalization expenses and contribute to higher turnover ward, more efficient utilization of medical resources and lower risk of nosocomial infection as a result of shorter length of stay. Besides, early rehabilitation of gastrointestinal function might not only facilitate wound healing and early mobilization, thereby reducing the incidence of basic complications such as cardiopulmonary disease, but also improve patients’ psychological trauma and stress response, increase self-confidence and motivation in treatments, and then lead to unexpected benefits. Further large volume, multicenter randomized controlled studies are warranted before making the final clinical guidelines.
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Affiliation(s)
- Dechao Feng
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Shengzhuo Liu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Yiping Lu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Wuran Wei
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Ping Han
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
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99
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Chen B, He Y, Xiao Y, Guo D, Liu P, He Y, Sun Q, Jiang P, Liu Z, Liu Q. Heated fennel therapy promotes the recovery of gastrointestinal function in patients after complex abdominal surgery: A single-center prospective randomized controlled trial in China. Surgery 2020; 168:793-799. [PMID: 32682507 DOI: 10.1016/j.surg.2020.05.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/13/2020] [Accepted: 05/19/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Postoperative gastrointestinal dysfunction remains a major determinant of the duration of stay after complex abdominal surgery. This study was performed to evaluate the effectiveness of heated fennel therapy in accelerating the recovery of gastrointestinal function. METHODS This surgeon-blinded, prospective randomized controlled study included 381 patients with hepatobiliary, pancreatic, and gastric tumors who were divided into 2 groups. The patients in the experimental groups received heated fennel therapy, and those in the control groups received heated rice husk therapy. We compared the baseline characteristics, time to first postoperative flatus and defecation, fasting time, duration of postoperative hospital stay, grading of abdominal pain, classification of abdominal distension, inflammatory markers, and nutritional status indicators. RESULTS The time to first flatus and first defecation and the fasting time were statistically significantly less in the heated fennel therapy group than those in the control groups (P < .05 each); and abdominal distension was also relieved in the experimental groups (P < .001). Heated fennel therapy had no obvious beneficial effect on inflammatory markers but improved the serum albumin (ALB) level of the patients at postop day 9 (P < .001). Among the patients with alimentary tract reconstruction, those in the heated fennel therapy group had a clinically important, lesser hospital stay than those in the control group (9.2 5 ± 5.1 versus 11.1 ± 6.4; P < .023). CONCLUSION Heated fennel therapy facilitated the gastrointestinal motility function of patients early postoperatively.
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Affiliation(s)
- Baiyang Chen
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Yukun He
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Yusha Xiao
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Deliang Guo
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Pengpeng Liu
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Yueming He
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Quan Sun
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Ping Jiang
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Zhisu Liu
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Quanyan Liu
- Department of General Surgery, General Hospital of Tianjin Medical University, Tianjin, PR China.
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100
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Sartori A, Botteri E, Agresta F, Gerardi C, Vettoretto N, Arezzo A, Pisanu A, Di Saverio S, Campanelli G, Podda M. Should enhanced recovery after surgery (ERAS) pathways be preferred over standard practice for patients undergoing abdominal wall reconstruction? A systematic review and meta-analysis. Hernia 2020; 25:501-521. [PMID: 32683579 DOI: 10.1007/s10029-020-02262-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/09/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE Although many studies assessing enhanced recovery after surgery (ERAS) pathways in abdominal wall reconstruction (AWR) have recently demonstrated lower rates of postoperative morbidity and a decrease in postoperative length of stay compared to standard practice, the utility of ERAS in AWR remains largely unknown. METHODS A systematic literature search for randomized and non-randomized studies comparing ERAS (ERAS +) pathways and standard protocols (Control) as an adopted practice for patients undergoing AWR was performed using MEDLINE, the Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and EMBASE databases. A predefined search strategy was implemented. The included studies were reviewed for primary outcomes: overall postoperative morbidity, abdominal wall morbidity, surgical site infection (SSI), and length of hospital stay; and for secondary outcome: operative time, estimated blood loss, time to discontinuation of narcotics, time to urinary catheter removal, time to return to bowel function, time to return to regular diet, and readmission rate. Standardized mean difference (SMD) was calculated for continuous variables and Odds Ratio for dichotomous variables. RESULTS Five non-randomized studies were included for qualitative and quantitative synthesis. 840 patients were allocated to either ERAS + (382) or Control (458). ERAS + and Control groups showed equivalent results with regard to the incidence of postoperative morbidity (OR 0.73, 95% CI 0.32-1.63; I2= 76%), SSI (OR 1.17, 95% CI 0.43-3.22; I2= 54%), time to return to bowel function (SMD - 2.57, 95% CI - 5.32 to 0.17; I2= 99%), time to discontinuation of narcotics (SMD - 0.61, 95% CI - 1.81 to 0.59; I2= 97%), time to urinary catheter removal (SMD - 2.77, 95% CI - 6.05 to 0.51; I2= 99%), time to return to regular diet (SMD - 0.77, 95% CI - 2.29 to 0.74; I2= 98%), and readmission rate (OR 0.82, 95% CI 0.52-1.27; I2= 49%). Length of hospital stay was significantly shorter in the ERAS + compared to the Control group (SMD - 0.93, 95% CI - 1.84 to - 0.02; I2= 97%). CONCLUSIONS The introduction of an ERAS pathway into the clinical practice for patients undergoing AWR may cause a decreased length of hospitalization. These results should be interpreted with caution, due to the low level of evidence and the high heterogeneity.
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Affiliation(s)
- A Sartori
- Department of General Surgery, Montebelluna Civil Hospital, ULSS 2 Marca Trevigiana, Montebelluna, Italy.
| | - E Botteri
- Department of General Surgery, Montichiari Hospital, Montichiari, Italy
| | - F Agresta
- Department of General Surgery, Adria and Trecenta Civil Hospitals, ULSS 19, Adria, Italy
| | - C Gerardi
- Istituto di Ricerche Farmacologiche "Mario Negri" IRCCS, Milan, Italy
| | - N Vettoretto
- Department of General Surgery, Montichiari Hospital, Montichiari, Italy
| | - A Arezzo
- Department of Surgical Sciences, Università di Torino, Turin, Italy
| | - A Pisanu
- Department of Surgery, General and Emergency Surgery Unit, Azienda Ospedaliero-Universitaria, Cagliari University Hospital "Duilio Casula" University of Cagliari, Cagliari, Italy
| | - S Di Saverio
- Department of Surgery, University of Insubria, Varese, Italy
| | - G Campanelli
- Department of Medicine and Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Milan, Italy
| | - M Podda
- Department of Surgery, General and Emergency Surgery Unit, Azienda Ospedaliero-Universitaria, Cagliari University Hospital "Duilio Casula" University of Cagliari, Cagliari, Italy
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