Enhanced recovery after surgery for head and neck free flap reconstruction: A systematic review and meta-analysis

INTRODUCTION

Head and neck free flap reconstruction requires multidisciplinary and coordinated care in the perioperative setting to ensure safe recovery and success. Several institutions have introduced enhanced recovery after surgery (ERAS) protocols to attenuate the surgical stress response and improve postoperative recovery. With multiple studies demonstrating mixed results, the success of these interventions on clinical outcomes has yet to be determined.

OBJECTIVE

To evaluate the impact of ERAS protocols and clinical care pathways for head and neck free flap reconstruction.

METHODS

We searched PubMed, SCOPUS, EMBASE, and grey literature up to September 1st, 2020 to identify studies comparing patients enrolled in an ERAS protocol and control group. Our primary outcomes included hospital length of stay (LOS) and readmission. Mortality, reoperations, wound complication and ICU (intensive care unit) LOS comprised our secondary outcomes.

RESULTS

18 studies met inclusion criteria, representing a total of 2630 patients. The specific components of ERAS protocols used by institutions varied. Nevertheless, patients enrolled in ERAS protocols had reduced hospital LOS (MD -4.36 days [-7.54, -1.18]), readmission rates (OR 0.64 [0.45;0.92]), and wound complications (RR 0.41 [0.21, 0.83]), without an increase in reoperations (RR 0.65 [0.41, 1.02]), mortality (RR 0.38 [0.05, 2.88]), or ICU LOS (MD -2.55 days [-5.84, 0.74]).

CONCLUSION

There is growing body of evidence supporting the role of ERAS protocols for the perioperative management of head and neck free flap patients. Our findings reveal that structured clinical algorithms for perioperative interventions improve clinically-meaningful outcomes in patients undergoing complex ablation and microvascular reconstruction procedures.

A Single-Institution Case Series of Outpatient Same-Day Mastectomy: Implementation of a Quality Improvement Project and Initiative for Enhanced Recovery After Surgery

Background: National data demonstrate a trend toward outpatient same-day mastectomy. The possible drivers of this change include the costs related to hospital admission and effective management of postoperative pain. We retrospectively analyzed our single-institution experience with outpatient same-day mastectomy that incorporates a multimodal pain management regimen.

Methods: We retrospectively reviewed the medical records of patients who underwent same-day mastectomy at a single academic hospital. All patients received a multimodal, perioperative pain management regimen consisting of the intraoperative administration of 1,000 mg of intravenous (IV) acetaminophen and 30 mg of IV ketorolac, combined with the operating surgeon performing a 4- to 5-level, midaxillary, intercostal nerve block using liposomal bupivacaine. All patients were discharged with a prescription for acetaminophen with codeine, along with options for nonnarcotic alternatives as needed for pain.

Results: We reviewed the data on 72 patients who underwent mastectomies: 11 (15.3%) bilateral and 61 (84.7%) unilateral. The average age was 57 years, and average body mass index was 30 kg/m². The average length of stay of 4 to 6 hours was a marked reduction compared to a 23-hour observational period or an inpatient hospital stay. The average follow-up was 20.1 weeks. Five patients presented to the emergency department (ED) within the 30-day postoperative period, with 2 patients (2.8%) requiring readmission to the hospital for non–pain-related issues. The other 3 patients (4.2%) were evaluated for specific pain-related issues but did not require admission and were discharged home from the ED.

Conclusion: Our data support outpatient same-day mastectomy incorporating a multimodal, perioperative pain management regimen as a safe and feasible treatment option. Potential additional benefits may include decreased oral opioid use and cost savings for the hospital.

Comparison of analgesic efficacy between rectus sheath blockade, intrathecal morphine with bupivacaine, and intravenous patient-controlled analgesia in patients undergoing robot-assisted laparoscopic prostatectomy: a prospective, observational clinical study

Background

We explored the analgesic outcomes on postoperative day (POD) 1 in patients undergoing robot-assisted laparoscopic prostatectomy (RALP) who received intravenous patient-controlled analgesia (IV-PCA), rectus sheath bupivacaine block (RSB), or intrathecal morphine with bupivacaine block (ITMB).

Methods

This was a prospective, observational clinical trial. Patients were divided into three groups: IV-PCA (n = 30), RSB (n = 30), and ITMB (n = 30). Peak pain scores at rest and with coughing, cumulative IV-PCA drug consumption, the need for IV rescue opioids, and Quality of Recovery-15 (QoR-15) questionnaire scores collected on POD 1 were compared among the groups.

Results

The preoperative and intraoperative findings were comparable among the groups; the ITMB group required the least remifentanil of all groups. During POD 1, the ITMB group reported lower levels of pain at rest and with coughing, compared with the other two groups. During POD 1, incidences of severe pain at rest (10.0% vs. 23.3% vs. 40.0%) and with coughing (16.7% vs. 36.7% vs. 66.7%) were the lowest in the ITMB group compared with the RSB and IV-PCA groups, respectively. After adjustment for age, body mass index, diabetes mellitus, hypertension, and intraoperative remifentanil infusion, severe pain at rest was 0.167-fold less common in the ITMB group than in the IV-PCA group, while pain with coughing was 0.1-fold lower in the ITMB group and 0.306-fold lower in the RSB group, compared with the IV-PCA group. The ITMB group required lower cumulative IV-PCA drug infusions and less IV rescue opioids, while exhibiting a better QoR-15 global score, compared with the other two groups. Complications (nausea and pruritus) were significantly more common in the ITMB group than in the other two groups; however, we noted no ITMB- or RSB-related anesthetic complications (respiratory depression, post-dural headache, nerve injury, or puncture site hematoma or infection), and all patients were assessed as Clavien-Dindo grade I or II during the hospital stay.

Conclusion

Although ITMB induced complications of nausea and pruritus, this analgesic technique provided appropriate pain relief that enhanced patient perception related to early postoperative recovery.

Trial registration

Clinical Research Information Service, Republic of Korea, (approval number: KCT0005040) on May 20, 2020

Enhanced recovery principles applied to revision hip and knee arthroplasty leads to better patient outcomes

Aims

There is very little published literature on Enhanced Recovery Principles (ERP) used in primary joint replacements applied to revision hip and knee arthroplasty (rTHA, rTKA).

Methods

Retrospective series of 268 rTHA and rTKA surgeries from 2010 -2018, treated with ERP, focusing on multimodal pain management, blood management and early functional recovery.

Results

No patients from the latest cohort required readmission within 6 weeks. Only 20 patients (7.5%) required a blood transfusion. Surgical site local anaesthetic infiltration was associated with lower PCA use in aseptic rTHA and rTKA (p<0.001; p<0.001). Revisions for infection had a longer length of stay (LOS) and increased PCA usage in both rTHA (6.5 vs. 5.2 days) and rTKA (10.1 vs. 5.3 days), similar to our previous study.¹ Use of an intra-articular catheter for analgesia in rTKA showed reduced PCA use. Tourniquets were not beneficial for blood loss in rTKA and had greater PCA use post-operatively (p<0.001).

Conclusion

The application of ERP to revision THA and TKA surgery is safe and effective.

How we assess the perioperative anxiety of surgical patients with pulmonary nodules: the revision of state-trait anxiety inventory

PURPOSE

The aim of the study was to develop a short form of State-Trait Anxiety Inventory (STAI) and calculate the norms for the assessment of anxiety in surgical patients in mainland China.

METHODS

Patients who were scheduled to carry out pulmonary surgery in our department were included. The sinicized 40-item STAI Form-Y was used to assess the anxiety on the surgery eve. Then the coefficient of variation, coefficient of correlation, stepwise regression analysis, principal component analysis, and structural equation model were successively to filter the items. The reliability and validity of the revised STAI was estimated and the norms were computed.

RESULTS

445 intact replies were collected. A 13-item STAI with 6 items in state subscale and 7 items in trait subscale produced similar scores with the full version of STAI. The Cronbach alpha coefficients for the state and trait subscales were 0.924 and 0.936, respectively. The determinant coefficients were 0.781 and 0.822, respectively. Moreover, the norms of both state subscale and trait subscale are provided according to the age and gender.

CONCLUSIONS

The revised short form of STAI has good reliability and validity. It is likely to be more acceptable by reducing the fatigue effects, and is suitable for follow-up study on the assessment and intervention of perioperative anxiety of surgical patients with pulmonary nodules.

An Optimized Enhanced Recovery After Surgery (ERAS) Pathway Improved Patient Care in Adolescent Idiopathic Scoliosis Surgery: A Retrospective Cohort Study

OBJECTIVE

An optimized Enhanced Recovery After Surgery (ERAS) program is lacking for adolescent idiopathic scoliosis (AIS). The aim of the present study was to evaluate the impact and feasibility of an optimized ERAS pathway in patients with surgically treated AIS.

METHODS

In total, 79 patients with AIS who underwent corrective surgery without 3-column osteotomy were recruited from Xijing Hospital of the Fourth Military Medical University between 2012 and 2018. Forty-four patients were treated according to a traditional protocol and 35 were managed using an optimized ERAS pathway, which was designed and implemented by a multidisciplinary team. The following data were collected and retrospectively analyzed, demographic characteristics, Cobb angle, curve type (Lenke), surgical duration, fusion level, correction rate, estimated blood loss, postoperative hemoglobin level, postoperative pain score, pain relief time, hemovac drainage, drainage removal time, first ambulation time, length of hospital stay, and postoperative complications.

RESULTS

There was no significant difference between the traditional and ERAS groups with respect to demographic characteristics, Cobb angle, curve type (Lenke), fusion level, and correction rate. However, the ERAS group had a shorter surgical duration, less blood loss and hemovac drainage, a higher postoperative hemoglobin level, and earlier pain relief, ambulation, and discharge. The rates of postoperative nausea and vomiting were lower in the ERAS group than in the traditional group.

CONCLUSIONS

The ERAS pathway is capable of improving the perioperative status of patients with AIS by offering stronger analgesia, faster ambulation, and earlier discharge.

The Improved Mediastinal Drainage Strategy for the Enhanced Recovery System After Esophagectomy

BACKGROUND

The improved drainage strategy was the transperitoneal placement of a single mediastinal drainage tube after esophagectomy. This study aimed to explore its effect on the incidence of postoperative complications, pain scores, and hospital stay.

METHODS

Data from 108 patients who underwent minimally invasive esophagectomy were retrospectively analyzed. Patients were divided into 2 groups: those in group A were treated with transthoracic placement of mediastinal drain and those in group B were treated with transperitoneal placement. The incidence of postoperative complications, pain scores, and postoperative hospital stay were compared.

RESULTS

The maximum pain scores in group B were significantly lower than those in group A from the first to the fourth postoperative days (PODs): POD1, 3.9 ± 0.7 vs 2.3 ± 0.7; POD2, 3.5 ± 0.8 vs 2.1 ± 0.7; POD3, 3.3 ± 0.8 vs 1.7 ± 0.8; and POD4, 3.1 ± 0.7 vs 1.7 ± 0.8 (all P < .001). Compared with group A, there were fewer postoperative analgesic drug users in group B (44.6% vs 17.9%; P = .005), fewer cases of pleural effusion (10.7% vs 0%; P = .045), and fewer cases of closed thoracic drainage due to pleural effusion or pneumothorax (14.3% vs 0%; P = .014). There were no significant differences in the incidence of anastomotic leakage, mediastinitis, major pulmonary complications, major abdominal complications, surgical site infection, and total postoperative complications, without statistical differences in postoperative hospital stay and 30-d mortality (all P > .05).

CONCLUSIONS

The transperitoneal placement of a single mediastinal drain can reduce postoperative pain and the incidence of pleural effusion, without increasing the incidence of other major postoperative complications and postoperative hospital stay.

Enhanced Recovery Implementation and Perioperative Outcomes in Posterior Fusion Patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

We sought to determine if there was an association between enhanced recovery after surgery (ERAS) implementation level and complication risk, length of stay, and cost of hospitalization.

SUMMARY OF BACKGROUND DATA

ERAS protocols aim to minimize the stress response of surgery by promoting early mobilization, oral intake, as well as improvement of analgesia. Implementation of ERAS protocols in spine surgeries has been limited to mostly single-institution studies, and no population-based data exist on the impact of the level of implementation of various ERAS components on outcomes.

METHODS

In this study we identified 265,576 posterior lumbar fusion surgeries from 2006 to 2016. The main effect was the application of eight ERAS-related practices: (1) multimodal analgesia, (2) tranexamic acid, (3) antiemetics, (4) steroids, (5) early physical therapy, (6) avoidance of urinary catheters, (7) avoidance of patient-controlled analgesia, (8) avoidance of wound drains. Patients were classified by levels of ERAS implementation: "High," "Medium," and "Low" ERAS implementation if they received more than five, three to five, or less than three ERAS components, respectively. Mixed-effects models measured associations between ERAS implementation categories and complications, length and cost of hospitalization; odds ratios (OR, or average ratios for continuous outcomes), and 99.4% confidence intervals (CI) were reported.

RESULTS

Overall, 13.3%, 62.8%, and 24.4% of cases were categorized as "High," "Medium," and "Low" ERAS implementation, respectively. After adjusting for study variables, "Medium" and "High" (compared with "Low") ERAS implementation levels were significantly associated with incrementally improved outcomes regarding "any complication" (OR 0.84 CI 0.80-0.88 and OR 0.77 CI 0.71-0.84), cardiopulmonary complications (OR 0.75 CI 0.68-0.73 and OR 0.69 CI 0.59-0.80), length of stay (average ratio 0. 94 CI 0.93-0.94 and average ratio 0.91 CI 0.90-0.91), and hospitalization cost (average ratio 0.99 CI 0.98-0.99 and average ratio OR 0.95 0.95-0.96).

CONCLUSION

In a cohort undergoing posterior lumbar spine fusion the level of utilization of ERAS protocol components was independently associated with incrementally improved complication odds as well as reduced length of stay and a small decrease in overall hospitalization cost.

LEVEL OF EVIDENCE

3.

Preoperative Treatment of Malnutrition and Sarcopenia in Cardiac Surgery: New Frontiers

Cardiac surgery is performed more often in a population with an increasing number of comorbidities. Although these surgeries can be lifesaving, they disturb homeostasis and may induce a temporary overall loss of physiologic function. The required postoperative intensive care unit and hospital stay often lead to a mid- to long-term decline of nutritional and physical status, mental health, and health-related quality of life. Prehabilitation before elective surgery might be an opportunity to optimize the state of the patient. This article discusses current evidence and potential effects of preoperative optimization of nutrition and physical status before cardiac surgery.

Enhanced Recovery After Surgery Trends in Adult Spine Surgery: A Systematic Review

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a multimodal, multidisciplinary approach to optimizing the postsurgical recovery process through preoperative, perioperative, and postoperative interventions. ERAS protocols are emerging quickly within orthopedic spine surgery, yet there is a lack of consensus on optimal ERAS practices.

OBJECTIVE

The aim of this systematic review is to identify and discuss the trends in spine ERAS protocols and the associated outcomes.

METHODS

A literature search on PubMed was conducted to identify clinical studies that implemented ERAS protocols for various spine procedures in the adult population. The search included English-language literature published through December 2019. Additional sources were retrieved from the reference lists of key studies. Studies that met inclusion criteria were identified manually. Data regarding the study population, study design, spine procedures, ERAS interventions, and associated outcome metrics were extracted from each study that met inclusion criteria.

RESULTS

Of the 106 studies identified from the literature search, 22 studies met inclusion criteria. From the ERAS protocols in these studies, common preoperative elements include patient education and modified preoperative nutrition regimens. Perioperative elements include multimodal analgesia and minimally invasive surgery. Postoperative elements include multimodal pain management and early mobilization/rehabilitation/nutrition regimens. Outcomes from ERAS implementation include significant reductions in length of stay, cost, and opioid consumption. Although these trends were observed, there remained great variability among the ERAS protocols, as well as in the reported outcomes.

CONCLUSIONS

ERAS may improve cost-effectiveness to varying degrees for spinal procedures. Specifically, the use of multimodal analgesia may reduce overall opioid consumption. However, the benefits of ERAS likely will vary based on the specific procedure.

CLINICAL RELEVANCE

This review contributes to the assessment of ERAS protocol implementation in the field of adult spine surgery.

Preemptive Nalbuphine Attenuates Remifentanil-Induced Postoperative Hyperalgesia After Laparoscopic Cholecystectomy: A Prospective Randomized Double-Blind Clinical Trial

Background

Remifentanil-induced hyperalgesia (RIH) is a paradoxical phenomenon that may increase sensitivity to painful stimuli. Nalbuphine, which is both a μ-receptor antagonist and κ-receptor agonist, may affect RIH. The aim of this study was to evaluate the effects of nalbuphine on RIH during laparoscopic cholecystectomy.

Methods

A total of 96 patients were divided into the following four groups: 0.4 μg/kg/min of remifentanil with 0.2 mg/kg of nalbuphine (HRNA), 0.4 μg/kg/min of remifentanil with saline (HRSA), 0.1 μg/kg/min of remifentanil with 0.2 mg/kg of nalbuphine (LRNA), and 0.1 μg/kg/min of remifentanil with saline (LRSA). The pain thresholds of postoperative mechanical hyperalgesia were measured with von Frey filaments. Pain intensity and analgesic consumption were recorded up to 48 h after surgery.

Results

Pain thresholds on the inner forearm decreased in the HRSA group compared with the HRNA (P = 0.0167), LRNA (P = 0.0027), and LRSA (P = 0.0318) groups at 24 h after surgery. Pain thresholds on the peri-incisional area decreased in the HRSA group compared with HRNA, LRNA, and LRSA (all P < 0.0001) groups at 24 h after surgery. Patients in the HRNA group showed lower numeric rating scale scores at 1 h (P = 0.0159), 3 h (P = 0.0118), 6 h (P = 0.0213), and 12 h (P = 0.0118) than those in the HRSA group. Postoperative requirement for sufentanil was greater in the HRSA group than the HRNA group during the first 3 h (P = 0.0321) and second 3 h (P = 0.0040). Postoperative sufentanil consumption was also greater in the LRSA group than in the LRNA group during the first 3 h (P = 0.0321) and second 3 h (P = 0.0416).

Conclusion

Preemptive nalbuphine can ameliorate postoperative hyperalgesia induced by high-dose remifentanil in patients undergoing laparoscopic cholecystectomy.

Delayed remnant kidney function recovery is less observed in living donors who receive an analgesic, intrathecal morphine block in laparoscopic nephrectomy for kidney transplantation: a propensity score-matched analysis

BACKGROUND

This study analyzed remnant kidney function recovery in living donors after laparoscopic nephrectomy to establish a risk stratification model for delayed recovery and further investigated clinically modifiable factors.

PATIENTS AND METHODS

This retrospective study included 366 adult living donors who underwent elective donation surgery between January 2017 and November 2019 at our hospital. ITMB was included as an analgesic component in the living donor strategy for early postoperative pain relief from November 2018 to November 2019 (n = 116). Kidney function was quantified based on the estimated glomerular filtration rate (eGFR), and delayed functional recovery of remnant kidney was defined as eGFR < 60 mL/min/1.73 m² on postoperative day (POD) 1 (n = 240).

RESULTS

Multivariable analyses revealed that lower risk for development of eGFR < 60 mL/min/1.73 m² on POD 1 was associated with ITMB, female sex, younger age, and higher amount of hourly fluid infusion (area under the receiver operating characteristic curve = 0.783; 95% confidence interval = 0.734-0.832; p < 0.001). Propensity score (PS)-matching analyses showed that prevalence rates of eGFR < 60 mL/min/1.73 m² on PODs 1 and 7 were higher in the non-ITMB group than in the ITMB group. ITMB adjusted for PS was significantly associated with lower risk for development of eGFR < 60 mL/min/1.73 m² on POD 1 in PS-matched living donors. No living donors exhibited severe remnant kidney dysfunction and/or required renal replacement therapy at POD 7.

CONCLUSIONS

We found an association between the analgesic impact of ITMB and better functional recovery of remnant kidney in living kidney donors. In addition, we propose a stratification model that predicts delayed functional recovery of remnant kidney in living donors: male sex, older age, non-ITMB, and lower hourly fluid infusion rate.

Expanded Analysis of a Modified Enhanced Recovery Protocol in Cleft Palatoplasty

OBJECTIVE

We have previously shown the efficacy of an enhanced recovery after surgery (ERAS) protocol in pediatric cleft palatoplasty for proof of concept (POC). We sought to validate the efficacy of ERAS when expanded to patients of variable age and complexity undergoing primary palatoplasty.

MAIN OUTCOME MEASURE(S)

Between April 2017 and December 2018, 100 patients were collected prospectively for the expanded assessment (ERAS₂) and POC (ERAS₁) and compared to historical controls both independently and in aggregate (ERAS_(T)). We compared patient demographics, perioperative narcotic administration, length of stay (LOS), and rates of return to service (RTS).

RESULTS

Despite increased complexity, total narcotic usage (morphine equivalents normalized per weight) during each phase of care was significantly greater in controls when compared to ERAS₁, ERAS₂, or ERAS_T, respectively (intraoperative: 0.44 mg/kg vs 0.013 mg/kg vs 0.016 mg/kg vs 0.014 mg/kg; postanesthesia care unit: 0.061 mg/kg vs 0.006 mg/kg vs 0.007 mg/kg vs 0.007 mg/kg; postoperative: 0.389 mg/kg vs 0.009 mg/kg vs 0.026 mg/kg vs 0.017 mg/kg). ERAS₁ and ERAS₂ groups each demonstrated a decrease in LOS (-36.6%, -26.3%) when compared to controls. Overall, application of ERAS led to a 95.7% reduction in narcotic administration and a 31.7% decrease in LOS when compared to controls. The incidence of RTS was higher in ERAS₂ (13.0%) when compared to ERAS₁ (2.1%) or controls (2.4%), with the strongest independent predictor being a positive perioperative respiratory viral panel (PRVP).

CONCLUSIONS

Application of ERAS to palatoplasty patients of advanced age and complexity evidenced consistency with respect to decreased perioperative narcotic administration and shortened LOS. A positive PRVP was found to be an independent predictor of RTS even when ERAS was applied.

Using a Mobile Application for Real-Time Collection of Patient-Reported Outcomes in Hepatopancreatobiliary Surgery within an ERAS® Pathway

Patient-reported outcomes (PROs) are essential for patient-centered health care. This pilot study implemented a mobile application customized to an hepatopancreatobiliary Enhanced Recovery After Surgery (ERAS®) program—a novel environment—for real-time collection of PROs, including ERAS® pathway compliance. Patients undergoing hepatectomy, distal pancreatectomy, or pancreaticoduodenectomy through the ERAS® program were prospectively enrolled over 10 months. The application provided education and questionnaires before surgery through 30 days postdischarge. Thresholds were set for initial adoption of the application (75%), PRO response rate (50%), and patient satisfaction (75%). Daily postdischarge health checks integrated customized responses to guide out-of-hospital care. Of 165 enrolled patients, 122 met inclusion criteria. Application adoption was 93 per cent (114/122) and in-hospital engagement remained high at 88 per cent (107/122). Patients completed 62 per cent of PRO on quality of life, postoperative pain, nausea, opioid consumption, and compliance to ERAS® pathway items, including ambulation and breathing exercises. During postcharge tracking, 12 patients reported that the application prevented a phone call to the hospital and three patients reported prevention of an emergency room visit. PRO collection through this mobile device created an integrated platform for comprehensive perioperative care, patient-initiated outcome tracking with automatic reporting, and real-time feedback for process change. Improving proactive outpatient management of complex patients through mobile technology could help restructure health-care delivery and improve resource utilization for all patients.

Effect of enhanced recovery after surgery program on patient-reported outcomes and function recovery in patients undergoing liver resection for hepatocellular carcinoma

The aim of this study was to investigate the effect of enhanced recovery after surgery (ERAS) on perioperative outcomes, with an emphasis on patient-reported outcomes (PROs) and functional recovery.We compared the clinical outcomes in a cohort of 275 patients undergoing liver resection before and after the implementation of ERAS. The PROs were preoperatively and postoperatively compared until 14 days after surgery using the MD Anderson Symptom Inventory.The patients in the ERAS group experienced fewer symptoms and a shorter functional recovery time than the patients in the non-ERAS group. The group × time interactions were different between the groups for pain (F = 4.70, P = .001) and walking (F = 2.75, P = .03). On the 3rd, 4, and 5th days after surgery, the ERAS group experienced less pain and more walking than the non-ERAS group. The ERAS group experienced less fatigue (0.407 [95% confidence interval, CI: -0.795, -0.020], P = .035), less sleep interference (0.615 [95% CI: -1.215, -0.014], P = .045), a lower rate of reduced appetite (0.281 [95% CI: -0.442, -0.120], P = .001), and less abdominal distension (0.262 [95% CI: -0.504, -0.020], P = .034) than the non-ERAS group. Those in the ERAS group had a significantly shorter median time from surgery to mild fatigue (5.41 vs 6.87 days, P = .003), mild pain (4.45 vs 6.09 days, P = .001), mild interference when walking (3.85 vs 5.54 days, P < .001), and mild interference when sleeping (5.49 vs 7.43 days, P < .001). ERAS patients were more likely than non-ERAS patients to achieve a functional recovery (5.70 vs 6.79 days, P < .001) status in a shorter time period. The ERAS pathway, operation time, and the minimally invasive approach were independent predictors of functional recovery time.In hepatocellular carcinoma liver resection patients, the primary mechanism of ERAS is to reduce the postoperative interference burden and promote rapid functional recovery.

The Endoscopic Approach to Lumbar Discectomy, Fusion, and Enhanced Recovery: A Review

STUDY DESIGN

Review.

OBJECTIVES

To review the current state of endoscopic spine surgery with regard to discectomy, interbody fusion, and combination with Enhanced Recovery After Surgery programs in order to evaluate its relevance to the future of spine care.

METHODS

A review of the literature and expert opinion is used to accomplish the objectives.

RESULTS

The greatest strength of endoscopic spine surgery lies in its adherence to the basic tenets of minimally invasive surgery and its innate compatibility with Enhanced Recovery After Surgery programs, which aim to improve outcomes and reduce health care costs. The greatest challenge faced is the unique surgical skill set and significant learning curve.

CONCLUSIONS

Endoscopic spine surgery strives to achieve the core goals of minimally invasive surgery, while reducing cost and enhancing quality. In a healthcare market that is becoming increasingly burdened by cost and regulatory constraints, the utilization of endoscopy may become more widespread in the coming years.

Comparison of enhanced recovery protocol with conventional care in patients undergoing minor gynecologic surgery

Introduction

Data regarding the role of the enhanced recovery after surgery (ERAS) protocol in improving postoperative outcomes and postoperative compliance in patients undergoing gynecological surgery, in particular, minor laparoscopic and hysteroscopic gynecological procedures, are limited.

Aim

To investigate the impact of the ERAS protocol on time to ambulation, length of stay (LOS), readmissions and postoperative complications in patients undergoing minor gynecological surgical procedures.

Material and methods

A total of 104 patients undergoing minor laparoscopic and hysteroscopic gynecological procedures were randomized to the ERAS protocol or conventional care. Time to defecation, ambulation, and solid food intake, bleeding and LOS were recorded for each patient.

Results

The amount of intravenous fluid administered in the perioperative (p < 0.001) and postoperative period (p < 0.001) was significantly higher in the conventional care group than in the ERAS group. In addition, time to first defecation (p < 0.001), time to eating solid food (p < 0.001), and time to ambulation (p = 0.008) were shorter in the ERAS group compared to the conventional care group. Length of stay was also significantly shorter in the ERAS group than in the conventional care group (p < 0.001).

Conclusions

Implementation of ERAS protocols provides shorter LOS, less fluid intake, early return of bowel function and early mobilization without an increase in complication rate in women undergoing minor laparoscopic or hysteroscopic gynecologic surgery.

Improving Maximal Strength in the Initial Postoperative Phase After Anterior Cruciate Ligament Reconstruction Surgery: Randomized Controlled Trial of an App-Based Serious Gaming Approach

Background

Anterior cruciate ligament reconstruction surgery is one of the most common orthopedic procedures. One of the main factors that influence the outcome is regaining strength in the postoperative phase. Because anterior cruciate ligament reconstruction surgeries are often performed in young patients, we combined the concept of prehabilitation with an app-based serious gaming approach to improve maximal strength postoperatively.

Objective

Our objective was to conduct a prospective randomized trial to evaluate whether an app-based active muscle training program (GenuSport Knee Trainer) can improve postoperative strength by starting rehabilitation immediately after primary anterior cruciate ligament reconstruction surgery.

Methods

We designed a pilot study in which we randomly assigned patients receiving primary anterior cruciate ligament reconstruction to either the serious gaming training (intervention) group or a conventional rehabilitation (control) group. Except for the serious gaming-based training, both groups followed the same postoperative treatment protocol. Outcome parameters were absolute and relative change in maximal strength, as well as the International Knee Documentation Committee Subjective Knee evaluation form, Knee Injury and Osteoarthritis Outcome Score, and Lysholm Knee Score.

Results

In total 26 patients agreed to participate (14 patients in the intervention group and 12 patients in the control group, 1 of whom was lost to follow-up). We noted a difference in absolute maximum strength between the exergaming intervention and the control groups. Mean maximum strength preoperatively was 155.1 (SD 79.2) N in the intervention group (n=14) and 157.0 (SD 40.8) N in the control group (n=11). Postoperative mean maximum strength was 212.8 (SD 78.5) N in the intervention group and 154.5 (SD 27.1) N in the control group. Mean absolute change in maximum strength was 57.7 (SD 95.2) N in the intervention group and –4.8 (22.2) N in the control group. The analysis of covariance model with absolute change as the dependent variable and treatment group and baseline maximum strength as covariates showed a relevant difference in relative change between treatment groups (intervention – control) of 59.7 N (95% CI 10.1-109.3; P=.02). Similarly to the absolute increase, the relative change in maximum strength was relevantly higher in the exergaming group. The mean relative change in maximum strength was 1.7 (SD 1.17) in the intervention group and 1 (SD 0.13) in the control group. No adverse events or problems were reported during the study period.

Conclusions

Implementation of an app-based active muscle training program in the early postoperative therapy scheme was associated with an improvement in maximal strength. Therefore, we considered the use of GenuSport training after anterior cruciate ligament reconstruction to be a helpful complement to rehabilitation after anterior cruciate ligament reconstruction surgery to improve strength in the early postoperative phase. To our knowledge this was the first study to analyze immediate postoperative serious gaming-based training with the GenuSport device based on strength improvement.

Effects of a Perioperative Safety Checklist on Postoperative Complications Following Surgery for Gastric Cancer: A Single-Center Preliminary Study

Objective. A Perioperative Safety Checklist (PSC) for gastric cancer (GC) was established to evaluate the effects of PSC on the clinical outcomes of GC. Methods. This single-center preliminary observational study conducted at a tertiary referral hospital included patients with GC who underwent surgery from January 1, 2016, to June 30, 2016, treated without PSC (allocated to the control group) and those who underwent surgery between January 1, 2017, and June 30, 2017, managed according to the PSC designated as the PSCGC (Perioperative Safety Checklist for Gastric Cancer) group. Results. Overall, 1072 cases were enrolled, 556 cases in PSCGC group and 526 cases in control group. After matching, there were 474 patients in each group. PSC intervention led to significant reductions of the incidence of postoperative intestinal fistula formation ( P = .034), the incidence of unplanned secondary surgery ( P = 0.039), and the total hospitalization expenses ( P < .001). Total completion rate of all 14 checklists items was 79.1%. Intraoperative blood loss in the complete and partial implementation groups was significantly lower than the complete nonimplementation group ( P = .002), whereas hospitalization cost showed an opposite trend, which was significantly higher in the incomplete nonimplementation group ( P = .015). Conclusion. PSC implementation was associated with a decreased incidence of gastrointestinal fistula formation, unplanned secondary surgery, and hospitalization cost in patients with GC. However, it had no effect on the in-hospital mortality, the incidence of postoperative complications during hospitalization (ie, incision complications and lung infections), unplanned secondary admission, and the duration of postoperative hospital stay.

FACTORS RELATED TO THE REDUCTION OF THE RISK OF COMPLICATIONS IN COLORECTAL SURGERY WITHIN PERIOPERATIVE CARE RECOMMENDED BY THE ACERTO PROTOCOL

Background:

Perioperative care multimodal protocol significantly improve outcome in surgery.

Aim:

To investigate risk factors to various endpoints in patients submitted to elective colorectal operations under the ACERTO protocol.

Methods:

Cohort study analyzing through a logistic regression model able to assess independent risk factors for morbidity and mortality, patients submitted to elective open colon and/or rectum resection and primary anastomosis who were either exposed or non-exposed to demographic, clinical, and ACERTO interventions.

Results:

Two hundred thirty four patients were analyzed and submitted to 156 (66.7%) rectal and 78 (33.3%) colonic procedures. The length of hospital postoperative stay (LOS) ≥ 7 days was related to rectal surgery and high NNIS risk index; preoperative fasting ≤4 h (OR=0.250; CI95=0.114-0.551) and intravenous volume of crystalloid infused > 30ml/kg/day (OR=0.290; CI95=0.119-0.706). The risk of postoperative site infection (SSI) was approximately four times greater in malnourished; eight in rectal surgery and four in high NNIS index. The duration of preoperative fasting ≤4 h was a protective factor by reducing by 81.3% the risk of surgical site infection (SSI). An increased risk for anastomotic fistula was found in malnutrition, rectal surgery and high NNIS index. Conversely, preoperative fasting ≤4 h (OR=0.11; CI95=0.05-0.25; p<0.0001) decreased the risk of fistula. Factors associated with pneumonia-atelectasis were cancer and rectal surgery, while preoperative fasting ≤ 4 h (OR=0.10; CI95=0.04-0.24; p<0.0001) and intravenous crystalloid ≤ 30 ml/kg/day (OR=0.36; CI95=0.13-0.97, p=0.044) shown to decrease the risk. Mortality was lower with preoperative fasting ≤4 h and intravenous crystalloids infused ≤30 ml/kg/day.

Conclusion:

This study allows to conclude that rectal procedures, high NNIS index, preoperative fasting higher than 4 h and intravenous fluids greater than 30 ml/kg/day during the first 48 h after surgery are independent risk factors for: 1) prolonged LOS; 2) surgical site infection and anastomotic fistula associated with malnutrition; 3) postoperative pneumonia-atelectasis; and 4) postoperative mortality.

Metabolic consequences of perioperative oral carbohydrates in breast cancer patients - an explorative study

Background

The metabolic consequences of preoperative carbohydrate load in breast cancer patients are not known. The present explorative study investigated the systemic and tumor metabolic changes after preoperative per-oral carbohydrate load and their influence on tumor characteristics and survival.

Methods

The study setting was on university hospital level with primary and secondary care functions in south-west Norway. Serum and tumor tissue were sampled from a population-based cohort of 60 patients with operable breast cancer who were randomized to either per-oral carbohydrate load (preOp™; n = 25) or standard pre-operative fasting (n = 35) before surgery. Magnetic resonance (MR) metabolomics was performed on serum samples from all patients and high-resolution magic angle spinning (HR-MAS) MR analysis on 13 tumor samples available from the fasting group and 16 tumor samples from the carbohydrate group.

Results

Fourteen of 28 metabolites were differently expressed between fasting and carbohydrate groups. Partial least squares discriminant analysis showed a significant difference in the metabolic profile between the fasting and carbohydrate groups, compatible with the endocrine effects of insulin (i.e., increased serum-lactate and pyruvate and decreased ketone bodies and amino acids in the carbohydrate group). Among ER-positive tumors (n = 18), glutathione was significantly elevated in the carbohydrate group compared to the fasting group (p = 0.002), with a positive correlation between preoperative S-insulin levels and the glutathione content in tumors (r = 0.680; p = 0.002). In all tumors (n = 29), glutamate was increased in tumors with high proliferation (t-test; p = 0.009), independent of intervention group. Moreover, there was a positive correlation between tumor size and proliferation markers in the carbohydrate group only. Patients with ER-positive / T2 tumors and high tumor glutathione (≥1.09), high S-lactate (≥56.9), and high S-pyruvate (≥12.5) had inferior clinical outcomes regarding relapse-free survival, breast cancer-specific survival, and overall survival. Moreover, Integrated Pathway Analysis (IPA) in serum revealed activation of five major anabolic metabolic networks contributing to proliferation and growth.

Conclusions

Preoperative carbohydrate load increases systemic levels of lactate and pyruvate and tumor levels of glutathione and glutamate in ER-positive patients. These biological changes may contribute to the inferior clinical outcomes observed in luminal T2 breast cancer patients.

Trial of registration

ClinicalTrials.gov; NCT03886389. Retrospectively registered March 22, 2019.

Pain therapy to reduce perioperative complications

The incidence rates of adverse events secondary to any operation are a well-known problem in any surgical field. One outstanding example of such adverse events is postoperative pain. Thus, the incidence of acute postoperative pain following any surgical procedure and its treatment are central issues for every surgeon. In the times of Enhanced Recovery After Surgery (ERAS) programs, acute pain therapy became an increasingly well investigated and accepted aspect in almost all surgical subspecialties. However, if it comes to the reduction of postoperative complications, in the actual context of postoperative pain, surgeons tend to focus on the operative process rather than on the perioperative procedures. Undoubtedly, postoperative pain became an important factor with regard to the quality of surgical care: both, the extent and the quality of the surgical procedure and the extent and the quality of the analgesic technique are decisive issues for a successful pain management. There is growing evidence that supports the role of acute pain therapy in reducing postoperative morbidity, and it has been demonstrated that high pain scores postoperatively may contribute to a complicated postoperative course. This overview comprises the current knowledge on the role of acute pain therapy with regard to the occurrence of postoperative complications. Most of the knowledge is derived from studies that primarily focus on the type and quality of postoperative pain therapy in relation to specific surgical procedures and only secondary on complications. As far as existent, data that report on the recovery period after surgery, on the rehabilitation status, on perioperative morbidity, on the development of chronic pain after surgery, and on possible solutions of the latter problem with the institution of transitional pain services will be presented.

Current Opioid Prescribing Patterns after Microdirect Laryngoscopy

Background:

The prevalence of opioid abuse has become epidemic in the United States. Microdirect laryngoscopy (MDL) is a common otolaryngological procedure, yet prescribing practices for opioids following this operation are not well characterized.

Objective:

To characterize current opioid-prescribing patterns among otolaryngologists performing MDL.

Methods:

A cross-sectional survey of otolaryngologists at a national laryngology meeting.

Results:

Fifty-eight of 205 physician registrants (response rate 28%) completed the survey. Fifty-nine percent of respondents were fellowship-trained in laryngology. Respondents performed an average of 13.3 MDLs per month. Thirty-four percent of surgeons prescribe opioids for over two-thirds of their MDLs, while only 7% of surgeons never prescribe opioids. Eighty-eight percent of surgeons prescribed a combination opioid and acetaminophen compound, hydrocodone being the most common opioid component. Many surgeons prescribe non-opioid analgesics as well, with 70% and 84% of surgeons recommending acetaminophen and ibuprofen after MDL respectively. When opioids were prescribed, patient preference, difficult exposure and history of opioid use were the most influential patient factors. Concerns of opioid abuse, the physician role in the opioid crisis, and literature about postoperative non-opioid analgesia were also underlying themes in influencing opioid prescription patterns after MDL.

Conclusions:

In this study, over 90% of practicing physicians surveyed are prescribing opioids after MDL, though many are also prescribing non-opioid analgesia as well. Further studies should be completed to investigate the needs of patients following MDL in order to allow physicians to selectively and appropriately prescribe opioid analgesia postoperatively.

Drainage tube hole suture improvement: Removal-free stitches

Surgical method improvements aim to optimize the patient experience. The problem of healing of the drainage tube hole has not received attention and is of concern because it can plague patient recovery. In this article we report on how we have improved the method of suturing the drainage tube hole and explore the safety and effectiveness of this method. Between December 2017 to August 2018, 102 patients underwent thoracoscopic lung resection (single port or single utility port) using different methods of suturing drainage tube holes. The intervention group received improved methods with subcuticular and intradermal suture and removal-free stitches, whilst the control group received a conventional mattress suture and fixed chest tube. A preset line was left to tie knots and close the hole after the removal of the chest tube. The stitches were removed 7-12 days after surgery. The baseline clinical features of the patients were subsequently analyzed. The objective and subjective conditions of scars were evaluated using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS) at one month after surgery. The intervention group (n = 71) and control group (n = 31) had balanced baseline clinical characteristics. There were no significant differences between the two groups in terms of three-day postoperative pain and postoperative hospital stay. In the intervention group, three patients (4.23%) had wound splitting that required re-suturing, which was better than five patients (16.13%) in the control group (P < 0.05). The incidence of pleural fluid outflow, wound infection, post-removal pneumothorax, chest tube prolapse and incisional hernia were not different between the two groups. We conclude that the objective and subjective evaluation results of scars were significantly different between the two groups (P < 0.05), and the experimental group was superior to the control group. A balanced result between aesthetic appearance and safety as regards video-assisted thoracic surgery can be achieved through the chest tube hole improved suture method. This method also improves the patient's recovery experience.

International validation of Enhanced Recovery After Surgery Society guidelines on enhanced recovery for gynecologic surgery

BACKGROUND

Enhanced Recovery After Surgery Society publishes guidelines on perioperative care, but these guidelines should be validated prospectively.

OBJECTIVE

To evaluate the association between compliance with Enhanced Recovery After Surgery Gynecologic/Oncology guideline elements and postoperative outcomes in an international cohort.

STUDY DESIGN

The study comprised 2101 patients undergoing elective gynecologic/oncology surgery between January 2011 and November 2017 in 10 hospitals across Canada, the United States, and Europe. Patient demographics, surgical/anesthesia details, and Enhanced Recovery After Surgery protocol compliance elements (pre-, intra-, and postoperative phases) were entered into the Enhanced Recovery After Surgery Interactive Audit System. Surgical complexity was stratified according to the Aletti scoring system (low vs medium/high). The following covariates were accounted for in the analysis: age, body mass index, smoking status, presence of diabetes, American Society of Anesthesiologists class, International Federation of Gynecology and Obstetrics stage, preoperative chemotherapy, radiotherapy, operating time, surgical approach (open vs minimally invasive), intraoperative blood loss, hospital, and Enhanced Recovery After Surgery implementation status. The primary end points were primary hospital length of stay and complications. Negative binomial regression was used to model length of stay, and logistic regression to model complications, as a function of compliance score and covariates.

RESULTS

Patient demographics included a median age 56 years, 35.5% obese, 15% smokers, and 26.7% American Society of Anesthesiologists Class III-IV. Final diagnosis was malignant in 49% of patients. Laparotomy was used in 75.9% of cases, and the remainder minimally invasive surgery. The majority of cases (86%) were of low complexity (Aletti score ≤3). In patients with ovarian cancer, 69.5% had a medium/high complexity surgery (Aletti score 4-11). Median length of stay was 2 days in the low- and 5 days in the medium/high-complexity group. Every unit increase in Enhanced Recovery After Surgery guideline score was associated with 8% (IRR, 0.92; 95% confidence interval, 0.90-0.95; P<.001) decrease in days in hospital among low-complexity, and 12% (IRR, 0.88; 95% confidence interval, 0.82-0.93; P<.001) decrease among patients with medium/high-complexity scores. For every unit increase in Enhanced Recovery After Surgery guideline score, the odds of total complications were estimated to be 12% lower (P<.05) among low-complexity patients.

CONCLUSION

Audit of surgical practices demonstrates that improved compliance with Enhanced Recovery After Surgery Gynecologic/Oncology guidelines is associated with an improvement in clinical outcomes, including length of stay, highlighting the importance of Enhanced Recovery After Surgery implementation.

Enhanced recovery after surgery: Prediction for early extubation in video-assisted thoracic surgery using a response surface model in anesthesia

BACKGROUND/PURPOSE

Enhanced recovery after surgery (ERAS) is a growing tendency in modern perioperative period management, but no protocol has been established for a strategy that optimally facilitates rapid recovery from anesthesia. We hypothesized that applying a total intravenous anesthesia (TIVA) method to the response surface model (RSM) would allow prediction of the emergence and endotracheal tube extubation in cases undergoing video-assisted thoracotomy surgery (VATS).

METHODS

Thirty patients who were scheduled to undergo VATs under TIVA were enrolled. Pharmacokinetic profiles were calculated using a Tivatrainer. Emergence from anesthesia was observed and the exact time point of the regained response (RR) was recorded. The effect of concentration was analyzed and applied to a response surface model.

RESULTS

The cumulative prediction curve of the RR was closer to the 50% probability as set by the OAA/S ≥ 4 than by the OAA/S ≥ 2 model. The median, averages, and standard deviations of the time differences were 14.5, 22.05 ± 19.23 min for the OAA/S ≥2 model and 10.4, 14.26 ± 10.40 min for the OAA/S ≥ 4 model.

CONCLUSION

The OAA/S ≥ 4 model could identify the target concentration in propofol-remifentanil pairs that predicted the time of emergence from VATS in 10 min. Our results indicate that RSM can be used to derive an ERAS protocol for VATS under TIVA. Further studies should investigate application of RSM to predict ERAS for various types of procedures.

Postoperative complications are main reason for noncompliance with enhanced recovery after surgery program in patients undergoing hepatectomy and pancreatectomy

Background and Aim

Enhanced recovery after surgery (ERAS) protocols are reported to improve postoperative outcomes in patients undergoing a routine protocol and postoperative outcomes in patients undergoing hepatic and pancreatic resections at our institution.

Methods

A total of 99 consecutive patients at a single institution managed with a similar ERAS protocol were divided into the “early” (50 patients) and “late” (49 patients) cohorts. Both cohorts were statistically identical in demographics and range of surgical procedures performed. Postoperative complications, readmission, reoperation rates, and length of stay were analyzed. Categorical variables were statistically compared using Fisher's exact test and continuous variables using t‐test and Mann–Whitney U‐test when appropriate.

Results

There were 32 hepatectomies/18 pancreatectomies in the “early” cohort and 22 hepatectomies/29 pancreatectomies in the “late” cohort. The overall complication rate was 38.8%, with a 30‐day readmission rate and reoperation rate of 16.1 and 5%, respectively. There was one mortality (1%). Group‐specific overall complication rate (40 vs 38.7%, P = 0.8), readmission rate (20 vs 12.2%, P = 0.4), reoperation rate (6 vs 4%, P = 1.0), and mortality (2 vs 0%, P = 1.0) were not statistically significant between both groups.

Conclusions

Despite similar rates of adherence to the established ERAS 24 protocol, there was no improvement in median length of stay (7 days) between the “early” and “late” groups. The only reason for noncompliance with the ERAS protocol was development of surgery‐related complications.

Potential role of pharmacogenomics testing in the setting of enhanced recovery pathways after surgery

In 2001, a group of European academic surgeons created the Enhanced Recovery After Surgery (ERAS) study group and established the first official ERAS protocol. One of the most significant challenges during ERAS implementation is variability of drugs used throughout the perioperative period. Pharmacogenomic testing (blood or saliva) results (obtained within approximately 48 hrs) provide guidelines on how to prescribe the optimal drug with the optimal dosage to each patient based on an individual's unique genetic profile. Pharmacogenomic testing of various methods of multimodal analgesia is an essential element of ERAS protocols spanning the entire perioperative period to ultimately optimize postoperative pain control. The key goal for anesthetic management in ERAS protocols is to facilitate rapid emergence by using the shortest acting agents available, thus accelerating recovery and reducing length of stay, hospital expenses, and postoperative complications. Postoperative nausea and vomiting (PONV) is an additional challenge that should be overcome to ensure an enhanced recovery and shorter length of stay with the use of antiemetics. Postoperative ileus (POI) can result in longer hospital stay with increasing susceptibility to associated morbidities along with an increase in associated hospitalization costs. Genetics-guided pharmacotherapy and its impact on clinical outcomes should be thoroughly studied for better understanding and managing drug administration in the settings of ERAS.

Trends in hospital length of stay and 30-day morbidity in pediatric patients undergoing laparoscopic ileocecal resection, 2012-2016

PURPOSE

To examine postoperative length of stay (LOS), hospital readmission, and 30-day complications in pediatric patients undergoing laparoscopic ileocecal resection in a contemporary cohort.

METHODS

Retrospective review of the American College of Surgeons National Surgery Quality Improvement Project, Pediatric (NSQIP-P) 2012-2016 participant user files for patients <19 years old who underwent laparoscopic ileocecal resection. Mean postoperative LOS, hospital readmission and both wound-specific and composite complications were calculated and compared by year of operation.

RESULTS

348 patients were identified (range, 46-96 per year); 55.2-69.8% of these were admitted the day of operation, with a nonsignificant increase in frequency over the study period. Postoperative LOS ranged from 5.4 ± 2.9 days to 7.3 ± 9.1 days (p = 0.24). In subset analysis of only those patients admitted on the day of operation, postoperative LOS remained relatively long, ranging from 5.0 ± 3.0 days to 5.7 ± 4.0 days (p = 0.89). 30-day hospital readmission proportions rose insignificantly, from 6.9% in 2012 to 15.5% in 2016 (p = 0.41). Wound complication rates (including superficial, deep, and deep organ space infections, as well as wound dehiscence) ranged from 0.0% to 8.6%, but did not vary in a statistically significant manner. Nonwound complication rates were vanishingly small.

CONCLUSIONS

Postoperative LOS in pediatric patients undergoing laparoscopic ileocecal resection in a select group of patients cared for in hospitals participating in NSQIP-P has not decreased in the past 5 years despite emerging evidence of the safety and relevance of enhanced recovery after surgery programs. Opportunities for shortening LOS without compromising patient safety may still exist.

LEVEL-OF-EVIDENCE

III Retrospective comparative study.

Comparison of Clinical Outcomes in Surgical Patients Subjected to CIPA Nutrition Screening and Treatment versus Standard Care

Malnutrition is prevalent in surgical patients and leads to comorbidities and a poorer postoperative course. There are no studies that compare the clinical outcomes of implementing a nutrition screening tool in surgical patients with standard clinical practice. An open, non-randomized, controlled study was conducted in general and digestive surgical hospitalized patients, who were either assigned to standard clinical care or to nutrition screening using the Control of Food Intake, Protein, and Anthropometry (CIPA) tool and an associated treatment protocol (n = 210 and 202, respectively). Length of stay, mortality, readmissions, in-hospital complications, transfers to critical care units, and reinterventions were evaluated. Patients in the CIPA group had a higher Charlson index on admission and underwent more oncological and hepatobiliary-pancreatic surgeries. Although not significant, a shorter mean length of stay was observed in the CIPA group (-1.48 days; p < 0.246). There were also fewer cases of exitus (seven vs. one) and fewer transfers to critical care units in this group (p = 0.068 for both). No differences were detected in other clinical variables. In conclusion, patients subjected to CIPA nutrition screening and treatment showed better clinical outcomes than those receiving usual clinical care. The results were not statistically significant, possibly due to the heterogeneity across patient groups.

Jejunostomy or nasojejunal tube after esophagectomy: a review of the literature

Patients undergoing esophagectomy for cancer are a difficult to treat group of patients. At diagnosis they will present some degree of malnutrition in up to 80% and the causes are from multifactorial origin: the inability of food ingestion, advanced age, taste disturbances, and morbidity related to neoadjuvant treatment. In order to restaure the nutritional status, enteral nutritional support is preferable to parenteral support because of the risks of septic complications associated with venous catheters. During the postoperative period, the oral route is often inaccessible in these patients due to swallowing disorders and eventually mechanical ventilation, and if possible, often it does not provide sufficient caloric amounts for postoperative energy balance. For these reasons, it is usually recommended additional nutritional support. There are few studies in the literature that specifically address which is the most adequate route for enteral nutrition in patients undergoing esophagectomy. Nasojejunal catheters present a higher incidence of local complications, such as displacement and occlusion, whereas jejunostomy is more associated with reinterventions for the treatment of complications secondary to extravasation. Although there is weak evidence in the literature and a lack of randomized, prospective and multicenter studies evaluating the best enteral nutrition route in the postoperative period of esophagectomy, the use of the nasoenteric catheter seems to be adequate due to its simplicity of positioning and low rates of severe complications. In this paper a review is performed of the evidence about this subject.

Preoperative nutritional optimization of esophageal cancer patients

Optimization of the nutritional and metabolic state prior to major surgery leads to improved surgical outcomes and is increasingly seen as an important part of oncology disease management. For locally advanced esophageal cancer the treatment is multimodal, including neoadjuvant chemoradiotherapy or perioperative chemotherapy in combination with esophageal resection. Patients undergoing such a multimodal treatment have a higher risk for progressive decline in their nutritional status. Preoperative malnutrition and loss of skeletal muscle mass has been reported to correlate with unfavorable outcomes in patients who undergo esophageal cancer surgery. Decline in nutritional status is most likely caused by insufficient nutritional intake, reduced physical activity, systemic inflammation and the effects of anticancer therapy. To ensure an optimal nutritional status prior to surgery, it is key to assess the nutritional status in all preoperative esophageal cancer patients, preferable early in the treatment trajectory, and to apply nutritional interventions accordingly. Nutritional management of esophageal cancer can be challenging, the optimal nutritional therapy is still under debate, and warrants more nutritional scientific research. In this review, the most recent findings regarding preoperative nutrition associated with outcomes in patients with esophageal cancer will be explored.

Enhanced recovery after spine surgery: review of the literature

The concept of Enhanced Recovery After Surgery (ERAS) entails recovery facilitation of patients who undergo surgery through the implementation of a multidisciplinary and multimodal perioperative care approach. By its application, ERAS improves the overall functional outcome after surgery while maintaining high standards of care. A review of the essential aspects of ERAS in spine surgery was undertaken. Special consideration was given to the risks and benefits for patients and caregivers, as well as the medical and economical aspects of this concept. ABBREVIATIONS EBL = estimated blood loss; ERAS = Enhanced Recovery After Surgery; MISS = minimally invasive spine surgery; TLIF = transforaminal lumbar interbody fusion.

Randomized clinical trial of liposomal bupivacaine transverse abdominis plane block versus intrathecal analgesia in colorectal surgery

Background

Transverse abdominis plane (TAP) block is considered an effective alternative to neuraxial analgesia for abdominal surgery. However, limited evidence supports its use over traditional analgesic modalities in colorectal surgery. This study compared the analgesic efficacy of liposomal bupivacaine TAP block with intrathecal (IT) opioid administration in a multicentre RCT.

Methods

Patients undergoing elective small bowel or colorectal resection were randomized to receive TAP block or a single injection of IT analgesia with hydromorphone. Patients were assessed at 4, 8, 16, 24 and 48 h after surgery. Primary outcomes were mean pain scores and morphine milligram equivalents (MMEs) administered within 48 h after surgery. Secondary outcomes included duration of hospital stay, incidence of postoperative ileus and use of intravenous patient-controlled analgesia.

Results

In total, 209 patients were recruited and 200 completed the trial (TAP 102, IT 98). The TAP group had a 1·6-point greater mean pain score than the IT group at 4 h after surgery, and this difference lasted for 16 h after operation. The TAP group received more MMEs within the first 24 h after surgery than the IT group (median difference in MMEs 10·0, 95 per cent c.i. 3·0 to 20·5). There were no differences in MME use at 24 and 48 h, or with respect to secondary outcomes.

Conclusion

IT opioid administration provided better immediate postoperative pain control than TAP block. Both modalities resulted in low pain scores in patients undergoing elective colorectal surgery and should be considered in multimodal postoperative analgesic plans. Registration number: NCT02356198 ( http://www.clinicaltrials.gov).

An enhanced recovery after surgery program in orthopedic surgery: a systematic review and meta-analysis

Objectives

There is an increased interest in enhanced recovery after surgery (ERAS) minimizing adverse events after orthopedic surgery. Little consensus supports the effectiveness of these interventions. The purpose of present systematic review and meta-analysis is to comprehensively analyze and evaluate the significance of ERAS interventions for postoperative outcomes after orthopedic surgery.

Methods

PubMed, EMBASE, and Cochrane databases were totally searched from the inception dates to May 31, 2018. Two reviewers independently extracted the data from the selected articles using a standardized form and assessed the risk of bias. The analysis was performed using STATA 12.0.

Results

A total of 15 published studies fulfilled the requirements of inclusion criteria. We found that the ERAS group showed a significant association with lower incidence of postoperative complications (OR, 0.70; 95% CI, 0.64 to 0.78). Meanwhile, ERAS was also associated with the decline in 30-day mortality rate and Oswestry Disability Index (ODI). However, no significant differences were identified between the two groups regarding the 30-day readmission rate (P = 0.397).

Conclusions

Our meta-analysis suggested that the ERAS group had more advantages in reducing incidence of postoperative complications, 30-day mortality rate, and ODI after orthopedic surgery, but not of 30-day readmission rate. However, further research with standardized, unbiased methods and larger sample sizes is required for deeper analysis.

Electronic supplementary material

The online version of this article (10.1186/s13018-019-1116-y) contains supplementary material, which is available to authorized users.

A novel anesthesiologist-led multidisciplinary model for evaluating high-risk surgical patients at a comprehensive cancer center

The objective of this retrospective analysis was to describe the development and implementation of an anesthesiologist-led multidisciplinary committee to evaluate high-risk surgical patients in order to improve surgical appropriateness. The study was conducted in an anesthesia preoperative evaluation clinic at an academic comprehensive cancer center. One hundred sixty-seven high-risk surgical patients with cancer-related diagnoses were evaluated and discussed at a High-Risk Committee (HRC) meeting to determine surgical appropriateness and optimize perioperative care. The HRC is an anesthesiologist-led model for multidisciplinary review of high-risk patients developed at Roswell Park Comprehensive Cancer Center. The group of high-risk patients in which surgery was not performed had, on average, a greater percentage of hypertension, smoking history, dyspnea, heart failure, chronic obstructive pulmonary disease, diabetes, renal failure, and sleep apnea than the group in whom surgery was performed. Only one of 107 high-risk patients who had surgery died within the first 30 days after surgery. A smaller percentage of patients died in the group that had surgery versus the group in which surgery was canceled. For all patients discussed by the HRC, the mortality was less than 2% within the first 30 days after the HRC.

Postoperative Care and Functional Recovery After Laparoscopic Sleeve Gastrectomy vs. Laparoscopic Roux-en-Y Gastric Bypass Among Patients Under ERAS Protocol

Background

The most commonly performed bariatric procedures are laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). There are major differences between LSG and LRYGB during postoperative period. Optimization of the postoperative care may be achieved by using enhanced recovery after surgery (ERAS) protocol, which allows earlier functional recovery.

Purpose

The aim was to assess differences in the course of postoperative care conducted in accordance with ERAS protocol among patients after LSG and LRYGB.

Material and Methods

Data concerning patients treated for morbid obesity were prospectively gathered in one academic center. Patients were divided into two groups: LSG (n = 364, 63.41%) and LRYGB (n = 210, 36.59%). Multiple factors were used as endpoints to determine the influence of the type of bariatric procedure on postoperative course.

Results

The rate of postoperative nausea and vomiting and incidence of intravenous fluid administration during the operation was higher in LSG group. LRYGB patients were able to tolerate higher oral fluid intake volumes during the first and the second postoperative day. Mean diuresis during the second and the third postoperative day was significantly higher in LRYGB group. Administration of diuretics and painkillers was comparable between groups, while the risk of fever after the operation was higher in LRYGB group. Mean length of stay was higher in LSG group (LRYGB vs. LSG, 3.46 days ± 1.58 vs. 3.64 days ± 4.41, p = 0.039).

Conclusions

In our opinion, postoperative treatment after LSG requires more supervision and longer time until functional recovery is achieved.

Safety and efficacy of early oral feeding for enhanced recovery following gastrectomy for gastric cancer: A systematic review

BACKGROUND

Early oral feeding (EOF) is believed to be a crucial item of Enhanced Recovery After Surgery (ERAS) programs. Though this is widely accepted for colorectal surgery, evidence for early oral feeding after gastrectomy is scarce. The aim of this review is to assess the evidence of safety and benefits of early oral feeding after gastrectomy in patients with gastric cancer.

METHODS

A systematic literature search of Pubmed, Embase and Cochrane was performed for eligible studies published till September 2018. Studies were analyzed and selected by predetermined criteria.

RESULTS

After having assessed 23 eligible articles, a total of four randomized controlled trials (RCT) remained who fully met all requirements to be included in this review. All four RCTs compared early oral feeding (n = 320) with conventional care (n = 334) after gastrectomy. In all four studies, EOF was associated with a decreased length of hospital stay ranging from -1.3 to -2.5 days when compared to conventional care. A faster time to first flatus was recorded in all four studies in the EOF group, ranging from -6.5 hours to -1.5 days. Furthermore, EOF does not increase postoperative complication risk when compared to conventional care.

CONCLUSION

Current evidence for early oral feeding after gastrectomy is promising, proving its safety, feasibility and benefits. However, most studies have been conducted amongst an Asian population. Well powered and larger randomized controlled trials performed amongst a Western population is needed.

Implementation of a urogynecology-specific enhanced recovery after surgery (ERAS) pathway

OBJECTIVE

Enhanced recovery after surgery protocols were developed for colorectal surgery to hasten postoperative recovery. Variations of the protocol are being adopted for gynecological procedures despite limited population and procedure-specific outcome data. Our objective was to evaluate whether implementation of an enhanced recovery after surgery pathway would facilitate reduced length of admission in a urogynecology population.

MATERIALS AND METHODS

In this retrospective analysis of patients undergoing pelvic floor reconstructive surgery by 7 female pelvic medicine and reconstructive surgeons, we compared same-day discharge, length of admission and postoperative complications before and after implementation of an enhanced recovery after surgery pathway at a tertiary care hospital. Groups were compared using χ² and Student t tests. Candidate variables that could have an impact on patient outcomes with P < .2 were included in multivariable logistic regression models. Satisfaction with surgical experience was assessed using a phone-administered questionnaire the day after discharge.

RESULTS

Mean age and body mass index of 258 women (137 before enhanced recovery after surgery and 121 enhanced recovery after surgery) were 65.5 ± 11.3 years and 28.2 ± 5.0 kg/m². The most common diagnosis was pelvic organ prolapse (n = 242, 93.8%) including stage III pelvic organ prolapse (n = 61, 65.1%). Apical suspension procedures included 58 transvaginal (25.1%), 112 laparoscopic/robotic (48.8%), and 61 obliterative (26.4%). Hysterectomy was performed in 57.4% of women. Demographic and surgical procedures were similar in both groups. Compared with before enhanced recovery after surgery, the enhanced recovery after surgery group had a higher proportion of same-day discharge (25.9% vs 91.7%, P < .001) and a 13.8 hour shorter duration of stay (25.9 ± 13.5 vs 12.1 ± 11.2 hours, P <.001). Operative and postsurgical recovery room times were similar (2.6 ± 0.8 vs 2.6 ± 0.9 hours, P =.955; 3.7 ± 2.1 vs 3.6 ± 2.2 hours, P = .879). Women in the enhanced recovery after surgery group were more likely to be discharged using a urethral catheter (57.9% enhanced recovery after surgery vs 25.4% before enhanced recovery after surgery, P = .005). There were no group differences in total 30 day postoperative complications overall and for the following categories: urinary tract infections, emergency room visits, unanticipated office visits, and return to the operating room. However, enhanced recovery after surgery patients had higher 30 day hospital readmission rates (n = 8, 6.7% vs n = 2, 1.5%, P = .048). Patients before enhanced recovery after surgery were readmitted for myocardial infarction and chest pain. Enhanced recovery after surgery patients were admitted for weakness, chest pain, hyponatremia, wound complications, nausea/ileus, and ureteral obstruction. Three enhanced recovery after surgery patients returned to the operating room for ureteral obstruction (n = 1), incisional hernia (n = 1), and vaginal cuff bleeding (n = 1). Enhanced recovery after surgery patients also had more postoperative nursing phone notes (2.6 ± 1.7 vs 2.1 ± 1.4, P = .030). On multivariable logistic regressions adjusting for age and operative time, same-day discharge was more likely in the enhanced recovery after surgery group (odds ratio, 32.73, 95% confidence interval [15.23-70.12]), while the odds of postoperative complications and emergency room visits were no different. After adjusting for age, operative time, and type of prolapse surgery, readmission was more likely in the enhanced recovery after surgery group (odds ratio, 32.5, 95% confidence interval [1.1-28.1]). In the enhanced recovery after surgery group, patient satisfaction (n = 77 of 121) was reported as very good or excellent by 86.7% for pain control, 89.6% for surgery preparedness, and 93.5% for overall surgical experience; 89.6% did not recall any postoperative nausea during recovery.

CONCLUSION

Enhanced recovery after surgery implementation in a urogynecology population resulted in a greater proportion of same-day discharge and high patient satisfaction but with slightly increased hospital readmissions within 30 days.

Association of Thoracic Epidural Pain Management with Urinary Retention after Complex Abdominal Wall Reconstruction

The association of thoracic epidural analgesia and urinary retention after complex abdominal wall reconstruction (CAWR) is unknown. The purpose of this study was to investigate the association between the presence of a thoracic epidural, timing of Foley catheter removal, and the rates of urinary retention and catheter-associated urinary tract infections (CAUTIs) in patients undergoing CAWR. All patients undergoing CAWR, who had an epidural catheter for postoperative pain management at our institution from September 2015 through April 2016, were prospectively followed. Patients were divided into two groups. Group 1 had their Foley catheters removed on postoperative day one, whereas Group 2 had their Foley catheters removed after epidural removal. The incidence of urinary retention and CAUTI were compared between the two groups. A total of 67 patients met inclusion criteria; 27 (40.3%) patients were in Group 1. Patients in Group 1 were significantly more likely to experience urinary retention requiring Foley catheter replacement ( P = 0.02). There was no statistically significant difference in the rate of CAUTI between the two groups ( P = 0.51). Patients undergoing CAWR with thoracic epidural pain management are at risk of experiencing postoperative urinary retention. Foley catheter removal after epidural removal does not place the patient at an increased risk for CAUTI and therefore should be strongly considered in this patient population.

Implementation of an Enhanced Recovery After Spine Surgery program at a large cancer center: a preliminary analysis

This study describes the implementation of a multimodal, multidisciplinary, evidence-based ERAS program in oncologic spine surgery, identifies and measures several relevant postoperative recovery outcomes, and demonstrates the feasibility and potential benefit of the program in improving analgesia and decreasing opioid consumption. The study underscores the importance of defining and capturing meaningful, patient-specific, and patient-reported outcomes, and constant evaluation and monitoring of a group's compliance with the program. The study represents the steppingstone for evaluation and improvement of a young ERAS program for spine surgery and serves as a roadmap for further initiatives and larger-scale studies.

Improved early outcome after TKA through an app-based active muscle training programme-a randomized-controlled trial

PURPOSE

The purpose of this prospective randomized-controlled trial (RCT) was to evaluate if an app-based feedback-controlled active muscle training programme can be used to improve the outcome in the immediate postoperative period after total knee arthroplasty (TKA).

METHODS

Sixty patients, with a median age of 65.9 years (range 45-84), awaiting primary TKA were randomized into a control and training group. Both groups followed an identical postoperative protocol. In addition, the training group postoperatively performed an app-based feedback-controlled active muscle training programme multiple times daily. Outcome measures were active and passive range of motion (ROM), pain at rest and in motion, knee extension strength, the timed "Up and Go", 10-m Walk Test, 30-s Chair Stand Test, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Society Score (KSS), and clinical data.

RESULTS

The training group performed an average of 18.4 training sessions, which led to significantly higher ROM, less pain at rest and in motion, higher strength, and significantly higher functional scores. More training correlated with a better outcome.

CONCLUSIONS

The use of an app-based feedback-controlled active muscle training programme can improve the clinical outcome after TKA, especially ROM and reduce pain. Clinically relevant is that the training programme could be considered an alternative to continuous passive motion after total knee arthroplasty.

LEVEL OF EVIDENCE

II.

Decreased hospital charges and postoperative pain in septoplasty by application of enhanced recovery after surgery

Objective

Septoplasty has been the definitive treatment for nasal septum deviation, but its postoperative procedure may affect patients’ quality of life. While new procedures in general surgery, such as enhanced recovery after surgery (ERAS), can speed up postoperative rehabilitations to improve quality of life, it is rarely applied in the ear–nose–throat field. This study therefore aims to evaluate the application of ERAS in patients with nasal septum deviation as a means of improving perioperative outcomes.

Materials and methods

Fifty patients with nasal septum deviation undergoing septoplasty were randomized as ERAS or control group (25 patients in both groups). Patients were investigated for outcomes including length of stay, operating time, bleeding volume, total cost, complications, and Self-Rating Anxiety Scale (SAS) and visual analog symptom score of nasal obstruction, sleep disturbance, and head facial pain.

Results

The preoperative anxiety in ERAS group (SAS 35.4±6.2) was lower than the control group (SAS 43.6±8.6). The anxiety levels in ERAS group (SAS 31.6±5.4) was also reduced compared to the control group (SAS 38.1±10.4) in the 3 days postsurgery, but showed no significant difference thereafter at 7 days postsurgery. In addition, the length of stay and total cost were significantly lower for the ERAS group as well. The visual analog symptom score of nasal obstruction, sleep disturbance, and head facial pain in ERAS group were all also found to be lower than the control group. The only outcomes with no significant differences were the operation time, blood volume, and complications between the groups.

Conclusion

Our study indicated ERAS application can reduce hospital charges and postoperative pain in septoplasty, thereby improving patient quality of life and hospital expenses at the same time.