151
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Tebala GD, Gallucci A, Khan AQ. The impact of complications on a programme of enhanced recovery in colorectal surgery. BMC Surg 2018; 18:60. [PMID: 30115063 PMCID: PMC6097404 DOI: 10.1186/s12893-018-0390-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 08/02/2018] [Indexed: 01/22/2023] Open
Abstract
Background The advantages of Enhanced Recovery (ER) programmes are well known, in terms of improved overall experience of the patients, which associates with low morbidity and reduced length of stay. As a result, the pattern of morbidity is changing and some patients may develop complications after discharge. Aim of this work was to evaluate the impact of morbidity and related outcomes such as unplanned readmission and reoperation rate on an ER programme in colorectal surgery. Methods Prospectively collected clinical data of patients who underwent colorectal resection have been retrospectively analysed. Endpoints were: 90-day mortality and morbidity, length of hospital stay (LOS) and rate of unplanned readmissions and reoperations. Results Mortality and morbidity did not change in the analysed period, but LOS reduced significantly. Main determinant of postoperative LOS was the type of surgical approach, laparoscopy being associated with earlier discharge. LOS was longer in patients who developed complications. Morbidity and reoperation rate were significantly higher in patients discharged after day 4. Majority of complications happened in patients who were still in the hospital. However, the few patients who developed complications after discharge did not have a worse outcome if compared to those who had complications in hospital. Conclusions ER protocols must become integral part of the perioperative management of colorectal patients. ER and laparoscopy have a synergic effect to improve the postoperative recovery and reduce morbidity. Early discharge of patients does not affect the outcome of postoperative complications.
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Affiliation(s)
- Giovanni D Tebala
- Colorectal Team, Noble's Hospital, Douglas, Isle of Man, UK. .,East Kent Hospitals University NHS Foundation Trust, William Harvey Hospital, Kennington Rd, Willesborough, Ashford, Kent, TN24 0LZ, UK.
| | | | - Abdul Q Khan
- Colorectal Team, Noble's Hospital, Douglas, Isle of Man, UK
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152
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Saltzman AF, Warncke JC, Colvin AN, Carrasco A, Roach JP, Bruny JL, Cost NG. Development of a postoperative care pathway for children with renal tumors. J Pediatr Urol 2018; 14:326.e1-326.e6. [PMID: 29891188 DOI: 10.1016/j.jpurol.2018.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 05/03/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE To identify the factors associated with a shorter postoperative stay, as an initial step to develop a care pathway for children undergoing extirpative kidney surgery. STUDY DESIGN This study retrospectively reviewed patients managed with upfront open radical nephrectomy for renal tumors between 2005 and 2016 at a pediatric tertiary care facility. Univariate and multivariate logistic regression were performed to identify factors associated with early discharge (by postoperative day 4). RESULTS A total of 84 patients met inclusion criteria. Median age was 28.1 months (range 1.8-193.1). Thirty-four (40.5%) patients had a nasogastric tube postoperatively. The patients were advanced to a clear liquid diet on a median postoperative day 2 (range 0-7) and regular diet on a median postoperative day 3 (range 1-8). Median time from surgery to discharge was 5 days (range 2-12), with 38 (45.2%) discharged early. Univariate and multivariate logistic regression analyses showed that earlier resumption of regular diet (OR 0.523, P = 0.028) was positively associated with early discharge. Other analyzed factors were not significant (see Table). DISCUSSION Timely initiation of adjuvant therapy is a specific requirement of Children's Oncology Group (COG) protocols. Chemotherapy and radiation therapy are ideally initiated simultaneously, as early as possible, within 2 weeks of surgery. Thus, factors that can facilitate early discharge from the hospital can maximize protocol adherence with respect to timing of adjuvant therapy initiation and optimize patient outcome. This study shed light on several postoperative factors and how these relate to postoperative stay and recovery. Specifically, tumor size, pre-operative bowel preparation, extent of lymph node sampling, stage, operative time, estimated blood loss, surgical service, postoperative nasogastric tube use, transfusion, and chemotherapy prior to discharge were not associated with discharge timing. Early re-feeding was associated with early discharge. Thus, it seems reasonable that, when developing a postoperative care pathway for these patients, these factors be considered and specifically encourage early re-feeding. In pediatrics, data on early recovery after surgery protocols are limited, and high-quality studies are unavailable. Within pediatric urology, early recovery after surgery protocols in children undergoing major urologic reconstruction have been shown to reduce hospital stay and can decrease complication rates. It seems reasonable that a similar pathway can be applied to children undergoing radical nephrectomy for suspected malignancy. CONCLUSIONS For children with renal tumors who underwent radical nephrectomy, early re-feeding was associated with a shorter time to discharge. Use of bowel preparation and nasogastric tube did not appear to shorten time to discharge. These data are important for developing postoperative care pathways for these patients.
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Affiliation(s)
- A F Saltzman
- Department of Surgery, Division of Urology, University of Colorado School of Medicine and the Children's Hospital of Colorado, Aurora, CO, USA
| | - J C Warncke
- Department of Surgery, Division of Urology, University of Colorado School of Medicine and the Children's Hospital of Colorado, Aurora, CO, USA
| | - A N Colvin
- Department of Surgery, Division of Urology, University of Colorado School of Medicine and the Children's Hospital of Colorado, Aurora, CO, USA
| | - A Carrasco
- Department of Surgery, Division of Urology, University of Colorado School of Medicine and the Children's Hospital of Colorado, Aurora, CO, USA
| | - J P Roach
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine and the Children's Hospital of Colorado, Aurora, CO, USA
| | - J L Bruny
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine and the Children's Hospital of Colorado, Aurora, CO, USA
| | - N G Cost
- Department of Surgery, Division of Urology, University of Colorado School of Medicine and the Children's Hospital of Colorado, Aurora, CO, USA.
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153
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Affiliation(s)
- Renyuan Gao
- Department of Gastroenterology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China.,Institute of Intestinal Disease, Tongji University School of Medicine, Shanghai 200072, China
| | - Huanlong Qin
- Department of Gastroenterology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China.,Institute of Intestinal Disease, Tongji University School of Medicine, Shanghai 200072, China
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154
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Moon A, Tangada A, Andikyan V, Chuang L. Enhanced Recovery after Surgery (ERAS) in Gynecologic Surgery—A Review. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2018. [DOI: 10.1007/s13669-018-0247-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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155
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Trimodal prehabilitation for colorectal surgery attenuates post-surgical losses in lean body mass: A pooled analysis of randomized controlled trials. Clin Nutr 2018; 38:1053-1060. [PMID: 30025745 DOI: 10.1016/j.clnu.2018.06.982] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/21/2018] [Accepted: 06/25/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Preservation of lean body mass is an important cancer care objective. The capacity for prehabilitation interventions to modulate the lean body mass (LBM) of colorectal cancer patients before and after surgery is unknown. METHODS A pooled analysis of two randomized controlled trials of trimodal prehabilitation vs. trimodal rehabilitation at a single university-affiliated tertiary center employing Enhanced Recovery After Surgery (ERAS) care was conducted. The prehabilitation interventions included exercise, nutrition, and anxiety-reduction elements that began approximately four weeks before surgery and continued for eight weeks after surgery. The rehabilitation interventions were identical to the prehabilitation interventions but were initiated only after surgery. Body composition, measured using multifrequency bioelectrical impedance analysis, was recorded at baseline, pre-surgery, 4 and 8 weeks after surgery. The primary outcome was change in LBM before and after colorectal surgery for cancer. A mixed effects regression model was used to estimate changes in body mass and body composition over time controlling for age, sex, baseline body mass index (BMI), baseline six-minute walk test (6MWT), and postoperative compliance to the interventions. NCT02586701 &NCT01356264. RESULTS Pooled data included 76 patients who followed prehabilitation and 63 patients who followed rehabilitation (n = 139). Neither group experienced changes in preoperative LBM. Compared to rehabilitated patients, prehabilitated patients had significantly more absolute and relative LBM at four and eight-weeks post-surgery in models controlling for age, sex, baseline BMI, baseline 6MWT, and compliance to the postoperative intervention. CONCLUSION Trimodal prehabilitation attenuated the post-surgical LBM loss compared to the loss observed in patients who received the rehabilitation intervention. Patients who receive neither intervention (i.e., standard of care) would be likely to lose more LBM. Offering a prehabilitation program to colorectal cancer patients awaiting resection is a useful strategy to mitigate the impact of the surgical stress response on lean tissue in an ERAS setting, and, in turn, might have a positive impact on the cancer care course. CLINICAL TRIAL REGISTRATION NCT02586701 &NCT01356264 (clinicaltrials.gov).
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156
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Cabellos Olivares M, Labalde Martínez M, Torralba M, Rodríguez Fraile JR, Atance Martínez JC. C-reactive protein as a marker of the systemic inflammatory response to surgery reduction within an enhanced recovery after surgery protocol in elective colorectal surgery of the elderly: A prospective cohort study. SURGICAL PRACTICE 2018. [DOI: 10.1111/1744-1633.12319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | | | - Miguel Torralba
- Department of Internal Medicine; University Hospital of Guadalajara; Guadalajara Spain
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157
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Enhanced recovery after surgery protocol versus conventional perioperative care in colorectal surgery. A single center cohort study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 29609882 PMCID: PMC9391696 DOI: 10.1016/j.bjane.2018.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Enhanced recovery after surgery (ERAS) protocols consist of a set of perioperative measures aimed at improving patient recovery and decreasing length of stay and postoperative complications. We assess the implementation and outcomes of an ERAS program for colorectal surgery. Methods Single center observational study. Data were collected from consecutive patients undergoing open or laparoscopic colorectal surgery during 2 time periods, 3 years before (Pre-ERAS) and 2 years after (Post-ERAS) the implementation of an ERAS protocol. Baseline characteristics of both groups were compared. The primary outcome was the number of patients with 180 days follow-up with moderate or severe complications; secondary outcomes were postoperative length of stay, and specific complications. Data were extracted from patient records. Results There were 360 patients in the Pre-ERAS group and 319 patients in the Post-ERAS Group. 214 (59.8%) patients developed at least one complication in the pre ERAS group, versus 163 patients in the Post-ERAS group (51.10%). More patients in the Pre-ERAS group developed moderate or severe complications (31.9% vs. 22.26%, p = 0.009); and severe complications (15.5% vs. 5.3%; p < 0.0001). The median length of stay was 13 (17) days in Pre-ERAS Group and 11 (10) days in the Post-ERAS Group (p = 0.034). No differences were found on mortality rates (4.7% vs. 2.5%; p = 0.154), or readmission (6.39% vs. 4.39%; p = 0.31). Overall ERAS protocol compliance in the Post-ERAS cohort was 88%. Conclusions The implementation of ERAS protocol for colorectal surgery was associated with a significantly reduction of postoperative complications and length of stay.
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158
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Abstract
PURPOSE OF REVIEW Enhanced recovery protocols (ERPs) have been adopted for a variety of adult surgical conditions and resulted in markedly improved outcomes, including decreased length of stays, complications, costs, and narcotic utilization. In this review, we describe the development and implementation of an ERP for children undergoing gastrointestinal surgery. RECENT FINDINGS Existing ERP components from adult and pediatric surgical populations were reviewed and modified through an iterative process that included literature review, a national survey of practicing pediatric surgeons, and appropriateness assessment by a multidisciplinary expert panel. A single-center pilot implementing a gastrointestinal ERP demonstrated a steady increase in the number of ERP elements being employed over time with a simultaneous decrease in length of stays, decrease in median time to regular diet, decrease in median dose of intraoperative and postoperative narcotics, and decrease in median volume of intraoperative fluids. Balancing measures such as complication rates and 30-day readmission rates were stable or trended toward improved outcomes. SUMMARY ERPs for children undergoing gastrointestinal surgery appear feasible, safe, and associated with improved outcomes. Further validation of these results and expansion to a wider breadth of children's surgical care will help to establish ERPs as a new standard of surgical care.
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159
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Yang J, Xiao J, Feng J, Li K. One-year Unplanned Readmission After Colorectal Cancer Surgery in Western China. J INVEST SURG 2018; 32:602-606. [PMID: 29851535 DOI: 10.1080/08941939.2018.1443176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Purpose: Readmissions are common after colorectal cancer surgery. There are limited data related one-year unplanned readmission after colorectal cancer surgery. The aim of this study was to ascertain the incidence rate of unplanned readmission in Western China, identify causes and risk factors of one-year unplanned readmission (UR) in patients who underwent enhanced recovery pathways for colorectal cancer (CRC) surgery. Materials and Methods: A retrospective study using a CRC surgery database of patients treated in West China Hospital was performed. Patients who underwent enhanced recovery pathways for colorectal cancer surgery between January 2013 and May 2016 were investigated. The postoperative follow-up data were all routinely recorded for up to one year or more, the one-year unplanned readmission rate after initial discharge and major reasons for UR were recorded. Multivariate logistic regression analyses was used to identify risk factors of UR. Results: A total of 446 patients were included, with 18.6% of patients readmitted. In a multivariable analysis, preoperative comorbidity was associated with the largest risk of readmission (odds ratio, 2.91[95% CI, 1.32- 6.99]). The main reason of readmission within 30 days after discharge was wound bleeding or infection. While intestinal obstruction was the major cause for readmission after 3 months of discharge. Conclusions: One-year unplanned readmission occurs frequently after CRC in Western China and is strongly associated with preoperative comorbidity. Attention should be paid to wound healing at the early stage of discharge, and bowel obstruction 3 months after discharge.
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Affiliation(s)
- Jie Yang
- Department of Gastrointestinal, West China Hospital, Sichuan University , Sichuan , P.R.China
| | - Jun Xiao
- Intensive Care Unit, West China Hospital, Sichuan University , Sichuan , P.R.China
| | - Jinhua Feng
- Department of Gastrointestinal, West China Hospital, Sichuan University , Sichuan , P.R.China
| | - Ka Li
- Department of Gastrointestinal, West China Hospital, Sichuan University , Sichuan , P.R.China
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160
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Borggreve AS, Kingma BF, Domrachev SA, Koshkin MA, Ruurda JP, Hillegersberg R, Takeda FR, Goense L. Surgical treatment of esophageal cancer in the era of multimodality management. Ann N Y Acad Sci 2018; 1434:192-209. [DOI: 10.1111/nyas.13677] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/05/2018] [Accepted: 02/23/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Alicia S. Borggreve
- Department of Surgery, University Medical Center UtrechtUtrecht University Utrecht the Netherlands
- Moscow Clinical Scientific Center Moscow Russia
| | - B. Feike Kingma
- Department of Surgery, University Medical Center UtrechtUtrecht University Utrecht the Netherlands
| | | | | | - Jelle P. Ruurda
- Department of Surgery, University Medical Center UtrechtUtrecht University Utrecht the Netherlands
| | - Richard Hillegersberg
- Department of Surgery, University Medical Center UtrechtUtrecht University Utrecht the Netherlands
| | - Flavio R. Takeda
- Sao Paulo Institute of CancerUniversity of Sao Paulo School of Medicine Sao Paulo Brazil
| | - Lucas Goense
- Department of Surgery, University Medical Center UtrechtUtrecht University Utrecht the Netherlands
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161
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Hill A, Nesterova E, Lomivorotov V, Efremov S, Goetzenich A, Benstoem C, Zamyatin M, Chourdakis M, Heyland D, Stoppe C. Current Evidence about Nutrition Support in Cardiac Surgery Patients-What Do We Know? Nutrients 2018; 10:nu10050597. [PMID: 29751629 PMCID: PMC5986477 DOI: 10.3390/nu10050597] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 05/03/2018] [Accepted: 05/08/2018] [Indexed: 12/27/2022] Open
Abstract
Nutrition support is increasingly recognized as a clinically relevant aspect of the intensive care treatment of cardiac surgery patients. However, evidence from adequate large-scale studies evaluating its clinical significance for patients’ mid- to long-term outcome remains sparse. Considering nutrition support as a key component in the perioperative treatment of these critically ill patients led us to review and discuss our understanding of the metabolic response to the inflammatory burst induced by cardiac surgery. In addition, we discuss how to identify patients who may benefit from nutrition therapy, when to start nutritional interventions, present evidence about the use of enteral and parenteral nutrition and the potential role of pharmaconutrition in cardiac surgery patients. Although the clinical setting of cardiac surgery provides advantages due to its scheduled insult and predictable inflammatory response, researchers and clinicians face lack of evidence and several limitations in the clinical routine, which are critically considered and discussed in this paper.
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Affiliation(s)
- Aileen Hill
- Department of Intensive Care Medicine, University Hospital RWTH, D-52074 Aachen, Germany.
- 3CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, D-52074 Aachen, Germany.
| | - Ekaterina Nesterova
- Department of Anesthesiology and Intensive Care Medicine, National Pirogov Medical Center, 105203 Moscow, Russia.
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care Medicine, E. Meshalkin National Medical Research Center, 630055 Novosibirsk, Russia.
| | - Sergey Efremov
- Department of Anesthesiology and Intensive Care Medicine, E. Meshalkin National Medical Research Center, 630055 Novosibirsk, Russia.
| | - Andreas Goetzenich
- 3CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, D-52074 Aachen, Germany.
- Department of Thoracic, Cardiac and Vascular Surgery, University Hospital RWTH, D-52074 Aachen, Germany.
| | - Carina Benstoem
- Department of Intensive Care Medicine, University Hospital RWTH, D-52074 Aachen, Germany.
- 3CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, D-52074 Aachen, Germany.
| | - Mikhail Zamyatin
- Department of Anesthesiology and Intensive Care Medicine, National Pirogov Medical Center, 105203 Moscow, Russia.
| | - Michael Chourdakis
- Department of Medicine, School of Health Sciences, 54124 Thessaloniki, Greece.
| | - Daren Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON K7L 2V7, Canada.
| | - Christian Stoppe
- Department of Intensive Care Medicine, University Hospital RWTH, D-52074 Aachen, Germany.
- 3CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, D-52074 Aachen, Germany.
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162
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Kwon MA. Perioperative surgical home: a new scope for future anesthesiology. Korean J Anesthesiol 2018; 71:175-181. [PMID: 29690755 PMCID: PMC5995011 DOI: 10.4097/kja.d.18.27182] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 11/23/2017] [Accepted: 12/10/2017] [Indexed: 01/08/2023] Open
Abstract
The health care system is changing from ‘pay for volume’ to ‘pay for value.’ These changes are turning health care delivery into a more cost-effective and coordinated care setup that drives hospitals to lower costs and greater quality gains. The present perioperative care service in Korea has proven to be costly, fragmented, and neither evidence-based nor patient-centered. Recently, a new concept of a perioperative care model termed perioperative surgical home (PSH) has been proposed. The PSH is a patient-centered, team-based, and coordinated perioperative care setup, composed of the head anesthesiologist-perioperativist in tandem with dedicated nurse practitioners and other PSH team doctors. All pre-, intra-, and postoperative patient care functions are performed by a single PSH team, not several different departments. The PSH care extends from the decision to operate till 30 days post-discharge. Several evidence-driven perioperative strategies for reducing postoperative complications and shortening hospital stay can be adapted to each specific hospital situation, rather than strictly applying any given strategies. With the PSH, patients are more satisfied and experience better outcomes. It is also a good hospital business model. The expanded role of anesthesiologists in the PSH has the potential to invigorate the specialty.
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Affiliation(s)
- Min A Kwon
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Cheonan, Korea
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163
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Vignaud M, Paugam-Burtz C, Garot M, Jaber S, Slim K, Panis Y, Lucet JC, Bourdier J, Morand D, Pereira B, Futier E. Comparison of intravenous versus combined oral and intravenous antimicrobial prophylaxis (COMBINE) for the prevention of surgical site infection in elective colorectal surgery: study protocol for a multicentre, double-blind, randomised controlled clinical trial. BMJ Open 2018; 8:e020254. [PMID: 29654027 PMCID: PMC5898320 DOI: 10.1136/bmjopen-2017-020254] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Surgical site infections (SSIs) account for 30% of all healthcare-associated infections, with reported rates ranging from 8% and 30% after colorectal surgery and are associated with increased morbidity and mortality rates, length of hospital stay and costs in healthcare. Administration of systemic antimicrobial prophylaxis before surgery is recommended to reduce the risk of SSI, but the optimal regimen remains unclear. We aim to evaluate whether a combined oral and intravenous antimicrobial prophylaxis could be more effective to reduce the incidence of SSI after colorectal surgery, as compared with the standard practice of intravenous antimicrobial prophylaxis alone. METHODS AND ANALYSIS Comparison of intravenous versus combined oral and intravenous antimicrobial prophylaxis (COMBINE) trial is a randomised, placebo-controlled, parallel, double-blind, multicentre study of 960 patients undergoing elective colorectal surgery. Patients will be randomly allocated in a 1:1 ratio to receive either combined oral and intravenous antimicrobial prophylaxis or intravenous antibiotic prophylaxis alone, stratified by centre, the surgical procedure (laparoscopic or open surgery) and according to the surgical skin antisepsis (chlorexidine-alcohol or povidione-iodine alcoholic solution). The primary endpoint is the rate of SSI by day 30 following surgery, with SSI defined by the criteria developed by the Centers for Disease Control and Prevention. Data will be analysed on the intention-to-treat principle and a per-protocol basis. ETHICS AND DISSEMINATION COMBINE trial has been approved by an independent ethics committee for all study centres. Participant recruitment began in May 2016. Results will be published in international peer-reviewed medical journals. TRIAL REGISTRATION NUMBER EudraCT 2015-002559-84; NCT02618720.
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Affiliation(s)
- Marie Vignaud
- Département Anesthésie et Réanimation, Centre Hospitalier Universitaire de Clermont-Ferrand, Hôpital Estaing, Clermont-Ferrand, France
| | - Catherine Paugam-Burtz
- Assistance publique-Hôpitaux de Paris (AP-HP), Département Anesthésie Réanimation, Hôpital Beaujon, Hôpitaux Universitaires Paris Nord Val de Seine, Paris, France
| | - Matthias Garot
- Pôle Anesthesie Réanimation, Centre Hospitalier Universitaire (CHU) Lille, Lille, France
| | - Samir Jaber
- Département Anesthesie Réanimation B (DAR B), Centre Hospitalier Regional Universitaire de Montpellier, Hôpital Saint-Eloi, and Inserm U-1046, Montpellier, France
| | - Karem Slim
- Service de Chirurgie Digestive, Centre Hospitalier Universitaire de Clermont-Ferrand, Hôpital Estaing, CLERMONT-FERRAND, France
| | - Yves Panis
- Unité d’Hygiène et de Lutte contre l’Infection Nosocomiale, Assistance publique-Hôpitaux de Paris (AP-HP), Hôpital Bichat-Claude Bernard, Paris, France
| | - Jean-Christophe Lucet
- Direction de la Recherche Clinique & Innovation (DRCI), Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Justine Bourdier
- Departement de Chirurgie Colorectale, Assistance publique-Hôpitaux de Paris (AP-HP), Pôle des Maladies de l’Appareil Digestif (PMAD), Hôpital Beaujon, Clichy, France
| | - Dominique Morand
- Departement de Chirurgie Colorectale, Assistance publique-Hôpitaux de Paris (AP-HP), Pôle des Maladies de l’Appareil Digestif (PMAD), Hôpital Beaujon, Clichy, France
| | - Bruno Pereira
- Unité de Biostatistiques, Direction de la Recherche Clinique & Innovations (DRCI), Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Emmanuel Futier
- Département Anesthésie et Réanimation, Centre Hospitalier Universitaire de Clermont-Ferrand, Hôpital Estaing, Clermont-Ferrand, France
- GreD, CNRS, Inserm U1103, Université Clermont Auvergne, Clermont-Ferrand, France
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164
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Ripollés-Melchor J, Fuenmayor-Varela MLD, Camargo SC, Fernández PJ, Barrio ÁCD, Martínez-Hurtado E, Casans-Francés R, Abad-Gurumeta A, Ramírez-Rodríguez JM, Calvo-Vecino JM. [Enhanced recovery after surgery protocol versus conventional perioperative care in colorectal surgery. A single center cohort study]. Rev Bras Anestesiol 2018; 68:358-368. [PMID: 29609882 DOI: 10.1016/j.bjan.2018.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 12/21/2017] [Accepted: 01/03/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols consist of a set of perioperative measures aimed at improving patient recovery and decreasing length of stay and postoperative complications. We assess the implementation and outcomes of an ERAS program for colorectal surgery. METHODS Single center observational study. Data were collected from consecutive patients undergoing open or laparoscopic colorectal surgery during 2 time periods, 3 years before (Pre-ERAS) and 2 years after (Post-ERAS) the implementation of an ERAS protocol. Baseline characteristics of both groups were compared. The primary outcome was the number of patients with 180 days follow-up with moderate or severe complications; secondary outcomes were postoperative length of stay, and specific complications. Data were extracted from patient records. RESULTS There were 360 patients in the Pre-ERAS group and 319 patients in the Post-ERAS Group. 214 (59.8%) patients developed at least one complication in the pre ERAS group, versus 163 patients in the Post-ERAS group (51.10%). More patients in the Pre-ERAS group developed moderate or severe complications (31.9% vs. 22.26%, p=0.009); and severe complications (15.5% vs. 5.3%; p<0.0001). The median length of stay was 13 (17) days in Pre-ERAS Group and 11 (10) days in the Post-ERAS Group (p=0.034). No differences were found on mortality rates (4.7% vs. 2.5%; p=0.154), or readmission (6.39% vs. 4.39%; p=0.31). Overall ERAS protocol compliance in the Post-ERAS cohort was 88%. CONCLUSIONS The implementation of ERAS protocol for colorectal surgery was associated with a significantly reduction of postoperative complications and length of stay.
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Affiliation(s)
- Javier Ripollés-Melchor
- Universidad Complutense de Madrid, Madri, Espanha; Hospital Universitario Infanta Leonor, Departamento de Anestesia, Madri, Espanha; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Espanha.
| | | | - Susana Criado Camargo
- Universidad Complutense de Madrid, Madri, Espanha; Hospital Universitario Infanta Leonor, Madri, Espanha
| | - Pablo Jerez Fernández
- Universidad Complutense de Madrid, Madri, Espanha; Hospital Universitario Infanta Leonor, Madri, Espanha
| | | | - Eugenio Martínez-Hurtado
- Universidad Complutense de Madrid, Madri, Espanha; Hospital Universitario Infanta Leonor, Departamento de Anestesia, Madri, Espanha; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Espanha
| | - Rubén Casans-Francés
- Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Espanha; Hospital Clínico Universitario Lozano Blesa, Departamento de Anestesia, Zaragoza, Espanha
| | - Alfredo Abad-Gurumeta
- Universidad Complutense de Madrid, Madri, Espanha; Hospital Universitario Infanta Leonor, Departamento de Anestesia, Madri, Espanha; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Espanha
| | - José Manuel Ramírez-Rodríguez
- Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Espanha; Hospital Clínico Universitario Lozano Blesa, Departamento de Cirugía, Zaragoza, Espanha
| | - José María Calvo-Vecino
- Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Espanha; Universidad de Salamanca, Salamanca, Espanha; Complejo Hospitalario de Salamanca, Departamento de Anestesia, Salamanca, Espanha
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Giarratano G, Toscana E, Toscana C, Petrella G, Shalaby M, Sileri P. Transanal Hemorrhoidal Dearterialization Versus Stapled Hemorrhoidopexy: Long-Term Follow-up of a Prospective Randomized Study. Surg Innov 2018; 25:236-241. [DOI: 10.1177/1553350618761757] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Aim. This study aims to compare the early and late outcomes of transanal hemorrhoidal dearterialization (THD) versus stapled hemorrhoidopexy (SH) for the treatment of hemorrhoidal disease. Methods. From January 2013 to December 2014, 100 patients—50 patients on each arm—were randomly allocated to THD or SH groups. The inclusion criteria were grade III and IV hemorrhoids diagnosed by clinical examination and proctoscopy. The primary outcome was to compare the recurrence rate with a minimum follow-up of 2 years, and the secondary outcome was to compare complications rate, time to return to work postsurgery, procedure length, and patient’s satisfaction between the 2 techniques. Results. The mean follow-up period was 33.7 ± 7.6. The recurrence rate was 4% in the SH group and 16% in the THD group ( P = .04). There was no difference in the intraoperative and postoperative complications rate; the pain score was significantly higher in the THD group. The mean operative time was significantly shorter in the SH group compared with the THD group. Patients in the THD group returned to work or routine activities significantly later compared with patients in the SH group. The overall satisfaction rate was also higher in the SH group. Conclusion. Both procedures are simple and easy to perform for the treatment of grade III and IV hemorrhoids. SH showed better results in terms of lower rate of recurrence, lower postoperative pain, quicker return to work, and higher patient satisfaction.
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Prevalence and duration of reasons for enteral nutrition feeding interruption in a tertiary intensive care unit. Nutrition 2018; 53:26-33. [PMID: 29627715 DOI: 10.1016/j.nut.2017.11.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 11/14/2017] [Accepted: 11/17/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Intensive care unit (ICU) enteral nutrition (EN) can involve frequent feeding interruption (FI). The prevalence, causes, and duration of such interruption were investigated. METHODS Reasons for EN FI identified from extensive literature review were prospectively collected in adult mechanically ventilated critically ill patients. Results were reported by descriptive statistics. Baseline and nutritional characteristics between patients who died and those alive at day 60 were compared. RESULTS A total of 148 patients receiving ≥1 day of EN for the full 12-day observational period were included in the analysis. About 332 episodes of EN FI were recorded and contributed to 12.8% (4190 hours) of the total 1367 evaluable nutrition days. For each patient, FI occurred for a median of 3 days and the total duration of FI for the entire ICU stay was 24.5 hours. Median energy and protein deficits per patient due to FI for the entire ICU stay were -1780.23 kcal and -100.58 g, respectively. Duration of FI, days with FI, and the amount of energy and protein deficits due to FI were not different between patients who had died and those who were still alive at day 60 (all P > 0.05). About 72% of the total duration of EN FI was due to procedural-related and potentially avoidable causes (primarily human factors), while only about 20% was due to feeding intolerances. CONCLUSIONS EN FI occurred primarily due to human factors, which may be minimized by adherence to an evidence-based feeding protocol as determined by a nutrition support team.
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Efficacy of Nalbuphine with Flurbiprofen on Multimodal Analgesia with Transverse Abdominis Plane Block in Elderly Patients Undergoing Open Gastrointestinal Surgery: A Randomized, Controlled, Double-Blinded Trial. Pain Res Manag 2018; 2018:3637013. [PMID: 29623143 PMCID: PMC5830023 DOI: 10.1155/2018/3637013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 11/08/2017] [Indexed: 12/30/2022]
Abstract
Objective To assess different doses of nalbuphine with flurbiprofen compared to sufentanil with flurbiprofen in multimodal analgesia efficacy for elderly patients undergoing gastrointestinal surgery with a transverse abdominis plane block (TAPB). Methods 158 elderly patients scheduling for elective open gastrointestinal surgery under general anesthesia and TAPB were randomly assigned to four groups according to different doses of nalbuphine with flurbiprofen in postoperative intravenous analgesia (PCIA). Postoperative pain intensity, effective pressing numbers of PCIA, and adverse effects were recorded at 6, 12, 24, and 48 hours after surgery. Results Postoperative pain intensity, effective pressing numbers, and the incidence of postoperative nausea and vomiting (PONV) were similar among the four groups after surgery, while the severity of PONV was decreased in Group L compared with Group S at 6, 12, and 48 h after surgery. No individual experienced pruritus, respiratory depression, or hypotension. Conclusions Low dose of nalbuphine (15 μg·kg−1·ml−1) combined with flurbiprofen is superior for elderly patients undergoing elective open gastrointestinal surgery with TAPB in terms of the efficient postoperative analgesia and decreased severity of PONV. This trial is registered with NCT02984865.
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168
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Smith F, Öhlén J, Persson LO, Carlsson E. Daily Assessment of Stressful events and Coping in early post-operative recovery after colorectal cancer surgery. Eur J Cancer Care (Engl) 2018; 27:e12829. [DOI: 10.1111/ecc.12829] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2017] [Indexed: 11/30/2022]
Affiliation(s)
- F. Smith
- Surgical Department; Colorectal Unit Sahlgrenska University Hospital/Östra Gothenburg; Gothenburg Sweden
- Institute of Healthcare Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
- University of Gothenburg Centre for Person-centred Care (GPCC); Gothenburg Sweden
| | - J. Öhlén
- Institute of Healthcare Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
- University of Gothenburg Centre for Person-centred Care (GPCC); Gothenburg Sweden
| | - L.-O. Persson
- Institute of Healthcare Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - E. Carlsson
- Surgical Department; Colorectal Unit Sahlgrenska University Hospital/Östra Gothenburg; Gothenburg Sweden
- Institute of Healthcare Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
- University of Gothenburg Centre for Person-centred Care (GPCC); Gothenburg Sweden
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Cabellos Olivares M, Labalde Martínez M, Torralba M, Rodríguez Fraile JR, Atance Martínez JC. C-reactive protein as a marker of the surgical stress reduction within an ERAS protocol (Enhanced Recovery After Surgery) in colorectal surgery: A prospective cohort study. J Surg Oncol 2018; 117:717-724. [PMID: 29355975 DOI: 10.1002/jso.24909] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 10/12/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND The aim of this study is to evaluate the effectiveness of an Enhanced Recovery After Surgery Protocol (ERAS) in relation to reduce the Systemic Inflammatory Response (SIR) to surgery using C-reactive protein (CRP) in the first (POD1), second (POD2) and third (POD3) postoperative day. METHODS We enrolled 121 patients (ERAS group) that underwent elective colorectal surgery with ERAS, and compared them with 135 patients (preERAS group) that had undergone surgery prior to the implementation. We made a univariate analysis to compare the CRP values in POD1, POD2, and POD3 between preERAS/ERAS group, laparoscopic/open surgery and the presence or not of Clavien Dindo complications. Multivariable lineal regression was used to assess if the ERAS had a decreasing effect on the CRP in POD1, POD2, and POD3, and was adjusted by age, male sex, use of laparoscopy, and complications. RESULTS The presence of complications was independently associated with an increase in CRP values in POD1, POD2, and POD3. Laparoscopy in POD1 and POD2, and ERAS in POD2 was independently associated with a decrease in CRP values. CONCLUSION The analysis shows an increase in SIR measured as a CRP value in those patients that had complications. The SIR decreased with laparoscopy in POD1 and POD2 and with ERAS in POD2.
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Affiliation(s)
| | | | - Miguel Torralba
- Department of Internal Medical, Research Unit, Hospital Universitario de Guadalajara. Universidad de Alcalá, Guadalajara, Spain
| | | | - Juan C Atance Martínez
- Department of Health Inspection, Hospital Universitario de Guadalajara. Universidad de Alcalá, Guadalajara, Spain
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Perioperative nutrition and enhanced recovery after surgery in gastrointestinal cancer patients. A position paper by the ESSO task force in collaboration with the ERAS society (ERAS coalition). Eur J Surg Oncol 2018; 44:509-514. [PMID: 29398322 DOI: 10.1016/j.ejso.2017.12.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 12/28/2017] [Indexed: 12/15/2022] Open
Abstract
Malnutrition in cancer patients - in both prevalence and degree - depends primarily on tumor stage and site. Preoperative malnutrition in surgical patients is a frequent problem and is associated with prolonged hospital stay, a higher rate of postoperative complications, higher re-admission rates, and a higher incidence of postoperative death. Given the focus on the cancer and its cure, nutrition is often neglected or under-evaluated, and this despite the availability of international guidelines for nutritional care in cancer patients and the evidence that nutritional deterioration negatively affects survival. Inadequate nutritional support for cancer patients should be considered ethically unacceptable; prompt nutritional support must be guaranteed to all cancer patients, as it can have many clinical and economic advantages. Patients undergoing multimodal oncological care are at particular risk of progressive nutritional decline, and it is essential to minimize the nutritional/metabolic impact of oncological treatments and to manage each surgical episode within the context of an enhanced recovery pathway. In Europe, enhanced recovery after surgery (ERAS) and routine nutritional assessment are only partially implemented because of insufficient awareness among health professionals of nutritional problems, a lack of structured collaboration between surgeons and clinical nutrition specialists, old dogmas, and the absence of dedicated resources. Collaboration between opinion leaders dedicated to ERAS from both the European Society of Surgical Oncology (ESSO) and the ERAS Society was born with the aim of promoting nutritional assessment and perioperative nutrition with and without an enhanced recovery program. The goal will be to improve awareness in the surgical oncology community and at institutional level to modify current clinical practice and identify optimal treatment options.
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Perioperative risk prediction in the era of enhanced recovery: a comparison of POSSUM, ACPGBI, and E-PASS scoring systems in major surgical procedures of the colorectal surgeon. Int J Colorectal Dis 2018; 33:1627-1634. [PMID: 30078107 PMCID: PMC6208691 DOI: 10.1007/s00384-018-3141-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE This study aims to determine whether traditional risk models can accurately predict morbidity and mortality in patients undergoing major surgery by colorectal surgeons within an enhanced recovery program. METHODS One thousand three hundred eighty patients undergoing surgery performed by colorectal surgeons in a single UK hospital (2008-2013) were included. Six risk models were evaluated: (1) Physiology and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM), (2) Portsmouth POSSUM (P-POSSUM), (3) ColoRectal (CR-POSSUM), (4) Elderly POSSUM (E-POSSUM), (5) the Association of Great Britain and Ireland (ACPGBI) score, and (6) modified Estimation of Physiologic Ability and Surgical Stress Score (E-PASS). Model accuracy was assessed by observed to expected (O:E) ratios and area under Receiver Operating Characteristic curve (AUC). RESULTS Eleven patients (0.8%) died and 143 patients (10.4%) had a major complication within 30 days of surgery. All models overpredicted mortality and had poor discrimination: POSSUM 8.5% (O:E 0.09, AUC 0.56), P-POSSUM 2.2% (O:E 0.37, AUC 0.56), CR-POSSUM 7.1% (O:E 0.11, AUC 0.61), and E-PASS 3.0% (O:E 0.27, AUC 0.46). ACPGBI overestimated mortality in patients undergoing surgery for cancer 4.4% (O:E = 0.28, AUC = 0.41). Predicted morbidity was also overestimated by POSSUM 32.7% (O:E = 0.32, AUC = 0.51). E-POSSUM overestimated mortality (3.25%, O:E 0.57 AUC = 0.54) and morbidity (37.4%, O:E 0.30 AUC = 0.53) in patients aged ≥ 70 years and over. CONCLUSION All models overestimated mortality and morbidity. New models are required to accurately predict the risk of adverse outcome in patients undergoing major abdominal surgery taking into account the reduced physiological and operative insult of laparoscopic surgery and enhanced recovery care.
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Chazapis M, Gilhooly D, Smith A, Myles P, Haller G, Grocott M, Moonesinghe S. Perioperative structure and process quality and safety indicators: a systematic review. Br J Anaesth 2018; 120:51-66. [DOI: 10.1016/j.bja.2017.10.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/28/2017] [Accepted: 10/02/2017] [Indexed: 12/12/2022] Open
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Weimann A. Influence of nutritional status on postoperative outcome in patients with colorectal cancer - the emerging role of the microbiome. Innov Surg Sci 2017; 3:55-64. [PMID: 31579766 PMCID: PMC6754043 DOI: 10.1515/iss-2017-0039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 11/20/2017] [Indexed: 12/13/2022] Open
Abstract
Many patients with colorectal cancer are overweight. Even then, nutritional status is a frequently underestimated risk factor for perioperative complications. Enhanced Recovery after Surgery is the goal for perioperative management, and preoperative nutritional risk screening should be a standard. In case of nutritional risk, perioperative nutrition therapy should be started without delay and should follow recent guideline recommendations. The preservation of the microbiome has an emerging role in preventing postoperative anastomotic leakage and septic complications. The time window for recovery after neoadjuvant treatment for rectal cancer may be used for conditioning appropriate-risk patients in a “prehabilitation” program. In order to assess metabolic recovery and the prognosis for long-term survival, C-reactive protein/albumin ratio may be a promising parameter, which has to be validated in the future. This narrative review summarizes recent strategies and guideline recommendations.
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Affiliation(s)
- Arved Weimann
- Department of General, Visceral and Oncologic Surgery including Division of Clinical Nutrition, Klinikum St. Georg gGmbH, Delitzscher Str. 141, 04129 Leipzig, Germany
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174
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Full or limited enhanced recovery program? That is the question. Ann Surg 2017; 268:e66. [PMID: 29206672 DOI: 10.1097/sla.0000000000002618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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175
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Segelman J, Nygren J. Best practice in major elective rectal/pelvic surgery: enhanced recovery after surgery (ERAS). Updates Surg 2017; 69:435-439. [PMID: 29067634 PMCID: PMC5686231 DOI: 10.1007/s13304-017-0492-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 08/30/2017] [Indexed: 12/13/2022]
Abstract
Within traditional clinical care, the postoperative recovery after pelvic/rectal surgery has been slow with high morbidity and long hospital stay. The enhanced recovery after surgery program is a multimodal approach to perioperative care designed to accelerate recovery and safely reduce hospital stay. This review will briefly summarize optimal perioperative care, before, during and after surgery in this group of patients and issues related to implementation and audit.
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Affiliation(s)
- Josefin Segelman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
- Department of Surgery, Ersta Hospital, Box 4622, 116 91, Stockholm, Sweden.
| | - Jonas Nygren
- Department of Surgery, Ersta Hospital, Box 4622, 116 91, Stockholm, Sweden
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
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de-Aguilar-Nascimento JE, Salomão AB, Waitzberg DL, Dock-Nascimento DB, Correa MITD, Campos ACL, Corsi PR, Portari Filho PE, Caporossi C. ACERTO guidelines of perioperative nutritional interventions in elective general surgery. Rev Col Bras Cir 2017; 44:633-648. [DOI: 10.1590/0100-69912017006003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 07/20/2017] [Indexed: 12/22/2022] Open
Abstract
ABSTRACT Objective: to present recommendations based on the ACERTO Project (Acceleration of Total Post-Operative Recovery) and supported by evidence related to perioperative nutritional care in General Surgery elective procedures. Methods: review of relevant literature from 2006 to 2016, based on a search conducted in the main databases, with the purpose of answering guiding questions previously formulated by specialists, within each theme of this guideline. We preferably used randomized controlled trials, systematic reviews and meta-analyzes but also selected some cohort studies. We contextualized each recommendation-guiding question to determine the quality of the evidence and the strength of this recommendation (GRADE). This material was sent to authors using an open online questionnaire. After receiving the answers, we formalized the consensus for each recommendation of this guideline. Results: the level of evidence and the degree of recommendation for each item is presented in text form, followed by a summary of the evidence found. Conclusion: this guideline reflects the recommendations of the group of specialists of the Brazilian College of Surgeons, the Brazilian Society of Parenteral and Enteral Nutrition and the ACERTO Project for nutritional interventions in the perioperative period of Elective General Surgery. The prescription of these recommendations can accelerate the postoperative recovery of patients submitted to elective general surgery, with decrease in morbidity, length of stay and rehospitalization, and consequently, of costs.
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Nadri S, Mahmoudvand H, Rokrok S, Tarrahi MJ. Comparison of Two Methods: Spinal Anesthesia and Ischiorectal Block on Post Hemorrhoidectomy Pain and Hospital Stay: A Randomized Control Trial. J INVEST SURG 2017; 31:420-424. [DOI: 10.1080/08941939.2017.1349221] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Affiliation(s)
- Sedigheh Nadri
- Department of Anesthesiology, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Hormoz Mahmoudvand
- Department of Surgery, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Shirin Rokrok
- Student of Committee Research, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Mohammad Javad Tarrahi
- Department of Epidemiology and Biostatistics, School of Public Health, Lorestan University of Medical Sciences, Khorramabad, Iran
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Can early oral prolonged-release oxycodone with or without naloxone reduce the duration of epidural analgesia after cystectomy? A 3-arm, randomized, double-blind, placebo-controlled trial. Pain 2017; 159:560-567. [DOI: 10.1097/j.pain.0000000000001112] [Citation(s) in RCA: 2] [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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179
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Brandal D, Keller MS, Lee C, Grogan T, Fujimoto Y, Gricourt Y, Yamada T, Rahman S, Hofer I, Kazanjian K, Sack J, Mahajan A, Lin A, Cannesson M. Impact of Enhanced Recovery After Surgery and Opioid-Free Anesthesia on Opioid Prescriptions at Discharge From the Hospital: A Historical-Prospective Study. Anesth Analg 2017; 125:1784-1792. [PMID: 29049123 DOI: 10.1213/ane.0000000000002510] [Citation(s) in RCA: 137] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The United States is in the midst of an opioid epidemic, and opioid use disorder often begins with a prescription for acute pain. The perioperative period represents an important opportunity to prevent chronic opioid use, and recently there has been a paradigm shift toward implementation of enhanced recovery after surgery (ERAS) protocols that promote opioid-free and multimodal analgesia. The objective of this study was to assess the impact of an ERAS intervention for colorectal surgery on discharge opioid prescribing practices. METHODS We conducted a historical-prospective quality improvement study of an ERAS protocol implemented for patients undergoing colorectal surgery with a focus on the opioid-free and multimodal analgesia components of the pathway. We compared patients undergoing colorectal surgery 1 year before implementation (June 15, 2015, to June 14, 2016) and 1 year after implementation (June 15, 2016, to June 14, 2017). RESULTS Before the ERAS intervention, opioids at discharge were not significantly increasing (1% per month; 95% confidence interval [CI], -1% to 3%; P = .199). Immediately after the ERAS intervention, opioid prescriptions were not significantly lower (13%; 95% CI, -30% to 3%; P = .110). After the intervention, the rate of opioid prescriptions at discharge did not decrease significantly 1% (95% CI, -3% to 1%) compared to the pre-period rate (P = .399). Subgroup analysis showed that in patients with a combination of low discharge pain scores, no preoperative opioid use, and low morphine milligram equivalents consumption before discharge, the rate of discharge opioid prescription was 72% (95% CI, 61%-83%). CONCLUSIONS This study is the first to report discharge opioid prescribing practices in an ERAS setting. Although an ERAS intervention for colorectal surgery led to an increase in opioid-free anesthesia and multimodal analgesia, we did not observe an impact on discharge opioid prescribing practices. The majority of patients were discharged with an opioid prescription, including those with a combination of low discharge pain scores, no preoperative opioid use, and low morphine milligram equivalents consumption before discharge. This observation in the setting of an ERAS pathway that promotes multimodal analgesia suggests that our findings are very likely to also be observed in non-ERAS settings and offers an opportunity to modify opioid prescribing practices on discharge after surgery. For opioid-free anesthesia and multimodal analgesia to influence the opioid epidemic, the dose and quantity of the opioids prescribed should be modified based on the information gathered by in-hospital pain scores and opioid use as well as pain history before admission.
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Affiliation(s)
- Delara Brandal
- From the *Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles (UCLA) David Geffen School of Medicine, Los Angeles, California; †UCLA Fielding School of Public Health, Los Angles, California; ‡Department of Anesthesiology, Osaka City University, Osaka, Japan; §Department of Anesthesiology, Nimes University, Nimes, France; ∥Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan; and ¶Department of Surgery, University of California, Los Angeles (UCLA) David Geffen School of Medicine, Los Angeles, California
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Abstract
BACKGROUND Enhanced recovery pathways, also known as fast-track protocols, have been adopted since the early 2000s by various surgical specialties with the goal of improving patient outcomes and reducing the cost burden of major surgery on the health care system. OBJECTIVE To review the scientific literature on the origin of enhanced recovery pathways, track the contemporary utilization of such practices for patients undergoing radical cystectomy, and analyze the available data regarding their effect on morbidity, mortality, and treatment cost. METHODS A literature search of multiple electronic databases was undertaken. Manuscripts including patients undergoing radical cystectomy were chosen based on predefined criteria with an emphasis on randomized controlled trials and cohort studies. Strength of evidence for each study that met inclusion criteria was assessed based on the risk of bias, consistency, directness, and precision. RESULTS Database searches resulted in 1,236 potentially relevant articles. A total of 485 articles were selected for full-text dual review and 106 studies in 52 publications met the inclusion criteria. CONCLUSION The utilization of enhanced recovery pathways with the goal of improving overall patient morbidity and mortality is well supported in the literature, however standardization of implementation and adherence across institutions is lacking, and their direct efficacy on reducing preventable treatment related expenditures is unconfirmed.
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Affiliation(s)
- Ian Maloney
- Department of Urology, The University of Oklahoma Health Sciences Center and The Stephenson Cancer Center, Oklahoma City, OK, USA
| | - Daniel C. Parker
- Department of Urology, The University of Oklahoma Health Sciences Center and The Stephenson Cancer Center, Oklahoma City, OK, USA
| | - Michael S. Cookson
- Department of Urology, The University of Oklahoma Health Sciences Center and The Stephenson Cancer Center, Oklahoma City, OK, USA
| | - Sanjay Patel
- Department of Urology, The University of Oklahoma Health Sciences Center and The Stephenson Cancer Center, Oklahoma City, OK, USA
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Steel EJ, Trainer AH, Heriot AG, Lynch C, Parry S, Win AK, Keogh LA. The Experience of Extended Bowel Resection in Individuals With a High Metachronous Colorectal Cancer Risk: A Qualitative Study. Oncol Nurs Forum 2017; 43:444-52. [PMID: 27314187 DOI: 10.1188/16.onf.444-452] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE/OBJECTIVES To ascertain individual experiences of extended bowel resection as treatment for colorectal cancer (CRC) in those with a high metachronous CRC risk, including the self-reported adequacy of information received at different time points of treatment and recovery.
. RESEARCH APPROACH Qualitative.
. SETTING Participants were recruited through the Australasian Colorectal Cancer Family Registry and two hospitals in Melbourne, Australia.
. PARTICIPANTS 18 individuals with a high metachronous CRC risk who had an extended bowel resection from 6-12 months ago.
. METHODOLOGIC APPROACH Semistructured interviews. Data were analyzed thematically.
. FINDINGS In most cases, the treating surgeon decided on the best option regarding surgical treatment. Participants felt well informed about the surgical procedure. Information related to surgical outcomes, recovery, and lifestyle adjustment from surgery was not always adequate. Many participants described ongoing worry about developing another cancer.
. CONCLUSIONS Patients undergoing an extended resection to reduce metachronous CRC risk require detailed information delivered at more than one time point and relating to several different aspects of the surgical procedure and its outcomes.
. INTERPRETATION An increased emphasis should be given to the provision of patient information on surgical outcomes, recovery, and lifestyle adjustment. Colorectal nurses could provide support for some of the reported unmet needs.
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Melloul E, Hübner M, Scott M, Snowden C, Prentis J, Dejong CHC, Garden OJ, Farges O, Kokudo N, Vauthey JN, Clavien PA, Demartines N. Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg 2017; 40:2425-40. [PMID: 27549599 DOI: 10.1007/s00268-016-3700-1] [Citation(s) in RCA: 381] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) is a multimodal pathway developed to overcome the deleterious effect of perioperative stress after major surgery. In colorectal surgery, ERAS pathways reduced perioperative morbidity, hospital stay and costs. Similar concept should be applied for liver surgery. This study presents the specific ERAS Society recommendations for liver surgery based on the best available evidence and on expert consensus. METHODS A systematic review was performed on ERAS for liver surgery by searching EMBASE and Medline. Five independent reviewers selected relevant articles. Quality of randomized trials was assessed according to the Jadad score and CONSORT statement. The level of evidence for each item was determined using the GRADE system. The Delphi method was used to validate the final recommendations. RESULTS A total of 157 full texts were screened. Thirty-seven articles were included in the systematic review, and 16 of the 23 standard ERAS items were studied specifically for liver surgery. Consensus was reached among experts after 3 rounds. Prophylactic nasogastric intubation and prophylactic abdominal drainage should be omitted. The use of postoperative oral laxatives and minimally invasive surgery results in a quicker bowel recovery and shorter hospital stay. Goal-directed fluid therapy with maintenance of a low intraoperative central venous pressure induces faster recovery. Early oral intake and mobilization are recommended. There is no evidence to prefer epidural to other types of analgesia. CONCLUSIONS The current ERAS recommendations were elaborated based on the best available evidence and endorsed by the Delphi method. Nevertheless, prospective studies need to confirm the clinical use of the suggested protocol.
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Affiliation(s)
- Emmanuel Melloul
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.,Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Martin Hübner
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Michael Scott
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Chris Snowden
- Department of Perioperative and Critical Care Medicine, Freeman Hospital, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, The Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - James Prentis
- Department of Perioperative and Critical Care Medicine, Freeman Hospital, Newcastle upon Tyne, UK
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Center and NUTRIM School for Translational Research in Metabolism, Maastricht, The Netherlands
| | - O James Garden
- Department of Clinical Surgery, School of Clinical Sciences, The University of Edinburgh, Edinburgh, UK
| | - Olivier Farges
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, U.T. MD Anderson Cancer Center, Houston, TX, USA
| | - Pierre-Alain Clavien
- Swiss Hepato-pancreato-biliary and Transplantation Center, Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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183
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Kingma BF, Steenhagen E, Ruurda JP, van Hillegersberg R. Nutritional aspects of enhanced recovery after esophagectomy with gastric conduit reconstruction. J Surg Oncol 2017; 116:623-629. [PMID: 28968919 DOI: 10.1002/jso.24827] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 08/09/2017] [Indexed: 12/18/2022]
Abstract
Enhanced Recovery After Surgery (ERAS) aims to accelerate recovery by a set of multimodality management strategies. For esophagectomy, several nutritional elements of ERAS can be safely introduced and are advised in routine practice, including preadmission counseling to screen and treat for potential malnutrition, shortened preoperative fasting, and carbohydrate loading. However, the timing of oral intake and the use of routine nasogastric decompression remain matter of debate after esophagectomy. Furthermore, more research is needed on future developments such as perioperative immunonutrition.
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Affiliation(s)
- B Feike Kingma
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Elles Steenhagen
- Department of Dietetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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184
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Zhang HW, Sun L, Yang XW, Feng F, Li GC. Safety of total gastrectomy without nasogastric and nutritional intubation. Mol Clin Oncol 2017; 7:421-426. [PMID: 28894580 DOI: 10.3892/mco.2017.1331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 04/03/2017] [Indexed: 02/04/2023] Open
Abstract
The aim of the present study was to evaluate the safety of gastrectomy without nasogastric and nutritional intubations. Between January 2010 and August 2015, 74 patients with gastric cancer received total gastric resection and esophagogastric anastomosis without nasogastric and nutritional intubations at the First Department of Digestive Surgery of the XiJing Hospital of Digestive Diseases (Xi'an, China), of whom 42 were also received earlier oral feeding within 48 h. The data were retrospectively analyzed. An additional 301 cases who underwent traditional postoperative intubation were used for comparison. In patients without intubation compared with those managed traditionally with intubation, the mean operative time was decreased (190.97±38.18 vs. 216.12±59.52 min, respectively; P=0.026). In addition, the postoperative activity was resumed earlier (1.16±0.47 vs. 1.36±0.84 days, respectively; P=0.009), oral food intake was started earlier (4.28±1.79 vs. 5.71±2.66 days, respectively; P=0.009), the incidence of fever was lower (12.16 vs. 29.23%, respectively; P=0.003), and the incidence of total complications was not statistically significantly different between the two groups (9.41 vs. 6.31%, respectively; P=0.317). There were no significant differences regarding complications of the anastomotic port (1.37 vs. 1.69%, respectively; P=0.849). Compared with traditional postoperative management, earlier oral feeding did not increase the incidence of complications (7.21 vs. 4.76%, respectively; P=0.557). Our results suggest that total gastric resection without nasogastric and nutritional intubation is a safe and feasible option for patients undergoing total gastrectomy.
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Affiliation(s)
- Hong-Wei Zhang
- First Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Li Sun
- First Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Xue-Wen Yang
- First Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Fan Feng
- First Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Guo-Cai Li
- First Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
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185
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Wrzosek A, Jakowicka-Wordliczek J, Zajaczkowska R, Serednicki WT, Jankowski M, Bala MM, Polak M, Wordliczek J. Perioperative restrictive versus goal-directed fluid therapy for adults undergoing major non-cardiac surgery. Hippokratia 2017. [DOI: 10.1002/14651858.cd012767] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Anna Wrzosek
- Jagiellonian University, Medical College; Department of Interdisciplinary Intensive Care; Krakow Poland
| | | | - Renata Zajaczkowska
- Jagiellonian University, Medical College; Department of Interdisciplinary Intensive Care; Krakow Poland
| | - Wojciech T Serednicki
- Jagiellonian University, Medical College; Department of Interdisciplinary Intensive Care; Krakow Poland
| | - Milosz Jankowski
- University Hospital; Department of Anaesthesiology and Intensive Care; Krakow Poland
| | - Malgorzata M Bala
- Jagiellonian University Medical College; Department of Hygiene and Dietetics; Systematic Reviews Unit - Polish Cochrane Branch; Kopernika 7 Krakow Poland 31-034
| | - Maciej Polak
- Jagiellonian University, Medical College Krakow; Department of Epidemiology and Population Studies in the Institute of Public Health; Krakow Poland
| | - Jerzy Wordliczek
- Jagiellonian University, Medical College; Department of Interdisciplinary Intensive Care; Krakow Poland
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186
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Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations. Plast Reconstr Surg 2017; 139:1056e-1071e. [PMID: 28445352 DOI: 10.1097/prs.0000000000003242] [Citation(s) in RCA: 205] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Enhanced recovery following surgery can be achieved through the introduction of evidence-based perioperative maneuvers. This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery and to provide evidence-based recommendations for an enhanced perioperative protocol. METHODS A systematic review of meta-analyses, randomized controlled trials, and large prospective cohorts was conducted for each protocol element. Smaller prospective cohorts and retrospective cohorts were considered only when higher level evidence was unavailable. The available literature was graded by an international panel of experts in breast reconstructive surgery and used to form consensus recommendations for each topic. Each recommendation was graded following a consensus discussion among the expert panel. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society. RESULTS High-quality randomized controlled trial data in patients undergoing breast reconstruction informed some of the recommendations; however, for most items, data from lower level studies in the population of interest were considered along with extrapolated data from high-quality studies in non-breast reconstruction populations. Recommendations were developed for a total of 18 unique enhanced recovery after surgery items and are discussed in the article. Key recommendations support use of opioid-sparing perioperative medications, minimal preoperative fasting and early feeding, use of anesthetic techniques that decrease postoperative nausea and vomiting and pain, use of measures to prevent intraoperative hypothermia, and support of early mobilization after surgery. CONCLUSION Based on the best available evidence for each topic, a consensus review of optimal perioperative care for patients undergoing breast reconstruction is presented. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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187
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Pajarón-Guerrero M, Fernández-Miera MF, Dueñas-Puebla JC, Cagigas-Fernández C, Allende-Mancisidor I, Cristóbal-Poch L, Gómez-Fleitas M, Manzano-Peral MA, Gonzalez-Fernandez CR, Aguilera-Zubizarreta A, Sanroma-Mendizábal P. Early Discharge Programme on Hospital-at-Home Evaluation for Patients with Immediate Postoperative Course after Laparoscopic Colorectal Surgery. Eur Surg Res 2017; 58:263-273. [PMID: 28793287 DOI: 10.1159/000479004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 06/26/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND To audit the safety of the early hospital discharge care model offered by a Hospital-at-home (HAH) unit during early postoperative follow-up of these patients, and to determine whether this care model is more efficient compared to the traditional care model. METHODS A prospective study of 50 patients included consecutively for 1 year in an early discharge programme after laparoscopic colorectal surgery was performed. As of day 3 after surgery, if the patient met the relevant inclusion criteria they were transferred to the HAH unit. The domiciliary protocol consists of daily clinical follow-up and a series of analytical controls with the purpose of early detection of postoperative complications. If the clinical course was favourable on day 7 after the postoperative period the patient was discharged. RESULTS A total of 66% were males, and the mean age was 60.6 years. The surgical procedure most commonly performed was sigmoidectomy. The mean stay was 5.5 days. There were no deaths during follow-up. The average estimated cost per day of stay in a HAH system was EUR 174.29 whilst the same average cost on a surgery ward stood at EUR 1,032.42. CONCLUSIONS For patients undergoing major colorectal surgery with minimally invasive surgical technique, an early hospital discharge care programme by means of referral to a HAH unit is a safe and efficient care model which entails a significant cost saving for the public healthcare system.
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Affiliation(s)
- Marcos Pajarón-Guerrero
- Domiciliary Hospitalisation Unit, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | | | - Carmen Cagigas-Fernández
- Department of General and Gastrointestinal Surgery, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | - Lidia Cristóbal-Poch
- Department of General and Gastrointestinal Surgery, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Manuel Gómez-Fleitas
- Department of General and Gastrointestinal Surgery, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | | | - Ana Aguilera-Zubizarreta
- Domiciliary Hospitalisation Unit, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Pedro Sanroma-Mendizábal
- Domiciliary Hospitalisation Unit, Hospital Universitario Marqués de Valdecilla, Santander, Spain
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188
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Carmichael JC, Keller DS, Baldini G, Bordeianou L, Weiss E, Lee L, Boutros M, McClane J, Steele SR, Feldman LS. Clinical practice guideline for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons (ASCRS) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Surg Endosc 2017; 31:3412-3436. [DOI: 10.1007/s00464-017-5722-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 07/10/2017] [Indexed: 12/16/2022]
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189
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Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2017; 60:761-784. [PMID: 28682962 DOI: 10.1097/dcr.0000000000000883] [Citation(s) in RCA: 267] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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190
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Giske A, Nymo LS, Fuskevåg OM, Amundsen S, Simonsen GS, Lassen K. Systemic antibiotic prophylaxis prior to gastrointestinal surgery - is oral administration of doxycycline and metronidazole adequate? Infect Dis (Lond) 2017; 49:785-791. [PMID: 28657405 DOI: 10.1080/23744235.2017.1342044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Antibiotic prophylaxis is recommended prior to a wide range of gastrointestinal operations to reduce the rate of surgical site infections (SSIs). Traditional intravenous (IV) drugs are costly and their preparation strains nursing resources at the wards. While oral administration may attenuate these limitations, its use remains limited. We aimed to assess whether a dual oral antibiotic prophylaxis regimen provides adequate serum concentrations throughout the surgical procedure. METHODS We measured serum concentrations of doxycycline and metronidazole following single oral doses of 400 mg doxycycline and 1200 mg metronidazole at first incision and repeated at wound closure in a cohort of patients undergoing elective gastrointestinal surgery. Both drugs were dispensed at least two hours before skin incision. Serum concentrations were compared to minimum inhibitory concentrations (MIC) and epidemiological cut-off values (ECOFFs) for relevant pathogens. RESULTS Mean serum concentrations of doxycycline at first incision and at wound closure were 5.75 mg/L and 4.66 mg/L and of metronidazole 18.88 mg/L and 15.56 mg/L, respectively. Metronidazole concentrations were above ECOFF (2 mg/L) for relevant anaerobic species in 103/104 of patients in both samples. Doxycycline serum concentrations were above the ECOFF for common Enterobacteriaceae species (4 mg/L) in both samples in 58/104 patients (55.8%). CONCLUSIONS A single dose of orally administered metronidazole provides adequate concentrations throughout surgery in a heterogeneous cohort of patients. Uncertainty persists regarding the adequacy of doxycycline concentrations, as the optimal serum level of doxycycline in a prophylactic setting has not been established.
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Affiliation(s)
- Anneli Giske
- a Department of Gastrointestinal Surgery , University Hospital of North Norway , Tromsø , Norway
| | - Linn Såve Nymo
- a Department of Gastrointestinal Surgery , University Hospital of North Norway , Tromsø , Norway
| | - Ole-Martin Fuskevåg
- b Department of Laboratory Medicine , University Hospital of North Norway , Tromsø , Norway
| | - Siri Amundsen
- b Department of Laboratory Medicine , University Hospital of North Norway , Tromsø , Norway.,c Experimental and Clinical Pharmacology Research Group, Department of Medical Biology, Faculty of Health Sciences , University of Tromsø - The Arctic University of Norway , Tromsø , Norway
| | - Gunnar Skov Simonsen
- d Department of Microbiology and Infection Control , University Hospital of North Norway , Tromsø , Norway.,e Research Group for Host-Microbe Interaction, Department of Medical Biology, Faculty of Health Sciences , University of Tromsø - The Arctic University of Norway , Tromsø , Norway
| | - Kristoffer Lassen
- a Department of Gastrointestinal Surgery , University Hospital of North Norway , Tromsø , Norway.,f Department of Gastrointestinal Surgery, Hepatopancreatobiliary Section , University Hospital of Oslo at Rikshospitalet , Oslo , Norway
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191
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Kverneng Hultberg D, Angenete E, Lydrup ML, Rutegård J, Matthiessen P, Rutegård M. Nonsteroidal anti-inflammatory drugs and the risk of anastomotic leakage after anterior resection for rectal cancer. Eur J Surg Oncol 2017; 43:1908-1914. [PMID: 28687432 DOI: 10.1016/j.ejso.2017.06.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/03/2017] [Accepted: 06/08/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) have been widely used in colorectal surgery due to their opioid-sparing effect. However, several studies have indicated an increased risk of anastomotic leakage following NSAID treatment, although conflicting results exist. The primary goal of this study was to further examine whether postoperative NSAIDs are independently associated with anastomotic leakage after anterior resection for rectal cancer. METHODS Patients who underwent anterior resection for rectal cancer during 2007-2013 in 15 different hospitals in three healthcare regions in Sweden were included in the study. Registry data and information from patient records were retrieved. The association between NSAID treatment (for at least two days in the first postoperative week) and symptomatic anastomotic leakage (within 90 days) was evaluated with multiple logistic regression, with adjustment for pertinent confounding factors. RESULTS Some 1495 patients were included in the study. Of these, 27% received postoperative NSAIDs for at least two days in the first postoperative week. Symptomatic anastomotic leakage occurred in 11% and 14% in the NSAID and non-NSAID group, respectively. With adjustment for confounders, the odds ratio for leakage among patients who received NSAIDs compared with those who did not was 0.88 (95% CI 0.65-1.20). No differences were seen between non-selective and COX-2-selective NSAIDs. CONCLUSION Postoperative NSAID treatment does not seem to increase the risk of symptomatic anastomotic leakage after anterior resection for rectal cancer. NSAID use appears to be safe, but a well-powered randomized clinical trial is warranted.
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Affiliation(s)
- D Kverneng Hultberg
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
| | - E Angenete
- Department of Surgery, Institute of Clinical Sciences, SSORG - Scandinavian Surgical Outcomes Research Group, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - M-L Lydrup
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Lund, Sweden
| | - J Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - P Matthiessen
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - M Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
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192
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Li L, Jin J, Min S, Liu D, Liu L. Compliance with the enhanced recovery after surgery protocol and prognosis after colorectal cancer surgery: A prospective cohort study. Oncotarget 2017; 8:53531-53541. [PMID: 28881829 PMCID: PMC5581128 DOI: 10.18632/oncotarget.18602] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 05/23/2017] [Indexed: 12/13/2022] Open
Abstract
We explored the effects of different levels of compliance with an enhanced recovery after surgery (ERAS) protocol on the short-term prognosis of patients who underwent colorectal cancer surgery. We conducted a single-center prospective cohort study in which 254 patients who received surgical treatment in a teaching tertiary care hospital were enrolled from March 2016 to November 2016. The patients were divided into four groups (I, II, III, and IV) based on individual compliance rates; the corresponding range of compliance rates was 0-60%, 60-70%, 70-80%, and 80-100%, and the number of patients in each group was 66, 63, 53, and 72, respectively. In the four groups from low to high compliance with ERAS (group I, II, III, and IV), the incidence of surgical site infections was 24.2%, 20.6%, 9.4%, and 6.9% (P < 0.05); the overall incidence of postoperative complications was 41.3%, 33.3%, 26.4%, and 16.7% (P < 0.05); the median length of postoperative hospital stay (in days) was 12.5, 10, 9, 8 (P < 0.05); and the median total hospital cost (Chinese Yuan) was 71,733, 73,632, 65,861, and 63,289 (P < 0.05), respectively. These results suggest that higher compliance with the ERAS protocol was associated with a lower incidence of surgical site infections, lower overall postoperative complication rate, shorter postoperative hospital stays, and lower total hospital costs.
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Affiliation(s)
- Liang Li
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Juying Jin
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Su Min
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dan Liu
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ling Liu
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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193
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Abstract
OBJECTIVE To study the effects of COX-2 on colonic surgical wound healing. BACKGROUND Cyclooxygenase-2 (COX-2) is a key enzyme in gastrointestinal homeostasis. COX-2 inhibitors have been associated with colonic anastomotic leakage. METHODS Wildtype, COX-2 knockout and COX-2 heterozygous mice were subjected to a model of colonic anastomotic leakage, and were treated with vehicle, diclofenac, or prostaglandin E2 (PGE2), the most important COX-2 product in the intestine. We assessed anastomotic leakage, mortality, angiogenesis, and inflammation. Furthermore, we investigated the association between anastomotic leakage and a human polymorphism of the COX-2 gene resulting in low COX-2 levels. RESULTS Diclofenac, a nonsteroidal anti-inflammatory drug inhibiting COX-2, increased anastomotic leakage compared to vehicle-treated mice (100% vs 25%, respectively). Similarly, 92% of COX-2-deficient mice developed anastomotic leakage (P = 0.003) compared to WT. PGE2 partly rescued this severe phenotype because only 46% of PGE2-administered COX-2 knockout mice developed anastomotic leakage (P = 0.02). This may be related to decreased neovascularization, because decreased CD31 staining, indicating less blood vessels, was observed in COX-2 mice (2 vessels/mm vs 6 vessels/mm in controls (P = 0.03)). This effect could partly be reversed by administration of PGE2 to COX-2 mice. No significant differences in inflammation were found. PTGS2-765G>C polymorphism in humans, associated with reduced COX-2 expression, was associated with higher anastomotic leakage rates. CONCLUSIONS COX-2-induced PGE2 production is essential for intestinal wound healing after colonic surgery, possibly via its effects on angiogenesis. These data emphasize that COX-2 inhibitors should be avoided after colonic surgery, and administration of PGE2 might be favorable for a selection of patients.
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194
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Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, Laviano A, Ljungqvist O, Lobo DN, Martindale R, Waitzberg DL, Bischoff SC, Singer P. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr 2017; 36:623-650. [DOI: 10.1016/j.clnu.2017.02.013] [Citation(s) in RCA: 975] [Impact Index Per Article: 139.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 02/13/2017] [Indexed: 02/07/2023]
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195
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Wahr JA, Thomas JJ. Even a Child of Four Could Do It!a Maximizing Efficiency in a Preoperative Clinic Using the Patient-Centered Anesthesia Triage System. Anesth Analg 2017; 124:1758-1759. [DOI: 10.1213/ane.0000000000001954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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196
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Inaba CS, Pigazzi A. Current Trends in the Use of Bowel Preparation for Colorectal Surgery. CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0369-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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197
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Onerup A, Angenete E, Bock D, Börjesson M, Fagevik Olsén M, Grybäck Gillheimer E, Skullman S, Thörn SE, Haglind E, Nilsson H. The effect of pre- and post-operative physical activity on recovery after colorectal cancer surgery (PHYSSURG-C): study protocol for a randomised controlled trial. Trials 2017; 18:212. [PMID: 28482864 PMCID: PMC5422966 DOI: 10.1186/s13063-017-1949-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 04/23/2017] [Indexed: 02/08/2023] Open
Abstract
Background Surgery for colorectal cancer is associated with a high risk of post-operative adverse events, re-operations and a prolonged post-operative recovery. Previously, the effect of prehabilitation (pre-operative physical activity) has been studied for different types of surgery, including colorectal surgery. However, the trials on colorectal surgery have been of limited methodological quality and size. The aim of this trial is to compare the effect of a combined pre- and post-operative intervention of moderate aerobic physical activity and inspiratory muscle training (IMT) with standard care on post-operative recovery after surgery for colorectal cancer. Methods/design We are conducting a randomised, controlled, parallel-group, open-label, multi-centre trial with physical recovery within 4 weeks after cancer surgery as the primary endpoint. Some 640 patients planned for surgery for colorectal cancer will be enrolled. The intervention consists of pre- and post-operative physical activity with increased daily aerobic activity of moderate intensity as well as IMT. In the control group, patients will be advised to continue their normal daily exercise routine. The primary outcome is patient-reported physical recovery 4 weeks post-operatively. Secondary outcomes are length of sick leave, complication rate and severity, length of hospital stay, re-admittances, re-operations, post-operative mental recovery, quality of life and mortality, as well as changes in insulin-like growth factor 1 and insulin-like growth factor-binding protein 3, perception of pain and a health economic analysis. Discussion An increase in moderate-intensity aerobic physical activity is a safe, cheap and feasible intervention that would be possible to implement in standard care for patients with colorectal cancer. If shown to be effective, this lifestyle intervention could be a clinical parallel to pre-operative smoke cessation that has already been implemented with good clinical results. Trial registration ClinicalTrials.gov identifier: NCT02299596. Registered on 17 November 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1949-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aron Onerup
- Scandinavian Surgical Outcomes Research Group (SSORG), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Eva Angenete
- Scandinavian Surgical Outcomes Research Group (SSORG), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - David Bock
- Scandinavian Surgical Outcomes Research Group (SSORG), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Börjesson
- Department of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Food and Nutrition and Sport Science, University of Gothenburg, Gothenburg, Sweden.,Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Monika Fagevik Olsén
- Department of Gastrosurgical Research and Education, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Department of Physical Therapy and Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elin Grybäck Gillheimer
- Scandinavian Surgical Outcomes Research Group (SSORG), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Sven-Egron Thörn
- Department of Anesthesiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eva Haglind
- Scandinavian Surgical Outcomes Research Group (SSORG), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hanna Nilsson
- Scandinavian Surgical Outcomes Research Group (SSORG), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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198
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Venara A, Barbieux J, Mucci S, Talbot MF, Lermite E, Hamy A. Short-Term Outcomes of Colorectal Resection for Cancer in Elderly in the Era of Enhanced Recovery. Scand J Surg 2017; 107:31-37. [PMID: 28464708 DOI: 10.1177/1457496917706010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS Early rehabilitation protocols should be assessed in elderly. We aimed to study the outcomes of colorectal surgery and the observance of the modalities of an early rehabilitation protocol in patients over 80 years. MATERIAL AND METHODS All consecutive patients who underwent surgery for colorectal cancer in our center over a 19-month period were included. All of these patients were managed using the same early rehabilitation protocol. Patients older than 80 were compared to younger patients. RESULTS A total of 173 patients were included and 36 were ≥80 years (20.8%). Patients aged ≥80 years had a significantly higher ASA score and were operated on in emergency. In the peroperative period, patients aged ≥80 years were more likely to undergo laparotomy than patients <80 years in univariate analysis (p = 0.048), but in multivariate analysis, the choice for a laparoscopy was influenced by ASA score ≤2 (odds ratio = 3.55, 95% confidence interval = 1.67-7.58) and emergency surgery (odds ratio = 0.18, 95% confidence interval = 0.06-0.50). In the postoperative period, peristalsis stimulation and vascular catheter ablation were significantly better followed in Group 1 (p = 0.012 and 0.031). However, in multivariate analysis, age was not significantly associated with these parameters. Peristalsis stimulation was influenced by ASA score ≥2 (odds ratio = 4.27, 95% confidence interval = 1.18-15.37) and vascular catheter ablation was also influenced by ASA score ≤2 (odds ratio = 2.63, 95% confidence interval = 1.33-5.21). Emergency surgery had a strong trend to influence these parameters (p = 0.08). CONCLUSION Although age or comorbidities may affect observance for certain modalities such as chewing gum use and vascular catheter ablation, an early rehabilitation protocol can be used after colorectal cancer surgery in patients ≥80 years old, where it would improve functional results and postoperative outcomes.
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Affiliation(s)
- A Venara
- 1 L'UNAM and University of Angers, Angers, France.,2 Department of Visceral Surgery, CHU Angers, Angers, France.,3 UMR INSERM 1235, TENS, the enteric nervous system in gut and brain disorder, University of Nantes, Nantes, France
| | - J Barbieux
- 1 L'UNAM and University of Angers, Angers, France.,2 Department of Visceral Surgery, CHU Angers, Angers, France
| | - S Mucci
- 1 L'UNAM and University of Angers, Angers, France
| | - M F Talbot
- 4 Department of Anesthesia and Intensive Care, CHU Angers, Angers, France
| | - E Lermite
- 1 L'UNAM and University of Angers, Angers, France.,2 Department of Visceral Surgery, CHU Angers, Angers, France
| | - A Hamy
- 1 L'UNAM and University of Angers, Angers, France.,2 Department of Visceral Surgery, CHU Angers, Angers, France
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199
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Du N, Guo C, Yang M, Ji Y, Wang W, Li J, Li C, Liu L, Che G. [Assessing the Current Status of Enhanced Recovery after Surgery in the Usage of Web-based Survey Questionnaires by Thoracic Surgeons and Nurses Attending the Meeting in Mainland China]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2017; 20:157-162. [PMID: 28302217 PMCID: PMC5973295 DOI: 10.3779/j.issn.1009-3419.2017.03.03] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Though the concept of enhanced recovery after surgery (ERAS) has been progressively known by the surgeons and applied clinically, the current status of its cognition among thoracic surgeons and application in thoracic surgery is still unknown. Based on the analysis of a survey of thoracic surgeons and nurses on chest ERAS during a national conference, we aimed to analyze the status and difficulties of the application of ERAS in thoracic surgery. METHODS A total of 773 questionnaires were collected during the first West China chest ERAS Forum and analyzed. The content of the questionnaire can be divided into two parts, including the respondents' institute and personal information, 10 questions on ERAS. RESULTS (1) Current status of clinical application of ERAS is the concept rather than the practice: 69.6% of the surgeons and 58.7% of the nurses agreed with this view; in addition, 88.5% of the doctors and 85.7% of the nurses believed that the concept of ERAS may be applicable to every branches of surgery; (2) 55.6% of the doctors and 69.1% of the nurses believed that the reason of poor clinical application of ERAS included no mature procedure, lack of consensus and specifications; (3) The best team for the clinical practice of ERAS should be based on surgeon-centered multidisciplinary cooperation and integration of medical care: 62.1% of the surgeons and 70.7% of nurses agreed with this view; (4) 73.7% of the surgeons and 81.9% of the nurses agreed that mean hospital stay, patients' experience in hospital and social satisfaction should be the evaluation standard of ERAS practice. CONCLUSIONS The application of ERAS in thoracic surgery is still the concept rather than the practice. The reason included the lack of clinical applicable specifications and scheme.
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Affiliation(s)
- Na Du
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Chenglin Guo
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Mei Yang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yanli Ji
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Wei Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jie Li
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Chuan Li
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Lunxu Liu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Guowei Che
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
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200
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Wolk S, Meißner T, Linke S, Müssle B, Wierick A, Bogner A, Sturm D, Rahbari NN, Distler M, Weitz J, Welsch T. Use of activity tracking in major visceral surgery-the Enhanced Perioperative Mobilization (EPM) trial: study protocol for a randomized controlled trial. Trials 2017; 18:77. [PMID: 28222805 PMCID: PMC5322788 DOI: 10.1186/s13063-017-1782-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 01/04/2017] [Indexed: 01/14/2023] Open
Abstract
Background Enhanced recovery after surgery (ERAS) programs are aimed at minimizing postoperative stress and accelerating postoperative recovery by implementing multiple perioperative principles. “Early mobilization” is one such principle, but the quality of assessment and monitoring is poor, and evidence of improved outcome is lacking. Activity trackers allow precise monitoring and automatic feedback to the patients to enhance their motivation for early mobilization. The aim of the study is to monitor and increase the postoperative mobilization of patients by giving them continuous automatic feedback in the form of a step count using activity-tracking wristbands. Methods/design Patients undergoing elective open and laparoscopic surgery of the colon, rectum, stomach, pancreas, and liver for any indication will be included. Further inclusion criteria are age between 18 and 75 years, American Society of Anesthesiologists Physical Status class less than IV, and a signed informed consent form. Patients will be stratified into two subgroups, laparoscopic and open surgery, and will be randomized 1:1 for automatic feedback of their step count using an activity tracker wristband. The control group will have no automatic feedback. The sample size (n = 30 patients in each of the four groups, overall n = 120) is calculated on the basis of an assumed difference in step count of 250 steps daily (intervention group versus control group). The primary study endpoint is the average step count during the first 5 postoperative days; secondary endpoints are the percentage of patients in the two groups who master the predefined mobilization (step count) targets, assessment of additional activity data obtained from the devices, assessment of preoperative mobility, length of hospital and intensive care unit stays, number of patients who receive physiotherapy, 30-day mortality, and overall 30-day morbidity. Discussion Early mobilization is a key element of ERAS. However, enhanced early mobilization is difficult to define, to assess objectively, and to implement in clinical practice. Consequently, there is a discrepancy between ERAS targets and actual practice, especially in patients undergoing major visceral surgery. This study is the first randomized controlled trial investigating the use and feasibility of activity tracking to monitor and enhance postoperative early mobilization. Trial registration ClinicalTrials.gov identifier: NCT02834338. Registered on 15 June 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1782-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Steffen Wolk
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Theresa Meißner
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Sebastian Linke
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Benjamin Müssle
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Ann Wierick
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Andreas Bogner
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Dorothée Sturm
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Nuh N Rahbari
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
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