151
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A Review of Enhanced Recovery Protocols in Pelvic Surgery. CURRENT BLADDER DYSFUNCTION REPORTS 2020. [DOI: 10.1007/s11884-020-00582-4] [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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152
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Weston E, Noel M, Douglas K, Terrones K, Grumbine F, Stone R, Levinson K. The impact of an enhanced recovery after minimally invasive surgery program on opioid use in gynecologic oncology patients undergoing hysterectomy. Gynecol Oncol 2020; 157:469-475. [DOI: 10.1016/j.ygyno.2020.01.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 01/31/2020] [Indexed: 01/01/2023]
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153
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Abrão MS, Andres MP, Barbosa RN, Bassi MA, Kho RM. Optimizing Perioperative Outcomes with Selective Bowel Resection Following an Algorithm Based on Preoperative Imaging for Bowel Endometriosis. J Minim Invasive Gynecol 2020; 27:883-891. [DOI: 10.1016/j.jmig.2019.06.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/23/2019] [Accepted: 06/15/2019] [Indexed: 01/04/2023]
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Markers of tissue damage and inflammation after robotic and abdominal hysterectomy in early endometrial cancer: a randomised controlled trial. Sci Rep 2020; 10:7226. [PMID: 32350297 PMCID: PMC7190843 DOI: 10.1038/s41598-020-64016-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 02/03/2020] [Indexed: 02/07/2023] Open
Abstract
The aim of this study was to analyse the dynamics of tissue damage and inflammatory response markers perioperatively and whether these differ between women operated with robotic and abdominal hysterectomy in treating early-stage endometrial cancer. At a Swedish university hospital fifty women with early-stage low-risk endometrial cancer were allocated to robotic or abdominal hysterectomy in a randomiszed controlled trial. Blood samples reflecting inflammatory responses (high sensitivity CRP, white blood cells (WBC), thrombocytes, IL-6, cortisol) and tissue damage (creatine kinase (CK), high-mobility group box 1 protein (HMGB1)) were collected one week preoperatively, just before surgery, postoperatively at two, 24 and 48 hours, and one and six weeks postoperatively. High sensitivity CRP (p = 0.03), WBC (p < 0.01), IL-6 (p = 0.03) and CK (p = 0.03) were significantly lower in the robotic group, but fast transitory. Cortisol returned to baseline two hours after robotic hysterectomy but remained elevated in the abdominal group comparable to the preoperative high levels for both groups just before surgery (p < 0.0001). Thrombocytes and HMGB1 were not affected by the mode of surgery. Postoperative inflammatory response and tissue damage were lower after robotic hysterectomy compared to abdominal hysterectomy. A significant remaining cortisol elevation two hours after surgery may reflect a higher stress response in the abdominal group.
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Netter A, Jauffret C, Brun C, Sabiani L, Blache G, Houvenaeghel G, Lambaudie E. Choosing the most appropriate minimally invasive approach to treat gynecologic cancers in the context of an enhanced recovery program: Insights from a comprehensive cancer center. PLoS One 2020; 15:e0231793. [PMID: 32324762 PMCID: PMC7179891 DOI: 10.1371/journal.pone.0231793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 03/31/2020] [Indexed: 02/06/2023] Open
Abstract
Objective The aim of the study was to compare the characteristics of procedures for gynecologic cancers conducted with conventional laparoscopy (CL) or robotically assisted laparoscopy (RAL) in the context of an enhanced recovery program (ERP). Methods This is a secondary analysis of prospectively collected data from a cohort study conducted between 2016 (when the ERP was first implemented at the Institut Paoli-Calmettes, a comprehensive cancer center in France) and 2018. We included patients who had undergone minimally invasive surgery for gynecological cancers and followed our ERP. The endpoints were the analysis of postoperative complications, the length of postoperative hospitalization (LPO), and the proportion of combined procedures depending on the approach (RAL or CL). Combined procedures were defined by the association of at least two of the following operative items: hysterectomy, pelvic lymphadenectomy, and para-aortic lymphadenectomy. Results A total of 362 women underwent either CL (n = 187) or RAL (n = 175) for gynecologic cancers and followed our ERP. The proportion of combined procedures performed by RAL was significantly higher (85/175 [48.6%]) than that performed by CL (23/187 [12.3%]; p < 0.001). The proportions of postoperative complications were similar between the two groups (19.4% versus 17.1%; p = 0.59). Logistic regression analysis revealed a statistically insignificant trend in the association of RAL with a reduced likelihood of an LPO > 3 days after adjusting for predictors of prolonged hospitalization (adjusted OR = 0.573 [0.236–1.388]; p = 0.217). Conclusion Experts from our cancer center preferentially choose RAL to perform gynecologic oncological procedures that present elements of complexity. More studies are needed to determine whether this strategy is efficient in managing complex procedures in the framework of an ERP.
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Affiliation(s)
- Antoine Netter
- Department of Surgical Oncology, Aix-Marseille Univ, CNRS, INSERM, Institut Paoli-Calmettes, CRCM, Marseille, France
- Department of Obstetrics and Gynecology, Assistance Publique Hôpitaux de Marseille, La Conception Hospital, Aix Marseille University, Marseille, France
- Institut Méditerranéen de Biodiversité et d'Écologie marine et continentale (IMBE), Aix Marseille University, CNRS, IRD, Avignon University, Marseille, France
- * E-mail: (AN); (EL)
| | - Camille Jauffret
- Department of Surgical Oncology, Aix-Marseille Univ, CNRS, INSERM, Institut Paoli-Calmettes, CRCM, Marseille, France
| | - Clément Brun
- Département d'Anesthésie Réanimation, Institut Paoli Calmettes et CRCM, Marseille, France
| | - Laura Sabiani
- Department of Surgical Oncology, Aix-Marseille Univ, CNRS, INSERM, Institut Paoli-Calmettes, CRCM, Marseille, France
| | - Guillaume Blache
- Department of Surgical Oncology, Aix-Marseille Univ, CNRS, INSERM, Institut Paoli-Calmettes, CRCM, Marseille, France
| | - Gilles Houvenaeghel
- Department of Surgical Oncology, Aix-Marseille Univ, CNRS, INSERM, Institut Paoli-Calmettes, CRCM, Marseille, France
| | - Eric Lambaudie
- Department of Surgical Oncology, Aix-Marseille Univ, CNRS, INSERM, Institut Paoli-Calmettes, CRCM, Marseille, France
- * E-mail: (AN); (EL)
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Enhanced recovery after surgery in minimally invasive gynecologic surgery surgical patients: one size fits all? Curr Opin Obstet Gynecol 2020; 32:248-254. [DOI: 10.1097/gco.0000000000000634] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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157
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Barreras González JE, Díaz Ortega I, Castillo Sánchez Y, Pereira Fraga JG, López Milhet AB. Laparoscopic Hysterectomy for 2780 Patients: In Havana's National Center for Minimally Invasive Surgery. J Gynecol Surg 2020. [DOI: 10.1089/gyn.2019.0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Javier Ernesto Barreras González
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
| | - Israel Díaz Ortega
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
| | - Yuderkis Castillo Sánchez
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
| | - Jorge Gerardo Pereira Fraga
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
| | - Ana Bertha López Milhet
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
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Wang X, Li T. Postoperative pain pathophysiology and treatment strategies after CRS + HIPEC for peritoneal cancer. World J Surg Oncol 2020; 18:62. [PMID: 32234062 PMCID: PMC7110707 DOI: 10.1186/s12957-020-01842-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/20/2020] [Indexed: 02/08/2023] Open
Abstract
Background Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment choice for peritoneal cancer. However, patients commonly suffer from severe postoperative pain. The pathophysiology of postoperative pain is considered to be from both nociceptive and neuropathic origins. Main body The recent advances on the etiology of postoperative pain after CRS + HIPEC treatment were described, and the treatment strategy and outcomes were summarized. Conclusion Conventional analgesics could provide short-term symptomatic relief. Thoracic epidural analgesia combined with opioids administration could be an effective treatment choice. In addition, a transversus abdominis plane block could also be an alternative option, although further studies should be performed.
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Affiliation(s)
- Xiao Wang
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tieyi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Tianzuo Li
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tieyi Road, Yangfangdian, Haidian District, Beijing, 100038, China.
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Comparison of enhanced recovery protocol with conventional care in patients undergoing minor gynecologic surgery. Wideochir Inne Tech Maloinwazyjne 2020; 15:220-226. [PMID: 32117508 PMCID: PMC7020716 DOI: 10.5114/wiitm.2019.85464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 04/29/2019] [Indexed: 12/20/2022] Open
Abstract
Introduction Data regarding the role of the enhanced recovery after surgery (ERAS) protocol in improving postoperative outcomes and postoperative compliance in patients undergoing gynecological surgery, in particular, minor laparoscopic and hysteroscopic gynecological procedures, are limited. Aim To investigate the impact of the ERAS protocol on time to ambulation, length of stay (LOS), readmissions and postoperative complications in patients undergoing minor gynecological surgical procedures. Material and methods A total of 104 patients undergoing minor laparoscopic and hysteroscopic gynecological procedures were randomized to the ERAS protocol or conventional care. Time to defecation, ambulation, and solid food intake, bleeding and LOS were recorded for each patient. Results The amount of intravenous fluid administered in the perioperative (p < 0.001) and postoperative period (p < 0.001) was significantly higher in the conventional care group than in the ERAS group. In addition, time to first defecation (p < 0.001), time to eating solid food (p < 0.001), and time to ambulation (p = 0.008) were shorter in the ERAS group compared to the conventional care group. Length of stay was also significantly shorter in the ERAS group than in the conventional care group (p < 0.001). Conclusions Implementation of ERAS protocols provides shorter LOS, less fluid intake, early return of bowel function and early mobilization without an increase in complication rate in women undergoing minor laparoscopic or hysteroscopic gynecologic surgery.
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160
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Takmaz O, Bastu E, Ozbasli E, Gundogan S, Karabuk E, Kocyigit M, Dede S, Naki M, Kose F, Gungor M. Perioperative Duloxetine for Pain Management After Laparoscopic Hysterectomy: A Randomized Placebo-Controlled Trial. J Minim Invasive Gynecol 2020; 27:665-672. [DOI: 10.1016/j.jmig.2019.04.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/18/2019] [Accepted: 04/22/2019] [Indexed: 01/22/2023]
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Nanthiphatthanachai A, Insin P. Effect of Chewing Gum on Gastrointestinal Function Recovery After Surgery of Gynecological Cancer Patients at Rajavithi Hospital: A Randomized Controlled Trial. Asian Pac J Cancer Prev 2020; 21:761-770. [PMID: 32212805 PMCID: PMC7437335 DOI: 10.31557/apjcp.2020.21.3.761] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Indexed: 12/24/2022] Open
Abstract
Objective: To evaluate the efficacy of postoperative gum-chewing compare with routine postoperative care on the recovery of gastrointestinal function after comprehensive surgical staging for gynecological cancer. Materials and Methods: A total of 82 patients who underwent comprehensive surgical staging for gynecological cancer at Rajavithi Hospital between October 1st, 2018 and June 30th, 2019 were randomly allocated into two groups: Gum-chewing group (n=40) and control group (n=42). In the gum-chewing group, patients were assigned to chew sugar-free gum for 30 minutes starting from the first postoperative morning then every 8 hours until the first passage of flatus. In the control group, patients have received routine postoperative care. The primary endpoint was time to first flatus after surgery. The secondary endpoints were time to first bowel sound, time to first defecation, time to first walk, postoperative analgesia and anti-emetic drug requirement, ileus symptoms, length of a hospital stay, and potential adverse events of gum-chewing, including dry mount, choking, and aspiration. Results: Chewing gum was statistically significant in reducing time to first flatus compared with routine postoperative care (median 24.7 (range 2.2-86.5) vs 35.4 (range 7.2-80.9) hours, p=0.025). The length of a hospital stay was also significantly shorter in the gum-chewing group (median 3.0 (range 1.0-8.8) vs 3.5 (range 1.8-50.0) days, p=0.023). There were no significant differences in time to first bowel sound, time to first defecation, time to first walk, postoperative analgesia and anti-emetic drug requirement, and ileus symptoms between both two groups. No adverse events related to postoperative gum-chewing were observed. Conclusion: Gum-chewing was associated with early recovery of gastrointestinal function in patients undergoing surgery for gynecological cancer. It is an inexpensive and physiologic intervention that appears to be reasonably safe and should be recommended as an adjunct in postoperative care of gynecological cancer surgery.
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Affiliation(s)
| | - Putsarat Insin
- Department of Obstetrics and Gynecology, Rajavithi Hospital, Bangkok, Thailand.,College of Medicine, Rangsit University, Bangkok, Thailand
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162
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Alimena S, Falzone M, Feltmate CM, Prescott K, Contrino Slattery L, Elias K. Perioperative glycemic measures among non-fasting gynecologic oncology patients receiving carbohydrate loading in an enhanced recovery after surgery (ERAS) protocol. Int J Gynecol Cancer 2020; 30:533-540. [PMID: 32107317 DOI: 10.1136/ijgc-2019-000991] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/14/2020] [Accepted: 01/22/2020] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Preoperative carbohydrate loading is an effective method to control postoperative insulin resistance. However, data are limited concerning the effects of carbohydrate loading on preoperative hyperglycemia and possible impacts on complication rates. METHODS A prospective cohort study was performed of patients enrolled in an enhanced recovery after surgery pathway at a single institution. All patients underwent laparotomy for known or suspected gynecologic malignancies. Patients who had been diagnosed with diabetes preoperatively and those prescribed total parenteral nutrition by their providers were excluded. Data regarding preoperative carbohydrate loading with a commercial maltodextrin beverage, preoperative glucose testing, postoperative day 1 glucose, insulin administration, and complications (all complications, infectious complications, and hyperglycemia-related complications) were collected. The primary endpoint of the study was the incidence of postoperative infectious complications, defined as superficial or deep wound infection, organ/space infection, urinary tract infection, pneumonia, sepsis, or septic shock. RESULTS Of 415 patients, 76.9% had a preoperative glucose recorded. The mean age was 60.5±12.4 years (range 18-93). Of those with recorded glucose values, 30 patients (9.4%) had glucose ≥180 mg/dL, none of whom were actually given insulin preoperatively. Median preoperative glucose value was significantly increased after carbohydrate loading (122.0 mg/dL with carbohydrate loading vs 101.0 mg/dL without, U=3143, p=0.001); however, there was no relationship between carbohydrate loading and complications. There was a significantly increased risk of hyperglycemia-related complications with postoperative day 1 morning glucose values ≥140 mg/dL (OR 1.85, 95% CI 1.07 to 3.23; p=0.03). Otherwise, preoperative and postoperative hyperglycemia with glucose thresholds of ≥140 mg/dL or ≥180 mg/dL were not associated with increased risk of other types of complications. DISCUSSION Carbohydrate loading is associated with increased preoperative glucose values; however, this is not likely to be clinically significant as it does not have an impact on complication rates. Preoperative hyperglycemia is not a risk factor for postoperative complications in a carbohydrate-loaded population when known diabetic patients are excluded. PRECIS While glucose increased with carbohydrate loading in non-diabetic patients, this was not associated with complications.
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Affiliation(s)
- Stephanie Alimena
- Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA .,Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michele Falzone
- Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Colleen M Feltmate
- Dana Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kia Prescott
- Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Leah Contrino Slattery
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kevin Elias
- Dana Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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163
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Licina A, Silvers A, Laughlin H, Russell J, Wan C. Proposed pathway for patients undergoing enhanced recovery after spinal surgery: protocol for a systematic review. Syst Rev 2020; 9:39. [PMID: 32085813 PMCID: PMC7035675 DOI: 10.1186/s13643-020-1283-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/22/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The best evidence-enhanced recovery care pathway is yet to be defined for patients undergoing spinal surgery. Minimally invasive surgery, multimodal analgesia, early mobilization, and early postoperative nutrition have been considered as critical components of enhanced recovery in spinal surgery (ERSS). The objective of this study will be to synthesize the evidence underpinning individual components of a proposed multidisciplinary enhanced recovery pathway for patients undergoing spinal surgery. METHODS This is the study protocol for a systematic review of complex interventions. Our team identified 22 individual care components of a proposed pathway based on clinical practice guidelines and published reviews. We will include systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled trials, and observational studies in adults or pediatric patients evaluating any one of the pre-determined care components. Our primary outcomes will be all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). We will search the following databases (1990 onwards) MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two reviewers will independently screen all citations, full-text articles, and abstract data. Potential conflicts will be resolved through discussion. The risk of bias for individual studies will be appraised using appropriate tools. A narrative synthesis will be provided with the information presented in the text and tables to summarize and explain the characteristics and findings of the included studies. Due to clinical and methodological heterogeneity, we do not anticipate to conduct meta-analyses. Confidence in cumulative evidence for each component of care will be classified according to the GRADE system. DISCUSSION This systematic review will identify, evaluate, and integrate the evidence underpinning individual components of a pathway for patients undergoing spinal surgery. The formation of an evidence-based pathway will allow for the standardization of clinical care delivery within the context of enhanced recovery in spinal surgery. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019135289.
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Affiliation(s)
- Ana Licina
- Austin Health, 145 Studley Road, Heidelberg, Victoria 3084 Australia
| | | | - Harry Laughlin
- Austin Health, 145 Studley Road, Heidelberg, Victoria 3084 Australia
| | - Jeremy Russell
- Austin Health, 145 Studley Road, Heidelberg, Victoria 3084 Australia
| | - Crispin Wan
- St Vincent’s Health, 41 Victoria Parade, Fitzroy, Victoria 3065 Australia
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Robotic-assisted interval cytoreductive surgery in ovarian cancer: a feasibility study. Obstet Gynecol Sci 2020; 63:150-157. [PMID: 32206654 PMCID: PMC7073361 DOI: 10.5468/ogs.2020.63.2.150] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 11/01/2019] [Accepted: 12/11/2019] [Indexed: 01/06/2023] Open
Abstract
Objective The primary objective was to assess the feasibility of robotic-assisted interval cytoreductive surgery for achieving complete cytoreduction for patients with advanced-stage ovarian cancer. The secondary objective was to examine the perioperative outcomes. Methods A retrospective study of 12 patients with stage IIIC or IV ovarian, fallopian tube, and primary peritoneal carcinoma who underwent interval cytoreductive surgery after neo-adjuvant chemotherapy. Results Optimal cytoreduction was achieved in 100% of selected patients. Complete cytoreductive surgery was achieved in 75% of patients. The estimated mean blood loss was 100 mL. The median length of hospital stay was 2 days. Perioperative complication and 30-day readmission rates were 8.3% (1 patient). The median follow-up time was 9.5 months. Conclusion Robotic-assisted interval cytoreductive surgery in ovarian cancer is safe and feasible and may be an alternative to standard laparotomy in selected patients.
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Yang Y, Xiong C, Xia L, Kang SS, Jian JJ, Yang XQ, Chen L, Wang Y, Yu JJ, Xu XZ. Consistency of postoperative pain assessments between nurses and patients undergoing enhanced recovery after gynaecological surgery. J Clin Nurs 2020; 29:1323-1331. [PMID: 31972867 DOI: 10.1111/jocn.15200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 12/17/2019] [Accepted: 01/10/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Yu'E Yang
- Department of Obstetrics and Gynaecology The Affiliated Hospital of Jiangnan University Wuxi China
| | - Chang Xiong
- Wuxi School of Medicine Jiangnan University Wuxi China
| | - Ling Xia
- Department of Obstetrics and Gynaecology The Affiliated Hospital of Jiangnan University Wuxi China
| | - Si Si Kang
- Department of Obstetrics and Gynaecology The Affiliated Hospital of Jiangnan University Wuxi China
| | - Jin Jin Jian
- Department of Anesthesiology The Affiliated Hospital of Jiangnan University Wuxi China
| | - Xue Qing Yang
- Wuxi School of Medicine Jiangnan University Wuxi China
| | - Ling Chen
- Wuxi School of Medicine Jiangnan University Wuxi China
| | - Yuan Wang
- Department of Obstetrics and Gynaecology The Affiliated Hospital of Jiangnan University Wuxi China
| | - Jin Jin Yu
- Department of Obstetrics and Gynaecology The Affiliated Hospital of Jiangnan University Wuxi China
| | - Xi Zhong Xu
- Department of Obstetrics and Gynaecology The Affiliated Hospital of Jiangnan University Wuxi China
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166
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Brindle M, Nelson G, Lobo DN, Ljungqvist O, Gustafsson UO. Recommendations from the ERAS® Society for standards for the development of enhanced recovery after surgery guidelines. BJS Open 2020; 4:157-163. [PMID: 32011810 PMCID: PMC6996628 DOI: 10.1002/bjs5.50238] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 10/22/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND ERAS® Society guidelines are holistic, multidisciplinary tools designed to improve outcomes after surgery. The enhanced recovery after surgery (ERAS) approach was initially developed for colorectal surgery and has been implemented successfully across a large number of settings, resulting in improved patient outcomes. As the ERAS approach is increasingly being adopted worldwide and new guidelines are being generated for new populations, there is a need to define an ERAS® Society guideline and the methodology that should be followed in its development. METHODS The ERAS® Society recommended approach for developing new guidelines is based on the creation of multidisciplinary guideline development groups responsible for defining topics, planning the literature search, and assessing the quality of the evidence. RESULTS Clear definitions for the elements of an ERAS guideline involve multimodal and multidisciplinary approaches impacting on multiple patient outcomes. Recommended methodology for guideline development follows a rigorous approach with systematic identification and evaluation of evidence, and consensus-based development of recommendations. Guidelines should then be evaluated and reviewed regularly to ensure that the best and most up-to-date evidence is used consistently to support surgical patients. CONCLUSION There is a need for a standardized, evidence-informed approach to both the development of new ERAS® Society guidelines, and the adaptation and revision of existing guidelines.
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Affiliation(s)
- M. Brindle
- Department of SurgeryAlberta Children's HospitalCalgaryAlbertaCanada
- Department of Community Health SciencesAlberta Children's HospitalCalgaryAlbertaCanada
| | - G. Nelson
- Division of Gynecologic OncologyTom Baker Cancer CentreCalgaryAlbertaCanada
| | - D. N. Lobo
- Gastrointestinal SurgeryNottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical CentreNottinghamUK
- Medical Research Council–Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life SciencesUniversity of Nottingham, Queen's Medical CentreNottinghamUK
| | - O. Ljungqvist
- Department of SurgeryÖrebro University and University HospitalÖrebroSweden
- Institute of Molecular Medicine and Surgery, Karolinska InstitutetStockholmSweden
| | - U. O. Gustafsson
- Department of SurgeryDanderyd HospitalStockholmSweden
- Department of Clinical SciencesDanderyd Hospital, Karolinska InstitutetStockholmSweden
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Altman AD, Helpman L, McGee J, Samouëlian V, Auclair MH, Brar H, Nelson GS. Enhanced recovery after surgery: implementing a new standard of surgical care. CMAJ 2020; 191:E469-E475. [PMID: 31036609 DOI: 10.1503/cmaj.180635] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Alon D Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences (Altman), University of Manitoba, Winnipeg, Man.; Division of Gynecologic Oncology (Helpman), McMaster University, Hamilton, Ont.; Division of Gynecologic Oncology (McGee), University of Western Ontario, London, Ont.; Division of Gynecologic Oncology (Auclair, Samouëlian), CHUM, Université de Montréal, Montréal, Que.; Division of Gynecologic Oncology (Brar), University of British Columbia, Vancouver, BC; Department of Gynecologic Oncology (Nelson), Tom Baker Cancer Centre, Calgary, Alta.
| | - Limor Helpman
- Department of Obstetrics, Gynecology and Reproductive Sciences (Altman), University of Manitoba, Winnipeg, Man.; Division of Gynecologic Oncology (Helpman), McMaster University, Hamilton, Ont.; Division of Gynecologic Oncology (McGee), University of Western Ontario, London, Ont.; Division of Gynecologic Oncology (Auclair, Samouëlian), CHUM, Université de Montréal, Montréal, Que.; Division of Gynecologic Oncology (Brar), University of British Columbia, Vancouver, BC; Department of Gynecologic Oncology (Nelson), Tom Baker Cancer Centre, Calgary, Alta
| | - Jacob McGee
- Department of Obstetrics, Gynecology and Reproductive Sciences (Altman), University of Manitoba, Winnipeg, Man.; Division of Gynecologic Oncology (Helpman), McMaster University, Hamilton, Ont.; Division of Gynecologic Oncology (McGee), University of Western Ontario, London, Ont.; Division of Gynecologic Oncology (Auclair, Samouëlian), CHUM, Université de Montréal, Montréal, Que.; Division of Gynecologic Oncology (Brar), University of British Columbia, Vancouver, BC; Department of Gynecologic Oncology (Nelson), Tom Baker Cancer Centre, Calgary, Alta
| | - Vanessa Samouëlian
- Department of Obstetrics, Gynecology and Reproductive Sciences (Altman), University of Manitoba, Winnipeg, Man.; Division of Gynecologic Oncology (Helpman), McMaster University, Hamilton, Ont.; Division of Gynecologic Oncology (McGee), University of Western Ontario, London, Ont.; Division of Gynecologic Oncology (Auclair, Samouëlian), CHUM, Université de Montréal, Montréal, Que.; Division of Gynecologic Oncology (Brar), University of British Columbia, Vancouver, BC; Department of Gynecologic Oncology (Nelson), Tom Baker Cancer Centre, Calgary, Alta
| | - Marie-Hélène Auclair
- Department of Obstetrics, Gynecology and Reproductive Sciences (Altman), University of Manitoba, Winnipeg, Man.; Division of Gynecologic Oncology (Helpman), McMaster University, Hamilton, Ont.; Division of Gynecologic Oncology (McGee), University of Western Ontario, London, Ont.; Division of Gynecologic Oncology (Auclair, Samouëlian), CHUM, Université de Montréal, Montréal, Que.; Division of Gynecologic Oncology (Brar), University of British Columbia, Vancouver, BC; Department of Gynecologic Oncology (Nelson), Tom Baker Cancer Centre, Calgary, Alta
| | - Harinder Brar
- Department of Obstetrics, Gynecology and Reproductive Sciences (Altman), University of Manitoba, Winnipeg, Man.; Division of Gynecologic Oncology (Helpman), McMaster University, Hamilton, Ont.; Division of Gynecologic Oncology (McGee), University of Western Ontario, London, Ont.; Division of Gynecologic Oncology (Auclair, Samouëlian), CHUM, Université de Montréal, Montréal, Que.; Division of Gynecologic Oncology (Brar), University of British Columbia, Vancouver, BC; Department of Gynecologic Oncology (Nelson), Tom Baker Cancer Centre, Calgary, Alta
| | - Gregg S Nelson
- Department of Obstetrics, Gynecology and Reproductive Sciences (Altman), University of Manitoba, Winnipeg, Man.; Division of Gynecologic Oncology (Helpman), McMaster University, Hamilton, Ont.; Division of Gynecologic Oncology (McGee), University of Western Ontario, London, Ont.; Division of Gynecologic Oncology (Auclair, Samouëlian), CHUM, Université de Montréal, Montréal, Que.; Division of Gynecologic Oncology (Brar), University of British Columbia, Vancouver, BC; Department of Gynecologic Oncology (Nelson), Tom Baker Cancer Centre, Calgary, Alta
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Piovano E, Ferrero A, Zola P, Marth C, Mirza MR, Lindemann K. Clinical pathways of recovery after surgery for advanced ovarian/tubal/peritoneal cancer: an NSGO-MaNGO international survey in collaboration with AGO-a focus on surgical aspects. Int J Gynecol Cancer 2020; 29:181-187. [PMID: 30640702 DOI: 10.1136/ijgc-2018-000021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 09/05/2018] [Accepted: 09/14/2018] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES This survey assessed the implementation of enhanced recovery after surgery (ERAS) for patients undergoing surgery for advanced ovarian cancer in three European cooperative study groups in Scandinavia, Italy, and Austria. The aim was to evaluate the landscape for future trials on ERAS pathways in ovarian cancer, because high-level evidence for such interventions is lacking. METHODS In July 2017, a web-based questionnaire (SurveyMonkey Inc, Palo Alto, CA, USA) was sent to centers conducting surgery for advanced ovarian cancer within the Nordic Society of Gynecologic Oncology (NSGO), Mario Negri Gynecologic Oncology Group (MaNGO) and other Italian institutions, and the Association for Gynecologic Oncology Austria (AGO Austria) (n = 100). The survey covered all aspects of an ERAS pathway including surgery, nursing, and anesthesia. We herein report on the survey findings relating to surgery, including nursing care issues; however, anesthesiologic issues will be discussed in a separate report. RESULTS The overall response rate was 62%. Only a third of the centers in Italy and Austria follow a written ERAS protocol compared with 60% of the Scandinavian centers. Only a minority of centers have completely abandoned bowel preparation, with the highest proportion in Scandinavia (36%). Two hours of fasting for fluids before surgery is routinely practiced in Scandinavia and Austria (67-57%, respectively), but not in Italy (5%). Carbohydrate loading is routinely administered only in Scandinavia (67%). Peritoneal drainage is used by 22% routinely and by 61% in cases of bowel resection/lymphadenectomy/peritonectomy. Early feeding with a light diet on day 0 or 1 is the standard of care in Scandinavia and Austria, but not in Italy. CONCLUSIONS The degree of implementation of ERAS protocols varies across and within cooperative groups. The centralization of ovarian cancer care seems to facilitate standardization of peri-operative protocols. Currently, the high heterogeneity in patterns of care may challenge an international approach to a clinical trial.
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Affiliation(s)
- Elisa Piovano
- Obstetrics and Gynecology Unit, Regina Montis Regalis Hospital, Mondovì (CN), Italy - MaNGO
| | - Annamaria Ferrero
- Academic Department of Gynaecology and Obstetrics, University of Torino, Mauriziano Hospital, Torino, Italy - MaNGO
| | - Paolo Zola
- Department Surgical Sciences, University of Torino, Torino, Italy.,Città della Salute e della Scienza di Torino, S. Anna University Hospital, Torino, Italy - MaNGO
| | - Christian Marth
- Department of Obstetrics and Gynecology, Innsbruck Medical University, Innsbruck, Austria - AGO Austria
| | - Mansoor Raza Mirza
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark - NSGO
| | - Kristina Lindemann
- Department of Gynaecological Cancer, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, NSGO, Oslo, Norway
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169
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Ore AS, Shear MA, Liu FW, Dalrymple JL, Awtrey CS, Garrett L, Stack-Dunnbier H, Hacker MR, Esselen KM. Adoption of enhanced recovery after laparotomy in gynecologic oncology. Int J Gynecol Cancer 2020; 30:122-127. [PMID: 31771963 PMCID: PMC8939246 DOI: 10.1136/ijgc-2019-000848] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/21/2019] [Accepted: 10/30/2019] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) pathways combine a comprehensive set of peri-operative practices that have been demonstrated to hasten patient post-operative recovery. We aimed to evaluate the adoption of ERAS components and assess attitudes towards ERAS among gynecologic oncologists. METHODS We developed and administered a cross-sectional survey of attending, fellow, and resident physicians who were members of the Society of Gynecologic Oncology in January 2018. The χ2 test was used to compare adherence to individual components of ERAS. RESULTS There was a 23% survey response rate and we analyzed 289 responses: 79% were attending physicians, 57% were from academic institutions, and 64% were from institutions with an established ERAS pathway. Respondents from ERAS institutions were significantly more likely to adhere to recommendations regarding pre-operative fasting for liquids (ERAS 51%, non-ERAS 28%; p<0.001), carbohydrate loading (63% vs 16%; p<0.001), intra-operative fluid management (78% vs 32%; p<0.001), and extended duration of deep vein thrombosis prophylaxis for malignancy (69% vs 55%; p=0.003). We found no difference in the use of mechanical bowel preparation, use of peritoneal drainage, or use of nasogastric tubes between ERAS and non-ERAS institutions. Nearly all respondents (92%) felt that ERAS pathways were safe. DISCUSSION Practicing at an institution with an ERAS pathway increased adoption of many ERAS elements; however, adherence to certain guidelines remains highly variable. Use of bowel preparation, nasogastric tubes, and peritoneal drainage catheters remain common. Future work should identify barriers to the implementation of ERAS and its components.
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Affiliation(s)
- Ana Sofia Ore
- Obstetrics and gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Matthew A Shear
- Obstetrics and gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Obstetrics, gynecology and reproductive biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Fong W Liu
- Obstetrics and gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Obstetrics, gynecology and reproductive biology, Harvard Medical School, Boston, Massachusetts, USA
| | - John L Dalrymple
- Obstetrics and gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Obstetrics, gynecology and reproductive biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Awtrey
- Obstetrics and gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Obstetrics, gynecology and reproductive biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Leslie Garrett
- Obstetrics and gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Obstetrics, gynecology and reproductive biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Hannah Stack-Dunnbier
- Obstetrics and gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Michele R Hacker
- Obstetrics and gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Obstetrics, gynecology and reproductive biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Katharine McKinley Esselen
- Obstetrics and gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Obstetrics, gynecology and reproductive biology, Harvard Medical School, Boston, Massachusetts, USA
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Harrison RF, Li Y, Guzman A, Pitcher B, Rodriguez-Restrepo A, Cain KE, Iniesta MD, Lasala JD, Ramirez PT, Meyer LA. Impact of implementation of an enhanced recovery program in gynecologic surgery on healthcare costs. Am J Obstet Gynecol 2020; 222:66.e1-66.e9. [PMID: 31376395 DOI: 10.1016/j.ajog.2019.07.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/16/2019] [Accepted: 07/26/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND Enhanced recovery programs have been associated with improved outcomes after gynecologic surgery. There are limited data on the effect of enhanced recovery programs on healthcare costs or healthcare service use. OBJECTIVE The purpose of this study was to evaluate differences in hospital charges for women who undergo surgery for a suspected gynecologic cancer that is managed in an enhanced recovery program as compared with conventional perioperative care. STUDY DESIGN We performed a retrospective cohort study of women who underwent open abdominal surgery for a suspected gynecologic cancer before and after the implementation of an enhanced recovery after surgery program. Consecutive patients from May to October 2014 and from November 2014 to November 2015 comprised the conventional perioperative care (before enhanced recovery after surgery) and enhanced recovery after surgery cohorts, respectively. Patients were excluded if they underwent surgery with a multidisciplinary surgical team or minimally invasive surgery. All technical and professional charges were ascertained for all healthcare services from the day of surgery until postoperative day 30. Charges for adjuvant treatment were excluded. Charges were classified according to the type of clinical service provided. The primary outcome was the difference in total hospital charges between the pre-enhanced recovery after surgery and the enhanced recovery after surgery groups. Secondary outcomes were between group differences in hospital charges within clinical service categories. RESULTS A total of 271 patients were included in the analysis (58 patients in the pre-enhanced recovery after surgery and 213 patients in the enhanced recovery after surgery cohort). A total of 70,177 technical charges and 6775 professional charges were identified and classified. The median hospital charge for a patient decreased 15.6% in the enhanced recovery after surgery group compared with the pre-enhanced recovery after surgery group (95% confidence interval, 5-24.5%; P=.008). Patients in the enhanced recovery after surgery group also had lower charges for laboratory services (20% lower; 95% confidence interval, 0--39%; P=.04), pharmacy services (30% lower; 95% confidence interval, 14--41%; P<.001), room and board (25% lower; 95% confidence interval, 20--47%; P=.005), and material goods (64% lower; 95% confidence interval, 44--81%; P<.001). No differences in charges were observed for perioperative services, diagnostic procedures, emergency department care, transfusion-related services, interventional radiology procedures, physical/occupational therapy, outpatient care, or other services. CONCLUSION Hospital charges and healthcare service use were lower for enhanced recovery patients compared with patients who received conventional perioperative care after open surgery for a suspected gynecologic cancer. Enhanced recovery programs may be considered to be high value in healthcare because they provide improved outcomes while lowering resource use.
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Adherence to Enhanced Recovery Protocols in NSQIP and Association With Colectomy Outcomes. Ann Surg 2019; 269:486-493. [PMID: 29064887 DOI: 10.1097/sla.0000000000002566] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To evaluate the effect of protocol adherence on length of stay (LOS) and recovery-specific outcomes after colectomy. BACKGROUND Enhanced recovery protocols (ERPs) may decrease postoperative morbidity and LOS; however, the effect of overall protocol adherence remains unclear. METHODS Using American College of Surgeons' National Surgical Quality Improvement Program colectomy data (July 2014-December 2015) and 13 novel ERP variables, propensity scores were constructed for low (0-5), moderate (6-9), and high adherence (10-13 components). Prolonged LOS (>75th percentile, uncomplicated cases) was modeled with multivariable logistic regression with robust standard errors, adjusted for hospital-level clustering and propensity score. Secondary recovery-specific outcomes were modeled with negative binomial regression. Subgroup analysis was conducted on uncomplicated cases. RESULTS Among 8139 elective colectomies at 113 hospitals, LOS increased with decreasing adherence (4.3 days [SD 3.3] high adherence vs 7.8 [SD 6.8] low adherence; P < 0.0001). High adherence was associated with fewer complications, including postoperative ileus, compared with moderate (P < 0.0001) and low adherence (P < 0.0001). High-adherence patients achieved recovery milestones earlier (vs low adherence), with return of bowel function at 1.9 (vs 3.7) days, tolerance of diet at 2.4 (vs 5.4) days, and oral pain control at 2.7 (vs 5.0) days (P < 0.0001). Risk-adjusted odds of prolonged LOS were significantly increased for low (odds ratio 2.7, 95% confidence interval 2.0-3.6) and moderate-adherence (odds ratio 1.7, 95% confidence interval 1.4-2.1) groups. In a negative binomial regression, time to recovery was 60% to 95% longer for low versus high adherence (P < 0.0001). CONCLUSIONS In this large, multi-institutional North American data registry, high adherence to ERPs was associated with earlier recovery, decreased complications, and shorter LOS. ERPs can improve outcomes; however, benefits correlate with adherence.
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Zakaria HM, Bazydlo M, Schultz L, Abdulhak M, Nerenz DR, Chang V, Schwalb JM. Ambulation on Postoperative Day #0 Is Associated With Decreased Morbidity and Adverse Events After Elective Lumbar Spine Surgery: Analysis From the Michigan Spine Surgery Improvement Collaborative (MSSIC). Neurosurgery 2019; 87:320-328. [DOI: 10.1093/neuros/nyz501] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 09/02/2019] [Indexed: 01/13/2023] Open
Abstract
Abstract
BACKGROUND
While consistently recommended, the significance of early ambulation after surgery has not been definitively studied.
OBJECTIVE
To identify the relationship between ambulation on the day of surgery (postoperative day (POD)#0) and 90-d adverse events after lumbar surgery.
METHODS
The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a prospective multicenter registry of spine surgery patients. As part of routine postoperative care, patients either ambulated on POD#0 or did not. The 90-d adverse events of length of stay (LOS), urinary retention (UR), urinary tract infection (UTI), ileus, readmission, surgical site infection (SSI), pulmonary embolism/deep vein thrombosis (PE/DVT), and disposition to a rehab facility were measured.
RESULTS
A total of 23 295 lumbar surgery patients were analyzed. POD#0 ambulation was associated with decreased LOS (relative LOS 0.83, P < .001), rehab discharge (odds ratio [OR] 0.52, P < .001), 30-d (OR 0.85, P = .044) and 90-d (OR 0.86, P = .014) readmission, UR (OR 0.73, P = 10), UTI (OR 73, P = .001), and ileus (OR 0.52, P < .001) for all patients. Significant improvements in LOS, rehab discharge, readmission, UR, UTI, and ileus were observed in subset analysis of single-level decompressions (4698 pts), multilevel decompressions (4079 pts), single-level fusions (4846 pts), and multilevel fusions (4413 pts). No change in rate of SSI or DVT/PE was observed for patients who ambulated POD#0.
CONCLUSION
POD#0 ambulation is associated with a significantly decreased risk for several key adverse events after lumbar spine surgery. Decreasing the incidence of these outcomes would be associated with significant cost savings. As ambulation POD#0 is a modifiable factor in any patient's postoperative care following most spine surgery, it should be encouraged and incorporated into spine-related, enhanced-recovery-after-surgery programs.
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Affiliation(s)
| | - Michael Bazydlo
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, Michigan
| | - Lonni Schultz
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, Michigan
| | | | - David R Nerenz
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan
- Center for Health Policy and Health Services Research, Henry Ford Hospital, Detroit, Michigan
| | - Victor Chang
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan
| | - Jason M Schwalb
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan
- Center for Health Policy and Health Services Research, Henry Ford Hospital, Detroit, Michigan
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Gentry ZL, Boitano TKL, Smith HJ, Eads DK, Russell JF, Straughn JM. The financial impact of an enhanced recovery after surgery (ERAS) protocol in an academic gynecologic oncology practice. Gynecol Oncol 2019; 156:284-287. [PMID: 31776038 DOI: 10.1016/j.ygyno.2019.11.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/01/2019] [Accepted: 11/10/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine the financial impact of an enhanced recovery after surgery (ERAS) protocol in gynecologic oncology patients. METHODS This study identified gynecologic oncology patients who were placed on the ERAS protocol after elective laparotomy from 10/2016-6/2017. A control group was identified from the year prior to ERAS implementation. Financial experts assisted in procuring data for these patient encounters, including payer status, direct and indirect costs, contribution margin, and length of stay (LOS). SPSS Statistics v. 24 was used for statistical analysis. RESULTS 376 patients met criteria for inclusion: 179 in the ERAS group and 197 in the control group. Patient demographics were similar between the two cohorts. Payer status across the groups was not statistically significant in patients with private insurance (control 43.7% vs. ERAS 41.3%), Medicare (38.1% vs. 31.8%), or self-pay patients (12.2% vs. 15.1%). There was a significantly higher number of Medicaid patients in the ERAS group (6.1% vs. 11.7%; p = 0.05). Hospital direct costs ($5596 vs. 5346) and indirect costs ($5182 vs. $4954) per encounter were similar between groups. However, overall contribution margin per encounter decreased in the ERAS group ($11,619 vs. $8528; p = 0.01). LOS was significantly lower in the ERAS group (4.1 vs. 2.9 days; p = 0.04). CONCLUSIONS Implementation of the ERAS protocol in gynecologic oncology patients does not lead to increased costs for the patient or hospital system. The decreased contribution margin is likely due to a reduction in per diem payments caused by the reduction in LOS. On a per-patient-day basis, contribution margin was the same for both groups ($2877 vs $2857). The reduction in LOS also created capacity for additional cases, the financial impact of which was not evaluated.
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Affiliation(s)
- Zachary L Gentry
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Teresa K L Boitano
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Haller J Smith
- Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Dustin K Eads
- UAB Finance, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John F Russell
- UAB Finance, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J Michael Straughn
- Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
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Iniesta MD, Lasala J, Mena G, Rodriguez-Restrepo A, Salvo G, Pitcher B, Washington LD, Harris M, Meyer LA, Ramirez PT. Impact of compliance with an enhanced recovery after surgery pathway on patient outcomes in open gynecologic surgery. Int J Gynecol Cancer 2019; 29:1417-1424. [PMID: 31601647 DOI: 10.1136/ijgc-2019-000622] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/27/2019] [Accepted: 09/04/2019] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE The aim of this study was to evaluate if varying levels of compliance with an enhanced recovery after surgery (ERAS) protocol impacted post-operative outcomes (length of stay, complications, readmissions, and re-operations) in gynecologic surgery at a tertiary center. METHODS We included 584 patients who had open gynecologic surgery between November 1, 2014 and December 31, 2016. Patients were categorized into subgroups according to their date of surgery from the time of the ERAS protocol implementation. Patients were categorized by their per cent compliance into two groups:<80% versus ≥80%. We analyzed compliance with the elements of the protocol over time and its relation with post-operative outcomes, length of stay, post-operative complications, readmission, and re-operations rates. We modeled the probability of having a post-operative complication within 30 days of surgery as a function of overall compliance. RESULTS Overall compliance was 72.3%. Patients with compliance ≥80% had significantly less complications (P<0.001) and shorter length of stay (P<0.001). Readmission and re-operation rates were not impacted by compliance (P=0.182, P=0.078, respectively). Avoidance of salt water overload, early mobilization, early oral nutrition, and early removal of Foley catheter were significantly associated with less post-operative complications within 30 days. CONCLUSIONS Compliance with an ERAS pathway exceeding 80% was associated with lower complication rates and shorter length of stay without impacting on re-operations or readmissions.
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Affiliation(s)
- Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Andrea Rodriguez-Restrepo
- Department of Anesthesiology and Perioperative Medicine, Northern Arizona University-Tucson Campus, Tucson, Arizona, USA
| | - Gloria Salvo
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brandelyn Pitcher
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lakisha D Washington
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Melinda Harris
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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175
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Prehabilitation programs and ERAS protocols in gynecological oncology: a comprehensive review. Arch Gynecol Obstet 2019; 301:315-326. [DOI: 10.1007/s00404-019-05321-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 09/21/2019] [Indexed: 12/18/2022]
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Webb C, Day R, Velazco CS, Pockaj BA, Gray RJ, Stucky CC, Young-Fadok T, Wasif N. Implementation of an Enhanced Recovery After Surgery (ERAS) Program is Associated with Improved Outcomes in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2019; 27:303-312. [PMID: 31605328 DOI: 10.1245/s10434-019-07900-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been associated with increased postoperative complications and a prolonged length of stay (LOS). We report on our experience following implementation of an Enhanced Recovery After Surgery (ERAS) program for CRS and HIPEC. METHODS Patients were divided into pre- and post-ERAS groups. Modifications in the ERAS group included routine use of transversus abdominis plane blocks, intra- and postoperative fluid restriction, and minimizing the use of narcotics, drains, and nasogastric tubes. RESULTS Of a total of 130 procedures, 49 (38%) were in the pre-ERAS group and 81 (62%) were in the ERAS group. Mean LOS was reduced from 10.3 ± 8.9 days to 6.9 ± 5.0 days (p = 0.007) and the rate of grade III/IV complications was reduced from 24 to 15% (p = 0.243) following ERAS implementation. The ERAS group received less intravenous fluid during hospitalization (19.2 ± 18.7 L vs. 32.8 ± 32.5 L, p = 0.003) and used less opioids than the pre-ERAS group (median of 159.7 mg of oral morphine equivalents vs. 272.6 mg). There were no significant changes in the rates of 30-day readmission or acute kidney injury between the two groups (p = non-significant). On multivariable analyses, ERAS was significantly associated with a reduction in LOS (- 2.89 days, 95% CI - 4.84 to - 0.94) and complication rates (odds ratio 0.22, 95% CI 0.08-0.57). CONCLUSIONS Implementation of an ERAS program for CRS and HIPEC is associated with a reduction in overall intravenous fluids, postoperative narcotic use, complication rates, and LOS.
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Affiliation(s)
- Christopher Webb
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Ryan Day
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Cristine S Velazco
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Barbara A Pockaj
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Richard J Gray
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Chee-Chee Stucky
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Tonia Young-Fadok
- Department of Surgery, Division of Colorectal Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Nabil Wasif
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA.
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Biçer Ç, Raoufi J, İşcan SC, Güney M, Erdemoğlu E. Surgical risk assessment for gynecological oncologic patients. Turk J Obstet Gynecol 2019; 16:158-163. [PMID: 31673467 PMCID: PMC6792055 DOI: 10.4274/tjod.galenos.2019.93584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 06/09/2019] [Indexed: 12/01/2022] Open
Abstract
Objective Preoperative surgical risk assessment is important in terms of postoperative morbidity and mortality. Therefore, it is necessary to evaluate the efficacy and safety of these surgeries via an ideal risk assessment model, and reduce risks via applying some findings (for instance, perioperative beta-blockers). There are some risk assessment systems, but these have generally not been verified for patients with gynecologic cancer. The aim of this study was to assess the risk of surgery for gynecological oncologic patients and suggest an easy risk assessment model and risk reduction by applying our findings. Materials and Methods We retrospectively analyzed 258 gynecologic patients with cancer. Age, diagnosis, staging, performance scale, metoprolol use, heart, renal diabetes, Chronic Obstructive Pulmonary disease, diabetes, operation type and length, carcinoma antigen 125, ascites, albumin, surgical procedure, hospitalization length, and complications were recorded. Results Of the 258 patients, 173 patients (67.1%) had no complications, 43 patients (16.7%) had one and 42 patients (16.3%) had two or more complications. The most common complication was the acid-base imbalance (14%), followed by urinary tract infection (9.7%). Parameters associated with complications were performance status, ascites, operating length, metoprolol use, and upper abdominal surgery. In our proposed scoring model with a total score range 0-23, cut-off value points for both the presence and rate of complications was found as >5. Conclusion In gynecological patients with cancer, the addition of metoprolol use and upper abdominal surgery within preoperative risk assessment evaluation parameters are significantly effective in predicting the rate and severity of complications. Moreover, we have suggested a simple, practical, and convenient scoring model for this evaluation.
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Affiliation(s)
- Çağlayan Biçer
- Süleyman Demirel University Faculty of Medicine, Department of Obstetrics and Gynecology, Isparta, Turkey
| | - Jalal Raoufi
- Süleyman Demirel University Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Isparta, Turkey
| | - Serhan Can İşcan
- Süleyman Demirel University Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Isparta, Turkey
| | - Mehmet Güney
- Süleyman Demirel University Faculty of Medicine, Department of Obstetrics and Gynecology, Isparta, Turkey
| | - Evrim Erdemoğlu
- Süleyman Demirel University Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Isparta, Turkey
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178
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Vilkins AL, Sahara M, Till S, Ceci C, Howard R, Griffith K, Waljee J, Lim C, Skinner B, Clauw DJ, Brummett CM, As-Sanie S. Effects of Shared Decision Making on Opioid Prescribing After Hysterectomy. Obstet Gynecol 2019; 134:823-833. [PMID: 31503160 PMCID: PMC6945818 DOI: 10.1097/aog.0000000000003468] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate the effects of shared decision making using a simple decision aid for opioid prescribing after hysterectomy. METHODS We conducted a prospective quality initiative study including all patients undergoing hysterectomy for benign, nonobstetric indications between March 1, 2018, and July 31, 2018, at our academic institution. Using a visual decision aid, patients received uniform education regarding postoperative pain management. They were then educated on the department's guidelines regarding the maximum number of tablets recommended per prescription and the mean number of opioid tablets used by a similar cohort of patients in a previously published study at our institution. Patients were then asked to choose their desired number of tablets to receive on discharge. Structured telephone interviews were conducted 14 days after surgery. The primary outcome was total opioids prescribed before compared with after implementation of the decision aid. Secondary outcomes included opioid consumption, patient satisfaction, and refill requests after intervention implementation. RESULTS Of 170 eligible patients, 159 (93.5%) used the decision aid (one patient who used the decision aid was subsequently excluded from the analysis owing to significant perioperative complications), including 110 (69.6%) laparoscopic, 40 (25.3%) vaginal, and eight (5.3%) abdominal hysterectomies. Telephone surveys were completed for 89.2% (n=141) of participants. Student's t-test showed that patients who participated in the decision aid (post-decision aid cohort) were discharged with significantly fewer oral morphine equivalents than patients who underwent hysterectomy before implementation of the decision aid (pre-decision aid cohort) (92±35 vs 160±81, P<.01), with no significant change in the number of requested refills (9.5% [n=15] vs 5.7% [n=14], P=.15). In the post-decision aid cohort, 76.6% of patients (n=121) chose fewer tablets than the guideline-allotted maximum. Approximately 76% of patients (n=102) reported having leftover tablets. CONCLUSION This quality improvement initiative illustrates that a simple decision aid can result in a significant decrease in opioid prescribing without compromising patient satisfaction or postoperative pain management.
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Affiliation(s)
| | | | - Sara Till
- University of Michigan Department of Obstetrics and Gynecology
| | | | - Ryan Howard
- University of Michigan Department of Surgery
| | | | - Jennifer Waljee
- University of Michigan Section of Plastic Surgery, Department of Surgery
- University of Michigan Institute for Healthcare Policy and Innovation
| | - Courtney Lim
- University of Michigan Department of Obstetrics and Gynecology
| | - Bethany Skinner
- University of Michigan Department of Obstetrics and Gynecology
| | | | - Chad M. Brummett
- University of Michigan Department of Anesthesia
- University of Michigan Institute for Healthcare Policy and Innovation
| | - Sawsan As-Sanie
- University of Michigan Department of Obstetrics and Gynecology
- University of Michigan Institute for Healthcare Policy and Innovation
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179
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Opioid use after minimally invasive hysterectomy in gynecologic oncology patients. Gynecol Oncol 2019; 155:119-125. [DOI: 10.1016/j.ygyno.2019.08.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/30/2019] [Accepted: 08/02/2019] [Indexed: 12/12/2022]
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180
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Effect of an Enhanced Recovery After Surgery Program on Opioid Use and Patient-Reported Outcomes. Obstet Gynecol 2019; 132:281-290. [PMID: 29995737 DOI: 10.1097/aog.0000000000002735] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To investigate the effect of an enhanced recovery after surgery (ERAS) program on perioperative outcomes with an emphasis on opioid consumption and patient-reported outcomes in the immediate and extended postoperative periods. METHODS We initiated our ERAS program as part of a quality improvement initiative in November 2014. We compared clinical outcomes among a cohort of 607 women undergoing open gynecologic surgery before or after implementation of ERAS. For 293 patients, patient-reported outcomes were compared using the MD Anderson Symptom Inventory-Ovarian Cancer. RESULTS Median age was 58 years (range 18-85 years). Median length of stay decreased by 25% for patients in the ERAS pathway (P<.001). Overall, patients in the ERAS group had a 72% reduction in median opioid consumption and 16% were opioid-free during admission up to postoperative day 3 (P<.001). There was no difference in pain scores (P=.80). Patients on ERAS reported less fatigue (P=.01), interference with walking (P=.003), and total interference (composite score of physical and affective measures) during hospitalization (P=.008). After discharge, those on the ERAS pathway demonstrated a significantly shorter median time to return to no or mild fatigue (10 vs 30 days, P=.03), mild or no interference with walking (5 vs 13 days, P=.003), and mild to no total interference (3 vs 13 days, P=.02). There were no significant differences in complications, rates of readmission, or reoperation between the pre- and post-ERAS groups. CONCLUSION Implementation of an ERAS program was associated with significantly decreased opioid use after surgery and improvement in key patient-reported outcomes associated with functional recovery after surgery without compromising pain scores.
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181
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Postoperative pain management in the era of ERAS: An overview. Best Pract Res Clin Anaesthesiol 2019; 33:259-267. [DOI: 10.1016/j.bpa.2019.07.016] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 07/19/2019] [Indexed: 02/07/2023]
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182
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Lin C, Gill R, Kumar K. [Bilateral lower thoracic erector spinae plane block in open abdominal gynecologic oncology surgery: a cases series]. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2019; 69:517-520. [PMID: 31635757 PMCID: PMC9391891 DOI: 10.1016/j.bjan.2019.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/13/2019] [Accepted: 03/03/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE AND BACKGROUND Erector spinae plane block is a novel analgesic truncal block that has been popularized due to its ease of performance and perceived safety. Erector spinae plane block has been postulated to target the ventral rami and rami communicates of spinal nerves, thus providing somatic and visceral analgesia. In this case series, we describe our experience of bilateral erector spinae plane block placed at the low thoracic level in open gynecologic oncology surgery in three patients. METHOD Under ultrasound guidance, erector spinae plane blocks were done, preoperatively, at the 8th thoracic transverse process bilaterally. Numeric rating scale for pain and opioid consumption of the first 48 postoperative hours were recorded. RESULTS Pain scores ranged from 0 to 4 among the three patients and 48h opioid consumption in oral morphine equivalents of 4, 6 and 18mg. No adverse events were recorded up to patient discharge from the hospital. CONCLUSIONS Erector spinae plane block provided effective analgesia in our case series. While its true mechanism of action remains obscure, the available case reports show encouraging analgesic results with no adverse events recorded. Formal prospective randomized trials are underway to provide further evidence on its efficacy, failure rate and safety.
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Affiliation(s)
- Cheng Lin
- Western University, Department of Anesthesia and Perioperative Medicine, London, Canadá
| | - Rajwinder Gill
- Western University, Department of Anesthesia and Perioperative Medicine, London, Canadá
| | - Kamal Kumar
- Western University, Department of Anesthesia and Perioperative Medicine, London, Canadá.
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183
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Lin C, Gill R, Kumar K. Bilateral lower thoracic erector spinae plane block in open abdominal gynecologic oncology surgery: a cases series. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 31635757 PMCID: PMC9391891 DOI: 10.1016/j.bjane.2019.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objective and background Erector spinae plane block is a novel analgesic truncal block that has been popularized due to its ease of performance and perceived safety. Erector spinae plane block has been postulated to target the ventral rami and rami communicates of spinal nerves, thus providing somatic and visceral analgesia. In this case series, we describe our experience of bilateral erector spinae plane block placed at the low thoracic level in open gynecologic oncology surgery in three patients. Method Under ultrasound guidance, erector spinae plane blocks were done, preoperatively, at the 8th thoracic transverse process bilaterally. Numeric rating scale for pain and opioid consumption of the first 48 postoperative hours were recorded. Results Pain scores ranged from 0 to 4 among the three patients and 48 h opioid consumption in oral morphine equivalents of 4, 6 and 18 mg. No adverse events were recorded up to patient discharge from the hospital. Conclusions Erector spinae plane block provided effective analgesia in our case series. While its true mechanism of action remains obscure, the available case reports show encouraging analgesic results with no adverse events recorded. Formal prospective randomized trials are underway to provide further evidence on its efficacy, failure rate and safety.
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184
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Wijk L, Udumyan R, Pache B, Altman AD, Williams LL, Elias KM, McGee J, Wells T, Gramlich L, Holcomb K, Achtari C, Ljungqvist O, Dowdy SC, Nelson G. International validation of Enhanced Recovery After Surgery Society guidelines on enhanced recovery for gynecologic surgery. Am J Obstet Gynecol 2019; 221:237.e1-237.e11. [PMID: 31051119 DOI: 10.1016/j.ajog.2019.04.028] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/17/2019] [Accepted: 04/24/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery Society publishes guidelines on perioperative care, but these guidelines should be validated prospectively. OBJECTIVE To evaluate the association between compliance with Enhanced Recovery After Surgery Gynecologic/Oncology guideline elements and postoperative outcomes in an international cohort. STUDY DESIGN The study comprised 2101 patients undergoing elective gynecologic/oncology surgery between January 2011 and November 2017 in 10 hospitals across Canada, the United States, and Europe. Patient demographics, surgical/anesthesia details, and Enhanced Recovery After Surgery protocol compliance elements (pre-, intra-, and postoperative phases) were entered into the Enhanced Recovery After Surgery Interactive Audit System. Surgical complexity was stratified according to the Aletti scoring system (low vs medium/high). The following covariates were accounted for in the analysis: age, body mass index, smoking status, presence of diabetes, American Society of Anesthesiologists class, International Federation of Gynecology and Obstetrics stage, preoperative chemotherapy, radiotherapy, operating time, surgical approach (open vs minimally invasive), intraoperative blood loss, hospital, and Enhanced Recovery After Surgery implementation status. The primary end points were primary hospital length of stay and complications. Negative binomial regression was used to model length of stay, and logistic regression to model complications, as a function of compliance score and covariates. RESULTS Patient demographics included a median age 56 years, 35.5% obese, 15% smokers, and 26.7% American Society of Anesthesiologists Class III-IV. Final diagnosis was malignant in 49% of patients. Laparotomy was used in 75.9% of cases, and the remainder minimally invasive surgery. The majority of cases (86%) were of low complexity (Aletti score ≤3). In patients with ovarian cancer, 69.5% had a medium/high complexity surgery (Aletti score 4-11). Median length of stay was 2 days in the low- and 5 days in the medium/high-complexity group. Every unit increase in Enhanced Recovery After Surgery guideline score was associated with 8% (IRR, 0.92; 95% confidence interval, 0.90-0.95; P<.001) decrease in days in hospital among low-complexity, and 12% (IRR, 0.88; 95% confidence interval, 0.82-0.93; P<.001) decrease among patients with medium/high-complexity scores. For every unit increase in Enhanced Recovery After Surgery guideline score, the odds of total complications were estimated to be 12% lower (P<.05) among low-complexity patients. CONCLUSION Audit of surgical practices demonstrates that improved compliance with Enhanced Recovery After Surgery Gynecologic/Oncology guidelines is associated with an improvement in clinical outcomes, including length of stay, highlighting the importance of Enhanced Recovery After Surgery implementation.
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Affiliation(s)
- Lena Wijk
- Department of Obstetrics and Gynecology, Örebro University Hospital, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Sweden.
| | - Ruzan Udumyan
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Sweden
| | - Basile Pache
- Department of Obstetrics and Gynecology, Lausanne University Hospital, Lausanne, Switzerland
| | - Alon D Altman
- Winnipeg Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Laura L Williams
- Gynecologic Oncology of Middle Tennessee, HCA Centennial Hospital, Nashville, TN
| | - Kevin M Elias
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Jake McGee
- London Health Sciences Centre, London, ON, Canada
| | | | | | - Kevin Holcomb
- Clinical Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY
| | - Chahin Achtari
- Gynecology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Olle Ljungqvist
- Department of Surgery, Örebro University Hospital, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Sweden
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, AB, Canada
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185
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Combined General and Epidural Anesthesia is Associated With Decreased Opioid Consumption and Enhanced Pain Control After Penile Inversion Vaginoplasty in Transwomen. Ann Plast Surg 2019; 83:681-686. [DOI: 10.1097/sap.0000000000001921] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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186
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Pache B, Joliat GR, Hübner M, Grass F, Demartines N, Mathevet P, Achtari C. Cost-analysis of Enhanced Recovery After Surgery (ERAS) program in gynecologic surgery. Gynecol Oncol 2019; 154:388-393. [DOI: 10.1016/j.ygyno.2019.06.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/29/2019] [Accepted: 06/03/2019] [Indexed: 12/12/2022]
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187
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Abstract
In the past, best practices for perioperative management have been based as much on dogma as science. The creation of optimized perioperative pathways, known as enhanced recovery after surgery, has been shown to simultaneously improve patient outcomes and reduce cost. In this article, we critically review interventions (and omission of interventions) that should be considered by every surgical team to optimize preanesthesia care. This includes patient education, properly managing existing medical comorbidities, optimizing nutrition, and the use of medications before incision that have been shown to reduce surgical stress, opioid requirements, and postoperative complications. Anesthetic techniques, the use of adjunct medications administered after incision, and postoperative management are beyond the scope of this review. When possible, we have relied on randomized trials, meta-analyses, and systematic reviews to support our recommendations. In some instances, we have drawn from the general and colorectal surgery literature if evidence in gynecologic surgery is limited or of poor quality. In particular, hospital systems should aim to adhere to antibiotic and thromboembolic prophylaxis for 100% of patients, the mantra, "nil by mouth after midnight" should be abandoned in favor of adopting a preoperative diet that maintains euvolemia and energy stores to optimize healing, and bowel preparation should be abandoned for patients undergoing gynecologic surgery for benign indications and minimally invasive gynecologic surgery.
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188
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Awad H, Ahmed A, Urman RD, Stoicea N, Bergese SD. Potential role of pharmacogenomics testing in the setting of enhanced recovery pathways after surgery. Pharmgenomics Pers Med 2019; 12:145-154. [PMID: 31440074 PMCID: PMC6666379 DOI: 10.2147/pgpm.s198224] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 07/10/2019] [Indexed: 11/23/2022] Open
Abstract
In 2001, a group of European academic surgeons created the Enhanced Recovery After Surgery (ERAS) study group and established the first official ERAS protocol. One of the most significant challenges during ERAS implementation is variability of drugs used throughout the perioperative period. Pharmacogenomic testing (blood or saliva) results (obtained within approximately 48 hrs) provide guidelines on how to prescribe the optimal drug with the optimal dosage to each patient based on an individual's unique genetic profile. Pharmacogenomic testing of various methods of multimodal analgesia is an essential element of ERAS protocols spanning the entire perioperative period to ultimately optimize postoperative pain control. The key goal for anesthetic management in ERAS protocols is to facilitate rapid emergence by using the shortest acting agents available, thus accelerating recovery and reducing length of stay, hospital expenses, and postoperative complications. Postoperative nausea and vomiting (PONV) is an additional challenge that should be overcome to ensure an enhanced recovery and shorter length of stay with the use of antiemetics. Postoperative ileus (POI) can result in longer hospital stay with increasing susceptibility to associated morbidities along with an increase in associated hospitalization costs. Genetics-guided pharmacotherapy and its impact on clinical outcomes should be thoroughly studied for better understanding and managing drug administration in the settings of ERAS.
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Affiliation(s)
- Hamdy Awad
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ahmed Ahmed
- Department of Anesthesiology, The University of Texas, Houston, TX, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicoleta Stoicea
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sergio D Bergese
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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189
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Lambaudie E, Mathis J, Zemmour C, Jauffret-Fara C, Mikhael ET, Pouliquen C, Sabatier R, Brun C, Faucher M, Mokart D, Houvenaeghel G. Prediction of early discharge after gynaecological oncology surgery within ERAS. Surg Endosc 2019; 34:1985-1993. [PMID: 31309314 DOI: 10.1007/s00464-019-06974-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 07/01/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Enhanced recovery after surgery programs (ERAS) have been proven to decrease the length of hospital stay without increasing readmission rates or complications. However, the patient and operative characteristics that improve the chance of a successful early hospital discharge are not well established. The aim of this study was to design a nomogram which could be used before surgery, using the characteristics of patients, to establish who could benefit from early discharge (POD ≤ 2 days). METHODS This observational study has been prospectively conducted. All the included patients were referred for surgical treatment of gynecologic cancer. We defined two sub-groups of patients on surgical procedure characteristics: isolated procedures (hysterectomy or lymphadenectomy) and combined procedures (at least the association of two procedures). RESULTS 230 patients were enrolled during the study protocol. 83.9% of patients were treated with a minimally invasive surgery (MIS). 159 patients (69.1%) were discharged on or before POD 2. On multivariate analysis, the surgical approach (open surgery vs. laparoscopy, OR 0.02 (95% CI [0-0.07]), p < 0.001) and the type of surgery (combined procedure versus isolated procedure, OR 0.41 (95% CI [0.18-0.91]), p = 0.028) were found to be significant predictors of increased hospital stay. A nomogram has been built for the purpose of predicting eligible patients for early post-operative discharge based on the multivariate analysis results (AUC = 0.86, 95% CI [0.81-0.92]). CONCLUSION The use of MIS for isolated procedures in oncologic indications constitutes an independent factor of early discharge in a setting of ERAS. These promising preliminary results still require to be validated on a prospective cohort.
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Affiliation(s)
- Eric Lambaudie
- Department of Surgery, Paoli Calmettes Institute, Marseille, France. .,Aix Marseille University, INSERM, IRD, SESSTIM, Marseille, France. .,Department of Surgical Oncology, Institut Paoli Calmettes, 232 Bd. Sainte-Marguerite, 13009, Marseille, France.
| | - Jérome Mathis
- Department of Surgery, Paoli Calmettes Institute, Marseille, France
| | - Christophe Zemmour
- Department of Clinical Research and Innovation, Biostatistics and Methodology Unit, Paoli Calmettes Institute, Marseille, France.,Aix Marseille University, INSERM, IRD, SESSTIM, Marseille, France
| | | | | | - Camille Pouliquen
- Department of Anaesthesiology, Paoli Calmettes Institute, Marseille, France
| | - Renaud Sabatier
- Aix Marseille University, INSERM, IRD, SESSTIM, Marseille, France.,Department of Medical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Clément Brun
- Department of Anaesthesiology, Paoli Calmettes Institute, Marseille, France
| | - Marion Faucher
- Department of Anaesthesiology, Paoli Calmettes Institute, Marseille, France
| | - Djamel Mokart
- Department of Anaesthesiology, Paoli Calmettes Institute, Marseille, France
| | - Gilles Houvenaeghel
- Department of Surgery, Paoli Calmettes Institute, Marseille, France.,Aix Marseille University, INSERM, IRD, SESSTIM, Marseille, France
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190
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Sohl SJ, Tooze JA, Wheeler A, Zeidan F, Wagner LI, Evans S, Kelly M, Shalowitz D, Green M, Levine B, Danhauer SC. Iterative adaptation process for eHealth Mindful Movement and Breathing to improve gynecologic cancer surgery outcomes. Psychooncology 2019; 28:1774-1777. [PMID: 31219212 DOI: 10.1002/pon.5146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 05/15/2019] [Accepted: 06/06/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Stephanie J Sohl
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Janet A Tooze
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Amy Wheeler
- Department of Kinesiology, California State University, San Bernardino, San Bernardino, California
| | - Fadel Zeidan
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lynne I Wagner
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Sue Evans
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael Kelly
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - David Shalowitz
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Meg Green
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Beverly Levine
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Suzanne C Danhauer
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
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191
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Moulder JK, Boone JD, Buehler JM, Louie M. Opioid Use in the Postoperative Arena: Global Reduction in Opioids After Surgery Through Enhanced Recovery and Gynecologic Surgery. Clin Obstet Gynecol 2019; 62:67-86. [PMID: 30407228 DOI: 10.1097/grf.0000000000000410] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Enhanced recovery programs aim to reduce surgical stress to improve the patient perioperative experience. Through a combination of multimodal analgesia and maintaining a physiological state, postoperative recovery is improved. Many analgesic adjuncts are available that improve postoperative pain control and limit opioid analgesia requirements. Adjuncts are often used in combination, but different interventions may be incorporated for patient-specific and procedure-specific needs. Postoperative pain control can be optimized by continuing nonopioid adjuncts, and prescribing opioid analgesia to address breakthrough pain. Prescribing practices should balance optimizing pain relief, minimizing the risk of chronic pain, while limiting the potential for opioid misuse.
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Affiliation(s)
| | | | - Jason M Buehler
- Anesthesiology, University of Tennessee Medical Center Knoxville, Graduate School of Medicine, Knoxville, Tennessee
| | - Michelle Louie
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
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192
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Phillips E, Archer S, Montague J, Bali A. Experiences of enhanced recovery after surgery in general gynaecology patients: An interpretative phenomenological analysis. Health Psychol Open 2019; 6:2055102919860635. [PMID: 31321068 PMCID: PMC6610470 DOI: 10.1177/2055102919860635] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
There is little qualitative research exploring non-cancer gynaecology patients’
experiences of enhanced recovery after surgery (ERAS) protocols. Seven women
participated in audio-recorded interviews, discussing their experiences of
enhanced recovery after surgery for gynaecological surgery. Data were
transcribed and analysed using interpretative phenomenological analysis. Three
themes were identified: meeting informational needs, taking control of pain, and
mobilising when feeling fragile. Control emerged as a key element throughout the
themes and was supported by provision of factual information. While participants
were generally satisfied with their experience, topics such as concerns about
analgesic use, the informal role of staff in mobilisation, and the expressed
desire for more experiential information for participants require further
research.
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193
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Kuster Uyeda MGB, Batista Castello Girão MJ, Carbone ÉDSM, Machado Fonseca MC, Takaki MR, Ferreira Sartori MG. Fast-track protocol for perioperative care in gynecological surgery: Cross-sectional study. Taiwan J Obstet Gynecol 2019; 58:359-363. [PMID: 31122525 DOI: 10.1016/j.tjog.2019.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To compare clinical and surgical outcomes in patients admitted to a gynecological surgery ward before and after the implementation of an evidence-based multimodal and multiprofessional care protocol by the hospital staff. MATERIAL AND METHODS In this historically-controlled cross-sectional study, we compared clinical and surgical outcomes among all women admitted to the gynecological ward of a university public hospital for elective surgery for various reasons before and after the implementation of a multimodal care protocol. The protocol had been implemented to adjust the following procedures to evidence-based recommendations: fluid management/hydration, antimicrobial prophylaxis, management of nausea and vomiting, antithrombotic prophylactic therapy, preoperative fasting, mechanical bowel preparation (reduction), pain management, use of urinary catheters, and stimulus to ambulation. RESULTS After the protocol implementation, fasting time was reduced in approximately 10 h. Patients had to undergo bowel preparation significantly less frequently, and the volume of fluids was reduced too. The use of nausea and vomit prophylaxis increased almost 20 times, but only nausea episodes were reduced. The frequency of antithrombotic prophylactic therapy more than doubled. Hospitalization time decreased significantly. CONCLUSIONS In this study, we observed significant improvements in clinical outcomes after the implementation of a multimodal protocol for perioperative care in the gynecological ward of a public university hospital in Brazil. The protocol implementation was associated with reductions in fasting time, bowel preparation, administration of fluids, pain, nausea and hospitalization time, allowing the treatment of more patients per year in the same ward.
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Affiliation(s)
- Maria Gabriela B Kuster Uyeda
- Department of Gynecology and Obstetrics, Universidade Federal de São Paulo, Escola Paulista de Medicina (Unifesp-EPM), Brazil.
| | | | - Ébe Dos Santos Monteiro Carbone
- Department of Gynecology and Obstetrics, Universidade Federal de São Paulo, Escola Paulista de Medicina (Unifesp-EPM), Brazil.
| | - Marcelo Cunio Machado Fonseca
- Department of Gynecology and Obstetrics, Universidade Federal de São Paulo, Escola Paulista de Medicina (Unifesp-EPM), Brazil.
| | - Mayara Ronzini Takaki
- Department of Gynecology and Obstetrics, Universidade Federal de São Paulo, Escola Paulista de Medicina (Unifesp-EPM), Brazil.
| | - Marair Gracio Ferreira Sartori
- Department of Gynecology and Obstetrics, Universidade Federal de São Paulo, Escola Paulista de Medicina (Unifesp-EPM), Brazil.
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194
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Pache B, Grass F, Hübner M, Kefleyesus A, Mathevet P, Achtari C. Prevalence and Consequences of Preoperative Weight Loss in Gynecologic Surgery. Nutrients 2019; 11:nu11051094. [PMID: 31108841 PMCID: PMC6566827 DOI: 10.3390/nu11051094] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 05/12/2019] [Accepted: 05/14/2019] [Indexed: 12/16/2022] Open
Abstract
Preoperative malnutrition and weight loss negatively impact postoperative outcomes in various surgical fields. However, for gynecologic surgery, evidence is still scarce, especially if surgery is performed within enhanced recovery after surgery (ERAS) pathways. This study aimed to assess the prevalence and impact of preoperative weight loss in patients undergoing major gynecologic procedures within a standardized ERAS pathway between October 2013 and January 2017. Out of 339 consecutive patients, 33 (10%) presented significant unintentional preoperative weight loss of more than 5% during the 6 months preceding surgery. These patients were less compliant to the ERAS protocol (>70% of all items: 70% vs. 94%, p < 0.001) presented more postoperative overall complications (15/33 (45%) vs. 69/306 (22.5%), p = 0.009), and had an increased length of hospital stay (5 ± 4 days vs. 3 ± 2 days, p = 0.011). While patients experiencing weight loss underwent more extensive surgical procedures, after multivariate analysis, weight loss ≥5% was retained as an independent risk factor for postoperative complications (OR 2.44; 95% CI 1.00-5.95), and after considering several surrogates for extensive surgery including significant blood loss (OR 2.23; 95% CI 1.15-4.31) as confounders. The results of this study suggest that systematic nutritional screening in ERAS pathways should be implemented.
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Affiliation(s)
- Basile Pache
- Department of Gynecology, Department "Femme-Mère-Enfant", Lausanne University Hospital, 1011 Lausanne, Switzerland.
| | - Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital, 1011 Lausanne, Switzerland.
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital, 1011 Lausanne, Switzerland.
| | - Amaniel Kefleyesus
- Department of Visceral Surgery, Lausanne University Hospital, 1011 Lausanne, Switzerland.
| | - Patrice Mathevet
- Department of Gynecology, Department "Femme-Mère-Enfant", Lausanne University Hospital, 1011 Lausanne, Switzerland.
| | - Chahin Achtari
- Department of Gynecology, Department "Femme-Mère-Enfant", Lausanne University Hospital, 1011 Lausanne, Switzerland.
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195
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Schwartz AR, Lim S, Broadwater G, Cobb L, Valea F, Marosky Thacker J, Habib A, Havrilesky L. Reduction in opioid use and postoperative pain scores after elective laparotomy with implementation of enhanced recovery after surgery protocol on a gynecologic oncology service. Int J Gynecol Cancer 2019; 29:935-943. [DOI: 10.1136/ijgc-2018-000131] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/26/2019] [Accepted: 03/04/2019] [Indexed: 01/31/2023] Open
Abstract
ObjectiveEnhanced Recovery After Surgery (ERAS) protocols are designed to mitigate the physiologic stress response created by surgery, to decrease the time to resumption of daily activities, and to improve overall recovery. This study aims to investigate postoperative recovery outcomes following gynecologic surgery before and after implementation of an ERAS protocol.MethodsA retrospective chart review was performed of patients undergoing elective laparotomy at a major academic center following implementation of an ERAS protocol (11/4/2014–7/27/2016) with comparison to a historical cohort (6/23/2013–9/30/2014). The primary outcome was length of hospital stay. Secondary outcomes included surgical variables, time to recovery of baseline function, opioid usage, pain scores, and complication rates. Statistical analyses were performed using Wilcoxon rank sum, Fisher’s exact, and chi squared tests.ResultsOne hundred and thirty-three women on the ERAS protocol who underwent elective laparotomy were compared with 121 historical controls. There was no difference in length of stay between cohorts (median 4 days; P = 0.71). ERAS participants had lower intraoperative (45 vs 75 oral morphine equivalents; P < 0.0001) and postoperative (45 vs 154 oral morphine equivalents; P < 0.0001) opioid use. ERAS patients reported lower maximum pain scores in the post-anesthesia care unit (three vs six; P < 0.0001) and on postoperative day 1 (four vs six; P = 0.002). There was no statistically significant difference in complication or readmission rates.ConclusionsERAS protocol implementation was associated with decreased intraoperative and postoperative opioid use and improved pain scores without significant changes in length of stay or complication rates.
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196
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Huepenbecker SP, Cusworth SE, Kuroki LM, Lu P, Samen CD, Woolfolk C, Deterding R, Wan L, Helsten DL, Bottros M, Mutch DG, Powell MA, Massad LS, Thaker PH. Continuous epidural infusion in gynecologic oncology patients undergoing exploratory laparotomy: The new standard for decreased postoperative pain and opioid use. Gynecol Oncol 2019; 153:356-361. [DOI: 10.1016/j.ygyno.2019.02.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/12/2019] [Accepted: 02/19/2019] [Indexed: 02/07/2023]
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197
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Enhanced Recovery after Surgery Pathway for Microsurgical Breast Reconstruction: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2019; 143:655-666. [PMID: 30589825 DOI: 10.1097/prs.0000000000005300] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The enhanced recovery after surgery pathway was introduced in 1997 as a multimodal approach to reduce preventable postoperative harm and shorten hospital length of stay. However, there is yet no widely accepted enhanced recovery after surgery protocol for microsurgical breast reconstruction. The authors conducted a systematic review and meta-analysis of the current literature on enhanced recovery after surgery for microsurgical breast reconstruction with regard to postoperative length of stay and morbidity. METHODS The PubMed, Embase, Cochrane, Scopus, and Web of Science databases were searched for all studies published before June of 2016 containing original data on enhanced recovery after surgery in microsurgical breast reconstruction in relation to postoperative length of stay and morbidity. Studies were screened using eligibility criteria. Meta-analysis, odds ratio, and 95 percent confidence interval were used to pool acquired data. RESULTS The initial search identified 86 studies. Two independent screeners identified four original articles with a total of 676 patients. Length of stay was significantly shorter for patients on an enhanced recovery after surgery pathway (mean difference, -1.23; 95 percent CI, -1.50 to -0.96; p < 0.001; I = 0 percent; random effects model). Enhanced recovery was not associated with changes in 30-day postoperative morbidity; specifically, no significant difference was observed in rates of partial flap loss (p = 0.44), total flap loss (p = 0.91), breast hematoma (p = 0.69), donor-site infection (p = 0.53), urinary tract infection (p = 0.29), and pneumonia (p = 0.42). CONCLUSION The authors' review suggests that enhanced recovery after surgery in microsurgical breast reconstruction is associated with a reduced length of stay, and is not associated with increased postoperative morbidity.
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198
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Meyer LA, Shi Q, Lasala J, Iniesta MD, Lin HK, Nick AM, Williams L, Sun C, Wang XS, Lu KH, Ramirez PT. Comparison of patient reported symptom burden on an enhanced recovery after surgery (ERAS) care pathway in patients with ovarian cancer undergoing primary vs. interval tumor reductive surgery. Gynecol Oncol 2019; 152:501-508. [PMID: 30876495 DOI: 10.1016/j.ygyno.2018.10.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/22/2018] [Accepted: 10/30/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To compare symptom burden and functional recovery in women undergoing primary cytoreductive surgery (PCS) or neoadjuvant chemotherapy (NACT) and interval cytoreductive surgery (ICS) within an enhanced recovery after surgery program (ERAS). METHODS Symptom burden was measured using the MD Anderson Symptom Inventory-Ovarian Cancer, a 27-item validated tool that was administered preoperatively, daily while hospitalized, and weekly for 8 weeks after hospital discharge. Mixed-effect modeling was performed. RESULTS 196 patients (71 PCS, 125 ICS) participated. Patients in the PCS group were younger, median age of 59 vs. 63 in ICS group. Median length of stay was 4 days for PCS and 3 days for ICS group. PCS pts had a significantly higher median surgical complexity score (4 vs. 2, p = 0.002), and longer median surgical time (257 min vs. 220 min, p = 0.03). While patients undergoing PCS had significantly different symptom burden profiles prior to surgery compared to those undergoing ICS, there were no significant differences in symptoms in the immediate in-hospital and extended post-hospital discharge period. Irrespective of the timing of surgery in relation to chemotherapy, patients undergoing intermediate or high complexity surgery had more nausea, fatigue, and higher total interference scores compared to patients undergoing low complexity surgery. CONCLUSION Within a center with a standardized, systematic method for patient selection for PCS and a standardized ERAS care pathway, there were not significant differences in surgery-related symptoms related to recovery between patients undergoing PCS or ICS. However, patient-reported symptom burden and symptom interference did meaningfully differentiate based on surgical complexity score.
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Affiliation(s)
- Larissa A Meyer
- The University of Texas MD Anderson Cancer Center, Department of Gynecologic Oncology, Houston, TX, United States of America.
| | - Qiuling Shi
- The University of Texas MD Anderson Cancer Center, Department of Symptoms Research, Houston, TX, United States of America
| | - Javier Lasala
- The University of Texas MD Anderson Cancer Center, Department of Anesthesiology and Perioperative Medicine, Houston, TX, United States of America
| | - Maria D Iniesta
- The University of Texas MD Anderson Cancer Center, Department of Gynecologic Oncology, Houston, TX, United States of America
| | - Huei Kai Lin
- The University of Texas MD Anderson Cancer Center, Department of Symptoms Research, Houston, TX, United States of America
| | - Alpa M Nick
- Tennessee Oncology, Nashville, Tennessee, University of Tennessee Health Sciences Center, Memphis, TN, United States of America
| | - Loretta Williams
- The University of Texas MD Anderson Cancer Center, Department of Symptoms Research, Houston, TX, United States of America
| | - Charlotte Sun
- The University of Texas MD Anderson Cancer Center, Department of Gynecologic Oncology, Houston, TX, United States of America
| | - Xin Shelley Wang
- The University of Texas MD Anderson Cancer Center, Department of Symptoms Research, Houston, TX, United States of America
| | - Karen H Lu
- The University of Texas MD Anderson Cancer Center, Department of Gynecologic Oncology, Houston, TX, United States of America
| | - Pedro T Ramirez
- The University of Texas MD Anderson Cancer Center, Department of Gynecologic Oncology, Houston, TX, United States of America
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Renaud MC, Bélanger L, Lachapelle P, Grégoire J, Sebastianelli A, Plante M. Effectiveness of an Enhanced Recovery After Surgery Program in Gynaecology Oncologic Surgery: A Single-Centre Prospective Cohort Study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:436-442. [DOI: 10.1016/j.jogc.2018.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 05/31/2018] [Indexed: 11/30/2022]
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200
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Jamel S, Tukanova K, Markar SR. The evolution of fast track protocols after oesophagectomy. J Thorac Dis 2019; 11:S675-S684. [PMID: 31080644 DOI: 10.21037/jtd.2018.11.63] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Fast track is a standardised goal directed patient's care pathway that aims to facilitate recovery following surgery. Currently, there are large variations in the fast track protocols used in oesophagectomy due to the complexity of the procedure. The objective of this systematic review is to assess the evolution of fast track protocols following oesophagectomy since its implementation and the resulting effect on postoperative outcomes. Relevant electronic databases were searched for studies assessing the clinical outcome from fast track in oesophagectomy and also those assessing the effects of the individual key components in fast track protocols. The search yielded twenty-three publications regarding fast track implementation in oesophagectomy. A pattern of consistent evolution in fast-track protocols was clearly demonstrated and these have shown variations in the core-identified components across the studies. However, evolution in fast track protocols over time showed, an overall improvement in length of stay, anastomotic leak, pulmonary complications and mortality over time. Thirty publications were included that evaluated specific components of fast track protocols, with an increasing trend towards addressing the nutritional aspect in oesophagectomy care in more recent years. The variations in the key components of fast track protocol of care identify the need for continued assessment and identification for areas of improvement. In the future incremental gains through focused improvements in key components will lend itself to even better postoperative outcomes and patient experience during oesophageal cancer treatment.
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Affiliation(s)
- Sara Jamel
- Department Surgery & Cancer, Imperial College London, London, UK
| | - Karina Tukanova
- Department Surgery & Cancer, Imperial College London, London, UK
| | - Sheraz R Markar
- Department Surgery & Cancer, Imperial College London, London, UK
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