201
|
Wood T, Aarts MA, Okrainec A, Pearsall E, Victor JC, McKenzie M, Rotstein O, McLeod RS. Emergency Room Visits and Readmissions Following Implementation of an Enhanced Recovery After Surgery (iERAS) Program. J Gastrointest Surg 2018; 22:259-266. [PMID: 28916971 DOI: 10.1007/s11605-017-3555-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 08/17/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) guidelines have been widely promoted and supported largely due to several studies showing decreased post-operative complications and length of stay. The objective of this study was to review the emergency room (ER) visits and readmission rates and reasons for both in patients who were part of the Implementation of an Enhanced Recovery After Surgery (iERAS) program for colorectal surgery. METHODS All patients having elective colorectal surgery at 15 academic hospitals were enrolled in the iERAS program. All patients were prospectively followed until 30 days post-discharge. Data were analyzed using descriptive statistics and multivariable analysis. RESULTS A total of 2876 patients (48% female; mean 60 years old) were enrolled. Cancer was the most frequent indication (68.2%) for surgery. Overall, the median length of stay (LOS) was 5 days. Post-discharge, 359 (11.6%) of patients had a visit to the ER not requiring admission. The most common reasons for visiting the ER were surgical site infections (SSI) (34.5%), other wound complications (10.0%), and urinary tract infections (UTI) (8.6%). In addition, a smaller proportion of patients, 260 (8.2%) required readmission. The most common reasons for readmission were ileus and nausea/vomiting (26.1%), intra-abdominal abscess (23.9%), and SSI (11.5%). Patient and disease factors associated with ER visits, on multivariable analysis, included extremes of BMI (RR 1.02, 95%CI 1.01-1.04, p = 0.002), rectal surgery versus colon surgery (RR 1.34, 95%CI 1.14-1.58, p < 0.001), and open operative approach (RR 1.63, 95%CI 1.28-2.09, p < 0.001). Independent factors associated with hospital readmissions included rectal surgery (RR 1.89, 95%CI 1.34-2.77, p < 0.001), formation of a stoma (RR 1.34, 95%CI 1.04-1.74, p = 0.026), and reoperation during first admission (RR 4.60, 95%CI 3.50-6.05, p < 0.001). Length of stay of 5 days or less was not associated with ER visits or readmission (RR 0.99, 95%CI 0.72-1.35 and RR 0.91, 95%CI 0.71-1.18, respectively). CONCLUSION Following colorectal surgery using an ERAS pathway, shortened length of stay is not associated with an increased return to the ER or hospital readmission. The majority of return visits to the hospital are ER visits not requiring readmission and the predominant reason for return are surgical site infections and wound complications.
Collapse
Affiliation(s)
- Trevor Wood
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mary-Anne Aarts
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Allan Okrainec
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, University Health Network, Toronto, Ontario, Canada
| | - Emily Pearsall
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - J Charles Victor
- Institute of Health Policy Management, University of Toronto, Toronto, Ontario, Canada
| | - Marg McKenzie
- Zane Cohen Clinical Research Unit, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Ori Rotstein
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, St. Michaels Hospital, Toronto, Ontario, Canada
| | - Robin S McLeod
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada. .,Institute of Health Policy Management, University of Toronto, Toronto, Ontario, Canada. .,Zane Cohen Clinical Research Unit, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada.
| | | |
Collapse
|
202
|
Perioperative nutrition and enhanced recovery after surgery in gastrointestinal cancer patients. A position paper by the ESSO task force in collaboration with the ERAS society (ERAS coalition). Eur J Surg Oncol 2018; 44:509-514. [PMID: 29398322 DOI: 10.1016/j.ejso.2017.12.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 12/28/2017] [Indexed: 12/15/2022] Open
Abstract
Malnutrition in cancer patients - in both prevalence and degree - depends primarily on tumor stage and site. Preoperative malnutrition in surgical patients is a frequent problem and is associated with prolonged hospital stay, a higher rate of postoperative complications, higher re-admission rates, and a higher incidence of postoperative death. Given the focus on the cancer and its cure, nutrition is often neglected or under-evaluated, and this despite the availability of international guidelines for nutritional care in cancer patients and the evidence that nutritional deterioration negatively affects survival. Inadequate nutritional support for cancer patients should be considered ethically unacceptable; prompt nutritional support must be guaranteed to all cancer patients, as it can have many clinical and economic advantages. Patients undergoing multimodal oncological care are at particular risk of progressive nutritional decline, and it is essential to minimize the nutritional/metabolic impact of oncological treatments and to manage each surgical episode within the context of an enhanced recovery pathway. In Europe, enhanced recovery after surgery (ERAS) and routine nutritional assessment are only partially implemented because of insufficient awareness among health professionals of nutritional problems, a lack of structured collaboration between surgeons and clinical nutrition specialists, old dogmas, and the absence of dedicated resources. Collaboration between opinion leaders dedicated to ERAS from both the European Society of Surgical Oncology (ESSO) and the ERAS Society was born with the aim of promoting nutritional assessment and perioperative nutrition with and without an enhanced recovery program. The goal will be to improve awareness in the surgical oncology community and at institutional level to modify current clinical practice and identify optimal treatment options.
Collapse
|
203
|
Kumar R, Donahue JM. Editorial for economic impact of an enhanced recovery pathway for lung resection. J Thorac Dis 2018; 10:7-9. [PMID: 29600009 DOI: 10.21037/jtd.2017.12.73] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Rajat Kumar
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - James M Donahue
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| |
Collapse
|
204
|
Ommundsen N, Wyller TB, Nesbakken A, Bakka AO, Jordhøy MS, Skovlund E, Rostoft S. Preoperative geriatric assessment and tailored interventions in frail older patients with colorectal cancer: a randomized controlled trial. Colorectal Dis 2018. [PMID: 28649755 DOI: 10.1111/codi.13785] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Colorectal cancer (CRC) is prevalent in the older population, and surgery is the mainstay of curative treatment. A preoperative geriatric assessment (GA) can identify frail older patients at risk for developing postoperative complications. In this randomized controlled trial we wanted to investigate whether tailored interventions based on a preoperative GA could reduce the frequency of postoperative complications in frail patients operated on for CRC. METHOD Patients > 65 years scheduled for elective CRC surgery and fulfilling predefined criteria for frailty were randomized to either a preoperative GA followed by a tailored intervention or care as usual. The primary end-point was Clavien-Dindo Grade II-V postoperative complications. Secondary end-points included complications of any grade, reoperation, length of stay, readmission and survival. RESULTS One hundred and twenty-two patients with a mean age of 78.6 years were randomized. We found no statistically significant differences between the intervention group and the control group for Grade II-V complications (68% vs 75%, P = 0.43), reoperation (19% vs 11%, P = 0.24), length of stay (8 days in both groups), readmission (16% vs 6%, P = 0.12) or 30-day survival (4% vs 5%, P = 0.79). Grade I-V complications occurred in 76% of patients in the intervention group compared with 87% in the control group (P = 0.10). In secondary analyses adjusting for prespecified prognostic factors, there was a statistically significant difference in favour of the intervention for reducing the total number of Grade I-V complications (P = 0.05). CONCLUSION A preoperative GA and tailored interventions did not reduce the rate of Grade II-V complications, reoperations, readmission or mortality in frail older patients electively operated on for CRC.
Collapse
Affiliation(s)
- N Ommundsen
- Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway.,Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - T B Wyller
- Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway.,Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - A Nesbakken
- Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway.,Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway.,K.G. Jebsen Colorectal Cancer Research Centre, Oslo University Hospital, Oslo, Norway
| | - A O Bakka
- Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway.,Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway
| | - M S Jordhøy
- Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway.,The Cancer Unit, Innlandet Hospital Trust, Hamar, Norway
| | - E Skovlund
- Department of Public Health and Nursing, NTNU, Norway
| | - S Rostoft
- Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway.,Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
205
|
Byrnes A, Banks M, Mudge A, Young A, Bauer J. Enhanced Recovery After Surgery as an auditing framework for identifying improvements to perioperative nutrition care of older surgical patients. Eur J Clin Nutr 2017; 72:913-916. [DOI: 10.1038/s41430-017-0049-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 10/19/2017] [Accepted: 10/30/2017] [Indexed: 11/09/2022]
|
206
|
Lambaudie E, de Nonneville A, Brun C, Laplane C, N'Guyen Duong L, Boher JM, Jauffret C, Blache G, Knight S, Cini E, Houvenaeghel G, Blache JL. Enhanced recovery after surgery program in Gynaecologic Oncological surgery in a minimally invasive techniques expert center. BMC Surg 2017; 17:136. [PMID: 29282059 PMCID: PMC5745717 DOI: 10.1186/s12893-017-0332-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/12/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Enhanced Recovery After Surgery Programs (ERP) includes multimodal approaches of perioperative patient's clinical pathways designed to achieve early recovery after surgery and a decreased length of hospital stay (LOS). METHODS This observational study evaluated the implementation of ERP in gynaecologic oncological surgery in a minimally invasive techniques (MIT) expert center with more than 85% of procedures done with MIT. We compared a prospective cohort of 100 patients involved in ERP between December 2015 and June 2016 to a 100 patients control group, without ERP, previously managed in the same center between April 2015 and November 2015. All the included patients were referred for hysterectomy and/or pelvic or para-aortic lymphadenectomy for gynaecological cancer. The primary objective was to achieve a significant decrease of median LOS in the ERP group. Secondary objectives were decreases in proportion of patients achieving target LOS (2 days), morbidity and readmissions. RESULTS Except a disparity in oncological indications with a higher proportion of endometrial cancer in the group with ERP vs. the group without ERP (42% vs. 22%; p = 0.003), there were no differences in patient's characteristics and surgical procedures. ERP were associated with decreases of median LOS (2.5 [0 to 11] days vs. 3 [1 to 14] days; p = 0.002) and proportion of discharged patient at target LOS (45% vs. 24%; p = 0.002). Morbidities occurred in 25% and 26% in the groups with and without ERP and readmission rates were respectively of 6% and 8%, without any significant difference. CONCLUSION ERP in gynaecologic oncological surgery is associated with a decrease of LOS without increases of morbidity or readmission rates, even in a center with a high proportion of MIT. Although it is already widely accepted that MIT improves early recovery, our study shows that the addition of ERP's clinical pathways improve surgical outcomes and patient care management.
Collapse
Affiliation(s)
- Eric Lambaudie
- Département de Chirurgie Oncologique 2, Institut Paoli Calmettes et CRCM, 232 Bd. Sainte-Marguerite, 13009, Marseille, France.
| | - Alexandre de Nonneville
- Aix-Marseille Univ, CNRS, INSERM, Institut Paoli-Calmettes, Department of Medical Oncology, CRCM, Marseille, France
| | - Clément Brun
- Département d'Anesthésie Réanimation, Institut Paoli Calmettes et CRCM, Marseille, France
| | - Charlotte Laplane
- Département de Chirurgie Oncologique 2, Institut Paoli Calmettes et CRCM, 232 Bd. Sainte-Marguerite, 13009, Marseille, France
| | - Lam N'Guyen Duong
- Département d'Anesthésie Réanimation, Institut Paoli Calmettes et CRCM, Marseille, France
| | - Jean-Marie Boher
- Aix-Marseille Univ, INSERM IRD, SESSTIM, Institut Paoli-Calmettes, Department of Clinical Research and Investigation, Biostatistics and Methodology Unit, Marseille, France
| | - Camille Jauffret
- Département de Chirurgie Oncologique 2, Institut Paoli Calmettes et CRCM, 232 Bd. Sainte-Marguerite, 13009, Marseille, France
| | - Guillaume Blache
- Département de Chirurgie Oncologique 2, Institut Paoli Calmettes et CRCM, 232 Bd. Sainte-Marguerite, 13009, Marseille, France
| | - Sophie Knight
- Département de Chirurgie Oncologique 2, Institut Paoli Calmettes et CRCM, 232 Bd. Sainte-Marguerite, 13009, Marseille, France
| | - Eric Cini
- Département de Chirurgie Oncologique 2, Institut Paoli Calmettes et CRCM, 232 Bd. Sainte-Marguerite, 13009, Marseille, France
| | - Gilles Houvenaeghel
- Département de Chirurgie Oncologique 2, Institut Paoli Calmettes et CRCM, 232 Bd. Sainte-Marguerite, 13009, Marseille, France
| | - Jean-Louis Blache
- Département d'Anesthésie Réanimation, Institut Paoli Calmettes et CRCM, Marseille, France
| |
Collapse
|
207
|
|
208
|
Strickland LH, Kelly L, Hamilton TW, Murray DW, Pandit HG, Jenkinson C. Early recovery following lower limb arthroplasty: Qualitative interviews with patients undergoing elective hip and knee replacement surgery. Initial phase in the development of a patient-reported outcome measure. J Clin Nurs 2017; 27:2598-2608. [PMID: 28960546 DOI: 10.1111/jocn.14086] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2017] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To explore the patients' perspective of surgery and early recovery when undergoing lower limb (hip or knee) arthroplasty. BACKGROUND Lower limb arthroplasty is a commonly performed procedure for symptomatic arthritis, which has not responded to conservative medical treatment. Each patient's perspective of the surgical process and early recovery period impacts on their quality of life. DESIGN Open, semistructured qualitative interviews were used to allow for a deeper understanding of the patient perspective when undergoing a hip or knee arthroplasty. METHODS Following ethical approval, 30 patients were interviewed between August and November 2016 during the perioperative period while undergoing an elective hip or knee arthroplasty (n = 30). The interviews were performed between the day of surgery and a nine-week postoperative clinic appointment. Data were analysed using an in-depth narrative thematic analysis method. NVivo qualitative data analysis software was used. RESULTS Seven main themes evolved from the interviews: "improving function and mobility", "pain", "experiences of health care", "support from others", "involvement and understanding of care decisions", "behaviour and coping" and "fatigue and sleeping". CONCLUSIONS The early postoperative recovery period is of vital importance to all surgical patients. This is no different for the orthopaedic patient. However, identifying key self-reported areas of importance from patients can guide clinical focus for healthcare professionals. RELEVANCE TO CLINICAL PRACTICE To have specific patient-reported information regarding key areas of importance during the perioperative phase is invaluable when caring for the orthopaedic surgical patient. It gives insight and understanding in to this increasing population group. This study has also served as a starting point in the development of a questionnaire which could be used to assess interventions in the lower limb arthroplasty population. These results will influence both items and content of the questionnaire.
Collapse
Affiliation(s)
- Louise H Strickland
- Oxford Orthopaedic Engineering Centre (OOEC), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, University of Oxford, Oxford, UK
| | - Laura Kelly
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Thomas W Hamilton
- Oxford Orthopaedic Engineering Centre (OOEC), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, University of Oxford, Oxford, UK
| | - David W Murray
- Oxford Orthopaedic Engineering Centre (OOEC), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, University of Oxford, Oxford, UK
| | - Hemant G Pandit
- Oxford Orthopaedic Engineering Centre (OOEC), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, University of Oxford, Oxford, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), Chapel Allerton Hospital, University of Leeds, Leeds, UK
| | - Crispin Jenkinson
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| |
Collapse
|
209
|
Li S, Zhou K, Che G, Yang M, Su J, Shen C, Yu P. Enhanced recovery programs in lung cancer surgery: systematic review and meta-analysis of randomized controlled trials. Cancer Manag Res 2017; 9:657-670. [PMID: 29180901 PMCID: PMC5695257 DOI: 10.2147/cmar.s150500] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background Enhanced recovery after surgery (ERAS) program is an effective evidence-based multidisciplinary protocol of perioperative care, but its roles in thoracic surgery remain unclear. This systematic review of randomized controlled trials (RCTs) aims to investigate the efficacy and safety of the ERAS programs for lung cancer surgery. Materials and methods We searched the PubMed and EMBASE databases to identify the RCTs that implemented an ERAS program encompassing more than four care elements within at least two phases of perioperative care in lung cancer surgery. The heterogeneity levels between studies were estimated by the Cochrane Collaborations. A qualitative review was performed if considerable heterogeneity was revealed. Relative risk (RR) and weighted mean difference served as the summarized statistics for the meta-analyses. Additional analyses were also performed to perceive potential bias risks. Results A total of seven RCTs enrolling 486 patients were included. The meta-analysis indicated that the ERAS group patients had significantly lower morbidity rates (RR=0.64; p<0.001), especially the rates of pulmonary (RR=0.43; p<0.001) and surgical complications (RR=0.46; p=0.010), than those of control group patients. No significant reduction was found in the in-hospital mortality (RR=0.70; p=0.58) or cardiovascular complications (RR=1.46; p=0.25). In the qualitative review, most of the evidence reported significantly shortened length of hospital and intensive care unit stay and decreased hospitalization costs in the ERAS-treated patients. No significant publication bias was detected in the meta-analyses. Conclusion Our review demonstrates that the implementation of an ERAS program for lung cancer surgery can effectively accelerate postoperative recovery and save hospitalization costs without compromising patients’ safety. A worldwide consensus guideline is urgently required to standardize the ERAS protocols for elective lung resections in the future.
Collapse
Affiliation(s)
| | | | | | | | - Jianhua Su
- Department of Rehabilitation, Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | | | - Pengming Yu
- Department of Rehabilitation, Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
210
|
Nagra NS, Hamilton TW, Strickland L, Murray DW, Pandit H. Enhanced recovery programmes for lower limb arthroplasty in the UK. Ann R Coll Surg Engl 2017; 99:631-636. [PMID: 28768427 PMCID: PMC5696927 DOI: 10.1308/rcsann.2017.0124] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2017] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Enhanced recovery programmes (ERPs) reduce patient morbidity and mortality, and provide significant cost savings by reducing length of stay. Currently, no uniform ERP guidelines exist for lower limb arthroplasty in the UK. The aim of this study was to identify variations in ERPs and determine adherence to local policy. METHODS Hospitals offering elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) (23 and 22 centres respectively) contributed details of their ERPs, and performed an audit (15 patients per centre) to assess compliance. RESULTS Contrasting content and detail of ERPs was noted across centres. Adherence to ERPs varied significantly (40-100% for TKA, 17-94% for THA). Analysis identified perioperative use of dexamethasone, tranexamic acid and early mobilisation for TKA, and procedures performed in teaching hospitals for THA as being associated with a reduced length of stay. CONCLUSIONS This study highlights variation in practice and poor compliance with local ERPs. Given the proven benefits of ERPs, evidence-based guidelines in the context of local skillsets should be established to optimise the patient care pathway.
Collapse
Affiliation(s)
- N S Nagra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| | - T W Hamilton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| | - L Strickland
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| | - D W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| | - H Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| |
Collapse
|
211
|
Lin T, Li K, Liu H, Xue X, Xu N, Wei Y, Chen Z, Zhou X, Qi L, He W, Tong S, Jin F, Liu X, Wei Q, Han P, Gou X, He W, Zhang X, Yang G, Shen Z, Xu T, Xie X, Xue W, Cao M, Yang J, Hu J, Chen F, Li P, Li G, Xu T, Tian Y, Wang W, Song D, Shi L, Yang X, Yang Y, Shi B, Zhu Y, Liu X, Xing J, Wu Z, Zhang K, Li W, Liang C, Yang C, Li W, Qi J, Xu C, Xu W, Zhou L, Cai L, Xu E, Cai W, Weng M, Su Y, Zhou F, Jiang L, Liu Z, Chen Q, Pan T, Liu B, Zhou Y, Gao X, Qiu J, Situ J, Hu C, Chen S, Zheng Y, Huang J. Enhanced recovery after surgery for radical cystectomy with ileal urinary diversion: a multi-institutional, randomized, controlled trial from the Chinese bladder cancer consortium. World J Urol 2017; 36:41-50. [PMID: 29080948 DOI: 10.1007/s00345-017-2108-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 10/20/2017] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) has played an important role in recovery management for radical cystectomy with ileal urinary diversion (RC-IUD). This study is to evaluate ERAS compared with the conventional recovery after surgery (CRAS) for RC-IUD. METHODS From October 2014 and July 2016, bladder cancer patients scheduled for curative treatment from 25 centers of Chinese Bladder Cancer Consortium were randomly assigned to either ERAS or CRAS group. Primary endpoint was the 30-day complication rate. Secondary endpoints included recovery of fluid and regular diet, flatus, bowel movement, ambulation, and length of stay (LOS) postoperatively. Follow-up period was 30-day postoperatively. RESULTS There were 144 ERAS and 145 CRAS patients. Postoperative complications occurred in 25.7 and 30.3% of the ERAS and CRAS patients with 55 complications in each group, respectively (p = 0.40). There was no significant difference between groups in major complications (p = 0.82), or type of complications (p = 0.99). The ERAS group had faster recovery of bowel movements (median 88 versus 100 h, p = 0.01), fluid diet tolerance (68 versus 96 h, p < 0.001), regular diet tolerance (125 versus 168 h, p = 0.004), and ambulation (64 versus 72 h, p = 0.047) than the CRAS group, but similar time to flatus and LOS. CONCLUSIONS ERAS did not increase 30-day complications compared with CRAS after RC. ERAS may be better than CRAS in terms of bowel movement, tolerance of fluid and regular diet, and ambulation.
Collapse
Affiliation(s)
- Tianxin Lin
- Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 W Yanjiang Road, Yuexiu District, Guangzhou, 510120, Guangdong, China
| | - Kaiwen Li
- Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 W Yanjiang Road, Yuexiu District, Guangzhou, 510120, Guangdong, China
| | - Hao Liu
- Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 W Yanjiang Road, Yuexiu District, Guangzhou, 510120, Guangdong, China
| | - Xueyi Xue
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Ning Xu
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yong Wei
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Zhiwen Chen
- Department of Urology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Xiaozhou Zhou
- Department of Urology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Lin Qi
- Department of Urology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Wei He
- Department of Urology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Shiyu Tong
- Department of Urology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Fengshuo Jin
- Department of Urology, The Third Affiliated Hospital, Third Military Medical University, Chongqing, China
| | - Xudong Liu
- Department of Urology, The Third Affiliated Hospital, Third Military Medical University, Chongqing, China
| | - Qiang Wei
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ping Han
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xin Gou
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Weiyang He
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xu Zhang
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Guoqiang Yang
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Zhoujun Shen
- Department of Urology, Ruijin Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Tianyuan Xu
- Department of Urology, Ruijin Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Xin Xie
- Department of Urology, Ruijin Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Wei Xue
- Department of Urology, Renji Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Ming Cao
- Department of Urology, Renji Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Jin Yang
- Department of Urology, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Jianyun Hu
- Department of Urology, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Fubao Chen
- Department of Urology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Peijun Li
- Department of Urology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Guangyong Li
- Department of Urology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Tong Xu
- Department of Urology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Ye Tian
- Department of Urology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wenying Wang
- Department of Urology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Dongkui Song
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Lei Shi
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Xiaoming Yang
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yang Yang
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Benkang Shi
- Department of Urology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Yaofeng Zhu
- Department of Urology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Xigao Liu
- Department of Urology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Jinchun Xing
- Department of Urology, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian, China
| | - Zhun Wu
- Department of Urology, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian, China
| | - Kaiyan Zhang
- Department of Urology, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian, China
| | - Wei Li
- Department of Urology, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian, China
| | - Chaozhao Liang
- Department of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Cheng Yang
- Department of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Wei Li
- Department of Urology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jinchun Qi
- Department of Urology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Chuanliang Xu
- Department of Urology, Shanghai Changhai Hospital of Second Military Medical University, Shanghai, China
| | - Weidong Xu
- Department of Urology, Shanghai Changhai Hospital of Second Military Medical University, Shanghai, China
| | - Liqun Zhou
- Department of Urology, Peking University First Hospital, Beijing, China
| | - Lin Cai
- Department of Urology, Peking University First Hospital, Beijing, China
| | - En'ci Xu
- Department of Urology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Weizhong Cai
- Department of Urology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Minggao Weng
- Department of Urology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Yiming Su
- Department of Urology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Fangjian Zhou
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Lijuan Jiang
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Zhuowei Liu
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Qiuhong Chen
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Tiejun Pan
- Department of Urology, Wuhan General Hospital of Guangzhou Military Command, Wuhan, Hubei, China
| | - Bo Liu
- Department of Urology, Wuhan General Hospital of Guangzhou Military Command, Wuhan, Hubei, China
| | - Yu Zhou
- Department of Urology, Wuhan General Hospital of Guangzhou Military Command, Wuhan, Hubei, China
| | - Xin Gao
- Department of Urology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jianguang Qiu
- Department of Urology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jie Situ
- Department of Urology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Cheng Hu
- Department of Urology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Shan Chen
- Department of Urology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yupeng Zheng
- Department of Urology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Jian Huang
- Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 W Yanjiang Road, Yuexiu District, Guangzhou, 510120, Guangdong, China. .,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
| |
Collapse
|
212
|
Chen CCH, Li HC, Liang JT, Lai IR, Purnomo JDT, Yang YT, Lin BR, Huang J, Yang CY, Tien YW, Chen CN, Lin MT, Huang GH, Inouye SK. Effect of a Modified Hospital Elder Life Program on Delirium and Length of Hospital Stay in Patients Undergoing Abdominal Surgery: A Cluster Randomized Clinical Trial. JAMA Surg 2017; 152:827-834. [PMID: 28538964 DOI: 10.1001/jamasurg.2017.1083] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Older patients undergoing abdominal surgery commonly experience preventable delirium, which extends their hospital length of stay (LOS). Objective To examine whether a modified Hospital Elder Life Program (mHELP) reduces incident delirium and LOS in older patients undergoing abdominal surgery. Design, Setting, and Participants This cluster randomized clinical trial of 577 eligible patients enrolled 377 older patients (≥65 years of age) undergoing gastrectomy, pancreaticoduodenectomy, and colectomy at a 2000-bed urban medical center in Taipei, Taiwan, from August 1, 2009, through October 31, 2012. Consecutive older patients scheduled for elective abdominal surgery with expected LOS longer than 6 days were enrolled, with a recruitment rate of 65.3%. Participants were cluster randomized by room to receive the mHELP or usual care. Interventions The intervention (implemented by an mHELP nurse) consisted of 3 protocols administered daily: orienting communication, oral and nutritional assistance, and early mobilization. Intervention group participants received all 3 mHELP protocols postoperatively, in addition to usual care, as soon as they arrived in the inpatient ward and until hospital discharge. Adherence to protocols was tracked daily. Main Outcomes and Measures Presence of delirium was assessed daily by 2 trained nurses who were masked to intervention status by using the Confusion Assessment Method. Data on LOS were abstracted from the medical record. Results Of 577 eligible patients, 377 (65.3%) were enrolled and randomly assigned to the mHELP (n = 197; mean [SD] age, 74.3 [5.8] years; 111 [56.4%] male) or control (n = 180; mean [SD] age, 74.8 [6.0] years; 103 [57.2%] male) group. Postoperative delirium occurred in 13 of 196 (6.6%) mHELP participants vs 27 of 179 (15.1%) control individuals, representing a relative risk of 0.44 in the mHELP group (95% CI, 0.23-0.83; P = .008). Intervention group participants received the mHELP for a median of 7 days (interquartile range, 6-10 days) and had a shorter median LOS (12.0 days) than control participants (14.0 days) (P = .04). Conclusions and Relevance For older patients undergoing abdominal surgery who received the mHELP, the odds of delirium were reduced by 56% and LOS was reduced by 2 days. Our findings support using the mHELP to advance postoperative care for older patients undergoing major abdominal surgery. Trial Registration clinicaltrials.gov Identifier: NCT01045330.
Collapse
Affiliation(s)
- Cheryl Chia-Hui Chen
- Department of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsiu-Ching Li
- Department of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Nursing, Sijhih Cathy General Hospital, New Taipei City, Taiwan
| | - Jin-Tung Liang
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - I-Rue Lai
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Yi-Ting Yang
- Taiwan Center for Disease Control, Taipei, Taiwan
| | - Been-Ren Lin
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - John Huang
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Yao Yang
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Wen Tien
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chiung-Nien Chen
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Tsan Lin
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Guan-Hua Huang
- Institute of Statistics, National Chiao Tung University, Hsinchu, Taiwan
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Institute for Aging Research, Hebrew Senior-Life, Boston, Massachusetts
| |
Collapse
|
213
|
Leeds IL, Alimi Y, Hobson DR, Efron JE, Wick EC, Haut ER, Johnston FM. Racial and Socioeconomic Differences Manifest in Process Measure Adherence for Enhanced Recovery After Surgery Pathway. Dis Colon Rectum 2017; 60:1092-1101. [PMID: 28891854 PMCID: PMC5647878 DOI: 10.1097/dcr.0000000000000879] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Adherence to care processes and surgical outcomes varies by population subgroups for the same procedure. Enhanced recovery after surgery pathways are intended to standardize care, but their effect on process adherence and outcomes for population subgroups is unknown. OBJECTIVE This study aims to demonstrate the association between recovery pathway implementation, process measures, and short-term surgical outcomes by population subgroup. DESIGN This study is a pre- and post-quality improvement implementation cohort study. SETTING This study was conducted at a tertiary academic medical center. INTERVENTION A modified colorectal enhanced recovery after surgery pathway was implemented. PATIENTS Patients were included who had elective colon and rectal resections before (2013) and following (2014-2016) recovery pathway implementation. MAIN OUTCOME MEASURE Thirty-day outcomes by race and socioeconomic status were analyzed using a difference-in-difference approach with correlation to process adherence. RESULTS We identified 639 cases (199 preimplementation, 440 postimplementation). In these cases, 75.2% of the patients were white, and 91.7% had a high socioeconomic status. Groups were similar in terms of other preoperative characteristics. Following pathway implementation, median lengths of stay improved in all subgroups (-1.0 days overall, p ≤ 0.001), but with no statistical difference by race or socioeconomic status (p = 0.89 and p = 0.29). Complication rates in both racial and socioeconomic groups were no different (26.4% vs 28.8%, p = 0.73; 27.3% vs 25.0%, p = 0.86) and remained unchanged with implementation (p = 0.93, p = 0.84). By race, overall adherence was 31.7% in white patients and 26.5% in nonwhite patients (p = 0.32). Although stratification by socioeconomic status demonstrated decreased overall adherence in the low-status group (31.8% vs 17.1%, p = 0.05), white patients were more likely to have regional pain therapy (57.1% vs 44.1%, p = 0.02) with a similar trend seen with socioeconomic status. LIMITATIONS Data were collected primarily for quality improvement purposes. CONCLUSIONS Differences in outcomes by race and socioeconomic status did not arise following implementation of an enhanced recovery pathway. Differences in process measures by population subgroups highlight differences in care that require further investigation. See Video Abstract at http://links.lww.com/DCR/A386.
Collapse
Affiliation(s)
- Ira L Leeds
- 1 Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland 2 The Johns Hopkins Hospital, Baltimore, Maryland
| | | | | | | | | | | | | |
Collapse
|
214
|
Manso M, Schmelz J, Aloia T. ERAS-Anticipated outcomes and realistic goals. J Surg Oncol 2017; 116:570-577. [DOI: 10.1002/jso.24791] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 07/10/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Maria Manso
- Department of Anesthesia; Hospital Beatriz Ângelo-Luz Saúde; Lisbon Portugal
| | - Jacob Schmelz
- Department of Surgical Oncology; MD Anderson Cancer Center; Houston Texas
- McGovern Medical School at UTHealth; Houston Texas
| | - Thomas Aloia
- Department of Surgical Oncology; MD Anderson Cancer Center; Houston Texas
| |
Collapse
|
215
|
Paci P, Madani A, Lee L, Mata J, Mulder DS, Spicer J, Ferri LE, Feldman LS. Economic Impact of an Enhanced Recovery Pathway for Lung Resection. Ann Thorac Surg 2017; 104:950-957. [PMID: 28778343 DOI: 10.1016/j.athoracsur.2017.05.085] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 05/24/2017] [Accepted: 05/30/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Multimodal enhanced recovery pathways (ERP) improve clinical outcomes and hospital length of stay for patients undergoing lung resection. However, data supporting their economic impact is lacking. This study evaluated the effect of an ERP on costs of lung resection. METHODS Adult patients undergoing elective lung resection from August 2011 to August 2013 at a single university-affiliated institution were prospectively recruited. Pneumonectomies and extended resections were excluded. Beginning in September 2012, patients were enrolled in a multimodal ERP. Outcomes were recorded until 90 days after discharge. Total costs from institutional, health care system, and societal perspectives are reported in 2016 Canadian dollars, with uncertainty expressed as 95% confidence intervals derived using bootstrapped estimates (10,000 repetitions). RESULTS The study included 133 patients (conventional care: n = 58; ERP: n = 75). Patient and operative characteristics were similar between the groups. The ERP group had shorter median (interquartile range) length of stay (4 [3 to 6] days vs 6 [4 to 9] days, p < 0.01), decreased total complications (32% vs 52%, p = 0.02), and decreased pulmonary complications (16% vs 34%, p = 0.01), with no difference in readmissions. After discharge, there was a trend towards less caregiver burden for the ERP group (53 ± 90 hours vs 101 ± 252 hours, p = 0.17). Overall societal costs were lower in the ERP group (mean difference per patient: -$4,396 Canadian; 95% confidence interval -$8,674 to $618 Canadian). CONCLUSIONS A multidisciplinary ERP is associated with improved clinical outcomes and societal cost savings compared with conventional perioperative management for elective lung resection.
Collapse
Affiliation(s)
- Philippe Paci
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, Quebec, Canada
| | - Amin Madani
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, Quebec, Canada
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, Quebec, Canada
| | - Juan Mata
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, Quebec, Canada
| | - David S Mulder
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Division of Thoracic Surgery, McGill University, Montreal, Quebec, Canada
| | - Jonathan Spicer
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Division of Thoracic Surgery, McGill University, Montreal, Quebec, Canada
| | - Lorenzo E Ferri
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Division of Thoracic Surgery, McGill University, Montreal, Quebec, Canada
| | - Liane S Feldman
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, Quebec, Canada.
| |
Collapse
|
216
|
Abrahamsson A, Oras J, Snygg J, Block L. Perioperative COX-2 inhibitors may increase the risk of post-operative acute kidney injury. Acta Anaesthesiol Scand 2017; 61:714-721. [PMID: 28614595 DOI: 10.1111/aas.12912] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 04/27/2017] [Accepted: 05/05/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND In enhanced recovery protocols (ERP), a restrictive fluid regimen is proposed. Patients who undergo major surgery have an increased risk of post-operative acute kidney injury (AKI). This combination may pose difficulties when ERP is used for patients undergoing major surgery. The aim of this study was to evaluate whether patients undergoing pancreatic surgery and treated with a restrictive fluid regimen are at greater risk of post-operative AKI. Furthermore, if there was an increased risk of AKI, we aimed to identify its cause. METHODS We reviewed the medical records of patients who underwent pancreatic surgery during 2014 (preERP, n = 58) and 2015 (ERP, n = 65). Fluid balance, the administration of cyclooxygenase-2 inhibitors, creatinine levels and mean arterial pressure were recorded. The Kidney Disease: Improving Global Outcomes criteria were used to define AKI. RESULTS The incidence of AKI was higher in the ERP group than in the PreERP group (12.5% vs. 1.8%, respectively, P = 0.035). The increased incidence of AKI could not be explained by differences in comorbidities, age, pre-operative creatinine or perioperative hypotension. Administration of coxibs was higher in the ERP group and was associated with increased incidence of post-operative AKI (P = 0.018). The combination of coxibs and restrictive fluid regimen seems particularly harmful. CONCLUSION Pancreatic surgery with a restrictive fluid regimen carries an increased risk of post-operative AKI if patients are also treated with cyclooxygenase-2 inhibitors. It is therefore suggested that in protocols including a restrictive fluid regimen for open pancreatic surgery, the use of cyclooxygenase-2 inhibitors should be avoided.
Collapse
Affiliation(s)
- A. Abrahamsson
- Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
- Department of Anaesthesiology and Intensive Care; Sahlgrenska University Hospital; Gothenburg Sweden
| | - J. Oras
- Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
- Department of Anaesthesiology and Intensive Care; Sahlgrenska University Hospital; Gothenburg Sweden
| | - J. Snygg
- Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
- Department of Anaesthesiology and Intensive Care; Sahlgrenska University Hospital; Gothenburg Sweden
| | - L. Block
- Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
- Department of Anaesthesiology and Intensive Care; Sahlgrenska University Hospital; Gothenburg Sweden
| |
Collapse
|
217
|
Liu VX, Rosas E, Hwang J, Cain E, Foss-Durant A, Clopp M, Huang M, Lee DC, Mustille A, Kipnis P, Parodi S. Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System. JAMA Surg 2017; 152:e171032. [PMID: 28492816 DOI: 10.1001/jamasurg.2017.1032] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Novel approaches to perioperative surgical care focus on optimizing nutrition, mobility, and pain management to minimize adverse events after surgical procedures. Objective To evaluate the outcomes of an enhanced recovery after surgery (ERAS) program among 2 target populations: patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair. Design, Setting, and Participants A pre-post difference-in-differences study before and after ERAS implementation in the target populations compared with contemporaneous surgical comparator groups (patients undergoing elective gastrointestinal surgery and emergency orthopedic surgery). Implementation began in February and March 2014 and concluded by the end of 2014 at 20 medical centers within the Kaiser Permanente Northern California integrated health care delivery system. Exposures A multifaceted ERAS program designed with a particular focus on perioperative pain management, mobility, nutrition, and patient engagement. Main Outcomes and Measures The primary outcome was hospital length of stay. Secondary outcomes included hospital mortality, home discharge, 30-day readmission rates, and complication rates. Results The study included a total of 3768 patients undergoing elective colorectal resection (mean [SD] age, 62.7 [14.1] years; 1812 [48.1%] male) and 5002 patients undergoing emergency hip fracture repair (mean [SD] age, 79.5 [11.8] years; 1586 [31.7%] male). Comparator surgical patients included 5556 patients undergoing elective gastrointestinal surgery and 1523 patients undergoing emergency orthopedic surgery. Most process metrics had significantly greater changes in the ERAS target populations after implementation compared with comparator surgical populations, including those for ambulation, nutrition, and opioid use. Hospital length of stay and postoperative complication rates were also significantly lower among ERAS target populations after implementation. The rate ratios for postoperative complications were 0.68 (95% CI, 0.46-0.99; P = .04) for patients undergoing colorectal resection and 0.67 (95% CI, 0.45-0.99, P = .05) for patients with hip fracture. Among patients undergoing colorectal resection, ERAS implementation was associated with decreased rates of hospital mortality (0.17; 95% CI, 0.03-0.86; P = .03), whereas among patients with hip fracture, implementation was associated with increased rates of home discharge (1.24; 95% CI, 1.06-1.44; P = .007). Conclusions and Relevance Multicenter implementation of an ERAS program among patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair successfully altered processes of care and was associated with significant absolute and relative decreases in hospital length of stay and postoperative complication rates. Rapid, large-scale implementation of a multidisciplinary ERAS program is feasible and effective in improving surgical outcomes.
Collapse
Affiliation(s)
- Vincent X Liu
- Division of Research, Kaiser Permanente, Oakland, California2The Permanente Medical Group, Oakland, California
| | - Efren Rosas
- The Permanente Medical Group, Oakland, California
| | - Judith Hwang
- The Permanente Medical Group, Oakland, California
| | - Eric Cain
- The Permanente Medical Group, Oakland, California
| | - Anne Foss-Durant
- Kaiser Foundation Hospitals and Health Plan, Oakland, California
| | - Molly Clopp
- Kaiser Foundation Hospitals and Health Plan, Oakland, California
| | | | | | | | - Patricia Kipnis
- Kaiser Foundation Hospitals and Health Plan, Oakland, California
| | | |
Collapse
|
218
|
Is Trainee Participation Really Associated With Adverse Outcomes in Emergency General Surgery? Ann Surg 2017; 266:e35-e36. [PMID: 28692564 DOI: 10.1097/sla.0000000000001376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
219
|
Burch J, Fecher-Jones I, Balfour A, Fitt I, Carter F. What is an enhanced recovery nurse: a literature review and audit. ACTA ACUST UNITED AC 2017. [DOI: 10.12968/gasn.2017.15.6.43] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Jennie Burch
- Head of Gastrointestinal Nursing Education, St Mark's Hospital, London
| | - Imogen Fecher-Jones
- Perioperative Medicine Project Manager, University Hospital Southampton NHS Foundation Trust
| | - Angie Balfour
- Enhanced Recovery Nurse Specialist, Western General Hospital, NHS Lothian, Edinburgh
| | - Irene Fitt
- Enhanced Recovery Nurse, Luton and Dunstable University Foundation Trust Hospital
| | - Fiona Carter
- ERAS UK Manager, South West Surgical Training Network
| |
Collapse
|
220
|
Michard F, Giglio M, Brienza N. Perioperative goal-directed therapy with uncalibrated pulse contour methods: impact on fluid management and postoperative outcome. Br J Anaesth 2017; 119:22-30. [DOI: 10.1093/bja/aex138] [Citation(s) in RCA: 175] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
|
221
|
Michard F, Gan T, Kehlet H. Digital innovations and emerging technologies for enhanced recovery programmes. Br J Anaesth 2017; 119:31-39. [DOI: 10.1093/bja/aex140] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
|
222
|
Li L, Jin J, Min S, Liu D, Liu L. Compliance with the enhanced recovery after surgery protocol and prognosis after colorectal cancer surgery: A prospective cohort study. Oncotarget 2017; 8:53531-53541. [PMID: 28881829 PMCID: PMC5581128 DOI: 10.18632/oncotarget.18602] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 05/23/2017] [Indexed: 12/13/2022] Open
Abstract
We explored the effects of different levels of compliance with an enhanced recovery after surgery (ERAS) protocol on the short-term prognosis of patients who underwent colorectal cancer surgery. We conducted a single-center prospective cohort study in which 254 patients who received surgical treatment in a teaching tertiary care hospital were enrolled from March 2016 to November 2016. The patients were divided into four groups (I, II, III, and IV) based on individual compliance rates; the corresponding range of compliance rates was 0-60%, 60-70%, 70-80%, and 80-100%, and the number of patients in each group was 66, 63, 53, and 72, respectively. In the four groups from low to high compliance with ERAS (group I, II, III, and IV), the incidence of surgical site infections was 24.2%, 20.6%, 9.4%, and 6.9% (P < 0.05); the overall incidence of postoperative complications was 41.3%, 33.3%, 26.4%, and 16.7% (P < 0.05); the median length of postoperative hospital stay (in days) was 12.5, 10, 9, 8 (P < 0.05); and the median total hospital cost (Chinese Yuan) was 71,733, 73,632, 65,861, and 63,289 (P < 0.05), respectively. These results suggest that higher compliance with the ERAS protocol was associated with a lower incidence of surgical site infections, lower overall postoperative complication rate, shorter postoperative hospital stays, and lower total hospital costs.
Collapse
Affiliation(s)
- Liang Li
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Juying Jin
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Su Min
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dan Liu
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ling Liu
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
223
|
Enhanced recovery pathway versus standard care in patients undergoing video-assisted thoracoscopic lobectomy. J Thorac Cardiovasc Surg 2017; 154:2084-2090. [PMID: 28728783 DOI: 10.1016/j.jtcvs.2017.06.037] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/09/2017] [Accepted: 06/16/2017] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The objective of this study was to compare outcomes after video-assisted thoracoscopic lobectomy or segmentectomy before and after introduction of an enhanced recovery program. METHODS Data from 600 patients undergoing video-assisted lobectomy or segmentectomy between April 2014 and January 2017 were analyzed. A comparative analysis was performed between patients undergoing operation before (365 patients) and after (235 patients) the start of the enhanced recovery program. The incidence of cardiopulmonary complications and 30-day and 90-day mortality, postoperative length of stay, and 30-day and 90-day hospital readmission rates were evaluated. Risk-adjusted cardiopulmonary morbidity and 30-day mortality were calculated for each group and compared. RESULTS The 2 groups had a similar postoperative length of stay (enhanced recovery pathway median 5 days vs pre-enhanced recovery pathway 4, P = .44), cardiopulmonary complication rates (enhanced recovery pathway 22.6% vs pre-enhanced recovery pathway 22.4%, P = .98), 30-day mortality rates (enhanced recovery pathway 3.8% vs pre-enhanced recovery pathway 2.2%, P = .31), and 90-day mortality rates (enhanced recovery pathway 4.7% vs pre-enhanced recovery pathway 3.0%, P = .37). No differences were noted in terms of 30-day (enhanced recovery pathway 7.2% vs pre-enhanced recovery pathway 7.4%, P = .94) or 90-day readmission rates (enhanced recovery pathway 9.8% vs pre-enhanced recovery pathway 12.3%, P = .34). The risk-adjusted cardiopulmonary morbidity rates were similar in the 2 periods (P = .76), whereas the risk-adjusted 30-day mortality was higher in the enhanced recovery pathway period compared with the pre-enhanced recovery pathway mortality (P = .0004). CONCLUSIONS We found no benefit conferred by the enhanced recovery program on outcomes such as cardiopulmonary complications, 30- and 90-day mortality, length of stay, and readmissions. Enhanced recovery program elements may be insufficiently different than previous standards of perioperative care to confer detectable benefits in our settings.
Collapse
|
224
|
Partoune A, Coimbra C, Brichant JF, Joris J. Quality of life at home and satisfaction of patients after enhanced recovery protocol for colorectal surgery. Acta Chir Belg 2017; 117:176-180. [PMID: 28103758 DOI: 10.1080/00015458.2017.1279871] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Quality of life of patients at home after an enhanced recovery protocol (ERP) for surgery has been least studied especially in elderly patients. METHODS Our first 41 patients entered in the colorectal GRACE database were interviewed through telephone about their postoperative stress, fatigue, pain, difficulty in feeding, home autonomy, and satisfaction. We compared the responses of the elderly patients (>70 years, n = 19) with those of the younger patients. RESULTS The time between the surgery and the questionnaire was 79 ± 48 days. Early return was experienced as stressful by ±20% of the patients. Fatigue and pain were low (respectively: simple numerical scale [SNS] = 4.2 ± 3.2 and 2.5 ± 2.9). When present, pain was relieved by the prescribed treatment. One-third of the patients described some difficulty in feeding. Fifty percent of the patients felt completely autonomous when returned at home, 80% attributed the rapid recovery of autonomy to the ERP. Finally, 87% were globally satisfied (SNS: 8.5 ± 1.0). The characteristics of the 'elderly' group (77 ± 6 years) and their questionnaire responses were similar to those of the younger patients. CONCLUSIONS Despite some limitations (retrospective, different time between surgery and the telephone survey), our study suggests that quality of life at home after ERP for colorectal surgery is very satisfactory for over 80% of patients. Furthermore, this study confirms that elderly patients benefit from an ERP for colorectal surgery like younger patients.
Collapse
Affiliation(s)
- Aurélien Partoune
- Department of anaesthesia reanimation, CHU Liège, domaine du Sart Tilman, University of Liège, Liège, Belgium
| | - Carla Coimbra
- Service of digestive surgery, CHU Liège, domaine du Sart Tilman, University of Liège, Liège, Belgium
- GRACE (Groupe francophone de Réhabilitation Après ChirurgiE), Baumont, France
| | - Jean-François Brichant
- Department of anaesthesia reanimation, CHU Liège, domaine du Sart Tilman, University of Liège, Liège, Belgium
| | - Jean Joris
- Department of anaesthesia reanimation, CHU Liège, domaine du Sart Tilman, University of Liège, Liège, Belgium
- GRACE (Groupe francophone de Réhabilitation Après ChirurgiE), Baumont, France
| |
Collapse
|
225
|
Alverdy JC, Hyoju SK, Weigerinck M, Gilbert JA. The gut microbiome and the mechanism of surgical infection. Br J Surg 2017; 104:e14-e23. [PMID: 28121030 DOI: 10.1002/bjs.10405] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 09/20/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Since the very early days of surgical practice, surgeons have recognized the importance of considering that intestinal microbes might have a profound influence on recovery from surgical diseases such as appendicitis and peritonitis. Although the pathogenesis of surgical diseases such as cholelithiasis, diverticulosis, peptic ulcer disease and cancer have been viewed as disorders of host biology, they are emerging as diseases highly influenced by their surrounding microbiota. METHODS This is a review of evolving concepts in microbiome sciences across a variety of surgical diseases and disorders, with a focus on disease aetiology and treatment options. RESULTS The discovery that peptic ulcer disease and, in some instances, gastric cancer can now be considered as infectious diseases means that to advance surgical practice humans need to be viewed as superorganisms, consisting of both host and microbial genes. Applying this line of reasoning to the ever-ageing population of patients demands a more complete understanding of the effects of modern-day stressors on both the host metabolome and microbiome. CONCLUSION Despite major advances in perioperative care, surgeons today are witnessing rising infection-related complications following elective surgery. Many of these infections are caused by resistant and virulent micro-organisms that have emerged as a result of human progress, including global travel, antibiotic exposure, crowded urban conditions, and the application of invasive and prolonged medical and surgical treatment. A more complete understanding of the role of the microbiome in surgical disease is warranted to inform the path forward for prevention.
Collapse
Affiliation(s)
- J C Alverdy
- Department of Surgery and Laboratory of Surgical Infection Research and Therapeutics, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - S K Hyoju
- Department of Surgery and Laboratory of Surgical Infection Research and Therapeutics, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - M Weigerinck
- Department of Surgery, Radboud University, Nijmegen, The Netherlands
| | - J A Gilbert
- Department of Surgery and Laboratory of Surgical Infection Research and Therapeutics, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| |
Collapse
|
226
|
Pisarska M, Pędziwiatr M, Major P, Kisielewski M, Migaczewski M, Rubinkiewicz M, Budzyński P, Przęczek K, Zub-Pokrowiecka A, Budzyński A. Laparoscopic Gastrectomy with Enhanced Recovery After Surgery Protocol: Single-Center Experience. Med Sci Monit 2017; 23:1421-1427. [PMID: 28331173 PMCID: PMC5375176 DOI: 10.12659/msm.898848] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Surgery remains the mainstay of gastric cancer treatment. It is, however, associated with a relatively high risk of perioperative complications. The use of laparoscopy and the Enhanced Recovery After Surgery (ERAS) protocol allows clinicians to limit surgically induced trauma, thus improving recovery and reducing the number of complications. The aim of the study is to present clinical outcomes of patients with gastric cancer undergoing laparoscopic gastrectomy combined with the ERAS protocol. Material/Methods Fifty-three (21 female/32 male) patients who underwent elective laparoscopic total gastrectomy due to cancer were prospectively analyzed. Demographic and surgical parameters were assessed, as well as the compliance with ERAS protocol elements, length of hospital stay, number of complications, and readmissions. Results Mean operative time was 296.4±98.9 min, and mean blood loss was 293.3±213.8 mL. In 3 (5.7%) cases, conversion was required. Median length of hospital stay was 5 days. Compliance with ERAS protocol was 79.6±14.5%. Thirty (56.6%) patients tolerated an early oral diet well within 24 h postoperatively; in 48 (90.6%) patients, mobilization in the first 24 hours was successful. In 17 (32.1%) patients, postoperative complications occurred, with 7 of them (13.2%) being serious (Clavien-Dindo 3-5). The 30-day readmission rate was 9.4%. Conclusions The combination of laparoscopy and the ERAS protocol in patients with gastric cancer is feasible and allows achieving good clinical outcomes.
Collapse
Affiliation(s)
- Magdalena Pisarska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Michał Kisielewski
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Marcin Migaczewski
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Mateusz Rubinkiewicz
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Krzysztof Przęczek
- Jagiellonian University Medical College, 2nd Department of General Surgery, Cracow, Poland
| | - Anna Zub-Pokrowiecka
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| |
Collapse
|
227
|
Brescia A, Tomassini F, Berardi G, Sebastiani C, Pezzatini M, Dall'Oglio A, Laracca GG, Apponi F, Gasparrini M. Development of an enhanced recovery after surgery (ERAS) protocol in laparoscopic colorectal surgery: results of the first 120 consecutive cases from a university hospital. Updates Surg 2017; 69:359-365. [PMID: 28332129 DOI: 10.1007/s13304-017-0432-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/11/2017] [Indexed: 12/20/2022]
Abstract
The ERAS® represents a dynamic culmination of upon perioperative care elements, successfully applied to different surgical specialties with shorter hospital stay and lower morbidity rates. The aim of this study is to describe the introduction of the ERAS protocol in colorectal surgery in our hospital analysing our first series. Between September 2014 and June 2016, 120 patients suffering from colorectal diseases were included in the study. Laparoscopic approach was used in all patients if not contraindicated. Patients were discharged when adequate mobilization, canalization, and pain control were obtained. Analysed outcomes were: length of hospital stay, readmission rate, perioperative morbidity, and mortality. Malignant lesions were the most common indication (84.2%; 101/120). Laparoscopic approach was performed in the 95.8% of cases (115/120) with a conversion rate of 4.4% (5/115). Surgical procedures performed were: 36 rectal resections (30%), 36 left colonic resections (30%), 42 right hemicolectomy (35%), and 6 Miles (5%). The median hospital stay was of 4 (3-34) days in the whole series with a morbidity rate of 10% (12/120); four patients experienced Clavien-Dindo ≥ IIIa complications; and only one anastomotic leak was observed. No 30-day readmission and no perioperative mortality were recorded. At the univariate analysis, the presence of complications was the only predictive factor for prolonged hospital stay (p < 0.001). In our experience, implementation of ERAS protocol for colorectal surgery allows a significant reduction of hospital stay improving perioperative management and postoperative outcomes.
Collapse
Affiliation(s)
- Antonio Brescia
- Department of General Surgery, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Federico Tomassini
- Department of General Surgery, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy.
| | - Giammauro Berardi
- Department of General Surgery, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Carola Sebastiani
- Department of General Surgery, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Massimo Pezzatini
- Department of General Surgery, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Anna Dall'Oglio
- Department of General Surgery, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Giovanni Guglielmo Laracca
- Department of General Surgery, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Fabrizio Apponi
- Department of Anaesthesiology, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Marcello Gasparrini
- Department of General Surgery, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy
| |
Collapse
|
228
|
Corso E, Hind D, Beever D, Fuller G, Wilson MJ, Wrench IJ, Chambers D. Enhanced recovery after elective caesarean: a rapid review of clinical protocols, and an umbrella review of systematic reviews. BMC Pregnancy Childbirth 2017; 17:91. [PMID: 28320342 PMCID: PMC5359888 DOI: 10.1186/s12884-017-1265-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 02/28/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The rate of elective Caesarean Section (CS) is rising in many countries. Many obstetric units in the UK have either introduced or are planning to introduce enhanced recovery (ER) as a means of reducing length of stay for planned CS. However, to date there has been very little evidence produced regarding the necessary components of ER for the obstetric population. We conducted a rapid review of the composition of published ER pathways for elective CS and undertook an umbrella review of systematic reviews evaluating ER components and pathways in any surgical setting. METHODS Pathways were identified using MEDLINE, EMBASE and the National Guideline Clearing House, appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool and their components tabulated. Systematic reviews were identified using the Cochrane Library and Database of Abstracts of Reviews of Effects (DARE) and appraised using The Grading of Recommendations Assessment, Development and Evaluation (GRADE). Two reviewers aggregated summaries of findings for Length of Stay (LoS). RESULTS Five clinical protocols were identified, involving a total of 25 clinical components; 3/25 components were common to all five pathways (early oral intake, mobilization and removal of urinary catheter). AGREE II scores were generally low. Systematic reviews of single components found that minimally invasive Joel-Cohen surgical technique, early catheter removal and post-operative antibiotic prophylaxis reduced LoS after CS most significantly by around half to 1 and a half days. Ten meta-analyses of multi-component Enhanced Recovery after Surgery (ERAS) packages demonstrated reductions in LoS of between 1 and 4 days. The quality of evidence was mostly low or moderate. CONCLUSIONS Further research is needed to develop, using formal methods, and evaluate pathways for enhanced recovery in elective CS. Appropriate quality improvement packages are needed to optimise their implementation.
Collapse
Affiliation(s)
- Ellena Corso
- School of Medicine and Dentistry, University of Sheffield, Sheffield, UK
| | - Daniel Hind
- Clinical Trials Research Unit, Regent Court, 30 Regent St, Sheffield, S1 4DA UK
| | - Daniel Beever
- Clinical Trials Research Unit, Regent Court, 30 Regent St, Sheffield, S1 4DA UK
| | - Gordon Fuller
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent St, Sheffield, S1 4DA UK
| | - Matthew J. Wilson
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent St, Sheffield, S1 4DA UK
| | - Ian J. Wrench
- Sheffield Teaching Hospitals Trust, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF UK
| | - Duncan Chambers
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent St, Sheffield, S1 4DA UK
| |
Collapse
|
229
|
Hospitals with Briefer than Average Lengths of Stays for Common Surgical Procedures Do Not Have Greater Odds of Either Re-Admission Or Use of Short-Term Care Facilities. Anaesth Intensive Care 2017; 45:210-219. [DOI: 10.1177/0310057x1704500211] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We considered whether senior hospital managers and department chairs need to be concerned that small reductions in average hospital length of stay (LOS) may be associated with greater rates of re-admission, use of home health care, and/or transfers to short-term care facilities. The 2013 United States Nationwide Readmissions Database was used to study surgical Diagnosis Related Groups (DRG) with 1) national median LOS ≥3 days and 2) ≥10 hospitals in the database that each had ≥100 discharges for the DRG. Dependent variables were considered individually: 1) re-admission within 30 days of discharge, 2) discharge disposition to home health care, and/or 3) discharge disposition of transfer to short-term care facility (i.e., inpatient rehabilitation hospital or skilled nursing facility). While controlling for DRG, each one-day decrease in hospital median LOS was associated with an odds of re-admission nationwide of 0.95 (95% confidence interval [CI] 0.92–0.99; P=0.012), odds of disposition upon discharge being home care of 0.95 (95% CI 0.83–1.10; P=0.64), and odds of transfer to short-term care facility of 0.68 (95% CI 0.54–0.85; P=0.0008). Results were insensitive to the addition of patient-specific data. In the USA, patients at hospitals with briefer median LOS across multiple common surgical procedures did not have a greater risk for either hospital re-admission within 30 days of discharge or transfer to an inpatient rehabilitation hospital or a skilled nursing facility. The generalisable implication is that, across many surgical procedures, DRG-based financial incentives to shorten hospital stays seem not to influence post–acute care decisions.
Collapse
|
230
|
Pecorelli N, Capretti G, Balzano G, Castoldi R, Maspero M, Beretta L, Braga M. Enhanced recovery pathway in patients undergoing distal pancreatectomy: a case-matched study. HPB (Oxford) 2017; 19:270-278. [PMID: 27914764 DOI: 10.1016/j.hpb.2016.10.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 10/20/2016] [Accepted: 10/28/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Enhanced recovery (ER) pathways have improved outcomes across multiple surgical specialties, but reports concerning their application in distal pancreatectomy (DP) are lacking. The aim of this study was to assess compliance with an ER protocol and its impact on short-term outcomes in patients undergoing DP. METHODS Prospectively collected data were reviewed. One hundred consecutive patients undergoing DP were treated within an ER pathway comprising 18 care elements. Each patient was matched 1:1 with a patient treated with usual perioperative care. Match criteria were age, BMI, ASA score, lesion site, and type of disease. RESULTS Adherence to ER items ranged from 15% for intraoperative restrictive fluids to 100% for intraoperative warming, antibiotic and anti-thrombotic prophylaxis. Patients in ER group experienced earlier recovery of gastrointestinal function (2 vs. 3 days, p < 0.001), oral intake (2 vs. 4 days, p < 0.001), and suspension of intravenous infusions (3 vs. 5 days, p < 0.001). Overall morbidity was similar in the two groups (72% vs. 78%). Length of hospital stay (LOS) was reduced in ER patients without postoperative complications (6.7 ± 1.2 vs. 7.6 ± 1.6 days, p = 0.041). CONCLUSIONS An ER pathway for DP yielded an earlier postoperative recovery and shortened LOS in uneventful patients. Postoperative morbidity and readmissions were similar in both groups.
Collapse
Affiliation(s)
- Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Vita-Salute University, San Raffaele Hospital, Milan, Italy
| | - Giovanni Capretti
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Vita-Salute University, San Raffaele Hospital, Milan, Italy
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Vita-Salute University, San Raffaele Hospital, Milan, Italy
| | - Renato Castoldi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Vita-Salute University, San Raffaele Hospital, Milan, Italy
| | - Marianna Maspero
- Department of Surgery, Vita-Salute University, San Raffaele Hospital, Milan, Italy
| | - Luigi Beretta
- Department of Anesthesiology, Vita-Salute University, San Raffaele Hospital, Milan, Italy
| | - Marco Braga
- Department of Surgery, Vita-Salute University, San Raffaele Hospital, Milan, Italy.
| |
Collapse
|
231
|
An enhanced recovery programme after caesarean delivery increases maternal satisfaction and improves maternal-neonatal bonding: A case control study. Eur J Obstet Gynecol Reprod Biol 2017; 210:212-216. [DOI: 10.1016/j.ejogrb.2016.12.034] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 12/22/2016] [Accepted: 12/28/2016] [Indexed: 11/18/2022]
|
232
|
Abeles A, Kwasnicki RM, Darzi A. Enhanced recovery after surgery: Current research insights and future direction. World J Gastrointest Surg 2017; 9:37-45. [PMID: 28289508 PMCID: PMC5329702 DOI: 10.4240/wjgs.v9.i2.37] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 09/14/2016] [Accepted: 11/01/2016] [Indexed: 02/06/2023] Open
Abstract
Since the concept of enhanced recovery after surgery (ERAS) was introduced in the late 1990s the idea of implementing specific interventions throughout the peri-operative period to improve patient recovery has been proven to be beneficial. Minimally invasive surgery is an integral component to ERAS and has dramatically improved post-operative outcomes. ERAS can be applicable to all surgical specialties with the core generic principles used together with added specialty specific interventions to allow for a comprehensive protocol, leading to improved clinical outcomes. Diffusion of ERAS into mainstream practice has been hindered due to minimal evidence to support individual facets and lack of method for monitoring and encouraging compliance. No single outcome measure fully captures recovery after surgery, rather multiple measures are necessary at each stage. More recently the pre-operative period has been the target of a number of strategies to improve clinical outcomes, described as prehabilitation. Innovation of technology in the surgical setting is also providing opportunities to overcome the challenges within ERAS, e.g., the use of wearable activity monitors to record information and provide feedback and motivation to patients peri-operatively. Both modernising ERAS and providing evidence for key strategies across specialties will ultimately lead to better, more reliable patient outcomes.
Collapse
|
233
|
Lightner AL, Pemberton JH, Dozois EJ, Larson DW, Cima RR, Mathis KL, Pardi DS, Andrew RE, Koltun WA, Sagar P, Hahnloser D. The surgical management of inflammatory bowel disease. Curr Probl Surg 2017; 54:172-250. [PMID: 28576304 DOI: 10.1067/j.cpsurg.2017.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Rachel E Andrew
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Walter A Koltun
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Peter Sagar
- Division of Colorecal surgery, St. James University Hospital, Leeds, England
| | - Dieter Hahnloser
- Division of Colorecal surgery, Lausanne University Hospital, Lausanne, Switzerland
| |
Collapse
|
234
|
Carli F, Silver JK, Feldman LS, McKee A, Gilman S, Gillis C, Scheede-Bergdahl C, Gamsa A, Stout N, Hirsch B. Surgical Prehabilitation in Patients with Cancer. Phys Med Rehabil Clin N Am 2017; 28:49-64. [DOI: 10.1016/j.pmr.2016.09.002] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
235
|
Dai J, Jiang Y, Fu D. Reducing postoperative complications and improving clinical outcome: Enhanced recovery after surgery in pancreaticoduodenectomy - A retrospective cohort study. Int J Surg 2017; 39:176-181. [PMID: 28132917 DOI: 10.1016/j.ijsu.2017.01.089] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 01/18/2017] [Accepted: 01/20/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND An enhanced recovery after surgery (ERAS) programme aims to reduce the stress response to surgery and thereby accelerate recovery. The experience of implementing the ERAS programmes in pancreatoduodenectomy (PD) is relatively limited. The aim of this study was to evaluate the feasibility, safety and clinical outcomes of the ERAS programme after PD at a high-volume Chinese university referral centre. METHODS Between September 2014 and July 2016, a retrospective analysis of 166 consecutive patients who underwent PD at a tertiary referral care center was carried out. Ninety-eight patients who received conventional perioperative management (the conventional group) were compared with 68 patients who received ERAS programme (the ERAS group). The incidences of postoperative complications, length of stay, expenses, postoperative readmissions, and reoperation rates were compared. RESULTS A total of 166 patients who underwent PD were analysed (68 patients in the ERAS group, and 98 patients in the conventional group). There were no significant differences in mortality, reoperation, and readmission rates. The ERAS group had a lower morbidity rate than the conventional group (50% vs. 90.8%; P = 0.00), as well as a shorter length of hospital stay (7.5 vs 12 days; P = 0.00). Delayed gastric emptying was significantly reduced in the ERAS group (0 vs. 11.2%; P = 0.011). Pancreatic fistula (grade B,C) was significantly reduced in the ERAS group (14.7 vs 30.6%; P = 0.018). The median total hospital cost was also significantly reduced in the ERAS group (¥79790.40 vs ¥102982.81; P = 0.000). CONCLUSION The ERAS programme is feasible and safe in patients who underwent PD, and it can reduce postoperative complications and improve clinical outcomes.
Collapse
Affiliation(s)
- Juntao Dai
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yongjian Jiang
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China.
| |
Collapse
|
236
|
Otero JJ, Detriche O, Mommaerts MY. Fast-track Orthognathic Surgery: An Evidence-based Review. Ann Maxillofac Surg 2017; 7:166-175. [PMID: 29264281 PMCID: PMC5717890 DOI: 10.4103/ams.ams_106_17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The aim of this study was to establish a fast-track protocol for bimaxillary orthognathic surgery (OGS). Fast-track surgery (FTS) is a multidisciplinary approach where the pre-, intra-, and postoperative management is focusing maximally on a quick patient recovery and early discharge. To enable this, the patients' presurgical stress and postsurgical discomfort should be maximally reduced. Both referral patterns and expenses within the health-care system are positively influenced by FTS. University hospital-literature review through Medline, Embase, and the Cochrane Library (January 2000-July 2016) using the following words - "fast track, enhanced recovery, multimodal, and perioperative care" - to define a protocol evidence based for OGS, as well as evidenced-based medicine search of every term added to the protocol during the same period. The process has resulted in an OGS protocol that may improve the outcome of the patient through several nonoperative and operative measures such as preoperative patient education and intra/postoperative measures that should improve overall patient satisfaction, decrease morbidity such as postoperative nausea, headache, dizziness, pain, and intubation discomfort, and shorten hospital stay. A literature review allowed us to fine-tune a fast-track protocol for uncomplicated OGS that can be prospectively studied against currently applied ones.
Collapse
Affiliation(s)
- Joel Joshi Otero
- European Face Centre, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - Olivier Detriche
- Department of Anesthesiology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - Maurice Yves Mommaerts
- European Face Centre, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| |
Collapse
|
237
|
Impact of Enhanced Recovery After Surgery and Fast Track Surgery Pathways on Healthcare-associated Infections. Ann Surg 2017; 265:68-79. [DOI: 10.1097/sla.0000000000001703] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
238
|
McConnell KJ, Guzman OE, Pherwani N, Spencer DD, Van Cura JD, Shea KM. Operational and Clinical Strategies to Address Drug Cost Containment in the Acute Care Setting. Pharmacotherapy 2016; 37:25-35. [DOI: 10.1002/phar.1858] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
| | - Oscar E. Guzman
- Innovative Delivery Solutions; Cardinal Health; Houston Texas
| | - Nisha Pherwani
- Innovative Delivery Solutions; Cardinal Health; Houston Texas
| | | | | | | |
Collapse
|
239
|
Leeds IL, Boss EF, George JA, Strockbine V, Wick EC, Jelin EB. Preparing enhanced recovery after surgery for implementation in pediatric populations. J Pediatr Surg 2016; 51:2126-2129. [PMID: 27663124 PMCID: PMC5373552 DOI: 10.1016/j.jpedsurg.2016.08.029] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 08/29/2016] [Accepted: 08/30/2016] [Indexed: 01/31/2023]
Abstract
UNLABELLED Standardization in perioperative care has led to major improvements in surgical outcomes during the last two decades. Enhanced recovery after surgery (ERAS) programs are one example of a clinical pathway impacting both surgical outcomes and efficiency of care, but these programs have not yet been widely adapted for surgery in children. In adults, ERAS pathways have been shown to reduce length of stay, reduce complication rates, and improve patient satisfaction. These pathways improve outcomes through standardization of existing evidence-based best practices. Currently, the direct evidence for adapting ERAS pathways to pediatric surgery patients is limited. Challenges for implementation of ERAS programs for children include lack of direct translatability of adult evidence as well as varying levels acceptability of ERAS principles among pediatric providers and patients' families. We describe our newly implemented ERAS program for pediatric colorectal surgery patients in an era of limited direct evidence and discuss what further issues need to be addressed for broader implementation of pediatric ERAS pathways. LEVEL OF EVIDENCE Level 5.
Collapse
Affiliation(s)
- Ira L. Leeds
- Department of Surgery, The Johns Hopkins Hospital and Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 618, Baltimore, MD 21287
| | - Emily F. Boss
- Department of Otolaryngology-Head and Neck Surgery and Health Policy & Management, Johns Hopkins University School of Medicine and Bloomberg School of Public Health, 601 North Caroline Street, 6th Floor, Baltimore, MD 21287
| | - Jessica A. George
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Children’s Center and Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287
| | - Valerie Strockbine
- Department of Surgery, Johns Hopkins Bloomberg Children’s Center and Johns Hopkins University School of Medicine, 1800 Orleans Street, Bloomberg 7323, Baltimore, MD 21287
| | - Elizabeth C. Wick
- Department of Surgery, The Johns Hopkins Hospital and Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 618, Baltimore, MD 21287
| | - Eric B. Jelin
- Department of Surgery, Johns Hopkins Bloomberg Children’s Center and Johns Hopkins University School of Medicine, 1800 Orleans Street, Bloomberg 7323, Baltimore, MD 21287
| |
Collapse
|
240
|
Epidural analgesia combined with a comprehensive physiotherapy program after Cytoreductive Surgery and HIPEC is associated with enhanced post-operative recovery and reduces intensive care unit stay: A retrospective study of 124 patients. Eur J Surg Oncol 2016; 42:1938-1943. [DOI: 10.1016/j.ejso.2016.06.390] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 05/17/2016] [Accepted: 06/04/2016] [Indexed: 12/20/2022] Open
|
241
|
Shi Q, Wang XS, Vaporciyan AA, Rice DC, Popat KU, Cleeland CS. Patient-Reported Symptom Interference as a Measure of Postsurgery Functional Recovery in Lung Cancer. J Pain Symptom Manage 2016; 52:822-831. [PMID: 27521528 PMCID: PMC5154813 DOI: 10.1016/j.jpainsymman.2016.07.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 06/14/2016] [Accepted: 07/29/2016] [Indexed: 01/29/2023]
Abstract
CONTEXT Few empirical studies have combined the patient's perspective (patient-reported outcomes [PROs]) with clinical outcomes (risk for complications, length of hospital stay, return to planned treatment) to assess the effectiveness of treatment after thoracic surgery for early-stage non-small cell lung cancer (NSCLC). OBJECTIVES Quantitatively measure PROs to assess functional recovery postsurgery. METHODS Treatment-naïve patients (N = 72) with NSCLC who underwent either open thoracotomy or video-assisted thoracoscopic surgery (VATS) used the MD Anderson Symptom Inventory (MDASI) to report symptom interference with general activity, work, walking, mood, relations with others, and enjoyment of life for three months after surgery. Functional recovery was defined as interference scores returning to presurgery levels. The MDASI's sensitivity to change in functional recovery over time was evaluated via its ability to distinguish between surgical techniques. RESULTS Interference scores increased sharply by Day 3 after surgery (all P < 0.001), then returned to baseline levels via different trajectories. Patients who had unscheduled clinic visits during the study period reported higher scores on all six MDASI interference items (all P < 0.05). Compared with the open-thoracotomy group, the VATS group returned more quickly to baseline interference levels for walking (18 vs. 43 days), mood (8 vs. 19 days), relations with others (4 vs. 16 days), and enjoyment of life (15 vs. 41 days) (all P < 0.05). CONCLUSION Repeated measurement of MDASI interference characterized functional recovery after thoracic surgery for NSCLC and was sensitive to VATS' ability to enhance postoperative recovery. Further study of the clinical applicability of measuring recovery outcomes using PRO-based functional assessment is warranted.
Collapse
Affiliation(s)
- Qiuling Shi
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Xin Shelley Wang
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Ara A Vaporciyan
- Department of Thoracic & Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David C Rice
- Department of Thoracic & Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Keyuri U Popat
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Charles S Cleeland
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
242
|
Lau CSM, Chamberlain RS. Enhanced Recovery After Surgery Programs Improve Patient Outcomes and Recovery: A Meta-analysis. World J Surg 2016; 41:899-913. [DOI: 10.1007/s00268-016-3807-4] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
243
|
Abstract
Enhanced recovery programs (ERP) after surgery are now being increasingly applied in daily practice. The purpose of this article is to review specific aspects and advantages of this approach. Beyond the reduction in overall morbidity (found for multiple surgical specialties), ERP include issues and stakes that affect patient care, the care team and society in general. Data from the literature are in agreement, emphasizing that, in this clinical pathway, the patient has thus become an actor in his own care, whose active participation is paramount to the success of the program. In parallel with this, a spirit of teamwork is required and the program contributes substantially to cohesion within the team. Finally, all studies show that ERP have a beneficial effect in economic terms for society.
Collapse
Affiliation(s)
- K Slim
- Service de Chirurgie Digestive, CHU Estaing, 1, place Lucie-Aubrac, 63003 Clermont-Ferrand, France; Groupe francophone de réhabilitation améliorée après chirurgie (GRACE), 63110 Beaumont, France.
| |
Collapse
|
244
|
Hamill JK, Rahiri JL, Gunaratna G, Hill AG. Interventions to optimize recovery after laparoscopic appendectomy: a scoping review. Surg Endosc 2016; 31:2357-2365. [PMID: 27752812 DOI: 10.1007/s00464-016-5274-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 10/03/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND No enhanced recovery after surgery protocol has been published for laparoscopic appendectomy. This was a review of evidence-based interventions that could optimize recovery after appendectomy. METHODS Interventions for the review Clinical pathway, fast-track or enhanced recovery protocols; needlescopic approach; single incision laparoscopic (SIL) approach; natural orifice transluminal endoscopic surgery (NOTES); regional nerve blocks; intraperitoneal local anaesthetic (IPLA); drains. Data sources MEDLINE, EMBASE, the Cochrane Library, and the Web of Science Core Collection. Study eligibility criteria Randomized controlled trial (RCT); prospective evaluation with historical controls for studies assessing clinical pathways/protocols. Participants People undergoing laparoscopic appendectomy for acute appendicitis. Study appraisal and synthesis methods Meta-analysis, random effects model. RESULTS Clinical pathways for laparoscopic appendectomy were safe in selected patients, but may be associated with a higher readmission rate. Needlescopic surgery offered no recovery advantage over traditional laparoscopic appendectomy. SIL afforded no recovery advantage over conventional laparoscopic surgery, but may increase operative time in children. The search found no RCT on NOTES appendectomy. Transversus abdominis plane blocks did not significantly reduce pain after laparoscopic appendectomy. IPLA should be considered in laparoscopic appendectomy; studies in paediatric surgery are needed. The search found no RCT on the use of drains in appendectomy. CONCLUSIONS This review identified gaps in the literature on optimizing recovery after laparoscopic appendectomy and found the need for more randomized controlled trials on regional anaesthesia and intraperitoneal local anaesthesia in children.
Collapse
Affiliation(s)
- James K Hamill
- Department of Surgery, Starship Hospital, Park Road, Grafton, Private Bag 92024, Auckland, 1142, New Zealand. .,Department of Surgery, The University of Auckland, Auckland, New Zealand.
| | - Jamie-Lee Rahiri
- Department of Surgery, South Auckland Clinical Campus, The University of Auckland, Middlemore Hospital, Otahuhu, Auckland, New Zealand
| | - Gamage Gunaratna
- School of Medicine, The University of Auckland, Auckland, New Zealand
| | - Andrew G Hill
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Department of Surgery, South Auckland Clinical Campus, The University of Auckland, Middlemore Hospital, Otahuhu, Auckland, New Zealand
| |
Collapse
|
245
|
Abstract
Hospital readmission is a focus of quality measures used by the Center for Medicare and Medicaid (CMS) to evaluate quality of care. Policy changes provide incentives and enforce penalties to decrease 30-day hospital readmissions. CMS implemented the Readmission Penalty Program. Readmission rates are being used to determine reimbursement rates for physicians. The need for readmission is deemed an indication for inadequate quality of care subjected to financial penalties. This reviews identifies risk factors that have been significantly associated with higher readmission rates, addresses approaches to minimize 30-day readmission, and discusses the potential future direction within this area as regulations evolve.
Collapse
|
246
|
|
247
|
Veziant J, Raspado O, Entremont A, Joris J, Pereira B, Slim K. Large-scale implementation of enhanced recovery programs after surgery. A francophone experience. J Visc Surg 2016; 154:159-166. [PMID: 27638322 DOI: 10.1016/j.jviscsurg.2016.08.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Enhanced recovery after surgery program (ERP) has now surpassed the stage of clinical research in certain specialties and currently poses the problematic of large-scale implementation. The goal of this study was to report the experience during the first year of implementation in three French-speaking countries. MATERIAL AND METHODS This is a prospective study in which 67 healthcare centers, all registered in the Grace-Audit databank, participated. Included were patients undergoing colorectal (CRS), bariatric (BS) and orthopedic hip and knee surgery (OS), performed within an ERP. The main endpoints were duration of hospital stay, postoperative morbidity, the degree of compliance with the elements of the ERP, the relation between the extent of application of the elements and postoperative hospital stay, and finally the completeness of data inclusions in the databank. RESULTS A total of 1904 patients were included in the Grace-Audit databank between January 1, 2015 and January 31, 2016, undergoing CRS (n=490), BS (n=431), and OS (n=983). The mean implementation rate was 83.7±10.0% for CRS, 75.0±23.7% for BS, and 83.5±14.9% for OS. The duration of hospital stay was 6.5 days for CRS, 2.6 days for BS and 3.4 days for OS. Overall postoperative morbidity (onset of postoperative undesirable event), surgical morbidity (superficial or deep organ space surgical site complications such as bleeding, infection or defective healing) and readmission rates were 20.6%, 7.5%, and 5.7% for CRS; 2.5%, 1.4%, and 1.6% for BS and 2.9%, 0.2%, and 2% for OS, respectively. A statistically significant relationship was found between the degree of compliance of the elements of ERP and the duration of hospital stay for CRS and BS; hospital stay was reduced when at least 15 of the 22 elements of the program were applied (P<0.001). The patients included in the Grace-Audit databank represented less than 20% of the patients undergoing operation in the same establishments during the study period for all three specialties. CONCLUSIONS This study shows that large-scale ERPs are feasible and safe in French-speaking countries. Nonetheless, although encouraging, these preliminary results highlight that implementation must be improved in specialties such as bariatric surgery and that more complete data collection is needed.
Collapse
Affiliation(s)
- J Veziant
- Service de chirurgie digestive, CHU Estaing, 63003 Clermont-Ferrand, France; Groupe francophone de réhabilitation améliorée après chirurgie, 63110 Beaumont, France
| | - O Raspado
- Groupe francophone de réhabilitation améliorée après chirurgie, 63110 Beaumont, France; Infirmerie protestante, 69300 Caluire, France
| | - A Entremont
- Groupe francophone de réhabilitation améliorée après chirurgie, 63110 Beaumont, France
| | - J Joris
- Groupe francophone de réhabilitation améliorée après chirurgie, 63110 Beaumont, France; Service d'anesthésie et de réanimation, CHU de Liège, 4000 Liège, Belgium
| | - B Pereira
- Département de statistiques, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - K Slim
- Service de chirurgie digestive, CHU Estaing, 63003 Clermont-Ferrand, France; Groupe francophone de réhabilitation améliorée après chirurgie, 63110 Beaumont, France.
| | -
- Groupe francophone de réhabilitation améliorée après chirurgie, 63110 Beaumont, France
| |
Collapse
|
248
|
Abstract
IMPORTANCE Enhanced recovery programs (ERPs) are considered standard of care across a variety of surgical disciplines, but ERPs have not been widely adopted in gynecology. OBJECTIVE The aim of this study was to describe ERP principles and the role of ERPs in gynecology and gynecologic oncology. EVIDENCE ACQUISITION Comprehensive literature search was performed using MEDLINE, the Cochrane Collaboration Database, and PubMed. RESULTS Meta-analyses of a substantial number of randomized controlled trials have shown that implementation of ERP protocols is associated with decreased length of hospital stay, a decrease in rates of postoperative complication, decreased morbidity, and cost savings while preserving patient satisfaction and quality of life. CONCLUSIONS AND RELEVANCE High-quality evidence exists for improved outcomes among patients in ERPs. Enhanced recovery programs save resources and costs across the health care system. As quality metrics and bundled payments increase in health care, ERPs will have increasing prominence.
Collapse
|
249
|
Cundy TP, Sierakowski K, Manna A, Cooper CM, Burgoyne LL, Khurana S. Fast-track surgery for uncomplicated appendicitis in children: a matched case-control study. ANZ J Surg 2016; 87:271-276. [PMID: 27599307 DOI: 10.1111/ans.13744] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/05/2016] [Accepted: 07/18/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Standardized post-operative protocols reduce variation and enhance efficiency in patient care. Patients may benefit from these initiatives by improved quality of care. This matched case-control study investigates the effect of a multidisciplinary criteria-led discharge protocol for uncomplicated appendicitis in children. METHODS Key protocol components included limiting post-operative antibiotics to two intravenous doses, avoidance of intravenous opioid analgesia, prompt resumption of diet, active encouragement of early ambulation and nursing staff autonomy to discharge patients that met assigned criteria. The study period was from August 2015 to February 2016. Outcomes were compared with a historical control group matched for operative approach. RESULTS Outcomes for 83 patients enrolled to our protocol were compared with those of 83 controls. There was a 29.2% reduction in median post-operative length of stay in our protocol-based care group (19.6 versus 27.7 h; P < 0.001). The rate of discharges within 24 h improved from 12 to 42%. There was no significant difference in complication rate (4.8 versus 7.2%; P = 0.51). Mean oral morphine dose equivalent per kilogram requirement was less than half (46%) that of control group patients (P < 0.001). Mean number of ondansetron doses was also significantly lower. Projected annual direct cost savings following protocol implementation was AUD$77 057. CONCLUSION Implementation of a criteria-led discharge protocol at our hospital decreased length of stay, reduced variation in care, preserved existing low morbidity, incurred substantial cost savings, and safely rationalized opioid and antiemetic medication. These protocols are inexpensive and offer tangible benefits that are accessible to all health care settings.
Collapse
Affiliation(s)
- Thomas P Cundy
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Kyra Sierakowski
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Alexandra Manna
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Celia M Cooper
- Department of Infectious Diseases, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Paediatrics, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Laura L Burgoyne
- Department of Children's Anaesthesia, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Sanjeev Khurana
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Paediatrics, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| |
Collapse
|
250
|
Carrier G, Cotte E, Beyer-Berjot L, Faucheron J, Joris J, Slim K. Post-discharge follow-up using text messaging within an enhanced recovery program after colorectal surgery. J Visc Surg 2016; 153:249-52. [DOI: 10.1016/j.jviscsurg.2016.05.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|