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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.
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Affiliation(s)
- Ira L Leeds
- 1 Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland 2 The Johns Hopkins Hospital, Baltimore, Maryland
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202
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Horres CR, Adam MA, Sun Z, Thacker JK, Moon RE, Miller TE, Grant SA. Enhanced recovery protocols for colorectal surgery and postoperative renal function: a retrospective review. Perioper Med (Lond) 2017; 6:13. [PMID: 28948012 PMCID: PMC5609048 DOI: 10.1186/s13741-017-0069-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 09/05/2017] [Indexed: 12/20/2022] Open
Abstract
Background While enhanced recovery protocols (ERPs) reduce physiologic stress and improve outcomes in general, their effects on postoperative renal function have not been directly studied. Methods Patients undergoing major colorectal surgery under ERP (February 2010 to March 2013) were compared with a traditional care control group (October 2004 October 2007) at a single institution. Multivariable regression models examined the association of ERP with postoperative creatinine changes and incidence of postoperative acute kidney dysfunction (based on the Risk, Injury, Failure, Loss, and End-stage renal disease criteria). Results Included were 1054 patients: 590 patients underwent surgery with ERP and 464 patients without ERP. Patient demographics were not significantly different. Higher rates of neoplastic and inflammatory bowel disease surgical indications were found in the ERP group (81 vs. 74%, p = 0.045). Patients in the ERP group had more comorbidities (ASA ≥ 3) (62 vs. 40%, p < 0.001). In unadjusted analysis, postoperative creatinine increase was slightly higher in the ERP group compared with control (median 0.1 vs. 0 mg/dL, p < 0.001), but levels of postoperative acute kidney injury were similar in both groups (p = 0.998). After adjustment with multivariable regression, postoperative changes in creatinine were similar in ERP vs. control (p = 0.25). Conclusions ERP in colorectal surgery is not associated with a clinically significant increase in postoperative creatinine or incidence of postoperative kidney injury. Our results support the safety of ERPs in colorectal surgery and may promote expanding implementation of these protocols. Trial registration Not applicable, prospective data collection and retrospective chart review only.
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Affiliation(s)
- Charles R Horres
- Department of Anesthesiology, Duke University, DUMC 3094, Durham, NC 27710 USA
| | | | - Zhifei Sun
- Department of Surgery, Duke University, Durham, USA
| | | | - Richard E Moon
- Department of Anesthesiology, Duke University, DUMC 3094, Durham, NC 27710 USA
| | - Timothy E Miller
- Department of Anesthesiology, Duke University, DUMC 3094, Durham, NC 27710 USA
| | - Stuart A Grant
- Department of Anesthesiology, Duke University, DUMC 3094, Durham, NC 27710 USA
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203
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Radomski M, Zenati M, Novak S, Tam V, Steve J, Bartlett DL, Zureikat AH, Zeh HJ, Hogg ME. Factors associated with prolonged hospitalization in patients undergoing pancreatoduodenectomy. Am J Surg 2017; 215:636-642. [PMID: 28958654 DOI: 10.1016/j.amjsurg.2017.06.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/06/2017] [Accepted: 06/15/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Complex surgeries such as a pancreatoduodenectomy (PD) traditionally have long hospital stays (LOS). METHODS Patients who underwent elective PD at our institution from 8/2011-6/2015 were retrospectively examined. Interquartile ranges were calculated from LOS. Patient were compared between the highest quartile and the remainder of the cohort. RESULTS 492 patients had a median LOS of 9 days, with 106 (22%) admitted for >14 days. Characteristics associated with prolong hospitalization include age (p = 0.004) and preoperative albumin <3.5 (p = 0.007). Significant intra-operative measures associated with prolonged LOS were blood loss (EBL, p = 0.004) and increased operative time (p = 0.008). Any complication extended hospitalizations (p < 0.001). Patients in the top quartile were less likely to be discharged home (p < 0.0001) and more likely to be readmitted (p < 0.0001). CONCLUSION Older patients with hypoalbuminemia are at higher risk of prolonged LOS following PD as well as high EBL, operative time, and surgical complications. Focused efforts to counsel and optimize patients pre-operatively and minimize intra-operative complications may shorten hospital stays.
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Affiliation(s)
- Michal Radomski
- Department of Surgery, George Washington University, 2150 Pennsylvania Ave. NW, Suite 6B, Washington, DC 20037, United States.
| | - Mazen Zenati
- Department of Surgery, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Stephanie Novak
- Division of Surgical Oncology, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Vernissia Tam
- Division of Surgical Oncology, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Jennifer Steve
- Division of Surgical Oncology, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - David L Bartlett
- Division of Surgical Oncology, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Herbert J Zeh
- Division of Surgical Oncology, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Melissa E Hogg
- Division of Surgical Oncology, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213, United States.
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204
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Emmanuel A, Chohda E, Botfield C, Ellul J. Accelerated discharge within 72 hours of colorectal cancer resection using simple discharge criteria. Ann R Coll Surg Engl 2017; 100:52-56. [PMID: 29022790 DOI: 10.1308/rcsann.2017.0149] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Introduction Short hospital stays and accelerated discharge within 72 hours following colorectal cancer resections have not been widely achieved. Series reporting on accelerated discharge involve heterogeneous patient populations and exclude important groups. Strict adherence to some discharge requirements may lead to delays in discharge. The aim of this study was to evaluate the safety and feasibility of accelerated discharge within 72 hours of all elective colorectal cancer resections using simple discharge criteria. Methods Elective colorectal cancer resections performed between August 2009 and December 2015 by a single surgeon were reviewed. Perioperative care was based on an enhanced recovery programme. A set of simplified discharge criteria were used. Outcomes including postoperative complications, readmissions and reoperations were compared between patients discharged within 72 hours and those with a longer postoperative stay. Results Overall, 256 colorectal cancer resections (90% laparoscopic) were performed. The mean patient age was 70.8 years. The median length of stay was 3 days. Fifty-eight per cent of all patients and sixty-three per cent of patients undergoing laparoscopic surgery were discharged within 72 hours. Accelerated discharge was not associated with adverse outcomes compared with delayed discharge. Patients discharged within 72 hours had significantly fewer postoperative complications, readmissions and reoperations. Open surgery and stoma formation were associated with discharge after 72 hours but not age, co-morbidities, neoadjuvant chemoradiation or surgical procedure. Conclusions Accelerated discharge within 72 hours of elective colorectal resection for cancer is safely achievable for the majority of patients without compromising short-term outcomes.
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Affiliation(s)
- A Emmanuel
- King's College Hospital NHS Foundation Trust , UK
| | - E Chohda
- King's College Hospital NHS Foundation Trust , UK
| | - C Botfield
- King's College Hospital NHS Foundation Trust , UK
| | - J Ellul
- King's College Hospital NHS Foundation Trust , UK
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205
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Dexter F, Epstein RH, Sun EC, Lubarsky DA, Dexter EU. Readmissions to Different Hospitals After Common Surgical Procedures and Consequences for Implementation of Perioperative Surgical Home Programs. Anesth Analg 2017; 125:943-951. [DOI: 10.1213/ane.0000000000002017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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206
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Minimally invasive gastrectomy for gastric cancer: A national perspective on oncologic outcomes and overall survival. Surg Oncol 2017; 26:324-330. [DOI: 10.1016/j.suronc.2017.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 06/06/2017] [Accepted: 06/13/2017] [Indexed: 02/06/2023]
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207
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Herbert G, Sutton E, Burden S, Lewis S, Thomas S, Ness A, Atkinson C. Healthcare professionals' views of the enhanced recovery after surgery programme: a qualitative investigation. BMC Health Serv Res 2017; 17:617. [PMID: 28859687 PMCID: PMC5580205 DOI: 10.1186/s12913-017-2547-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 08/15/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The Enhanced Recovery After Surgery (ERAS) programme is an approach to the perioperative care of patients which aims to improve outcomes and speed up recovery after surgery. Although the evidence base appears strong for this programme, the implementation of ERAS has been slow. This study aimed to gain an understanding of the facilitating factors and challenges of implementing the programme with a view to providing additional contextual information to aid implementation. The study had a particular focus on the nutritional elements as these have been highlighted as important. METHODS The study employed qualitative research methods, guided by the Normalisation Process Theory (NPT) to explore the experiences and opinions of 26 healthcare professionals from a range of disciplines implementing the programme. RESULTS This study identified facilitating factors to the implementation of ERAS: alignment with evidence based practice, standardising practice, drawing on the evidence base of other specialties, leadership, teamwork, ERAS meetings, patient involvement and education, a pre-operative assessment unit, staff education, resources attached to obtaining The Commissioning for Quality and Innovation (CQUIN) money, the ward layout, data collection and feedback, and adapting the care pathway. A number of implementation challenges were also identified: resistance to change, standardisation affecting personalised patient care, the buy-in of relevant stakeholders, keeping ERAS visible, information provision to patients, resources, palatability of nutritional drinks, aligning different ward cultures, patients going to non-ERAS departments, spreading the programme within the hospital, differences in health issue, and utilising a segmental approach. CONCLUSIONS: The findings presented here provide useful contextual information from diverse surgical specialties to inform healthcare providers when implementing ERAS in practice. Addressing the challenges and utilising the facilitating factors identified in this study, could speed up the rate at which ERAS is adopted, implemented and embedded.
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Affiliation(s)
- Georgia Herbert
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK.
| | - Eileen Sutton
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK
| | - Sorrel Burden
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK.,School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Stephen Lewis
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK.,Derriford Hospital, Plymouth, UK
| | - Steve Thomas
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK.,Oral and Maxillofacial Surgery, University of Bristol, Bristol, UK
| | - Andy Ness
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK
| | - Charlotte Atkinson
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK
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208
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Leissner KB, Shanahan JL, Bekker PL, Amirfarzan H. Enhanced Recovery After Surgery in Laparoscopic Surgery. J Laparoendosc Adv Surg Tech A 2017; 27:883-891. [PMID: 28829221 DOI: 10.1089/lap.2017.0239] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND As part of an effort to maximize value in the perioperative setting, a paradigm shift is underway in the way that patients are cared for preoperatively, on the day of surgery, and postoperatively-a setting collectively known as the perioperative care. Enhanced Recovery After Surgery (ERAS®) is an evidence-based, patient-centered team approach to delivering high-quality perioperative care to surgical patients. METHODS This review focuses on anesthesiologists, with their unique purview of perioperative setting, who are important drivers of change in the delivery of valuable perioperative care. ERAS care pathways begin in the preoperative setting by both preparing the patient for the psychological stress of surgery and optimizing the patient's medical and physiologic status so the body is ready for the physical demands of surgery. RESULTS Minimization of perioperative fasting is important to maintain volume status-decreasing reliance on intravenous fluid administration, and to reduce protein catabolism around the time of surgery. Intraoperative management in ERAS pathways relies on goal-directed fluid therapy and opioid-sparing multimodal analgesia. Postoperatively, early feeding and ambulation, as well as discontinuation of extraneous lines and catheters facilitate patients' functional recovery. CONCLUSION The laparoscopic approach to surgery, when possible, compliments ERAS techniques by reducing abdominal wall trauma and the resultant milieu of inflammatory, neurohumoral, and pain responses. Anesthesiologists driving change in the perioperative setting, in collaboration with surgeons and other disciplines, can improve value in healthcare and provide optimal outcomes that matter most to patients and healthcare providers alike.
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Affiliation(s)
- Kay B Leissner
- Department of Anesthesiology, Critical Care and Pain Management, VA Boston Healthcare System, Harvard Medical School , West Roxbury, Massachusetts
| | - Jessica L Shanahan
- Department of Anesthesiology, Critical Care and Pain Management, VA Boston Healthcare System, Harvard Medical School , West Roxbury, Massachusetts
| | - Peter L Bekker
- Department of Anesthesiology, Critical Care and Pain Management, VA Boston Healthcare System, Harvard Medical School , West Roxbury, Massachusetts
| | - Houman Amirfarzan
- Department of Anesthesiology, Critical Care and Pain Management, VA Boston Healthcare System, Harvard Medical School , West Roxbury, Massachusetts
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209
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Wrzosek A, Jakowicka-Wordliczek J, Zajaczkowska R, Serednicki WT, Jankowski M, Bala MM, Polak M, Wordliczek J. Perioperative restrictive versus goal-directed fluid therapy for adults undergoing major non-cardiac surgery. Hippokratia 2017. [DOI: 10.1002/14651858.cd012767] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Anna Wrzosek
- Jagiellonian University, Medical College; Department of Interdisciplinary Intensive Care; Krakow Poland
| | | | - Renata Zajaczkowska
- Jagiellonian University, Medical College; Department of Interdisciplinary Intensive Care; Krakow Poland
| | - Wojciech T Serednicki
- Jagiellonian University, Medical College; Department of Interdisciplinary Intensive Care; Krakow Poland
| | - Milosz Jankowski
- University Hospital; Department of Anaesthesiology and Intensive Care; Krakow Poland
| | - Malgorzata M Bala
- Jagiellonian University Medical College; Department of Hygiene and Dietetics; Systematic Reviews Unit - Polish Cochrane Branch; Kopernika 7 Krakow Poland 31-034
| | - Maciej Polak
- Jagiellonian University, Medical College Krakow; Department of Epidemiology and Population Studies in the Institute of Public Health; Krakow Poland
| | - Jerzy Wordliczek
- Jagiellonian University, Medical College; Department of Interdisciplinary Intensive Care; Krakow Poland
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210
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Senturk JC, Kristo G, Gold J, Bleday R, Whang E. The Development of Enhanced Recovery After Surgery Across Surgical Specialties. J Laparoendosc Adv Surg Tech A 2017; 27:863-870. [PMID: 28795911 DOI: 10.1089/lap.2017.0317] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS®) principles have gained traction in variety of surgical disciplines. The promise of a reduced length of stay without compromising patient safety or increasing readmission rates has produced a body of literature examining the implementation of ERAS in the care of general, thoracic, urologic, and gynecologic surgery patients. METHODS We performed a review of the literature pertaining to studies of ERAS implementation across colorectal surgery, general surgery, thoracic surgery, urology, and gynecology. The extent of ERAS implementation and reported outcomes across key studies as well as systematic reviews and meta-analyses in each field were summarized. RESULTS The implementation of ERAS protocols has not been uniform across surgical specialties. Despite this, ERAS has produced improvements in patient outcomes. The most commonly described benefit of ERAS application has been reduced length of stay; complication and readmission rates are most consistently decreased in the colorectal literature. Studies have started to measure more nuanced measures of postoperative patient well-being. Efforts are growing to standardize ERAS protocols across diverse fields and call attention to the need for quality control. CONCLUSIONS Challenges remain in the study and execution of ERAS. Controlling for adherence to ERAS components and implementing uniform ERAS protocols across studies are burgeoning topics that have significant implications for study design. The practice of ERAS and its benefits to patients are expected to evolve. Assessing improvements in postdischarge quality of life, timing of return to work and independent living, and adherence to scheduled delivery of adjuvant treatments will strengthen future ERAS investigations.
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Affiliation(s)
- James C Senturk
- 1 Department of Surgery, Brigham and Women's Hospital/Harvard Medical School , Boston, Massachusetts
| | - Gentian Kristo
- 2 Department of Surgery, VA Boston Healthcare System , West Roxbury, Massachusetts
| | - Jason Gold
- 1 Department of Surgery, Brigham and Women's Hospital/Harvard Medical School , Boston, Massachusetts.,2 Department of Surgery, VA Boston Healthcare System , West Roxbury, Massachusetts
| | - Ronald Bleday
- 1 Department of Surgery, Brigham and Women's Hospital/Harvard Medical School , Boston, Massachusetts
| | - Edward Whang
- 1 Department of Surgery, Brigham and Women's Hospital/Harvard Medical School , Boston, Massachusetts.,2 Department of Surgery, VA Boston Healthcare System , West Roxbury, Massachusetts
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211
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Ban KA, Gibbons MM, Ko CY, Wick EC. Surgical Technical Evidence Review for Colorectal Surgery Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery. J Am Coll Surg 2017; 225:548-557.e3. [PMID: 28797562 DOI: 10.1016/j.jamcollsurg.2017.06.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 06/24/2017] [Accepted: 06/26/2017] [Indexed: 01/01/2023]
Affiliation(s)
- Kristen A Ban
- American College of Surgeons, Chicago, IL; Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Melinda M Gibbons
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Clifford Y Ko
- American College of Surgeons, Chicago, IL; Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD.
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212
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Pappalardo G, Coiro S, De Lucia F, Giannella A, Ruffolo F, Frattaroli FM. Open sphincter-preserving surgery of extraperitoneal rectal cancer without primary stoma and Fast Track Protocol. G Chir 2017; 37:257-261. [PMID: 28350972 DOI: 10.11138/gchir/2016.37.6.257] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
AIM Fast track protocol (FTP) showed to improve perioperative care. The study aims to evaluate the impact of the FTP in the open extraperitoneal rectal cancer (ERC) surgical treatment without a primary derivative stoma (DS) and the QoL in patients with or without a secondary DS. PATIENTS AND METHODS 50 patients affected by ERC were enrolled and operated on with open low anterior resection without a primary DS. They were randomized in two groups: one was treated perioperativelly in the traditional way (group T), the other using a modif ed FTP (group FT). A QoL questionnaire was administered prior to discharge and at 1-month follow-up. RESULTS Five courses (10%) were complicated by anastomotic leakage: 3 (12%) in the FT group (2 minor and 1 maior) and 2 (8%) in the T group (1 minor and 1 maior) (p=n.s.). All the maiors and one minor were treated with a DS. Patients of the group FTP were considered dischargeable earlier that those of group T (p<0.05). Patients with DS had a significantly lower QoL score (p<0.0001). CONCLUSION FTP with minor modifications is feasible and safe in the ERC open surgery without using a DS. Better results were obtained without increasing complication rate. A secondary DS impacts detrimentally on QoL.
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213
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Johnson NM, Fogel SL. An Expanded Preoperative Component within an Enhanced Recovery Protocol Improves Outcomes in Colorectal Surgery. Am Surg 2017. [DOI: 10.1177/000313481708300849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Enhanced Recovery Protocols (ERPs) have been shown to lead to quicker recovery in colorectal surgery, with reduced postoperative length of stay (LOS). ERPs could potentially be improved with an expanded preoperative component reflecting current evidence. We hypothesize that an ERP with an expanded preoperative component will reduce LOS consistent with or exceeding that seen with traditional ERPs. Our ERP was implemented in June of 2014. Data was collected for two full years from July 2014 through June 2016. The protocol was employed in colorectal cases, both elective and emergent. Data from ERP cases were compared with contemporaneous controls that did not go through the ERP. Patients who underwent colorectal procedures and participated in the ERP with the expanded preoperative component had an average LOS of 5.33 days, whereas controls stayed for an average of 7.93 days (P value, <0.01). ERP cases also experienced fewer read-missions and complications, although statistical significance could not be established. The results demonstrate that an ERP with an enhanced preoperative component significantly reduces LOS and potentially decreases the rate of readmissions and total complications.
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Affiliation(s)
| | - Sandy L. Fogel
- Department of Surgery, Carilion Clinic and Virginia Tech Carilion School of Medicine, Roanoke, Virginia
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214
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Moran B, Cunningham C, Singh T, Sagar P, Bradbury J, Geh I, Karandikar S. Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Surgical Management. Colorectal Dis 2017. [PMID: 28632309 DOI: 10.1111/codi.13704] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Brendan Moran
- Basingstoke & North Hampshire Hospital, Basingstoke, UK
| | | | | | | | | | - Ian Geh
- Queen Elizabeth Hospital, Birmingham, UK
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215
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Zeng WG, Liu MJ, Zhou ZX, Wang ZJ. Enhanced recovery programme following laparoscopic colorectal resection for elderly patients. ANZ J Surg 2017. [PMID: 28640971 DOI: 10.1111/ans.14074] [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] [Indexed: 01/20/2023]
Abstract
BACKGROUND The aim of this study was to investigate the feasibility and safety of an enhanced recovery programme (ERP) in patients aged ≥75 years who undergo laparoscopic surgery for colorectal cancer. METHODS Patients were divided into two groups according to perioperative management: the ERP group (Group A, n = 94) and the conventional perioperative care group (Group B, n = 157). The postoperative outcomes were compared between two groups. RESULTS There were no differences in terms of age, gender, American Society of Anesthesiologists score, operative time or blood loss between two groups. Postoperative return of gastrointestinal function was significantly faster in Group A compared to Group B, including time to first flatus (2 versus 3 days, P < 0.001), first stool (3 versus 4 days, P = 0.001) and oral intake (1 versus 4 days, P < 0.001). Group A was associated with lower overall postoperative complication rate (26.6% versus 44.6%, P = 0.004) and general complication rate (14.9% versus 31.2%, P = 0.004). The median postoperative hospital stay was 6 days in Group A and 8 days in Group B (P < 0.001), respectively. CONCLUSIONS ERP following laparoscopic colorectal resection for elderly patients is associated with faster postoperative recovery, shorter postoperative hospital stay and fewer complications compared with conventional perioperative care.
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Affiliation(s)
- Wei Gen Zeng
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Meng Jia Liu
- Department of Ultrasound, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Zhi Xiang Zhou
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Zhen Jun Wang
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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216
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Ripollés-Melchor J, Chappell D, Espinosa Á, Mhyten MG, Abad-Gurumeta A, Bergese SD, Casans-Francés R, Calvo-Vecino JM. Perioperative fluid therapy recommendations for major abdominal surgery. Via RICA recommendations revisited. Part I: Physiological background. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2017; 64:328-338. [PMID: 28364973 DOI: 10.1016/j.redar.2017.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 02/08/2017] [Accepted: 02/08/2017] [Indexed: 06/07/2023]
Affiliation(s)
- J Ripollés-Melchor
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España.
| | - D Chappell
- Departamento de Anestesia, Hospital Universitario LMU de Múnich, Múnich, Alemania
| | - Á Espinosa
- Departamento de Anestesia Cardiovascular y Torácica, y Cuidados Intensivos, Bahrain Defence Force Hospital, Riffa, Reino de Baréin
| | - M G Mhyten
- University College London Hospital, National Institute of Health Research, Biomedical Research Centre, Londres, Reino Unido
| | - A Abad-Gurumeta
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España
| | - S D Bergese
- Departamento de Anestesia y Neurocirugía, Wexner Medical Center, The Ohio State University, Columbus, OH, Estados Unidos
| | - R Casans-Francés
- Departamento de Anestesia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J M Calvo-Vecino
- Departamento de Anestesia, Complejo Asistencial de Salamanca, Universidad de Salamanca, Salamanca, España
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Siekmann W, Eintrei C, Magnuson A, Sjölander A, Matthiessen P, Myrelid P, Gupta A. Surgical and not analgesic technique affects postoperative inflammation following colorectal cancer surgery: a prospective, randomized study. Colorectal Dis 2017; 19:O186-O195. [PMID: 28258664 DOI: 10.1111/codi.13643] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 01/04/2017] [Indexed: 12/12/2022]
Abstract
AIM Epidural analgesia reduces the surgical stress response. However, its effect on pro- and anti-inflammatory cytokines in the genesis of inflammation following major abdominal surgery remains unclear. Our main objective was to elucidate whether perioperative epidural analgesia prevents the inflammatory response following colorectal cancer surgery. METHODS Ninety-six patients scheduled for open or laparoscopic surgery were randomized to epidural analgesia (group E) or patient-controlled intravenous analgesia (group P). Surgery and anaesthesia were standardized in both groups. Plasma cortisol, insulin and serum cytokines [interleukin 1β (IL-1β), IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p70, IL-13, tumour necrosis factor α, interferon γ, granulocyte-macrophage colony-stimulating factor, prostaglandin E2 and vascular endothelial growth factor] were measured preoperatively (T0), 1-6 h postoperatively (T1) and 3-5 days postoperatively (T2). Mixed model analysis was used, after logarithmic transformation when appropriate, for analyses of cytokines and stress markers. RESULTS >There were no significant differences in any serum cytokine concentration between groups P and E at any time point except for IL-10 which was 87% higher in group P [median and range 4.1 (2.3-9.2) pg/ml] compared to group E [2.6 (1.3-4.7) pg/ml] (P = 0.002) at T1. There was no difference in plasma cortisol and insulin between the groups at any time point after surgery. A significant difference in median serum cytokine concentration was found between open and laparoscopic surgery with higher levels of IL-6, IL-8 and IL-10 at T1 in patients undergoing open surgery compared to laparoscopic surgery. No difference in serum cytokine concentration was detected between the groups or between the surgical technique at T2. CONCLUSIONS Open surgery, compared to laparoscopic surgery, has greater impact on these inflammatory mediators than epidural analgesia vs intravenous analgesia.
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Affiliation(s)
- W Siekmann
- Department of Anaesthesiology and Intensive Care, Örebro University Hospital and School of Medical Sciences, Örebro University, Örebro, Sweden
| | - C Eintrei
- Department of Anesthesiology and Intensive Care, County Council of Östergötland, Linköping, Sweden
| | - A Magnuson
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - A Sjölander
- Cell and Experimental Pathology, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - P Matthiessen
- Department of Surgery, Örebro University Hospital and School of Medical Sciences, Örebro University, Örebro, Sweden
| | - P Myrelid
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Surgery, Linköping University Hospital, Linköping, Sweden
| | - A Gupta
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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218
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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.
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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
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219
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Venara A, Barbieux J, Mucci S, Talbot MF, Lermite E, Hamy A. Short-Term Outcomes of Colorectal Resection for Cancer in Elderly in the Era of Enhanced Recovery. Scand J Surg 2017; 107:31-37. [PMID: 28464708 DOI: 10.1177/1457496917706010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS Early rehabilitation protocols should be assessed in elderly. We aimed to study the outcomes of colorectal surgery and the observance of the modalities of an early rehabilitation protocol in patients over 80 years. MATERIAL AND METHODS All consecutive patients who underwent surgery for colorectal cancer in our center over a 19-month period were included. All of these patients were managed using the same early rehabilitation protocol. Patients older than 80 were compared to younger patients. RESULTS A total of 173 patients were included and 36 were ≥80 years (20.8%). Patients aged ≥80 years had a significantly higher ASA score and were operated on in emergency. In the peroperative period, patients aged ≥80 years were more likely to undergo laparotomy than patients <80 years in univariate analysis (p = 0.048), but in multivariate analysis, the choice for a laparoscopy was influenced by ASA score ≤2 (odds ratio = 3.55, 95% confidence interval = 1.67-7.58) and emergency surgery (odds ratio = 0.18, 95% confidence interval = 0.06-0.50). In the postoperative period, peristalsis stimulation and vascular catheter ablation were significantly better followed in Group 1 (p = 0.012 and 0.031). However, in multivariate analysis, age was not significantly associated with these parameters. Peristalsis stimulation was influenced by ASA score ≥2 (odds ratio = 4.27, 95% confidence interval = 1.18-15.37) and vascular catheter ablation was also influenced by ASA score ≤2 (odds ratio = 2.63, 95% confidence interval = 1.33-5.21). Emergency surgery had a strong trend to influence these parameters (p = 0.08). CONCLUSION Although age or comorbidities may affect observance for certain modalities such as chewing gum use and vascular catheter ablation, an early rehabilitation protocol can be used after colorectal cancer surgery in patients ≥80 years old, where it would improve functional results and postoperative outcomes.
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Affiliation(s)
- A Venara
- 1 L'UNAM and University of Angers, Angers, France.,2 Department of Visceral Surgery, CHU Angers, Angers, France.,3 UMR INSERM 1235, TENS, the enteric nervous system in gut and brain disorder, University of Nantes, Nantes, France
| | - J Barbieux
- 1 L'UNAM and University of Angers, Angers, France.,2 Department of Visceral Surgery, CHU Angers, Angers, France
| | - S Mucci
- 1 L'UNAM and University of Angers, Angers, France
| | - M F Talbot
- 4 Department of Anesthesia and Intensive Care, CHU Angers, Angers, France
| | - E Lermite
- 1 L'UNAM and University of Angers, Angers, France.,2 Department of Visceral Surgery, CHU Angers, Angers, France
| | - A Hamy
- 1 L'UNAM and University of Angers, Angers, France.,2 Department of Visceral Surgery, CHU Angers, Angers, France
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Are we ready for the ERAS protocol in colorectal surgery? Wideochir Inne Tech Maloinwazyjne 2017; 12:7-12. [PMID: 28446926 PMCID: PMC5397552 DOI: 10.5114/wiitm.2017.66672] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 03/02/2017] [Indexed: 12/21/2022] Open
Abstract
Introduction Modern perioperative care principles in elective colorectal surgery have already been established by international surgical authorities. Nevertheless, barriers to the introduction of routine evidence-based clinical care and changing dogmas still exist. One of the factors is the surgeon. Aim To assess perioperative care trends in elective colorectal surgery among general surgery consultants in surgical departments in Malopolska Voivodeship, Poland. Material and methods An anonymous standardized 20-question questionnaire was developed based on ERAS principles and sent out to Malopolska Voivodeship general surgery departments. Answers of general surgery consultants showed the level of acceptance of elements of perioperative care. Results The overall response rate was 66%. Several elements (antibiotic and antithrombotic prophylaxis, postoperative oxygen therapy, no nasogastric tubes) had quite a high acceptance rate. On the other hand, most crucial surgical perioperative elements (lack of mechanical bowel preparation, preoperative oral carbohydrate loading, use of laparoscopy and lack of drains, early fluid and oral diet intake, early mobilization) were not followed according to evidence-based ERAS protocol recommendations. Surgeons were not willing to change their practice, but were supportive of changes in anesthesiologist-dependent elements of perioperative care, such as restrictive fluid therapy, use of transversus abdominis plane blocks, etc. Conclusions Many elements of perioperative care in elective colorectal surgery in Malopolska Voivodeship are still dictated by dogma and are not evidence-based. The level of acceptance of many important ERAS protocol elements is low. Surgeons are ready to accept only changes that do not interfere with their practice.
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222
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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.
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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
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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.
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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
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Armstrong JG, Li CH, Liao J, Byrn JC. Right Colectomy and Abdominal Perineal Resection for Cancer: Do Urinary Tract Infections Impact Outcomes? Surg Infect (Larchmt) 2017; 18:570-576. [PMID: 28266900 DOI: 10.1089/sur.2016.282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND We aim to assess the patient factors and concomitant infectious outcomes associated with urinary tract infection (UTI) occurrence and the impact of UTI on length of stay (LOS), re-admission, and death in a colorectal surgical population. PATIENTS AND METHODS National Surgical Quality Improvement Program User Data for right colectomy and abdominal perineal resection (APR) procedures for cancer between 2006 and 2012 were analyzed. Concomitant infectious complications and timing of UTI diagnosis, inpatient versus outpatient, were considered. RESULTS We identified 7,615 right colectomies with 107 (1.4%) UTIs and 2,493 APRs with 88 (3.5%) UTIs (p < 0.001). On multivariable analysis and correction for other post-operative complications, UTI remained statistically correlated with prolonged LOS for right colectomy and APR (LOS increases of 59.0% and 37.4%, respectively, p < 0.001) but not death. Patients with a diagnosis of UTI after discharge showed significantly increased re-admission rates compared with UTI diagnosis before discharge (37.7% vs. 9.7%, p < 0.001). CONCLUSIONS After excluding deaths, outpatient UTI occurrences, and correcting for other infectious complications, UTI is associated with increased LOS but is not correlated with re-admission or death. Outpatient occurrence of UTI after hospital discharge is associated with a dramatic re-admission rate of 37.7%.
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Affiliation(s)
- John G Armstrong
- 1 Department of Surgery, The University of Iowa Carver College of Medicine , Iowa City, Iowa
| | - Chien-Hsun Li
- 1 Department of Surgery, The University of Iowa Carver College of Medicine , Iowa City, Iowa
| | - Junlin Liao
- 1 Department of Surgery, The University of Iowa Carver College of Medicine , Iowa City, Iowa
| | - John C Byrn
- 2 Department of Surgery, University of Michigan Health System , Ann Arbor, Michigan
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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.
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226
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Fast-Track Surgery Could Improve Postoperative Recovery in Patients with Laparoscopy D2 Gastrectomy. Int Surg 2017. [DOI: 10.9738/intsurg-d-17-00110.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The objective of this study is to evaluate the safety and efficacy of fast track surgery (FTS) management in gastric cancer (GC) with laparoscopy D2 gastrectomy. FTS is the integration of different medical intervention activities during the perioperative period to accelerate the recovery of patients undergoing surgery. It has been used for colorectal cancer. The present study focuses on evaluating FTS in GC with laparoscopy D2 gastrectomy. Seventy-five patients diagnosed with GC between June 2014 and December 2016 were enrolled in this study and were divided into FTS and conventional care groups. All patients received elective standard D2 gastrectomy. The clinical parameters and serum indicators were compared. FTS was associated with shorter postoperative hospital stay (17.17 ± 9.27 versus 14.06 ± 5.05 days; P = 0.046), shorter time to bowel function return (4.56 ± 1.16 versus 3.12 ± 0.88 days; P < 0.01), less stress response on postoperative day 1 (108.13 ± 40.55 versus 79.01 ± 37.10; P < 0.01), and accelerated decrease in serum albumin (30.76 ± 4.10 versus 32.56 ± 3.20 g/L; P = 0.04) and lymphocyte count (0.78 ± 0.34 versus 0.78 ± 0.34 g/L; P = 0.016). The postoperative complications, including ileus, anastomotic leakage, and infection, were similar (all P > 0.05). FTS combined with laparoscopy D2 gastrectomy can promote faster postoperative recovery, improve early postoperative nutritional status, and more effectively reduce postoperative stress reaction and is safe and effective for GC patients.
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227
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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
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Shida D, Tagawa K, Inada K, Nasu K, Seyama Y, Maeshiro T, Miyamoto S, Inoue S, Umekita N. Modified enhanced recovery after surgery (ERAS) protocols for patients with obstructive colorectal cancer. BMC Surg 2017; 17:18. [PMID: 28209144 PMCID: PMC5314620 DOI: 10.1186/s12893-017-0213-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 02/09/2017] [Indexed: 12/15/2022] Open
Abstract
Background Enhanced recovery after surgery (ERAS) protocols are now well-known to be useful for elective colorectal surgery, as they result in shorter hospital stays without adversely affecting morbidity. However, the efficacy and safety of ERAS protocols for patients with obstructive colorectal cancer have yet to be clarified. Methods We evaluated 122 consecutive resections for obstructive colorectal cancer performed between July 2008 and November 2012 at Tokyo Metropolitan Bokutoh Hospital. Patients with rupture or impending rupture and those who received simple colostomy were excluded. The first set of 42 patients was treated based on traditional protocols, and the latter 80 according to modified ERAS protocols. The main endpoints were length of postoperative hospital stay, postoperative short-term morbidity, rate of readmission within 30 days, and mortality. Differences in modified ERAS protocols relative to traditional care include intensive preoperative counseling (by both surgeons and anesthesiologists), perioperative fluid management (avoidance of sodium/fluid overload), shortening of postoperative fasting period and early provision of oral nutrition, intraoperative warm air body heating, enforced postoperative mobilization, stimulation of gut motility, early removal of urinary catheter, and a multidisciplinary team approach to care. Results Median (interquartile range) postoperative hospital stay was 10 (10–14.25) days in the traditional group, and seven (7–8.75) days in the ERAS group, showing a 3-day reduction in hospital stay (p < 0.01). According to the Clavien-Dindo classification, overall incidences of grade 2 or higher postoperative complications for the traditional and ERAS groups were 15 and 10% (p = 0.48), and 30-day readmission rates were 0 and 1.3% (p = 1.00), respectively. As for mortality, one patient in the traditional group died and none in the ERAS group (p = 0.34). Conclusion Modified ERAS protocols for obstructive colorectal cancer reduced hospital stay without adversely affecting morbidity, indicating that ERAS protocols are feasible for patients with obstructive colorectal cancer.
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Affiliation(s)
- Dai Shida
- Colorectal Surgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 1040045, Japan.
| | - Kyoko Tagawa
- Department of Anesthesiology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Koto-bashi, Sumida-ku, Tokyo, 1308575, Japan
| | - Kentaro Inada
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Koto-bashi, Sumida-ku, Tokyo, 1308575, Japan
| | - Keiichi Nasu
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Koto-bashi, Sumida-ku, Tokyo, 1308575, Japan
| | - Yasuji Seyama
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Koto-bashi, Sumida-ku, Tokyo, 1308575, Japan
| | - Tsuyoshi Maeshiro
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Koto-bashi, Sumida-ku, Tokyo, 1308575, Japan
| | - Sachio Miyamoto
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Koto-bashi, Sumida-ku, Tokyo, 1308575, Japan
| | - Satoru Inoue
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Koto-bashi, Sumida-ku, Tokyo, 1308575, Japan
| | - Nobutaka Umekita
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Koto-bashi, Sumida-ku, Tokyo, 1308575, Japan
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Scott AR, Alore EA, Naik AD, Berger DH, Suliburk JW. Mixed-Methods Analysis of Factors Impacting Use of a Postoperative mHealth App. JMIR Mhealth Uhealth 2017; 5:e11. [PMID: 28179215 PMCID: PMC5322201 DOI: 10.2196/mhealth.6728] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/02/2016] [Accepted: 12/16/2016] [Indexed: 01/10/2023] Open
Abstract
Background Limited communication and care coordination following discharge from hospitals may contribute to surgical complications. Smartphone apps offer a novel mechanism for communication and care coordination. However, factors which may affect patient app use in a postoperative, at-home setting are poorly understood. Objective The objectives of this study were to (1) gauge interest in smartphone app use among patients after colorectal surgery and (2) better understand factors affecting patient app use in a postoperative, at-home setting. Methods A prospective feasibility study was performed at a hospital that principally serves low socioeconomic status patients. After colorectal surgery, patients were enrolled and given a smartphone app, which uses previously validated content to provide symptom-based recommendations. Patients were instructed to use the app daily for 14 days after discharge. Demographics and usability data were collected at enrollment. Usability was measured with the System Usability Scale (SUS). At follow-up, the SUS was repeated and patients underwent a structured interview covering ease of use, willingness to use, and utility of use. Two members of the research team independently reviewed the field notes from follow-up interviews and extracted the most consistent themes. Chart and app log reviews identified clinical endpoints. Results We screened 115 patients, enrolled 20 patients (17.4%), and completed follow-up interviews with 17 patients (85%). Reasons for nonenrollment included: failure to meet inclusion criteria (47/115, 40.9%), declined to participate (26/115, 22.6%), and other reasons (22/115, 19.1%). There was no difference in patient ratings between usability at first-use and after extended use, with SUS scores greater than the 95th percentile at both time points. Despite high usability ratings, 6/20 (30%) of patients never used the app at home after hospital discharge and 2/20 (10%) only used the app once. Interviews revealed three themes related to app use: (1) patient-related barriers could prevent use even though the app had high usability scores; (2) patients viewed the app as a second opinion, rather than a primary source of information; and (3) many patients viewed the app as an external burden. Conclusions Use patterns in this study, and response rates after prompts to contact the operative team, suggest that apps need to be highly engaging to be adopted by patients. The growing penetration of smartphones and the proliferation of app-based interventions are unlikely to improve care coordination and communication, unless apps address the barriers and patient perceptions identified in this study. This study shows that high usability alone is not sufficient to motivate patients to use smartphone apps in the postoperative period.
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Affiliation(s)
- Aaron R Scott
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Elizabeth A Alore
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Aanand D Naik
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research and Development Center of Innovation, Houston, TX, United States.,Alkek Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - David H Berger
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research and Development Center of Innovation, Houston, TX, United States
| | - James W Suliburk
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Department of Surgery, Ben Taub General Hospital, Houston, TX, United States
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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]
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231
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Abstract
Surgery involving the gastrointestinal tract continues to prove challenging because of the persistence of unpredictable complications such as anastomotic leakage and life-threatening infections. Removal of diseased intestinal segments results in substantial catabolic stress and might require complex reconstructive surgery to maintain the functional continuity of the intestinal tract. As gastrointestinal surgery necessarily involves a breach of an epithelial barrier colonized by microorganisms, preoperative intestinal antisepsis is used to reduce infection-related complications. The current approach to intestinal antisepsis varies widely across institutions and countries with little understanding of its mechanism of action, effect on the gut microbiota and overall efficacy. Many of the current approaches to intestinal antisepsis before gastrointestinal surgery run counter to emerging concepts of intestinal microbiota contributing to immune function and recovery from injury. Here, we review evidence outlining the role of gut microbiota in recovery from gastrointestinal surgery, particularly in the development of infections and anastomotic leak. To make surgery safer and further reduce complications, a molecular, genetic and functional understanding of the response of the gastrointestinal tract to alterations in its microbiota is needed. Methods can then be developed to preserve the health-promoting functions of the microbiota while at the same time suppressing their harmful effects.
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Affiliation(s)
- Kristina Guyton
- MC-6040, Department of Surgery, University of Chicago Medicine, 5841 South Maryland Avenue, Chicago, Illinois 60637, USA
| | - John C Alverdy
- MC-6090, Department of Surgery, University of Chicago Medicine, 5841 South Maryland Avenue, Chicago, Illinois 60637, USA
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232
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Dai X, Ge X, Yang J, Zhang T, Xie T, Gao W, Gong J, Zhu W. Increased incidence of prolonged ileus after colectomy for inflammatory bowel diseases under ERAS protocol: a cohort analysis. J Surg Res 2016; 212:86-93. [PMID: 28550927 DOI: 10.1016/j.jss.2016.12.031] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/13/2016] [Accepted: 12/22/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Postoperative ileus is a common problem after colorectal surgery. The aim of the study was to investigate the incidence and risk factors for prolonged postoperative ileus (POI) after colectomy for inflammatory bowel diseases (IBDs). METHODS Consecutive patients who underwent colorectal resection for IBD versus colorectal cancer (CRC) patients under enhanced recovery after surgery protocol were retrospectively analyzed. Primary assessment end point is the incidence of prolonged POI (>4 days); secondary end points were GI-2 recovery (time to first toleration of solid food and first bowel movement), nasogastric tube reinsertion, and postoperative length of stay. Risk factors for prolonged POI in IBD patients were assessed by multiple logistic regression analysis with P score matching. RESULTS The incidence of prolonged POI was higher in IBD versus CRC group (28.8% versus 14.8%, P < 0.001). Patients with IBD had a longer time to GI-2 recovery (4.8 ± 2.1 versus 3.7 ± 1.4 d, P < 0.001), postoperative length of stay (10.7 ± 6.2 versus 7.9 ± 5.3 d, P < 0.001), higher incidence of nasogastric tube reinsertion (9.8% versus 4.0%, P = 0.02). After propensity-score matching analysis, the differences were still significant. Preoperative steroid use >20 mg/d (odds ratio, [OR] = 2.19, P = 0.048), hypoalbuminemia (<35 g/L; OR 2.72, P = 0.03), systemic inflammatory response syndrome status (OR 4.91, P = 0.03), and postoperative intraabdominal sepsis (OR 9.31, P = 0.001) were independent risk factors for prolonged POI in IBD patients. CONCLUSIONS In the setting of enhanced recovery after surgery, colectomy for IBD is associated with delayed gastrointestinal function recovery and higher incidence of prolonged POI compared to CRC patients. Normalizing preoperative albumin level, weaning off steroids, reducing preoperative systemic inflammatory response syndrome, and early management of postoperative intraabdominal sepsis may reduce POI in IBD population.
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Affiliation(s)
- Xujie Dai
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiaolong Ge
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jianbo Yang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Tenghui Zhang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Tingbin Xie
- Department of General Surgery, Jinling Hospital Affiliated to Southern Medical University, Nanjing, China
| | - Wen Gao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China; Department of General Surgery, Jinling Hospital Affiliated to Southern Medical University, Nanjing, China.
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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233
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Uptake of enhanced recovery practices by SAGES members: a survey. Surg Endosc 2016; 31:3519-3526. [DOI: 10.1007/s00464-016-5378-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 11/27/2016] [Indexed: 12/15/2022]
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234
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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.
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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
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235
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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
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Quality and Safety in Health Care, Part XVIII: Improving Outcomes in Colorectal Surgery. Clin Nucl Med 2016; 42:40-41. [PMID: 27764038 DOI: 10.1097/rlu.0000000000001412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
An important way to improve outcomes after colorectal surgery is to follow the recommendations of the enhanced recovery pathway after surgery (ERAS). The ERAS guidelines are recommendations that address certain aspects of what should be done before surgery, in the operating room, and following surgery. There is a substantial fall in complications and a decrease in the length of stay for the patient if the recommendations are followed. Elements of the ERAS program are now being adopted for other surgical procedures besides colorectal surgery.
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237
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Lee H, Cho CW, Yoon S, Suh KS, Ryu HG. Effect of sham feeding with gum chewing on postoperative ileus after liver transplantation-a randomized controlled trial. Clin Transplant 2016; 30:1501-1507. [DOI: 10.1111/ctr.12849] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2016] [Indexed: 01/15/2023]
Affiliation(s)
- Hannah Lee
- Department of Anesthesiology and Pain Medicine; Seoul National University College of Medicine; Seoul National University Hospital; Seoul Korea
| | - Chan Woo Cho
- Department of Anesthesiology and Pain Medicine; Seoul National University College of Medicine; Seoul National University Hospital; Seoul Korea
| | - Susie Yoon
- Department of Anesthesiology and Pain Medicine; Seoul National University College of Medicine; Seoul National University Hospital; Seoul Korea
| | - Kyung-Suk Suh
- Department of Surgery; Seoul National University College of Medicine; Seoul National University Hospital; Seoul Korea
| | - Ho Geol Ryu
- Department of Anesthesiology and Pain Medicine; Seoul National University College of Medicine; Seoul National University Hospital; Seoul Korea
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238
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90-Day complication rate in patients undergoing radical cystectomy with enhanced recovery protocol: a prospective cohort study. World J Urol 2016; 35:907-911. [PMID: 27734131 DOI: 10.1007/s00345-016-1950-z] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 10/04/2016] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To report 90-day complication rates following radical cystectomy (RC) with enhanced recovery after surgery (ERAS) protocol. METHODS All consecutive patients who underwent open RC with ERAS protocol from 2012 to 2014 were included. The protocol includes no bowel preparation or NGT, early feeding, predominantly non-narcotic pain management and μ-opioid antagonists. Non-consenting and lost to follow-up patients were excluded. All patients were closely followed up, and 90-day complication (Clavien-Dindo grading), readmission and emergency room (ER) visits were prospectively recorded. RESULTS One hundred and sixty-nine cases with a median age of 71 years were included in the study. 90-Day major and minor complication rates were 24.3 and 53.9 %, respectively. The most common complications were infectious and gastrointestinal. The 90-day ER visit rate was 37.9 %, whereas the readmission rate was 29.6 %. The most common cause of hospital readmission and ER visits was infections. CONCLUSION Radical cystectomy and urinary diversion with enhanced recovery protocol is a morbid surgery. The most common complication, cause of ER visit and readmission is yet infections. Further studies on methods to decrease these rates are underway.
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239
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Abstract
Postoperative ileus (POI) is a major focus of concern for surgeons because it increases duration of hospitalization, cost of care, and postoperative morbidity. The definition of POI is relatively consensual albeit with a variable definition of interval to resolution ranging from 2 to 7 days for different authors. This variation, however, leads to non-reproducibility of studies and difficulties in interpreting the results. Certain risk factors for POI, such as male gender, advanced age and major blood loss, have been repeatedly described in the literature. Understanding of the pathophysiology of POI has helped combat and prevent its occurrence. But despite preventive and therapeutic efforts arising from such knowledge, 10 to 30% of patients still develop POI after abdominal surgery. In France, pharmacological prevention is limited by the unavailability of effective drugs. Perioperative nutrition is very important, as well as limitation of preoperative fasting to 6 hours for solid food and 2 hours for liquids, and virtually no fasting in the postoperative period. Coffee and chewing gum also play a preventive role for POI. The advent of laparoscopy has led to a significant improvement in the recovery of gastrointestinal function. Enhanced recovery programs, grouping together all measures for prevention or cure of POI by addressing the mechanisms of POI, has reduced the duration of hospitalization, morbidity and interval to resumption of transit.
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240
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Thiele RH, Raghunathan K, Brudney CS, Lobo DN, Martin D, Senagore A, Cannesson M, Gan TJ, Mythen MMG, Shaw AD, Miller TE. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery. Perioper Med (Lond) 2016; 5:24. [PMID: 27660701 PMCID: PMC5027098 DOI: 10.1186/s13741-016-0049-9] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 08/24/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Enhanced recovery may be viewed as a comprehensive approach to improving meaningful outcomes in patients undergoing major surgery. Evidence to support enhanced recovery pathways (ERPs) is strong in patients undergoing colorectal surgery. There is some controversy about the adoption of specific elements in enhanced recovery "bundles" because the relative importance of different components of ERPs is hard to discern (a consequence of multiple simultaneous changes in clinical practice when ERPs are initiated). There is evidence that specific approaches to fluid management are better than alternatives in patients undergoing colorectal surgery; however, several specific questions remain. METHODS In the "Perioperative Quality Initiative (POQI) Fluids" workgroup, we developed a framework broadly applicable to the perioperative management of intravenous fluid therapy in patients undergoing elective colorectal surgery within an ERP. DISCUSSION We discussed aspects of ERPs that impact fluid management and made recommendations or suggestions on topics such as bowel preparation; preoperative oral hydration; intraoperative fluid therapy with and without devices for goal-directed fluid therapy; and type of fluid.
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Affiliation(s)
- Robert H Thiele
- Departments of Anesthesiology and Biomedical Engineering, Divisions of Cardiac, Thoracic, and Critical Care Anesthesiology, UVA Enhanced Recovery after Surgery (ERAS) Program, University of Virginia School of Medicine, Charlottesville, VA USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710 USA
| | - C S Brudney
- Duke University and Durham VA Medical Center, Durham, NC USA
| | - Dileep N Lobo
- Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH UK
| | - Daniel Martin
- Division of Surgery and Interventional Science, University College London, Royal Free Hospital, London, NW3 2QG UK ; Anaesthetic Department, Royal Free Perioperative Research Group, Royal Free Hospital, London, NW3 2QG UK
| | - Anthony Senagore
- Department of Surgery, University of Texas-Medical Branch at Galveston, Galveston, TX 77555 USA
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA USA
| | - Tong Joo Gan
- Department of Anesthesiology, Stony Brook University School of Medicine, Stony Brook, NY USA
| | - Michael Monty G Mythen
- University College London Hospitals, National Institute of Health Research Biomedical Research Centre, London, UK
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Timothy E Miller
- Division of General, Vascular and Transplant Anesthesia, American Society for Enhanced Recovery, Duke University Medical Center, Durham, NC 27710 USA
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Messenger DE, Curtis NJ, Jones A, Jones EL, Smart NJ, Francis NK. Factors predicting outcome from enhanced recovery programmes in laparoscopic colorectal surgery: a systematic review. Surg Endosc 2016; 31:2050-2071. [PMID: 27631314 DOI: 10.1007/s00464-016-5205-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 08/18/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To perform a systematic review of published literature for the factors reported to predict outcomes of enhanced recovery after surgery (ERAS) programmes following laparoscopic colorectal surgery. BACKGROUND ERAS programmes and the use of laparoscopy have been widely adopted in colorectal surgery bringing short-term patient benefit. However, there is a minority of patients that do not benefit from these strategies and their identification is not well characterised. The factors that underpin outcomes from ERAS programmes for laparoscopic patients are not understood. METHODS A systematic search of the MEDLINE, Embase and Cochrane databases was conducted to identify suitable articles published between 2000 and 2015. The search strategy captured terms for ERAS, colorectal resection, prediction and outcome measures. RESULTS Thirty-four studies containing 10,861 laparoscopic resections were included. Thirty-one (91 %) studies were confined to elective cases. Predictive analysis of outcome was most frequently based on length of stay (LOS), morbidity and readmission which were the main outcome measures of 29 (85 %), 26 (76 %) and 18 (53 %) of the included studies, respectively. Forty-seven percentage of included studies investigated the impact of ERAS programme compliance on these outcomes. Reduced protocol compliance was the most frequently identified modifiable predictive factor for adverse LOS, morbidity and readmission. CONCLUSION Protocol compliance is the most frequently reported predictive factor for outcomes of ERAS programmes following laparoscopic colorectal resection. Reduced compliance increases LOS, morbidity and readmission to hospital. The impact of compliance with individual ERAS protocol elements is insufficiently studied, and the lack of a standardised framework for evaluating ERAS programmes makes it difficult to draw definite conclusions about which factors exert the greatest impact on outcome after laparoscopic colorectal resection.
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Affiliation(s)
- David E Messenger
- Colorectal Surgical Unit, University Hospitals Bristol NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8HW, UK
| | - Nathan J Curtis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK
| | - Adam Jones
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK
| | - Emma L Jones
- Department of Health Sciences, University of Leicester, 22-28 Princess Road West, Leicester, LE1 6TP, UK
| | - Neil J Smart
- Department of General Surgery, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Nader K Francis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK.
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Tevis SE, Kennedy GD. Postoperative Complications: Looking Forward to a Safer Future. Clin Colon Rectal Surg 2016; 29:246-52. [PMID: 27582650 DOI: 10.1055/s-0036-1584501] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Colorectal surgery patients frequently suffer from postoperative complications. Patients with complications have been shown to be at higher risk for mortality, poor oncologic outcomes, additional complications, and worse quality of life. Complications are increasingly recognized as markers of quality of care with more use of risk-adjusted national surgical databases and increasing transparency in health care. Quality improvement work in colorectal surgery has identified methods to decrease complication rates and improve outcomes in this patient population. Future work will continue to identify best practices and standardized ways to measure quality of care.
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Affiliation(s)
- Sarah E Tevis
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Gregory D Kennedy
- Department of Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
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243
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Ripollés-Melchor J, Casans-Francés R, Abad-Gurumeta A, Suárez-de-la-Rica A, Ramírez-Rodríguez JM, López-Timoneda F, Calvo-Vecino JM. Spanish survey on enhanced recovery after surgery. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:376-383. [PMID: 26796041 DOI: 10.1016/j.redar.2015.09.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 09/01/2015] [Accepted: 09/17/2015] [Indexed: 06/05/2023]
Abstract
INTRODUCTION The aim of this study was to determine the interest in ERAS protocols, and the extent to which clinicians are familiar with and apply these protocols during perioperative care. MATERIALS AND METHODS Free access survey hosted on the Spanish Society of Anesthesiology and Critical Care; Spanish Association of Surgeons and Spanish Society of Enteral and Parenteral nutrition and ERAS Spain (GERM) websites conducted between September and December 2014. RESULTS The survey was answered by 272 professionals (44.5% anaesthetists, 45.2% general surgeons) from 110 hospitals, 73% of whom had experience in ERAS protocols. Most (86.1%) had specific knowledge of ERAS protocols, whereas only 50.9% were familiar with ERAS recommendations and 42.4% with GERM recommendations. Most (73.1%) respondents reported that ERAS protocols are performed in their hospitals, mainly in colorectal surgery (93%), and 52.2% reported that GERM/ERAS recommendations are followed. Nearly all (95.5%) would be interested in the development of multidisciplinary national guidelines. Less than half (46.6%) perform preoperative nutritional assessment, albeit without a universal malnutrition screening method (56.8%). Preoperative loading with carbohydrate drinks is carried out in only 51.4% of cases; nasogastric tube and drainage are avoided (79.3%), prophylaxis for postoperative nausea and vomiting (73.4%), goal directed fluid therapy (73.3%), and active normothermia maintenance (87.4%) are performed. In most cases, mobilization (90.1%) and early feeding (87.9%) are performed. The leading causes of protocol failure are postoperative nausea and vomiting (46.5%) and ileus (58.9%). CONCLUSION Clinicians in Spain are familiar with fast track protocols, although there is no overall consensus, and hospitals do not adhere to existing guidelines. Overall compliance with the items of the protocol is adequate, although perioperative nutritional management is poor.
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Affiliation(s)
- J Ripollés-Melchor
- Department of Anesthesia, Infanta Leonor University Hospital, Complutense University of Madrid, Madrid, Spain.
| | - R Casans-Francés
- Department of Anesthesia, Lozano Blesa University Hospital, University of Zaragoza, Zaragoza, Spain
| | - A Abad-Gurumeta
- Department of Anesthesia, La Paz University Hospital, Madrid, Spain
| | | | - J M Ramírez-Rodríguez
- Department of Surgery, Lozano Blesa University Hospital, University of Zaragoza, Zaragoza, Spain
| | - F López-Timoneda
- Department of Anesthesia, Clínico San Carlos University Hospital, Complutense University of Madrid, Madrid, Spain
| | - J M Calvo-Vecino
- Department of Anesthesia, Infanta Leonor University Hospital, Complutense University of Madrid, Madrid, Spain
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Thorn CC, White I, Burch J, Malietzis G, Kennedy R, Jenkins JT. Active and passive compliance in an enhanced recovery programme. Int J Colorectal Dis 2016; 31:1329-39. [PMID: 27112591 DOI: 10.1007/s00384-016-2588-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2016] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) is a well-established and accepted practice following colorectal surgery and has been demonstrated to reduce hospital length of stay (LOS) and 30-day morbidity. Despite evidence to support the individual elements on which the programme is based, there remains uncertainty as to how many and which of these are required to realise its benefits. Furthermore, elements of an ERAS programme might either precipitate or reflect recovery, in which case compliance could have a role in the improvement or prediction of outcome. MATERIALS AND METHODS A multidimensional prospective database of 799 consecutive patients undergoing colorectal surgery within an established ERAS programme at a single institution was interrogated. After application of exclusion criteria, 614 patients were studied. The novel concept of 'active compliance' is introduced. An ERAS element is classified as 'active' if the participation of the patient is required to achieve its compliance. This contrasts with 'passive' compliance, where an intervention is delivered to the patient without their direct contribution. The short-term surgical outcomes of this cohort are reported with reference to ERAS protocol compliance. RESULTS Compliance with the passive elements of the programme was higher than with the active elements. Univariate and multivariate analyses demonstrate that poor compliance with active but not passive elements of the programme was significantly associated with major morbidity. Receiver operator characteristic curve analysis demonstrated active compliance to be a stronger predictor of both major morbidity (AUC 0.71 vs. AUC 0.56) and length of stay (AUC 0.83 vs. 0.57) when compared with passive compliance. CONCLUSION The results suggest that poor active compliance may be a surrogate marker of morbidity which can be recognised in the early post-operative period. This implies the potential for timely diagnosis and intervention. This aspect of ERAS compliance is clinically relevant yet has achieved scant attention. Independent validation of our observations is required.
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Affiliation(s)
| | - Ian White
- St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK
| | - Jennie Burch
- St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK
| | | | - Robin Kennedy
- St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK
| | - John T Jenkins
- St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK.
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245
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Vignali A, Elmore U, Cossu A, Lemma M, Calì B, de Nardi P, Rosati R. Enhanced recovery after surgery (ERAS) pathway vs traditional care in laparoscopic rectal resection: a single-center experience. Tech Coloproctol 2016; 20:559-66. [PMID: 27262309 DOI: 10.1007/s10151-016-1497-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 02/21/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of this study was to compare the outcome of an enhanced recovery after surgery (ERAS) pathway with traditional perioperative care in laparoscopic rectal resection. METHODS A retrospective analysis of prospectively collected data was conducted. Single-center consecutive patients who underwent laparoscopic rectal surgery after an ERAS program were compared with patients who received traditional care over an 8-year period. Primary and total length of stay, and readmission, morbidity and mortality rates were analyzed. For ERAS group, the actual adherence to protocol was also evaluated. RESULTS Two hundred and ninety-seven patients, 162 in the ERAS group and 135 in conventional care, were studied. Median primary and total length of stay were significantly shorter in the ERAS group (9 vs 12 days; p = 0.0001; 10 vs 12 days; p = 0.01; respectively). The ERAS group experienced a faster recovery of bowel function than the traditional care group (p = 0.0001). A similar morbidity rate was observed in the two groups (32.3 % in ERAS vs 36.1 % in traditional care p = 0.41). Readmission rates were 4.9 % in the ERAS versus 1.5 % in the traditional care group (p = 0.19). There was no mortality in either group. Overall mean compliance with the ERAS protocol was 85.7 % (range 54.4-100 %). CONCLUSIONS The introduction of the ERAS protocol in laparoscopic rectal resection led to a reduction in primary and total length of hospital stay without an increase in morbidity or readmission rates when compared to traditional care.
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Affiliation(s)
- A Vignali
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Via Olgettina 60, 20132, Milan, Italy.
| | - U Elmore
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Via Olgettina 60, 20132, Milan, Italy
| | - A Cossu
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Via Olgettina 60, 20132, Milan, Italy
| | - M Lemma
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Via Olgettina 60, 20132, Milan, Italy
| | - B Calì
- Department of General and Minimally-Invasive Surgery, Humanitas Research Hospital, University of Milan, Rozzano, Milan, Italy
| | - P de Nardi
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Via Olgettina 60, 20132, Milan, Italy
| | - R Rosati
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Via Olgettina 60, 20132, Milan, Italy
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246
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Yoshida T, Homma S, Shibasaki S, Shimokuni T, Sakihama H, Takahashi N, Kawamura H, Taketomi A. Postoperative analgesia using fentanyl plus celecoxib versus epidural anesthesia after laparoscopic colon resection. Surg Today 2016; 47:174-181. [PMID: 27194126 DOI: 10.1007/s00595-016-1356-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 04/19/2016] [Indexed: 12/20/2022]
Abstract
PURPOSE Effective postoperative analgesia is essential to a patient's recovery after laparoscopic colon resection (LCR). We introduce a new analgesic protocol using fentanyl plus celecoxib following LCR. METHODS The subjects of this retrospective comparative study were 137 patients who underwent LCR, 63 of whom were treated with 72 h of epidural anesthesia (group E), and 74 of whom were treated with 24 h of fentanyl intravenous injection followed by 7 days of oral celecoxib (group FC). We evaluated the safety and efficacy of this new protocol. RESULTS The combination of fentanyl and celecoxib maintained a low postoperative pain score (<1.5, evaluated by the FACES Pain Scale) and reduced the need for rescue analgesic drugs for 7 days (groups E vs. FC: 5.39 ± 3.77 vs. 2.79 ± 2.92, p < 0.001). The postoperative hospital stay was almost equal for the two groups (E vs. FC: 11.1 ± 4.5 vs. 10.3 ± 4.8 days, p = 0.315). The operating room stay other than for surgery was significantly shorter for group FC (E vs. FC: 128.7 ± 30.5 vs. 107.2 ± 17.0 min, p < 0.001). Neither group experienced complications, apart from one group FC patient, who suffered transient nausea and vertigo. CONCLUSIONS The new analgesic protocol using fentanyl plus celecoxib is an effective and time-saving strategy for LCR.
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Affiliation(s)
- Tadashi Yoshida
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, N15, W7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Shigenori Homma
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, N15, W7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan.
| | - Susumu Shibasaki
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, N15, W7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Tatsushi Shimokuni
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, N15, W7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Hideyasu Sakihama
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, N15, W7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Norihiko Takahashi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, N15, W7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Hideki Kawamura
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, N15, W7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, N15, W7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
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247
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Atkinson C, Penfold CM, Ness AR, Longman RJ, Thomas SJ, Hollingworth W, Kandiyali R, Leary SD, Lewis SJ. Randomized clinical trial of postoperative chewing gum versus standard care after colorectal resection. Br J Surg 2016; 103:962-70. [PMID: 27146793 PMCID: PMC5084762 DOI: 10.1002/bjs.10194] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 03/08/2016] [Accepted: 03/10/2016] [Indexed: 12/20/2022]
Abstract
Background Chewing gum may stimulate gastrointestinal motility, with beneficial effects on postoperative ileus suggested in small studies. The primary aim of this trial was to determine whether chewing gum reduces length of hospital stay (LOS) after colorectal resection. Secondary aims included examining bowel habit symptoms, complications and healthcare costs. Methods This clinical trial allocated patients randomly to standard postoperative care with or without chewing gum (sugar‐free gum for at least 10 min, four times per day on days 1–5) in five UK hospitals. The primary outcome was LOS. Cox regression was used to calculate hazard ratios for LOS. Results Data from 402 of 412 patients, of whom 199 (49·5 per cent) were allocated to chewing gum, were available for analysis. Some 40 per cent of patients in both groups had laparoscopic surgery, and all study sites used enhanced recovery programmes. Median (i.q.r.) LOS was 7 (5–11) days in both groups (P = 0·962); the hazard ratio for use of gum was 0·94 (95 per cent c.i. 0·77 to 1·15; P = 0·557). Participants allocated to gum had worse quality of life, measured using the EuroQoL 5D‐3L, than controls at 6 and 12 weeks after operation (but not on day 4). They also had more complications graded III or above according to the Dindo–Demartines–Clavien classification (16 versus 6 in the group that received standard care) and deaths (11 versus 0), but none was classed as related to gum. No other differences were observed. Conclusion Chewing gum did not alter the return of bowel function or LOS after colorectal resection. Registration number: ISRCTN55784442 (http://www.controlled-trials.com). No advantage observed
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Affiliation(s)
- C Atkinson
- Schools of Oral and Dental Sciences, University of Bristol, Bristol, UK.,National Institute for Health Research Biomedical Research Unit in Nutrition, Diet and Lifestyle, University Hospitals Bristol Education Centre, Bristol, UK
| | - C M Penfold
- Schools of Oral and Dental Sciences, University of Bristol, Bristol, UK.,National Institute for Health Research Biomedical Research Unit in Nutrition, Diet and Lifestyle, University Hospitals Bristol Education Centre, Bristol, UK
| | - A R Ness
- Schools of Oral and Dental Sciences, University of Bristol, Bristol, UK.,National Institute for Health Research Biomedical Research Unit in Nutrition, Diet and Lifestyle, University Hospitals Bristol Education Centre, Bristol, UK
| | - R J Longman
- Department of Coloproctology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - S J Thomas
- Schools of Oral and Dental Sciences, University of Bristol, Bristol, UK.,National Institute for Health Research Biomedical Research Unit in Nutrition, Diet and Lifestyle, University Hospitals Bristol Education Centre, Bristol, UK
| | - W Hollingworth
- Schools of Social and Community Medicine, University of Bristol, Bristol, UK
| | - R Kandiyali
- Schools of Social and Community Medicine, University of Bristol, Bristol, UK
| | - S D Leary
- Schools of Oral and Dental Sciences, University of Bristol, Bristol, UK.,National Institute for Health Research Biomedical Research Unit in Nutrition, Diet and Lifestyle, University Hospitals Bristol Education Centre, Bristol, UK
| | - S J Lewis
- National Institute for Health Research Biomedical Research Unit in Nutrition, Diet and Lifestyle, University Hospitals Bristol Education Centre, Bristol, UK.,Department of Gastroenterology, Derriford Hospital, Plymouth, UK
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248
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Casans Francés R, Ripollés Melchor J, Abad-Gurumeta A, Longás Valién J, Calvo Vecino JM. The role of the anaesthesiologist in enhanced recovery programs. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:273-288. [PMID: 26775121 DOI: 10.1016/j.redar.2015.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 11/04/2015] [Accepted: 11/09/2015] [Indexed: 06/05/2023]
Affiliation(s)
- R Casans Francés
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Clínico Universitario «Lozano Blesa», Zaragoza, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España.
| | - J Ripollés Melchor
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario «Infanta Leonor», Madrid, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España
| | - A Abad-Gurumeta
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario La Paz, Madrid, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España
| | - J Longás Valién
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Clínico Universitario «Lozano Blesa», Zaragoza, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España
| | - J M Calvo Vecino
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario «Infanta Leonor», Madrid, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España
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249
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Miralpeix E, Nick AM, Meyer LA, Cata J, Lasala J, Mena GE, Gottumukkala V, Iniesta-Donate M, Salvo G, Ramirez PT. A call for new standard of care in perioperative gynecologic oncology practice: Impact of enhanced recovery after surgery (ERAS) programs. Gynecol Oncol 2016; 141:371-378. [PMID: 26906066 PMCID: PMC5989566 DOI: 10.1016/j.ygyno.2016.02.019] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 02/15/2016] [Accepted: 02/18/2016] [Indexed: 02/07/2023]
Abstract
Enhanced recovery after surgery (ERAS) programs aim to hasten functional recovery and improve postoperative outcomes. However, there is a paucity of data on ERAS programs in gynecologic surgery. We reviewed the published literature on ERAS programs in colorectal surgery, general gynecologic surgery, and gynecologic oncology surgery to evaluate the impact of such programs on outcomes, and to identify key elements in establishing a successful ERAS program. ERAS programs are associated with shorter length of hospital stay, a reduction in overall health care costs, and improvements in patient satisfaction. We suggest an ERAS program for gynecologic oncology practice involving preoperative, intraoperative, and postoperative strategies including; preadmission counseling, avoidance of preoperative bowel preparation, use of opioid-sparing multimodal perioperative analgesia (including loco-regional analgesia), intraoperative goal-directed fluid therapy (GDT), and use of minimally invasive surgical techniques with avoidance of routine use of nasogastric tube, drains and/or catheters. Postoperatively, it is important to encourage early feeding, early mobilization, timely removal of tubes and drains, if present, and function oriented multimodal analgesia regimens. Successful implementation of an ERAS program requires a multidisciplinary team effort and active participation of the patient in their goal-oriented functional recovery program. However, future outcome studies should evaluate the efficacy of an intervention within the pathway, include objective measures of symptom burden and control, study measures of functional recovery, and quantify outcomes of the program in relation to the rates of adherence to the key elements of care in gynecologic oncology such as oncologic outcomes and return to intended oncologic therapy (RIOT).
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Affiliation(s)
- Ester Miralpeix
- Department of Obstetrics and Gynecology, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alpa M Nick
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Juan Cata
- Department of Anesthesia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Javier Lasala
- Department of Anesthesia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gabriel E Mena
- Department of Anesthesia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vijaya Gottumukkala
- Department of Anesthesia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria Iniesta-Donate
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gloria Salvo
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Sunstrom R, Hamilton N, Fialkowski E, Lofberg K, McKee J, Sims T, Krishnaswami S, Azarow K. Minimizing variance in pediatric gastrostomy: does standardized perioperative feeding plan decrease cost and improve outcomes? Am J Surg 2016; 211:948-53. [DOI: 10.1016/j.amjsurg.2016.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 01/27/2016] [Accepted: 02/01/2016] [Indexed: 11/30/2022]
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