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Ardò NP, Loizzi D, Panariti S, Piccinin I, Sollitto F. Enhanced recovery pathways in thoracic surgery from Italian VATS group: nursing care program. J Thorac Dis 2018; 10:S529-S534. [PMID: 29629199 DOI: 10.21037/jtd.2017.12.85] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Enhanced recovery after surgery (ERAS) is an interprofessional program that can lead to hastened patient recovery and reduced time in hospital. Nursing staff play a key role in the implementation of enhanced recovery protocols. This issue focalizes the role of nurses in ERAS program for patients submitted to Thoracic Surgery, in particular for cases of major lung resection performed by a minimally invasive surgical approach (VATS, video assisted thoracic surgery).
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Affiliation(s)
- Nicoletta Pia Ardò
- Thoracic Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Domenico Loizzi
- Thoracic Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | | | - Ivana Piccinin
- Thoracic Surgery Unit, Ospedale San Raffaele, Milano, Italy
| | - Francesco Sollitto
- Thoracic Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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252
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de Leede EM, van Leersum NJ, Kroon HM, van Weel V, van der Sijp JRM, Bonsing BA, Woltz S, Tromp M, Neijenhuis PA, Maaijen RCLA, Steup WH, Schepers A, Guicherit OR, Huurman VAL, Karsten TM, van de Pool A, Boerma D, Deroose JP, Beek M, Wijsman JH, Derksen WJM, Festen S, de Nes LCF. Multicentre randomized clinical trial of the effect of chewing gum after abdominal surgery. Br J Surg 2018; 105:820-828. [DOI: 10.1002/bjs.10828] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 11/30/2017] [Accepted: 12/28/2017] [Indexed: 12/21/2022]
Abstract
Abstract
Background
Postoperative ileus is a common complication of abdominal surgery, leading to patient discomfort, morbidity and prolonged postoperative length of hospital stay (LOS). Previous studies suggested that chewing gum stimulates bowel function after abdominal surgery, but were underpowered to evaluate its effect on LOS and did not include enhanced recovery after surgery (ERAS)-based perioperative care. This study evaluated whether chewing gum after elective abdominal surgery reduces LOS and time to bowel recovery in the setting of ERAS-based perioperative care.
Methods
A multicentre RCT was performed of patients over 18 years of age undergoing abdominal surgery in 12 hospitals. Standard postoperative care (control group) was compared with chewing gum three times a day for 30 min in addition to standard postoperative care. Randomization was computer-generated; allocation was concealed. The primary outcome was postoperative LOS. Secondary outcomes were time to bowel recovery and 30-day complications.
Results
Between 2011 to 2015, 1000 patients were assigned to chewing gum and 1000 to the control arm. Median LOS did not differ: 7 days in both arms (P = 0·364). Neither was any difference found in time to flatus (24 h in control group versus 23 h with chewing gum; P = 0·873) or time to defaecation (60 versus 52 h respectively; P = 0·562). The rate of 30-day complications was not significantly different either.
Conclusion
The addition of chewing gum to an ERAS postoperative care pathway after elective abdominal surgery does not reduce the LOS, time to bowel recovery or the rate of postoperative complications. Registration number: NTR2594 (Netherlands Trial Register).
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Affiliation(s)
- E M de Leede
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - N J van Leersum
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - H M Kroon
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands
| | - V van Weel
- Department of Surgery, Medical Centre Haaglanden, The Hague, The Netherlands
- Department of Surgery, Meander Medisch Centrum, Amersfoort, The Netherlands
| | - J R M van der Sijp
- Department of Surgery, Medical Centre Haaglanden, The Hague, The Netherlands
| | - B A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - S Woltz
- Department of Surgery, Medical Centre Haaglanden, The Hague
| | - M Tromp
- Department of Surgery, Groene Hart Hospital, Gouda
| | | | | | - W H Steup
- Department of Surgery, Haga Hospital, The Hague
| | - A Schepers
- Department of Surgery, Haga Hospital, The Hague
| | | | | | - T M Karsten
- Department of Surgery, Reinier de Graaf Group, Delft
| | | | - D Boerma
- Department of Surgery, Amphia Hospital, Breda
| | - J P Deroose
- Department of Surgery, Amphia Hospital, Breda
| | - M Beek
- Department of Surgery, Amphia Hospital, Breda
| | - J H Wijsman
- Department of Surgery, Sint Antonius Hospital, Nieuwegein
| | - W J M Derksen
- Department of Surgery, Sint Antonius Hospital, Nieuwegein
| | - S Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam
| | - L C F de Nes
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam
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253
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Lambaudie E, de Nonneville A, Brun C, Laplane C, N'Guyen Duong L, Boher JM, Jauffret C, Blache G, Knight S, Cini E, Houvenaeghel G, Blache JL. Enhanced recovery after surgery program in Gynaecologic Oncological surgery in a minimally invasive techniques expert center. BMC Surg 2017; 17:136. [PMID: 29282059 PMCID: PMC5745717 DOI: 10.1186/s12893-017-0332-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/12/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Enhanced Recovery After Surgery Programs (ERP) includes multimodal approaches of perioperative patient's clinical pathways designed to achieve early recovery after surgery and a decreased length of hospital stay (LOS). METHODS This observational study evaluated the implementation of ERP in gynaecologic oncological surgery in a minimally invasive techniques (MIT) expert center with more than 85% of procedures done with MIT. We compared a prospective cohort of 100 patients involved in ERP between December 2015 and June 2016 to a 100 patients control group, without ERP, previously managed in the same center between April 2015 and November 2015. All the included patients were referred for hysterectomy and/or pelvic or para-aortic lymphadenectomy for gynaecological cancer. The primary objective was to achieve a significant decrease of median LOS in the ERP group. Secondary objectives were decreases in proportion of patients achieving target LOS (2 days), morbidity and readmissions. RESULTS Except a disparity in oncological indications with a higher proportion of endometrial cancer in the group with ERP vs. the group without ERP (42% vs. 22%; p = 0.003), there were no differences in patient's characteristics and surgical procedures. ERP were associated with decreases of median LOS (2.5 [0 to 11] days vs. 3 [1 to 14] days; p = 0.002) and proportion of discharged patient at target LOS (45% vs. 24%; p = 0.002). Morbidities occurred in 25% and 26% in the groups with and without ERP and readmission rates were respectively of 6% and 8%, without any significant difference. CONCLUSION ERP in gynaecologic oncological surgery is associated with a decrease of LOS without increases of morbidity or readmission rates, even in a center with a high proportion of MIT. Although it is already widely accepted that MIT improves early recovery, our study shows that the addition of ERP's clinical pathways improve surgical outcomes and patient care management.
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Affiliation(s)
- Eric Lambaudie
- Département de Chirurgie Oncologique 2, Institut Paoli Calmettes et CRCM, 232 Bd. Sainte-Marguerite, 13009, Marseille, France.
| | - Alexandre de Nonneville
- Aix-Marseille Univ, CNRS, INSERM, Institut Paoli-Calmettes, Department of Medical Oncology, CRCM, Marseille, France
| | - Clément Brun
- Département d'Anesthésie Réanimation, Institut Paoli Calmettes et CRCM, Marseille, France
| | - Charlotte Laplane
- Département de Chirurgie Oncologique 2, Institut Paoli Calmettes et CRCM, 232 Bd. Sainte-Marguerite, 13009, Marseille, France
| | - Lam N'Guyen Duong
- Département d'Anesthésie Réanimation, Institut Paoli Calmettes et CRCM, Marseille, France
| | - Jean-Marie Boher
- Aix-Marseille Univ, INSERM IRD, SESSTIM, Institut Paoli-Calmettes, Department of Clinical Research and Investigation, Biostatistics and Methodology Unit, Marseille, France
| | - Camille Jauffret
- Département de Chirurgie Oncologique 2, Institut Paoli Calmettes et CRCM, 232 Bd. Sainte-Marguerite, 13009, Marseille, France
| | - Guillaume Blache
- Département de Chirurgie Oncologique 2, Institut Paoli Calmettes et CRCM, 232 Bd. Sainte-Marguerite, 13009, Marseille, France
| | - Sophie Knight
- Département de Chirurgie Oncologique 2, Institut Paoli Calmettes et CRCM, 232 Bd. Sainte-Marguerite, 13009, Marseille, France
| | - Eric Cini
- Département de Chirurgie Oncologique 2, Institut Paoli Calmettes et CRCM, 232 Bd. Sainte-Marguerite, 13009, Marseille, France
| | - Gilles Houvenaeghel
- Département de Chirurgie Oncologique 2, Institut Paoli Calmettes et CRCM, 232 Bd. Sainte-Marguerite, 13009, Marseille, France
| | - Jean-Louis Blache
- Département d'Anesthésie Réanimation, Institut Paoli Calmettes et CRCM, Marseille, France
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Nelson G, Dowdy S, Lasala J, Mena G, Bakkum-Gamez J, Meyer L, Iniesta M, Ramirez P. Enhanced recovery after surgery (ERAS®) in gynecologic oncology – Practical considerations for program development. Gynecol Oncol 2017; 147:617-620. [DOI: 10.1016/j.ygyno.2017.09.023] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 09/11/2017] [Accepted: 09/19/2017] [Indexed: 12/15/2022]
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255
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Weber LeBrun EE. Update on Surgical Treatments for Pelvic Organ Prolapse. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0221-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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256
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Essential Elements of Multimodal Analgesia in Enhanced Recovery After Surgery (ERAS) Guidelines. Anesthesiol Clin 2017; 35:e115-e143. [PMID: 28526156 DOI: 10.1016/j.anclin.2017.01.018] [Citation(s) in RCA: 240] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Perioperative multimodal analgesia uses combinations of analgesic medications that act on different sites and pathways in an additive or synergistic manner to achieve pain relief with minimal or no opiate consumption. Although all medications have side effects, opiates have particularly concerning, multisystemic, long-term, and short-term side effects, which increase morbidity and prolong admissions. Enhanced recovery is a systematic process addressing each aspect affecting recovery. This article outlines the evidence base forming the current multimodal analgesia recommendations made by the Enhanced Recovery After Surgery Society (ERAS). We describe current evidence and important future directions for effective perioperative multimodal analgesia in enhanced recovery pathways.
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257
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Preventable Surgical Harm in Gynecologic Oncology: Optimizing Quality and Patient Safety. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0226-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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258
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Kingma BF, Steenhagen E, Ruurda JP, van Hillegersberg R. Nutritional aspects of enhanced recovery after esophagectomy with gastric conduit reconstruction. J Surg Oncol 2017; 116:623-629. [PMID: 28968919 DOI: 10.1002/jso.24827] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 08/09/2017] [Indexed: 12/18/2022]
Abstract
Enhanced Recovery After Surgery (ERAS) aims to accelerate recovery by a set of multimodality management strategies. For esophagectomy, several nutritional elements of ERAS can be safely introduced and are advised in routine practice, including preadmission counseling to screen and treat for potential malnutrition, shortened preoperative fasting, and carbohydrate loading. However, the timing of oral intake and the use of routine nasogastric decompression remain matter of debate after esophagectomy. Furthermore, more research is needed on future developments such as perioperative immunonutrition.
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Affiliation(s)
- B Feike Kingma
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Elles Steenhagen
- Department of Dietetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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259
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Manso M, Schmelz J, Aloia T. ERAS-Anticipated outcomes and realistic goals. J Surg Oncol 2017; 116:570-577. [DOI: 10.1002/jso.24791] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 07/10/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Maria Manso
- Department of Anesthesia; Hospital Beatriz Ângelo-Luz Saúde; Lisbon Portugal
| | - Jacob Schmelz
- Department of Surgical Oncology; MD Anderson Cancer Center; Houston Texas
- McGovern Medical School at UTHealth; Houston Texas
| | - Thomas Aloia
- Department of Surgical Oncology; MD Anderson Cancer Center; Houston Texas
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260
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Seagle BLL, Miller ES, Strohl AE, Hoekstra A, Shahabi S. Transversus abdominis plane block with liposomal bupivacaine compared to oral opioids alone for acute postoperative pain after laparoscopic hysterectomy for early endometrial cancer: a cost-effectiveness analysis. GYNECOLOGIC ONCOLOGY RESEARCH AND PRACTICE 2017; 4:12. [PMID: 28852531 PMCID: PMC5567769 DOI: 10.1186/s40661-017-0048-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 08/10/2017] [Indexed: 11/15/2022]
Abstract
Background To determine the cost-effectiveness of transversus abdominis plane block with liposomal bupivacaine (TAP) compared to oral opioids alone for acute postoperative pain after laparoscopic hysterectomy for early endometrial cancer. Methods A cost-effectiveness analysis using a decision tree structure with a 30.5 day time-horizon was used to calculate incremental cost-effectiveness ratio (ICER) values per quality-adjusted life-year (QALY). Base-case costs, probabilities, and QALY values were identified from recently published all-payer national database studies, 2017 Medicare fee-schedules, randomized trials, institutional case series, or assumed, when published values were not available. One-way, two-way and multiple probabilistic sensitivity analyses were performed. Results The TAP strategy dominated the oral opioid-only strategy, with decreased costs and increased effectiveness. Specifically, the TAP strategy saved $235.90 under the base-case assumptions. Threshold analyses demonstrated that if the relative same-day discharge probability was ≥ 12% higher in the TAP group, then TAP was cost-saving over oral opioids-alone. Similarly, TAP was cost-saving whenever the costs saved by same-day discharge compared to admission were ≥ $1115.22. Cost-effectiveness of the TAP strategy was highly robust of a variety of sensitivity analyses. Conclusions TAP with liposomal bupivacaine was robustly cost-effective at conventional willingness-to-pay thresholds. Further, TAP was cost-saving compared to opioids-only when the same-day discharge rate among TAP users was greater than among opioid-only users. Electronic supplementary material The online version of this article (doi:10.1186/s40661-017-0048-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Brandon-Luke L Seagle
- Department of Obstetrics and Gynecology, Prentice Women's Hospital, Northwestern University, Feinberg School of Medicine, 250 E Superior Street, Suite 05-2168, Chicago, IL 60611 USA
| | - Emily S Miller
- Department of Obstetrics and Gynecology, Prentice Women's Hospital, Northwestern University, Feinberg School of Medicine, 250 E Superior Street, Suite 05-2168, Chicago, IL 60611 USA
| | - Anna E Strohl
- Department of Obstetrics and Gynecology, Prentice Women's Hospital, Northwestern University, Feinberg School of Medicine, 250 E Superior Street, Suite 05-2168, Chicago, IL 60611 USA
| | - Anna Hoekstra
- West Michigan Cancer Center and Western Michigan University, Homer Stryker School of Medicine, Kalamazoo, MI USA
| | - Shohreh Shahabi
- Department of Obstetrics and Gynecology, Prentice Women's Hospital, Northwestern University, Feinberg School of Medicine, 250 E Superior Street, Suite 05-2168, Chicago, IL 60611 USA
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261
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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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262
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Dowdy SC, Nelson G. Enhanced recovery in gynecologic oncology – A sea change in perioperative management. Gynecol Oncol 2017. [DOI: 10.1016/j.ygyno.2017.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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263
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Prabhu M, Bortoletto P, Bateman BT. Perioperative pain management strategies among women having reproductive surgeries. Fertil Steril 2017; 108:200-206. [PMID: 28697915 PMCID: PMC5545053 DOI: 10.1016/j.fertnstert.2017.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 06/06/2017] [Indexed: 12/14/2022]
Abstract
This review presents opioid-sparing strategies for perioperative pain management among women undergoing reproductive surgeries and procedures. Recommendations are provided regarding the use of nonsteroidal anti-inflammatory drugs, acetaminophen, other adjunctive medications, and regional anesthetic blocks. Additional considerations for chronic opioid users or patients using opioid replacement or antagonist therapy are discussed.
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Affiliation(s)
- Malavika Prabhu
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General Hospital, 55 Fruit Street, Boston MA 02114,
| | - Pietro Bortoletto
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women’s Hospital, 75 Francis Street, Boston MA 02115,
| | - Brian T. Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, and Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, ., 617-529-7058
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264
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Enhanced Recovery After Surgery for Advanced Ovarian Cancer: A Systematic Review of Interventions Trialed. Int J Gynecol Cancer 2017; 27:1274-1282. [DOI: 10.1097/igc.0000000000000981] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
ObjectivesWe sought to summarize the evidence for interventions aiming at enhanced recovery after surgery (ERAS) in ovarian cancer through a systematic review.MethodsWe searched MEDLINE, EMBASE, and The Cochrane Library for studies testing ERAS interventions in patients undergoing surgery for ovarian cancer. Study selection and data extraction were done independently by 2 reviewers with disagreements resolved by discussion with a senior, third reviewer.ResultsWe identified 25 studies including 1648 participants with ovarian cancer. Nine observational studies addressed ERAS protocols. Four of them were prospective, and 3 included historical controls. The other 16 studies reported single interventions, for example, early feeding, omission of pelvic drains, early orogastric tube removal, Doppler-guided fluid management, and patient-controlled epidural analgesia. Early feeding protocols were tested in 7 of the 12 randomized trials. Early feeding appeared to be safe and was associated with significantly faster recovery of bowel function.ConclusionsFew studies have specifically studied ERAS interventions in ovarian cancer. All studies on protocols including multiple interventions were susceptible to bias. Early feeding is the intervention that is best supported by randomized trials. Application of evidence for ERAS derived from nonovarian cancer is challenged by the differences not only in the scope of surgery but also in ovarian cancer patients’ comorbidities. Postoperative morbidity is particularly high in these patients because of their poor nutritional status, perioperative fluids shifts, and long operating times. These patients may also show excessive response to surgical stress. Innovative, randomized trials are needed to reliably determine the feasibility, safety, and effectiveness of specific ERAS interventions in ovarian cancer.
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265
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Rattray M, Roberts S, Marshall A, Desbrow B. A systematic review of feeding practices among postoperative patients: is practice in-line with evidenced-based guidelines? J Hum Nutr Diet 2017; 31:151-167. [PMID: 28589624 DOI: 10.1111/jhn.12486] [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: 01/22/2023]
Abstract
BACKGROUND Early oral feeding after surgery is best practice among adult, noncritically ill patients. Evidenced-based guidelines (EBG) recommend commencing liquid and solid feeding within 24 h of surgery to improve patient (e.g. reduced morbidity) and hospital (e.g. reduced length of stay) outcomes. Whether these EBG are adhered to in usual clinical practice remains unknown. The present study aimed to identify the time to commencement of first oral feed (liquid or solid) and first solid feed among postoperative, noncritically ill, adult patients. METHODS MEDLINE, CINAHL, SCOPUS and Web of Science databases were searched from inception to June 2016 for observational studies reporting liquid and/or solid feeding practices among postoperative patients. Studies reporting a mean/median time to first feed or first solid feed within 24 h of surgery or where ≥75% of patients were feeding by postoperative day one were considered in-line with EBG. RESULTS Of 5826 articles retrieved, 29 studies were included. Only 40% and 22% of studies reported time to first feed and time to first solid feed in-line with EBG, respectively. Clear and free liquids were the first diet types commenced in 86% of studies. When solids were commenced, 44% of studies reported using various therapeutic diet types (e.g. light) prior to the commencement of a regular diet. Patients who underwent gastrointestinal procedures appeared more likely to experience delayed postoperative feeding. CONCLUSIONS Our findings demonstrate a gap between postoperative feeding evidence and its practical application. This information provides a strong rationale for interventions targeting improved nutritional care following surgery.
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Affiliation(s)
- M Rattray
- School of Allied Health Sciences, Griffith University, Southport, QLD, Australia.,Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
| | - S Roberts
- Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia.,National Centre of Research Excellence in Nursing (NCREN), Griffith University, Southport, QLD, Australia
| | - A Marshall
- Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia.,National Centre of Research Excellence in Nursing (NCREN), Griffith University, Southport, QLD, Australia.,School of Nursing and Midwifery, Griffith University, Southport, QLD, Australia
| | - B Desbrow
- School of Allied Health Sciences, Griffith University, Southport, QLD, Australia.,Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
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Gramlich LM, Sheppard CE, Wasylak T, Gilmour LE, Ljungqvist O, Basualdo-Hammond C, Nelson G. Implementation of Enhanced Recovery After Surgery: a strategy to transform surgical care across a health system. Implement Sci 2017; 12:67. [PMID: 28526041 PMCID: PMC5438526 DOI: 10.1186/s13012-017-0597-5] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 05/08/2017] [Indexed: 02/07/2023] Open
Abstract
Background Enhanced Recovery After Surgery (ERAS) programs have been shown to have a positive impact on outcome. The ERAS care system includes an evidence-based guideline, an implementation program, and an interactive audit system to support practice change. The purpose of this study is to describe the use of the Theoretic Domains Framework (TDF) in changing surgical care and application of the Quality Enhancement Research Initiative (QUERI) model to analyze end-to-end implementation of ERAS in colorectal surgery across multiple sites within a single health system. The ultimate intent of this work is to allow for the development of a model for spread, scale, and sustainability of ERAS in Alberta Health Services (AHS). Methods ERAS for colorectal surgery was implemented at two sites and then spread to four additional sites. The ERAS Interactive Audit System (EIAS) was used to assess compliance with the guidelines, length of stay, readmissions, and complications. Data sources informing knowledge translation included surveys, focus groups, interviews, and other qualitative data sources such as minutes and status updates. The QUERI model and TDF were used to thematically analyze 189 documents with 2188 quotes meeting the inclusion criteria. Data sources were analyzed for barriers or enablers, organized into a framework that included individual to organization impact, and areas of focus for guideline implementation. Results Compliance with the evidence-based guidelines for ERAS in colorectal surgery at baseline was 40%. Post implementation compliance, consistent with adoption of best practice, improved to 65%. Barriers and enablers were categorized as clinical practice (22%), individual provider (26%), organization (19%), external environment (7%), and patients (25%). In the Alberta context, 26% of barriers and enablers to ERAS implementation occurred at the site and unit levels, with a provider focus 26% of the time, a patient focus 26% of the time, and a system focus 22% of the time. Conclusions Using the ERAS care system and applying the QUERI model and TDF allow for identification of strategies that can support diffusion and sustainment of innovation of Enhanced Recovery After Surgery across multiple sites within a health care system.
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Affiliation(s)
- Leah M Gramlich
- Department of Medicine, University of Alberta, Edmonton, Canada. .,Gastroenterology, Royal Alexandra Hospital, 214 CSC, 10240 Kingsway Avenue NW, Edmonton, AB, T5H 3V9, Canada.
| | | | | | | | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | | | - Gregg Nelson
- Tom Baker Cancer Centre, Department of Oncology, University of Calgary, 1331 29 Street NW, Calgary, Alberta, Canada
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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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Abeles A, Kwasnicki RM, Darzi A. Enhanced recovery after surgery: Current research insights and future direction. World J Gastrointest Surg 2017; 9:37-45. [PMID: 28289508 PMCID: PMC5329702 DOI: 10.4240/wjgs.v9.i2.37] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 09/14/2016] [Accepted: 11/01/2016] [Indexed: 02/06/2023] Open
Abstract
Since the concept of enhanced recovery after surgery (ERAS) was introduced in the late 1990s the idea of implementing specific interventions throughout the peri-operative period to improve patient recovery has been proven to be beneficial. Minimally invasive surgery is an integral component to ERAS and has dramatically improved post-operative outcomes. ERAS can be applicable to all surgical specialties with the core generic principles used together with added specialty specific interventions to allow for a comprehensive protocol, leading to improved clinical outcomes. Diffusion of ERAS into mainstream practice has been hindered due to minimal evidence to support individual facets and lack of method for monitoring and encouraging compliance. No single outcome measure fully captures recovery after surgery, rather multiple measures are necessary at each stage. More recently the pre-operative period has been the target of a number of strategies to improve clinical outcomes, described as prehabilitation. Innovation of technology in the surgical setting is also providing opportunities to overcome the challenges within ERAS, e.g., the use of wearable activity monitors to record information and provide feedback and motivation to patients peri-operatively. Both modernising ERAS and providing evidence for key strategies across specialties will ultimately lead to better, more reliable patient outcomes.
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271
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Readmission and Reoperation After Surgery for Pelvic Organ Prolapse. Female Pelvic Med Reconstr Surg 2017; 23:131-135. [DOI: 10.1097/spv.0000000000000379] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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272
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Altman AD, Nelson GS. The Canadian Gynaecologic Oncology Perioperative Management Survey: Baseline Practice Prior to Implementation of Enhanced Recovery After Surgery (ERAS) Society Guidelines. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:1105-1109.e2. [DOI: 10.1016/j.jogc.2016.09.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 09/12/2016] [Indexed: 12/28/2022]
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273
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Simmons J, Powell M. Acute traumatic coagulopathy: pathophysiology and resuscitation. Br J Anaesth 2016; 117:iii31-iii43. [DOI: 10.1093/bja/aew328] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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274
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Kalogera E, Dowdy SC. Enhanced Recovery Pathway in Gynecologic Surgery. Obstet Gynecol Clin North Am 2016; 43:551-73. [DOI: 10.1016/j.ogc.2016.04.006] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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276
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Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach. Surg Res Pract 2016; 2016:3561249. [PMID: 27504486 PMCID: PMC4967675 DOI: 10.1155/2016/3561249] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 06/14/2016] [Indexed: 02/07/2023] Open
Abstract
ERAS approach (Enhanced Recovery After Surgery) is a multimodal, perioperative pathway designed to achieve early recovery after surgery. ERAS has shown documented efficacy in elective surgery, and the concept of "multimodal" and "multidisciplinary" approach seems still to be of higher importance than each single item within ERAS protocols. New perspectives include the use of ERAS in emergency surgery, where efficacy and safety on outcome have been documented, and flexibility of traditional items may add benefits for traditionally high-risk patients. Obstetric surgery, as well, may open wide horizons for future research, since extremely poor data are currently available, and ERAS benefits may translate even on the baby. Finally, the concept of "outcome" may be extended when considering the specific setting of cancer surgery, in which variables like cancer recurrence, early access to adjuvant therapies, and, finally, long-term survival are as important as the reduced perioperative complications. In this perspective, different items within ERAS protocols should be reinterpreted and eventually integrated towards "protective" techniques, to develop cancer-specific ERAS approaches keeping pace with the specific aims of oncologic surgery.
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Eldawlatly A. Is enhanced recovery after anesthesia a synonym to enhanced recovery after surgery? Saudi J Anaesth 2016; 10:119-20. [PMID: 27051358 PMCID: PMC4799599 DOI: 10.4103/1658-354x.177413] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Abdelazeem Eldawlatly
- Department of Anesthesia, College of Medicine, King Saud University, Riyadh, Saudi Arabia E-mail:
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The Combined Blockade of β-Adrenoceptor and COX-2 During the Perioperative Period to Improve Long-term Cancer Outcomes. Int Anesthesiol Clin 2016; 54:72-91. [DOI: 10.1097/aia.0000000000000116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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