251
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Adherence to ERAS elements in major visceral surgery—an observational pilot study. Langenbecks Arch Surg 2016; 401:349-56. [DOI: 10.1007/s00423-016-1407-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 03/14/2016] [Indexed: 02/06/2023]
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252
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Wisely JC, Barclay KL. Effects of an Enhanced Recovery After Surgery programme on emergency surgical patients. ANZ J Surg 2016; 86:883-888. [PMID: 26990499 DOI: 10.1111/ans.13465] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) programmes have been used in elective surgery since the 1990s to optimize peri-operative care, reducing post-operative complications, length of stay and overall costs. Following the local introduction of an ERAS programme for colorectal elective patients, it was suggested an increase in the use of ERAS-type principles in emergency patients may have occurred. The aims of this study were to determine whether management changes could be demonstrated and if there was a difference in outcomes. METHOD A retrospective cohort study comparing emergency patients undergoing major abdominal surgery October 2008 to May 2010 (pre-ERAS) and January 2011 to December 2012 (post-ERAS) was performed. Details collected included admission and operative details, post-operative management and outcomes. RESULTS A total of 370 patients were studied. Baseline variables were comparable. Post-ERAS, intra-operative (P < 0.001) and post-operative 48 h totals (P < 0.001) of intravenous fluids were significantly reduced. Significantly fewer patients in the post-ERAS group had a catheter (P < 0.001), drain (P = 0.001) and patient controlled analgesia (P = 0.01) for more than two days. Major complications (P = 0.002) and individual minor complications such as urinary tract infections (P = 0.02), urinary retention (P = 0.001) and chest infections (P = 0.001) were all significantly reduced in the post-ERAS period. CONCLUSION This study demonstrates a significant change in management towards ERAS principles in emergency patients following the introduction of such a programme in elective patients. The lack of increased complications in the second period suggests the use of ERAS principles is not harmful. The wider application of ERAS principles could improve outcomes in emergency surgery and deserves further study.
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Affiliation(s)
- Jessica C Wisely
- The Department of General Surgery, Northern Health, Melbourne, Victoria, Australia.,The Academic Department of Surgery, NCHER, The University of Melbourne, Melbourne, Victoria, Australia
| | - Karen L Barclay
- The Department of General Surgery, Northern Health, Melbourne, Victoria, Australia. .,The Academic Department of Surgery, NCHER, The University of Melbourne, Melbourne, Victoria, Australia.
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253
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Cost minimization analysis of laparoscopic surgery for colorectal cancer within the enhanced recovery after surgery (ERAS) protocol: a single-centre, case-matched study. Wideochir Inne Tech Maloinwazyjne 2016; 11:14-21. [PMID: 28133495 PMCID: PMC4840186 DOI: 10.5114/wiitm.2016.58617] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 02/29/2016] [Indexed: 02/07/2023] Open
Abstract
Introduction The goal of modern medical treatment is to provide high quality medical care in a cost-effective environment. Aim To assess the cost-effectiveness of laparoscopic colorectal surgery combined with the enhanced recovery after surgery protocol (ERP) in Poland. Material and methods We designed a single-centre, case-matched study. Economic and clinical data were collected in 3 groups of patients (33 patients in each group): group 1 – patients undergoing laparoscopy with ERP; group 2 – laparoscopy without ERP; group 3 – open resection without ERP. An independent administrative officer, not involved in the treatment process, matched patients for age, sex and type of resection. Primary outcome was cost analysis. It was carried out incorporating institutional costs: hospital bed stay, anaesthesia, surgical procedure and equipment, drugs and complications. Secondary outcomes were length of stay (LOS), readmission and complication rate. Results Cost of laparoscopic procedure alone was significantly more expensive than open resection. However, implementation of the ERAS protocol reduced additional costs. Total cost per patient in group 1 was significantly lower than in groups 2 and 3 (EUR 1826 vs. EUR 2355.3 vs. EUR 2459.5, p < 0.0001). Median LOS was 3, 6 and 9 days in groups 1, 2 and 3 respectively (p < 0.001). Postoperative complications were noted in 5 (15.2%), 6 (18.2%) and 13 (39.4%) patients in groups 1, 2, 3 respectively (p = 0.0435). Conclusions In a low medical care expenditure country, minimally invasive surgery combined with ERP can be a safe and a cost-effective alternative to open surgery with traditional perioperative care.
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254
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Majumder A, Fayezizadeh M, Neupane R, Elliott HL, Novitsky YW. Benefits of Multimodal Enhanced Recovery Pathway in Patients Undergoing Open Ventral Hernia Repair. J Am Coll Surg 2016; 222:1106-15. [PMID: 27049780 DOI: 10.1016/j.jamcollsurg.2016.02.015] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 02/17/2016] [Accepted: 02/18/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Use of Enhanced Recovery After Surgery (ERAS) pathways have evidenced improved outcomes in several surgical specialties. The effectiveness of ERAS pathways specific to hernia surgery, however, has not yet been investigated. We hypothesized that our ERAS pathway would accelerate functional recovery and shorten hospitalization in patients undergoing open ventral hernia repair (VHR). STUDY DESIGN Consecutive patients undergoing open major VHR using transversus abdominis release and sublay synthetic mesh placement, with use of our ERAS pathway, were compared with a historical cohort before ERAS implementation. Main outcomes measures were time to diet advancement, time to return of bowel function, time to oral narcotics, length of stay (LOS), and 90-day readmissions. RESULTS Between January 2014 and January 2015, 100 patients undergoing VHR with ERAS implementation were compared with a historical cohort. The ERAS group demonstrated significantly shorter times to liquid and regular diet: 1.1 vs 2.7 and 3.0 vs 4.8 days, respectively (p < 0.001). Furthermore, ERAS patients demonstrated significantly shorter times to flatus and bowel movement: 3.1 vs 3.9 and 3.6 vs 5.2 days, respectively (p < 0.001). Average LOS was reduced from 6.1 to 4.0 days (p < 0.001), and ERAS patients had significantly fewer 90-day readmissions, 4% vs 16% (p < 0.001). CONCLUSIONS A comprehensive ERAS pathway for major open VHR was implemented safely. Multimodal perioperative pain management, oral opioid-receptor blockade, and early feeding strategies resulted in accelerated intestinal recovery, shorter hospitalizations, and fewer readmissions. Use of our ERAS pathway appears to result in improved outcomes in patients undergoing open VHR.
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Affiliation(s)
- Arnab Majumder
- Case Comprehensive Hernia Center, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH
| | - Mojtaba Fayezizadeh
- Case Comprehensive Hernia Center, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH
| | - Ruel Neupane
- Case Comprehensive Hernia Center, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH
| | - Heidi L Elliott
- Case Comprehensive Hernia Center, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH
| | - Yuri W Novitsky
- Case Comprehensive Hernia Center, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH.
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255
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Zhao JH, Sun JX, Huang XZ, Gao P, Chen XW, Song YX, Liu J, Cai CZ, Xu HM, Wang ZN. Meta-analysis of the laparoscopic versus open colorectal surgery within fast track surgery. Int J Colorectal Dis 2016; 31:613-22. [PMID: 26732262 DOI: 10.1007/s00384-015-2493-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Laparoscopic methods and fast-track surgery (FTS) can enhance recovery and reduce postoperative hospital stay. However, whether laparoscopic surgery can provide short-term benefits within FTS is controversial. Thus, we conducted a meta-analysis of published studies to evaluate the effect of laparoscopic colorectal surgery within FTS. METHODS We searched PubMed, EMBASE, Cochrane Library, and Ovid databases for eligible studies. Endpoints were duration of postoperative hospital stay, time to first bowel movement, total postoperative complication rate, readmission rate, mortality within 30 days after surgery, and conversation rate of laparoscopic surgery. RESULTS Four randomized controlled trials and six clinical controlled trials (1510 patients) were eligible for analyses. Duration of postoperative hospital stay (weighted mean difference, -1.65 days; p < 0.001), time to first bowel movement (-1.13 days; p < 0.001), total postoperative complication rate (risk ratio [RR], 0.65; p < 0.001), readmission rate (0.46; p < 0.001), and mortality (0.45; p < 0.001) were significantly reduced in the laparoscopic surgery group. Overall conversion rate of laparoscopic surgery was 11.1%. Subgroup analyses based on each FT element demonstrated that studies without the element "prevention of hypothermia," "no bowel preparation," or "no routine use of drains" did not show significant differences between two groups with regard to duration of postoperative hospital stay or total prevalence of postoperative complications. CONCLUSION Within FTS, laparoscopic methods can significantly shorten postoperative hospital stay, accelerate postoperative recovery, and enhance safety in colorectal surgery. The FT elements "prevention of hypothermia," "no bowel preparation," and "no routine use of drains" may play important parts in the combined effect of these two methods.
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Affiliation(s)
- Jun-hua Zhao
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Jing-xu Sun
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Xuan-zhang Huang
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Peng Gao
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Xiao-wan Chen
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Yong-xi Song
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Jing Liu
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Cheng-zhe Cai
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Hui-mian Xu
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Zhen-ning Wang
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
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256
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Cost-effectiveness of Enhanced Recovery Versus Conventional Perioperative Management for Colorectal Surgery. Ann Surg 2016; 262:1026-33. [PMID: 25371130 DOI: 10.1097/sla.0000000000001019] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine the cost-effectiveness of enhanced recovery pathways (ERPs) versus conventional care for patients undergoing elective colorectal surgery. BACKGROUND ERPs for colorectal surgery are clinically effective, but their cost-effectiveness is unknown. METHODS A multi-institutional prospective cohort cost-effectiveness analysis was performed. Adult patients undergoing elective colorectal resection at 2 university-affiliated institutions from October 2012 to October 2013 were enrolled. One center used an ERP, whereas the other did not. Postoperative outcomes were recorded up to 60 days. Total costs were reported in 2013 Canadian dollars. Effectiveness was measured using the SF-6D, a health utility measure validated for postoperative recovery. Uncertainty was expressed using bootstrapped estimates (10,000 repetitions). RESULTS A total of 180 patients were included (conventional care: n = 95; ERP: n = 95). There were no differences in patient characteristics except for a higher proportion of laparoscopy in the ERP group. Mean length of stay was shorter in the ERP group (6.5 vs 9.8 days; P = 0.017), but there were no differences in complications or readmissions. Patients in the ERP group returned to work quicker and had less caregiver burden. There was no difference in quality of life between the 2 groups. The cost of the ERP program was $153 per patient. Overall societal costs were lower in the ERP group (mean difference = -2985; 95% confidence interval, -5753 to -373). The ERP had a greater than 99% probability of cost-effectiveness. The results were insensitive to a range of assumptions and subgroups. CONCLUSIONS Enhanced recovery is cost-effective compared with conventional perioperative management for elective colorectal resection.
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257
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Pędziwiatr M, Pisarska M, Kisielewski M, Matłok M, Major P, Wierdak M, Budzyński A, Ljungqvist O. Is ERAS in laparoscopic surgery for colorectal cancer changing risk factors for delayed recovery? Med Oncol 2016; 33:25. [PMID: 26873739 PMCID: PMC4752577 DOI: 10.1007/s12032-016-0738-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 01/31/2016] [Indexed: 12/13/2022]
Abstract
There is evidence that implementation of enhanced recovery after surgery (ERAS) protocols into colorectal surgery reduces complication rate and improves postoperative recovery. However, most published papers on ERAS outcomes and length of stay in hospital (LOS) include patients undergoing open resections. The aim of this pilot study was to determine the factors affecting recovery and LOS in patients after laparoscopic colorectal surgery for cancer combined with ERAS protocol. One hundred and forty-three consecutive patients undergoing elective laparoscopic resection were prospectively evaluated. They were divided into two subgroups depending on their reaching the targeted length of stay—LOS (75 patients in group 1—≤4 days, 68 patients in group 2—>4 days). A univariate and multivariate logistic regression analysis was performed to assess for factors (demographics, perioperative parameters, complications and compliance with the ERAS protocol) independently associated with LOS of 4 days or longer. The median LOS in the entire group was 4 days. The postoperative complication rate was higher (18.7 vs. 36.7 %), and the compliance with ERAS protocol was lower (91.2 vs. 76.7 %) in group 2. There was an association between the pre- and postoperative compliance and the subsequent complications. In uni- and multivariate analysis, the lack of balanced fluid therapy (OR 3.87), lack of early mobilization (OR 20.74), prolonged urinary catheterization (OR 4.58) and use of drainage (OR 2.86) were significantly associated with prolonged LOS. Neither traditional patient risk factors nor the stage of the cancer was predictive of the duration of hospital stay. Instead, compliance with the ERAS protocol seems to influence recovery and LOS when applied to laparoscopic colorectal cancer surgery.
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Affiliation(s)
- Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland. .,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland.
| | - Magdalena Pisarska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland
| | - Michał Kisielewski
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland
| | - Maciej Matłok
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland
| | - Mateusz Wierdak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
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258
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Papageorge CM, Kennedy GD, Carchman EH. National Trends in Short-term Outcomes Following Non-emergent Surgery for Diverticular Disease. J Gastrointest Surg 2016; 20:1376-87. [PMID: 27120447 PMCID: PMC4916196 DOI: 10.1007/s11605-016-3150-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 04/11/2016] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Elective surgery for diverticulitis has evolved over the last decade. We aimed to evaluate the impact of changing practice patterns on postoperative outcomes. We hypothesized that the increased use of laparoscopy, and other management changes, would correlate with a decrease in postoperative complications. METHODS Patients undergoing non-emergent surgery for diverticulitis from 2005 to 2013 were selected from the National Surgical Quality Improvement Program (NSQIP) database. We compared patient demographics, comorbidities, and operative approach by year of operation using chi-square tests and investigated temporal trends in postoperative outcomes using univariate, trend, and multivariate analyses. RESULTS The analytic cohort, which included 29,893 patients, had increasing rates of obesity, advanced age, and higher American Society of Anesthesiologists (ASA) class over the study period. The use of laparoscopy increased significantly from 48 % in 2005/2006 to 70 % in 2013 (p < 0.001), while the rate of stoma creation remained unchanged (10-12 %, p = 0.072). The absolute risk of any postoperative complication decreased by 5.8 % over the study period, driven primarily by a reduction in infectious complications. Year of operation was a significant independent predictor of fewer complications for 2011-2013. CONCLUSION Despite a trend towards increasing patient complexity, there has been a decline in postoperative morbidity following non-emergent surgery for diverticulitis. This trend coincides with the steadily increasing use of laparoscopy in this population.
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Affiliation(s)
- Christina M. Papageorge
- Department of Surgery, Division of Colon and Rectal Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, K4/730, Madison, WI 53792-7375 USA
| | - Gregory D. Kennedy
- Department of Surgery, Division of Colon and Rectal Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, K4/730, Madison, WI 53792-7375 USA
| | - Evie H. Carchman
- Department of Surgery, Division of Colon and Rectal Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, K4/730, Madison, WI 53792-7375 USA
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259
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Steenhagen E. Enhanced Recovery After Surgery: It's Time to Change Practice! Nutr Clin Pract 2015; 31:18-29. [PMID: 26703956 DOI: 10.1177/0884533615622640] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Perioperative surgical care is undergoing a paradigm shift. Traditional practices such as prolonged preoperative fasting (nil by mouth from midnight), bowel cleaning, and reintroduction of oral nutrition 3-5 days after surgery are being shunned. These and other similar changes have been formulated into a protocol called Enhanced Recovery After Surgery (ERAS) pathway. It is a multimodal perioperative care pathway designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of an ERAS protocol include preoperative counseling, optimization of nutrition, standardized analgesic and anesthetic regimes, and early mobilization. The recent literature is heavily influenced by colorectal surgery, but the principles are now being applied to a wide range of disciplines. As they challenge traditional surgical doctrine, the implementation of ERAS guidelines has been slow, despite the significant body of evidence indicating that ERAS guidelines may lead to improved outcomes.
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Affiliation(s)
- Elles Steenhagen
- Internal Medicine and Dermatology, Department of Dietetics, University Medical Center Utrecht, the Netherlands
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260
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Martin TD, Lorenz T, Ferraro J, Chagin K, Lampman RM, Emery KL, Zurkan JE, Boyd JL, Montgomery K, Lang RE, Vandewarker JF, Cleary RK. Newly implemented enhanced recovery pathway positively impacts hospital length of stay. Surg Endosc 2015; 30:4019-28. [PMID: 26694181 DOI: 10.1007/s00464-015-4714-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 12/01/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Enhanced recovery pathways (ERPs) are thought to improve surgical outcomes by standardizing perioperative patient care established in evidence-based literature. The objective of this study was to determine the impact of a colorectal surgery ERP on hospital length of stay (LOS) and other patient outcomes. METHODS This is a comparative effectiveness study of patients undergoing elective colorectal surgery 2 years prior (pre-ERP group) and 2 years after (ERP group) implementation of an ERP program. The primary outcome was hospital LOS. Secondary outcomes included postoperative complications, 30-day readmissions, and 30-day reoperations. Multivariable regression analyses were utilized to control for patient factors, general health factors, diagnosis, surgeon, colon versus rectal operations, and open versus minimally invasive operations-laparoscopic and robotic. An ERP checklist was developed to track adherence to components of the pathway. RESULTS The study population included 1036 patients: 523 in the pre-ERP group and 513 in the ERP group. Unadjusted LOS was significantly shorter in the ERP group than the control pre-ERP group [3 (IQR 3.5) vs 5 days (IQR 4.6); p < 0.0001]. Multivariable regression analysis confirmed the reduction in LOS, controlling for age, colon/rectum procedure, open/laparoscopic/robotic approach, primary diagnosis, and alvimopan use. Postoperative outcomes were not significantly different between groups except for 30-day readmissions, which were unexpectedly higher in the ERP group (14.6 vs 8.7 %, p = 0.04). CONCLUSIONS A newly implemented ERP on a dedicated colorectal surgery service in an academic non-university hospital setting resulted in shorter hospital LOS, but increased readmissions, for patients undergoing elective open and minimally invasive colon and rectal surgery. Future multi-institutional studies are needed to understand the impact of ERP on postoperative complications and readmissions.
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Affiliation(s)
- Thomas D Martin
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Talya Lorenz
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Jane Ferraro
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Kevin Chagin
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Richard M Lampman
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Karen L Emery
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Joan E Zurkan
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Jami L Boyd
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Karin Montgomery
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Rachel E Lang
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - James F Vandewarker
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Robert K Cleary
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA.
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261
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de Groot JJA, Ament SMC, Maessen JMC, Dejong CHC, Kleijnen JMP, Slangen BFM. Enhanced recovery pathways in abdominal gynecologic surgery: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2015; 95:382-95. [PMID: 26613531 DOI: 10.1111/aogs.12831] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 11/16/2015] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Enhanced recovery pathways have been widely accepted and implemented for different types of surgery. Their overall effect in abdominal gynecologic surgery is still underdetermined. A systematic review and meta-analysis were performed to provide an overview of current evidence and to examine their effect on postoperative outcomes in women undergoing open gynecologic surgery. MATERIAL AND METHODS Searches were conducted using Embase, Medline, CINAHL, and the Cochrane Library up to 27 June 2014. Reference lists were screened to identify additional studies. Studies were included if at least four individual items of an enhanced recovery pathway were described. Outcomes included length of hospital stay, complication rates, readmissions, and mortality. Quantitative analysis was limited to comparative studies. Effect sizes were presented as relative risks or as mean differences (MD) with 95% confidence intervals (CI). RESULTS Thirty-one records, involving 16 observational studies, were included. Diversity in reported elements within studies was observed. Preoperative education, early oral intake, and early mobilization were included in all pathways. Five studies, with a high risk of bias, were eligible for quantitative analysis. Enhanced recovery pathways reduced primary (MD -1.57 days, 95% CI CI -2.94 to -0.20) and total (MD -3.05 days, 95% CI -4.87 to -1.23) length of hospital stay compared with traditional perioperative care, without an increase in complications, mortality or readmission rates. CONCLUSION The available evidence based on a broad range of non-randomized studies at high risk of bias suggests that enhanced recovery pathways may reduce length of postoperative hospital stay in abdominal gynecologic surgery.
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Affiliation(s)
- Jeanny J A de Groot
- Department of Family Medicine, CAPHRI, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Stephanie M C Ament
- Department of Family Medicine, CAPHRI, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - José M C Maessen
- Department of Family Medicine, CAPHRI, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Department of Patient & Integrated Care, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,NUTRIM, School for Nutrition, Toxicology, and Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jos M P Kleijnen
- Department of Family Medicine, CAPHRI, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Kleijnen Systematic Reviews Ltd, York, UK
| | - Brigitte F M Slangen
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
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262
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Development of an Enhanced Recovery After Surgery Guideline and Implementation Strategy Based on the Knowledge-to-action Cycle. Ann Surg 2015; 262:1016-25. [DOI: 10.1097/sla.0000000000001067] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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263
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Abstract
Abstract
Surgery represents a major stressor that disrupts homeostasis and can lead to loss of body cell mass. Integrated, multidisciplinary medical strategies, including enhanced recovery programs and perioperative nutrition support, can mitigate the surgically induced metabolic response, promoting optimal patient recovery following major surgery. Clinical therapies should identify those who are poorly nourished before surgery and aim to attenuate catabolism while preserving the processes that promote recovery and immunoprotection after surgery. This review will address the impact of surgery on intermediary metabolism and describe the clinical consequences that ensue. It will also focus on the role of perioperative nutrition, including preoperative nutrition risk, carbohydrate loading, and early initiation of oral feeding (centered on macronutrients) in modulating surgical stress, as well as highlight the contribution of the anesthesiologist to nutritional care. Emerging therapeutic concepts such as preoperative glycemic control and prehabilitation will be discussed.
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264
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Impact of urinary tract infection definitions on colorectal outcomes. J Surg Res 2015; 199:331-7. [DOI: 10.1016/j.jss.2015.04.073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 03/13/2015] [Accepted: 04/21/2015] [Indexed: 11/18/2022]
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265
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Is robotic-assisted radical cystectomy (RARC) with intracorporeal diversion becoming the new gold standard of care? World J Urol 2015; 34:25-32. [PMID: 26607697 DOI: 10.1007/s00345-015-1730-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/05/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Totally intracorporeal robotic-assisted radical cystectomy (RARC) has perceived difficulties compared to open radical cystectomy (ORC). As the technique is increasingly adopted around the world, the benefits of RARC with intra- or extracorporeal urinary diversion or ORC for the patients are still unclear. In this article, we consider the current evidence for this issue. METHODS We assessed two questions through using expert opinion and the medical literature: (A) Is RARC better than ORC for removing the cancer surgery and outcome? (B) Is RARC better than ORC for the urinary diversion? OUTCOMES (A) RARC is better than ORC for shorter length of stay, blood loss and complication rates. (B) Intracorporeal orthotopic neobladder may have a significant physiological and surgical benefit to the patient recovery. CONCLUSIONS RARC with total intracorporeal reconstruction has potential benefits to the patient. We recommend that all surgeons document patient-related outcome measures, urodynamics and enhanced recovery protocols for cystectomy patients to help us understand the real improvements within bladder cancer surgery and reconstruction.
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266
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Huang DD, Wang SL, Zhuang CL, Zheng BS, Lu JX, Chen FF, Zhou CJ, Shen X, Yu Z. Sarcopenia, as defined by low muscle mass, strength and physical performance, predicts complications after surgery for colorectal cancer. Colorectal Dis 2015. [PMID: 26194849 DOI: 10.1111/codi.13067] [Citation(s) in RCA: 162] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIM Recent studies have shown that sarcopenia is associated with negative postoperative outcomes. However, none of these studies analysed muscle strength or physical performance, which are also important components of sarcopenia. The present study aimed to investigate whether sarcopenia itself, as defined by low muscle mass, strength and physical performance, would predict complications after surgery for colorectal cancer. METHOD We conducted a prospective study of patients who underwent surgery for colorectal cancer at our department between August 2014 and February 2015. Sarcopenia was diagnosed by a combination of third lumbar vertebra muscle index (L3 MI), handgrip strength and 6-m usual gait speed. Univariate and multivariate analyses evaluating the risk factors for postoperative complications were performed. Only complications classified as Grade II or above according to the Clavien-Dindo classification were analysed in this study. RESULTS A total of 142 patients were included in the study, and 17 patients were diagnosed as having sarcopenia. Postoperative complications of Grade II or above occurred in 40 patients, including 10 with sarcopenia and 30 without sarcopenia. Multivariate analysis showed that sarcopenia and previous abdominal surgery were independent risk factors for postoperative complications. Patients with sarcopenia also had an obvious tendency to a higher incidence of infectious complications. By comparing two logistic regression models, sarcopenia showed a better predictive power for postoperative complications than did low muscle mass. CONCLUSION Sarcopenia and previous abdominal surgery are independent risk factors for complications after surgery for colorectal cancer. Including a functional aspect to the definition of sarcopenia may result in a better prediction of postoperative complications.
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Affiliation(s)
- D-D Huang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - S-L Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - C-L Zhuang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - B-S Zheng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - J-X Lu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - F-F Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - C-J Zhou
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - X Shen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Z Yu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China.,Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
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267
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Shida D, Wakamatsu K, Tanaka Y, Yoshimura A, Kawaguchi M, Miyamoto S, Tagawa K. The postoperative patient-reported quality of recovery in colorectal cancer patients under enhanced recovery after surgery using QoR-40. BMC Cancer 2015; 15:799. [PMID: 26503497 PMCID: PMC4624174 DOI: 10.1186/s12885-015-1799-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 10/16/2015] [Indexed: 12/20/2022] Open
Abstract
Background Enhanced recovery after surgery (ERAS) protocols may reduce postoperative complications and the length of hospital stay. Studies of the effectiveness of ERAS should include not only doctor-reported outcomes, but also patient-reported outcomes, in order to better estimate their impact on recovery. However, patient-reported outcomes are not commonly reported. Thus, it needs to be assessed whether early discharge from the hospital is compatible with a better outcome from the viewpoint of the patients themselves. Methods The 40-item quality of recovery score (QoR-40) is a recovery-specific, and patient-rated questionnaire, which provides a good measurement of early postoperative recovery. Ninety-four colorectal cancer patients undergoing surgery under ERAS protocol management were asked to answer QoR-40 questionnaires preoperatively and on post-operative day (POD) 1, 3, 6 and one month after surgery. Results The median (25th, 75th percentiles) preoperative global QoR-40 scores as an indicator of the baseline health status, was 189 (176.75, 197). On POD1 and POD3, the scores had decreased significantly to 154 (132.5, 164.25) and 177 (161.75, 190), respectively. On POD 6, the score dramatically recovered up to 183.5 (167.9, 191), which was not significantly different from the baseline level (p = 0.06). The scores at 1 month after surgery were 190 (176, 197). Younger patients, compared to older patients, and rectal cancer patients, compared to colon cancer patients, had significantly lower scores on POD1. Conclusion This study clearly demonstrated that the quality of recovery based on patient-reported outcomes is in agreement with discharge around POD6 for colorectal cancer patients under ERAS.
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Affiliation(s)
- Dai Shida
- Colorectal Surgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Cyuo-ku, Tokyo, 1040045, Japan.
| | - Kotaro Wakamatsu
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Koto-bashi, Sumida-ku, Tokyo, 1308575, Japan.
| | - Yuu Tanaka
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 6348522, Japan.
| | - Atsushi Yoshimura
- Department of Anesthesiology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Koto-bashi, Sumida-ku, Tokyo, 1308575, Japan.
| | - Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 6348522, Japan.
| | - Sachio Miyamoto
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Koto-bashi, Sumida-ku, Tokyo, 1308575, Japan.
| | - Kyoko Tagawa
- Department of Anesthesiology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Koto-bashi, Sumida-ku, Tokyo, 1308575, Japan.
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268
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Electroacupuncture for postoperative pain and gastrointestinal motility after laparoscopic appendectomy (AcuLap): study protocol for a randomized controlled trial. Trials 2015; 16:461. [PMID: 26466590 PMCID: PMC4606555 DOI: 10.1186/s13063-015-0981-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 09/28/2015] [Indexed: 01/26/2023] Open
Abstract
Background Acupuncture is a widely serviced complementary medicine. Although acupuncture is suggested for managing postoperative ileus and pain, supporting evidence is weak. The AcuLap trial is designed to provide high-level evidence regarding whether or not electroacupuncture is effective in promoting gastrointestinal motility and controlling pain after laparoscopic surgery. Methods/design This study is a prospective randomized controlled trial with a three-arm, parallel-group structure evaluating the efficacy of electroacupuncture for gastrointestinal motility and postoperative pain after laparoscopic appendectomy. Patients with appendicitis undergoing laparoscopic surgery are included and randomized into three groups: 1) electroacupuncture group, 2) sham acupuncture group, and 3) control group. Patients receive 1) acupuncture with electrostimulation or 2) fake electroacupuncture with sham device twice a day or 3) no acupuncture after laparoscopic appendectomy. The primary outcome is time to first passing flatus after operation. Secondary outcomes include postoperative pain, analgesics, nausea/vomiting, bowel motility, time to tolerable diet, complications, hospital stay, readmission rates, time to recovery, quality of life, medical costs, and protocol failure rate. Patients and hospital staff (physicians and nurses) are blinded to which group the patient is assigned, electroacupuncture or sham acupuncture. Data analysis personnel are blinded to group assignment among all three groups. Estimated sample size to detect a minimum difference of time to first flatus with 80 % power, 5 % significance, and 10 % drop rate is 29 × 3 groups = 87 patients. Analysis will be performed according to the intention-to-treat principle. Discussion The AcuLap trial will provide evidence on the merits and/or demerits of electroacupuncture for bowel motility recovery and pain relief after laparoscopic appendectomy. Trial registration The trial was registered in Clinical Research Information Service (CRiS), Republic of Korea (KCT0001486) on 14 May 2015.
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269
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Auyong DB, Allen CJ, Pahang JA, Clabeaux JJ, MacDonald KM, Hanson NA. Reduced Length of Hospitalization in Primary Total Knee Arthroplasty Patients Using an Updated Enhanced Recovery After Orthopedic Surgery (ERAS) Pathway. J Arthroplasty 2015; 30:1705-9. [PMID: 26024988 DOI: 10.1016/j.arth.2015.05.007] [Citation(s) in RCA: 142] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 04/27/2015] [Accepted: 05/05/2015] [Indexed: 02/07/2023] Open
Abstract
Decreasing hospital length of stay may attenuate costs associated with total knee arthroplasty. The purpose of this study was to determine if updates to an existing orthopedic enhanced recovery after surgery (ERAS) pathway would improve length of hospitalization. Clinical and demographic data were collected on 252 primary total knee arthroplasties between January 2012 and July 2013. Pre-updated and post-updated ERAS pathway cohorts were analyzed for length of stay, clinical outcomes, and re-admissions. The mean length of stay decreased from 76.6 hours to 56.1 hours after implementation of the evidence-based orthopedic enhanced recovery after surgery pathway (P<0.001). This improvement was possible without a concomitant increase in readmission rates.
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270
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Affiliation(s)
- Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden,
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271
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Levolger S, van Vugt JLA, de Bruin RWF, IJzermans JNM. Systematic review of sarcopenia in patients operated on for gastrointestinal and hepatopancreatobiliary malignancies. Br J Surg 2015; 102:1448-58. [PMID: 26375617 DOI: 10.1002/bjs.9893] [Citation(s) in RCA: 196] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 04/28/2015] [Accepted: 06/09/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Preoperative risk assessment in cancer surgery is of importance to improve treatment and outcome. The aim of this study was to assess the impact of CT-assessed sarcopenia on short- and long-term outcomes in patients undergoing surgical resection of gastrointestinal and hepatopancreatobiliary malignancies. METHODS A systematic search of Embase, PubMed and Web of Science was performed to identify relevant studies published before 30 September 2014. PRISMA guidelines for systematic reviews were followed. Screening for inclusion, checking the validity of included studies and data extraction were carried out independently by two investigators. RESULTS After screening 692 records, 13 observational studies with a total of 2884 patients were included in the analysis. There was wide variation in the reported prevalence of sarcopenia (17.0-79 per cent). Sarcopenia was independently associated with reduced overall survival in seven of ten studies, irrespective of tumour site. Hazard ratios (HRs) of up to 3.19 (hepatic cancer), 1.63 (pancreatic cancer), 1.85 (colorectal cancer) and 2.69 (colorectal liver metastases, CLM) were reported. For oesophageal cancer, the HR was 0.31 for increasing muscle mass. In patients with colorectal cancer and CLM, sarcopenia was independently associated with postoperative mortality (colorectal cancer: odds ratio (OR) 43.3), complications (colorectal cancer: OR 0.96 for increasing muscle mass; CLM: OR 2.22) and severe complications (CLM: OR 3.12). CONCLUSION Sarcopenia identified before surgery by single-slice CT is associated with impaired overall survival in gastrointestinal and hepatopancreatobiliary malignancies, and increased postoperative morbidity in patients with colorectal cancer with or without hepatic metastases.
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Affiliation(s)
- S Levolger
- Department of Surgery, Erasmus MC - University Medical Centre, Wytemaweg 80, 3015 CE Rotterdam, The Netherlands
| | - J L A van Vugt
- Department of Surgery, Erasmus MC - University Medical Centre, Wytemaweg 80, 3015 CE Rotterdam, The Netherlands
| | - R W F de Bruin
- Department of Surgery, Erasmus MC - University Medical Centre, Wytemaweg 80, 3015 CE Rotterdam, The Netherlands
| | - J N M IJzermans
- Department of Surgery, Erasmus MC - University Medical Centre, Wytemaweg 80, 3015 CE Rotterdam, The Netherlands
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272
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Barclay KL, Zhu YY, Tacey MA. Nausea, vomiting and return of bowel function after colorectal surgery. ANZ J Surg 2015; 85:823-8. [PMID: 26350160 DOI: 10.1111/ans.13290] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND Although patterns of return of bowel function (ROBF) following colorectal surgery with enhanced recovery after surgery (ERAS) programmes have been well delineated, regular morphine use is uncommon. This study describes the patterns of post-operative nausea and vomiting (PONV) and ROBF in this context. METHOD Patients undergoing elective major colorectal surgery on an ERAS programme over 1 year were included. Patient details, intra-operative course, post-operative management, outcomes and complications were collected retrospectively from clinical records. Statistical analysis was performed using Stata version 12. RESULTS A total of 136/142 (96%) patients received morphine for post-operative analgesia. Most (112/142, 79%) experienced either no vomiting (87/142, 61%) or small amounts (25/142, 18%). On average, patients without an ileostomy passed flatus and opened their bowels after 2.4 and 4.3 days, those with an ileostomy taking 1.5 and 2.1 days. Vomiting was not related to ROBF (P = 0.370) or overall complications; wound complications (odds ratio (OR) = 8.1, 95% confidence interval (CI): 2.0-32.5), electrolyte abnormalities (OR = 2.9, 95% CI: 1.2-7.1) and length of stay (hazard ratio = 1.3, 95% CI: 1.2-1.5) were related. CONCLUSION Most patients do not experience PONV in this context. ROBF is predictable without prolonged delays. This information could be used to allow confident early discharge and identify patients whose deviation from normal may indicate complications.
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Affiliation(s)
- Karen L Barclay
- Department of General Surgery, Northern Health, Melbourne, Victoria, Australia.,Northern Clinical School, Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ying-Yan Zhu
- Northern Clinical School, Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Mark A Tacey
- Northern Clinical Research Centre, Northern Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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273
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Organizational Culture Changes Result in Improvement in Patient-Centered Outcomes: Implementation of an Integrated Recovery Pathway for Surgical Patients. J Am Coll Surg 2015; 221:669-77; quiz 785-6. [DOI: 10.1016/j.jamcollsurg.2015.05.008] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 04/01/2015] [Accepted: 05/12/2015] [Indexed: 02/02/2023]
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274
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Factors associated with failure of enhanced recovery programs after laparoscopic colon cancer surgery: a single-center retrospective study. Surg Endosc 2015; 30:1086-93. [DOI: 10.1007/s00464-015-4302-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 06/02/2015] [Indexed: 12/15/2022]
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275
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Feasibility of Fast-Track Surgery in Elderly Patients with Gastric Cancer. J Gastrointest Surg 2015; 19:1391-8. [PMID: 25943912 DOI: 10.1007/s11605-015-2839-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 04/24/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to investigate the role of the fast-track surgery (FTS) program in elderly patients (aged ≥75 years) who underwent open surgery for gastric cancer (GC) in China. METHODS A total of 256 patients with GC were randomly assigned to four groups, each of which consisted of 64 cases: the 45-74-year-old age group was subdivided into the FTS-1 group and the conventional care (CC)-1 group, and the 75-89-year-old age group was subdivided into the FTS-2 group and the CC-2 group. All patients underwent open gastrectomy by the same experienced surgical team. We compared the differences between the pairs of groups in different age ranges with respect to the postoperative recovery index, complications, and medical costs. RESULTS Compared with the CC-1 group, the FTS-1 group exhibited earlier postoperative flatus, a shorter postoperative hospital stay, lower medical costs, and a decreased incidence of sore throat (P = 0.010, P = 0.000, P = 0.000, and P = 0.019, respectively). Compared with the CC-2 group, the FTS-2 group had more nausea and vomiting, stomach retention, and intestinal obstruction, as well as a higher readmission rate (P = 0.015, P = 0.011, P = 0.041, and P = 0.013, respectively). CONCLUSION The application of FTS can significantly speed up postoperative rehabilitation, shorten the hospitalization time, and lower the medical costs for 45-74-year-old GC patients, but this procedure does not show the same benefits for elderly patients. These findings suggest that we should carefully consider whether the FTS program should be applied to elderly patients with GC.
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276
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Gotlib Conn L, McKenzie M, Pearsall EA, McLeod RS. Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: a process evaluation of champions' experiences. Implement Sci 2015; 10:99. [PMID: 26183086 PMCID: PMC4504167 DOI: 10.1186/s13012-015-0289-y] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 07/02/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is a multimodal evidence-based approach to patient care that has become the standard in elective colorectal surgery. Implemented globally, ERAS programmes represent a considerable change in practice for many surgical care providers. Our current understanding of specific implementation and sustainability challenges is limited. In January 2013, we began a 2-year ERAS implementation for elective colorectal surgery in 15 academic hospitals in Ontario. The purpose of this study was to understand the process enablers and barriers that influenced the success of ERAS implementation in these centres with a view towards supporting sustainable change. METHODS A qualitative process evaluation was conducted from June to September 2014. Semi-structured interviews with implementation champions were completed, and an iterative inductive thematic analysis was conducted. Following a data-driven analysis, the Normalization Process Theory (NPT) was used as an analytic framework to understand the impact of various implementation processes. The NPT constructs were used as sensitizing concepts, reviewed against existing data categories for alignment and fit. RESULTS Fifty-eight participants were included: 15 surgeons, 14 anaesthesiologists, 15 nurses, and 14 project coordinators. A number of process-related implementation enablers were identified: champions' belief in the value of the programme, the fit and cohesion of champions and their teams locally and provincially, a bottom-up approach to stakeholder engagement targeting organizational relationship-building, receptivity and support of division leaders, and the normalization of ERAS as everyday practice. Technical enablers identified included effective integration with existing clinical systems and using audit and feedback to report to hospital stakeholders. There was an overall optimism that ERAS implementation would be sustained, accompanied by concern about long-term organizational support. CONCLUSIONS Successful ERAS implementation is achieved by a complex series of cognitive and social processes which previously have not been well described. Using the Normalization Process Theory as a framework, this analysis demonstrates the importance of champion coherence, external and internal relationship building, and the strategic management of a project's organization-level visibility as important to ERAS uptake and sustainability.
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Affiliation(s)
- Lesley Gotlib Conn
- Evaluative Clinical Sciences, Trauma, Emergency and Critical Care Research Program, Sunnybrook Research Institute, 2075 Bayview Ave., Room K3W-28, Toronto, ON, M4N 3M5, Canada.
| | - Marg McKenzie
- Department of Surgery, Mount Sinai Hospital Joseph and Wolf Lebovic Health Complex, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
| | - Emily A Pearsall
- Department of Surgery, Mount Sinai Hospital Joseph and Wolf Lebovic Health Complex, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
| | - Robin S McLeod
- Department of Surgery, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, M5T 1P5, Canada.
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277
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Khasanov AF, Sigal EI, Trifonov VR, Khasanova NA, Baisheva NA, Shaĭmuratov IM, Gubaĭdullin SR, Sigal AM. [The program of accelerated rehabilitation after esophagoplasty (fast track surgery) in esophageal cancer surgery]. Khirurgiia (Mosk) 2015:37-43. [PMID: 26031818 DOI: 10.17116/hirurgia2015237-43] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Esophagectomy with simultaneous plasty in patient with esophageal cancer is still associated with a high incidence of postoperative complications and long-stay patient in the clinic. The purpose of our report is to inform the use of the program of accelerated rehabilitation after esophagectomy in a prospective study of 13 patients during the period from 2010 to 2011 year and the role of the anesthesiologist in its implementation. Methods aimed at the preoperative examination, minimally invasive surgery, thoracic epidural anesthesia/analgesia with local anesthetics as a component of anesthesia and postoperative analgesia, early extubation and mobilization of the patient with the implementation of breathing exercises, early enteral feeding, and the planned short postoperative stay in resuscitation and hospital were used. Postoperative complications were observed in 3 (23/1%) patients: one patient (7/7%) had right-side pneumonia, two patients (15/4%) had right-side pneumothorax requiring emergency re drainage. The average intensive care stay was 2 (1-4) days, postoperative hospital stay--9 (7-12) days. Further monitoring of the patients did not show any long-term complications. The results confirm that it is possible to optimize the healing perioperative process in patients after esophagectomy with simultaneous plasty by using of accelerated rehabilitation program without the risk of increasing the frequency of postoperative complications. it will provide the reduction of length of hospital stay. In view of multifaceted and controversial issue the following researches in this direction are necessary.
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Affiliation(s)
- A F Khasanov
- Respublikanskiĭ klinicheskiĭ onkologicheskiĭ dispanser Minzdrava RT, Privolzhskiĭ filial RONTs im. N.N. Blokhina RAMN, Kazan', Rossiia
| | - E I Sigal
- Respublikanskiĭ klinicheskiĭ onkologicheskiĭ dispanser Minzdrava RT, Privolzhskiĭ filial RONTs im. N.N. Blokhina RAMN, Kazan', Rossiia
| | - V R Trifonov
- Respublikanskiĭ klinicheskiĭ onkologicheskiĭ dispanser Minzdrava RT, Privolzhskiĭ filial RONTs im. N.N. Blokhina RAMN, Kazan', Rossiia
| | - N A Khasanova
- Respublikanskiĭ klinicheskiĭ onkologicheskiĭ dispanser Minzdrava RT, Privolzhskiĭ filial RONTs im. N.N. Blokhina RAMN, Kazan', Rossiia
| | - N A Baisheva
- Respublikanskiĭ klinicheskiĭ onkologicheskiĭ dispanser Minzdrava RT, Privolzhskiĭ filial RONTs im. N.N. Blokhina RAMN, Kazan', Rossiia
| | - I M Shaĭmuratov
- Respublikanskiĭ klinicheskiĭ onkologicheskiĭ dispanser Minzdrava RT, Privolzhskiĭ filial RONTs im. N.N. Blokhina RAMN, Kazan', Rossiia
| | - Sh R Gubaĭdullin
- Respublikanskiĭ klinicheskiĭ onkologicheskiĭ dispanser Minzdrava RT, Privolzhskiĭ filial RONTs im. N.N. Blokhina RAMN, Kazan', Rossiia
| | - A M Sigal
- Respublikanskiĭ klinicheskiĭ onkologicheskiĭ dispanser Minzdrava RT, Privolzhskiĭ filial RONTs im. N.N. Blokhina RAMN, Kazan', Rossiia
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278
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Angarita FA, Dueck AD, Azouz SM. Postoperative electrolyte management: Current practice patterns of surgeons and residents. Surgery 2015; 158:289-99. [DOI: 10.1016/j.surg.2015.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 02/15/2015] [Accepted: 02/28/2015] [Indexed: 10/23/2022]
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279
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Amini N, Kim Y, Hyder O, Spolverato G, Wu CL, Page AJ, Pawlik TM. A nationwide analysis of the use and outcomes of perioperative epidural analgesia in patients undergoing hepatic and pancreatic surgery. Am J Surg 2015; 210:483-91. [PMID: 26105799 DOI: 10.1016/j.amjsurg.2015.04.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 04/13/2015] [Accepted: 04/17/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND We sought to define trends in the use of epidural analgesia (EA) for hepatopancreatic procedures, as well as to characterize inpatient outcomes relative to the use of EA. METHODS The Nationwide Inpatient Sample database was queried to identify all elective hepatopancreatic surgeries between 2000 and 2012. In-hospital outcomes were compared among patients receiving EA vs conventional analgesia using propensity matching. RESULTS EA utilization was 7.4% (n = 3,961). The use of EA among minimally invasive procedures increased from 3.8% in 2000 to 9.1% in 2012. The odds of sepsis (odds ratio [OR] .72, 95% confidence interval [CI] .56 to .93), respiratory failure (OR .79, 95% CI .69 to .91), and postoperative pneumonia (OR .77, 95% CI .61 to .98), as well as overall in-hospital mortality (OR .72, 95% CI .56 to .93) were lower in the EA cohort (all P < .05). In contrast, no association was noted between EA and postoperative hemorrhage (OR .81, 95% CI .65 to 1.01, P = .06). CONCLUSIONS EA use among patients undergoing hepatopancreatic procedures remains low. After controlling for confounding factors, EA remained associated with a reduction in specific pulmonary-related complications, as well as in-hospital mortality.
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Affiliation(s)
- Neda Amini
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Yuhree Kim
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Omar Hyder
- Department of Anesthesia, Critical Care, and Pain Management, Massachusetts General Hospital, Boston, MA, USA
| | - Gaya Spolverato
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Christopher L Wu
- Department of Anesthesia and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Andrew J Page
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 688, Baltimore, MD 21287, USA.
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280
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Wang H, Zhu D, Liang L, Ye L, Lin Q, Zhong Y, Wei Y, Ren L, Xu J, Qin X. Short-term quality of life in patients undergoing colonic surgery using enhanced recovery after surgery program versus conventional perioperative management. Qual Life Res 2015; 24:2663-70. [DOI: 10.1007/s11136-015-0996-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2015] [Indexed: 12/22/2022]
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281
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Keenan JE, Speicher PJ, Nussbaum DP, Adam MA, Miller TE, Mantyh CR, Thacker JKM. Improving Outcomes in Colorectal Surgery by Sequential Implementation of Multiple Standardized Care Programs. J Am Coll Surg 2015. [PMID: 26206639 DOI: 10.1016/j.jamcollsurg.2015.04.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The purpose of this study was to examine the impact of the sequential implementation of the enhanced recovery program (ERP) and surgical site infection bundle (SSIB) on short-term outcomes in colorectal surgery (CRS) to determine if the presence of multiple standardized care programs provides additive benefit. STUDY DESIGN Institutional ACS-NSQIP data were used to identify patients who underwent elective CRS from September 2006 to March 2013. The cohort was stratified into 3 groups relative to implementation of the ERP (February 1, 2010) and SSIB (July 1, 2011). Unadjusted characteristics and 30-day outcomes were assessed, and inverse proportional weighting was then used to determine the adjusted effect of these programs. RESULTS There were 787 patients included: 337, 165, and 285 in the pre-ERP/SSIB, post-ERP/pre-SSIB, and post-ERP/SSIB periods, respectively. After inverse probability weighting (IPW) adjustment, groups were balanced with respect to patient and procedural characteristics considered. Compared with the pre-ERP/SSIB group, the post-ERP/pre-SSIB group had significantly reduced length of hospitalization (8.3 vs 6.6 days, p = 0.01) but did not differ with respect to postoperative wound complications and sepsis. Subsequent introduction of the SSIB then resulted in a significant decrease in superficial SSI (16.1% vs 6.3%, p < 0.01) and postoperative sepsis (11.2% vs 1.8%, p < 0.01). Finally, inflation-adjusted mean hospital cost for a CRS admission fell from $31,926 in 2008 to $22,044 in 2013 (p < 0.01). CONCLUSIONS Sequential implementation of the ERP and SSIB provided incremental improvements in CRS outcomes while controlling hospital costs, supporting their combined use as an effective strategy toward improving the quality of patient care.
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Affiliation(s)
- Jeffrey E Keenan
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Paul J Speicher
- Department of Surgery, Duke University Medical Center, Durham, NC
| | | | | | - Timothy E Miller
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
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282
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Abstract
Post-operative ileus (POI) is a common condition after surgery. Failure to restore adequate bowel function after surgery generates a series of complications and it is associated to patients frustration and discomfort, worsening their perioperative experience. Even mild POI can be source of anxiety and could be perceived as a drop out from the "straight-forward" pathway. Enhanced recovery programmes have emphasized the importance of early commencement of oral diet, avoiding the ancient dogmata of prolonged gastric decompression and fasting. These protocols with early oral feeding and mobilization have led to improved perioperative management and have decreased hospital length of stay, ameliorating patient's postoperative experience as well. Nonetheless, the incidence of POI is still high especially after major open abdominal surgery. In order to decrease the incidence of POI, minimally-invasive surgical approaches and minimization of surgical manipulation have been suggested. From a pharmacological perspective, a meta-analysis of pro-kinetics showed beneficial results with alvimopan, although its use has been limited by the augmented risk of myocardial infarction and the high costs. A more simple approach based on the postoperative use of chewing-gum has provided some benefits in restoring bowel function. From an anaesthesiological perspective, epidural anaesthesia/analgesia does not only reduce the postoperative consumption of systemic opioids but directly improve gastrointestinal function and should be considered where possible, at least for open surgical procedures. POI represents a common and debilitating complication that should be challenged with multi-disciplinary approach. Prospective research is warranted on this field and should focus also on patient s reported outcomes.
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Affiliation(s)
- Filippo Sanfilippo
- Cardiothoracic Intensive Care Unit, Intensive Care Directorate, St George's Hospital , London , UK
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283
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Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery. J Am Coll Surg 2015; 220:430-43. [DOI: 10.1016/j.jamcollsurg.2014.12.042] [Citation(s) in RCA: 283] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 12/22/2014] [Indexed: 12/12/2022]
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284
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Gómez-Izquierdo JC, Feldman LS, Carli F, Baldini G. Meta-analysis of the effect of goal-directed therapy on bowel function after abdominal surgery. Br J Surg 2015; 102:577-89. [DOI: 10.1002/bjs.9747] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 10/16/2014] [Accepted: 11/13/2014] [Indexed: 02/04/2023]
Abstract
Abstract
Background
Intraoperative goal-directed therapy (GDT) was introduced to titrate intravenous fluids, with or without inotropic drugs, based on objective measures of hypovolaemia and cardiac output measurements to improve organ perfusion. This meta-analysis aimed to determine the effect of GDT on the recovery of bowel function after abdominal surgery.
Methods
MEDLINE, Embase, the Cochrane Library and PubMed databases were searched for randomized clinical trials and cohort studies, from January 1989 to June 2013, that compared patients who did, or did not, receive intraoperative GDT, and reported outcomes on the recovery of bowel function. Time to first flatus and first bowel motion, time to tolerate oral diet, postoperative nausea and vomiting, and primary postoperative ileus were included.
Results
Thirteen trials with 1399 patients were included in the analysis. GDT shortened the time to the first bowel motion (weighted mean difference (WMD −0·67, 95 per cent c.i. −1·23 to −0·11; P = 0·020) and time to tolerate oral intake (WMD −0·95, −1·81 to −0·10; P = 0·030), and reduced postoperative nausea and vomiting (risk difference −0·15, −0·26 to −0·03; P = 0·010). When only high-quality studies were included, GDT reduced only the time to tolerate oral intake (WMD −1·18, −2·03 to −0·33; P = 0·006). GDT was more effective outside enhanced recovery programmes and in patients undergoing colorectal surgery.
Conclusion
GDT facilitated the recovery of bowel function, particularly in patients not treated within enhanced recovery programmes and in those undergoing colorectal operations.
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Affiliation(s)
- J C Gómez-Izquierdo
- Department of Anaesthesia, Montreal General Hospital. McGill University Health Centre, Montreal, Quebec, Canada
| | - L S Feldman
- Department of Surgery, Montreal General Hospital. McGill University Health Centre, Montreal, Quebec, Canada
| | - F Carli
- Department of Anaesthesia, Montreal General Hospital. McGill University Health Centre, Montreal, Quebec, Canada
| | - G Baldini
- Department of Anaesthesia, Montreal General Hospital. McGill University Health Centre, Montreal, Quebec, Canada
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285
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Barr J, Boulind C, Foster JD, Ewings P, Reid J, Jenkins JT, Williams-Yesson B, Francis NK. Impact of analgesic modality on stress response following laparoscopic colorectal surgery: a post-hoc analysis of a randomised controlled trial. Tech Coloproctol 2015; 19:231-9. [PMID: 25715786 DOI: 10.1007/s10151-015-1270-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 01/27/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Epidural analgesia is perceived to modulate the stress response after open surgery. This study aimed to explore the feasibility and impact of measuring the stress response attenuation by post-operative analgesic modalities following laparoscopic colorectal surgery within an enhanced recovery after surgery (ERAS) protocol. METHODS Data were collected as part of a double-blinded randomised controlled pilot trial at two UK sites. Patients undergoing elective laparoscopic colorectal resection were randomised to receive either thoracic epidural analgesia (TEA) or continuous local anaesthetic infusion to the extraction site via wound infusion catheter (WIC) post-operatively. The aim of this study was to measure the stress response to the analgesic modality by measuring peripheral venous blood samples analysed for serum concentrations of insulin, cortisol, epinephrine and interleukin-6 at induction of anaesthesia, at 3, 6, 12 and 24 h after the start of operation. Secondary endpoints included mean pain score in the first 48 h, length of hospital stay, post-operative complications and 30-day re-admission rates. RESULTS There was a difference between the TEA and WIC groups that varies across time. In the TEA group, there was significant but transient reduced level of serum epinephrine and a higher level of insulin at 3 and 6 h. In the WIC, there was a significant reduction of interleukin-6 values, especially at 12 h. There was no significant difference observed in the other endpoints. CONCLUSIONS There is a significant transient attenuating effect of TEA on stress response following laparoscopic colorectal surgery and within ERAS as expressed by serum epinephrine and insulin levels. Continuous wound infusion with local anaesthetic, however, attenuates cytokine response as expressed by interleukin-6.
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Affiliation(s)
- J Barr
- Yeovil District Hospital Foundation, Higher Kingston, Yeovil, Somerset, BA21 4AT, UK
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286
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Jorgensen M, Young J, Dobbins T, Solomon M. A mortality risk prediction model for older adults with lymph node-positive colon cancer. Eur J Cancer Care (Engl) 2015; 24:179-88. [DOI: 10.1111/ecc.12288] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2014] [Indexed: 01/20/2023]
Affiliation(s)
- M.L. Jorgensen
- Cancer Epidemiology and Services Research (CESR); Sydney School of Public Health; Sydney Medical School; University of Sydney; Sydney NSW Australia
| | - J.M. Young
- Cancer Epidemiology and Services Research (CESR); Sydney School of Public Health; Sydney Medical School; University of Sydney; Sydney NSW Australia
- Surgical Outcomes Research Centre (SOuRCe); Sydney Local Health District and University of Sydney; Sydney NSW Australia
| | - T.A. Dobbins
- Cancer Epidemiology and Services Research (CESR); Sydney School of Public Health; Sydney Medical School; University of Sydney; Sydney NSW Australia
| | - M.J. Solomon
- Surgical Outcomes Research Centre (SOuRCe); Sydney Local Health District and University of Sydney; Sydney NSW Australia
- Discipline of Surgery; University of Sydney; Sydney NSW Australia
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287
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Page AJ, Ejaz A, Spolverato G, Zavadsky T, Grant MC, Galante DJ, Wick EC, Weiss M, Makary MA, Wu CL, Pawlik TM. Enhanced recovery after surgery protocols for open hepatectomy--physiology, immunomodulation, and implementation. J Gastrointest Surg 2015; 19:387-99. [PMID: 25472030 DOI: 10.1007/s11605-014-2712-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 11/19/2014] [Indexed: 01/31/2023]
Abstract
There has been recent interest in enhanced-recovery after surgery (ERAS®) or "fast-track" perioperative protocols in the surgical community. The subspecialty field of colorectal surgery has been the leading adopter of ERAS protocols, with less data available regarding its adoption in hepato-pancreato-biliary surgery. This review focuses on available data pertaining to the application of ERAS to open hepatectomy. We focus on four fundamental variables that impact normal physiology and exacerbate perioperative inflammation: (1) the stress of laparotomy, (2) the use of opioids, (3) blood loss and blood product transfusions, and (4) perioperative fasting. The attenuation of these inflammatory stressors is largely responsible for the improvements in perioperative outcomes due to the implementation of ERAS-based pathways. Collectively, the data suggest that the implementation of ERAS principles should be strongly considered in all patients undergoing hepatectomy.
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Affiliation(s)
- Andrew J Page
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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288
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Peters EG, Smeets BJJ, Dekkers M, Buise MD, de Jonge WJ, Slooter GD, Reilingh TSDV, Wegdam JA, Nieuwenhuijzen GAP, Rutten HJT, de Hingh IHJT, Hiligsmann M, Buurman WA, Luyer MDP. The effects of stimulation of the autonomic nervous system via perioperative nutrition on postoperative ileus and anastomotic leakage following colorectal surgery (SANICS II trial): a study protocol for a double-blind randomized controlled trial. Trials 2015; 16:20. [PMID: 25623276 PMCID: PMC4318130 DOI: 10.1186/s13063-014-0532-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 12/19/2014] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Postoperative ileus and anastomotic leakage are important complications following colorectal surgery associated with short-term morbidity and mortality. Previous experimental and preclinical studies have shown that a short intervention with enriched enteral nutrition dampens inflammation via stimulation of the autonomic nervous system and thereby reduces postoperative ileus. Furthermore, early administration of enteral nutrition reduced anastomotic leakage. This study will investigate the effect of nutritional stimulation of the autonomic nervous system just before, during and early after colorectal surgery on inflammation, postoperative ileus and anastomotic leakage. METHODS/DESIGN This multicenter, prospective, double-blind, randomized controlled trial will include 280 patients undergoing colorectal surgery. All patients will receive a selfmigrating nasojejunal tube that will be connected to a specially designed blinded tubing system. Patients will be allocated either to the intervention group, receiving perioperative nutrition, or to the control group, receiving no nutrition. The primary endpoint is postoperative ileus. Secondary endpoints include anastomotic leakage, local and systemic inflammation, (aspiration) pneumonia, surgical complications classified according to Clavien-Dindo, quality of life, gut barrier integrity and time until functional recovery. Furthermore, a cost-effectiveness analysis will be performed. DISCUSSION Activation of the autonomic nervous system via perioperative enteral feeding is expected to dampen the local and systemic inflammatory response. Consequently, postoperative ileus will be reduced as well as anastomotic leakage. The present study is the first to investigate the effects of enriched nutrition given shortly before, during and after surgery in a clinical setting. TRIAL REGISTRATION ClinicalTrials.gov: NCT02175979 - date of registration: 25 June 2014. Dutch Trial Registry: NTR4670 - date of registration: 1 August 2014.
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Affiliation(s)
- Emmeline G Peters
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands. .,Academic Medical Center, Tytgat Institute for Intestinal and Liver Research, Department of Gastroenterology, Meibergdreef 69-71, 1105 BK, Amsterdam, The Netherlands.
| | - Boudewijn J J Smeets
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
| | - Marloes Dekkers
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
| | - Marc D Buise
- Department of Anesthesiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
| | - Wouter J de Jonge
- Academic Medical Center, Tytgat Institute for Intestinal and Liver Research, Department of Gastroenterology, Meibergdreef 69-71, 1105 BK, Amsterdam, The Netherlands.
| | - Gerrit D Slooter
- Department of Surgery, Maxima Medical Center, De Run 4600, 5504 DB, Veldhoven, The Netherlands.
| | | | - Johannes A Wegdam
- Department of Surgery, Elkerliek Hospital, Wesselmanlaan 25, 5707 HA, Helmond, The Netherlands.
| | - Grard A P Nieuwenhuijzen
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
| | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
| | - Mickael Hiligsmann
- Department of Health Services Research, Maastricht University, Duboisdomein 30, 6229 GT, Maastricht, The Netherlands.
| | - Wim A Buurman
- Institute MHeNS, Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
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289
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Byrne BE, Pinto A, Aylin P, Bottle A, Faiz OD, Vincent CA. Understanding how colorectal units achieve short length of stay: an interview survey among representative hospitals in England. Patient Saf Surg 2015; 9:2. [PMID: 25621007 PMCID: PMC4304175 DOI: 10.1186/s13037-014-0050-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 12/17/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Wide variation in the outcomes of colorectal surgery persists, despite a well-established evidence-base to inform clinical practice. This variation may be attributed to differences in quality of care, but we do not know what this means in practical terms of care delivery. This telephone interview study aimed to identify distinguishing characteristics in the organisation of care among colorectal units with the best length of stay results in England. METHODS Ten English National Health Service hospitals were identified with the shortest length of stay after elective colonic surgery between January 2011 and December 2012. Semi-structured telephone interviews were conducted with a senior colorectal surgeon and ward nurse, who were not informed of their performance, at each site. Audio recordings were professionally transcribed and thematically analysed for similarities and differences in practice between units. RESULTS All ten short length of stay units approached agreed to participate, and 19 of 20 interviews were recorded. These units standardised clinical care based upon an Enhanced Recovery Program. Beyond this, they organised the clinical team to efficiently and reliably deliver this package of care, with the majority of day-to-day care delivered by consultants and nurses. Patients were closely monitored for postoperative deterioration, using a combination of early warning scores, nurses' clinical judgement and regular senior medical review. Of note, operative volume and laparoscopy rates in these units were not statistically significantly different from the national average (p = 0.509 and p = 0.131, respectively). The postoperative analgesic strategy varied widely between units, from routine epidural use to local anaesthetic infiltration or patient-controlled analgesia. CONCLUSIONS The Enhanced Recovery Program may be seen as necessary but not sufficient to achieve the best length of stay results. In the study units, consultants and nurses led and delivered the majority of patient care on the ward. High quality teamwork helped detect and resolve clinical issues promptly, with nurses empowered to contact consultants directly if needed. Other units may learn from these teams by adopting protocol-based, consultant- or nurse-delivered care, and by improving coordination and communication between consultants and ward nurses.
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Affiliation(s)
- Ben E Byrne
- Imperial Patient Safety Translational Research Centre, Imperial College London, Office 5.03, 5th Floor, Medical School Building, St Mary's Campus, Norfolk Place, London, W2 1PG UK
| | - Anna Pinto
- Imperial Patient Safety Translational Research Centre, Imperial College London, Office 5.03, 5th Floor, Medical School Building, St Mary's Campus, Norfolk Place, London, W2 1PG UK
| | - Paul Aylin
- Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Alex Bottle
- Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Omar D Faiz
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital, Harrow, Middlesex UK
| | - Charles A Vincent
- Department of Experimental Psychology, University of Oxford, Oxford, UK
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290
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Enhancing surgical performance outcomes through process-driven care: a systematic review. World J Surg 2015; 38:1362-73. [PMID: 24370544 DOI: 10.1007/s00268-013-2424-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Recent evidence has demonstrated the variability in quality of postoperative care, as measured by rates of failure to rescue (FTR). The identification of structure- and process-related factors affecting the quality of postoperative care is the first step towards understanding and improving outcomes. The aim of this review is to review current evidence for structure and process factors affecting postoperative care. METHODS A systematic review was conducted. Studies were selected that examined structure or process variables affecting FTR rates and postoperative outcomes. Quality analysis with Jadad and Newcastle-Ottawa scales was conducted and poor-quality studies were excluded. RESULTS Thirty-seven studies were included in final analysis. Of these, 23 were related to enhanced recovery protocols in seven surgical specialties. Twenty-one of these 23 studies reported decreases in length of stay. Six studies also reported decreases in morbidity. No studies reported increases in stay duration or morbidity. Of the 16 studies that examined other structural and process factors, the strongest evidence was for the association between nursing ratios and FTR rates. The effects of hospital size, resources, and subspecialist care processes were less clear. CONCLUSION Process-led care represents a clear, evidence-based approach that can be integrated on a local scale, without necessitating major structural or organisational change, to improve outcomes and may also be cost effective. To foster success, process improvement must be driven on a local level and backed up by appropriate understanding, education, and multidisciplinary involvement.
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291
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Lohsiriwat V. Impact of an enhanced recovery program on colorectal cancer surgery. Asian Pac J Cancer Prev 2015; 15:3825-8. [PMID: 24870801 DOI: 10.7314/apjcp.2014.15.8.3825] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Surgical outcomes of colorectal cancer treatment depend not only on good surgery and tumor biology but also on an optimal perioperative care. The enhanced recovery program (ERP) - a multidisciplinary and multimodal approach, or so called 'fast-track surgery' - has been designed to minimize perioperative and intraoperative stress responses, and to support the recovery of organ function aiming to help patients getting better sooner after surgery. Compared with conventional postoperative care, the enhanced recovery program results in quicker patient recovery, shorter length of hospital stay, faster recovery of gastrointestinal function, and a lower incidence of postoperative complications. Although not firmly established as yet, the enhanced recovery program after surgery could be of oncological benefit in colorectal cancer patients because it can enhance recovery, maintain integrity of the postoperative immune system, increase feasibility of postoperative chemotherapy, and shorten the time interval from surgery to chemotherapy. This commentary summarizes short-term outcomes and potential long-term benefits of enhanced recovery programs in the treatment of colorectal cancer.
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Affiliation(s)
- Varut Lohsiriwat
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand E-mail :
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292
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Pędziwiatr M, Pisarska M, Wierdak M, Major P, Rubinkiewicz M, Kisielewski M, Matyja M, Lasek A, Budzyński A. The Use of the Enhanced Recovery After Surgery (ERAS) Protocol in Patients Undergoing Laparoscopic Surgery for Colorectal Cancer – A Comparative Analysis of Patients Aged above 80 and below 55. POLISH JOURNAL OF SURGERY 2015; 87:565-72. [DOI: 10.1515/pjs-2016-0004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Indexed: 11/15/2022]
Abstract
AbstractAge is one of the principal risk factors for colorectal adenocarcinoma. To date, older patients were believed to achieve worse treatment results in comparison with younger patients due to reduced vital capacity. However, papers have emerged in recent years which confirm that the combination of lap-aroscopy and postoperative care based on the ERAS protocol improves treatment results and may be particularly beneficial also for elderly patients.was to compare the outcomes of laparoscopic surgery for colorectal cancer in combination with the ERAS protocol in patients aged above 80 and below 55.. The analysis included patients aged above 80 and below 55 undergoing elective laparoscopic colorectal resection for cancer at the 2Group 1 comprised 34 patients and group 2, 43 patients. No differences were found between both groups in terms of gender, BMI, tumour progression or surgical parameters. Older patients typically had higher ASA scores. No statistically significant differences were found with regard to the length hospital stay following surgery (5.4 vs 7 days, p=0.446481), the occurrence of complications (23.5% vs 37.2%, p=0.14579) or hospital readmissions (2.9% vs 2.4%). The degree of compliance with the ERAS protocol in group 1 and 2 was 85.2% and 83.0%, respectively (p=0.482558). Additionally, recovery parameters such as tolerance of oral nutrition (82.4% vs 72.1%, p=0.28628) and mobilisation (94.1% vs 83.7%, p=0.14510) within 24 hours of surgery did not differ among the groups. However, a smaller proportion of older patients required opioids in comparison with younger patients (26.5% vs 55.8%, p=0.00891).Similar levels of compliance with the ERAS protocol may be achieved among patients aged ≥80 and younger patients. When laparoscopy is combined with the ERAS protocol, age does not seem to be a significant factor that could account for worse utcomes. Therefore, older patients should not be excluded from perioperative care based on ERAS principles.
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293
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Abstract
Surgery for IBD is in constant evolution; it does not appear that the introduction of biologicals has had a major effect on the chance of a patient being operated on or not. Pouch surgery had its heydays in the 80s and 90s and has since then become less frequent, but the number of patients undergoing surgery still seem about the same from one year to the other. Likewise, there is no substantial evidence that surgery for Crohn's disease is diminishing. There have been fears that patients on biological treatment have an increased risk of postoperative complications. The issue is not completely settled but it is likely that patients on biological treatment who come to surgery are those who do not benefit from biologicals. Thus, they are compromised in that they have an ongoing inflammation, are in bad nutritional state, and might have several other known risk factors for a complicated postoperative course. These factors and perhaps not the biologicals per se is what surgeons should consider. During the recent years, we have seen several new developments in IBD surgery; the ileorectal anastomosis is being used for ulcerative colitis and laparoscopic surgery usually resulting in a shorter hospital stay, less pain, and better cosmetics. We have also seen the introduction of robotic surgery, single incision minimal invasive surgery, transanal minimal invasive surgery, and other approaches to minimize surgical trauma. Time will show which of these innovations patients will benefit from.
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Affiliation(s)
- Tom Øresland
- Clinic for Surgical Sciences, Univ of Oslo, Akerhus University Hospital , Lorenskog , Norway
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294
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Øresland T, Bemelman WA, Sampietro GM, Spinelli A, Windsor A, Ferrante M, Marteau P, Zmora O, Kotze PG, Espin-Basany E, Tiret E, Sica G, Panis Y, Faerden AE, Biancone L, Angriman I, Serclova Z, de Buck van Overstraeten A, Gionchetti P, Stassen L, Warusavitarne J, Adamina M, Dignass A, Eliakim R, Magro F, D'Hoore A. European evidence based consensus on surgery for ulcerative colitis. J Crohns Colitis 2015; 9:4-25. [PMID: 25304060 DOI: 10.1016/j.crohns.2014.08.012] [Citation(s) in RCA: 232] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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295
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Abstract
Studies on enhanced recovery after gynecological surgery are limited but seem to report outcome benefits similar to those reported after colorectal surgery. Regional anesthesia is recommended in enhanced recovery protocols. Effective regional anesthetic techniques in gynecologic surgery include spinal anesthesia, epidural analgesia, transversus abdominis plane blocks, local anesthetic wound infusions and intraperitoneal instillation catheters. Non-opioid analgesics including pregabalin, gabapentin, NSAIDs, COX-2 inhibitors, and paracetamol reduce opioid consumption after surgery. This population is at high risk for PONV, thus, a multimodal anti-emetic strategy must be employed, including strategies to reduce the baseline risk of PONV in conjunction with combination antiemetic therapy.
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Affiliation(s)
- Jeanette R Bauchat
- Northwestern University, Feinberg School of Medicine, 250 East Huron Street, F5-704, Chicago, IL 60611, USA
| | - Ashraf S Habib
- Duke University Medical Center, Box 3094, Durham, NC 27710, USA.
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296
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Abstract
PURPOSE OF REVIEW Advances in medical care have led to an increasing elderly population. Elderly individuals should be able to participate in society as long as possible. However, with an increasing age their adaptive capacity gradually decreases, specially before and after major life events (like hospitalization and surgery) making them vulnerable to reduced functioning and societal participation. Therapeutic exercise before and after surgery might augment the postoperative outcomes by improving functional status and reducing the complication and mortality rate. RECENT FINDINGS There is high quality evidence that preoperative exercise in patients scheduled for cardiovascular surgery is well tolerated and effective. Moreover, there is circumstantial evidence suggesting preoperative exercise for thoracic, abdominal and major joint replacement surgery is effective, provided that this is offered to the high-risk patients. Postoperative exercise should be initiated as soon as possible after surgery according to fast-track or enhanced recovery after surgery principles. SUMMARY The perioperative exercise training protocol known under the name 'Better in, Better out' could be implemented in clinical care for the vulnerable group of patients scheduled for major elective surgery who are at risk for prolonged hospitalization, complications and/or death. Future research should aim to include this at-risk group, evaluate perioperative high-intensity exercise interventions and conduct adequately powered trials.
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297
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Zhuang CL, Huang DD, Chen FF, Zhou CJ, Zheng BS, Chen BC, Shen X, Yu Z. Laparoscopic versus open colorectal surgery within enhanced recovery after surgery programs: a systematic review and meta-analysis of randomized controlled trials. Surg Endosc 2014; 29:2091-100. [PMID: 25414064 DOI: 10.1007/s00464-014-3922-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/22/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic surgery and enhanced recovery after surgery (ERAS) programs were two major improvements for the management of colorectal diseases. The purpose of this systemic review was to examine whether laparoscopic colorectal surgery still improved short-term postoperative outcomes in comparison with open surgery when both groups of patients received ERAS programs. METHODS PubMed, Embase, the Cochrane Central Register of Controlled Trials, and reference lists of the identified studies were searched to identify randomized clinical trials that compared laparoscopic with open surgery in patients undergoing colorectal resection in the context of ERAS programs. The outcome measures were analyzed, and the quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. RESULTS Five randomized clinical trials encompassing 598 patients were included in the final analysis. Two of them were multicenter trials. The ERAS programs implemented in the five included trials cannot be classified as optimal ERAS programs, but suboptimal ERAS programs. Laparoscopic colorectal surgery significantly reduced total hospital stay (weighted mean difference (WMD) -1.92 days; 95 % confidence interval (CI) -2.61--1.23 days; P < 0.00001) and number of complications (relative risk (RR) 0.78; 95 % CI 0.66-0.94; P = 0.007) compared with open surgery in the setting of ERAS programs. No significant differences were found between groups for primary hospital stay, number of patients with complications, readmission rates, and mortality. The quality of evidence for all outcomes was low-to-moderate on the GRADE scale, and none had high quality. CONCLUSIONS Laparoscopic colorectal resection significantly reduced total hospital stay and number of complications when compared with open surgery in the setting of suboptimal ERAS programs, but the benefits of laparoscopic colorectal resection remain to be proved within optimal ERAS programs.
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Affiliation(s)
- Cheng-Le Zhuang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Wenzhou Medical University, 2 Fuxue Lane, Wenzhou, 325000, Zhejiang, China
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298
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Feldman LS, Lee L, Fiore J. What outcomes are important in the assessment of Enhanced Recovery After Surgery (ERAS) pathways? Can J Anaesth 2014; 62:120-30. [PMID: 25391733 DOI: 10.1007/s12630-014-0263-1] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 10/24/2014] [Indexed: 12/13/2022] Open
Abstract
PURPOSE The purpose of this narrative review is to provide a framework from which to measure the outcomes of Enhanced Recovery After Surgery (ERAS) programs. PRINCIPLE FINDINGS We define the outcomes of recovery from the perspective of different stakeholders and time frames. There is no single definition of recovery. There are overlapping phases of recovery which are of particular interest to different stakeholders (surgeons, anesthesiologists, nurses, patients and their caregivers), and the primary outcome of interest may vary depending on the phase and the perspective. In the earliest phase (from the end of the surgery to discharge from the postanesthesia care unit [PACU]), biologic and physiologic outcomes are emphasized. In the intermediate phase (from PACU to discharge from the hospital), symptoms related to pain and gastrointestinal function as well as basic activities are important. Studies of ERAS pathways have reported clinical outcomes and symptoms, including complications, hospital stay, mobilization, and gastrointestinal function, largely during hospitalization. Nevertheless, patients define recovery as return to normal functioning, a process that occurs over weeks to months (late phase). Outcomes reflecting functional status (e.g., physical activity, activities of daily living) and overall health (e.g., quality of life) are important in this phase. To date, few studies reporting the effectiveness of ERAS pathways compared with conventional care have included functional status or quality-of-life outcomes, and there is little information about recovery after discharge from hospital. CONCLUSION Recovery after surgery is a complex construct. Different outcomes are important at different phases along the recovery trajectory. Measures for quantifying recovery in hospital and after discharge are available. A consensus-based core set of outcomes with input from multiple stakeholders would facilitate research reporting.
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Affiliation(s)
- Liane S Feldman
- Division of General Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, L9-303, Montreal, QC, H3G 1A4, Canada,
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299
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Wang LH, Fang F, Lu CM, Wang DR, Li P, Fu P. Safety of fast-track rehabilitation after gastrointestinal surgery: Systematic review and meta-analysis. World J Gastroenterol 2014; 20:15423-15439. [PMID: 25386092 PMCID: PMC4223277 DOI: 10.3748/wjg.v20.i41.15423] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 03/27/2014] [Accepted: 07/22/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the safety of fast-track rehabilitation protocols (FT) and conventional care strategies (CC), or FT and laparoscopic surgery (LFT) and FT and open surgery (OFT) after gastrointestinal surgery.
METHODS: We searched MEDLINE, WHO International Trial Register, Embase and The Cochrane Central Register of Controlled Trials up to 2014 for randomized controlled trials (RCTs) comparing FT and CC or comparing LFT and OFT, with 10 or more randomized participants and about 30 d follow-up. Two reviewers independently extracted data on complications, anastomotic leak, obstruction, wound infection, re-admission between FT and CC or LFT and OFT after gastrointestinal surgery.
RESULTS: Twenty-four RCTs of FT vs CC or LFT vs OFT were included. Compared with CC, FT reduced overall complications and wound infection. However, anastomotic leak, obstruction and re-admission were not significantly reduced. The pooled risk ratio (RR) of 0.69 (95%CI: 0.60-0.78; P < 0.001), pooled RR of 0.71 (95%CI: 0.57-0.88; P < 0.001), pooled RR of 0.93 (95%CI: 0.68-1.25; P > 0.05), a pooled RR of 0.87 (95%CI: 0.67-1.15; P > 0.05) and pooled RR of 0.94 (95%CI: 0.73-1.22; P > 0.05) respectively. Compared with OFT, LFT reduced complications, with a pooled RR of 0.66 (95%CI: 0.54-0.81; P < 0.001).
CONCLUSION: FTs are safe after gastrointestinal surgery. Additional large, prospective RCTs should be conducted to establish further the safety of this approach.
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Abstract
Approximately 18% of patients undergoing cardiac surgery experience AKI (on the basis of modern standardized definitions of AKI), and approximately 2%-6% will require hemodialysis. The development of AKI after cardiac surgery portends poor short- and long-term prognoses, with those developing RIFLE failure or AKI Network stage III having an almost 2-fold increase in the risk of death. AKI is caused by a variety of factors, including nephrotoxins, hypoxia, mechanical trauma, inflammation, cardiopulmonary bypass, and hemodynamic instability, and it may be affected by the clinician's choice of fluids and vasoactive agents as well as the transfusion strategy used. The risk of AKI may be ameliorated by avoidance of nephrotoxins, achievement of adequate glucose control preoperatively, and use of goal-directed therapy hemodynamic strategies. Remote ischemic preconditioning is an exciting future strategy, but more work is needed before widespread implementation. Unfortunately, there are no pharmacologic agents known to reduce the risk of AKI or treat established AKI.
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Affiliation(s)
| | | | - Mitchell H Rosner
- Medicine, University of Virginia Health System, Charlottesville, Virginia
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