Systematic review and meta-analysis of enhanced recovery programmes in surgical patients

Enhanced Recovery Protocol Versus Conventional Care in Patients Undergoing Esophagectomy for Cancer: Advantages in Clinical and Patient-Reported Outcomes

BACKGROUND

This study was designed to compare the clinical and patient-reported outcomes (PROs) between the enhanced recovery after surgery (ERAS) protocol and conventional care in patients undergoing esophagectomy for cancer, which have not previously been compared.

METHODS

This single-center retrospective study included prospective PRO data from August 2019 to June 2021. Clinical outcomes included perioperative complications and postoperative length of stay (PLOS). Patient-reported outcomes were assessed by using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (QLQ-C30) and esophagus-specific module (QLQ-OES18) preoperatively to 6 months postoperatively. Mixed-effects models were used to longitudinally compare quality of life (QOL) scores between the two modes.

RESULTS

Patients undergoing conventional care and ERAS were analyzed (n = 348 and 109, respectively). The ERAS group had fewer overall complications, pneumonia, arrhythmia, and a shorter PLOS than the conventional group, and outperformed the conventional group in five functional QLQ-C30 domains and five symptom QLQ-OES18 domains, including less dysphagia (p < 0.0001), trouble talking (p = 0.0006), and better eating (p < 0.0001). These advantages persisted for 3 months postoperatively. For the cervical circular stapled anastomosis, the initial domains and duration of benefit were reduced in the ERAS group.

CONCLUSIONS

The ERAS protocol has significant advantages over conventional care in terms of clinical outcomes, lowering postoperative symptom burden, and improving functional QOL in patients who have undergone esophagectomy. Selection of the optimal technique for cervical anastomosis is a key operative component of ERAS that maintains the symptom domains and duration of the advantages of PROs.

Perioperative care in orthognathic surgery - A systematic review and meta-analysis for enhanced recovery after surgery

The aim of this study was to determine whether implementing ERAS (Enhanced Recovery After Surgery) elements/protocols improves outcomes in orthognathic surgery (OGS) compared to conventional care. To achieve this, ERAS-specific perioperative elements were identified and literature on ERAS for OGS was systematically reviewed. Using PRISMA methodology and GRADE approach, 44 studies with 49 perioperative care elements (13 pre-, 15 intra-, 21 postoperative) were analyzed. While 39 studies focused on single elements, only five presented multimodal protocols, with three related to ERAS. Preoperative elements included antimicrobial and steroid prophylaxis and prevention of postoperative nausea and vomiting. Intraoperative aspects, especially anesthesiological, showed high evidence. Outcome parameters were heterogeneous: complications and postoperative pain were well-investigated with high evidence, while length of stay (LOS) and patient satisfaction received low to medium evidence. ICU LOS, healthcare costs, and readmission rates were underreported. The meta-analysis revealed significant results for pain reduction and trends towards fewer complications and shorter LOS in the ERAS group. Overall, ERAS protocols are not established in OMFS, particularly OGS. Further research is needed in pre- and postoperative care and standardized multimodal analgesia. The next step should be developing a comprehensive OGS protocol through a consensus conference and implementing it in clinical practice.

Comparison of Spinal Morphine and Transversus Abdominis Plane Block on Opioid Requirements After Caesarean Section: An Observational Study

Objective

Acute postoperative pain is one of the major clinical problems that occurs in patients undergoing cesarean section with a prevalence of 89.8%. Postoperative pain causes discomfort and various complications for the mother. In addition, postoperative pain that is not handled properly can increase the risk of becoming chronic pain by 2.5 times. One of the methods recommended in the Enhanced Recovery After Caesarean Section (ERACS) protocol to prevent acute postoperative pain is the use of intrathecal long-acting opioids, with intrathecal morphine as the gold standard and Transversus Abdominis Plane (TAP) block. This study aims to assess the comparison of opioid needs as analgesic rescue between the administration of 0.1mg spinal morphine and TAP block with bupivacaine 0.2% 10mg in patients undergoing cesarean section.

Methods

This study is an observational study in a single Tertiary Hospital in West Java - Indonesia. Patients were given patient-controlled anesthesia (PCA) with fentanyl as analgesic rescue. Statistical analysis of the numerical data used the unpaired t-test and Chi-Square test for categorical data.

Results

In the group that was given spinal morphine, the duration of additional opioids was longer (p < 0.05), and the total dose of additional opioids was less than the TAP block group (p < 0.05).

Conclusion

The spinal morphine requires fewer additional opioids than the TAP block.

Anatomic Lung Resection Outcomes After Implementation of a Universal Thoracic ERAS Protocol Across a Diverse Health Care System

OBJECTIVE

We sought to evaluate how implementing a thoracic enhanced recovery after surgery (ERAS) protocol impacted surgical outcomes after elective anatomic lung resection.

BACKGROUND

The effect of implementing the ERAS Society/European Society of Thoracic Surgery thoracic ERAS protocol on postoperative outcomes throughout an entire health care system has not yet been reported.

METHODS

This was a prospective cohort study within one health care system (January 2019-March, 2023). A thoracic ERAS protocol was implemented on May 1, 2021 for elective anatomic lung resections, and postoperative outcomes were tracked using the electronic health record and Vizient data. The primary outcome was overall morbidity; secondary outcomes included individual complications, length of stay, opioid use, chest tube duration, and total cost. Patients were grouped into pre-ERAS and post-ERAS cohorts. Bivariable comparisons were performed using independent t -test, χ 2 , or Fisher exact tests, and multivariable logistic regression was performed to control for confounders.

RESULTS

There were 1007 patients in the cohort; 450 (44.7%) were in the post-ERAS group. Mean age was 66.2 years; most patients were female (65.1%), white (83.8%), had a body mass index between 18.5 and 29.9 (69.7%), and were ASA class 3 (80.6%). Patients in the postimplementation group had lower risk-adjusted rates of any morbidity, respiratory complication, pneumonia, surgical site infection, arrhythmias, infections, opioid usage, ICU use, and shorter postoperative length of stay (all P <0.05).

CONCLUSIONS

Postoperative outcomes were improved after the implementation of an evidence-based thoracic ERAS protocol throughout the health care system. This study validates the ERAS Society/European Society of Thoracic Surgery guidelines and demonstrates that simultaneous multihospital implementation can be feasible and effective.

Implementing Enhanced Recovery Pathways: A Qualitative Study of Factors That Distinguished Higher Performing Hospitals

OBJECTIVE

The aim of this study was to explore barriers and facilitators to implementing enhanced recovery pathways, with a focus on identifying factors that distinguished hospitals achieving greater levels of implementation success.

BACKGROUND

Despite the clinical effectiveness of enhanced recovery pathways, the implementation of these complex interventions varies widely. While there is a growing list of contextual factors that may affect implementation, little is known about which factors distinguish between higher and lower levels of implementation success.

METHODS

We conducted in-depth interviews with 168 perioperative leaders, clinicians, and staff from 8 US hospitals participating in the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Guided by the Consolidated Framework for Implementation Research, we coded interview transcripts and conducted a thematic analysis of implementation barriers and facilitators. We also rated the perceived effect of factors on different levels of implementation success, as measured by hospitals' adherence with 9 process measures over time.

RESULTS

Across all hospitals, factors with a consistently positive effect on implementation included information-sharing practices and the implementation processes of planning and engaging. Consistently negative factors included the complexity of the pathway itself, hospitals' infrastructure, and the implementation process of "executing" (particularly in altering electronic health record systems). Hospitals with the greatest improvement in process measure adherence were distinguished by clinicians' positive knowledge and beliefs about pathways and strong leadership support from both clinicians and executives.

CONCLUSION

We draw upon diverse perspectives from across the perioperative continuum of care to qualitatively describe implementation factors most strongly associated with successful implementation of enhanced recovery pathways.

Surgery-related outcomes from a close-knit surgeons' team in thoracic oncology

Reducing morbidity, length of hospital stay, and readmission rate are of paramount importance to improve patients' care. In the present paper, we aim to describe our experience in managing major oncologic thoracic surgery in clinical practice. This is a retrospective experience over the last 7 years. Data from 215 consecutive patients (performed by a single-team of two surgeon) undergoing thoracic surgery were reviewed and evaluated. The total hospital mean stay was 3,3 days. Complications were represented by 4 hemothorax, 1 pleural empyema without fistula, 3 arrhythmias (atrial fibrillation), 2 pnuemonias and 1 chylotorax. No 30-day severe surgery-related complication occurred, no mortality. In 169 Vats procedures, no convertion was necessary. We conclude that a united team work represented by two close-knit surgeons, with similar clinical background, propensity to share problems, no competitive behavior, allow to do faster surgery, to standardize the procedure improving the post-operative outcomes of cancer patients.

An investigation on the compliance of perioperative practices using ERAS protocols and barriers to the implementation of the ERAS protocols in colorectal surgery

BACKGROUND

Although ERAS protocols have many benefits, there are some deficiencies in their understanding and implementation by healthcare professionals. The present study was conducted to investigate the compliance of the current perioperative practices of healthcare professional with the ERAS protocols and to assess barriers to the implementation of ERAS protocols in colorectal surgery.

METHODS

This cross-sectional descriptive study conducted in the surgical clinics and operating rooms of a training and research hospital between January 2020 and September 2020 included 110 physician and nurse members of surgical teams. Data were collected using the Questionnaire for Evaluating the Use of the ERAS Protocol and Identifying Barriers to Implementation in Colorectal Surgery.

RESULTS

The compliance of the current perioperative practices by healthcare professionals with the ERAS protocols ranged between 15.5% (routinely leaving nasogastric tubes in situ following colorectal resection) and 61.8% (being aware of the concept of balanced analgesia). Variables such as the healthcare professional's profession, title, years in practice and colorectal surgery experience led to a difference between them in terms of their compliance of the practices with the ERAS protocols (p < 0.05). Based on the healthcare professionals' comments about barriers to the implementation of the ERAS protocol, themes such as education, teamwork, communication and lack of resources were created.

CONCLUSION

Healthcare professionals' compliance level of the current perioperative practices with the ERAS protocols was mostly low. Barriers to the implementation of the ERAS protocols had a multi-factor structure that concerns the multidisciplinary team.

[Modern Perioperative Care Concepts in Thoracic Surgery: Enhanced Recovery After Thoracic Surgery (ERATS)]

In modern perioperative care concepts, multimodal ERAS (Enhanced Recovery After Surgery) is a multimodal perioperative treatment concept for improving postoperative recovery of surgical patients after an operation. This is managed by the so-called ERAS Society and through which hospitals can also be officially certified. The focus of the ERAS concept is on uniform patient care from admission to discharge, with the aim of improving perioperative processes by implementing evidence-based protocols involving a multidisciplinary treatment team. In 2019, ERAS guidelines were published for the first time by the European Society of Thoracic Surgery (ESTS), in cooperation with the ERAS Society, for specific lung resection procedures, and these identified a total of 45 graduated recommendations or Enhanced Recovery Pathways (ERP). The implementation of ERAS concepts in thoracic surgery (ERATS = Enhanced Recovery After Thoracic Surgery) is intended to establish standardised perioperative procedures based on study results and/or expert recommendations. These recommendations take into account organisational aspects as well as thoracic surgical and anaesthesiological procedures, with the overriding goal of creating a structured treatment plan tailored to the patient. All these measures should result in a multimodal overall concept, which should primarily lead to an improved outcome after elective thoracic surgery and secondarily to shorter hospital stays with correspondingly lower costs.This review article describes basic ERAS principles and provides a compact presentation of the most important European ERAS recommendations from the authors' point of view, together with typical obstacles to the implementation of the corresponding ERATS program in German thoracic surgery.

Pulmonary Rehabilitation Exercises Effectively Improve Chronic Cough After Surgery for Non-small Cell Lung Cancer

INTRODUCTION

Cough is a major complication after lung cancer surgery, potentially impacting lung function and quality of life. However, effective treatments for managing long-term persistent postoperative cough remain elusive. In this study, we investigated the potential of a pulmonary rehabilitation training program to effectively address this issue.

METHODS

Between January 2019 and December 2022, a retrospective review was conducted on patients with non-small cell lung cancer (NSCLC) who underwent lobectomy and lymph node dissection via video-assisted thoracoscopic surgery (VATS) at Daping hospital. Based on their postoperative rehabilitation methods, the patients were categorized into 2 groups: the traditional rehabilitation group and the pulmonary rehabilitation group. All patients underwent assessment using the Leicester cough questionnaire (LCQ) on the third postoperative day. Additionally, at the 6-month follow-up, patients' LCQ scores and lung function were re-evaluated to assess the long-term effects of the pulmonary rehabilitation training programs.

RESULTS

Among the 276 patients meeting the inclusion criteria, 195 (70.7%) were in the traditional rehabilitation group, while 81 (29.3%) participated in the pulmonary rehabilitation group. The pulmonary rehabilitation group showed a significantly lower incidence of cough on the third postoperative day (16.0% vs 29.7%, P = .018) and higher LCQ scores in the somatic dimension (5.09 ± .81 vs 4.15 ± 1.22, P = .007) as well as in the total score (16.44 ± 2.86 vs 15.11 ± 2.51, P = .018, whereas there were no significant differences in psychiatric and sociological dimensions. At the 6-month follow-up, the pulmonary rehabilitation group continued to have a lower cough incidence (3.7% vs 12.8%, P = .022) and higher LCQ scores across all dimensions: somatic (6.19 ± .11 vs 5.75 ± 1.20, P = .035), mental (6.37 ± 1.19 vs 5.85 ± 1.22, P = .002), sociological (6.76 ± 1.22 vs 5.62 ± 1.08, P < .001), and total (18.22 ± 2.37 vs 16.21 ± 2.53, P < .001). Additionally, lung function parameters including FVC, FVC%, FEV1, FEV1%, MVV, MVV%, DLCO SB, and DLCO% were all significantly higher in the pulmonary rehabilitation group compared to the traditional group.

CONCLUSION

Pulmonary rehabilitation exercises significantly reduced the incidence of postoperative cough and improved cough-related quality of life in patients undergoing lobectomy, with sustained benefits observed at the 6-month follow-up. Additionally, these exercises demonstrated superior lung function outcomes compared to traditional rehabilitation methods.

Recovery of surgery in the elderly (ROSE) program: The efficacy of a multi-modal prehabilitation program implemented in frail and pre-frail elderly undergoing major abdominal surgery

BACKGROUND

Major abdominal surgery is associated with a high rate of post-operative complications with increased risk of adverse surgical outcomes due to the presence of frailty. This study aims to evaluate the effectiveness of the multimodal Recovery of Surgery in the Elderly (ROSE) prehabilitation program with supervised exercise in mitigating postoperative functional decline when compared to standard care.

METHOD

The ROSE program enrolled ambulant patients who were 65 years and above, had a Clinical Frailty Scale score of 4 or more and were planned for major abdominal surgery. Participation in supervised exercise sessions before surgery were compared with standard physiotherapy advice. The primary outcome was 6-min walk test (6MWT) distance assessed at baseline, after prehabilitation and 30 days follow-up after surgery. Secondary outcomes included physical performance, length of hospital stay and postoperative morbidity.

RESULTS

Data from 74 eligible patients, 37 in each group, were included. Median age was 78 years old. Forty-two patients (22 in Prehab group and 20 in control group) with complete 6MWT follow-up data at 30 days follow-up were analysed for outcomes. Most patients underwent laparoscopic surgery (63.5%) and almost all of the surgeries were for abdominal malignancies (97.3%). The Prehab group had an increase in 6MWT distance at the 30-day follow up, from a baseline mean (SD) of 277.4 (125) m to 287.6 (143.5) m (p = 0.415). The 6MWT distance in the control group decreased from a baseline mean (SD) of 281.7 (100.5) m to 260.1 (78.6) m at the 30-day follow up (p = 0.086). After adjusting for baseline 6MWT distance and frailty score, the Prehab group had significantly higher 6MWT distance at 30-day follow-up than control (difference in adjusted means 41.7 m, 95% confidence interval 8.7-74.8 m, p = 0.015). There were no significant between-group differences in the secondary outcomes.

CONCLUSION

A multimodal prehabilitation program with supervised exercise within a short time frame can improve preoperative functional capacity and maintain baseline functional capacity in frail older adults undergoing major abdominal surgery.

Surgeon factors but not hospital factors associated with length of stay after colorectal surgery - A population based study

AIM

Length of stay (LOS) after colorectal surgery (CRS) is a significant driver of healthcare utilization and adverse patient outcomes. To date, there is little high-quality evidence in the literature examining how individual surgeon and hospital factors independently impact LOS. We aimed to identify and quantify the independent impact of surgeon and hospital factors on LOS after CRS.

METHODS

A retrospective population-based cohort study was conducted using validated health administrative databases, encompassing all patients from the province of Ontario, Canada. All patients from 121 hospitals in Ontario who underwent elective CRS between 2008 and 2019 in Ontario were included, and factors pertaining to these patients and their treating surgeon and hospital were assessed. A negative binomial regression model was used to assess the independent effect of surgeon and hospital factors on LOS, accounting for a comprehensive collection of determinants of LOS. To minimize unmeasured confounding, the analysis was repeated in a subgroup comprising patients undergoing lower-complexity CRS without postoperative complications.

RESULTS

A total of 90,517 CRS patients were analysed. Independent of patient and procedural factors, low surgeon volume (lowest volume quartile) was associated with a 20% increase in LOS (95% CI: 12-29, p < 0.0001) compared to high surgeon volume (highest volume quartile). In the 22,639 patients undergoing uncomplicated lower-complexity surgeries, a 43% longer LOS was seen in the lowest volume surgeon quartile (95% CI: 26-61, p < 0.0001). In both models, more years-in-practice was associated with a small increase in LOS (RR 1.02, 95% CI: 1.02-1.03, p < 0.0001). Hospital factors were not significantly associated with increased LOS.

CONCLUSIONS

Surgeon factors, including low surgeon volume and increasing years-in-practice, were strongly and independently associated with longer LOS, whereas hospital factors did not have an independent impact. This suggests that LOS is driven primarily by surgeon-mediated care processes and may provide actionable targets for provider-level interventions to reduce LOS after CRS.

Impact of enhanced recovery pathways on patient-reported outcomes after abdominal surgery: a systematic review

INTRODUCTION

Evidence supports that enhanced recovery pathways (ERPs) reduce length of stay and complications; however, these measures may not reflect the perspective of patients who are the main stakeholders in the recovery process. This systematic review aimed to appraise the evidence regarding the impact of ERPs on patient-reported outcomes (PROs) after abdominal surgery.

METHODS

Five databases (Medline, Embase, Biosis, Cochrane, and Web of Science) were searched for randomized controlled trials (RCTs) addressing the impact of ERPs on PROs after abdominal surgery. We focused on distinct periods of recovery: early (within 7 days postoperatively) and late (beyond 7 days). Risk of bias was assessed using Cochrane's RoB 2.0. Results were appraised descriptively as heterogeneity hindered meta-analysis. Certainty of evidence was evaluated using GRADE.

RESULTS

Fifty-six RCTs were identified [colorectal (n = 18), hepatopancreaticobiliary (HPB) (n = 11), upper gastrointestinal (UGI) (n = 10), gynecological (n = 7), urological (n = 7), general surgery (n = 3)]. Most trials had 'some concerns' (n = 30) or 'high' (n = 25) risk of bias. In the early postoperative period, ERPs improved patient-reported general health (colorectal, HPB, UGI, urological; very low to low certainty), physical health (colorectal, gynecological; very low to low certainty), mental health (colorectal, gynecological; very low certainty), pain (all specialties; very low to moderate certainty), and fatigue (colorectal; low certainty). In the late postoperative period, ERPs improved general health (HPB, UGI, urological; very low certainty), physical health (UGI, gynecological, urological; very low to low certainty), mental health (UGI, gynecological, urological; very low certainty), social health (gynecological; very low certainty), pain (gynecological, urological; very low certainty), and fatigue (gynecological; very low certainty).

CONCLUSION

This review supports that ERPs may have a positive impact on patient-reported postoperative health status (i.e., general, physical, mental, and social health) and symptom experience (i.e., pain and fatigue) after abdominal surgery; however, data were largely derived from low-quality trials. Although these findings contribute important knowledge to inform evidence-based ERP implementation, there remains a great need to improve PRO assessment in studies focused on postoperative recovery.

A critical review of the perioperative fluid therapy and hemodynamic monitoring recommendations of the Enhanced Recovery of the Adult Pathway (RICA): A position statement of the fluid therapy and hemodynamic monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR)

In an effort to standardize perioperative management and improve postoperative outcomes of adult patients undergoing surgery, the Ministry of Health, through the Spanish Multimodal Rehabilitation Group (GERM), and the Aragonese Institute of Health Sciences, in collaboration with multiple Spanish scientific societies and based on the available evidence, published in 2021 the Spanish Intensified Adult Recovery (RICA) guideline. This document includes 12 perioperative measures related to fluid therapy and hemodynamic monitoring. Fluid administration and hemodynamic monitoring are not straightforward but are directly related to postoperative patient outcomes. The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR) has reviewed these recommendations and concluded that they should be revised as they do not follow an adequate methodology.

Efficacy of the Enhanced Recovery After Surgery program for thoracic surgery in a developing country

Purpose

Enhanced Recovery After Surgery (ERAS) is a strategy used to improve perioperative outcomes and reduce complications. However, data on the efficacy of ERAS in thoracic surgery in developing countries are limited. The current study aimed to validate the benefits of ERAS among patients at a single institution.

Methods

This was a retrospective study of patients who underwent pulmonary resection at Vajira Hospital, Bangkok, Thailand, between 2016 and 2020. To compare outcomes, patients were divided into the pre-ERAS group (2016-2018) and the post-ERAS group (2019-2020) using propensity score matching (1:2) with the year 2019 as the cutoff for introducing ERAS protocols at our institution.

Results

In total, 321 patients were included in the analysis (pre-ERAS group, n = 74; post-ERAS group, n = 247). After propensity score matching, 56 and 112 patients were classified under the pre- and post-ERAS groups, respectively. The post-ERAS group had significantly lower pain scores than the pre-ERAS group on postoperative days 1, 2, and 3, and a lower volume of intraoperative blood loss. In the multivariable analysis, the post-ERAS group had a shorter chest tube duration (mean difference = -1.62 days, 95% confidence interval = -2.65 to -0.31) and length of hospital stay (mean difference = -2.40 days, 95% confidence interval = -4.45 to -0.65) than the pre-ERAS group.

Conclusion

The use of ERAS guidelines in pulmonary resection is beneficial. Although no significant differences were observed in postoperative complication rate, intensive care unit stay, and additional cost burden between the two groups, patients in the post-ERAS group had a shorter postoperative chest tube duration, shorter hospital stays, shorter operative time, lower postoperative pain score, and lower volume of intraoperative blood loss.

Efficacy of Enhanced Recovery After Surgery Program for Patients Undergoing Lobectomy for Lung Cancer: A Scoping Review and Single-Center Initial Result in Vietnam

Surgery for lung cancer can be invasive and the recovery process is often slow with many complications. To address this, the enhanced recovery after surgery (ERAS) program aims to minimize adverse clinical events for surgical patients. This is achieved through a multimodal perioperative care protocol that aims to preserve preoperative organ function and reduce postoperative complications. Initially applied to gastrointestinal surgery, this model has now been expanded to other major surgeries, including lung surgery. Through a review of seven retrospective and prospective cohort observational studies, we have examined the effects of the ERAS program on patients undergoing lobectomy for lung cancer treatment. Our analysis focused on outcomes such as length of stay, re-operation rate, re-admission rate, postoperative mortality, and costs, providing valuable insights into the real clinical practice setting. We also report on some initial results when applying ERAS at University Medical Center Ho Chi Minh City.

Optimizing Nutritional Status of Patients Prior to Major Surgical Intervention

In patients undergoing elective cardiovascular and thoracic surgery, malnutrition and the deterioration of nutritional status are associated with negative outcomes. Recognition of the contributory factors and the complications stemming from surgical stress is important for the prevention and management of these patients. We have reviewed the literature available and focused on the nutritional and metabolic aspects affecting surgical patients, with emphasis on the recommendations of enhanced recovery protocols. The implementation of enhanced recovery protocols and nutritional support guidelines focusing on the surgical patient as part of a multidisciplinary approach would improve the nutritional status of surgical patients at risk for negative outcomes.

Guidelines on perioperative optimization protocol for the adult patient 2023

OBJECTIVE

The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs.

DESIGN

A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format.

RESULTS

The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations.

CONCLUSIONS

Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.

Minimalistic approach to enhanced recovery after pediatric scoliosis surgery

PURPOSE

Prior studies of enhanced recovery protocols (ERP) have been conducted at large institutions with abundant resources. These results may not apply at institutions with less resources directed to quality improvement efforts. The purpose of this study was to assess the value of a minimalistic enhanced recovery protocol in reducing length of stay (LOS) following PSF for adolescent idiopathic scoliosis. We hypothesized that accelerated transition to oral pain medications and mobilization alone could shorten hospital length of stay in the absence of a formal multimodal pain regimen.

METHODS

AIS patients aged 10-18 who underwent PSF at a tertiary pediatric hospital between January 1, 2014 and December 31, 2017 were reviewed. The study population was further narrowed to consecutive patients from a single surgeon's practice that piloted the modified ERP. Reservation from key stakeholders regarding the feasibility of implementing widespread protocol change led to the minimal alterations made to the postoperative protocol following PSF. Patients were divided into either the Standard Recovery Protocol (SRP) or Enhanced Recovery Protocol (ERP). Primary variables analyzed were hospital LOS, complications, readmissions, and total narcotic requirement.

RESULTS

A total of 92 patients met inclusion criteria. SRP and ERP groups consisted of 44 (47.8%) and 48 (52.2%) patients. There was no difference between the two groups with regard to age, sex, and ASA score (p > 0.05). Fusion levels and EBL did not differ between treatment groups (p > 0.05). PCA pumps were discontinued later in the SRP group (39.5 ± 4.3 h) compared to the ERP group (17.4 ± 4.1 h, p < 0.0001). Narcotic requirement was similar between groups (p = 0.94) Patients in the SRP group had longer hospital stays than patients in the ERP group (p < 0.0001). 83% of the ERP group had LOS ≤ 3 days compared to 0% in the SRP group, whose mean LOS was 4.2 days. There was no difference in complications between the groups (2.2% vs 6.0%, p = 0.62). Readmission to the hospital within 30 days of surgery was rare in either group (2 SRP patients: 1 superior mesenteric artery syndrome, 1 bowel obstruction vs 0 ERP patients, p = 0.23).

CONCLUSION

In this cohort, minor changes to the postoperative protocol following surgery for AIS led to a significant decrease in hospital length of stay. This minimalistic approach may ease implementation of an ERP in the setting of stakeholder apprehension.

Enhanced Recovery after Surgery and Endometrial Cancers: Results from an Initial Experience Focused on Elderly Patients

Endometrial cancer is the fifth most common cancer among French women and occurs most frequently in the over-70-year-old population. Recent years have seen a significant shift towards minimally invasive surgery and Enhanced Recovery After Surgery (ERAS) protocols in endometrial cancer management. However, the impact of ERAS on endometrial cancer has not been well-established. We conducted a prospective observational study in a comprehensive cancer center, comparing the outcomes between endometrial cancer patients who received care in an ERAS pathway (261) and those who did not (166) between 2006 and 2020. We performed univariate and multivariate analysis. Our primary objective was to evaluate the impact of ERAS on length of hospital stay (LOS), with the secondary objectives being the determination of the rates of early discharge, post-operative morbidity, and rehospitalization. We found that patients in the ERAS group had a significantly shorter length of stay, with an average of 3.18 days compared to 4.87 days for the non-ERAS group (estimated decrease -1.69, p < 0.0001). This effect was particularly pronounced among patients over 70 years old (estimated decrease -2.06, p < 0.0001). The patients in the ERAS group also had a higher chance of early discharge (47.5% vs. 14.5% in the non-ERAS group, p < 0.0001), for which there was not a significant increase in post-operative complications. Our study suggests that ERAS protocols are beneficial for the management of endometrial cancer, particularly for older patients, and could lead to the development of ambulatory pathways.

Research trends from 1992 to 2022 of acupuncture anesthesia: a bibliometric analysis

Background

Acupuncture anesthesia is a significant technical development that originated in China in 1958 and was introduced to the West in the early 1970s. Due to its relative novelty, it has been the subject of intense scrutiny and contestation. Since the early 1970s, the use of acupuncture as a complementary treatment for opioid analgesics has been accepted. Research on acupuncture anesthesia has helped to reduce clinical opioid abuse. However, only a few articles have focused on previous publications that reflect the trend of the study, the main investigators, reciprocal collaboration, and other information in this field. In view of this, we utilized bibliographic analysis methods to objectively analyze current trends and research hotspots in this field, aiming to provide a foundation and reference for future studies.

Methods

The Web of Science database was searched for publications related to acupuncture anesthesia between 1992 and 2022. The CiteSpace and VOSviewer were used to analyze the annual publications, authors, Co-cited authors, and their countries (regions) and institutions, co-occurrence keywords, burst keywords, Co-citation references and Co-citation journals.

Results

A total of 746 eligible publications were retrieved from the database for the analysis, including 637 articles and 109 reviews. And the trend of annual publications continued to grow. Aashish J. Kumar, Daniel I. Sessler, Baoguo Wang, and Paul F. White published the most papers in this field (7), and all authors, had a very low centrality (<0.01). China (252) and the University of California System (21) were the most productive country (region) and institution, respectively, while the United States (0.62) and University of California System (0.16) had the highest centrality. After removing keywords related to the search strategy, the three most frequent were pain (115), electroacupuncture (109), and stimulation (91). The six most recent burst keywords were recovery, transcutaneous electrical acupoint stimulation, systematic review, quality, general anesthesia, and surgery. Wang et al.'s article had the highest co-citation count (20), whereas Zhang et al.'s articles had the highest centrality (0.25). The Journal of Anesthesia and Analgesia was the most influential one (408 co-citations).

Conclusion

This research provides valuable information for the study of acupuncture anesthesia. In recent years, frontier topics in acupuncture anesthesia research have been the promotion of perioperative rehabilitation, anesthesia management, and quality improvement.

Enhanced Recovery After Surgery Program and Opioid Consumption in Pulmonary Resection Surgery: A Retrospective Observational Study

BACKGROUND

Pulmonary resection surgery causes severe postoperative pain and usually requires opioid-based analgesia, particularly in the early postoperative period. However, the administration of large amounts of opioids is associated with various adverse events. We hypothesized that patients who underwent pulmonary resection under an enhanced recovery after surgery (ERAS) program consumed fewer opioids than patients who received conventional treatment.

METHODS

A total of 2147 patients underwent pulmonary resection surgery between August 2019 and December 2020. Two surgeons (25%) at our institution implemented the ERAS program for their patients. After screening, the patients were divided into the ERAS and conventional groups based on the treatment they received. The 2 groups were then compared after the stabilized inverse probability of treatment weighting. The primary end point was the total amount of opioid consumption from surgery to discharge. The secondary end points included daily average and highest pain intensity scores during exertion, opioid-related adverse events, and clinical outcomes, such as length of intensive care unit (ICU) stay, hospital stay, and postoperative complication grade defined by the Clavien-Dindo classification. Additionally, the number of patients discharged without opioids prescription was assessed.

RESULTS

Finally, 2120 patients were included in the analysis. The total amount of opioid consumption (median [interquartile range]) after surgery until discharge was lower in the ERAS group (n = 260) than that in the conventional group (n = 1860; morphine milligram equivalents, 44 [16-122] mg vs 208 [146-294] mg; median difference, -143 mg; 95% CI, -154 to -132; P < .001). The number of patients discharged without opioids prescription was higher in the ERAS group (156/260 [60%] vs 329/1860 [18%]; odds ratio, 7.0; 95% CI, 5.3-9.3; P < .001). On operation day, both average pain intensity score during exertion (3.0 ± 1.7 vs 3.5 ± 1.8; mean difference, -0.5; 95% CI, -0.8 to -0.3; P < .001) and the highest pain intensity score during exertion (5.5 ± 2.1 vs 6.4 ± 1.7; mean difference, -0.8; 95% CI, -1.0 to -0.5; P < .001) were lower in the ERAS group than in the conventional group. There were no significant differences in the length of ICU stay, hospital stay, or Clavien-Dindo classification grade.

CONCLUSIONS

Patients who underwent pulmonary resection under the ERAS program consumed fewer opioids than those who received conventional management while maintaining no significant differences in clinical outcomes.

Like I said, I would not have likely gotten up otherwise: patient experiences of using an Activity Board after abdominal cancer surgery

PURPOSE

Most patients treated in a hospital setting are fully or partially immobilised. The Activity Board (Träningstavlan^® Phystec) is a useful tool to enhance mobilisation after major abdominal cancer surgery. Knowledge of patient experiences of the mobilisation tool is crucial in implementing the Activity Board in health care. This study aimed to describe patient experiences of using the Activity Board after surgery for abdominal cancer.

MATERIALS AND METHODS

Semi-structured face-to-face interviews were conducted in 15 patients who underwent abdominal surgery due to colorectal, ovarian or urinary bladder cancer. All 15 patients (mean age 67.7 years, range 40-86) used the Activity Board postoperatively. The interviews were transcribed verbatim and analysed according to inductive content analysis.

RESULTS

The overarching theme that emerged from the interviews was that "enabling participation facilitates empowerment over rehabilitation". Three categories supported the theme: prerequisites for using the Activity Board, the value of using supportive behavioural techniques, and the possibility to influence the patients' care.

CONCLUSIONS

These findings suggest that the Activity Board could be a viable tool that activates the person-centred postoperative rehabilitation process by cooperating with the medical team at the hospital ward.Implications for rehabilitationPatients who are in hospital due to cancer surgery are often immobilised, which increases the risk of complications.The Activity Board can stimulate the patients to participate in the rehabilitation process in a more active way.The Activity Board can be used to improve and clarify the person-centred approach in hospital settings.

Comparison of efficacy of erector spinae plane block, thoracic paravertebral block, and erector spinae plane block and thoracic paravertebral block combination for acute pain after video-assisted thoracoscopic surgery: a randomized controlled study

BACKGROUND

The aim of this study was to compare the efficacy of ultrasound-guided erector spinae plane block (ESPB), thoracic paravertebral block (TPVB), and ESPB and TPVB combination on acute pain after video-assisted thoracoscopic surgery (VATS).

METHODS

Seventy-five patients were evaluated (three groups: ESPB, TPVB, or combined ESPB-TPVB [comb-group], each 25 patients). All interventions were performed with the same volume of bupivacaine (20 mL). Primary outcome was VAS (Visual Analog Scale) during the first 24 hours. Secondary outcomes were postoperative morphine consumption and rescue analgesic requirements.

RESULTS

VAS during rest and coughing of TPVB was significantly higher compared to other groups (in all measurements compared to comb-group; and in all but 24 hours measurement to ESPB) ESPB and comb-group had similar VAS in all measurements (e.g., median VAS in ESPB, TPVB and comb-group at 8^th hour: 3-4-2 [P=0.014] during coughing and 2-3-1 in rest [P<0.001], respectively). Morphine consumption was statistically significantly higher in TPVB than comb-group (ESPB: 15.28 mg; TPVB: 19.30 mg; ESPB+TPVB: 10.00 mg) (P=0.003). Rescue analgesic requirement was statistically significantly higher in the TPVB group than comb-group (P=0.009).

CONCLUSIONS

ESPB alone and the combination of ESPB and TPVB provided superior primary outcomes compared to TPVB alone. Morphine and rescue analgesic consumptions were higher in TPVB than comb-group. ESPB and comb-group were statistically similar in terms of primary and secondary outcomes. This study is one of the first studies using the combination of ESBP and TPVB for pain after VATS, and shows the efficacy of this approach.

Impact of Variations in the Nursing Care Supply-Demand Ratio on Postoperative Outcomes and Costs

INTRODUCTION

Improving surgical outcomes is a priority during the last decades because of the rising economic health care burden. The adoption of enhanced recovery programs has been proven to be part of the solution. In this context, the impact of variations in the nursing care supply-demand ratio on postoperative complications and its economic consequences is still not well elucidated. Because patients require different amounts of care, the present study focused on the more accurate relationship between demand and supply of nursing care rather than the nurse-to-patient ratio.

METHODS

Through a 3-year period, 838 patients undergoing elective and emergent colorectal and pancreatic surgery within the institutional enhanced recovery after surgery (ERAS) protocol were retrospectively investigated. Nursing demand and supply estimations were calculated using a validated program called the Projet de Recherche en Nursing (PRN), which assigns points to each patient according to the nursing care they need ( estimated PRN) and the actual care they received ( real PRN), respectively. The real/estimated PRN ratio was used to create 2 patient groups: one with a PRN ratio higher than the mean (PRN+) and a second with a PRN ratio below the mean (PRN-). These 2 groups were compared regarding their postoperative complication rates and cost-revenue characteristics.

RESULTS

The mean PRN ratio was 0.81. A total of 710 patients (84.7%) had a PRN+ ratio, and 128 (15.3%) had a PRN- ratio. Multivariable analysis focusing on overall complications, severe complications, and prolonged length of stay revealed no significant impact of the PRN ratio for all outcomes ( P > 0.2). The group PRN- had a mean margin per patient of U.S. dollars 1426 (95% confidence interval, 3 to 2903) compared with a margin of U.S. dollars 676 (95% confidence interval, -2213 to 3550) in the PRN+ group ( P = 0.633).

CONCLUSIONS

A PRN ratio of 0.8 may be sufficient for patients treated following enhanced recovery after surgery guidelines, pending the adoption of an accurate nursing planning system. This may contribute to better allocation of nursing resources and optimization of expenses on the long run.

State of the art of enhanced recovery after surgery (ERAS) protocols in esophagogastric cancer surgery: the Western experience

Enhanced recovery after surgery (ERAS) programs provide a framework to standardize care processes and improve outcomes. The results of this multimodal and multidisciplinary approach based on actions focused on reducing physiological surgical stress in the preoperative, intraoperative, and postoperative periods are beneficial in reducing morbidity and hospital stay, without increasing readmissions across different surgical settings. The implementation of ERAS in resection procedures of esophageal and gastric cancer has been challenging due to the complexity of these surgical techniques and the high risk of complications. Despite the limited evidence of ERAS in esophagectomy operations, systematic reviews and meta-analysis have confirmed a reduction of pulmonary complications and hospital stay without increasing readmissions. In gastrectomy operations, the implementation of ERAS reduces the use of nasogastric tubes and intraabdominal drains, facilitates early diet, and reduces the length of hospital stay, without increasing complications. There is, however, wide heterogeneity and absence of standardization in the number and definition of the ERAS components. The development of ERAS consensus guidelines including procedure-specific components may reduce this variability. Regardless growing evidence of the effectiveness of ERAS, the adherence rate is still low. The commitment of the multidisciplinary team and leadership is critical in the application and refinement of ERAS protocols in parallel with periodic audits. Pre- and post-habilitation methods are emerging concepts to be incorporated in ERAS protocols.

Enhanced Recovery Protocols Reduce Mortality Across Eight Surgical Specialties at Academic and University-affiliated Community Hospitals

OBJECTIVE

To determine if implementation of a simplified ERP across multiple surgical specialties in different hospitals is associated with improved short and long-term mortality. Secondary aims were to examine ERP effect on length of stay, 30-day readmission, discharge disposition, and complications.

SUMMARY BACKGROUND DATA

Enhanced recovery after surgery and various derivative ERPs have been successfully implemented. These protocols typically include elaborate sets of multimodal and multidisciplinary approaches, which can make implementation challenging or are variable across different specialties. Few studies have shown if a simplified version of ERP implemented across multiple surgical specialties can improve clinical outcomes.

METHODS

A simplified ERP with 7 key domains (minimally invasive surgical approach when feasible, pre-/intra-operative multimodal analgesia, postoperative multimodal analgesia, postoperative nausea and vomiting prophylaxis, early diet advancement, early ambulation, and early removal of urinary catheter) was implemented in 5 academic and community hospitals within a single health system. Patients who underwent nonemergent, major orthopedic or abdominal surgery including hip/knee replacement, hepatobiliary, colorectal, gynecology oncology, bariatric, general, and urological surgery were included. Propensity-matched, retrospective case-control analysis was performed on all eligible surgical patients between 2014 and 2017 after ERP implementation or in the 12 months preceding ERP implementation (control population).

RESULTS

A total of 9492 patients (5185 ERP and 4307 controls) underwent ERP eligible surgery during the study period. Three thousand three hundred sixty-seven ERP patients were matched by surgical specialty and hospital site to control non-ERP patients. Short and long-term mortality was improved in ERP patients: 30 day: ERP 0.2% versus control 0.6% ( P = 0.002); 1-year: ERP 3.9% versus control 5.1% ( P < 0.0001); 2-year: ERP 6.2% versus control 9.0% ( P < 0.0001). Length of stay was significantly lower in ERP patients (ERP: 3.9 ± 3.8 days; control: 4.8 ± 5.0 days, P < 0.0001). ERP patients were also less likely to be discharged to a facility (ERP: 11.3%; control: 14.8%, P < 0.0001). There was no significant difference for 30-day readmission. All complications except venous thromboembolism were significantly reduced in the ERP population (P < 0.02).

CONCLUSIONS

A simplified ERP can uniformly be implemented across multiple surgical specialties and hospital types. ERPs improve short and long-term mortality, clinical outcomes, length of stay, and discharge disposition to home.

The impact of an enhanced recovery after surgery pathway for video-assisted and robotic-assisted lobectomy on surgical outcomes and costs: a retrospective single-center cohort study

To determine the impact of enhanced recovery after surgery (ERAS) pathway implementation on outcomes and cost of robotic- and video-assisted thoracoscopic (RATS and VATS) lobectomy. Retrospective review of 116 consecutive VATS and RATS lobectomies in the pre-ERAS (Oct 2018-Sep 2019) and ERAS (Oct 2019-Sep 2020) period. Multivariate analysis was used to determine the impact of ERAS and operative approach alone, and in combination, on length of hospital stay (LOS) and overall cost. Operative approach was 49.1% VATS, 50.9% RATS, with 44.8% pre-ERAS, and 55.2% ERAS (median age 68, 65.5% female). ERAS patients had shorter LOS (2.22 vs 3.45 days) and decreased total cost ($15,022 vs $20,155) compared with non-ERAS patients, while RATS was associated with decreased LOS (2.16 vs 4.19 days) and decreased total cost ($14,729 vs $20,484) compared with VATS. The combination of ERAS + RATS showed the shortest LOS and the lowest total cost (1.35 days and $13,588, P < 0.001 vs other combinations). On multivariate analysis, ERAS significantly decreased LOS (P = 0.001) and total cost (P = 0.003) compared with pre-ERAS patients; RATS significantly decreased LOS (P < 0.001) and total cost (P = 0.004) compared with VATS approach. ERAS implementation and robotic approach were independently associated with LOS reduction and cost savings in patients undergoing minimally invasive lobectomy. A combination of ERAS and RATS approach synergistically decreases LOS and overall cost.

Individual- and Environmental- Level Predictors of Recess Activity and Sedentary Behavior: Findings from the I-CAN! study

Introduction/Purpose

Recess represents a prime opportunity for physical activity during the school day. However, evidence is mixed with regard to factors associated with activity during recess.

Methods

Data were collected as a part of the Texas Initiative for Children's Activity and Nutrition (I-CAN!) program from 14 elementary schools and 1,049 4th-grade students. Percent of time in moderate-to-vigorous physical activity (MVPA) and sedentary behavior during recess was measured using GT3X+ accelerometers. Students' demographics, aerobic fitness, and body mass index (BMI) were collected from school records and FITNESSGRAM® data. Aspects of the playground environment supporting activity (e.g. soccer goals) or sedentary behavior (e.g. benches) were calculated following the procedures of the System for Observing Play and Leisure Activity in Youth (SOPLAY), with recess spatial area calculated via the polygon measurement tool in Google™ Earth Pro software. Recess time was collected from school data. Weather during recess was determined using time-stamped archived weather data from Weather Underground. Two-level, linear mixed model regression examined associations between individual- and school-level characteristics and percent time in MVPA.

Results

At the student-level, boys were more active than girls (effect size (ES)=0.50) and percent time in MVPA was directly associated with aerobic fitness (ES=0.35). At the school-level, recess infrastructure was associated with percent time in MVPA (ES=1.45), except for factors related to sedentary behavior, which were indirectly associated with percent time in MVPA (ES=-1.98). Patterns for sedentary behavior mirrored these effects.

Conclusions

This is one of the few studies to test the associations of fitness and sedentary upgrades to play areas with MVPA and sedentary behavior. The results suggest that recess is most likely to support MVPA in boys and those who are already most fit (i.e., those who would not be the target of intervention). This is not surprising because the focus of recess is on free choice of play, and thus recess might be supported more for social and emotional benefits than the impact on physical activity.

Clinical outcomes following robotic versus conventional DIEP flap in breast reconstruction: A retrospective matched study

Background

A robotic deep inferior epigastric perforator (DIEP) flap created through a totally extraperitoneal approach minimizes violation of the donor site, which may lead to postoperative pain reduction and rapid recovery. The authors compared the clinical outcomes of robotic and conventional DIEP flap breast reconstructions.

Methods

Data from consecutive patients who underwent mastectomy with DIEP flaps for breast reconstruction between July 2017 and January 2021 were retrospectively reviewed. Patients were divided into robotic and conventional DIEP groups, and the two groups were matched using the inverse probability of treatment weighting method. They were compared based on the reconstruction time, drainage amount, postoperative pain, rescue analgesics, hospital stay, complications, and BREAST-Q scores.

Results

After matching, a dataset of 207 patients was formed, including 21 patients in the robotic DIEP group and 186 patients in the conventional DIEP group. The mean reconstruction time was longer in the robotic DIEP group than in the conventional DIEP group (P<0.001). In the robotic group, pain intensity during the postoperative 6–24 hours was significantly reduced (P=0.001) with less use of fentanyl (P=0.003) compared to the conventional DIEP group. The mean length of hospital stay for the robotic DIEP group was shorter than that for conventional DIEP (P=0.002). BREAST-Q scores indicated a higher level of the abdominal physical well-being domain in the robotic group (P=0.020). Complication rates were comparable between the two groups.

Conclusions

This study suggests that a robotic DIEP flap offers enhanced postoperative recovery, accompanied by a reduction in postoperative pain and hospital stay.

Analysis of Outcomes for Robotic-Assisted Lobectomy with an Enhanced Recovery after Surgery Protocol

BACKGROUND

The impact on cost relative to clinical efficacy of Enhanced Recovery after Surgery (ERAS) protocols for patients who undergo robotic-assisted lobectomy is currently unknown. The objective of this study was to compare cost and perioperative outcomes of robotic-assisted lobectomy before and after implementation of an ERAS protocol.

METHODS

This is a retrospective analysis of 574 patients who underwent robotic-assisted lobectomy for primary lung carcinoma from May 1, 2017 - June 1, 2021. The ERAS protocol was implemented on October 17, 2019. Inverse probability of treatment weighting (IPTW) of propensity scores was used to balance baseline characteristics. The primary outcomes of the study were mean direct and indirect hospital costs, complication rates, and hospital length of stay.

RESULTS

A total of 315 patients underwent robotic-assisted lobectomy prior to implementation of the ERAS protocol and 259 patients were enrolled on the protocol. A significantly higher percentage of patients were discharged home in less than 3 days following the ERAS protocol implementation [24.5% vs 9.8% (p =0.001)]. There was a significant decrease in the IPTW adjusted mean direct hospital costs (p< 0.001) and mean indirect costs (p= 0.018) for the total hospital stay after ERAS protocol implementation. The mean initial discharge opioid medication dose (Morphine Equivalent Dose) was significantly lower (p< 0.001) following the ERAS protocol.

CONCLUSIONS

Increased early discharge and decreased hospital costs were observed for robotic-assisted lobectomy after implementation of an ERAS protocol. There was also an observed significant decrease in the discharge opioid medication doses prescribed.

Aktuelle ERAS-Implementierung in der Thoraxchirurgie an deutschen Kliniken

Einleitung In den letzten Jahren haben sich zunehmend ERAS-Behandlungspfade in vielen chirurgischen Bereichen etabliert, da sie allgemeine Komplikationen reduzieren und die Genesung von Patienten erheblich beschleunigen können. Für die Thoraxchirurgie wurden 2019 erstmals ERAS-Guidelines von der ERAS Society in Zusammenarbeit mit der European Society of Thoracic Surgeons (ESTS) veröffentlicht. Inwieweit sich ERAS-Maßnahmen im klinischen Alltag in der Thoraxchirurgie in Deutschland etabliert haben, wurde anhand eines Online-Fragebogens evaluiert.

Material und Methoden Es wurde eine Onlineumfrage zur aktuellen ERAS-Implementierung an deutschen Kliniken durchgeführt. Zeitraum der Umfrage war vom 12.05.2021 bis zum 01.06.2021. Im Fragebogen, der 22 Fragen umfasste, wurde die aktuelle Umsetzung verschiedener perioperativer Maßnahmen (u. a. Mobilisation, Thoraxdrainagen-Management, Schmerzmanagement) als wesentliche Items des ERAS-Pathways erfragt. Anschließend wurden die Resultate zusammengefasst, beschreibend analysiert und in den Kontext der aktuellen Literatur gesetzt.

Ergebnisse Von 155 angeschriebenen leitenden Thoraxchirurgen beantworteten 32 den Fragebogen. Bei 28,1% (n = 9) der Kliniken war ein ERAS-Kernteam etabliert, eine Datenbank zur Erfassung der ERAS-Items gab es in 15,6% (n = 5). Zudem bekamen die Patienten meist kein ERAS-Tagebuch (96,9%, n = 31) ausgehändigt. Ein präoperatives Carboloading wurde von 15,6% (n = 5) durchgeführt. Eine PONV-Prophylaxe wurde bei 59,4% (n = 19) der Befragten standardmäßig durchgeführt. In der Regel wurde bei elektiven anatomischen Resektionen eine Thoraxdrainage (84,4%, n = 27) eingelegt. Bei 3% (n = 1) der Zentren wurden 2 Drainagen eingelegt, bei 12,5% (n = 4) wurde keine Drainage intraoperativ eingebracht. Meist wurden digitale Drainagesysteme verwendet (90,6%, n = 29). Der am häufigsten angewendete initiale Drainagensog war –10 cm H2O (75%, n = 24). Einen Sog von ≤ 2 cmH2O verwendeten lediglich 2 Befragte. Die Drainageentfernung erfolgte in 50% (n = 16) der Fälle am 1. oder 2. postoperativen Tag (POD), in 34,4% (n = 11) am 3. und 4. POD und bei 9,4% (n = 3) verblieb die Drainage über den 4. Tag hinaus. Bei 71,9% (n = 23) der Befragten erfolgte die erste Mobilisation postoperativ noch am OP-Tag.

Diskussion Die Implementierung der ERAS-Guidelines ist in Deutschland interindividuell noch sehr variabel. Bestimmte perioperative Prozesse werden bereits gut abgedeckt, allerdings ist eine vollständige Umsetzung von ERAS-Items noch nicht gänzlich in der klinischen Praxis angekommen. Erste Schritte in diese Richtung wurden bereits gemacht und legen die Grundlage für eine weitere zentrumsübergreifende Zusammenarbeit.

Neobladder "Function": Tips and Tricks for Surgery and Postoperative Management

Orthotopic neobladder (ONB) reconstruction is a continent urinary diversion procedure increasingly used in patients with muscle-invasive bladder cancer following radical cystectomy (RC). It represents a valid alternative to the ileal duct in suitable patients who do not prefer a stoma and are motivated to undergo adequate training of the neobladder. Careful patient selection, taking into account the absolute and relative contraindications for ONB as well as an adequate recovery protocol after surgery are integral to the success of this procedure and the oncological and functional outcomes. The objective of this review is to summarize the current data on RC with ONB in terms of patient selection, preoperative preparation, surgical techniques and functional (continence and sexual activity) and oncological outcomes, with particular attention to the management of complications and the impact on quality of life (QoL).

Identifying patients who suffered from post-discharge cough after lung cancer surgery

PURPOSE

To establish a discharge cutoff point (CP) on a simple patient-reported cough score to identify patients requiring post-discharge cough intervention.

METHODS

Data were extracted from a prospective cohort study of patients undergoing lung cancer surgery. Symptoms were assessed using the MD Anderson Symptom Inventory-Lung Cancer Module. Group-based trajectory modeling was used to identify patient subgroups defined by post-discharge cough trajectories. Generalized linear model and bootstrap resampling with 2000 samples were used to determine the optimal cutoff points of discharge cough scores and their robustness. Analysis of variance, chi-square test, and mixed-effects model were used to validate the optimal cutoff points.

RESULTS

The cough trajectories of post-discharge followed three patterns (high, middle, low); higher cough was associated with poor recovery of the enjoyment of life within 4 weeks after discharge (P < 0.001). The CP (3, 6) of discharge cough demonstrated as the optimal CP (F = 21.72). When discharged, 45.66% (179/392) of patients suffered a none/mild cough (0-2 points), 41.82% (164/392) suffered a moderate cough (3-5 points), and 12.5% (49/392) suffered a severe cough (6-10 points). Among these patients, there was a significant difference in the proportion of returning to work at 1 month after discharge (non-mild: 77.70%; moderate: 60.74%; severe: 48.57%; p < 0.001).

CONCLUSIONS

Moderate-to-severe cough is relatively common in patients undergoing lung cancer surgery, and the higher the cough trajectory, the worse the recovery to normal life. Therefore, these patients with a cough score ≥ 3 or ≥ 6 at discharge may require additional medical intervention and extensive care.

Enhanced recovery in elderly patients undergoing pancreatic resection: A retrospective monocentric study

Enhanced recovery after surgery (ERAS) pathway for pancreas has demonstrated its value in clinical practice. However, there is a lack of specific evidence about its application in elderly patients. The aim of the present study was to assess the impact of age on compliance and postoperative outcomes. Patients ≥70 years old that underwent pancreatic resection within an ERAS pathway between 2012 and 2018 were included, and divided into three groups: 70-74, 75-79, and ≥80 years old. Compliance with ERAS items, length of stay, mortality, and complications were analyzed. 114 patients were included: 49, 37, and 28 patients aged 70-74, 75-79, and ≥80 years, respectively. Overall compliance to ERAS items between groups was not different (66%, 66%, and 62%, P = .201). No significant difference was observed in terms of median length of stay (14, 17, and 17 days, P = .717), overall complications (67%, 78%, and 71%, P = .529), major complications (26%, 32%, and 39%, P = .507), or mortality (0%, 3%, and 4%, P = .448) with increasing age. Application of an ERAS pathway is feasible in elderly patients with pancreatic resection. Increasing age was neither associated with poorer compliance nor worse postoperative outcomes.

Implementation of an enhanced recovery after surgery protocol for head and neck cancer patients: Considerations and best practices

Enhanced recovery after surgery (ERAS) protocols have been developed in numerous surgical specialties as a means of systematically improving patient recovery, functional outcomes, cost savings, and resource utilization. Such multidisciplinary initiatives seek to minimize variability in several aspects of perioperative patient care, helping to reduce inpatient length of hospital stay, complications, and the overall resource and financial burden of surgical care. Head and neck oncology patients stand to benefit from the implementation of comprehensive ERAS protocols, as these patients have complex medical needs that may dramatically impact multiple aspects of their recovery, including breathing, eating, nutrition, pain, speech, swallowing, and communication. Implementing ERAS protocols for head and neck cancer patients may present unique challenges, and require significant interdisciplinary coordination and collaboration. We therefore sought to provide a comprehensive guide to the planning and institution of such ERAS systems at institutions undertaking care of head and neck cancer patients. Key elements to consider in the implementation of successful ERAS protocols for this population include organizing a team consisting of frontline leaders such as nursing staff, medical specialists, and associated health professionals; designing interventions based on systematically evaluated, high-quality literature; and instituting a clear methodology for regularly updating protocols and auditing the success or potential limitations of a given intervention. Potential obstacles to the success of ERAS interventions for head and neck cancer patients include challenges in systematically tracking progress of the protocol, as well as resource limitations in a given health system.

Impact of enhanced recovery implementation in women undergoing abdominal sacrocolpopexy

OBJECTIVE

To assess the effect of Enhanced Recovery After Surgery (ERAS) with and without liposomal bupivacaine (LB) on opioid use, hospital length of stay (LOS), costs, and morbidity of women undergoing sacrocolpopexy.

METHODS

Retrospective cohort of women who underwent abdominal sacrocolpopexy between April 1, 2009 and November 30, 2017. Costs for relevant healthcare services were determined by assigning 2017 charges multiplied by 2017 Medicare Cost Report's cost to charge ratios. Outcomes were compared among periods with multivariable regression models adjusted for age, American Society of Anesthesiologists score, and concurrent hysterectomy and posterior repair.

RESULTS

Patients were subdivided into pre-ERAS (G1, n = 128), post-ERAS (G2, n = 83), and post-ERAS plus LB (G3, n = 91). The proportion of patients needing opioids during postoperative days 0-2 was significantly less for G3 (75.8%) compared with G1 (97.7%) and G2 (92.8%); P < 0.001). The median morphine equivalent units (MEU) with interquartile ranges, mean LOS, and adjusted mean standardized costs were significantly lower in G3 compared with the other two groups (35 [20-75] vs. 67 [31-109], and 60 [30-122] MEUs; 1.8 vs. 2.3 vs. 2.9 days; and $2391, $2975, and $3844, for G3, G2, and G1, respectively; P < 0.001).

CONCLUSION

Implementation of an ERAS pathway led to significant decreases in opioid use, LOS, and costs. Supplementation with LB further improved these measures.

Role of regional anesthesia and analgesia in enhanced recovery after colorectal surgery: a systematic review of randomized controlled trials

BACKGROUND

Effective analgesia is an important element of enhanced recovery after surgery (ERAS), but the clinical impact of regional anesthesia and analgesia for colorectal surgery remains unclear.

OBJECTIVE

We aimed to determine the impact of regional anesthesia following colorectal surgery in the setting of ERAS.

EVIDENCE REVIEW

We performed a systematic review of nine databases up to June 2020, seeking randomized controlled trials comparing regional anesthesia versus control in an ERAS pathway for colorectal surgery. We analyzed the studies with successful ERAS implementation, defined as ERAS protocols with a hospital length of stay of ≤5 days. Data were qualitatively synthesized. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool.

FINDINGS

Of the 29 studies reporting ERAS pathways, only 13 comprising 1170 patients were included, with modest methodological quality and poor reporting of adherence to ERAS pathways. Epidural analgesia had limited evidence of outcome benefits in open surgery, while spinal analgesia with intrathecal opioids may potentially be associated with improved outcomes with no impact on length of stay in laparoscopic surgery, though dosing must be further investigated. There was limited evidence for fascial plane blocks or other regional anesthetic techniques.

CONCLUSIONS

Although there was variable methodological quality and reporting of ERAS, we found little evidence demonstrating the clinical benefits of regional anesthetic techniques in the setting of successful ERAS implementation, and future studies must report adherence to ERAS in order for their interventions to be generalizable to modern clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42020161200.

Improved clinical and survival outcomes after esophagectomy for cancer over 25 years

BACKGROUND

In recent decades, there have been major developments in the curative treatment of esophageal cancer, such as the implementation of PET/CT, neoadjuvant chemoradiotherapy, minimally invasive surgery and postoperative care programs. This observational study examined clinical and survival outcomes after esophagectomy for cancer over 25 years.

METHODS

Consecutive patients who underwent esophagectomy for cancer at a tertiary referral center between 1993 and 2018 were selected from a prospectively maintained database. Patients were assigned to five periods: 1993-1997, 1998-2002, 2003-2007, 2008-2012, and 2013-2017. The primary outcome was the 5-year overall survival (OS) using Kaplan-Meier log-rank tests for trends.

RESULTS

A total of 1616 patients were analyzed. The median follow-up of surviving patients was 91.0 months (IQR 62.6-127.5).The 5-year overall survival improved gradually from 32.8 to 48.2% over 25 years, P<.001. Hospital length of stay reduced from 16 days (median, IQR 14-24) in 1993-1997 to 11 days (IQR 8-18) in 2013-2017, P<.001. No decrease in mortality was encountered over 25 years, although over the last 5 years, in-hospital and 90-day mortality dropped from 4.2% and 8.3% in 2013 to 0% in 2017, P<.05. Anastomotic leakages reduced from 26.4 to 9.7% between 2013 and 2017, P<.001.

CONCLUSIONS

Over the last 25 years, clinical outcomes and 5-year overall survival significantly improved in patients who underwent esophagectomy for cancer at this tertiary referral center.

Non-intubated video-assisted thoracoscopic surgery under combination of erector spinae plane block and thoracic paravertebral block

Background

The use of anesthetics and analgesic drugs and techniques in combination yields a multimodal effect with increased efficiency. In this case series, we aimed to evaluate the anesthetic effect of the thoracic paravertebral block (TPVB) and erector spinae plane block (ESPB) combination in patients, who underwent non-intubated video-assisted thoracoscopic surgery (NIVATS).

Methods

Medical records of 16 patients, who underwent NIVATS for wedge resection under the combination of ESPB and TPVB were reviewed retrospectively. Demographic data of patients, duration of the sensory block, amount of the anesthetic agent used for premedication and sedo-analgesia, any presence of perioperative cough, operative times, postoperative visual analog scale (VAS) scores in the postoperative follow-up period, the need for additional analgesia, and patient satisfaction were reviewed.

Results

Of the patients included in the study, 12 were men and 4 were women. The mean age was 48.6 years and the mean BMI was 24.7 kg/m². The mean time needed for the achievement of the sensorial block was 14 min and the mean skin-to-skin operative time was 21.4 min. During the procedure, patients received 81.5 ± 27.7 mg of propofol and 30 ± 13.6 micrograms of remifentanil infusions, respectively. The mean dose of ketamine administered in total was 58.1 ± 12.2 mg. Only 2 patients needed an extra dose of remifentanil because of recurrent cough. No patients developed postoperative nausea vomiting. During the first 24 h, the VAS static scores of the patients were 3 and below, while VAS dynamic scores were 4 and below. Morphine consumption in the first postoperative 24 h was 13.2 mg.

Conclusions

In conclusion, combined ESPB and TPVB with added intravenous sedo-analgesia in the presence of good cooperation between the surgical team and the anesthesiologist in the perioperative period can provide optimal surgical conditions including the prevention of cough in NIVATS. It is not sufficient to state that this combination is superior to alone ESPB or alone TPVB, as it is a preliminary study with a limited number of cases.

Complicaciones nefrourológicas en pacientes sometidos a resección pulmonar según la utilización o no de sondaje vesical

Introducción: La implementación del protocolo ERAS (Enhanced Recovery After Surgery) en cirugía torácica ha implicado un cambio en el manejo perioperatorio de los pacientes. Una de las nuevas recomendaciones es evitar la colocación sistémica del catéter urinario en cirugía pulmonar. Existe poca evidencia en la bibliografía sobre las complicaciones nefrourológicas (URC) postoperatorias. Por ello, diseñamos un estudio con el fin de evaluar la incidencia de URC en la población sometida a resección pulmonar por videotoracoscopia. Material y Métodos: Realizamos un estudio longitudinal y prospectivo en la Unidad de Reanimación Postanestésica (URPA) en un hospital de tercer nivel durante el periodo comprendido entre abril 2019 y julio del 2020. Se recogieron variables perioperatorias así como la presencia de URC. Resultados: De los 62 pacientes (82%) ingresaron en URPA sin catéter urinario, 5 (8%) presentaron URC.  El 60% (3 de 5) de los pacientes con complicaciones presentaban volúmenes vesicales estimados por ecografía altos (>300 ml) a su ingreso en URPA y el 80% (4 de 5) a las 4 horas. Estas complicaciones no implicaron un deterioro significativo de la función renal durante el ingreso. Conclusiones: La recomendación de evitar el sondaje urinario en cirugía de resección pulmonar parece una práctica segura, aunque existe una incidencia no despreciable de URC en el postoperatorio inmediato. Sería muy interesante disponer de herramientas que permitan una detección y monitorización de los pacientes con riesgo incrementado para favorecer la detección precoz de complicaciones.

Perioperative enhanced recovery programmes for women with gynaecological cancers

BACKGROUND

Gynaecological cancers account for 15% of newly diagnosed cancer cases in women worldwide. In recent years, increasing evidence demonstrates that traditional approaches in perioperative care practice may be unnecessary or even harmful. The enhanced recovery after surgery (ERAS) programme has therefore been gradually introduced to replace traditional approaches in perioperative care. There is an emerging body of evidence outside of gynaecological cancer which has identified that perioperative ERAS programmes decrease length of postoperative hospital stay and reduce medical expenditure without increasing complication rates, mortality, and readmission rates. However, evidence-based decisions on perioperative care practice for major surgery in gynaecological cancer are limited. This is an updated version of the original Cochrane Review published in Issue 3, 2015.

OBJECTIVES

To evaluate the beneficial and harmful effects of perioperative enhanced recovery after surgery (ERAS) programmes in gynaecological cancer care on length of postoperative hospital stay, postoperative complications, mortality, readmission, bowel functions, quality of life, participant satisfaction, and economic outcomes.

SEARCH METHODS

We searched the following electronic databases for the literature published from inception until October 2020: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PubMed, AMED (Allied and Complementary Medicine), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus, and four Chinese databases including the China Biomedical Literature Database (CBM), WanFang Data, China National Knowledge Infrastructure (CNKI), and Weipu Database. We also searched four trial registration platforms and grey literature databases for ongoing and unpublished trials, and handsearched the reference lists of included trials and accessible reviews for relevant references.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared ERAS programmes for perioperative care in women with gynaecological cancer to traditional care strategies.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, extracted the data and assessed methodological quality for each included study using the Cochrane risk of bias tool 2 (RoB 2) for RCTs. Using Review Manager 5.4, we pooled the data and calculated the measures of treatment effect with the mean difference (MD), standardised mean difference (SMD), and risk ratio (RR) with a 95% confidence interval (CI) to reflect the summary estimates and uncertainty.

MAIN RESULTS

We included seven RCTs with 747 participants. All studies compared ERAS programmes with traditional care strategies for women with gynaecological cancer. We had substantial concerns regarding the methodological quality of the included studies since the included RCTs had moderate to high risk of bias in domains including randomisation process, deviations from intended interventions, and measurement of outcomes. ERAS programmes may reduce length of postoperative hospital stay (MD -1.71 days, 95% CI -2.59 to -0.84; I2 = 86%; 6 studies, 638 participants; low-certainty evidence). ERAS programmes may result in no difference in overall complication rates (RR 0.71, 95% CI 0.48 to 1.05; I2 = 42%; 5 studies, 537 participants; low-certainty evidence). The certainty of evidence was very low regarding the effect of ERAS programmes on all-cause mortality within 30 days of discharge (RR 0.98, 95% CI 0.14 to 6.68; 1 study, 99 participants). ERAS programmes may reduce readmission rates within 30 days of operation (RR 0.45, 95% CI 0.22 to 0.90; I2 = 0%; 3 studies, 385 participants; low-certainty evidence). ERAS programmes may reduce the time to first flatus (MD -0.82 days, 95% CI -1.00 to -0.63; I2 = 35%; 4 studies, 432 participants; low-certainty evidence) and the time to first defaecation (MD -0.96 days, 95% CI -1.47 to -0.44; I2 = 0%; 2 studies, 228 participants; low-certainty evidence). The studies did not report the effects of ERAS programmes on quality of life. The evidence on the effects of ERAS programmes on participant satisfaction was very uncertain due to the limited number of studies. The adoption of ERAS strategies may not increase medical expenditure, though the evidence was of very low certainty (SMD -0.22, 95% CI -0.68 to 0.25; I2 = 54%; 2 studies, 167 participants).

AUTHORS' CONCLUSIONS

Low-certainty evidence suggests that ERAS programmes may shorten length of postoperative hospital stay, reduce readmissions, and facilitate postoperative bowel function recovery without compromising participant safety. Further well-conducted studies are required in order to validate the certainty of these findings.

Postoperative Sedation Duration as an Independent Risk Factor for Postoperative Pneumonia in Head and Neck Cancer Patients Undergoing Free Flap Reconstruction

OBJECTIVE

Patients who had reconstruction for head and neck cancer usually have long duration of postoperative sedation and intensive care. This is due to the complex nature of large-area soft tissue defect surgeries and upper respiratory tract infections associated with them. Postoperative pulmonary complications are common in these patients. In this study, we analyzed the risk factors and the relationship between postoperative complications and the duration of sedation to improve the patients' recovery process after free flap reconstruction for head and neck surgery.

MATERIALS AND METHODS

This was a retrospective study that included 188 patients who had head and neck surgery with free flap reconstruction in 2011 (traditional recovery group) and 2018 (early recovery group). Postoperative recovery events were compared between the 2 groups. Complications such as pneumonia, wound infection, vascular thrombosis, and bleeding were also analyzed.

RESULTS

The results showed that the early recovery group had a shorter duration of sedation (P < 0.001), shorter duration of intensive care unit stay (P = 0.05), more rapid ventilator weaning (P < 0.001), and fewer pneumonia events (8.8% vs 39.1%) than the traditional recovery group. Wound- and vessel-related complications were not affected by the duration of sedation.

CONCLUSIONS

Our study demonstrated that shortening the duration of postoperative sedation can effectively decrease the length of intensive care unit stay and reduce postoperative incidence of pneumonia without increasing wound- and vessel-related complications.

Surgical Issues for Operable Early-Stage Non-Small-Cell Lung Cancer

Surgical care for early stage non-small-cell lung cancer continuously evolves with new procedures, techniques and care pathways. The most obvious recent change was the transition to minimally invasive procedures, but numerous other aspects of care have also been refined to improve safety and tolerability. These care advancements are essential as we move into an era with increased early detection as a result of screening and greater indications for the use of adjuvant and neoadjuvant strategies.

Impact of enhanced pathway of care in uniportal video-assisted thoracoscopic surgery

Enhanced Recovery After Surgery (E.R.A.S.) is a multimodal, evidence-based and patient-centered pathway designed to minimize surgical stress, enhancing recovery and improving perioperative outcomes. However, considering that the potential clinical implication of E.R.A.S. on patients undergoing video-assisted thoracic surgery (V.A.T.S.) has not properly defined, we proposed to implement our minimally invasive program with a specific clinical pathway able to enhance recovery after lung resection. Aim of this study was to assess the impact of this integrated program of Enhanced Pathway of Care (E.P.C.) in Uniportal V.A.T.S. patients undergoing lung resection, in terms of efficiency and safety. We conducted a retrospective, observational study enrolling patients undergoing uniportal V.A.T.S. resections from January 2015 to May 2020. Two groups were created: pre-E.P.C. and E.P.C. Propensity score matching analysis was performed to evaluate length of stay (LOS), postoperative cardiopulmonary complications (CPC) and readmission rate (READM). We analyzed 1167 patients (E.P.C. group: 182; pre-E.P.C. group: 985). E.P.C. group has a mean LOS shorter compared to pre-E.P.C. group (3.13 vs 4.19 days, p < 0.0001) without increasing on CPC (E.P.C. 12% vs pre-E.P.C. 11%, p = 0.74) and READM rate (E.P.C. 1.6% vs pre-E.P.C. 4.9%, p = 0.07). In particular, the LOS was shortened in the E.P.C. patients submitted to lobectomy, segmentectomy and wedge resection. Moreover, the three subgroups had similar CPC and READM rates for E.P.C. and control patients. In conclusion, this study demonstrated the benefits and safety of E.P.C. program showing a reduction of LOS for patients undergoing uniportal V.A.T.S. resection.

Physiotherapy Regimens in Esophagectomy and Gastrectomy: a Systematic Review and Meta-Analysis

Background

Esophageal and gastric cancer surgery are associated with considerable morbidity, specifically postoperative pulmonary complications (PPCs), potentially accentuated by underlying challenges with malnutrition and cachexia affecting respiratory muscle mass. Physiotherapy regimens aim to increase the respiratory muscle strength and may prevent postoperative morbidity.

Objective

The aim of this study was to assess the impact of physiotherapy regimens in patients treated with esophagectomy or gastrectomy.

Methods

An electronic database search was performed in the MEDLINE, EMBASE, CENTRAL, CINAHL and Pedro databases. A meta-analysis was performed to assess the impact of physiotherapy on the functional capacity, incidence of PPCs and postoperative morbidity, in-hospital mortality rate, length of hospital stay (LOS) and health-related quality of life (HRQoL).

Results

Seven randomized controlled trials (RCTs) and seven cohort studies assessing prehabilitation totaling 960 patients, and five RCTs and five cohort studies assessing peri- or postoperative physiotherapy with 703 total patients, were included. Prehabilitation resulted in a lower incidence of postoperative pneumonia and morbidity (Clavien–Dindo score ≥ II). No difference was observed in functional exercise capacity and in-hospital mortality following prehabilitation. Meanwhile, peri- or postoperative rehabilitation resulted in a lower incidence of pneumonia, shorter LOS, and better HRQoL scores for dyspnea and physical functioning, while no differences were found for the QoL summary score, global health status, fatigue, and pain scores.

Conclusion

This meta-analysis suggests that implementing an exercise intervention may be beneficial in both the preoperative and peri- or postoperative periods. Further investigation is needed to understand the mechanism through which exercise interventions improve clinical outcomes and which patient subgroup will gain the maximal benefit.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-11122-7.

New surgical realities: implementation of an enhanced recovery after surgery protocol for gynecological laparoscopy-a prospective study

Background

Multimodal rehabilitation allows optimization of functional recovery in surgery patients by reducing the postoperative stress and hospital stay duration, without increasing the morbidity and mortality. It is reportedly successful in other surgical disciplines, and guidelines for its application to gynecological surgery are available; however, most evidence for these guidelines is derived from observational and/or retrospective studies. Therefore, this study aimed to investigate the applicability of an enhanced recovery after surgery (ERAS) protocol in laparoscopic gynecological surgery and its influence on the postoperative stay, morbidity, mortality, and readmission, through a prospective approach.

Methods

This prospective cohort study was performed on 90 patients who underwent laparoscopic hysterectomy for benign causes from October 2017 to October 2019. Patients in whom the ERAS (ERAS group, n = 30) and traditional (control group, n = 60) protocols were implemented were compared. All patients were followed for 6 months.

Results

The groups were homogeneous and did not differ significantly with respect to the demographic characteristics (age, ASA score, body mass index), surgical indications, and surgery types. Adherence to the ERAS protocol was over 99%. The postoperative hospital-stay durations were 1.73 days (r = 1–3) and 2.97 days (r = 2–6) in the ERAS and control groups, respectively (p = 0.000). No significant intergroup differences were observed in the rates of complications and readmissions.

Conclusions

The ERAS protocol is applicable in laparoscopic gynecological surgery and can be implemented with good adherence. This can allow optimization of patient recovery by reducing the hospital stay duration, without increasing the rates of morbidity, mortality, or readmission.

Medico-economic impact of enhanced rehabilitation after surgery: an exhaustive, nation-wide claims study

Background

Study of the medico economic impact of enhanced rehabilitation after surgery (ERAS), by comparing the cost of patient care with or without ERAS, both from the point of view of the hospitals and the Social Security Health Insurance Program.

Methods

Retrospective longitudinal study on matched data from March 1, 2019 to December 31, 2019. The data are extracted from the French prospective payment system. We studied 12 of the most commonly performed in ERAS business segments. The primary outcome was the reduction of the average length of hospital stay and its implications on production costs and excess capacity. We also studied the impact on hospital incomes and Social Security Insurance Program expenses. The potential gain in hospital days was computed by comparing the length of stay of ERAS and non-ERAS cases. The cost reduction was estimated using the mean number of avoidable days of hospitalization, and the mean cost of the stays obtained from the national cost study. Finally, we studied an approximation of the additional expense for the Social Security Health Insurance Program on costs standardized by applying public sector rates.

Results

The average length of stay reduction attributed to ERAS is 1.45 (CI 95% 1.42 to 1.48) day per stay, translating to a cost reduction for the hospitals of € 1060 (CI 95% 995 to 1125) per patient and a total of €65 million (CI 95% 61 to 69). At the same time, the additional expenses for the Social Security Insurance Program can conservatively be approximated to € 1.6 million, breaking into a € 2.2 million increase partially compensated by cost savings of € 0.6 million over subsequent stays for complications. Overall, for each percent of additional ERAS activity over the scope of the study, the marginal cost reduction for the hospitals can be estimated to € 1.8 million (CI 95% 1.7 million to 2.0 million).

Conclusions

Associated with previously known clinical benefits for the patients, these convincing results in terms of economic gain strongly support expanding the adoption of ERAS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07379-z.

Patient-reported outcomes: Is this the missing link in patient-centered perioperative care?

Patient-reported outcomes (PROs) have been increasingly recognized as valuable information for delivery of optimal perioperative care to high-risk surgical patients in recent years. However, progress from clinical research on PROs has not been widely adopted in routine patient care. This review discusses the current concepts and practice status regarding PROs and addresses the missing links from research to practice adoption to further improve patient's experiences and clinical outcomes in perioperative care. Insufficient empirical research on appropriate PROs and its methodologies, insufficient implementation research to solve the practical issues, and insufficient data collection methods and experiences on ePROs are also discussed. Future research agenda should focus on evidence-supported, PRO-based symptom monitoring systems for early diagnosis and management of impending compromised clinical outcomes.