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Wiesenberger R, Müller J, Kaufmann M, Weiß C, Ghezel-Ahmadi D, Hardt J, Reissfelder C, Herrle F. Influence of motivational interviewing on postoperative mobilization in the enhanced recovery after surgery (ERAS®) pathway in elective colorectal surgery - a randomized patient-blinded pilot study. Langenbecks Arch Surg 2024; 409:134. [PMID: 38644386 PMCID: PMC11033226 DOI: 10.1007/s00423-024-03321-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/10/2024] [Indexed: 04/23/2024]
Abstract
PURPOSE Early mobilization is an essential component of the Enhanced Recovery after Surgery (ERAS®)-pathway. However, a large percentage of patients fail to achieve the ERAS® recommended goal (360 min out of bed from post-operative day 1/POD1). Motivational Interviewing (MI) is an evidence-based type of patient-centered consultation to promote intrinsic motivation. This study aims to evaluate if MI can improve postoperative mobilization. METHODS This two-arm, patient-blinded pilot randomized controlled trial included ERAS®-patients undergoing elective bowel resections. Conversations were validated by MI Treatment Integrity. Two validated motion sensors (movisens) and self-assessments were used to measure mobilization (POD1-POD3: Time out of bed, time on feet and step count). RESULTS 97 patients were screened, 60 finally included and randomized. Cumulatively across POD1-3, the intervention group (IG) was longer out of bed than the control group (CG) (median: 685 vs. 420 min; p=0.022). The IG achieved the ERAS®-goal of 360 min/day more frequently across POD1-3 (27.4% vs. 10.61%; p=0.013). Time on feet was 131.5 min/day (median per POD) in IG vs. 95.8 min/day in the CG (p=0.212), step count was 1347 in IG vs. 754 steps/day in CG (p=0.298). CONCLUSION MI could be conducted low threshold and was well accepted by patients. MI can improve mobilization in the context of ERAS®. Despite better performance, it should be noted that only 27.4% of the IG reached the ERAS®-compliance goal of 360 min/day. The findings of this pilot study stipulate to further test the promising perioperative effects of MI within a multicenter superiority trial. REGISTRATION This study was registered prospectively in the German Clinical Trials Register on 25.02.2022. Trial registration number is "DRKS00027863".
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Affiliation(s)
- Rico Wiesenberger
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Julian Müller
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Mario Kaufmann
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christel Weiß
- Institute for Medical Statistics, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - David Ghezel-Ahmadi
- Department of Anaesthesiology and Critical Care Medicine, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Julia Hardt
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christoph Reissfelder
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- DKFZ-Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
| | - Florian Herrle
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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Willis MA, Post S, Nothacker M, Follmann M, Langer T, Vilz TO. A methodological protocol for the development of a national guideline on perioperative management of gastrointestinal tumors in Germany. Perioper Med (Lond) 2024; 13:25. [PMID: 38561812 PMCID: PMC10983752 DOI: 10.1186/s13741-024-00380-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/21/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND The success of abdominal cancer surgery depends not only on the surgery itself but is influenced by the overall perioperative management. Given the multitude of perioperative measures and the ever-increasing number of studies on perioperative management, it is difficult to keep track and provide evidence-based perioperative management. The planned guideline on perioperative management will review the existing evidence and derive treatment recommendations. METHODS The processing of the evidence is carried out by 6 working groups according to an 8-step scheme: after drafting the guideline questions in PICO format (1), a systematic literature search is carried out (2), and the records found are screened by two independent reviewers from the coordination team. Subsequently, the full texts of the potentially relevant articles are made available to the working groups for full text screening (3). All articles to be included are reviewed for methodological quality (4) before summary of findings tables are generated (5). In line with the GRADE approach, confidence in the evidence is assessed (6) before a recommendation is derived from the evidence, using a modified GRADE Evidence to Decision Framework (7). Finally, all recommendations are compiled and agreed within the guideline group (8). DISCUSSION Guidelines serve as foundation for therapy decisions in everyday clinical practice and should therefore be based on up-to-date research results. However, while primary studies and systematic reviews are critically reviewed for their methodological quality, the process of guideline development is often not comprehensible. A protocol with predefined methodology should therefore create transparency and strengthen confidence in the recommendations. TRIAL REGISTRATION The guideline is registered in the AWMF (Association of the Scientific Medical Societies) Guideline Register (088-010OL).
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Affiliation(s)
- M A Willis
- Department of General, Visceral, Thorax and Vascular Surgery, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - S Post
- Department of Surgery, University Hospital Mannheim, Mannheim, Germany
| | - M Nothacker
- Association of the Scientific Medical Societies e.V., Philipps University Marburg, Marburg, Germany
| | - M Follmann
- German Guideline Program in Oncology, German Cancer Society, Berlin, Germany
| | - T Langer
- German Guideline Program in Oncology, German Cancer Society, Berlin, Germany
| | - T O Vilz
- Department of General, Visceral, Thorax and Vascular Surgery, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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Özbay T, Şanlı D, Springer JE. An investigation on the compliance of perioperative practices using ERAS protocols and barriers to the implementation of the ERAS protocols in colorectal surgery. Acta Chir Belg 2024:1-10. [PMID: 38445819 DOI: 10.1080/00015458.2024.2327813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 02/29/2024] [Indexed: 03/07/2024]
Abstract
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.
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Affiliation(s)
- Turna Özbay
- Department of Nursing, Graduate School of Health Sciences, Izmir Katip Celebi University, Izmir, Türkiye
| | - Deniz Şanlı
- Department of Surgical Nursing, Faculty of Health Sciences, Izmir Katip Celebi University, Izmir, Türkiye
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Byrnes A, Flynn R, Watt A, Barrimore S, Young A. Sustainability of enhanced recovery after surgery programmes in gastrointestinal surgery: A scoping review. J Eval Clin Pract 2024; 30:217-233. [PMID: 37957803 DOI: 10.1111/jep.13935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/03/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) is an evidence-based intervention that is well-recognised across multiple surgical specialties as having potential to lead to improved patient and hospital outcomes. Little is known about sustainability of ERAS programmes. AIMS This review aimed to describe available evidence evaluating sustainability of ERAS programmes in gastrointestinal surgery to understand: (a) how sustainability has been defined; (b) examine determinants of sustainability; (c) identify strategies used to facilitate sustainability; (d) identify adaptations to support sustainability; and (e) examine outcomes measured as indicators of sustainability of ERAS programmes. METHODS This scoping review was conducted following the Joanna Briggs Institute's methodology. Research databases (PubMed, Embase, CINHAL) and the grey literature were searched (inception to September 2022) for studies reporting sustainability of ERAS programmes in gastrointestinal surgery. Included articles reported an aspect of sustainability (i.e., definition, determinants, strategies, adaptations, outcomes and ongoing use) at ≥2 years following initial implementation. Aspects of sustainability were categorised according to relevant frameworks to facilitate synthesis. RESULTS The search strategy yielded 1852 records; first round screening excluded 1749, leaving 103 articles for full text review. Overall, 22 studies were included in this review. Sustainability was poorly conceptualised and inconsistently reported across included studies. Provision of adequate resources was the most frequently identified enabler to sustainability (n/N = 9/12, 75%); however, relatively few studies (n = 4) provided a robust report of determinants, with no study reporting determinants of sustainability and strategies and adaptations to support sustainability alongside patient and service delivery outcomes. CONCLUSION Improved reporting, particularly of strategies and adaptations to support sustainability is needed. Refinement of ERAS reporting guidelines should be made to facilitate this, and future implementation studies should plan to document and report changes in context and corresponding programme changes to help researchers and clinicians sustain ERAS programmes locally.
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Affiliation(s)
- Angela Byrnes
- Nutrition and Dietetics Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Rachel Flynn
- Health Information and Standards Directorate, Health Information and Quality Authority, Cork, Ireland
| | - Amanda Watt
- Nutrition and Dietetics Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Sally Barrimore
- Nutrition and Dietetics Department, Prince Charles Hospital, Chermside, Queensland, Australia
| | - Adrienne Young
- Nutrition and Dietetics Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Centre for Health Services Research, University of Queensland, St Lucia, Queensland, Australia
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Xue J, Xu Z, Wang Q, Hou H, Wei L, Zhang J, Zhao X, Chen L, Ding F, Ma L, Zhao Y, Wang Y, Ma D, Wang T, Liu R, Gan TJ, Robinson N, Frank Y, Su F, Chi Y, Yang D, Liu S, Cui S, Wei Y, Chen Z, Qin Y, Cao L, Chen G, Shu K, Xiao Z, Zhang H, Yu J, Hu Z, Cheng H, Ma W, Liu G, Wang X, Cao X, Gao J, Kong G, Tao Q, Wang B, Wang J, Li H, Lyu C, Zhang Z, Li T, Yang K. Clinical practice guidelines for prevention and treatment of postoperative gastrointestinal disorder with Integrated Traditional Chinese and Western Medicine (2023). J Evid Based Med 2024; 17:207-223. [PMID: 38530771 DOI: 10.1111/jebm.12587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 01/29/2024] [Indexed: 03/28/2024]
Abstract
Postoperative gastrointestinal disorder (POGD) was a common complication after surgery under anesthesia. Strategies in combination with Traditional Chinese Medicine and Western medicine showed some distinct effects but standardized clinical practice guidelines were not available. Thus, a multidisciplinary expert team from various professional bodies including the Perioperative and Anesthesia Professional Committees of the Chinese Association of Integrative Medicine (CAIM), jointly with Gansu Province Clinical Research Center of Integrative Anesthesiology/Anesthesia and Pain Medical Center of Gansu Provincial Hospital of Traditional Chinese Medicine and WHO Collaborating Center for Guideline Implementation and Knowledge Translation/Chinese Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Center/Gansu Provincial Center for Medical Guideline Industry Technology/Evidence-based Medicine Center of Lanzhou University, was established to develop evidence-based guidelines. Clinical questions (7 background and 12 clinical questions) were identified through literature reviews and expert consensus meetings. Based on systematic reviews/meta-analyses, evidence quality was analyzed and the advantages and disadvantages of interventional measures were weighed with input from patients' preferences. Finally, 20 recommendations were developed through the Delphi-based consensus meetings. These recommendations included disease definitions, etiologies, pathogenesis, syndrome differentiation, diagnosis, and perioperative prevention and treatment.
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Affiliation(s)
- Jianjun Xue
- Center for Evidence-Based Medicine, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Gansu Province Clinical Research Center of Integrative Anaesthesiology, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, China
- Anesthesiology and Pain Medicine Center, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, China
| | - Ziqing Xu
- Gansu Province Clinical Research Center of Integrative Anaesthesiology, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, China
- Anesthesiology and Pain Medicine Center, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, China
| | - Qiang Wang
- Department of Anesthesiology, Xi'an, China
| | - Huaijing Hou
- Gansu Province Clinical Research Center of Integrative Anaesthesiology, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, China
- Anesthesiology and Pain Medicine Center, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, China
| | - Lili Wei
- Center for Evidence-Based Medicine, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- School of Economics and Management, Gansu University of Chinese Medicine, Lanzhou, China
| | - Jie Zhang
- Gansu Province Clinical Research Center of Integrative Anaesthesiology, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, China
- Anesthesiology and Pain Medicine Center, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, China
| | - Xiaohong Zhao
- Gansu Province Clinical Research Center of Integrative Anaesthesiology, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, China
- Anesthesiology and Pain Medicine Center, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, China
| | - Liping Chen
- Gansu Province Clinical Research Center of Integrative Anaesthesiology, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, China
- Anesthesiology and Pain Medicine Center, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, China
| | - Fanfan Ding
- Gansu Province Clinical Research Center of Integrative Anaesthesiology, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, China
- Anesthesiology and Pain Medicine Center, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, China
| | - Li Ma
- Gansu Province Clinical Research Center of Integrative Anaesthesiology, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, China
- Anesthesiology and Pain Medicine Center, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, China
| | - Yongqiang Zhao
- Gansu Province Clinical Research Center of Integrative Anaesthesiology, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, China
| | | | - Daqing Ma
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, UK
- National Clinical Research Center for Child Health, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | | | - Renyu Liu
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University, Stony Brook, New York, USA
| | | | - Yurasek Frank
- Pain Clinic, Acupuncture Services Cook County Health, Stroger Hospital, Chicago, Illinois, USA
| | - Fan Su
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yongliang Chi
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Dianhui Yang
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Shujuan Liu
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Suyang Cui
- Jiangsu Provincial Hospital of Chinese Medicine, Nanjing, China
| | - Yousong Wei
- Jiangsu Provincial Hospital of Chinese Medicine, Nanjing, China
| | - Zhiqiang Chen
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - You Qin
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Lixing Cao
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Guiping Chen
- Department of Gastrointestinal Surgery, Zhejiang Provincial Hospital of Chinese Medicine, Hangzhou, China
| | - Kuanyong Shu
- Jiangxi Maternal and Child Health Hospital, Nanchang, China
| | - Zhongqing Xiao
- Jiangxi Maternal and Child Health Hospital, Nanchang, China
| | - Hui Zhang
- Tianjin Hospital of ITCWM Nankai Hospital, Tianjin, China
| | - Jianbo Yu
- Tianjin Hospital of ITCWM Nankai Hospital, Tianjin, China
| | - Zhiqian Hu
- Department of Anorectal Surgery, Changzheng Hospital Affiliated to Second Military Medical University, Shanghai, China
| | - Huakun Cheng
- Department of Neurosurgery, Heilongjiang Provincial Hospital, Harbin, China
| | - Wuhua Ma
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
| | - Guokai Liu
- Department of Anesthesiology, Dongzhimen Hospital of Beijing University of Chinese Medicine, Beijing, China
| | - Xiuli Wang
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xinghua Cao
- Department of Anesthesiology, Affiliated Hospital of Traditional Chinese Medicine of Xinjiang Medical University, Urumqi, China
| | - Ju Gao
- Department of Anesthesiology, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Gaoyin Kong
- Department of Anesthesiology, Hunan Provincial People's Hospital, Changsha, China
| | - Qing Tao
- The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, China
| | - Baohua Wang
- Department of Anesthesiology, Affiliated Hospital of Changchun University of Traditional Chinese Medicine, Changchun, China
| | - Junlu Wang
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hong Li
- Department of Anesthesiology, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Cuixia Lyu
- College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Zhiming Zhang
- Gansu Province Clinical Research Center of Integrative Anaesthesiology, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, China
| | - Tianzuo Li
- Department of Anesthesiology, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing, China
| | - Kehu Yang
- Center for Evidence-Based Medicine, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Centre for Evidence-Based Social Science/Center for Health Technology Assessment, School of Public Health, Lanzhou University, Lanzhou, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
- Chinese GRADE Centre, Lanzhou University, Lanzhou, China
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Rosowicz A, Brody JS, Lazar DJ, Bangla VG, Panahi A, Nobel TB, Dexter-Meldrum J, Divino CM. Early Ambulation is Associated with Improved Outcomes Following Colorectal Surgery. Am Surg 2023; 89:5225-5233. [PMID: 36445980 DOI: 10.1177/00031348221142590] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND The Enhanced Recovery After Surgery (ERAS) society lists early mobilization as one of their recommendations for improving patient outcomes following colorectal surgery. The level of supporting evidence, however, is relatively weak, and furthermore, the ERAS guidelines do not clearly define "early" mobilization. In this study, we define mobilization in terms of time to first ambulation after surgery and develop an outcome-based cutoff for early mobilization. METHODS This is a retrospective cohort study comprised of 291 patients who underwent colorectal operations at a large, academic medical center from June to December 2019. Three cutoffs (12 hours, 24 hours, and 48 hours) were used to divide patients into early and late ambulation groups for each cutoff, and statistical analysis was performed to determine differences in postoperative outcomes between the corresponding groups. RESULTS Multivariate analysis showed no difference between the early and late ambulation groups for the 12-hour and 48-hour cutoffs; however, ambulation before 24 hours was associated with a decreased rate of severe complications as well as fewer adverse events overall. Patients who ambulated within 24 hours had a 4.1% rate of severe complications and a 22.1% rate of experiencing some adverse event (complication, return to the emergency department, and/or readmission). In comparison, 11.8% of patients who ambulated later experienced a severe complication (P = 0.026), while 36.1% of patients experienced some adverse event (P = 0.011). CONCLUSIONS Ambulation within 24 hours after colorectal surgery is associated with improved postoperative outcomes, particularly a decreased rate of severe complications.
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Affiliation(s)
| | - Jason S Brody
- Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Damien J Lazar
- Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Venu G Bangla
- Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Armon Panahi
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Tamar B Nobel
- Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
| | | | - Celia M Divino
- Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
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Kenis I, Van Hecke A, Foulon V. The cocreation of care pathways for patients treated with oral anticancer drugs: From assessment data to an actual care pathway. J Eval Clin Pract 2023; 29:1354-1362. [PMID: 36949720 DOI: 10.1111/jep.13840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/23/2023] [Accepted: 03/09/2023] [Indexed: 03/24/2023]
Abstract
RATIONALE Due to the emergence of oral anticancer therapies, existing care processes in oncology - that are mainly focused on in-hospital treatments - must be rethought. The development of a care pathway is a well-known methodology to reorganise and standardise care for a specific patient group. However, care pathway development might be complex and burdensome for healthcare teams, requiring a well-thought-out methodology that provides guidance to the teams. AIMS AND OBJECTIVES In 10 Belgian oncology departments, multidisciplinary teams developed a tailored care pathway, aimed to offer high-quality patient-centred care. Each department followed a cocreation methodology, consisting of a current practice assessment, a priority setting, and the actual development of the care pathway. The aim of this study was to investigate how and to which extent underperformed evidence-based key elements (KEs), identified in the current practice assessment, guided the development of the care pathway, and how compliant the final care pathways are with the list of evidence-based KEs. METHODS A qualitative content analysis was conducted to describe and compare the results of each phase of the cocreation methodology. RESULTS This study shows that much of the evidence and feedback on current practice that was used as a starting point, got lost throughout the cocreation process. Only a limited proportion of the (seriously) underperformed KEs were prioritised by the multidisciplinary teams. Furthermore, several prioritised KEs could not be retrieved in the care pathway documents. Also, the final care pathways were not fully compliant with existing evidence. CONCLUSION Based on the findings, a more rigorous cocreation methodology seems needed, offering very concrete support for multidisciplinary teams to integrate the prioritised KEs in the care process (e.g., by using a model care pathway). Next to the selfreported performance data from healthcare professionals and patients, more objective data (e.g., walkthrough, medical records) and more extensive patient involvement should be considered in the priority setting.
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Affiliation(s)
- Ilyse Kenis
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium
- Department of Public Health and Primary Care, University Centre for Nursing and Midwifery, Ghent University, Ghent, Belgium
| | - Ann Van Hecke
- Department of Public Health and Primary Care, University Centre for Nursing and Midwifery, Ghent University, Ghent, Belgium
- Nursing Department, Ghent University Hospital, Ghent, Belgium
| | - Veerle Foulon
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium
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8
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Willis MA, Keller PS, Sommer N, Koch F, Ritz JP, Beyer K, Reißfelder C, Hardt J, Herold A, Buhr HJ, Emmanuel K, Kalff JC, Vilz TO. Adherence to fast track measures in colorectal surgery-a survey among German and Austrian surgeons. Int J Colorectal Dis 2023; 38:80. [PMID: 36964828 PMCID: PMC10039823 DOI: 10.1007/s00384-023-04379-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2023] [Indexed: 03/26/2023]
Abstract
PURPOSE The effectiveness of modern perioperative treatment concepts has been demonstrated in several studies and meta-analyses. Despite good evidence, limited implementation of the fast track (FT) concept is still a widespread concern. To assess the status quo in Austrian and German hospitals, a survey on the implementation of FT measures was conducted among members of the German Society of General and Visceralsurgery (DGAV), the German Society of Coloproctology (DGK) and the Austrian Society of Surgery (OEGCH) to analyze where there is potential for improvement. METHODS Twenty questions on perioperative care of colorectal surgery patients were sent to the members of the DGAV, DGK and OEGCH using the online survey tool SurveyMonkey®. Descriptive data analysis was performed using Microsoft Excel. RESULTS While some of the FT measures have already been routinely adopted in clinical practice (e.g. minimally invasive surgical approach, early mobilization and diet buildup), for other components there are discrepancies between current recommendations and present implementation (e.g. the use of local nerve blocks to provide opioid-sparing analgesia or the use of abdominal drains). CONCLUSION The implementation of the FT concept in Austria and Germany is still in need of improvement. Particularly regarding the use of abdominal drains and postoperative analgesia, there is a tendency to stick to traditional structures. To overcome the issues with FT implementation, the development of an evidence-based S3 guideline for perioperative care, followed by the founding of a surgical working group to conduct a structured education and certification process, may lead to significant improvements in perioperative patient care.
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Affiliation(s)
- Maria A Willis
- Department of Surgery, University Hospital Bonn, Campus 1, 53127, Bonn, Germany
| | - Peter S Keller
- Department of Surgery, University Hospital Bonn, Campus 1, 53127, Bonn, Germany
| | - Nils Sommer
- Department of Surgery, University Hospital Bonn, Campus 1, 53127, Bonn, Germany
| | - Franziska Koch
- Department of General and Abdominal Surgery, Helios Hospital Schwerin, Schwerin, Germany
| | - Jörg-Peter Ritz
- Department of General and Abdominal Surgery, Helios Hospital Schwerin, Schwerin, Germany
| | - Katharina Beyer
- Department of Surgery, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Christoph Reißfelder
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Heidelberg, Germany
| | - Julia Hardt
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Heidelberg, Germany
| | | | - Heinz J Buhr
- German Society of General- and Abdominal Surgeons, Germany, Berlin, Germany
| | - Klaus Emmanuel
- Department of Surgery, University Hospital Salzburg, Salzburg, Austria
| | - Joerg C Kalff
- Department of Surgery, University Hospital Bonn, Campus 1, 53127, Bonn, Germany
| | - Tim O Vilz
- Department of Surgery, University Hospital Bonn, Campus 1, 53127, Bonn, Germany.
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2023; 66:15-40. [PMID: 36515513 PMCID: PMC9746347 DOI: 10.1097/dcr.0000000000002650] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jennifer L. Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Traci L. Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - Benjamin D. Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Joel E. Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel L. Feingold
- Department of Surgery, Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L. Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic
| | - Ian M. Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Surg Endosc 2023; 37:5-30. [PMID: 36515747 PMCID: PMC9839829 DOI: 10.1007/s00464-022-09758-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Abstract
The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.
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Affiliation(s)
- Jennifer L Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Timothy E Miller
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Joel E Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel L Feingold
- Section of Colorectal Surgery, Rutgers University, New Brunswick, NJ, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, USA
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine Surgery (Colon and Rectal), 222 Piedmont #7000, Cincinnati, OH, 45219, USA.
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YAYLA A, ESKİCİ V, AY E, ÖZER N, KURT G. Ameliyat Öncesi ve Sonrası Dönemde Yapılan Uygulamaların ERAS Protokolüne Uygunluğunun Değerlendirilmesi. İSTANBUL GELIŞIM ÜNIVERSITESI SAĞLIK BILIMLERI DERGISI 2022. [DOI: 10.38079/igusabder.980901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Amaç: Bu çalışma, ameliyat öncesi ve sonrası dönemde yapılan uygulamaların ERAS (Enhanced Recovery After Surgery) protokolüne uygunluğunun değerlendirilmesi amacıyla yapılmıştır.Yöntem: Tanımlayıcı-kesitsel nitelikte tasarlanan araştırma, Ocak – Temmuz 2019 tarihleri arasında bir üniversitenin Sağlık Araştırma ve Uygulama Merkezinin cerrahi kliniklerinde yürütülmüştür. Ameliyatı planlanan, çalışmaya katılmayı kabul eden 863 hasta araştırma örneklemini oluşturmuştur. Veriler, araştırmacılar tarafından literatür doğrultusunda hazırlanan anket formu, Vizüel Analog Skala ve Bulantı Sayısal Ölçeği ile yüz yüze görüşme yöntemiyle toplanmıştır. Veriler, SPSS 20.0 paket programında tanımlayıcı istatistikler kullanılarak değerlendirilmiştir.Bulgular: Çalışmadaki hastaların tamamının ameliyat öncesi dönemde oral karbonhidrat almadığı, ameliyat öncesi aç kalma sürelerinin 10,55±6,91 saat olduğu ve hastalara premedikasyon uygulanmadığı belirlenmiştir. Hastaların ameliyat sonrası; ilk sıvı alma zamanı ortalamasının 10,45±15,44 saat, ilk katı gıda alma zamanı ortalamasının 18,70±29,23 saat olduğu, ilk mobilizasyon süresinin 19,02±21,39 saat, nazogastrik sonda kalış süresi ortalamasının 29,33±28,80 saat, drenin kalış süresi ortalamasının 54,30±28,06 saat, üriner kateter kalış süresi ortalamasının 49,51±27,40 saat olduğu saptanmıştır.Sonuç: Çalışma sonucunda ERAS protokollerine uyumun istenilen düzeyde olmadığı ve sağlık çalışanlarına ERAS’la uyumlu olmayan uygulamalarla ilgili eğitim verilmesi önerilebilir.
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12
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Response to the Comment on "Intracorporeal or Extracorporeal Ileocolic Anastomosis After Laparoscopic Right Colectomy: A Double-blinded Randomized Controlled Trial". Ann Surg 2021; 274:e694. [PMID: 32209910 DOI: 10.1097/sla.0000000000003862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Seys D, Coeckelberghs E, Sermeus W, Van Zelm R, Panella M, Babu Payedimarri A, Vanhaecht K. Overview on the target population and methods used in care pathway projects: A narrative review. Int J Clin Pract 2021; 75:e14565. [PMID: 34165865 DOI: 10.1111/ijcp.14565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 06/23/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND There is evidence that the efficiency and effectiveness of care processes can be improved in all countries. Care pathways (CPs) are proposed as a method to improve the quality of care by reducing variation. During the last decades, CPs have been intensively used in practice. The objective of this study is to examine the study designs for investigating CPs, for which pathologies CPs are used and what the reported indicators to measure the impact of CPs are. METHODS A narrative review of the literature published from 2015 to 2019 was performed. RESULTS We identified 286 studies, of which 207 evaluated the impact of CPs, 33 were review articles, 29 studies described the development of a CP, 12 were study protocols and 5 opinion papers. The most frequently reported study design for studying the impact of a CP is pre-posttest (n = 82), followed by cross-sectional studies (n = 50). Oncology, cardiovascular disease and abdominal surgery are the domains with the highest numbers of studies evaluating the impact of CPs. Financial (n = 86), process (n = 76) and clinical indicators (n = 74) are the most frequently reported indicators while service (n = 12) and team indicators (n = 6) are less reported. CONCLUSIONS Based on the relative low number of identified studies compared with the number of CP projects in organisations, we conclude that the CP knowledge is not only found in the literature. We, therefore, argue that (inter)national scientific societies should not only focus on searching and spreading evidence on the content of care but also enhance their knowledge sharing initiatives on the organisation of care processes.
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Affiliation(s)
- Deborah Seys
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Ellen Coeckelberghs
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Walter Sermeus
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Ruben Van Zelm
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Massimiliano Panella
- Department of Translational Medicine, University of Eastern Piedmont Amedeo Avogadro, Novara, Italy
| | - Anil Babu Payedimarri
- Department of Translational Medicine, University of Eastern Piedmont Amedeo Avogadro, Novara, Italy
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
- Department of Quality Management, University Hospitals Leuven, Leuven, Belgium
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Willis MA, Schwenk W, Post S, Nothacker M, Follmann M, Vilz TO. [Background, Necessity and Methodology of the S3 Guideline "Perioperative Management of Gastrointestinal Tumours (POMGAT)"]. Zentralbl Chir 2021; 146:241-248. [PMID: 34154005 DOI: 10.1055/a-1481-9394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Malignancies are among the most common diseases, especially in old age, and are responsible for 25% of all deaths in Germany. Especially carcinomas of the gastrointestinal tract can be cured in most cases only through extensive surgery with significant morbidity. About 25 years ago, the multimodal, perioperative Fast Track (FT) concept for reducing postoperative complications was introduced and additional elements were added in the following years. Meanwhile, there is growing evidence that adherence to the key elements of more than 70% leads to reduction in postoperative adverse events as well as a shorter hospital stay and could be associated with an improved oncological outcome. Despite the high level of awareness and the proven advantages of the FT concept, the implementation and maintenance of the measures is difficult and results in an adherence of only 20 - 40%. There are many reasons for this: In addition to a lack of interdisciplinary and interprofessional cooperation and the time consuming and extended logistical efforts, limited human resources are often listed as one of the main causes. We took these aspects as an opportunity and started to develop a S3 guideline for perioperative treatment to accelerate the recovery of patients with gastrointestinal malignancies. By creating a consensus- and evidence-based, multidisciplinary guideline, many of the problems listed above could probably be solved by optimising and standardising interdisciplinary care, which is particularly important in a setting with many different disciplines and their competing interests. Furthermore, the standardisation of the perioperative procedures will reduce the time and logistical effort. The presentation of the evidence allows increased transparency and justifies the additional personnel expenditure on hospital medicine and health insurance companies. In addition, the evidence-based quality indicators generated during the development of the guideline make it possible to include perioperative standards in certification systems and thus to measure and check the quality of perioperative care.
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Affiliation(s)
- Maria A Willis
- Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Deutschland
| | | | - Stefan Post
- ehemals Chirurgische Klinik, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - Monika Nothacker
- Philipps-Universität Marburg, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V., Marburg, Deutschland
| | - Markus Follmann
- Office des Leitlinienprogrammes Onkologie, Deutsche Krebsgesellschaft e. V., Berlin, Deutschland
| | - Tim O Vilz
- Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Deutschland
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Willis MA, Engel FM, Wiedemann C, van Beekum C, Coburn M, Thudium M, Kalff JC, Vilz TO. [Evaluation of the Effectiveness of a Standard Operating Procedure (SOP) for the Perioperative Management of Colorectal Surgery]. Zentralbl Chir 2021; 146:269-276. [PMID: 33851406 DOI: 10.1055/a-1402-0788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION In recent years, perioperative care of patients after colorectal surgery has been increasingly standardised according to the fast-track concept and is accepted as a structured method of care to reduce perioperative complications. Indeed, initial studies have indicated that there is a long-term favourable effect on the oncological outcome, if the adherence to the individual measures is at least 70%. Even though there is unambiguous evidence for the efficacy of the modern perioperative treatment concept, it is often difficult to comply with the protocol during normal clinical work, particularly in Germany. The objective of this study was to record the rate of compliance before and after the introduction of the SOP and to evaluate its efficacy. METHODS We performed a retrospective analysis of the patient data after all elective colorectal surgery in the Bonn University Hospital from 2017 to 2020. 153 patients were operated on before the implementation of the SOP in January 2019 (group I); the remaining 153 patients were operated on after the implementation of the SOP and received appropriate care (group II). Compliance to the protocol was analysed for both the individual key interventions and the overall concept. RESULTS There was significant improvement in the compliance for both the individual measures (prehabilitation group I: 5.9%, group II: 42.5%, p < 0.001; preparation of the intestine I: 16.5%, II: 73.9%, p < 0.001; intraoperative volume management I: 14,00 ml/kg BW/h, II: 9.12 ml/kg BW/h, p < 0.001, BW: body weight; minimally invasive surgical technique I: 53.6%, II: 73.9%, p < 0.001; etc.) and for the overall perioperative treatment concept (I: 39%, II: 54%, p = 0.02). However, we fell far short of compliance of at least 70%. Nevertheless, patient autonomy was achieved earlier after introduction of the SOP (I: day 15, II: day 9, p < 0.001) and the postoperative hospital stay was shortened (I: 14 [6 - 99] days, II 11 [4 - 64] days; p = 0.007). CONCLUSION Although the implementation of the SOP led to significant improvements, further optimisation is required to attain the recommended protocol compliance of 70%. Measures within the hospital could include foundation of an interdisciplinary fast-track team and a specialised nurse as the connecting link between the patients, nursing and physicians. On the other hand, implementation throughout Germany can only be achieved by more influential actions. One possible support would be the S3 guideline on perioperative management of gastrointestinal tumours, which is under development. This could, for example, be used to support argumentation with funding providers.
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Affiliation(s)
- Maria A Willis
- Klinik- und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Deutschland
| | - Felix M Engel
- Klinik- und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Deutschland
| | - Charlotte Wiedemann
- Klinik- und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Deutschland
| | - Cornelius van Beekum
- Klinik- und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Deutschland
| | - Mark Coburn
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Deutschland
| | - Marcus Thudium
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Deutschland
| | - Jörg C Kalff
- Klinik- und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Deutschland
| | - Tim O Vilz
- Klinik- und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Deutschland
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Byrnes A, Mudge A, Clark D. Implementation science approaches to enhance uptake of complex interventions in surgical settings. AUST HEALTH REV 2021; 44:310-312. [PMID: 30982502 DOI: 10.1071/ah18193] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 01/07/2019] [Indexed: 01/19/2023]
Abstract
Achieving practice change in the complex healthcare environment is difficult. Effective surgical care requires coordination of services across the continuum of care, involving interdisciplinary collaboration across multiple units, with systems and processes that may not connect effectively. Principles of enhanced recovery after surgery (ERAS) are increasingly being incorporated into facility policies and practice, but the literature reports challenges with both initial adherence and mid- to long-term sustainability. Greatest adherence is typically observed for the intraoperative elements, which are within the control of a single discipline, with poorest adherence reported for postoperative processes occurring in the complex ward environment. Using ERAS as an example, this perspective piece describes the challenges associated with implementation of complex interventions in the surgical setting, highlighting the value that implementation science approaches can bring to practice change initiatives and providing recommendations as to suggested course of action for effective implementation.
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Affiliation(s)
- Angela Byrnes
- School of Human Movement and Nutrition Sciences, The University of Queensland, St Lucia, Qld 4067, Australia; and Nutrition and Dietetics, Royal Brisbane and Women's Hospital, Herston, Qld 4029, Australia; and Corresponding author.
| | - Alison Mudge
- Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Qld 4029, Australia. ; and Institute for Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Qld 4006, Australia; and Faculty of Medicine, The University of Queensland, St Lucia, Qld 4067, Australia
| | - David Clark
- Faculty of Medicine, The University of Queensland, St Lucia, Qld 4067, Australia; and Surgical and Perioperative Services, Royal Brisbane and Women's Hospital, Herston, Qld 4029, Australia
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van Zelm R, Coeckelberghs E, Sermeus W, Wolthuis A, Bruyneel L, Panella M, Vanhaecht K. A mixed methods multiple case study to evaluate the implementation of a care pathway for colorectal cancer surgery using extended normalization process theory. BMC Health Serv Res 2021; 21:11. [PMID: 33397382 PMCID: PMC7784254 DOI: 10.1186/s12913-020-06011-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 12/10/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Specific factors that facilitate or prevent the implementation of enhanced recovery protocols for colorectal cancer surgery have been described in previous qualitative studies. This study aims to perform a concurrent qualitative and quantitative evaluation of factors associated with successful implementation of a care pathway (CP) for patients undergoing surgery for colorectal cancer. METHODS This comparative mixed methods multiple case study was based on a sample of 10 hospitals in 4 European countries that implemented a specific CP and performed pre- and post-implementation measurements. In-depth post-implementation interviews were conducted with healthcare professionals who were directly involved. Primary outcomes included protocol adherence and improvement rate. Secondary outcomes included length of stay (LOS) and self-rated protocol adherence. The hospitals were ranked based on these quantitative findings, and those with the highest and lowest scores were included in this study. Qualitative data were summarized on a per-case basis using extended Normalization Process Theory (eNPT) as theoretical framework. The data were then combined and analyzed using joint display methodology. RESULTS Data from 381 patients and 30 healthcare professionals were included. Mean protocol adherence rate increased from 56 to 62% and mean LOS decreased by 2.1 days. Both measures varied greatly between hospitals. The two highest-ranking hospitals and the three lowest-ranking hospitals were included as cases. Factors which could explain the differences in pre- and post-implementation performance included the degree to which the CP was integrated into daily practice, the level of experience and support for CP methodology provided to the improvement team, the intrinsic motivation of the team, shared goals and the degree of management support, alignment of CP development and hospital strategy, and participation of relevant disciplines, most notably, physicians. CONCLUSIONS Overall improvement was achieved but was highly variable among the 5 hospitals evaluated. Specific factors involved in the implementation process that may be contributing to these differences were conceptualized using eNPT. Multidisciplinary teams intending to implement a CP should invest in shared goals and teamwork and focus on integration of the CP into daily processes. Support from hospital management directed specifically at quality improvement including audit may likewise facilitate the implementation process. TRIAL REGISTRATION NCT02965794 . US National Library of Medicine, ClinicalTrials.gov . Registered 4 August 2014.
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Affiliation(s)
- R van Zelm
- Leuven Institute for Healthcare Policy, Katholieke Universiteit Leuven, Leuven, Belgium.
| | - E Coeckelberghs
- Leuven Institute for Healthcare Policy, Katholieke Universiteit Leuven, Leuven, Belgium
| | - W Sermeus
- Depertment of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - A Wolthuis
- Depertment of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - L Bruyneel
- Leuven Institute for Healthcare Policy, Katholieke Universiteit Leuven, Leuven, Belgium
| | - M Panella
- Department of Translational Medicine, University of Eastern Piemonte (UPO), Novarra, Italy
| | - K Vanhaecht
- Leuven Institute for Healthcare Policy, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Quality, Academic Policy Advisor, University Hospital Leuven, Leuven, Belgium
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Palese A, Navone E, Danielis M, Vryonides S, Sermeus W, Papastavrou E. Measurement tools used to assess unfinished nursing care: A systematic review of psychometric properties. J Adv Nurs 2020; 77:565-582. [PMID: 33074561 DOI: 10.1111/jan.14603] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 08/17/2020] [Accepted: 09/07/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Different tools have been developed and validated to measure unfinished nursing care. However, no systematic review of the psychometric properties has been performed describing the quality of the methods used to estimate their validity. AIMS (a) To identify tools measuring unfinished nursing care that have undergone validation processes; (b) to evaluate critically the quality of the methods used in ascertaining their psychometric properties; and (c) to compare the estimated psychometric properties of these tools. DESIGN A systematic review of the psychometric properties also evaluating their methodological quality was performed by following the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guideline for systematic reviews. DATA SOURCES The databases Medline, the Cumulative Index to Nursing and Allied Health Literature, PubMed, Google and Google Scholar were searched up to 30 June 2018. REVIEW METHODS Data extraction was performed following the predetermined eligibility criteria. Eight properties and their methodological quality were assessed using the COnsensus-based Standards for the selection of health Measurement INstruments criteria. RESULTS A total of 20 studies reported validation data regarding three family of tools: the Missed Care Survey (MISSCARE), the Basal Extent of Rationing of Nursing Care (BERNCA) and the Task Undone scale (TU-7). The most estimated psychometric properties across studies were internal consistency, followed by structural validity, content validity, and cross-cultural validity. The less evaluated psychometric properties were reliability, hypothesis testing and convergent and criterion validity. CONCLUSION The psychometric properties of the investigated tools showed a more than acceptable quality, as did the methodologies used to estimate these properties. IMPACT The MISSCARE survey is the most widely used tool validated across countries to date. Evaluating the concurrent reliability of the tools available is strongly recommended to assess their effectiveness in measuring the same phenomenon.
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Affiliation(s)
- Alvisa Palese
- Department of Medical Sciences, School of Nursing, Udine University, Udine, Italy
| | - Elena Navone
- Department of Medical Sciences, School of Nursing, Udine University, Udine, Italy
| | - Matteo Danielis
- Department of Medical Sciences, School of Nursing, Udine University, Udine, Italy
| | - Stavros Vryonides
- Department of Nursing, Cyprus University of Technology, Limassol, Cyprus
| | - Walter Sermeus
- KU Leuven Institute for Healthcare Policy, Leuven, Belgium
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Mendivelso Duarte F, Barrios Parra AJ, Zárate-López E, Navas-Camacho ÁM, Álvarez AO, Mc Loughlin S, Gabriela Renee Mendoza GR, Enciso-Pérez6 D, Rodríguez-Barajas R, Jiménez-Chávez MS, Ramírez J, Faber F, Solla G, Viola-Malet M, Rodríguez-Bedoya M. Asociación entre desenlaces clínicos y cumplimiento del protocolo de recuperación mejorada después de la cirugía (ERAS) en procedimientos colorrectales: estudio multicéntrico. REVISTA COLOMBIANA DE CIRUGÍA 2020. [DOI: 10.30944/20117582.662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Introducción. Los protocolos de recuperación mejorada después de cirugía se han diseñado como una innovación en salud tras demostrarse que la mejora en los dispositivos médicos y la depuración de técnicas alcanzaron la meseta en disminución de complicaciones. Con estas estrategias de la medicina perioperatoria, en cirugía colorrectal se reducen la morbilidad y estancia hospitalaria. El objetivo del estudio fue evaluar si la tasa de adherencia al programa de recuperación mejorada después de la cirugía (ERAS) está asociada con los resultados quirúrgicos.
Métodos. Estudio multicéntrico, observacional, retrospectivo de cohorte (2015-2019), en cinco hospitales latinoamericanos certificados por la sociedad ERAS. Se calculó la incidencia de complicaciones quirúrgicas durante el posquirúrgico inmediato (30 días) y la duración de la estancia hospitalaria. Se utilizaron análisis bivariado y regresión logística multivariada para evaluar los factores asociados con la tasa de complicaciones.
Resultados. Fueron incluidos en el estudio 648 pacientes en cinco hospitales ERAS, con edad promedio de 61 años y mayor porcentaje de hombres (51 %). El cumplimiento global al protocolo ERAS fue de 75 % y la estancia promedio de 6,2 días (mediana: 4 días). Se tuvo un cumplimiento óptimo del protocolo ERAS (igual o mayor al 80 %) en 23,6 % de los pacientes. Se documentó fuga de la anastomosis en 4 %, complicaciones infecciosas en 8,4 %, íleo en 5,7 %, reingreso en 10,2 % y mortalidad de 1,1 %. El análisis multivariado mostró que los niveles de adherencia óptima al protocolo ERAS reducen significativamente la aparición de complicaciones como fuga de la anastomosis (OR 0,08; IC95% 0,01-0,48; p=0,005) y complicaciones infecciosas (OR 0,17; IC95% 0,03-0,76; p=0,046).
Discusión. Los resultados sugieren que un cumplimiento del programa ERAS mayor al 80 % se asocia a menor frecuencia de complicaciones en pacientes con cirugía electiva colorrectal.
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Veziant J, Poirot K, Mulliez A, Pereira B, Slim K. Is an enhanced recovery program (ERP) after rectal surgery as feasible as after colonic surgery? A multicentre Francophone study of 870 rectal resections. Langenbecks Arch Surg 2020; 405:1155-1162. [PMID: 33057822 DOI: 10.1007/s00423-020-02001-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/23/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Enhanced recovery program (ERP) is well-established in colorectal surgery. Rectal surgery (RS) is known to be associated with high morbidity and prolonged hospital stay, which might explain why ERPs are less applied in this specific group of patients. The aim of this large-scale study was to assess the feasibility of an ERP in RS compared with colonic surgery. METHODS This study was a retrospective analysis of a prospective database including 3740 patients eligible for colorectal resection from February 2014 to January 2017 in 75 European Francophone centres. Patients were divided into two groups (colon group C vs. rectum group R). The main endpoint was compliance with ERP components. A subgroup analysis was performed in patients for whom a defunctioning stoma (DS) was required after RS. RESULTS A total of 3740 patients were included. There were 2870 patients in group C and 870 patients in group R. The overall compliance rate for ERPs was 81.71% in group C and 79.09% in group R. Patients were significantly less mobilized within 24 h in group R. Specific recommendations for RS concerning bowel preparation and abdominal drainage were significantly less implemented. Overall morbidity was significantly higher in group R. Mean length of stay (LOS) was significantly shorter in group C. In the sub-group analysis, a DS was significantly associated with fewer compliance with early mobilization and early feeding, leading to significantly longer LOS (group R). CONCLUSION ERP is safe and effective in RS, despite the well-known higher morbidity and LOS compared with colonic surgery. DS could be a limiting factor in ERP implementation after RS.
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Affiliation(s)
- J Veziant
- Department of Digestive and Hepatobiliary Surgery, University Hospital, Clermont-Ferrand, France.
| | - K Poirot
- Department of Digestive and Hepatobiliary Surgery, University Hospital, Clermont-Ferrand, France
| | - A Mulliez
- Biostatistics Unit, Department of Clinical Research and Innovation (DRCI), University Hospital, Clermont Ferrand, France
| | - B Pereira
- Biostatistics Unit, Department of Clinical Research and Innovation (DRCI), University Hospital, Clermont Ferrand, France
| | - K Slim
- Department of Digestive and Hepatobiliary Surgery, University Hospital, Clermont-Ferrand, France
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Eng OS, Blakely AM, Lafaro KJ, Fournier KF, Fackche NT, Johnston FM, Dineen S, Powers B, Hendrix R, Lambert LA, Ronnekleiv-Kelly S, Walle KV, Grotz TE, Leiting JL, Patel SH, Dhar VK, Baumgartner JM, Lowy AM, Clarke CN, Mogal H, Zaidi MY, Staley CA, Kimbrough C, Cloyd JM, Lee B, Raoof M. Institutional variation in recovery after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: An opportunity for enhanced recovery pathways. J Surg Oncol 2020; 122:980-985. [PMID: 32627199 DOI: 10.1002/jso.26099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 06/23/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Variations in care have been demonstrated both within and among institutions in many clinical settings. By standardizing perioperative practices, Enhanced Recovery After Surgery (ERAS) pathways reduce variation in perioperative care. We sought to characterize the variation in cytoreductive surgery (CRS)/heated intraperitoneal chemotherapy (HIPEC) perioperative practices among experienced US medical centers. METHODS Data from the US HIPEC Collaborative represents a retrospective multi-institutional cohort study of CRS and CRS/HIPEC procedures performed from 12 major academic institutions. Patient characteristics and perioperative practices were reported and compared. Institutional variation was analyzed using hierarchical mixed-effects linear (continuous outcomes) or logistic (binary outcomes) regression models. RESULTS A total of 2372 operations were included. CRS/HIPEC was performed most commonly for appendiceal histologies (64.2%). The rate of complications (overall 56.3%, range: 31.8-70.9) and readmissions (overall 20.6%, range: 8.9-33.3) varied by institution (P < .001). Institution-level variation in perioperative practice patterns existed among measured ERAS pathway process/outcomes (P < .001). The percentages of variation with each process/outcome measure attributable solely to institutional practices ranged from 0.6% to 66.6%. CONCLUSIONS Significant variation exists in the perioperative care of patients undergoing CRS/HIPEC at major US academic institutions. These findings provide a strong rationale for the investigation of best practices in CRS/HIPEC patients.
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Affiliation(s)
- Oliver S Eng
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Andrew M Blakely
- Department of Surgery, National Cancer Institute, Bethesda, Maryland
| | - Kelly J Lafaro
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Keith F Fournier
- Department of Surgery, MD Anderson Cancer Center, Houston, Texas
| | - Nadege T Fackche
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Sean Dineen
- Department of Surgery, Moffitt Cancer Center, Tampa, Florida
| | - Benjamin Powers
- Department of Surgery, Moffitt Cancer Center, Tampa, Florida
| | - Ryan Hendrix
- Department of Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Laura A Lambert
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | | | - Kara Vande Walle
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Travis E Grotz
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Sameer H Patel
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Vikrom K Dhar
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Joel M Baumgartner
- Department of Surgery, University of California at San Diego, San Diego, California
| | - Andrew M Lowy
- Department of Surgery, University of California at San Diego, San Diego, California
| | - Callisia N Clarke
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Harveshp Mogal
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | | | | | - Jordan M Cloyd
- Department of Surgery, Ohio State University, Columbus, Ohio
| | - Byrne Lee
- Department of Surgery, Stanford University, Palo Alto, California
| | - Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, California
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Cao LX, Chen ZQ, Jiang Z, Chen QC, Fan XH, Xia SJ, Lin JX, Gan HC, Wang T, Huang YX. Rapid rehabilitation technique with integrated traditional Chinese and Western medicine promotes postoperative gastrointestinal function recovery. World J Gastroenterol 2020; 26:3271-3282. [PMID: 32684741 PMCID: PMC7336322 DOI: 10.3748/wjg.v26.i23.3271] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/09/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND During the perioperative period, the characteristic therapy of traditional Chinese medicine is effective in improving postoperative rehabilitation. In large-scale hospitals practicing traditional Chinese medicine, there is accumulating experience related to the promotion of fast recovery in the perioperative period.
AIM To evaluate the efficacy and safety of Yikou-Sizi powder hot compress on Shenque acupuncture point combined with rapid rehabilitation technique.
METHODS This prospective, multicenter, randomized, controlled study included two groups: Treatment group and control group. The patients in the treatment group and control group received Yikou-Sizi powder hot compress on Shenque acupuncture point combined with rapid rehabilitation technique and routine treatment, respectively. Clinical observation regarding postoperative recovery of gastrointestinal function was performed, including the times to first passage of flatus, first defecation, and first normal bowel sounds. The comparison between groups was conducted through descriptive analysis, χ2, t, F, and rank-sum tests.
RESULTS There was a statistically significant difference in the time to postoperative first defecation between the treatment and control group (87.16 ± 32.09 vs 109.79 ± 40.25 h, respectively; P < 0.05). Similarly, the time to initial recovery of bowel sounds in the treatment group was significantly shorter than that in the control group (61.17 ± 26.75 vs 79.19 ± 33.35 h, respectively; P < 0.05). However, there was no statistically significant difference in the time to initial exhaust between the treatment and control groups (51.54 ± 23.66 vs 62.24 ± 25.95 h, respectively; P > 0.05). The hospitalization expenses for the two groups of patients were 62283.45 ± 12413.90 and 62059.42 ± 11350.51 yuan, respectively. Although the cost of hospitalization was decreased in the control group, the difference was not statistically significant (P > 0.05). This clinical trial was safe without reports of any adverse reaction or event.
CONCLUSION The rapid rehabilitation technique with integrated traditional Chinese and Western medicine promotes the recovery of postoperative gastrointestinal function and is significantly better than standard approach for patients after colorectal surgery.
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Affiliation(s)
- Li-Xing Cao
- Perioperative Research Team, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510000, Guangdong Province, China
| | - Zhi-Qiang Chen
- Perioperative Research Team, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510000, Guangdong Province, China
| | - Zhi Jiang
- Perioperative Research Team, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510000, Guangdong Province, China
| | - Qi-Cheng Chen
- Perioperative Research Team, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510000, Guangdong Province, China
| | - Xiao-Hua Fan
- Perioperative Research Team, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510000, Guangdong Province, China
| | - Shi-Jun Xia
- Perioperative Research Team, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510000, Guangdong Province, China
| | - Jin-Xuan Lin
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou 510000, Guangdong province, China
| | - Hua-Chan Gan
- Perioperative Research Team, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510000, Guangdong Province, China
| | - Tao Wang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou 510000, Guangdong province, China
| | - Yang-Xue Huang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou 510000, Guangdong province, China
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Fagard K, Wolthuis A, Verhaegen M, Flamaing J, Deschodt M. A retrospective observational study of enhanced recovery after surgery in older patients undergoing elective colorectal surgery. PLoS One 2020; 15:e0232857. [PMID: 32384120 PMCID: PMC7209103 DOI: 10.1371/journal.pone.0232857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/22/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Enhanced recovery programs (ERPs) in colorectal surgery have demonstrated beneficial effects on postoperative complications, return of bowel function, length of stay, and costs, without increasing readmissions or mortality. However, ERPs were not specifically designed for older patients and feasibility in older patients has been questioned. AIM The aim of this study was to assess ERP adherence and outcomes in older patients and to identify risk factors for postoperative complications and prolonged length of stay. METHOD Retrospective analysis of consecutive patients (≥70 years) undergoing elective colorectal resection in a tertiary referral hospital in 2017. RESULTS Ninety-six patients were included. Adherence rates were above 80% in 18 of 21 ERP interventions considered. The lowest adherence rates were noted for preoperative carbohydrate loading and cessation of intravenous fluids. Postoperative complications (Clavien-Dindo ≥2) and prolonged postoperative length of stay (>75th percentile) were observed in 39.6% and 26.3%, respectively. Median length of stay was 7 days. The 30-day mortality, readmission and reoperation rates were 2.1%, 12.6% and 8.3%, respectively. Multivariable analysis indicated that polypharmacy and site of surgery were independent risk factors for postoperative complications, while higher age, American Society of Anesthesiologists class and preoperative radiotherapy were independent risk factors for prolonged postoperative length of stay. CONCLUSION ERP adherence in older patients undergoing colorectal resection is high and ERP is therefore considered feasible. Postoperative complications and prolonged postoperative length of stay are common, so at risk patients should be targeted with tailored geriatric interventions.
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Affiliation(s)
- Katleen Fagard
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Albert Wolthuis
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Marleen Verhaegen
- Department of Anesthesia, University Hospitals Leuven, Leuven, Belgium
| | - Johan Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Division of Gerontology and Geriatrics, Department of Public Health & Primary Care, KU Leuven, Leuven, Belgium
| | - Mieke Deschodt
- Division of Gerontology and Geriatrics, Department of Public Health & Primary Care, KU Leuven, Leuven, Belgium
- Department of Public Health, Institute of Nursing Science, University of Basel, Basel, Switzerland
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Intracorporeal or Extracorporeal Ileocolic Anastomosis After Laparoscopic Right Colectomy: A Double-blinded Randomized Controlled Trial. Ann Surg 2020; 270:762-767. [PMID: 31592811 DOI: 10.1097/sla.0000000000003519] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The aim of the study was to determine whether there are clinically relevant differences in outcomes between laparoscopic right colectomy (LRC) with intracorporeal ileocolic anastomosis (IIA) and LRC with extracorporeal IA (EIA). BACKGROUND IIA and EIA are 2 well-established techniques for restoration of bowel continuity after LRC. There are no high-quality studies demonstrating the superiority of one anastomotic technique over the other. METHODS This is a double-blinded randomized controlled trial comparing the outcomes of LRC with IIA and LRC with EIA in patients with a benign or malignant right-sided colon neoplasm. Primary endpoint was length of hospital stay (LOS). This trial was registered with ClinicalTrials.gov, number NCT03045107. RESULTS A total of 140 patients were randomized and analyzed. Median operative time was comparable in IIA versus EIA group {130 [interquartile range (IQR) 105-195] vs 130 (IQR 110-180) min; P = 0.770} and no intraoperative complications occurred. The quicker recovery of bowel function after IIA than EIA [gas: 2 (IQR 2-3) vs 3 (IQR 2-3) days, P = 0.003; stool: 4 (IQR 3-5) vs 4.5 (IQR 3-5) days, P = 0.032] was not reflected in any advantage in the primary endpoint: median LOS was similar in the 2 groups [6 (IQR 5-7) vs 6 (IQR 5-8) days; P = 0.839]. No significant differences were observed in the number of lymph nodes harvested, length of skin incision, 30-day morbidity (17.1% vs 15.7%, P = 0.823), reoperation rate, and readmission rate between the 2 groups. CONCLUSIONS LRC with IIA is associated with earlier recovery of postoperative bowel function than LRC with EIA; however, it does not reflect into a shorter LOS.
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Pelsser L, Frankena K, Toorman J, Rodrigues Pereira R. Retrospective Outcome Monitoring of ADHD and Nutrition (ROMAN): The Effectiveness of the Few-Foods Diet in General Practice. Front Psychiatry 2020; 11:96. [PMID: 32226397 PMCID: PMC7081264 DOI: 10.3389/fpsyt.2020.00096] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/06/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Double-blind placebo-controlled studies investigating the effect of a few-foods diet (FFD) on attention-deficit/hyperactivity disorder (ADHD) have provided consistent evidence that ADHD can be triggered by foods, indicating the existence of a food-induced ADHD subtype. In 2001 the "few-foods" approach was included in an ADHD treatment protocol. This approach consists of (a) determining, by means of an FFD, whether food is a trigger of ADHD; (b) reintroducing, in FFD responders, foods to assess which foods are incriminated; (c) finally composing a personalised diet eliminating the involved foods only. In the Netherlands the few-foods approach is applied in practice. We aimed to retrospectively assess its effectiveness on ADHD and oppositional defiant disorder (ODD) in real life. METHODS Data from all children who started the few-foods approach in three specialised healthcare facilities during three consecutive months were included. Behavior was assessed at start and end of the 5-week FFD, using the ADHD Rating Scale and a structured psychiatric interview. Clinical responders (behavioral improvements ≥40%) proceeded with the reintroduction phase. RESULTS Data of 57 children, 27 taking medication and 15 following some elimination diet at start, were available. No differences were noted between parental scores of children with and without medication or some elimination diet at start. 21/27 (78%) children stopped taking medication during the FFD. 34/57 (60%) children were ADHD responders, 20/29 (65%) children meeting ODD criteria were ODD responders. 26/34 (76%) ADHD responders started the reintroduction phase; 14/26 (54%) still participated at six months. Teacher data were available of 18/57 (32%) children. 9/18 (50%) children were ADHD responders. CONCLUSION The FFD, if applied by trained specialists, may lead to clinically relevant reduction of ADHD and ODD symptoms in general practice, and a concomitant decrease of ADHD medication. These results corroborate the existence of an ADHD subgroup with food-induced ADHD. Defining and eliminating the incriminated foods, i.e. the underlying causal triggers, may result in secondary prevention of food-induced ADHD. Research into underlying mechanism(s) is of vital importance: finding an easier method or biomarkers for diagnosing food-induced ADHD and ascertaining the incriminated foods may lead to redundancy of the few-foods approach.
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Affiliation(s)
| | - Klaas Frankena
- Adaptation Physiology group, Wageningen University & Research, Wageningen, Netherlands
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Rodrigues Pessoa R, Urkmez A, Kukreja N, Baack Kukreja J. Enhanced recovery after surgery review and urology applications in 2020. BJUI COMPASS 2020; 1:5-14. [PMID: 35474909 PMCID: PMC8988792 DOI: 10.1002/bco2.9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 01/28/2020] [Accepted: 01/28/2020] [Indexed: 02/01/2023] Open
Abstract
Purpose: To explore enhanced recovery after surgery (ERAS) components and their current application to major urologic surgeries, barriers to implementation and maintenance of the associated quality improvement. Data Identification: An English language literature search was done using PubMed. Study Selection: After independent review, 55 of the original 214 articles were selected to specifically address the stated purpose. Data Extraction: Clinical trials were included, randomized trials were prioritized, but robust observational studies were also included. Results of Data Synthesis: Many ERAS components have good data to support usage in radical cystectomy (RC) patients. Most ERAS programs include multidisciplinary teams carrying out multimodal pathways to hasten recovery after a major operation. ERAS components generally include preoperative counseling and medical optimization, venous thromboembolism prophylaxis, ileus prevention, avoidance of fluid overload, normothermia maintenance, early mobilization, pain control and early feeding, all leading to early discharge without increased complications or readmissions. Although there may not be specific data pertaining to other major urologic operations, the principles remain similar and ERAS is easily applicable. Conclusion: The benefits of ERAS programs are well established for RC and principles are easily applicable to other major urology operations. Barriers to implantation and maintenance of ERAS must be recognized to continue to maintain the benefits of these programs.
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Affiliation(s)
| | - Ahmet Urkmez
- Department of Urology University of Texas MD Anderson Cancer Center Houston TX USA
| | - Naveen Kukreja
- Department of Anesthesia University of Colorado Aurora CO USA
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Minimizing the impact of colorectal surgery in the older patient: The role of enhanced recovery programs in older patients. Eur J Surg Oncol 2020; 46:338-343. [DOI: 10.1016/j.ejso.2019.12.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 09/04/2019] [Accepted: 12/19/2019] [Indexed: 02/07/2023] Open
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van Zelm R, Coeckelberghs E, Sermeus W, Wolthuis A, Bruyneel L, Panella M, Vanhaecht K. Effects of implementing a care pathway for colorectal cancer surgery in ten European hospitals: an international multicenter pre-post-test study. Updates Surg 2020; 72:61-71. [PMID: 31993994 DOI: 10.1007/s13304-020-00706-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 01/15/2020] [Indexed: 01/28/2023]
Abstract
Adherence to evidence-based recommendations is variable and generally low. This is also followed in colorectal surgery, despite the availability of the ERAS® protocol. The aim of the study was to evaluate the effect of implementing a care pathway for perioperative care in colorectal cancer surgery on outcomes and protocol adherence. So, we performed an international pre-test-post-test multicenter study, performed in ten hospitals in four European countries. The measures used included length of stay, morbidity and mortality, and documentation and adherence on intervention and patient level. Unadjusted pre-test-post-test differences were analyzed following an analysis adjusted for patient-mix variables. Importance-performance analysis was used to map the relationship between importance and performance of individual interventions. In total, 381 patients were included. Length of stay decreased from 12.6 to 10.7 days (p = 0.0230). Time to normal diet and walking also decreased significantly. Protocol adherence improved from 56 to 62% (p < 0.00001). Adherence to individual interventions remained highly variable. Importance-performance analysis showed 30 interventions were scored as important, of which 19 had an adherence < 70%, showing priorities for improvement. Across hospitals, change in protocol adherence ranged from a 13% decrease to a 22% increase. Implementing a care pathway for colorectal cancer surgery reduced length of stay, time to normal diet and walking. Documentation and protocol adherence improved after implementing the care pathway. However, not in all participating hospitals protocol adherence improved. Only in 25% of patients, protocol adherence of ≥ 70% was achieved, suggesting a large group is at risk for underuse. Importance-performance analysis showed which interventions are important, but have low adherence, prioritizing improvement efforts.
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Affiliation(s)
- Ruben van Zelm
- Leuven Institute for Healthcare Policy, KU Leuven, Kapucijnenvoer 35/3, 3000, Louvain, Belgium. .,European Pathway Association, Louvain, Belgium.
| | - Ellen Coeckelberghs
- Leuven Institute for Healthcare Policy, KU Leuven, Kapucijnenvoer 35/3, 3000, Louvain, Belgium
| | - Walter Sermeus
- Leuven Institute for Healthcare Policy, KU Leuven, Kapucijnenvoer 35/3, 3000, Louvain, Belgium.,European Pathway Association, Louvain, Belgium
| | - Albert Wolthuis
- Department of Abdominal Surgery, University Hospital Leuven, KU Leuven, Louvain, Belgium
| | - Luk Bruyneel
- Leuven Institute for Healthcare Policy, KU Leuven, Kapucijnenvoer 35/3, 3000, Louvain, Belgium.,University Hospitals Leuven, Louvain, Belgium
| | - Massimiliano Panella
- European Pathway Association, Louvain, Belgium.,Department of Translational Medicine, University of Eastern Piemonte (UPO), Novarra, Italy
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, KU Leuven, Kapucijnenvoer 35/3, 3000, Louvain, Belgium.,European Pathway Association, Louvain, Belgium.,Department of Quality, University Hospital Leuven, Louvain, Belgium
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Weimann A. Is there a rationale for perioperative nutrition therapy in the times of ERAS? Innov Surg Sci 2019; 4:152-157. [PMID: 33977125 PMCID: PMC8059352 DOI: 10.1515/iss-2019-0012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 09/16/2019] [Indexed: 12/13/2022] Open
Abstract
In order to increase patient compliance in Enhanced Recovery after Surgery (ERAS) programs, assessment and monitoring of functional and nutritional status should be routinely performed. Sarcopenic obesity is frequently underestimated and has been shown to be a significant risk factor for the development of postoperative complications. With special regard to gastrointestinal cancer patients undergoing neoadjuvant treatment, nutritional deficiencies may develop stepwise and increase during therapy. In the case of proven deficits, recent strategies including "prehabilitation" focus on making the patient fit for an ERAS program. Evidence-based guidelines for perioperative nutrition therapy have been available.
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Affiliation(s)
- Arved Weimann
- Klinik für Allgemein-, Viszeral- und Onkologische Chirurgie mit Abteilung Klinische Ernährung, Klinikum St. Georg gGmbH Leipzig, Delitzscher Str. 141, 04129 Leipzig, Germany
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Téoule P, Römling L, Schwarzbach M, Birgin E, Rückert F, Wilhelm TJ, Niedergethmann M, Post S, Rahbari NN, Reißfelder C, Ronellenfitsch U. Clinical Pathways For Pancreatic Surgery: Are They A Suitable Instrument For Process Standardization To Improve Process And Outcome Quality Of Patients Undergoing Distal And Total Pancreatectomy? - A Retrospective Cohort Study. Ther Clin Risk Manag 2019; 15:1141-1152. [PMID: 31632041 PMCID: PMC6778449 DOI: 10.2147/tcrm.s215373] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 09/09/2019] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Pancreatic surgery demands complex multidisciplinary management, which is often cumbersome to implement. Clinical pathways (CPs) are a tool to facilitate this task, but evidence for their utility in pancreatic surgery is scarce. This study evaluated if CPs are a suitable tool for process standardization in order to improve process and outcome quality in patients undergoing distal and total pancreatectomy. PATIENTS AND METHODS Data of consecutive patients who underwent distal or total pancreatectomy before (n=67) or after (n=61) CP introduction were evaluated regarding catheter management, postoperative mobilization, pancreatic enzyme substitution, resumption of diet and length of stay. Outcome quality was assessed using glycaemia management, morbidity, mortality, reoperation and readmission rates. RESULTS The usage of incentive spirometers for pneumonia prophylaxis increased. The median number of days with hyperglycemia decreased significantly from 2.5 to 0. For distal pancreatectomy, the incidence of postoperative diabetes dropped from 27.9% to 7.1% (p=0.012). The incidence of postoperative exocrine pancreatic insufficiency decreased from 37.2% to 11.9% (p=0.007). There was no significant difference in mortality, morbidity, reoperation and readmission rates between groups. CONCLUSION Following implementation of a pancreatic surgery CP, several indicators of process and outcome quality improved, while others such as mortality and reoperation rates remained unchanged. CPs are a promising tool to improve quality of care in pancreatic surgery.
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Affiliation(s)
- Patrick Téoule
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim68167, Germany
| | - Laura Römling
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim68167, Germany
| | - Matthias Schwarzbach
- Department of General, Visceral, Vascular, and Thoracic Surgery, Klinikum Frankfurt Höchst, Frankfurt65929, Germany
| | - Emrullah Birgin
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim68167, Germany
| | - Felix Rückert
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim68167, Germany
| | - Torsten J Wilhelm
- Department of General and Visceral Surgery, GRN-Klinik Weinheim, Weinheim69469, Germany
| | | | - Stefan Post
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim68167, Germany
| | - Nuh N Rahbari
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim68167, Germany
| | - Christoph Reißfelder
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim68167, Germany
| | - Ulrich Ronellenfitsch
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle, Halle, Germany
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van Beekum C, Stoffels B, von Websky M, Ritz JP, Stinner B, Post S, Schwenk W, Kalff JC, Vilz TO. Implementierung eines Fast-Track-Programmes. Chirurg 2019; 91:143-149. [DOI: 10.1007/s00104-019-1009-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Fagard K, Wolthuis A, D'Hoore A, Verhaegen M, Tournoy J, Flamaing J, Deschodt M. A systematic review of the intervention components, adherence and outcomes of enhanced recovery programmes in older patients undergoing elective colorectal surgery. BMC Geriatr 2019; 19:157. [PMID: 31170933 PMCID: PMC6555702 DOI: 10.1186/s12877-019-1158-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 05/13/2019] [Indexed: 12/20/2022] Open
Abstract
Background Enhanced recovery programmes (ERPs) aim to attenuate the surgical stress response and accelerate recovery after surgery, but are not specifically designed for older patients. The objective of this study was to review the components, adherence and outcomes of ERPs in older patients (≥65 years) undergoing elective colorectal surgery. Methods Pubmed, Embase and Cinahl were searched between 2000 and 2017 for randomised and non-randomised controlled trials, before-after studies, and observational studies. The methodological quality of the studies was evaluated using the MINORS quality assessment. The review was performed and reported according to the PRISMA guidelines. Results Twenty-one studies, including 3495 ERP patients aged ≥65 years, were identified. The ERPs consisted of a median of 13 intervention components. Adherence rates were reported in 9 studies and were the highest (≥80%) for pre-admission counselling, no bowel preparation, limited pre-operative fasting, antithrombotic and antimicrobial prophylaxis, no nasogastric tube, active warming, and limited intra-operative fluids. The median post-operative length of stay was 6 days. The median post-operative morbidity rate (Clavien-Dindo I-IV) was 23.5% in-hospital and 29.8% at 30 days. The in-hospital post-operative mortality rate was 0% in most studies and amounted to a median of 1.4% at 30 days. The median 30-day readmission rate was 4.9% and the median reoperation rate was 5.0%. Conclusions ERPs in older patients were in accordance with the ERP consensus guidelines. Although the number of intervention components applied increased over time, outcomes in earlier and later studies remained comparable. Adherence rates were under-reported. Future studies should explore adherence and age-related factors, such as frailty profile, that could influence adherence. Trial registration PROSPERO 2018 CRD42018084756. Electronic supplementary material The online version of this article (10.1186/s12877-019-1158-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katleen Fagard
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.
| | - Albert Wolthuis
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Abdominal Surgical Oncology, KU Leuven, Leuven, Belgium
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Abdominal Surgical Oncology, KU Leuven, Leuven, Belgium
| | - Marleen Verhaegen
- Department of Anaesthesia, University Hospitals Leuven, Leuven, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium
| | - Johan Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium
| | - Mieke Deschodt
- Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium.,Institute of Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
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Seys D, Panella M, VanZelm R, Sermeus W, Aeyels D, Bruyneel L, Coeckelberghs E, Vanhaecht K. Care pathways are complex interventions in complex systems: New European Pathway Association framework. INTERNATIONAL JOURNAL OF CARE COORDINATION 2019. [DOI: 10.1177/2053434519839195] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Care pathway implementation is characterised by a dual complexity. A care pathway itself represents a complex intervention with multiple interacting and interdependent intervention components and outcomes. The organisations in which care pathways are being implemented represent complex systems that need to be directed at change through an in-depth understanding of their external and internal context in which they are functioning in. This study sets out a new evidence-based and pragmatic framework that unpacks how intervention mechanisms, intervention fidelity and care context are converge and represent interacting processes that determine success or failure of the care pathway. We recommend researchers looking to increase the effectiveness of care pathway implementation and accelerate improvement of desired outcomes to adopt this framework from inception to implementation of the intervention.
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Affiliation(s)
- D Seys
- KU Leuven – University of Leuven, Belgium
| | - M Panella
- KU Leuven – University of Leuven, Belgium
- University of Eastern Piedmont ‘A. Avogadro’, Italy
| | - R VanZelm
- KU Leuven – University of Leuven, Belgium
| | - W Sermeus
- KU Leuven – University of Leuven, Belgium
| | - D Aeyels
- Universitair Ziekenhuis Brussel, Belgium
| | - L Bruyneel
- KU Leuven – University of Leuven, Belgium
- University Hospitals Leuven, Belgium
| | | | - K Vanhaecht
- KU Leuven – University of Leuven, Belgium
- University Hospitals Leuven, Belgium
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Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, Rockall TA, Young-Fadok TM, Hill AG, Soop M, de Boer HD, Urman RD, Chang GJ, Fichera A, Kessler H, Grass F, Whang EE, Fawcett WJ, Carli F, Lobo DN, Rollins KE, Balfour A, Baldini G, Riedel B, Ljungqvist O. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS ®) Society Recommendations: 2018. World J Surg 2019; 43:659-695. [PMID: 30426190 DOI: 10.1007/s00268-018-4844-y] [Citation(s) in RCA: 1008] [Impact Index Per Article: 201.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. METHODS A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. CONCLUSIONS The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.
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Affiliation(s)
- U O Gustafsson
- Department of Surgery, Danderyd Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - M J Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, VA, USA
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, USA
| | - M Hubner
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - J Nygren
- Department of Surgery, Ersta Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - N Demartines
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - N Francis
- Colorectal Unit, Yeovil District Hospital, Higher Kingston, Yeovil, BA21 4AT, UK
- University of Bath, Wessex House Bath, BA2 7JU, UK
| | - T A Rockall
- Department of Surgery, Royal Surrey County Hospital NHS Trust, and Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - T M Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - A G Hill
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland Middlemore Hospital, Auckland, New Zealand
| | - M Soop
- Irving National Intestinal Failure Unit, The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - H D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital, Groningen, The Netherlands
| | - R D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - G J Chang
- Department of Surgical Oncology and Department of Health Services Research, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - A Fichera
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, USA
| | - F Grass
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - E E Whang
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - W J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital NHS Foundation Trust and University of Surrey, Guildford, UK
| | - F Carli
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - K E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - A Balfour
- Department of Colorectal Surgery, Surgical Services, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - G Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - B Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | - O Ljungqvist
- Department of Surgery, Örebro University and University Hospital, Örebro & Institute of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Protocol for process evaluation of evidence-based care pathways: the case of colorectal cancer surgery. INT J EVID-BASED HEA 2019; 16:145-153. [PMID: 30095534 DOI: 10.1097/xeb.0000000000000149] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND AIM Care pathways are complex interventions, consisting of multiple 'active ingredients', to structure care processes around patient needs. Numerous studies have reported improved outcomes after implementation of care pathways. The structure-process-outcome framework and the context-mechanism-outcome framework both suggest that outcomes can only be achieved through a certain process within a context or structure. To understand how and why care pathways are effective, understanding of both this process and context is necessary. The aim of this article is to propose a study protocol to evaluate the implementation process of evidence-based care pathways, including the influence of the context. This protocol is explained by applying it to the implementation of a colorectal cancer surgery pathway in an international setting. METHODS The Medical Research Council (MRC) guidance on process evaluations for complex interventions is used as the basis for the protocol. The key components of process evaluation are intervention, context, implementation, mechanisms of impact and outcomes. In process evaluations, these components are studied using quantitative and qualitative methods. Among them are patient record analysis, questionnaires, on-site visits and interviews. DISCUSSION To guide our methodological choices, the MRC guidance for process evaluations of complex interventions, and published protocols for process evaluations of complex interventions were used. Our protocol is now tailored for the process evaluation of evidence-based care pathways and provides researchers and clinicians methods and tools, as well as a worked example, that can be used to study the process of care pathway implementation. As a result, healthcare professionals will be informed on context factors and implementation processes that can facilitate the implementation of care pathways, improving quality and effectiveness of care processes.
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Hoste P, Ferdinande P, Vogelaers D, Vanhaecht K, Hoste E, Rogiers X, Eeckloo K, Vandewoude K. Adherence to guidelines for the management of donors after brain death. J Crit Care 2018; 49:56-63. [PMID: 30388489 DOI: 10.1016/j.jcrc.2018.10.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/02/2018] [Accepted: 10/19/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Guideline adherence for the management of a donor after brain death (DBD) is largely unknown. This study aimed to perform an importance-performance analysis of prioritized key interventions (KIs) by linking guideline adherence rates to expert consensus ratings for the management of a DBD. MATERIALS AND METHODS This observational, cross-sectional multicenter study was performed in 21 Belgian ICUs. A retrospective review of patient records of adult utilized DBDs between 2013 and 2016 used 67 KIs to describe adherence to guidelines. RESULTS A total of 296 patients were included. Thirty-five of 67 KIs had a high level of adherence congruent to a high expert panel rating of importance. Nineteen of 67 KIs had a low level of adherence in spite of a high level of importance according to expert consensus. However, inadequate documentation proved an important issue, hampering true guideline adherence assessment. Adherence ranged between 3 and 100% for single KI items and on average, patients received 72% of the integrated expert panel recommended care set. CONCLUSIONS Guideline adherence to an expert panel predefined care set in DBD donor management proved moderate leaving substantial room for improvement. An importance-performance analysis can be used to improve implementation and documentation of guidelines.
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Affiliation(s)
- Pieter Hoste
- Department of General Internal Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium; Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 3K3, 9000 Ghent, Belgium; Department of Internal Medicine, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium; Department of Intensive Care, General Hospital Sint-Lucas Ghent, Groenebriel 1, 9000 Ghent, Belgium.
| | - Patrick Ferdinande
- Surgical and Transplantation ICU, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Dirk Vogelaers
- Department of General Internal Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium; Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 3K3, 9000 Ghent, Belgium; Department of Internal Medicine, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium.
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, Department of Public Health and Primary Care, KU Leuven - University of Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium; Department of Quality Management, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium; European Pathway Association, Kapucijnenvoer 35, 3000 Leuven, Belgium.
| | - Eric Hoste
- Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 3K3, 9000 Ghent, Belgium; Department of Internal Medicine, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium; Department of Intensive Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium; Research Foundation - Flanders (FWO), Egmontstraat 5, 1000 Brussels, Belgium.
| | - Xavier Rogiers
- Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 3K3, 9000 Ghent, Belgium; Department of Transplant Surgery, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium.
| | - Kristof Eeckloo
- Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 3K3, 9000 Ghent, Belgium.
| | - Koenraad Vandewoude
- Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 3K3, 9000 Ghent, Belgium; Department of Internal Medicine, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium.
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Recommended care received by geriatric hip fracture patients: where are we now and where are we heading? Arch Orthop Trauma Surg 2018; 138:1077-1087. [PMID: 29704045 DOI: 10.1007/s00402-018-2939-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Despite the availability of clinical guidelines on the prevention and treatment of geriatric hip fractures, the percentage of recommended care received by patients is low. We conducted an importance-performance analysis for prioritizing interventions to improve the in-hospital management of these patients. MATERIALS AND METHODS A secondary data analysis was conducted on the in-hospital treatment of 540 geriatric hip fracture patients in 34 hospitals in Belgium, Italy, and Portugal. First, we assessed the level of expert consensus on the process indicators composing international guidelines on hip fracture treatment. Second, guideline adherence on in-hospital care was evaluated within and across hospitals. Third, an importance-performance analysis was conducted, linking expert consensus to guideline adherence. RESULTS Level of expert consensus was high (above 75%) for 12 of 22 process indicators identified from the literature. There is large between and within hospital variation in guideline adherence for these indicators and for none of the 540 patients were all 22 process indicators adhered to. Importance-performance analysis demonstrated that three indicators that had a high level of expert consensus also had a high level of adherence (above 80%). Nine indicators, most of which have been previously linked to patient outcomes, had a high level of expert consensus but a consistently low level of adherence across hospitals and are identified as priority areas for improvement. CONCLUSIONS Guideline adherence for the treatment of geriatric hip fracture patients is remarkably suboptimal. Importance-performance analysis is a useful strategic approach to assist practitioners and healthcare managers to improve the quality of care.
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Denbo JW, Bruno M, Dewhurst W, Kim MP, Tzeng CW, Aloia TA, Soliz J, Speer BB, Lee JE, Katz MHG. Risk-stratified clinical pathways decrease the duration of hospitalization and costs of perioperative care after pancreatectomy. Surgery 2018; 164:424-431. [PMID: 29807648 DOI: 10.1016/j.surg.2018.04.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/21/2018] [Accepted: 04/09/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is associated with adverse events, increased duration of stay and hospital costs. We developed perioperative care pathways stratified by postoperative pancreatic fistula risk with the aims of minimizing variations in care, improving quality, and decreasing costs. STUDY DESIGN Three unique risk-stratified pancreatectomy clinical pathways-low-risk pancreatoduodenectomy, high-risk pancreatoduodenectomy, and distal pancreatectomy were developed and implemented. Consecutive patients treated after implementation of the risk-stratified pancreatectomy clinical pathways were compared with patients treated immediately prior. Duration of stay, rates of perioperative adverse effects, discharge disposition, and hospital readmission, as well as the associated costs of care, were evaluated. RESULTS The median hospital stay after pancreatectomy decreased from 10 to 6 days after implementation of the risk-stratified pancreatectomy clinical pathways (P < .001), and the median cost of index hospitalization decreased by 22%. Decreased changes in median hospital stay and costs of hospitalization were observed in association with low-risk pancreatoduodenectomy (P < .05) and distal pancreatectomy (P < .05), but not high-risk pancreatoduodenectomy. The rates of 90-day adverse events, grade B/C postoperative pancreatic fistula, discharge to a facility other than home, or readmission did not change after implementation. CONCLUSION Implementation of risk-stratified pancreatectomy clinical pathways decreased median stay and cost of index hospitalization after pancreatectomy without unfavorably affecting rates of perioperative adverse events or readmission, or discharge disposition. Outcomes were most favorably improved for low-risk pancreatoduodenectomy and distal pancreatectomy. Additional work is necessary to decrease the rate of postoperative pancreatic fistula, minimize variability, and improve outcomes after high-risk pancreatoduodenectomy.
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Affiliation(s)
- Jason W Denbo
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX; Department of Surgery, University of Minnesota, Minneapolis, MN
| | - Morgan Bruno
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Whitney Dewhurst
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael P Kim
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ching-Wei Tzeng
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas A Aloia
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jose Soliz
- Department of Anesthesia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Barbara Bryce Speer
- Department of Anesthesia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey E Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthew H G Katz
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX.
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Weimann A. Influence of nutritional status on postoperative outcome in patients with colorectal cancer - the emerging role of the microbiome. Innov Surg Sci 2017; 3:55-64. [PMID: 31579766 PMCID: PMC6754043 DOI: 10.1515/iss-2017-0039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 11/20/2017] [Indexed: 12/13/2022] Open
Abstract
Many patients with colorectal cancer are overweight. Even then, nutritional status is a frequently underestimated risk factor for perioperative complications. Enhanced Recovery after Surgery is the goal for perioperative management, and preoperative nutritional risk screening should be a standard. In case of nutritional risk, perioperative nutrition therapy should be started without delay and should follow recent guideline recommendations. The preservation of the microbiome has an emerging role in preventing postoperative anastomotic leakage and septic complications. The time window for recovery after neoadjuvant treatment for rectal cancer may be used for conditioning appropriate-risk patients in a “prehabilitation” program. In order to assess metabolic recovery and the prognosis for long-term survival, C-reactive protein/albumin ratio may be a promising parameter, which has to be validated in the future. This narrative review summarizes recent strategies and guideline recommendations.
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Affiliation(s)
- Arved Weimann
- Department of General, Visceral and Oncologic Surgery including Division of Clinical Nutrition, Klinikum St. Georg gGmbH, Delitzscher Str. 141, 04129 Leipzig, Germany
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