Fast-track surgery: procedure-specific aspects and future direction

Factors associated with postoperative discharge readiness and continuing care needs in patients with lung cancer undergoing fast-track surgery: A prospective cohort study

To investigate and analyze the characteristics and factors associated with readiness for hospital discharge and continuing care needs of postoperative patients with lung cancer undergoing fast-track surgery (FTS). FTS aims to reduce the body's stress response to surgery and improve patient outcomes. The study included adult patients with confirmed lung cancer who underwent lung cancer surgery under FTS management and were discharged from the Cancer Institute and Hospital, Chinese Academy of Medical Sciences, between June 2020 and September 2020. Patients with severe illnesses, comorbidities, disturbance of consciousness, cognitive disorders, or communication impairments were excluded. One-hundred-and-eighty patients were included, and 167 (92.8%) indicated that they were discharge-ready. Multivariable regression analysis showed that age 60 years or older (β = 16.29, 95% confidence interval (CI): 4.11-28.46, P = .009) and living alone (β = 37.07, 95% CI: 16.30-45.84, P < .001) were associated with the discharge readiness scores. In addition, those who were able to take care of themselves (β = 43.57, 95% CI: 19.60-67.54, P < .001) and needed little assistance at home (β = 28.39, 95% CI: 5.52-51.26, P = .015) had higher discharge readiness scores than those who needed a lot of assisted care. Patients who were cared for at home by children (β = 40.32, 95% CI: 4.91-75.73, P = .026), parents (β = 56.68, 95% CI: 12.33-101.03, P = .013), or spouses (β = 35.92, 95% CI: 2.45-69.38, P = .036), had higher discharge readiness scores than nursemaid. The discharge readiness scores of patients requiring continuing care were 146.5 ± 39.3, while patients who had no need scored 179.8 ± 36.5 (P < .01). Most patients with lung cancer undergoing FTS are discharge-ready. Discharge readiness is influenced by living conditions and self-care ability. This study identified factors influencing discharge readiness, and that could be used to identify patients who could benefit from help to improve discharge readiness.

Clinical outcomes of fenestration discectomy and iLESSYS-Delta interlaminar endoscopic system for treatment of LDH: a single-center retrospective cohort study

To compare the clinical efficacy of interlaminar endoscopic surgical system delta (iLESSYS-Delta) discectomy with that of classical fenestration discectomy for treating lumbar disc herniation. Patients who underwent iLESSYS-Delta or fenestration discectomy were enrolled in this study. Baseline information and clinical indicators were collected. The baseline data were matched using propensity score matching. Fifty-two patients were in each group. In the iLESSYS-Delta cohort, the volume of intraoperative bleeding was 18.17 ± 4.20 ml, the length of postoperative hospital stay was 4.16 ± 2.29 days, and the length of postoperative off-bed activity was 1.58 ± 0.88 days. In contrast, in the fenestration group, the volume of intraoperative bleeding was 32.50 ± 17.13 ml, the length of postoperative hospital stay was 6.66 ± 2.44 days, and the length of postoperative off-bed activity was 3.18 ± 1.28 days. The difference between the two groups was statistically significant (P < 0.05). The operation time was 88.90 ± 19.14 min in the iLESSYS-Delta group and 67.63 ± 19.32 min in the fenestration group, and the difference between the two groups was statistically significant (P < 0.05). Regarding the pain visual analogue scale scores at 24, 48, and 72 h after surgery, patients in the iLESSYS-Delta group had less pain than did those in the fenestration group (P < 0.05). The Oswestry disability indices of postoperative patients in both groups significantly improved at 3 months after surgery and at the last follow-up (P < 0.05); however, there was no statistically significant difference in the postoperative ODI scores between the two surgery groups (P > 0.05). The two groups showed no significant differences in clinical effects, postoperative recurrence rates, or perioperative complications. iLESSYS-Delta can cause less intraoperative bleeding and faster recovery than fenestration discectomy.

Second opinion machine learning for fast-track pathway assignment in hip and knee replacement surgery: the use of patient-reported outcome measures

BACKGROUND

The frequency of hip and knee arthroplasty surgeries has been rising steadily in recent decades. This trend is attributed to an aging population, leading to increased demands on healthcare systems. Fast Track (FT) surgical protocols, perioperative procedures designed to expedite patient recovery and early mobilization, have demonstrated efficacy in reducing hospital stays, convalescence periods, and associated costs. However, the criteria for selecting patients for FT procedures have not fully capitalized on the available patient data, including patient-reported outcome measures (PROMs).

METHODS

Our study focused on developing machine learning (ML) models to support decision making in assigning patients to FT procedures, utilizing data from patients' self-reported health status. These models are specifically designed to predict the potential health status improvement in patients initially selected for FT. Our approach focused on techniques inspired by the concept of controllable AI. This includes eXplainable AI (XAI), which aims to make the model's recommendations comprehensible to clinicians, and cautious prediction, a method used to alert clinicians about potential control losses, thereby enhancing the models' trustworthiness and reliability.

RESULTS

Our models were trained and tested using a dataset comprising 899 records from individual patients admitted to the FT program at IRCCS Ospedale Galeazzi-Sant'Ambrogio. After training and selecting hyper-parameters, the models were assessed using a separate internal test set. The interpretable models demonstrated performance on par or even better than the most effective 'black-box' model (Random Forest). These models achieved sensitivity, specificity, and positive predictive value (PPV) exceeding 70%, with an area under the curve (AUC) greater than 80%. The cautious prediction models exhibited enhanced performance while maintaining satisfactory coverage (over 50%). Further, when externally validated on a separate cohort from the same hospital-comprising patients from a subsequent time period-the models showed no pragmatically notable decline in performance.

CONCLUSIONS

Our results demonstrate the effectiveness of utilizing PROMs as basis to develop ML models for planning assignments to FT procedures. Notably, the application of controllable AI techniques, particularly those based on XAI and cautious prediction, emerges as a promising approach. These techniques provide reliable and interpretable support, essential for informed decision-making in clinical processes.

Fast track surgery for children with congenital pseudarthrosis of the tibia: A prospective interventional study

OBJECTIVE

The purpose of this study was to explore the effect of fast-track surgery combined with a clinical nursing pathway on the recovery and complications of congenital pseudarthrosis of tibia.

METHODS

82 children with congenital pseudarthrosis of tibia admitted from January 2019 to December 2020 were selected as the study subjects. The control group received routine clinical nursing pathway while the intervention group received a fast-track surgery combined with a clinical nursing pathway. The fasting and water deprivation time were arranged according to the pre operation time, and the accelerated rehabilitation nursing models such as progressive diet management, multi-functional analgesia, and early sequential functional exercise were given after the operation. After collecting data on perioperative diet, postoperative recovery, postoperative complications, and family satisfaction from both groups of patients in a large hospital in China, a comparative analysis was conducted.

RESULTS

The retention time of negative pressure drainage tube, urinary catheter and hospital stay in the intervention group were shorter than those in the control group (P < 0.05); The incidence of complications in the intervention group (5%) was significantly lower than that in the control group (21.42%) (P = 0.029). The family satisfaction of the intervention group (95.00%) was higher than that of the control group (80.95%).

CONCLUSION

Strengthening the concept of fast-track surgery nursing in the combined operation of congenital pseudarthrosis of tibia can shorten the hospitalization time of children, reduce the occurrence of postoperative complications and improve their family satisfaction.

Epidural versus general anesthesia for laparo-endoscopic single-site cholecystectomy: a randomized controlled trial

INTRODUCTION

This study compares outcomes after LESS cholecystectomy utilizing epidural versus general anesthesia.

METHODS

Patients undergoing LESS Cholecystectomy were randomized into receiving epidural or general anesthesia by protocol. Patients used a Visual Analog Scale to rate pain from 0 (no pain) to 10 (severe pain). Data presented as median (mean ± standard deviation).

RESULTS

75 patients underwent LESS cholecystectomy with general anesthesia [32 patients (22% men) after five patients withdrew consent] or epidural anesthesia [23 patients (22% men) after 15 patients withdrew consent]. Respectively, they were of age 38 years (41 ± 15.1) and 47 years (48 ± 13.9), BMI 29 (28 ± 4.9) kg/m2 and 28 (28 ± 3.8) kg/m2, and ASA 2 (2 ± 0.5) and 2 (2 ± 0.3) (p > 0.05 for all). LOS for patients receiving general vs. epidural anesthesia was 72 min (122 ± 104.4) vs. 95 min (113 ± 77.5) (p = 0.25). On POD 0, patients receiving general anesthesia rated pain as 4 (4 ± 2.9) vs. 0 (1 ± 2.2) for epidural anesthesia (p = 0.02). On POD 1, they rated pain as 6 (5 ± 2.3) vs. 6 (6 ± 2.9) (p = 0.68). On POD 6, patients rated pain as 3 (3 ± 2.7) vs. 4 (3 ± 2.2) (p = 1.00). For patient satisfaction with incisional scars for those receiving general vs. epidural anesthesia, patients rated their scars to be 10 (8 ± 3.6) vs. 10 (9 ± 1.2) (p = 0.21). Total costs for the hospital using general vs. epidural anesthesia were found $6,909 (7,167 ± 2,083.8) vs. $6,225 (5,848 ± 1530.1) (p = 0.014), respectively. Patients self-assessed satisfaction on a scale of 1 (worst) to 5 (best) as a 5 (5 ± 0).

CONCLUSIONS

Patients undergoing LESS cholecystectomy with general vs. epidural anesthesia had similar demographics, LOS, and pain scores. Patients that received epidural anesthesia reported less pain and incurred less cost. Utilization of epidural anesthesia in lieu of general anesthesia for LESS cholecystectomy is safe, reduces pain, and offers potential cost savings.

From volume to value: Improving peri-operative elective pathways through a roadmap from fast-track orthopedic surgery

Healthcare institutions face the pressure generated by modern medicine and society, in terms of increasing expectations and financial constraints. Chronic patients need multidisciplinary care pathways to preserve their wellbeing across the entire journey.The orthopaedic community has been particularly receptive in testing solutions to align good clinical outcomes and financial sustainability, given the increase in elective procedures provided among aging populations to alleviate pain and reduce disability. Fast-track (FT) total joint arthroplasty (TJA) and bundled payments (BPs) offer relevant examples both from the clinical and the financial perspective; however, they have not been evaluated in combination yet.The aim of this manuscript is to provide a road map to improve the value of high-volume, multidisciplinary elective procedures, with potential applications in a vast number of surgical specialties, (1) based on an integrated financial budget per episode of care (the BP), (2) building on lessons from a review of the literature on FT TJA.Although clinical outcomes vary from procedure to procedure, the coordination between the single treatments and providers involved across the patient journey; the commitment of patients and relatives; and the systematic adoption of patient-reported outcomes; can add further value for the benefit of patients, healthcare funders and providers, once essential clinical, financial and administrative conditions are guaranteed.

Impact of Tailored-Enhanced Recovery After Surgery Versus Conventional Care in Patients of Gastro-Duodenal Perforation: A Pilot Randomized Control Trial

BACKGROUND

The enhanced recovery after surgery (ERAS) program established improved clinical outcomes in elective surgery; however, its role in emergencies is uncertain. This study was designed to assess the feasibility, safety, and efficacy of a tailored-ERAS (t-ERAS) protocol in patients undergoing modified Graham's patch closure for gastro-duodenal perforation.

METHODS

A single-centre, prospective, parallel-arm, open-label, randomized controlled trial was conducted from February 2021 to December 2021. Patients with gastroduodenal perforation undergoing modified Graham's patch were randomly assigned to either conventional care or the t-ERAS pathway. Patients with refractory septic shock, psychiatric or neurological disorders, pregnancy, multiple perforations, sealed-off perforations, and perforation sizes greater than 1.5 cm were excluded. The primary outcome was to compare the length of hospitalization (LOH). Functional recovery parameters and morbidity were compared in secondary outcomes.

RESULTS

Twenty-five patients each were included in conventional care and the t-ERAS group. In the t-ERAS group, LOH was significantly shorter (6.3 SD2.15 days versus 9.56 SD4.33 days, p = 0.001). Patients in the t-ERAS group had significantly early functional recovery (days) with time to first bowel sound (1.8 SD0.41; p 0.002), first flatus (2.52 SD0.65; p = 0.026), first stool (3.04 SD0.68; p < 0.001), first liquid diet (2.24 SD0.60; p = 0.002), and duration of ileus (2.64 SD0.86; p = 0.038). There was no significant difference in morbidity such as post-operative nausea and vomiting, SSI, or pulmonary complications between the two groups.

CONCLUSION

Tailored ERAS pathways are safe and effective in reducing the LOH and promoting early functional recovery in patients undergoing emergency closure of gastro-duodenal perforation.

Assessment of Fast-Track Pathway in Hip and Knee Replacement Surgery by Propensity Score Matching on Patient-Reported Outcomes

Total hip (THA) and total knee (TKA) arthroplasty procedures have steadily increased over the past few decades, and their use is expected to grow further, mainly due to an increasing number of elderly patients. Cost-containment strategies, supporting a rapid recovery with a positive functional outcomes, high patient satisfaction, and enhanced patient reported outcomes, are needed. A Fast Track surgical procedure (FT) is a coordinated perioperative approach aimed at expediting early mobilization and recovery following surgery and, accordingly, shortening the length of hospital stay (LOS), convalescence and costs. In this view, rapid rehabilitation surgery optimizes traditional rehabilitation methods by integrating evidence-based practices into the procedure. The aim of the present study was to compare the effectiveness of Fast Track versus Care-as-Usual surgical procedures and pathways (including rehabilitation) on a mid-term patient-reported outcome (PROs), the SF12 (with regard both to Physical and Mental Scores), 3 months after hip or knee replacement surgery, with the use of Propensity score-matching (PSM) analysis to address the issue of the comparability of the groups in a non-randomized study. We were interested in the evaluation of the entire pathways, including the postoperative rehabilitation stage, therefore, we only used early home discharge as a surrogate to differentiate between the Fast Track and Care-as-Usual rehabilitation pathways. Our study shows that the entire Fast Track pathway, which includes the post-operative rehabilitation stage, has a significantly positive impact on physical health-related status (SF12 Physical Scores), as perceived by patients 3 months after hip or knee replacement surgery, as opposed to the standardized program, both in terms of the PROs score and the relative improvements observed, as compared with the minimum clinically important difference. This result encourages additional research into the effects of Fast Track rehabilitation on the entire process of care for patients undergoing hip or knee arthroplasty, focusing only on patient-reported outcomes.

Healthcare workers' perceptions of how eHealth applications can support self-care for patients undergoing planned major surgery

Background

In planned major surgery the duration of inpatient hospital care during the last decade has decreased because of a combination of different perioperative interventions. It is expected that patients can manage the needed pre- and postoperative self-care to a large extent on their own. This entails challenges to healthcare system to deliver appropriate information to patients in a safe and efficient manner. The aim of this study was therefore to describe healthcare workers’ perceptions of how eHealth applications can support patients’ self-care in relation to planned major surgery.

Methods

Semi-structured interviews were performed with sixteen healthcare workers from different disciplines. The interviews were transcribed and analysed using the phenomenography approach.

Results

Healthcare workers perceived both positive aspects and challenges with eHealth applications for self-care. eHealth applications can work as an information source, affect patients’ understanding of self-care, improve patients’ participation in self-care, streamline communication with healthcare professionals and improve patient safety during the pre- and postoperative period. The challenges included perceptions of that eHealth applications may have negative impact on personal interaction in care. eHealth applications may not be useful to all patients because of lack of equipment or knowledge and may increase patients’ suffering if physical visits are replaced by digital solutions.

Conclusions

This study improves our understanding of healthcare workers’ perceptions of how the use of self-care eHealth applications can support patients in performing pre- and postoperative self-care for major surgery. Access to appropriate and personalized information and instructions can improve patients’ understanding of self-care and enhance the participation and safety of those who can afford and handle digital tools. All these aspects must be considered in future digital development of eHealth applications to guarantee a person-centered care.

Perception and implementation status of enhanced recovery after surgery

Background: The enhanced recovery after surgery (ERAS) program that is being implemented in Korea is difficult to investigate because it is not a standardized protocol with a unified content, and it instead differs according to the details for each hospital. Herein, the author would like to introduce and analyze the results of a recently conducted large-scale survey on the current status and perception of the ERAS program in Korea among large domestic hospitals.Current Concepts: Surveys of domestic general surgeons in 2019 and hepatobiliary-pancreatic surgeons in 2020 both showed lower-than-expected response rates of less than 50% in questions related to perception and clinical implementation of the ERAS program. Thus, implementation of ERAS items related to the limited application of preoperative fasting and surgical drain insertion and active nutritional support before and after surgery remains low.Discussion and Conclusion: For surgeons in Korea, the implementation of ERAS programs and perception levels were low. In this regard, it is necessary to improve awareness through systematic education and promotion of the ERAS program, and supplementation of related multidisciplinary professional manpower and financial resources is essential to facilitate practical implementation of ERAS programs in clinical practice.

Effect of Mobilization on the Day of Surgery After Total Hip Arthroplasty in Elderly, Obese, and Severely Diseased Patients

BACKGROUND

Mobilization on the day of surgery after total hip arthroplasty (THA) is widely used. However, elderly, obese and severely diseased patients are often excluded from early mobilization. Therefore, it was our aim to investigate the effect of mobilization on the day of surgery with focus on these patients.

METHODS

167 patients underwent THA via direct anterior approach. Exclusion criterion was the use of wound drainage. The patients were randomly allocated to two groups. Day 0 group was mobilized 4 hours after surgery, day 1 group the day after surgery. Primary outcome was the time to readiness for discharge (TRD). Secondary outcome was the occurrence of adverse events (vertigo, nausea, vomiting, severe pain) on the day of surgery. Group comparisons were calculated with respect to elderly (age ≥75 years), obese (BMI ≥30 kg/m²) and severely diseased patients (ASA≥3).

RESULTS

TRD was shorter in day 0 group (3.25 vs 3.99 days, P < .01). The rate of adverse events on the day of surgery was similar in both groups (0.28 vs 0.25, P = .73). TRD differences were higher within all subgroups (3.85vs4.81; 3.25vs4.39; 4.08vs5.11days) while the rate of immediate adverse events was reduced (0.15vs0.24; 0.25vs0.3; 0.25vs0.33). Within 90 days 3 patients of group 0 underwent revision surgery, none of group 1 (P = .12).

CONCLUSION

Mobilization on the day of surgery reduces the TRD without increasing the rate of immediate adverse events, regardless of age, BMI and ASA score. Future studies are needed to investigate if early mobility increases the 90-days complication rate.

Enhanced Recovery After Surgery and Radical Cystectomy: A Systematic Review and Meta-Analysis

Introduction

Enhanced recovery after surgery (ERAS) protocols aim to optimize patient recovery after major surgery. Our study was to examine the evidence of the effectiveness of interventions designed to improve patient outcomes after radical cystectomy.

Design

Systematic review and meta-analysis.

Data Sources

PubMed, Medline, Embase, Cochrane from January 2005 to January 2021 without language restrictions.

Eligibility Criteria

Randomized and non-randomized controlled studies implementing ERAS measuring its interventions on rates of postoperative complications, 30-day readmission, length of stay (LOS) and bowel function after radical cystectomy.

Data Extraction and Synthesis

Two members of the investigating team independently selected studies and evaluated bias using the Cochrane collaboration tool. Meta-analysis of all comparative studies used inversed-weighted, fixed- effects models and random effects models to pool results. Publication bias was graphically assessed using contour-enhanced funnel plots and the Egger’s test of funnel plot symmetry.

Results

Fifteen studies were included in our meta-analysis; we observed that ERAS decreased the time for the first bowel movement (standardized mean difference [SMD]: –1.30, 95% CI −1.90 to −0.70, P<0.00001) and shortened the length of stay (LOS) ([SMD]: –0.49, 95% CI −0.77 to −0.20, (P < 0.00001)); however, 30-day readmission (risk ratio [RR]: 0.97,95% [CI] 0.73 to 1.28, P=0.52) and the overall postoperative complication rate (risk ratio [RR]: 0.98,95% confidence interval [CI]: 0.88 to 1.09, P= 0.41) showed no significant difference.

Enhanced recovery after surgery pathway reduces the length of hospital stay without additional complications in lumbar disc herniation treated by percutaneous endoscopic transforaminal discectomy

Background

Enhanced recovery after surgery (ERAS) pathway in spine surgery is increasingly popular which can reduce the length of hospital stay (LOS). However, there are few studies on the safety and effectiveness of ERAS pathway in the treatment of single-level lumbar disc herniation (LDH) by percutaneous endoscopic transforaminal discectomy (PETD). The aim of this study was to investigate whether ERAS can reduce LOS of patients with single segment LDH treated by PETD.

Methods

We reviewed the outcomes of all LDH patients (L4/5) who had been treated with PETD at our institution. Quasi-experimental study was adopted between patients treated in an ERAS after PETD with those rehabilitated on a traditional pathway. The two groups were analyzed for LOS, operation time, complications, visual analog scale (VAS), Oswestry Dysfunction Index (ODI), hospitalization expenses (HE), and improved MacNab efficacy assessment criteria (MacNab).

Results

A total of 120 single segment LDH patients (ERAS pathway 60 cases, traditional care pathway 60 cases) who were selected from January 2019 to January 2021 met the inclusion criteria. There was a significant difference in mean LOS postoperative VAS scores and ODI on the 3rd day after surgery between the two groups (P < 0.05). The incidence of complications and HE were similar in the two groups (P > 0.05). The mean LOS decreased from 3.47 ± 1.14 days to 5.65 ± 1.39 days after application of ERAS pathway (P < 0.05).

Conclusions

The ERAS pathway reduced LOS without resulting in additional complications after PETD. These findings support the application of the perioperative ERAS pathway in the treatment of single-level LDH with PETD.

Level of evidence

Level IV, therapeutic

Implementation of the ERAS (Enhanced Recovery After Surgery) protocol for colorectal cancer surgery in the Piemonte Region with an Audit and Feedback approach: study protocol for a stepped wedge cluster randomised trial: a study of the EASY-NET project

INTRODUCTION

The ERAS protocol (Enhanced Recovery After Surgery) is a multimodal pathway aimed to reduce surgical stress and to allow a rapid postoperative recovery. Application of the ERAS protocol to colorectal cancer surgery has been limited to a minority of hospitals in Italy. To promote the systematic adoption of ERAS in the entire regional hospital network in Piemonte an Audit and Feedback approach (A&F) has been adopted together with a cluster randomised trial to estimate the true impact of the protocol on a large, unselected population.

METHODS

A multicentre stepped wedge cluster randomised trial is designed for comparison between standard perioperative management and the management according to the ERAS protocol. The primary outcome is the length of hospital stay (LOS). Secondary outcomes are: incidence of postoperative complications, time to patients' recovery, control of pain and patients' satisfaction. With an A&F approach the adherence to the ERAS items is monitored through a dedicated area in the study web site. The study includes 28 surgical centres, stratified by activity volume and randomly divided into four groups. Each group is randomly assigned to a different activation period of the ERAS protocol. There are four activation periods, one every 3 months. However, the planned calendar and the total duration of the study have been extended by 6 months due to the COVID-19 pandemic.The expected sample size of about 2200 patients has a high statistical power (98%) to detect a reduction of LOS of 1 day and to estimate clinically meaningful changes in the other endpoints.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Ethical Committee of the coordinating centre and by all participating centres. Study results will be timely circulated within the hospital network and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04037787.

Influence of outpatient total knee arthroplasty compared to inpatient surgery on medical and economic outcomes

Firstly, this study compared the rate of readmission after a total knee arthroplasty between selected out- patients (no hospitalization, directly sent home after surgery) and inpatients (3 days hospitalization) at 6 weeks. Secondly, it examined the mobility and the complications in the two groups after the same period of time. The rate of readmission, complications and knee mobility of 32 outpatients (M-age : 61 years ± 10 ; 10 females), were compared against those of 32 birth- matched inpatients (M-age : 64 years ± 8.6 ; 10 females). No patient was re-admitted in either group. Post- surgical complications included one hematoma resorbed at 6 weeks in the outpatient group and three joint effusions in the inpatient group. There were no instances of deep venous thrombosis, failure of primary fixation, infection, or wound dehiscence. Knee mobility was identical between the two groups. This is the first study to compare inpatient and outpatient total knee arthroplasty in a Belgian setting. Our study suggests that day-care total knee arthroplasty in selected patients is possible without increasing the rate of re-admission and complications, and without affecting the mobility at 6 weeks. However, the Belgian financial incentives do not seem to currently promote this surgical approach. These results should be confirmed with a larger sample to define the adequate length of stay after a total knee arthroplasty.

Comparison of Clinical Outcomes Between Chinese Patients Receiving Hepatectomy With or Without Enhanced Recovery After Surgery Strategy

Purposes: For the first time in China, the current study was designed to compare the clinical outcomes between Chinese patients receiving hepatectomy with or without the enhanced recovery after surgery (ERAS) strategy. Methods: The current study enrolled 250 patients who would receive hepatectomy. Patients were randomized into two groups: ERAS group (n = 125, ERAS strategy) and control (n = 125, conventional care). Mortality, length of hospital stay, readmission, and complications were assessed over 30 days after the operation. Results: The average age of the whole cohort was 65 (63-68) years, with 152 males (60.8%). There was no difference between two groups in baseline features, such as age, sex, medical history, Child-Pugh hepatic function, American Society of Anaesthesiologists physical status, operative type, hepatectomy type, and hepatic pathology (P > 0.05 for all). There was no occurrence of death in the two groups. Patients in the ERAS group had significantly less occurrence of post-operative complications and a shorter length of hospital stay (P < 0.05 for all). Deep vein thrombosis occurred in seven patients in the control group, but did not occur in the ERAS group (P < 0.05). Patients in the two groups had similar occurrence of readmission (P > 0.05). Conclusions: ERAS strategy significantly decreased the occurrence of operative complications and shortened the length of hospital stay without any increase in mortality or readmission in Chinese patients receiving hepatectomy.

Fast track pathway provides safe, value based care on busy acute care surgery service

BACKGROUND

Fast track (FT) pathways have been adopted across a multitude of elective surgeries but have been slow to be adopted into the acute care surgery realm. We hypothesized that an FT pathway for acute cholecystitis patients would decrease patient length of stay and resource utilization.

METHODS

All patients at two hospitals, one with an FT pathway and one with a traditional pathway, who underwent an urgent laparoscopic cholecystectomy for acute cholecystitis between May 1, 2019, and October 31, 2019, were queried using CPT codes. Exclusion criteria were conversion to open or partial cholecystectomy. Retrospective chart review was used to gather demographics, operative, hospital course, and outcomes. Time to operating room, hospital length of stay, and resource utilization were the primary outcomes.

RESULTS

There was a total of 479 urgent laparoscopic cholecystectomies performed, 430 (89.8%) were performed under the FT pathway. The median (interquartile range [IQR]) time to the operating room was not different: 14.1 hours (IQR, 8.3-29.0 hours) for FT and 18.5 hours (IQR, 11.9-25.9 hours) for traditional (p = 0.316). However, the median length of stay was shorter by 15.9 hours in the FT cohort (22.6 hours; IQR, 14.2-40.4 hours vs. 38.5 hours; IQR, 28.3-56.3 hours; p < 0.001). Under the FT pathway, 33.0% of patients were admitted to the hospital and 75.6% were discharged from the postanesthesia care unit, compared with 91.8% and 12.2% on the traditional pathway (both p < 0.001). There were 59.6% of the FT patients that received a phone call follow up, as opposed to 100% of the traditional patients having clinic follow up (p < 0.001). The emergency department bounce back rate, readmission rates, and complication rates were similar (p > 0.2 for all). On multivariate analysis, having a FT pathway was an independent predictor of discharge within 24 hours of surgical consultation (odds ratio, 7.65; 95% confidence interval< 2.90-20.15; p < 0.001).

CONCLUSION

Use of a FT program for patients with acute cholecystitis has a significant positive impact on resource utilization without compromise of clinical outcomes.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

A Propensity Score-Matched Analysis to Assess the Outcomes in Pre- and Post-Fast-Track Hip and Knee Elective Prosthesis Patients

Fast-track surgery is a multimodal evidence-based approach to perioperative care aimed at reducing complications and recovery time. We compared a fast-track protocol to standard care in the setting of a small Italian general hospital. Propensity score estimation before and after the study was performed to compare pre-fast-track (pre-FT; January 2013–March 2014) and fast-track (FT; January 2016–December 2016) patients undergoing elective hip and knee replacement surgery with a three-year follow-up (up to January 2020). The primary endpoints were the mean hemoglobin drop, mean predischarge hemoglobin, transfusion and reinfusion rates, pain, ambulation day, hospital length of stay (LOS), and discharge to home/outpatient care or rehabilitation hospital center. The secondary endpoints were the adherence measures to the FT protocol, namely, tourniquet and surgical times, use of drains and catheters, type of anesthesia administered, and complications within three years. The risk difference (RD) and the adjusted odds ratio (aOR) were calculated for each outcome. After the propensity score estimation, we analyzed 59 patients in the pre-FT and 122 in the FT categories. The FT patients, with respect to the pre-FT patients, ameliorated their mean hemoglobin drop from 3.7 to 3.1 g/dl (p < 0.01) and improved their predischarge mean hemoglobin (10.5 g/dL versus 11.0 g/dL; p = 0.01). Furthermore, the aOR of being transfused was reduced by 81% (p < 0,01); the RD of being reinfused was reduced by 63% (p < 0.01); the aOR of having low pain on the first day was increased by more than six times (p < 0.01); the RD of ambulating the first day increased by 91% (p < 0.01); the aOR of admission to a rehabilitation hospital center was reduced by 98% (p < 0.01); the aOR of home discharge increased by 42 times (p < 0.01); the median LOS, tourniquet and surgical times, and use of catheters and drains significantly decreased. Patients with complications at 1 month were 43.1% and 38.2%, respectively, of pre-FT and FT patients (p = 0.63). Complications at 6, 12, 24, and 36 months were significantly lower for the FT patients. This study showed that the uptake of enhanced recovery practices was successful and resulted in the improvement of clinical and organizational outcomes. The fast-track concept and related programs may optimize perioperative care and streamline surgical and rehabilitation care paths.

Lymphedema and Post-Operative Complications after Sentinel Lymph Node Biopsy versus Lymphadenectomy in Endometrial Carcinomas-A Systematic Review and Meta-Analysis

Background: Lymph node dissection (LND) is recommended as staging procedure in presumed low stage endometrial cancer. LND is associated with risk of lower-extremity lymphedema and post-operative complications. The sentinel lymph node (SLN) procedure has been shown to have high diagnostic accuracy, but its effects on complication risk has been little studied. This systematic review compares the risk of lower-extremity lymphedema and post-operative complications in SLN versus LND in patients with endometrial carcinoma. Methods: A systematic search was conducted in PubMed and Cochrane Library. Results: Seven retrospective and prospective studies (total n = 3046 patients) were included. Only three studies reported the odds ratio of lower-extremity lymphedema after SLN compared to LND, which was 0.05 (95% CI 0.01-0.37; p = 0.067), 0.07 (95% CI 0.00-1.21; p = 0.007) and 0.54 (95% CI 0.37-0.80; p = 0.002) in these studies. The pooled odds ratio of any post-operative complications after SLN versus LND was 0.52 (95% CI 0.36-0.73; I2 = 48%; p < 0.001). For severe post-operative complications the pooled odds ratio was 0.52 (95% CI 0.28-0.96; I2 = 0%; p = 0.04). Conclusions: There are strong indications that SLN results in a lower incidence of lower-extremity lymphedema and less often severe post-operative complications compared to LND. In spite of the paucity and heterogeneity of studies, direction of results was similar in all studies, supporting the aforementioned conclusion. These results support the increasing uptake of SLN procedures in endometrial cancer.

Enhanced Recovery Protocol after Fronto-orbital Advancement Reduces Transfusions, Narcotic Usage, and Length of Stay

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols utilize multi-modal approaches to decrease morbidity, narcotic usage, and length of stay. In 2013, we made several changes to our perioperative approach to children undergoing complex craniofacial procedures. The goal of this study was to analyze our protocol for children undergoing fronto-orbital advancement (FOA) for craniosynostosis.

METHODS

A retrospective chart review was performed after IRB approval, for children who underwent fronto-orbital advancement for craniosynostosis from 2010 to 2018. The ERAS protocol, initiated in December 2013, involves hemoglobin optimization, cell-saver technology, tranexamic acid, specific postoperative fluid titration, and a transfusion algorithm. The analgesic regimen focuses on narcotic reduction through the utilization of scheduled acetaminophen, ibuprofen, or ketorolac, and a dexmedetomidine infusion with opioids only for breakthrough pain.

RESULTS

Fifty-five ERAS protocol children and 23 control children were analyzed. ERAS children had a decreased rate (13/53 versus 23/23, P < 0.0001) and volume of intraoperative transfusion (183.4 mL versus 339.8 mL, P = 0.05). Fewer ERAS children required morphine/dilaudid (12/55 versus 22/23 P < 0.0001) and for children who required morphine, fewer doses were required (2.8 versus 11, P = 0.02). For ERAS protocol children who required PO narcotics, fewer doses were required (3.2 versus 5.3, P = 0.02). ERAS children had a decreased length of stay (2.3 versus 3.6 nights, P < 0.0001). No patients were re-admitted due to poor oral intake, pain, hemodynamic, or pulmonary concerns.

CONCLUSIONS

Our ERAS protocol demonstrated a reduction in the overall and intraoperative allogenic blood transfusion rate, narcotic use, and hospital length of stay. This is a safe and effective multimodal approach to managing complex craniofacial surgical recovery.

Systematic Review and Meta-Analysis of the Efficacy and Safety of Enhanced Recovery After Surgery vs. Conventional Recovery After Surgery on Perioperative Outcomes of Radical Cystectomy

Background and objective: Radical cystectomy has been characterized as the most difficult operation in urology because of the complex surgical procedures and postoperative complications. Enhanced recovery after surgery (ERAS), which reduces the incidence of perioperative complications, has been widely used in clinical surgery. Herein, we performed a meta-analysis to evaluate the efficacy and safety of ERAS vs. conventional recovery after surgery (CRAS) on perioperative outcomes of radical cystectomy. Methods: We performed a systematic search of randomized controlled trials (RCTs) in the following databases: Medline, Embase, and the Cochrane Controlled Trials Register, based on the PICOS strategy. The reference lists of the retrieved studies were further surveyed for relevant publications. Results: Our search yielded seven RCTs containing 813 patients. The ERAS group was found to have better performance in the following parameters: length of hospital stay [mean difference (MD) = -1.12, 95% confidence interval (CI): -1.80 to -0.45, P = 0.001], time to first flatus (MD = -0.70, 95% CI: -0.98 to 0.41, P < 0.00001), and time to regular diet (MD = -0.12, 95% CI: -1.76 to -0.28, P = 0.007). However, there were no significant differences between the two groups in major complications [odds ratio (OR) = 0.91, 95% CI: 0.63 to 1.34, P = 0.64], readmission (OR = 1.15, 95% CI: 0.65 to 2.01, P = 0.63), ileus (OR = 0.75, 95% CI: 0.44 to 1.28, P = 0.29), wound infection (OR = 0.56, 95% CI: 0.31 to 1.01, P = 0.05), mortality (OR = 0.69, 95% CI: 0.24 to 1.99, P = 0.49), or time to first bowel movement (MD = -0.55, 95% CI: -1.62 to 0.53, P = 0.32). Conclusion: ERAS reduced the length of hospital stay, time to first flatus, and time to regular diet after cystectomy. Compared to CRAS protocols, ERAS protocols do not increase the risk of adverse events.

Early Feeding after Colorectal Surgery in Children: Is it Safe?

Aim of the Study

The aim of this study is to assess the role of early feeding after elective colorectal surgery in children and compare the outcome of feeding practice early versus traditional feeding.

Study Design

A randomized controlled, single-center study was conducted over a period of 3 years (November 2015-October 2018) at a tertiary care center.

Materials and Methods

Patients (n = 147), after colostomy closure (as elective colorectal surgery), were randomly selected for postoperative feeding initiation and were divided into two groups, namely the control (traditional feeding) group and study group (early feeding). In early group, feeding was initiated on the postoperative day 1 after the removal of nasogastric tube (removed after 16 h of surgery). Postoperative hospital stay and complications were compared among them.

Statistical Analysis Used

Data were tabulated and analyzed in Microsoft Excel 2010.

Results

Among 147 patients (boys[70] and girls [77]), the average age of colostomy closure was 4.36 years. Forty-five patients had early feeding and 102 traditional feeding. Average postoperative hospital stay was noted 5.62 ± 1.11 days for "Study group" and 8.1 ± 1.04 days for "Control group." Postoperative complications were found in 17 patients; 11 (7.5%) superficial surgical site infection (9 [8.8%] in control and 2 [4.4%] in study group) and 6 (4%) minor fecal fistulae (5 [4.9%] in control group and 1 [2.2%] in study group). None required any further surgical intervention. No mortality was reported.

Conclusions

Early feeding initiation after elective colorectal surgery is safe, and postoperative hospital stay is significantly reduced. It is definitely a step forward in the era of fast track surgery in pediatric population.

Introducing enhanced recovery after surgery in a high-volume orthopaedic hospital: a health technology assessment

BACKGROUND

The number of patients undergoing joint arthroplasty is increasing worldwide. An Enhanced Recovery After Surgery (ERAS) pathway for hip and knee arthroplasty was introduced in an Italian high-volume research hospital in March 2018.

METHODS

The aim of this mixed methods observational study is to perform a health technology assessment (HTA) of the ERAS pathway, considering 938 procedures performed after its implementation, by means of a hospital-based approach derived from the EUnetHTA (European Network for Health Technology Assessment) Core Model. The assessment process is based on dimensions of general relevance, safety, efficacy, effectiveness, economic and financial impact, equity, legal aspects, social and ethical impact, and organizational impact. A narrative review of the literature helped to identify general relevance, safety and efficacy factors, and a set of relevant sub-dimensions submitted to the evaluation of the professionals who use the technology through a 7-item Likert Scale. The economic and financial impact of the ERAS pathway on the hospital budget was supported by quantitative data collected from internal or national registries, employing economic modelling strategies to identify the amount of resources required to implement it.

RESULTS

The relevance of technology under assessment is recognized worldwide. A number of studies show accelerated pathways to dominate conventional approaches on pain reduction, functional recovery, prevention of complications, improvements in tolerability and quality of life, including fragile or vulnerable patients. Qualitative surveys on clinical and functional outcomes confirm most of these benefits. The ERAS pathway is associated with a reduced length of stay in comparison with the Italian hospitalization average for the same procedures, despite the poor spread of the pathway within the country may generate postcode inequalities. The economic analyses show how the resources invested in training activities are largely depreciated by benefits once the technology is permanently introduced, which may generate hospital cost savings of up to 2054,123.44 € per year.

CONCLUSIONS

Galeazzi Hospital's ERAS pathway for hip and knee arthroplasty results preferable to traditional approaches following most of the HTA dimensions, and offers room for further improvement. The more comparable practices are shared, the before this potential improvement can be identified and addressed.

Opposing needling for analgesia and rehabilitation after unilateral total knee arthroplasty: a randomized, sham-controlled trial protocol

BACKGROUND

This randomized controlled clinical trial aims to evaluate the efficacy and safety of opposing needling in patients undergoing unilateral total knee arthroplasty (TKA). Opposing needling is one of the special needling methods used in acupuncture and moxibustion therapy. It involves needling acupoints on the contralateral side for pain management. Although, opposing needling is used for pain management in clinics, evidence to support its effectiveness as an analgesic after total knee arthroplasty is scant. We designed a randomized controlled clinical trial to evaluate efficacy and safety of opposing electroacupuncture (EA) in alleviating pain associated with unilateral total knee arthroplasty.

METHODS/DESIGN

This is a protocol for a randomized controlled patient- and assessor-blinded trial with three parallel arms (A, opposing EA; B, operated side EA; C, sham EA). Yinlingquan (SP9), Yanglingquan (GB34), Futu (ST32), and Zusanli (ST36) acupoints are selected for all three groups. In group A, the healthy side will be treated with EA, while the operated side will be administered sham EA. In group B, the operated side will be treated with EA while on the healthy side sham EA will be used. For group C, sham EA will be used on both sides. All patients in the three groups will receive treatment once a day for 3 days. The post-operative pain measured using a visual analogue scale score (including pain while resting and being active) and the additional dose of the patient-controlled analgesic pump after operation will be recorded as the primary outcomes. Secondary outcomes such as knee function and swelling, range of motion (including active and passive range of motion), post-operative anxiety, and acupuncture tolerance will also be assessed.

DISCUSSION

Opposing needling is a potential non-pharmacological treatment for relieving pain and improving functional rehabilitation after TKA, during which patients receive acupuncture on the healthy side rather than on the operated side. This sham controlled clinical trial, designed to evaluate efficacy and safety of opposing needling for patients after TKA, will provide evidence for pain management and functional rehabilitation after unilateral TKA.

TRIAL REGISTRATION

ChiCTR, ChiCTR1800020297 (http://www.chictr.org.cn/edit.aspx?pid=34231&htm=4). Registered 22 December 2018.

Fast Track Program in Conversion Bariatric Surgery, as Safe as in Primary Bariatric Surgery?

OBJECTIVES

Evaluate the safety of fast track (FT) surgery program in patients undergoing primary and revisional bariatric surgery (conversion from one procedure to another); identify limiting factors for early discharge and predictive factors for readmission.

METHODS

This is a retrospective review of 730 consecutive morbidly obese patients who underwent bariatric surgery between January 2016 and December 2017. Fast track protocol was applied on all patients. Target discharge was after one-night stay. The primary end point is length of stay. The secondary end point is frequency of hospital contact after discharge, readmissions and reinterventions within 30 days.

RESULTS

Primary procedures (n = 633) were banded Roux-en-Y gastric bypass (BRYGB, 79.3%), sleeve gastrectomy (10.7%), gastric band (4.7%) and others (5.3%). Mean age (± SD) was 44.32 ± 11.26 years, and mean BMI (± SD) was 43.58 ± 6.12 kg/m². Conversion procedures (n = 97) were gastric band to BRYGB (40.2%), or to adjustable BRYGB (39.2%), Mason to BRYGB (11.3%), sleeve to BRYGB (4.1%) and others (5.2%). Mean age (± SD) was 47.22 ± 9.1 years, and mean BMI (± SD) was 37.9 ± 7.27 kg/m². Mean LOS in primary patients was 1.3 ± 0.99, and that in conversion patients was 1.5 ± 1.4. Successful discharge at one night or less was achieved in 650 cases (573 primary and 77 conversion). After one-night discharge, incidence of contact to the hospital, readmission and reintervention was 23.9%, 5.9% and 1.9%, in the primary group and 31.2%, 13% and 5.2% in the conversion group.

CONCLUSION

One-night discharge in FT managed conversion procedures is safe, compared to primary procedures. It is associated with higher readmission rates; however, the postdischarge hospital contacts and surgical complications were not statistically significant different.

Surgical Infections and Antibiotic Stewardship: In Need for New Directions

BACKGROUND AND AIMS

Patients undergoing surgery are prone to infections, either at the site of surgery (superficial or organ-space) or at remote sites (e.g. pneumonia or urinary tract). Surgical site infections are associated with substantial morbidity and mortality, increased length of hospital stay and represent a huge burden to the health economy across all healthcare systems. Here we discuss recent advances and challenges in the field of surgical site infections.

MATERIAL AND METHODS

Review of pertinent English language literature.

RESULTS

Numerous guidelines and recommendations have been published in order to prevent surgical site infections. Compliance with these evidence-based guidelines vary and has not resulted in any major decrease in the surgical site infection rate. To date, most efforts to reduce surgical site infection have focused on the role of the surgeon, but a more comprehensive approach is necessary.

CONCLUSION

Surgical site infections need to be addressed in a structured way, including checklists, audits, monitoring, and measurements. All stakeholders, including the medical profession, the society, and the patient, need to work together to reduce surgical site infections. Most surgical site infections are preventable-and we need a paradigm shift to tackle the problem.

Association Between Compliance to an Enhanced Recovery Protocol and Outcome After Elective Surgery for Gastric Cancer. Results from a Western Population-Based Prospective Multicenter Study

BACKGROUND

The association between compliance to an enhanced recovery protocol (ERAS) and outcome after surgery for gastric cancer has been poorly investigated, particularly in Western patients. The aim of the study was to evaluate whether the rate of adherence to the ERAS program was correlated with outcome and time of discharge.

METHODS

A prospective, observational, multicenter study was designed to be performed at Italian referral centers for gastric surgery. The protocol was discussed and approved by the Italian Research Group on Gastric Cancer. Twenty-three ERAS domains were applied. A multivariate logistic regression was used to assess the association between ERAS compliance and overall and major complication rates. The Poisson regression model (measured as mean ratios) was used to assess the association of ERAS compliance rate and length of stay (LOS).

RESULTS

Eight centers participated and 290 subjects with a median age of 73 years were enrolled. The overall rates of adherence to pre-, intra-, and postoperative ERAS items were 69.8%, 60.3%, and 82.5%, respectively. At the multivariate model, there was an association between overall rate of morbidity and an overall ERAS compliance rate greater than 70% (OR 0.413; 95% CI 0.235-0.7240; P 0.002). A similar association was found for major complications (OR 0.328; 95% CI 0.151-0.709; P 0.005). The Poisson regression showed that in patients with ERAS compliance rate >70%, LOS was reduced of approximately 20% (mean ratio 0.812; 95% CI 0.694-0.950; P 0.009).

CONCLUSIONS

These results suggest a moderate compliance to an ERAS program and a significant association between adherence and outcomes.

Enhanced recovery after surgery (ERAS) in elective intertrochanteric fracture patients result in reduced length of hospital stay (LOS) without compromising functional outcome

Background

Enhanced recovery after surgery (ERAS) has rapidly gained popularity among hip or knee arthroplasty area which can decrease hospital length of stay (LOS). However, limited data exist regarding its safety and efficacy among intertrochanteric fracture patients. The purpose of this study was to determine if LOS associated with intertrochanteric fracture patients can be improved following an existing orthopedic ERAS procedure.

Methods

We reviewed the outcomes of all patients who had been treated with the PFNA intramedullary fixation at our institution. Open fractures, metastatic pathological fractures, patients unable to walk independently before fracture and patients with Alzheimer's disease were excluded. A quasi-experimental study was adopted between patients treated in an ERAS after intramedullary fixation with those rehabilitated on a traditional pathway. Clinical and demographic data were collected among the two pathway cohorts including LOS, Harris hip scores (HHS), visual analog scale (VAS), and activity of daily living scale (ADL).

Results

A total of 100 intertrochanteric fracture patients (ERAS pathway 50 cases, traditional care pathway 50 cases) were selected between January 2016 and December 2017 met the inclusion criteria. ERAS procedure was associated with shorter LOS, lower postoperative VAS scores, reduced opioid consumption, earlier mobilization, significant improvement in the mean HHS scores at 3 months postoperatively, lower risk of complications, lower rates of readmission, and reoperation and higher likelihood of being discharged home. The mean LOS decreased from 8.21 ± 0.83 days to 5.82 ± 0.64 days after implementation of the evidence-based orthopedic ERAS pathway (p < 0.05).

Conclusions

This series of intertrochanteric fracture patients treated with the orthopedic ERAS procedure demonstrated that the procedure is capable of reducing LOS and preserving hip function without compromising functional outcome. This improvement was possible without a concomitant increase in postoperative complications and readmission rates.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Current practice and physicians' opinion about preoperative hair removal as a part of ERAS pathway implementation in gynecology and gynecology-oncology: a NOGGO-AGO survey of 148 gynecological departments in Germany

PURPOSE

To gather standardized information about current practices and doctors' opinions on preoperative hair removal (PHR) from the surgical site and to evaluate the extent of PHR as one of the elements of enhanced recovery after surgery (ERAS) pathways that is established in the clinical routine in gynecology and gynecology-oncology departments in Germany.

METHODS

We performed a nationwide survey among 638 primary, secondary and tertiary health care gynecological departments in Germany. Data were obtained by sending a multiple-choice questionnaire about preoperative management of hair removal. The authors also evaluated the awareness of doctors regarding PHR as well as the method and time frames of PHR. The results were compared to the existing standard of procedure (SOP) and guidelines.

RESULTS

148 units (23.2%) took part in the survey; participants in the survey were mostly chief physicians in 47.3% of the cases. Half (50.7%) of all the responses came from certified gynecological cancer centers. A SOP regarding PHR was reported as present in 113 clinics (76.4%). 83.8% of all units are performing PHR for midline laparotomy, 52.7% in laparoscopic operations, and 45.3% in vaginal operations. 48% used a clipper, while 43.2% utilized a single-use razor. 56.1% shaved instantly before the operation, whereas 35.8% did it the day before and earlier. 40.3% of chief physicians believe that PHR causes more surgical site infections (SSI) compared to only 11.5% of junior doctors.

CONCLUSION

PHR in gynecological departments in Germany is performed very heterogeneously and SOPs are often not based on guidelines and ERAS principles. Around one-third of the German gynecological clinics keep strictly to the guidelines. The awareness on PHR and SSI among junior doctors is very low.

Risk factors for ileus after hip and knee arthroplasty

PURPOSE

Postoperative ileus (POI) is one of the complications that can occur after every surgical procedure including arthroplasty. It can have detrimental consequences for the patient and portrays an economic burden on health care systems. The risk factors for POI after arthroplasty described in the literature are scarce and include hip arthroplasty, male gender and previous abdominal surgery. The purpose of the study was to determine the risk factors for POI after hip and knee arthroplasty.

METHODS

A retrospective review of 2760 patients undergoing primary hip and knee arthroplasty was performed. An in-depth analysis of patient history and physical operative and postoperative course was reviewed and statistically analyzed in a univariate and multivariate setting.

RESULTS

Overall incidence of POI was 0.54%. History of myocardial infarction and chronic kidney disease were statistically significant risk factors for developing POI after arthroplasty with values of p = 0.023 and p = 0.004, respectively. Other risk factors included previous abdominal surgery (p < 0.001) and hip arthroplasty (p = 0.026). Age or gender correlations were not observed.

CONCLUSIONS

Although postoperative ileus is an uncommon complication after joint arthroplasty, in addition to the known risk factors of male age, hip arthroplasty, and previous abdominal surgery, this study describes two previously unknown risk factors: chronic kidney disease and history of myocardial infarction. Patients with these risk factors should be monitored closely for developing postoperative ileus.

Pain management in patients with vascular disease

Vascular disease covers a wide range of conditions, including arterial, venous, and lymphatic disorders, with many of these being more common in the elderly. As the population ages, the incidence of vascular disease will increase, with a consequent increase in the requirement to manage both acute and chronic pain in this patient population. Pain management can be complex, as there are often multiple co-morbidities to be considered. An understanding of the underlying pain mechanisms is helpful in the logical direction of treatment, particularly in chronic pain states, such as phantom limb pain or complex regional pain syndrome. Acute pain management for vascular surgery presents a number of challenges, including coexisting anticoagulant medication, that may preclude the use of regional techniques. Within the limited evidence base, there is a suggestion that epidural analgesia provides better pain relief and reduced respiratory complications after major vascular surgery. For carotid endarterectomy, there is again some evidence supporting the use of local anaesthetic analgesia, either by infiltration or by superficial cervical plexus block. Chronic pain in vascular disease includes post-amputation pain, for which well-known risk factors include high pain levels before amputation and in the immediate postoperative period, emphasizing the importance of good pain control in the perioperative period. Complex regional pain syndrome is another challenging chronic pain syndrome with a wide variety of treatment options available, with the strongest evidence being for physical therapies. Further research is required to gain a better understanding of the underlying pathophysiological mechanisms in pain associated with vascular disease and the best analgesic approaches to manage it.

[Thoracoscopic pulmonary resection for metastatic lesion without pleural drainage: initial experience]

AIM

To analyze the possibility of thoracoscopic pulmonary resection for metastatic lesion without pleural drainage.

MATERIAL AND METHODS

There were 10 patients aged 53.8 years. Most of patients had solitary lung injury within 3 cm from the visceral pleura on the average. Surgical treatment was performed in standard fashion: hardware atypical pulmonary resection within healthy tissues. Pleural cavity was drained with 24 Fr tube. After that lung was inflated under visual control. Since wounds were closured residual air was evacuated by active aspiration and drainage tube was removed. Control chest X-ray was performed in 2 hours and 1 day after surgery.

RESULTS

The technique was successful in all patients. Mean surgery time was 52 minutes. There was no blood loss in all patients. Pneumo- and/or hydrothorax were absent according to control chest X-ray in postoperative period. Mean length of postoperative hospital-stay was 3 days (median 2 days). There were no cases of repeated hospitalization.

Postoperative local incision analgesia for acute pain treatment in patients with hepatocellular carcinoma

OBJECTIVE

The present study aimed to investigate the analgesic effect and safety of using local incision analgesia to treat acute postoperative pain in patients with hepatocellular carcinoma (HCC).

METHOD

A cohort of 60 patients undergoing liver cancer resection was randomly divided into three groups (n=20 per group): local incision analgesia (LIA) group, which received local infiltration with ropivacaine combined with a postoperative analgesia pump; intravenous patient-controlled analgesia (PCA) group, which received fentanyl intravenous analgesia postoperatively; and the control group, which received tramadol hydrochloride injection postoperatively according to the NRS scoring system. The postoperative analgesic effect in each group was compared and tumor recurrence (survival) was analyzed using the Kaplan-Meier method.

RESULTS

NRS scores, rate of analgesic usage, ambulation time (h) and intestinal function recovery time (h) were significantly reduced in LIA group compared with the control group at each postoperative time point (6, 12, 24 and 48 hours; p<0.05). Additionally, the NRS scores of LIA patients at 12 hours post-surgery was significantly reduced compared with PCA group (p<0.05), and the occurrence of postoperative adverse events in LIA group was significantly lower than that in PCA group (p<0.05). Survival analysis demonstrated that the mean survival time (tumor recurrence) was significantly increased in LIA group compared with the control group (χ2=4.749; p=0.029).

CONCLUSION

Local incision analgesia improves the analgesic effect, causes fewer adverse reactions and increases postoperative survival time. Our study demonstrated that local incision analgesia is a safe and effective method of postoperative pain management following hepatectomy.

Osteopathic Manipulative Treatment in Surgical Care: Short Review of Research Publications in Osteopathic Journals During the Period 1990 to 2017

Background.

A growing trend in surgical care is the investigation and incorporation of multimodal interventions into standardized programs. Additionally, manual therapies such as osteopathic manipulative treatment (OMT) are being used with patients in surgical care. Yet the scientific dialogue and the use of OMT in surgical care are currently insubstantial.

Objective.

The aim of this study was to present an overview of published research articles within the subject field of OMT in surgical care.

Method.

Summative review of peer-reviewed research articles published in osteopathic journals during the period 1990 to 2017. In total, 10 articles were identified.

Result.

Previous research has been conducted within the areas of abdominal, thoracic, gynecological, and/or orthopedic surgery with measured outcomes such as pain, analgesia consumption, length of hospital stay, and range of motion. Heterogeneity was identified in usage of osteopathic techniques, treatment duration, and occurrence, as well as in the treating osteopath’s experience.

Conclusion.

Despite the small number of research articles within this field, both positive measured effects as well as the absence of such effects were identified. Overall, there was a heterogeneity concerning surgical contexts, diagnoses, signs and symptoms, as well as surgical phases in current interprofessional osteopathic publications. In this era of multimodal surgical care, we argue that there is an urgent need to evaluate OMT in this context of care and with a proper research approach.

Enhanced Recovery after Vascular Surgery

The beginnings of the enhanced recovery after surgery (ERAS) program were first developed for patients in colorectal surgery, and after it was established as the standard of care in this surgical field, it began to be applied in many others surgical areas. This is multimodal, evidence-based approach program and includes simultaneous optimization of preoperative status of patients, adequate selection of surgical procedure and postoperative management. The aim of this program is to reduce complications, the length of hospital stay and to improve the patients outcome. Over the past decades, special attention was directed to the postoperative management in vascular surgery, especially after major vascular surgery because of the great risk of multiorgan failure, such as: respiratory failure, myocardial infarction, hemodynamic instability, coagulopathy, renal failure, neurological disorders, and intra-abdominal complications. Although a lot of effort was put into it, there is no unique acceptable program for ERAS in this surgical field, and there is still a need to point out the factors responsible for postoperative outcomes of these patients. So far, it is known that special attention should be paid to already existing diseases, type and the duration of the surgical intervention, hemodynamic and fluid management, nutrition, pain management, and early mobilization of patients.

Predictors of morbidity and mortality post emergency abdominal surgery: A national study

BACKGROUND/AIM

Emergency surgeries have increased in Saudi Arabia. This study examines these surgeries and associated complications.

PATIENTS AND METHODS

This was a prospective multicenter cohort study of patients undergoing emergency intraperitoneal surgery from the eight health sectors of Saudi Arabia. Patients' data were collected over 14 days.

RESULTS

In total, 283 patients were included (163 men [54.06%]). The majority of cases were open surgery (204 vs. 79). The 24 h and 30-day mortality rates for the cohort were 0.7 and 2.47%, respectively. Twenty-nine patients (10.24%) required re-intervention, while 19 (8.12%) needed critical care admission. The median length of hospital stay was 3 days. Multivariate analysis showed American Society of Anesthesiologist (ASA) classification score (P = 0.0003), diagnosis (P < 0.0001), stoma formation (P = 0.0123), and anastomotic leak (P = 0.0015) to correlate significantly with 30-day mortality.

CONCLUSION

American Society of Anesthesiologist score, diagnosis, stoma formation and anastomotic leak are associated with 30-day mortality after emergency surgery in Saudi Arabia.

Perioperative Outcomes From the Prospective Multicenter Least Invasive Fast-Track EVAR (LIFE) Registry

Purpose: To determine the feasibility, perioperative resource utilization, and safety of a fast-track endovascular aneurysm repair (EVAR) protocol in well-selected patients. Methods: Between October 2014 and May 2016, the LIFE (Least Invasive Fast-track EVAR) registry ( ClinicalTrials.gov identifier NCT02224794) enrolled 250 patients (mean age 73±8 years; 208 men) in a fast-track EVAR protocol comprised of bilateral percutaneous access using the 14-F Ovation stent-graft, no general anesthesia, no intensive care unit (ICU) admission, and next-day discharge. The primary endpoint was major adverse events (MAE) through 30 days. The target performance goal for the MAE endpoint was 10.4%. Results: Vascular access, stent-graft delivery, and stent-graft deployment success were 100%. A total of 216 (86%) patients completed all elements of the fast-track EVAR protocol. Completion of individual elements was 98% for general anesthesia avoidance, 97% for bilateral percutaneous access, 96% for ICU avoidance, and 92% for next-day discharge. Perioperative outcomes included mean procedure time of 88 minutes, median blood loss of 50 mL, early oral nutrition (median 6 hours), early mobilization (median 8 hours), and short hospitalization (median 26 hours). Fast-track EVAR completers had shorter procedure time (p<0.001), less blood loss (p=0.04), faster return to oral nutrition (p<0.001) and ambulation (p<0.01), and shorter hospital stay (p<0.001). With 241 (96%) of the 250 patients returning for the 30-day follow-up, the MAE incidence was 0.4% (90% CI 0.1% to 1.8%), significantly less than the 10.4% performance goal (p<0.001). No aneurysm rupture, conversion to surgery, or aneurysm-related secondary procedure was reported. There were no type III endoleaks and 1 (0.4%) type I endoleak. Iliac limb occlusion was identified in 2 (0.8%) patients. The 30-day hospital readmission rate was 1.6% overall. Conclusion: A fast-track EVAR protocol was feasible in well-selected patients and resulted in efficient perioperative resource utilization with excellent safety and effectiveness.

Research progress of fast track surgery

The purpose of surgical treatment is to remove the lesions, repair tissue, and reconstruct organ function, but the process will inevitably cause certain degrees of trauma and stress. As a traumatic treatment, surgical treatment can produce a series of pathophysiological changes while achieving the therapeutic effect. Surgical complications are significantly associated with perioperative stress. Therefore, controlling operation-related stress can effectively improve prognosis. In order to reduce the incidence of surgical stress and postoperative complications and promote the rehabilitation of patients as soon as possible, the concept of fast track surgery has been put forward in recent years. It is supported by evidence-based medicine and subverts the traditional concept of surgery, optimizing the multidisciplinary cooperation in the perioperative treatment and rehabilitation process. Moreover, it accelerates the recovery of postoperative patients. Since the concept was put forward, it has been widely applied in European and American countries in the fields of gastroenterology, cardiothoracic surgery, orthopedics, urology, and gynecology. This paper briefly reviews the advances of fast track surgery in recent years.

Enhanced Recovery After Surgery (ERAS) Protocol Enables Safe Same-Day Discharge After Alloplastic Breast Reconstruction

BACKGROUND

To compare enhanced recovery after surgery (ERAS) with traditional recovery after surgery (TRAS) for patients undergoing alloplastic breast reconstruction.

METHODS

A retrospective chart review of 2 patient groups (ERAS and TRAS) undergoing alloplastic breast reconstruction was performed. Data were collected from 2012 to 2013 (TRAS) and from 2013 to 2016 (ERAS). The ERAS protocol included day surgery, multimodal analgesia, and preoperative anti-emetic. The TRAS pathway involved overnight admission, narcotic-based analgesia, and no preoperative anti-emetic. Demographics, operative variables, and complications were compared between groups.

RESULTS

Seventy-eight ERAS patients and 78 TRAS patients were included. Length of stay was shorter for ERAS patients (0.38 nights ERAS and 1.45 nights TRAS; P < .001). The ERAS patients underwent significantly more bilateral surgery (80.8% ERAS and 55.1% TRAS; P < .001), immediate reconstruction (98.6% ERAS and 89.3% TRAS; P = .004), and had more implants versus expanders placed (66% [93/141] ERAS and 24.8% TRAS; P < .001). There were no differences in the number of post-operative emergency department visits (8% ERAS and 14% TRAS; P = .2) and readmissions (8% ERAS and 3.8% TRAS; P = .3) between the groups. There was no difference in the rate of hematoma (0.7% ERAS and 0% TRAS; P = .35), infection requiring explantation (1.4% ERAS and 0.8% TRAS; P = .65), infection requiring outpatient IV antibiotics (1.4% ERAS and 2.5% TRAS; P = .53), and infection requiring IV antibiotics and readmission (2.1% ERAS and 1.7% TRAS; P = .78) between the groups. There were no differences in the number of minor complications (22% ERAS and 23% TRAS; P = .82).

CONCLUSION

The ERAS protocol for alloplastic breast reconstruction is safe, without increased readmission or complication rates compared to TRAS, and significantly decreased length of stay.

Fast-Track Surgery in Intestinal Deep Infiltrative Endometriosis

Fast-track (FT), also known as enhanced recovery after surgery (ERAS), is an integrated management of patients undergoing surgery, which is focused on optimal recovery and improvement of the overall quality of care. Minimally invasive surgery is the gold standard to diagnose and treat endometriosis, and its beneficial role within the FT program was reviewed. A search was performed for recent medical literature regarding the findings of the FT approach applied to intestinal deep infiltrative endometriosis surgery. This pathway comprises a diverse number of procedures arranged in preoperative, intraoperative, and postoperative settings. Evidence-based findings in randomized clinical trials have repeatedly shown that these protocols lead to enhanced recovery after surgery, reduced morbidity and mortality with a reduction in postoperative complications, and with readmission rates similar to conventional regimes.

Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a multimodal pathway developed to overcome the deleterious effect of perioperative stress after major surgery. In colorectal surgery, ERAS pathways reduced perioperative morbidity, hospital stay and costs. Similar concept should be applied for liver surgery. This study presents the specific ERAS Society recommendations for liver surgery based on the best available evidence and on expert consensus.

METHODS

A systematic review was performed on ERAS for liver surgery by searching EMBASE and Medline. Five independent reviewers selected relevant articles. Quality of randomized trials was assessed according to the Jadad score and CONSORT statement. The level of evidence for each item was determined using the GRADE system. The Delphi method was used to validate the final recommendations.

RESULTS

A total of 157 full texts were screened. Thirty-seven articles were included in the systematic review, and 16 of the 23 standard ERAS items were studied specifically for liver surgery. Consensus was reached among experts after 3 rounds. Prophylactic nasogastric intubation and prophylactic abdominal drainage should be omitted. The use of postoperative oral laxatives and minimally invasive surgery results in a quicker bowel recovery and shorter hospital stay. Goal-directed fluid therapy with maintenance of a low intraoperative central venous pressure induces faster recovery. Early oral intake and mobilization are recommended. There is no evidence to prefer epidural to other types of analgesia.

CONCLUSIONS

The current ERAS recommendations were elaborated based on the best available evidence and endorsed by the Delphi method. Nevertheless, prospective studies need to confirm the clinical use of the suggested protocol.

Fast track in hip arthroplasty

‘Fast-track’ surgery was introduced more than 20 years ago and may be defined as a co-ordinated peri-operative approach aimed at reducing surgical stress and facilitating post-operative recovery.

The fast-track programmes have now been introduced into total hip arthroplasty (THA) surgery with reduction in post-operative length of stay, shorter convalescence and rapid functional recovery without increased morbidity and mortality. This has been achieved by focusing on a multidisciplinary collaboration and establishing ‘fast-track’ units, with a well-defined organisational set-up tailored to deliver an accelerated peri-operative course of fast-track surgical THA procedures.

Fast-track THA surgery now works extremely well in the standard THA patient. However, all patients are different and fine-tuning of the multiple areas in fast-track pathways to get patients with special needs or high co-morbidity burden through a safe and effective fast-track THA pathway is important.

In this narrative review, the principles of fast-track THA surgery are presented together with the present status of implementation and perspectives for further improvements.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160060. Originally published online at www.efortopenreviews.org