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Lin W, Yang Y, Zhuo Y, Qiu C, Guo Y, Yao Y. Efficacy of intraoperative systemic lidocaine on quality of recovery after laparoscopic colorectal surgery: a randomized controlled trial. Ann Med 2024; 56:2315229. [PMID: 38346397 PMCID: PMC10863528 DOI: 10.1080/07853890.2024.2315229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 02/01/2024] [Indexed: 02/15/2024] Open
Abstract
INTRODUCTION Many clinical trials have demonstrated the benefits of intraoperative systemic lidocaine administration in major abdominal surgeries. We tested the hypothesis that systemic lidocaine is associated with an enhanced early quality of recovery in patients following laparoscopic colorectal resection. PATIENTS AND METHODS We randomly allocated 126 patients scheduled for laparoscopic colorectal surgery in a 1:1 ratio to receive either lidocaine (1.5 mg kg-1 bolus over 10 min, followed by continuous infusion at 2 mg kg-1 h-1 until the end of surgery) or identical volumes and rates of saline. The primary outcome was the Quality of Recovery-15 score assessed 24 h after surgery. Secondary outcomes were areas under the pain numeric rating scale curve over time, 48-h morphine consumption, and adverse events. RESULTS Compared with saline, systemic lidocaine improved the Quality of Recovery-15 score 24 h postoperatively, with a median difference of 4 (95% confidence interval: 1-6; p = 0.015). Similarly, the area under the pain numeric rating scale curve over 48 h at rest and on movement was reduced in the lidocaine group (p = 0.004 and p < 0.001, respectively). However, these differences were not clinically meaningful. Lidocaine infusion reduced the intraoperative remifentanil requirements but not postoperative 48-h morphine consumption (p < 0.001 and p = 0.34, respectively). Additionally, patients receiving lidocaine had a quicker and earlier return of bowel function, as indicated by a shorter time to first flatus (log-rank p < 0.001), yet ambulation time was similar between groups (log-rank test, p = 0.11). CONCLUSIONS In patients undergoing laparoscopic colorectal surgery, intraoperative systemic lidocaine resulted in statistically but not clinically significant improvements in quality of recovery (see Graphical Abstract).Trial registration: Chinese Clinical Trial Registry; ChiCTR1900027635.
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Affiliation(s)
- Wenjun Lin
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Ying Yang
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Yifen Zhuo
- Department of Anesthesiology, Xiamen Haicang Hospital, Xiamen, China
| | - Chunlin Qiu
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Yanhua Guo
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Yusheng Yao
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
- Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou, China
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Pesce A, Portinari M, Fabbri N, Sciascia V, Uccellatori L, Vozza M, Righini E, Feo CV. Impact of enhanced recovery program on clinical outcomes after elective colorectal surgery in a rural hospital. A single center experience. Heliyon 2024; 10:e33989. [PMID: 39071659 PMCID: PMC11282988 DOI: 10.1016/j.heliyon.2024.e33989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/06/2024] [Accepted: 07/01/2024] [Indexed: 07/30/2024] Open
Abstract
Background The main purpose was to determine the impact on postoperative outcomes of a standardized enhanced recovery program (ERP) for elective colorectal surgery in a rural hospital. Methods A prospective series of patients (N = 80) undergoing elective colorectal resection completing a standardized ERP protocol in 2018-2020 (ERP group) was compared to patients (N = 80) operated at the same rural hospital in 2013-2015 (pre-ERP group), before the implementation of the program. The exclusion criteria for both groups were: ASA score IV, TNM stage IV, inflammatory bowel disease, emergency surgery, and rectal cancer. The primary outcome was hospital length of stay (LoS) which was used as an estimate of functional recovery. Secondary outcomes included 30-day readmission and mortality rates as well as associated factors with both postoperative complications and prolonged hospital LoS. Results Baseline characteristics were comparable in both groups. The median adherence to ERP protocol elements was 68 % versus 12 % in the retrospective control group. The median hospital LoS in the ERP-group was significantly lower than in the pre-ERP group (5 vs. 10 days) with no increase in 30-day readmission and mortality rates. The Body Mass Index ≥30 and the traditional peri-operative protocol were the associated factors to postoperative complications, while following a traditional peri-operative protocol was the only factor associated with a prolonged hospital LoS (p < 0.0001). Conclusions Although limited hospital resources are perceived as a barrier to ERP implementation, the current experience demonstrates how adopting an ERP program in a rural area is feasible and effective, despite it requires greater effort.
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Affiliation(s)
- Antonio Pesce
- Unit of General Surgery, Department of Surgery, Azienda Unità Sanitaria Locale of Ferrara, University of Ferrara, Ferrara, Italy
| | - Mattia Portinari
- Unit of Surgery 2, Department of Surgery, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Nicolò Fabbri
- Unit of General Surgery, Department of Surgery, Azienda Unità Sanitaria Locale of Ferrara, University of Ferrara, Ferrara, Italy
| | - Valeria Sciascia
- Unit of General Surgery, Department of Surgery, Azienda Unità Sanitaria Locale of Ferrara, University of Ferrara, Ferrara, Italy
| | - Lisa Uccellatori
- Unit of General Surgery, Department of Surgery, Azienda Unità Sanitaria Locale of Ferrara, University of Ferrara, Ferrara, Italy
| | - Michela Vozza
- Unit of Anesthesia and Intensive Care, Department of Emergency, Azienda Unità Sanitaria Locale of Ferrara, Ferrara, Italy
| | - Erminio Righini
- Unit of Anesthesia and Intensive Care, Department of Emergency, Azienda Unità Sanitaria Locale of Ferrara, Ferrara, Italy
| | - Carlo V. Feo
- Unit of General Surgery, Department of Surgery, Azienda Unità Sanitaria Locale of Ferrara, University of Ferrara, Ferrara, Italy
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Gianotti L, Nespoli L, Sandini M. Pharmaconutrition: Which substrates? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:106798. [PMID: 36526494 DOI: 10.1016/j.ejso.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/10/2022] [Indexed: 12/14/2022]
Abstract
With the term "pharmaconutrition" or "immunonutrition" is intended the use of specific nutritional substrates having the ability of modulating specific mechanisms involved in several immune and inflammatory pathways. To achieve these goals, these substrates have to be administered with over physiologic dose. Glutamine and omega-3 polyunsaturated fatty acids, used as single substrate, did not show clear clinical advantages on solid endpoints such as postoperative complications. Despite several multiple substrate enteral feeds are available on the market, very few of them have been tested in randomized clinical trial to prove efficacy. The most extensive investigated formulation is a combination of arginine, omega-3 fatty acids, ribonucleic acid with or without glutamine. Several meta-analyses of randomized clinical trials have been conducted to compare the effects of enteral immunonutrition with control diets on post-surgical morbidity. The results consistently showed that the use of enteral multiple substrate formulas significantly reduced infectious complications and duration of hospitalization. In a more contemporary view, pharmaconutrition should be tested more accurately in the contest of enhanced recovery programs, during neoadjuvant chemotherapy, and in the prehabilitation setting.
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Affiliation(s)
- Luca Gianotti
- School of Medicine and Surgery, Milano-Bicocca University, Department of Surgery, IRCCS San Gerardo Hospital, Monza, Italy.
| | - Luca Nespoli
- School of Medicine and Surgery, Milano-Bicocca University, Department of Surgery, IRCCS San Gerardo Hospital, Monza, Italy
| | - Marta Sandini
- Surgical Oncology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
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Chan KS, Liu B, Tan MNA, How KY, Wong KY. Feasibility and safety of minimally invasive multivisceral resection for T4b rectal cancer: A 9-year review. World J Gastrointest Surg 2024; 16:777-789. [PMID: 38577068 PMCID: PMC10989345 DOI: 10.4240/wjgs.v16.i3.777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/09/2024] [Accepted: 02/18/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Colorectal cancer is the third most common cancer and the second highest cause of cancer-related mortality worldwide. About 5%-10% of patients are diagnosed with locally advanced rectal cancer (LARC) on presentation. For LARC invading into other structures (i.e. T4b), multivisceral resection (MVR) and/or pelvic exenteration (PE) remains the only potential curative surgical treatment. MVR and/or PE is a major and complex surgery with high post-operative morbidity. Minimally invasive surgery (MIS) has been shown to improve short-term post-operative outcomes in other gastrointestinal malignancies, but there is little evidence on its use in MVR, especially so for robotic MVR. AIM To assess the feasibility and safety of minimally invasive MVR (miMVR), and compare post-operative outcomes between robotic and laparoscopic MVR. METHODS This is a single-center retrospective cohort study from 1st January 2015 to 31st March 2023. Inclusion criteria were patients diagnosed with cT4b rectal cancer and underwent MVR, or stage 4 disease with resectable systemic metastases. Patients who underwent curative MVR for locally recurrent rectal cancer, or metachronous rectal cancer were also included. Exclusion criteria were patients with systemic metastases with non-resectable disease. All patients planned for elective surgery were enrolled into the standard enhanced recovery after surgery pathway with standard peri-operative management for colorectal surgery. Complex surgery was defined based on technical difficulty of surgery (i.e. total PE, bladder-sparing prostatectomy, pelvic lymph node dissection or need for flap creation). Our primary outcomes were the margin status, and complication rates. Categorical values were described as percentages and analysed by the chi-square test. Continuous variables were expressed as median (range) and analysed by Mann-Whitney U test. Cumulative overall survival (OS) and recurrence-free survival (RFS) were analysed using Kaplan-Meier estimates with life table analysis. Log-rank test was performed to determine statistical significance between cumulative estimates. Statistical significance was defined as P < 0.05. RESULTS A total of 46 patients were included in this study [open MVR (oMVR): 12 (26.1%), miMVR: 36 (73.9%)]. Patients' American Society of Anesthesiologists score, body mass index and co-morbidities were comparable between oMVR and miMVR. There is an increasing trend towards robotic MVR from 2015 to 2023. MiMVR was associated with lower estimated blood loss (EBL) (median 450 vs 1200 mL, P = 0.008), major morbidity (14.7% vs 50.0%, P = 0.014), post-operative intra-abdominal collections (11.8% vs 50.0%, P = 0.006), post-operative ileus (32.4% vs 66.7%, P = 0.04) and surgical site infection (11.8% vs 50.0%, P = 0.006) compared with oMVR. Length of stay was also shorter for miMVR compared with oMVR (median 10 vs 30 d, P = 0.001). Oncological outcomes-R0 resection, recurrence, OS and RFS were comparable between miMVR and oMVR. There was no 30-d mortality. More patients underwent robotic compared with laparoscopic MVR for complex cases (robotic 57.1% vs laparoscopic 7.7%, P = 0.004). The operating time was longer for robotic compared with laparoscopic MVR [robotic: 602 (400-900) min, laparoscopic: Median 455 (275-675) min, P < 0.001]. Incidence of R0 resection was similar (laparoscopic: 84.6% vs robotic: 76.2%, P = 0.555). Overall complication rates, major morbidity rates and 30-d readmission rates were similar between laparoscopic and robotic MVR. Interestingly, 3-year OS (robotic 83.1% vs 58.6%, P = 0.008) and RFS (robotic 72.9% vs 34.3%, P = 0.002) was superior for robotic compared with laparoscopic MVR. CONCLUSION MiMVR had lower post-operative complications compared to oMVR. Robotic MVR was also safe, with acceptable post-operative complication rates. Prospective studies should be conducted to compare short-term and long-term outcomes between robotic vs laparoscopic MVR.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Biquan Liu
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | | | - Kwang Yeong How
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Kar Yong Wong
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
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Huang PY, Tsai MC, Kiu KT, Yen MH, Chang TC. Collagen patch cover facilitates recovery of bowel function after laparoscopic colectomy. BMC Surg 2024; 24:66. [PMID: 38378522 PMCID: PMC10880318 DOI: 10.1186/s12893-024-02339-w] [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: 10/01/2023] [Accepted: 01/31/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Numerous factors can influence bowel movement recovery and anastomotic healing in colorectal surgery, and poor healing can lead to severe complications and increased medical expenses. Collagen patch cover (CPC) is a promising biomaterial that has been demonstrated to be safe in animal models and has been successfully applied in various surgical procedures in humans. This study. METHODS A retrospective review of medical records from July 2020 to June 2022 was conducted to identify consecutive patients who underwent laparoscopic colectomy. Patients who received CPC at the anastomotic site were assigned to the collagen group, whereas those who did not receive CPC were assigned to the control group. RESULTS Data from 241 patients (collagen group, 109; control group, 132) were analyzed. Relative to the control group, the collagen group exhibited a faster recovery of bowel function, including an earlier onset of first flatus (2.93 days vs. 3.43 days, p < 0.01), first defecation (3.73 days vs. 4.18 days, p = 0.01), and oral intake (4.30 days vs. 4.68 days, p = 0.04). CPC use was also associated with lower use of postoperative intravenous analgesics. The complication rates in the two groups did not differ significantly. CONCLUSIONS CPCs can be safely and easily applied to the anastomotic site during laparoscopic colectomy, and can accelerate bowel movement recovery. Further studies on the effectiveness of CPCs in colorectal surgery involving larger sample sizes are required. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov registration number: NCT05831956 (26/04/2023).
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Affiliation(s)
- Pin-Yang Huang
- Department of General Medicine, Taipei Medical University Shuang-Ho Hospital, No. 291, Zhongzheng Road, Zhonghe District, New Taipei City, 235, Taiwan
| | - Meng-Che Tsai
- Department of General Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi County, No. 291, Zhongzheng Road, Zhonghe District, New Taipei City, 235, Taiwan
| | - Kee-Thai Kiu
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Shuang-Ho Hospital, No. 291, Zhongzheng Road, Zhonghe District, New Taipei City, 235, Taiwan
| | - Min-Hsuan Yen
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Shuang-Ho Hospital, No. 291, Zhongzheng Road, Zhonghe District, New Taipei City, 235, Taiwan
| | - Tung-Cheng Chang
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Shuang-Ho Hospital, No. 291, Zhongzheng Road, Zhonghe District, New Taipei City, 235, Taiwan.
- Division of Colorectal Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, No. 291, Zhongzheng Road, Zhonghe District, New Taipei City, 235, Taiwan.
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Seow-En I, Wu J, Tan IEH, Zhao Y, Seah AWM, Wee IJY, Ying-Ru Ng Y, Kwong-Wei Tan E. Transanal Total Mesorectal Excision With Delayed Coloanal Anastomosis (TaTME-DCAA) Versus Laparoscopic Total Mesorectal Excision (LTME) and Robotic Total Mesorectal Excision (RTME) for Low Rectal Cancer: A Propensity Score-Matched Analysis of Short-term Outcomes, Bowel Function, and Cost. Surg Laparosc Endosc Percutan Tech 2024; 34:54-61. [PMID: 37987634 PMCID: PMC10829900 DOI: 10.1097/sle.0000000000001247] [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: 05/27/2023] [Accepted: 10/17/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Total mesorectal excision (TME) with delayed coloanal anastomosis (DCAA) is surgical option for low rectal cancer, replacing conventional immediate coloanal anastomosis (ICAA) with bowel diversion. This study aimed to assess the outcomes of transanal TME (TaTME) with DCAA versus laparoscopic TME (LTME) with ICAA versus robotic TME (RTME) with ICAA. METHODS This was a retrospective propensity score-matched analysis of patients who underwent elective TaTME-DCAA between November 2021 and June 2022. Patients were propensity-score matched in a ratio of 1:3 to patients who underwent LTME-ICAA and RTME-ICAA from January 2019 to December 2020. Outcome measures were histopathologic results, postoperative morbidity, function, and inpatient costs. RESULTS Twelve patients in the TaTME-DCAA group were compared with 36 patients in the LTME-ICAA and RTME-ICAA groups each after propensity score matching. Histopathologic results and postoperative morbidity rates were statistically similar. Overall stoma-related complication rates in the ICAA groups were 11%. Median total length of hospital stays for TME plus stoma reversal surgery was similar across all techniques (10 vs. 10 vs. 9 days; P =0.532). Despite a significantly shorter duration of follow-up, bowel function after TaTME-DCAA was comparable to that of LTME-ICAA and RTME-ICAA. Overall median inpatient costs of TaTME-DCAA were comparable to LTME-ICAA and significantly cheaper than RTME-ICAA ($31,087 vs. $29,927 vs. $36,750; P =0.002). CONCLUSIONS TaTME with DCAA is a feasible and safe technique compared with other minimally invasive methods of TME, while avoiding bowel diversion and stoma-related complications, as well as comparing favorably in terms of overall hospitalization costs.
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Affiliation(s)
- Isaac Seow-En
- Department of Colorectal Surgery, Singapore General Hospital
| | - Jingting Wu
- Department of Colorectal Surgery, Singapore General Hospital
| | | | - Yun Zhao
- Group Finance Analytics, Singapore Health Services, Singapore
| | | | - Ian Jun Yan Wee
- Department of Colorectal Surgery, Singapore General Hospital
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Arena A, Degli Esposti E, Pazzaglia E, Orsini B, Cau I, Govoni F, Raimondo D, Palermo R, Lenzi J, Casadio P, Seracchioli R. Not All Bad Comes to Harm: Enhanced Recovery After Surgery for Rectosigmoid Endometriosis. J Minim Invasive Gynecol 2024; 31:49-56. [PMID: 37839779 DOI: 10.1016/j.jmig.2023.10.011] [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: 07/10/2023] [Revised: 10/04/2023] [Accepted: 10/08/2023] [Indexed: 10/17/2023]
Abstract
STUDY OBJECTIVE To assess the impact of implementing an enhanced recovery after surgery (ERAS) protocol on the length of hospitalization in women undergoing laparoscopy for rectosigmoid deep infiltrating endometriosis (DIE). DESIGN A retrospective cohort study. SETTING An academic referral center for endometriosis and minimally invasive gynecologic surgery. PATIENTS Women aged between 18 and 50 years scheduled for laparoscopic excision (shaving, full-thickness anterior wall resection, segmental resection) of rectosigmoid endometriosis between February 2017 and February 2023. INTERVENTIONS We divided patients into 2 groups (non-ERAS and ERAS) based on the timing of surgery (before or after March 5, 2020). Starting from this day, restrictions were issued to limit the spread of the coronavirus disease 2019 pandemic, inducing our group to implement an ERAS protocol for patients hospitalized after surgery for posterior DIE. MEASUREMENTS AND MAIN RESULTS We included 579 patients in the analysis, 316 (54.6%) in the non-ERAS group and 263 (45.4%) in the ERAS group. In the ERAS group, we observed a shorter length of hospital stay (5.8 ± 3.1 days vs 4.8 ± 2.9 days; p <.001) and lower complications rates (33, 12.5% vs 60, 19.0%; p = .04), despite a decreased frequency of conservative surgical approaches (shaving procedures 121 vs 196; p <.001). Repeated surgery or hospital readmissions owing to postdischarge complications were infrequent, with no significant differences between the 2 groups. The multiple linear regression analysis strengthened our results given the higher prevalence of bowel resection surgeries (both full-thickness anterior wall or segmental), showing that patients managed with a multimodal protocol had an overall reduction of hospital stay by 1.5 days. CONCLUSION The implementation of an ERAS program in patients undergoing laparoscopic surgery for DIE is associated with a significant reduction in hospital stay, without an increase in perioperative or postoperative complication rates.
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Affiliation(s)
- Alessandro Arena
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli); Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli)
| | - Eugenia Degli Esposti
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli); Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli)
| | - Enrico Pazzaglia
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli); Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli).
| | - Benedetta Orsini
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli); Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli)
| | - Irene Cau
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli)
| | - Francesca Govoni
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli)
| | - Diego Raimondo
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli)
| | - Roberto Palermo
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli); Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli)
| | - Jacopo Lenzi
- Department of biomedical and neuromotor sciences, Alma mater Studiorum, University of Bologna, Bologna, Italy (Dr. Lenzi)
| | - Paolo Casadio
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli)
| | - Renato Seracchioli
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli); Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli)
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Abdelnaby A, Alcabes A. Can Colorectal Surgery Be Performed as an Outpatient Surgery? Adv Surg 2023; 57:279-285. [PMID: 37536859 DOI: 10.1016/j.yasu.2023.04.008] [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] [Indexed: 08/05/2023]
Abstract
The potential to discharge patients safely within the same day after colorectal surgery has developed over time with concurrent advances in concepts of enhanced recovery pathways, along with minimally invasive techniques available to surgeons. The advent of planned same-day discharges after elective colectomy is made possible by research establishing improved length of stay with minimal morbidity in patients undergoing minimally invasive surgery and especially minimally invasive surgery in the setting of an enhanced recovery after surgery (ERAS) protocol. In tracing the timeline of research and development of knowledge in this setting, the safety of outpatient colorectal surgery can be established.
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Affiliation(s)
- Abier Abdelnaby
- Colon and Rectal Surgical Services, Montefiore Medical Center, Bronx, NY, USA; Department of Surgery, The University Hospital for Albert Einstein College of Medicine, 1825 Eastchester Road, Bronx, NY 10461, USA.
| | - Analena Alcabes
- Department of Surgery, The University Hospital for Albert Einstein College of Medicine, 1825 Eastchester Road, Bronx, NY 10461, USA; Montefiore Medical Center, Bronx, NY, USA
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Chan KS, Lo HY, Shelat VG. Carbon footprints in minimally invasive surgery: Good patient outcomes, but costly for the environment. World J Gastrointest Surg 2023; 15:1277-1285. [PMID: 37555111 PMCID: PMC10405111 DOI: 10.4240/wjgs.v15.i7.1277] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/02/2023] [Accepted: 04/18/2023] [Indexed: 07/21/2023] Open
Abstract
Advancements in technology and surgical training programs have increased the adaptability of minimally invasive surgery (MIS). Gastrointestinal MIS is superior to its open counterparts regarding post-operative morbidity and mortality. MIS has become the first-line surgical intervention for some types of gastrointestinal surgery, such as laparoscopic cholecystectomy and appendicectomy. Carbon dioxide (CO2) is the main gas used for insufflation in MIS. CO2 contributes 9%-26% of the greenhouse effect, resulting in global warming. The rise in global CO2 concentration since 2000 is about 20 ppm per decade, up to 10 times faster than any sustained rise in CO2 during the past 800000 years. Since 1970, there has been a steady yet worrying increase in average global temperature by 1.7 °C per century. A recent systematic review of the carbon footprint in MIS showed a range of 6-814 kg of CO2 emission per surgery, with higher CO2 emission following robotic compared to laparoscopic surgery. However, with superior benefits of MIS over open surgery, this poses an ethical dilemma to surgeons. A recent survey in the United Kingdom of 130 surgeons showed that the majority (94%) were concerned with climate change but felt that the lack of leadership was a barrier to improving environmental sustainability. Given the deleterious environmental effects of MIS, this study aims to summarize the trends of MIS and its carbon footprint, awareness and attitudes towards this issue, and efforts and challenges to ensuring environmental sustainability.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Hong Yee Lo
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
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10
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Xu W, Zhou J. The value of mesenteric closure after laparoscopic right hemicolectomy: a scoping review. BMC Surg 2023; 23:134. [PMID: 37198566 DOI: 10.1186/s12893-023-02033-3] [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: 02/15/2023] [Accepted: 05/08/2023] [Indexed: 05/19/2023] Open
Abstract
OBJECTIVE To evaluate the prognostic impact and describe suturing tools of mesenteric closure after laparoscopic right hemicolectomy (LRH). METHODS PubMed, Embase, Cochrane library, Web of Science, and Scopus databases, were searched and publications relating to mesenteric closure data and tools were extracted. Search terms: "Mesenteric Defects" and "Mesenteric Closure" were used, and manual searches of eligible articles from literature reference lists performed. RESULT A total of 7 publications were identified. 5 focused on prognostic impact and 4 referred to tools for mesenteric closure, two of which concerned both prognostic data and tools. All studies related to prognostic impact were single center with "low" modified GRADE quality. A high degree of heterogeneous was found. CONCLUSION The evidence from current research does not support routine closure of mesenteric defects. Use of a polymer ligation clip has produced favorable results in a small sample size trial and further investigation is merited. A large randomized controlled trial is still warranted.
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Affiliation(s)
- Weimin Xu
- Department of Gastrointestinal Surgery, The First Hospital, China Medical University, Shenyang, Liaoning Province, China
- Department of Health Statistics, School of Public Health, China Medical University, Shenyang, China
| | - Jianping Zhou
- Department of Gastrointestinal Surgery, The First Hospital, China Medical University, Shenyang, Liaoning Province, China.
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11
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Mao D, Flynn DE, Yerkovich S, Tran K, Gurunathan U, Chandrasegaram MD. Effect of obesity on post-operative outcomes following colorectal cancer surgery. World J Gastrointest Oncol 2022; 14:1324-1336. [PMID: 36051092 PMCID: PMC9305574 DOI: 10.4251/wjgo.v14.i7.1324] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/10/2022] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) resection is currently being undertaken in an increasing number of obese patients. Existing studies have yet to reach a consensus as to whether obesity affects post-operative outcomes following CRC surgery.
AIM To evaluate the post-operative outcomes of obese patients following CRC resection, as well as to determine the post-operative outcomes of obese patients in the subgroup undergoing laparoscopic surgery.
METHODS Six-hundred and fifteen CRC patients who underwent surgery at the Prince Charles Hospital between January 2010 and December 2020 were categorized into two groups based on body mass index (BMI): Obese [BMI ≥ 30, n = 182 (29.6%)] and non-obese [BMI < 30, n = 433 (70.4%)]. Demographics, comorbidities, surgical features, and post-operative outcomes were compared between both groups. Post-operative outcomes were also compared between both groups in the subgroup of patients undergoing laparoscopic surgery [n = 472: BMI ≥ 30, n = 136 (28.8%); BMI < 30, n = 336 (71.2%)].
RESULTS Obese patients had a higher burden of cardiac (73.1% vs 56.8%; P < 0.001) and respiratory comorbidities (37.4% vs 26.8%; P = 0.01). Obese patients were also more likely to undergo conversion to an open procedure (12.8% vs 5.1%; P = 0.002), but did not experience more post-operative complications (51.6% vs 44.1%; P = 0.06) or high-grade complications (19.2% vs 14.1%; P = 0.11). In the laparoscopic subgroup, however, obesity was associated with a higher prevalence of post-operative complications (47.8% vs 39.3%; P = 0.05) but not high-grade complications (17.6% vs 11.0%; P = 0.07).
CONCLUSION Surgical resection of CRC in obese individuals is safe. A higher prevalence of post-operative complications in obese patients appears to only be in the context of laparoscopic surgery.
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Affiliation(s)
- Derek Mao
- Faculty of Medicine and Health, The University of Sydney, Sydney 2050, New South Wales, Australia
| | - David E Flynn
- Department of General Surgery, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia
| | - Stephanie Yerkovich
- Faculty of Medicine, The University of Queensland, Brisbane 4006, Queensland, Australia
| | - Kayla Tran
- Department of Pathology, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia
| | - Usha Gurunathan
- Faculty of Medicine, The University of Queensland, Brisbane 4006, Queensland, Australia
- Department of Anaesthesia, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia
| | - Manju D Chandrasegaram
- Department of General Surgery, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane 4006, Queensland, Australia
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12
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Tavernier C, Flaris AN, Passot G, Glehen O, Kepenekian V, Cotte E. Assessing Criteria for a Safe Early Discharge After Laparoscopic Colorectal Surgery. JAMA Surg 2021; 157:52-58. [PMID: 34730770 DOI: 10.1001/jamasurg.2021.5551] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Early discharge after colorectal surgery has been advocated. However, there is little research evaluating clinical and/or laboratory criteria to determine who can be safely discharged early. Objective To evaluate the diagnostic performance of a C-reactive protein (CRP) level combined with 4 clinical criteria in ruling out an anastomotic leak and therefore allowing an early discharge on postoperative day 2 or 3. Design, Setting, and Participants This prospective, single-center cohort study was performed between February 2012 and July 2017. All consecutive adult patients undergoing laparoscopic colorectal surgery were included. All patients were followed up for 30 days postoperatively. Data analysis was performed in May 2021. Exposures Whether the 5 discharge criteria were fulfilled on postoperative day 3 (or day 2 for patients discharged on day 2). Fulfillment was defined as a CRP level less than 150 mg/dL on the day of discharge, a return of bowel function, tolerance of a diet, pain less than 5 of 10 on a visual analog scale, and being afebrile during the entire stay. Main Outcomes and Measures The primary outcome measurement was the diagnostic performance of the 5 discharge criteria in anticipating anastomotic leak development. The diagnostic performance of CRP level alone and 4 clinical criteria alone was also evaluated. Secondary measures were anastomotic leaks and mortality rates up to postoperative day 30. A discharge was successful if the patient left the hospital on postoperative day 2 or 3 without any complications or readmissions. Results A total of 287 patients were included (median [IQR] age, 58 [20] years; 141 men [49%] and 146 women [51%]). Mortality was 0%. There were 17 anastomotic leaks, of which 2 were on day 1 and were excluded. A total of 128 patients fulfilled all criteria, and 125 did not, including 34 for whom data were missing. Two leaks occurred in patients who had fulfilled all criteria vs 13 leaks in patients who did not (hazard ratio, 0.15 [95% CI, 0.03-0.69]; P = .01). Seventy-six of 128 patients (59.4%) were discharged successfully by postoperative day 3. The negative predictive value in ruling out an anastomotic leak was at least 96.9% for CRP alone (96.9% [95% CI, 93.3%-98.8%]), the 4 clinical criteria (98.4% [95% CI, 95.3%-99.7%]), and all 5 criteria combined (98.4% [95% CI, 94.5%-99.8%]). False-negative rates were 40% (95% CI, 16.3%-67.7%) for CRP level alone, 20% (95% CI, 4.3%-48.1%) for the other 4 criteria, and 13.3% (95% CI, 0%-40.5%) for all 5 criteria. Conclusions and Relevance These 5 criteria have a high negative predictive value and the lowest false-negative rate, indicating they have the potential to allow for safe early discharge after laparoscopic colorectal surgery.
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Affiliation(s)
- Clement Tavernier
- Department of Surgical Oncology, Lyon Sud University Hospital, Hospices Civils de Lyon, Lyon, France
| | - Alexandros N Flaris
- Department of Surgical Oncology, Lyon Sud University Hospital, Hospices Civils de Lyon, Lyon, France.,Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Guillaume Passot
- Department of Surgical Oncology, Lyon Sud University Hospital, Hospices Civils de Lyon, Lyon, France.,EMR 37-38, Lyon 1 University, Lyon, France
| | - Olivier Glehen
- Department of Surgical Oncology, Lyon Sud University Hospital, Hospices Civils de Lyon, Lyon, France.,EMR 37-38, Lyon 1 University, Lyon, France
| | - Vahan Kepenekian
- Department of Surgical Oncology, Lyon Sud University Hospital, Hospices Civils de Lyon, Lyon, France.,EMR 37-38, Lyon 1 University, Lyon, France
| | - Eddy Cotte
- EMR 37-38, Lyon 1 University, Lyon, France.,Department of Digestive and Oncological Surgery, Lyon Sud University Hospital, Hospices Civils de Lyon, Lyon, France
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13
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14
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Li R, Wang K, Qu C, Qi W, Fang T, Yue W, Tian H. The effect of the enhanced recovery after surgery program on lung cancer surgery: a systematic review and meta-analysis. J Thorac Dis 2021; 13:3566-3586. [PMID: 34277051 PMCID: PMC8264698 DOI: 10.21037/jtd-21-433] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/14/2021] [Indexed: 12/25/2022]
Abstract
Background Lung cancer is one of the most common causes of cancer-related death worldwide. The enhanced recovery after surgery (ERAS) program is an effective evidence-based multidisciplinary protocol of perioperative care. However, the roles of ERAS in lung cancer surgery remain unclear. This systematic review and meta-analysis aimed to investigate the short-term impact of the ERAS program on lung resection surgery, especially in relation to postoperative complications. Methods A systematic literature search of PubMed, EMBASE, and the Cochrane Library databases until October 2020 was performed to identify the studies that implemented an ERAS program in lung cancer surgery. The studies were selected and subjected to data extraction by 2 reviewers independently, which was followed by quality assessment. A random effects model was used to calculate overall effect sizes. Risk ratio (RR), risk difference (RD), and standardized mean difference (SMD) with 95% confidence interval (CI) served as the summary statistics for meta-analysis. Subgroup analysis and sensitivity analysis were subsequently performed. Results A total of 21 studies with 6,480 patients were included. The meta-analysis indicated that patients in the ERAS group had a significantly reduced risk of postoperative complications (RR =0.64; 95% CI: 0.52 to 0.78) and shortened postoperative length of stay (SMD=-1.58; 95% CI: -2.38 to -0.79) with a significant heterogeneity. Subgroup analysis showed that the risks of pulmonary (RR =0.58; 95% CI: 0.45 to 0.75), cardiovascular (RR =0.73; 95% CI: 0.59 to 0.89), urinary (RR =0.53; 95% CI: 0.32 to 0.88), and surgical complications (RR =0.64; 95% CI: 0.42 to 0.97) were significantly lower in the ERAS group. No significant reduction was found in the in-hospital mortality (RD =0.00; 95% CI: -0.01 to 0.00) and readmission rate (RR =1.00; 95% CI: 0.76 to 1.32). In the qualitative review, most of the evidence reported significantly decreased hospitalization costs in the ERAS group. Conclusions The implementation of an ERAS program for surgery of lung cancer can effectively reduce risks of postoperative complications, length of stay, and costs of patients who have undergone lung cancer surgery without compromising their safety.
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Affiliation(s)
- Rongyang Li
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Kun Wang
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chenghao Qu
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Weifeng Qi
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Tao Fang
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Weiming Yue
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Hui Tian
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
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15
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Balvardi S, Pecorelli N, Castelino T, Niculiseanu P, Alhashemi M, Liberman AS, Charlebois P, Stein B, Carli F, Mayo NE, Feldman LS, Fiore JF. Impact of Facilitation of Early Mobilization on Postoperative Pulmonary Outcomes After Colorectal Surgery: A Randomized Controlled Trial. Ann Surg 2021; 273:868-875. [PMID: 32324693 DOI: 10.1097/sla.0000000000003919] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To estimate the extent to which staff-directed facilitation of early mobilization impacts recovery of pulmonary function and 30-day postoperative pulmonary complications (PPCs) after colorectal surgery. SUMMARY BACKGROUND DATA Early mobilization after surgery is believed to improve pulmonary function and prevent PPCs; however, adherence is low. The value of allocating resources (eg, staff time) to increase early mobilization is unknown. METHODS This study involved the analysis of a priori secondary outcomes of a pragmatic, observer-blind, randomized trial. Consecutive patients undergoing colorectal surgery were randomized 1:1 to usual care (preoperative education) or facilitated mobilization (staff dedicated to assist transfers and walking during hospital stay). Forced vital capacity, forced expiratory volume in 1 second (FEV1), and peak cough flow were measured preoperatively and at 1, 2, 3 days and 4 weeks after surgery. PPCs were defined according to the European Perioperative Clinical Outcome Taskforce. RESULTS Ninety-nine patients (57% male, 80% laparoscopic, median age 63, and predicted FEV1 97%) were included in the intention-to-treat analysis (usual care 49, facilitated mobilization 50). There was no between-group difference in recovery of forced vital capacity [adjusted difference in slopes 0.002 L/d (95% CI -0.01 to 0.01)], FEV1 [-0.002 L/d (-0.01 to 0.01)] or peak cough flow [-0.002 L/min/d (-0.02 to 0.02)]. Thirty-day PPCs were also not different between groups [adjusted odds ratio 0.67 (0.23-1.99)]. CONCLUSIONS In this randomized controlled trial, staff-directed facilitation of early mobilization did not improve postoperative pulmonary function or reduce PPCs within an enhanced recovery pathway for colorectal surgery. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02131844.
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Affiliation(s)
- Saba Balvardi
- Department of Surgery, McGill University, Montreal, QC, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Nicolò Pecorelli
- Department of Surgery, McGill University, Montreal, QC, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Tanya Castelino
- Department of Surgery, McGill University, Montreal, QC, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Petru Niculiseanu
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Mohsen Alhashemi
- Department of Surgery, McGill University, Montreal, QC, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | | | | | - Barry Stein
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Franco Carli
- Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Nancy E Mayo
- Division of Clinical Epidemiology, McGill University, Montreal, QC, Canada
| | - Liane S Feldman
- Department of Surgery, McGill University, Montreal, QC, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Julio F Fiore
- Department of Surgery, McGill University, Montreal, QC, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
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16
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Creavin B, Balasubramanian I, Common M, McCarrick C, El Masry S, Carton E, Faul E. Intracorporeal vs extracorporeal anastomosis following neoplastic right hemicolectomy resection: a systematic review and meta-analysis of randomized control trials. Int J Colorectal Dis 2021; 36:645-656. [PMID: 33244717 DOI: 10.1007/s00384-020-03807-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE While minimally invasive surgery is the preferred approach for right hemicolectomy, the choice of anastomotic technique is still debated. Both intracorporeal (ICA) and extracorporeal anastomosis (ECA) are described, with conflicting reports on safety and efficacy seen. This study aimed to examine impact of ICA and ECA on outcomes in right hemicolectomy. METHODS A meta-analysis of randomized control trials (RCT) was performed. The primary outcome was overall morbidity. The secondary outcomes included both perioperative and post-operative outcomes. RESULTS Four RCTs were included incorporating 399 patients (199 patients (49.9%) ICA Vs 200 (50.1%) ECA). There was no significant difference in overall morbidity (RR 0.79, 95% CI 0.43, 1.48, p = 0.47), anastomotic leak (RR 1.34, 95% CI 0.58, 3.13, p = 0.5) or surgical site infections (RR 0.53, 95% CI 0.17, 1.64, p = 0.27). ICA patients had a significantly less post-operative ileus (RR 0.53, 95% CI 0.3-0.94, p = 0.03) quicker return to first flatus (WMD - 0.71, 95% CI - 1.12, 0.31, p = 0.0005), first bowel motion (WMD - 0.53, 95% CI - 0.69, - 0.37, p < 0.00001) and first meal (WMD - 0.68, 95% CI - 1.33, - 0.03, p = 0.04). Pain scores were significantly better for ICA patients on POD 3 (WMD - 0.76, 95% CI - 1.23, - 0.28, p = 0.002), POD 4 (WMD - 0.90, 95% CI - 1.71, - 0.09, p = 0.03) and POD 5 (WMD - 0.67, 95% CI - 1.22, - 0.13, p = 0.01). Length of hospital stay was similar (WMD - 0.46, 95% CI - 1.14, 0.22, p = 0.19). CONCLUSION ICA is associated with a quicker return to normal physiological function with equivalent post-operative morbidity. Both ECA and ICA are safe and feasible for restoring normal bowel continuity.
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Affiliation(s)
- B Creavin
- Department of Surgery, Our Lady of Lourdes Hospital Drogheda, Windmill Road, Moneymore, Drogheda, Co Louth, Ireland. .,Royal College of Surgeons, 123 St Stephens Green, Saint Peter's, Dublin, Ireland.
| | - I Balasubramanian
- Royal College of Surgeons, 123 St Stephens Green, Saint Peter's, Dublin, Ireland
| | - M Common
- Department of Surgery, Our Lady of Lourdes Hospital Drogheda, Windmill Road, Moneymore, Drogheda, Co Louth, Ireland.,Royal College of Surgeons, 123 St Stephens Green, Saint Peter's, Dublin, Ireland
| | - C McCarrick
- Department of Surgery, Our Lady of Lourdes Hospital Drogheda, Windmill Road, Moneymore, Drogheda, Co Louth, Ireland
| | - S El Masry
- Department of Surgery, Our Lady of Lourdes Hospital Drogheda, Windmill Road, Moneymore, Drogheda, Co Louth, Ireland.,Royal College of Surgeons, 123 St Stephens Green, Saint Peter's, Dublin, Ireland
| | - E Carton
- Department of Surgery, Our Lady of Lourdes Hospital Drogheda, Windmill Road, Moneymore, Drogheda, Co Louth, Ireland.,Royal College of Surgeons, 123 St Stephens Green, Saint Peter's, Dublin, Ireland
| | - E Faul
- Department of Surgery, Our Lady of Lourdes Hospital Drogheda, Windmill Road, Moneymore, Drogheda, Co Louth, Ireland.,Royal College of Surgeons, 123 St Stephens Green, Saint Peter's, Dublin, Ireland
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17
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Kienle P, Magdeburg R. [Minimally invasive and robot-assisted surgery for chronic inflammatory bowel disease : Current status and evidence situation]. Chirurg 2021; 92:21-29. [PMID: 33274393 DOI: 10.1007/s00104-020-01306-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The majority of cases of inflammatory bowel disease (IBD) can be treated by minimally invasive surgery. The advantages of standard laparoscopic approaches compared to open surgery with respect to short-term and long-term outcome parameters have been adequately proven with evidence level 1 for ileocecal resection in Crohn's disease. For many other indications there are at least several larger registry or case-control studies that have shown advantages for laparoscopy. For robot-assisted surgery the feasibility has principally been demonstrated for IBD, whereby at least for ulcerative colitis limited data suggest comparable results to the standard laparoscopic approach. Single port approaches have so far not been able to demonstrate any relevant advantages in IBD surgery. Major advantages for transanal minimally invasive surgery (TAMIS) for performing restorative proctocolectomy could not be demonstrated in two larger case-controlled studies but it was at least shown to be a comparable alternative to standard laparoscopy. Overall, it seems unlikely that the recently described new laparoscopic approaches will result in measurable advantages for the patient in comparison to standard laparoscopy as the access trauma is not significantly changed. In general, the indications to perform minimally invasive surgery must always be based on the basic principles of IBD surgery and contraindications have to be considered in individual cases as the advantages of laparoscopic approaches are levelled out in the long run.
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Affiliation(s)
- Peter Kienle
- Allgemein- und Viszeralchirurgie, Theresienkrankenhaus, Bassermannstr. 1, 68165, Mannheim, Deutschland.
| | - Richard Magdeburg
- Allgemein- und Viszeralchirurgie, Theresienkrankenhaus, Bassermannstr. 1, 68165, Mannheim, Deutschland
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Abstract
INTRODUCTION Perioperative enhanced recovery after surgery (ERAS) concepts or fast-track are supposed to accelerate recovery after surgery, reduce postoperative complications and shorten the hospital stay when compared to traditional perioperative treatment. METHODS Electronic search of the PubMed database to identify systematic reviews with meta-analysis (SR) comparing ERAS and traditional treatment. RESULTS The presented SR investigated 70 randomized controlled studies (RCT) with 12,986 patients and 93 non-RCT (24,335 patients) concerning abdominal, thoracic and vascular as well as orthopedic surgery. The complication rates were decreased under ERAS following colorectal esophageal, liver and pulmonary resections as well as after implantation of hip endoprostheses. Pulmonary complications were reduced after ERAS esophageal, gastric and pulmonary resections. The first bowel movements occurred earlier after ERAS colorectal resections and delayed gastric emptying was less often observed after ERAS pancreatic resection. Following ERAS fast-track esophageal resection, anastomotic leakage was diagnosed less often as well as surgical complications after ERAS pulmonary resection. The ERAS in all studies concerning orthopedic surgery and trials investigating implantation of a hip endoprosthesis or knee endoprosthesis reduced the risk for postoperative blood transfusions. Regardless of the type of surgery, ERAS shortened hospital stay without increasing readmissions. CONCLUSION Numerous clinical trials have confirmed that ERAS reduces postoperative morbidity, shortens hospital stay and accelerates recovery without increasing readmission rates following most surgical operations.
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19
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McEvoy MD, Wanderer JP, Shi Y, Ramanujan KS, Geiger TM, Shotwell MS, Shaw AD, Hawkins AT, Martin BJ, Mythen MG, Sandberg WS. The effect of adding goal-directed hemodynamic management for elective patients in an established enhanced recovery program for colorectal surgery: results of quasi-experimental pragmatic trial. Perioper Med (Lond) 2020; 9:35. [PMID: 33292514 PMCID: PMC7682072 DOI: 10.1186/s13741-020-00163-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 10/29/2020] [Indexed: 02/04/2023] Open
Abstract
Background Recent literature has demonstrated that hemodynamic instability in the intraoperative period places patients at risk of poor outcomes. Furthermore, recent studies have reported that stroke volume optimization and protocolized hemodynamic management may improve perioperative outcomes, especially surgical site infection (SSI), in certain high-risk populations. However, the optimal strategy for intraoperative management of all elective patients within an enhanced recovery program remains to be elucidated. Methods We performed a pre-post quasi-experimental study to assess the effect of adding goal-directed hemodynamic therapy to an enhanced recovery program (ERP) for colorectal surgery on SSI and other outcomes. Three groups were compared: “Pre-ERP,” defined as historical control (before enhanced recovery program); “ERP,” defined as enhanced recovery program using zero fluid balance; and “ERP+GDHT,” defined as enhanced recovery program plus goal-directed hemodynamic therapy. Outcomes were obtained through our National Surgical Quality Improvement Program participation. Results A total of 623 patients were included in the final analysis (Pre-ERP = 246, ERP = 140, and ERP + GDHT = 237). Demographics and baseline clinical characteristics were balanced between groups. We did not observe statistically significant differences in SSI or composite complication rates in unadjusted or adjusted analysis. There was no evidence of association between study group and 30-day readmission. American Society of Anesthesiologists status ≥ 3 and open surgical approach were significantly associated with increased risk of SSI, composite complication, and 30-day readmission (p < 0.05 for all) in all groups. Conclusions There was no evidence that addition of goal-directed hemodynamic therapy for all patients in an enhanced recovery program for colorectal surgery affects the risk of SSI, composite complications, or 30-day readmission. Further research is needed to investigate whether there is benefit of goal-directed hemodynamic therapy for select high-risk populations. Trial registration NCT03189550. Registered 16 June 2017–Retrospectively registered, https://www.clinicaltrials.gov/ct2/results?cond=&term=NCT03189550&cntry=&state=&city=&dist=
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Affiliation(s)
- Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA.
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA
| | - Krishnan S Ramanujan
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA
| | - Timothy M Geiger
- Department of Surgery, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA
| | - Andrew D Shaw
- Department of Anesthesiology & Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Alexander T Hawkins
- Department of Surgery, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA
| | - Barbara J Martin
- Department of Quality, Safety & Risk Prevention, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA
| | - Michael G Mythen
- University College London Hospitals National Institute of Health Research Biomedical Research Centre, London, UK
| | - Warren S Sandberg
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA
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Effects of laparoscopic vs open abdominal surgery on costs and hospital readmission rate and its effect modification by surgeons' case volume. Surg Endosc 2020; 34:1-12. [PMID: 31659507 DOI: 10.1007/s00464-019-07222-x] [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: 05/22/2019] [Accepted: 10/09/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Laparoscopy provides a minimally invasive alternative to open abdominal surgery. Current data describing its association with hospital readmission and costs in relation to surgeon laparoscopic case volume is limited to smaller databases and subsets of operations. METHODS This retrospective cohort study of 23,285 adult abdominal operations from 2007 to 2015 compares 30-day readmission rate and costs between laparoscopic and open abdominal operations and examines effect modification by surgeon laparoscopic case volume. Outcomes were all-cause hospital readmission within 30 days after discharge and index hospital admission cost. RESULTS All-cause hospital readmission rates were significantly lower after laparoscopic abdominal operations compared with open operations (adjusted odds ratio [aOR] 0.56, 95% CI 0.46-0.69, p < 0.001) with a difference in readmission risk attributable to laparoscopic approach of - 4.0% (95% CI - 5.4 to - 2.6%) in complete-case analysis. Among surgeons with a high laparoscopic case volume, the estimated difference in readmission risk through laparoscopy was magnified (- 5.8%, 95% CI - 7.5 to - 4.1%) compared to low surgeon laparoscopic case volume (- 2.9%, 95% CI - 4.8 to -1.1%, p for interaction = 0.005). The estimated difference in costs of the index hospital admission attributable to laparoscopic approach was - $3869 (95% CI - $4200 to - $3538; adjusted incidence rate ratio 0.77, 95% CI 0.75-0.79, p < 0.001). Laparoscopy was followed by significantly lower rates of readmissions related to gastrointestinal (aOR 0.68, 95% CI 0.55-0.85, p = 0.001), wound complications (infection: aOR 0.33, 95% CI 0.23-0.47, p < 0.001; non-infectious: aOR 0.47, 95% CI 0.30-0.74, p = 0.001), and malignancy (aOR 0.68, 95% CI 0.55-0.85, p < 0.001). The findings remain robust after multiple imputation and sensitivity analyses. CONCLUSIONS Laparoscopy versus open abdominal surgery is associated with reduced hospital readmissions related to malignancy, gastrointestinal, and wound complications. Effect modification by higher laparoscopy case volume argues for continued proliferation of laparoscopy in abdominal surgeries.
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Jeon Y, Song S, Han KW, Lee DH, Baek JH. Evaluation of a Novel Trocar-Site Closure Device in Laparoscopic Surgery. JSLS 2020; 24:JSLS.2020.00033. [PMID: 32714001 PMCID: PMC7343404 DOI: 10.4293/jsls.2020.00033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background and Objectives: We evaluated the effectiveness and safety of EZ-CloseTM compared to those of hand suture for trocar-site closure according to obesity. Methods: Fifty-four cases of laparoscopic colorectal surgery were enrolled. For the same patient, the right port site was closed using EZ-CloseTM and left port site was closed by hand suture among cases with port-site diameter ≥10 mm. Cases switched to use of a conventional fascial closure device or with closure time 120 s were considered failures. Closure time was analyzed according to body mass index (BMI) and abdominal wall thickness (AWT). Results: The mean closure time was significantly shorter with EZ-CloseTM than with hand suture (87.9 ± 21.0 vs. 128.0 ± 59.0 s, p < 0.001). The number of failure cases was significantly lower with EZ-CloseTM than with hand suture (7 vs. 27, p < 0.001). The closure time of EZ-CloseTM was significantly shorter than that of hand suture in patients with BMI ≥ 25 and < 27 kg/m2 (n = 15, 85.9 ± 19.8 vs. 135.6 ± 67.9 s, p < 0.014) and ≥ 27 kg/m2 (n = 13, 85.1 ± 18.4 vs. 150.2 ± 70.6 s, p < 0.010). With respect to AWT, the closure time of EZ-CloseTM was significantly shorter than that of hand suture in patients with AWT ≥ 20 and < 26 mm (n = 12, 81.1 ± 11.5 vs. 142.3 ± 83.7 s, p = 0.023) and ≥ 26 mm (n = 17, 85.6 ± 22.6 vs. 160.2 ± 55.5, p < 0.001). No infection and herniation were detected in both trocar sites during the follow-up period (median 20.4 months). Conclusion: EZ-CloseTM could provide time efficiency in trocar-site closure, especially in obese patients.
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Affiliation(s)
- Youngbae Jeon
- Department of Surgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Soohwa Song
- Department of Biomedical Engineering, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Kyoung-Won Han
- Department of Surgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Dong-Hyuk Lee
- Department of Biomedical Engineering, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Jeong-Heum Baek
- Department of Surgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
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Iranmanesh P, Delaune V, Meyer J, Liot E, Konrad B, Ris F, Toso C, Buchs NC. Comparison of Outcomes between Obese and Non-Obese Patients in a Colorectal Enhanced Recovery After Surgery (ERAS) Program: A Single-Center Cohort Study. Dig Surg 2020; 37:420-427. [PMID: 32434182 DOI: 10.1159/000507545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/26/2020] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Obese patients are considered at increased risk of postoperative adverse events after colorectal surgery. OBJECTIVE The objective of the present study was to compare postoperative outcomes between obese and non-obese patients undergoing elective colorectal surgery in an Enhanced Recovery After Surgery (ERAS) program. METHODS A retrospective analysis of a prospective cohort including patients who underwent elective colorectal surgery and were included in an ERAS protocol between February 2014 and December 2017 at Geneva University Hospital, Geneva, Switzerland, was performed. Postoperative outcomes of obese and non-obese patients were compared. RESULTS Data of 460 patients were analyzed, including 374 (81%) non-obese and 86 (19%) obese patients. Overall, there was no difference in postoperative outcomes between the 2 groups. Among patients undergoing oncologic surgery, obese subjects had a significantly higher rate of conversion to laparotomy (11.9 vs. 2.1%, p = 0.01) and longer time until return of bowel function (2.38 vs. 1.98 days, p = 0.03), without increased morbidity or longer length of stay. CONCLUSION Obese and non-obese patients had similar postoperative outcomes after elective colorectal surgery with ERAS management. ERAS can potentially reduce the increased morbidity usually observed in obese patients following elective colorectal surgery.
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Affiliation(s)
- Pouya Iranmanesh
- Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Medical School, Geneva, Switzerland,
| | - Vaihere Delaune
- Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Medical School, Geneva, Switzerland
| | - Jeremy Meyer
- Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Medical School, Geneva, Switzerland
| | - Emilie Liot
- Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Medical School, Geneva, Switzerland
| | - Beatrice Konrad
- Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Medical School, Geneva, Switzerland
| | - Frederic Ris
- Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Medical School, Geneva, Switzerland
| | - Christian Toso
- Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Medical School, Geneva, Switzerland
| | - Nicolas Christian Buchs
- Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Medical School, Geneva, Switzerland
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Turi S, Deni F, Lombardi G, Marmiere M, Nisi FG, Beretta L. Sufentanil Sublingual Tablet System (SSTS) for the management of postoperative pain after major abdominal and gynecological surgery within an ERAS protocol: an observational study. J Pain Res 2019; 12:2313-2319. [PMID: 31440075 PMCID: PMC6666368 DOI: 10.2147/jpr.s214600] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/08/2019] [Indexed: 12/22/2022] Open
Abstract
Background The Sufentanil Sublingual Tablet System (SSTS) is a new, pre-programmed, noninvasive, handheld system for patient-controlled analgesia (PCA) which may allow a faster postoperative recovery compared with standard PCA. The efficacy of SSTS in controlling pain after open abdominal surgery has already been documented. However, to our knowledge SSTS has never been investigated in patients undergoing major surgery within an Enhanced Recovery After Surgery (ERAS) protocol. Methods This observational, retrospective analysis included consecutive patients undergoing elective major abdominal and gynecological surgery. All patients received the SSTS device once they were fully awake and had a good control of pain at the end of the surgery. We analyzed changes in pain intensity according to the numerical rating scale (NRS) throughout the treatment as well as its duration, the number of administrations, and possible related adverse events. Patients were also interviewed to assess their quality of sleep and overall satisfaction with the SSTS device. Results The study included 308 patients. Compared to the first SSTS administration, pain intensity decreased from a median NRS of 6 to 0 at day 3, for an overall reduction of 79%. Results were already statistically significant at postoperative day 1 (p<0.01). Adverse reactions were observed in 62 patients, with nausea being the most frequent (12%), and in 93% of patients SSTS was discontinued because it was considered no longer necessary. Patient satisfaction was high, with 89% of them judging the device as “easy” or “very easy” to use. Conclusions Although the retrospective and observational nature of the study as well as the absence of a comparative group limits the strength of evidence, our results consider SSTS an effective and safe tool for the management of postoperative pain after major abdominal and gynecological surgery within an ERAS protocol.
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Affiliation(s)
- Stefano Turi
- Dipartimento di Anestesia e Rianimazione, Ospedale San Raffaele, Milano, Italy
| | - Francesco Deni
- Dipartimento di Anestesia e Rianimazione, Ospedale San Raffaele, Milano, Italy
| | - Gaetano Lombardi
- Dipartimento di Anestesia e Rianimazione, Ospedale San Raffaele, Milano, Italy
| | - Marilena Marmiere
- Dipartimento di Anestesia e Rianimazione, Ospedale San Raffaele, Milano, Italy
| | | | - Luigi Beretta
- Dipartimento di Anestesia e Rianimazione, Ospedale San Raffaele, Milano, Italy
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Mahendran R, Tewari M, Dixit VK, Shukla HS. Enhanced recovery after surgery protocol enhances early postoperative recovery after pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int 2019; 18:188-193. [PMID: 30573300 DOI: 10.1016/j.hbpd.2018.12.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 12/06/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocol is a multimodal, multidisciplinary and evidence-based approach to reduce surgical stress and enhance recovery in the postoperative period. This study aimed to analyze the outcome of ERAS protocol in patients after pancreaticoduodenectomy (PD). METHODS A total of 50 consecutive patients with pancreatic/periampullary cancer who underwent PD between January 2016 to August 2017 were included in the study. As per the institute ERAS protocol, nasogastric tube (NGT) was removed on postoperative day (POD) 1 if output was less than 200 mL and oral sips were allowed; oral liquids were allowed on POD2; semisolid diet by POD3; abdominal drain was removed on POD 4 if output was less than 100 mL with no evidence of postoperative pancreatic fistula (POPF); normal diet was allowed on POD5. Discharge criteria on POD6 were afebrile, tolerating oral normal diet, pain free and no surgery related complications (defined as per the ISGPS definitions). RESULTS NGT was removed on POD1 in 45 (90%) patients, abdominal drain removed by POD4 in 41 (82%) and 43 (86%) patients were discharged on POD6. There was no 30-day postoperative mortality. Three (6%) patients had delayed gastric emptying (DGE). None had postoperative hemorrhage and POPF. Readmission rate was 8%. A significant relation was found between the length of hospital stay (LOS) with age (P < 0.05) and a marginal relation between LOS and postoperative albumin (P = 0.05). CONCLUSIONS ERAS protocol can be safely followed in the perioperative care of patients who undergo PD. Early removal of NGT and allowing oral diet restore bowel function early. ERAS decreases the LOS and postoperative complications.
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Affiliation(s)
- Ramasamy Mahendran
- Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP 221005, India
| | - Mallika Tewari
- Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP 221005, India.
| | - Vinod Kumar Dixit
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP 221005, India
| | - Hari Shankar Shukla
- Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP 221005, India
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Lohsiriwat V. Learning curve of enhanced recovery after surgery program in open colorectal surgery. World J Gastrointest Surg 2019; 11:169-178. [PMID: 31057701 PMCID: PMC6478598 DOI: 10.4240/wjgs.v11.i3.169] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/18/2019] [Accepted: 03/20/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) reduces hospitalization and complication following colorectal surgery. Whether the experience of multidisciplinary ERAS team affects patients’ outcomes is unknown.
AIM To evaluate and establish a learning curve of ERAS program for open colorectal surgery.
METHODS This was a review of prospectively collected database of 380 “unselected” patients undergoing elective “open” colectomy and/or proctectomy under ERAS protocol from 2011 (commencing ERAS application) to 2017 in a university hospital. Patients were divided into 5 chronological groups (76 cases per quintile). Surgical outcomes and ERAS compliance among quintiles were compared. Learning curves were calculated based on criteria of optimal recovery: defined as absence of major postoperative complications, discharge by postoperative day 5, and no 30-d readmission.
RESULTS Hospitalization more than 5 d occurred in 22.6% (n = 86), major complication was present in 2.9% (n = 11) and 30-d readmission rate was 2.4% (n = 9) accounting for unsuccessful recovery of 25% (n = 95). Conversely, the overall rate of optimal recovery was 75%. The optimal recovery significantly increased from 57.9% in 1st quintile to 72.4%-85.5% in the following quintiles (P < 0.001). Average compliance with ERAS protocol gradually increased over the time - from 68.6% in 1st quintile to 75.5% in 5th quintile (P < 0.001). The application of preoperative counseling, nutrition support, goal-directed fluid therapy, O-ring wound protector and scheduled mobilization significantly increased over the study period.
CONCLUSION A number of 76 colorectal operations are required for a multidisciplinary team to achieve a significantly higher rate of optimal recovery and high compliance with ERAS program for open colorectal surgery.
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Affiliation(s)
- Varut Lohsiriwat
- Division of Colon and Rectal Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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Thoracic epidural analgesia (TEA) versus patient-controlled analgesia (PCA) in laparoscopic colectomy: a systematic review and meta-analysis. Int J Colorectal Dis 2019; 34:27-38. [PMID: 30519843 DOI: 10.1007/s00384-018-3207-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE A meta-analysis of RCTs was designed to provide an up-to-date comparison of thoracic epidural analgesia (TEA) and patient-controlled analgesia (PCA) in laparoscopic colectomy. METHODS Our study was completed following the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. A systematic literature screening was performed in MEDLINE and Web of Science. Fixed effects (FE) or random effects (RE) models were estimated based on the Cochran Q test result. RESULTS Totally, 8 studies were introduced in the present meta-analysis. Superiority of PCA in terms of length of hospital stay (LOS) (WMD 0.73, p = 0.004) and total complication rate (OR 1.57, p = 0.02) was found. TEA had a lower resting pain visual analogue scale (VAS) score at Day 1 (WMD - 2.23, p = 0.005) and Day 2 (WMD - 2.17, p = 0.01). TEA group had also a systematically lower walking VAS. Moreover, first bowel opened time (first defecation) (WMD - 0.88, p < 0.00001) was higher when PCA was applied. CONCLUSIONS TEA was related to a lower first bowel opened time, walking, and resting pain levels at the first postoperative days. However, the overall complication rate and LOS were higher in the epidural analgesia group. Thus, for a safe conclusion to be drawn, further randomized controlled trials (RCTs) of a higher methodological and quality level are required.
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Bruintjes MH, Albers KI, Gurusamy KS, Rovers MM, van Laarhoven CJHM, Warle MC. Deep neuromuscular blockade in adults undergoing an abdominal laparoscopic procedure. Hippokratia 2018. [DOI: 10.1002/14651858.cd013197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Moira H Bruintjes
- Radboud University Nijmegen Medical Center; Department of Surgery; Geert Grooteplein Zuid 10 Nijmegen Netherlands 6525 GA
| | - Kim I Albers
- Radboud University Nijmegen Medical Centre; Department of Anesthesiology; Nijmegen Netherlands
| | - Kurinchi Selvan Gurusamy
- University College London; Division of Surgery and Interventional Science; 9th Floor, Royal Free Hospital Rowland Hill Street London UK NW3 2PF
| | - Maroeska M Rovers
- Radboud University Nijmegen Medical Centre; Department of Operating Rooms; Hp 630, route 631 PO Box 9101 Nijmegen Netherlands 6500 HB
| | - Cornelis JHM van Laarhoven
- Radboud University Nijmegen Medical Centre; Department of Surgery; PO Box 9101 internal code 618 Nijmegen Netherlands 6500 HB
| | - Michiel C Warle
- Radboud University Nijmegen Medical Center; Department of Surgery; Geert Grooteplein Zuid 10 Nijmegen Netherlands 6525 GA
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De Witte B, Di Rienzo F, Martin X, Haixia Y, Collet C, Hoyek N. Implementing Cognitive Training Into a Surgical Skill Course: A Pilot Study on Laparoscopic Suturing and Knot Tying. Surg Innov 2018; 25:625-635. [PMID: 30222050 DOI: 10.1177/1553350618800148] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mini-invasive surgery-for example, laparoscopy-has challenged surgeons' skills by extending their usual haptic space and displaying indirect visual feedback through a screen. This may require new mental abilities, including spatial orientation and mental representation. This study aimed to test the effect of cognitive training based on motor imagery (MI) and action observation (AO) on surgical skills. A total of 28 postgraduate residents in surgery took part in our study and were randomly distributed into 1 of the 3 following groups: (1) the basic surgical skill, which is a short 2-day laparoscopic course + MI + AO group; (2) the basic surgical skill group; and (3) the control group. The MI + AO group underwent additional cognitive training, whereas the basic surgical skill group performed neutral activity during the same time. The laparoscopic suturing and knot tying performance as well as spatial ability and mental workload were assessed before and after the training period. We did not observe an effect of cognitive training on the laparoscopic performance. However, the basic surgical skill group significantly improved spatial orientation performance and rated lower mental workload, whereas the 2 others exhibited lower performance in a mental rotation test. Thus, actual and cognitive training pooled together during a short training period elicited too high a strain, thus limiting potential improvements. Because MI and AO already showed positive outcomes on surgical skills, this issue may, thus, be mitigated according to our specific learning conditions. Distributed learning may possibly better divide and share the strain associated with new surgical skills learning.
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Affiliation(s)
- Benjamin De Witte
- 1 University of Lyon, University Claude Bernard Lyon 1, Inter-University Laboratory of Human Movement Biology, Villeurbanne Cedex, France
| | - Franck Di Rienzo
- 1 University of Lyon, University Claude Bernard Lyon 1, Inter-University Laboratory of Human Movement Biology, Villeurbanne Cedex, France
| | - Xavier Martin
- 2 University of Lyon, University Claude Bernard Lyon 1, Faculty of Medicine, Surgery school, Lyon, France.,3 Service de Néphrologie, Transplantation et Immunologie Clinique, Hôpital Edouard Herriot, Hospices Civils de Lyon, France
| | - Ye Haixia
- 2 University of Lyon, University Claude Bernard Lyon 1, Faculty of Medicine, Surgery school, Lyon, France.,3 Service de Néphrologie, Transplantation et Immunologie Clinique, Hôpital Edouard Herriot, Hospices Civils de Lyon, France
| | - Christian Collet
- 1 University of Lyon, University Claude Bernard Lyon 1, Inter-University Laboratory of Human Movement Biology, Villeurbanne Cedex, France
| | - Nady Hoyek
- 1 University of Lyon, University Claude Bernard Lyon 1, Inter-University Laboratory of Human Movement Biology, Villeurbanne Cedex, France
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Abstract
PURPOSE OF REVIEW Enhanced recovery pathways are a well-defined perioperative health care program utilizing evidence-based interventions in a protocol-like manner designed to standardize techniques including drug selection and dosing to improve results and to reduce overall costs including facilitating earlier discharge from hospitals after surgery. RECENT FINDINGS A PubMed and World Wide Web search was performed with the following key words: enhanced recovery, surgical enhanced recovery, recovery pathways, and enhanced recovery pathways surgery. This introduction to enhanced recovery pathways reflects its 20-year history, worldwide appeal, and ever growing presence in our practices. Many clinical teams have not, as of yet, incorporated enhanced recovery pathway principles to their practices and therefore, continued evolution should include increasing outreach and formalized guidelines in the future.
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Laparoscopic combined resection of liver metastases and colorectal cancer: a multicenter, case-matched study using propensity scores. Surg Endosc 2018; 33:1124-1130. [PMID: 30069639 PMCID: PMC6430752 DOI: 10.1007/s00464-018-6371-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 07/20/2018] [Indexed: 12/21/2022]
Abstract
Background Combined laparoscopic resection of liver metastases and colorectal cancer (LLCR) may hold benefits for selected patients but could increase complication rates. Previous studies have compared LLCR with liver resection alone. Propensity score-matched studies comparing LLCR with laparoscopic colorectal cancer resection (LCR) alone have not been performed. Methods A multicenter, case-matched study was performed comparing LLCR (2009–2016, 4 centers) with LCR alone (2009–2016, 2 centers). Patients were matched based on propensity scores in a 1:1 ratio. Propensity scores were calculated with the following preoperative variables: age, sex, ASA grade, neoadjuvant radiotherapy, type of colorectal resection and T and N stage of the primary tumor. Outcomes were compared using paired tests. Results Out of 1020 LCR and 64 LLCR procedures, 122 (2 × 61) patients could be matched. All 61 laparoscopic liver resections were minor hepatectomies, mostly because of a solitary liver metastasis (n = 44, 69%) of small size (≤ 3 cm) (n = 50, 78%). LLCR was associated with a modest increase in operative time [206 (166–308) vs. 197 (148–231) min, p = 0.057] and blood loss [200 (100–700) vs. 75 (5–200) ml, p = 0.011]. The rate of Clavien–Dindo grade 3 or higher complications [9 (15%) vs. 13 (21%), p = 0.418], anastomotic leakage [5 (8%) vs. 4 (7%), p = 1.0], conversion rate [3 (5%) vs. 5 (8%), p = 0.687] and 30-day mortality [0 vs. 1 (2%), p = 1.0] did not differ between LLCR and LCR. Conclusion In selected patients requiring minor hepatectomy, LLCR can be safely performed without increasing the risk of postoperative morbidity compared to LCR alone.
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Structured box training improves stability of retraction while multitasking in colorectal surgery simulation. J Surg Res 2018; 229:82-89. [PMID: 29937020 DOI: 10.1016/j.jss.2018.03.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 02/06/2018] [Accepted: 03/15/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Laparoscopic colorectal surgery has an established role. The ability to multitask (use a retraction tool with one hand and navigate a laparoscopic camera with the other) is desired for efficient laparoscopic surgery. Surgical trainees must learn this skill to perform advanced laparoscopic tasks. The aim was to determine whether a box-training protocol improves the stability of retraction while multitasking in colorectal surgery simulation. MATERIALS AND METHODS Fifty-eight medical students were recruited to attend a basic laparoscopic box-training course. Ability to perform steady retraction with and without multitasking was measured initially and at the conclusion of the course. RESULTS Before training, students demonstrated a decrease in performance while multitasking with a greater maximal exerted force, a greater range of force, and a greater standard deviation for traction and minimal exerted force, range of force and a greater standard deviation for countertraction. Statistically significant improvement (lower maximal exerted force and lower range of force) was observed for traction while multitasking after training. After the training, no statistically significant differences were found when the student performed a single task versus multitasking, both for traction and countertraction. CONCLUSIONS A structured box-training curriculum improved the stability of retraction while multitasking in this colorectal surgery simulation. Although it did not improve stability of retraction as a single task, it did improve stability of retraction while multitasking. After training, this enables the trainee to retract as efficiently while operating the camera as they retract when only focusing on retraction as a single task.
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Máca J, Peteja M, Reimer P, Jor O, Šeděnková V, Panáčková L, Ihnát P, Burda M, Ševčík P. Surgical injury: comparing open surgery and laparoscopy by markers of tissue damage. Ther Clin Risk Manag 2018; 14:999-1006. [PMID: 29881282 PMCID: PMC5985784 DOI: 10.2147/tcrm.s153359] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Major abdominal surgery (MAS) is high-risk intervention usually accompanied by tissue injury leading to a release of signaling danger molecules called alarmins. This study evaluates the surgical injury caused by two fundamental types of gastrointestinal surgical procedures (open surgery and laparoscopy) in relation to the inflammation elicited by alarmins. Patients and methods Patients undergoing MAS were divided into a mixed laparoscopy group (LPS) and an open surgery group (LPT). Serum levels of alarmins (S100A8, S100A12, HMGB1, and HSP70) and biomarkers (leukocytes, C-reactive protein [CRP], and interleukin-6 [IL-6]) were analyzed between the groups. The secondary objectives were to compare LPT and LPS cancer subgroups and to find the relationship between procedure and outcome (intensive care unit length of stay [ICU-LOS] and hospital length of stay [H-LOS]). Results A total of 82 patients were analyzed. No significant difference was found in alarmin levels between the mixed LPS and LPT groups. IL-6 was higher in the LPS group on day 2 (p=0.03) and day 3 (p=0.04). Significantly higher S100A8 protein levels on day 1 (p=0.02) and day 2 (p=0.01) and higher S100A12 protein levels on day 2 (p=0.03) were obtained in the LPS cancer subgroup. ICU-LOS and H-LOS were longer in the LPS cancer subgroup. Conclusion The degree of surgical injury elicited by open MAS as reflected by alarmins is similar to that of laparoscopic procedures. Nevertheless, an early biomarker of inflammation (IL-6) was higher in the laparoscopy group, suggesting a greater inflammatory response. Moreover, the levels of S100A8 and S100A12 were higher with a longer ICU-LOS and H-LOS in the LPS cancer subgroup.
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Affiliation(s)
- Jan Máca
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic
| | - Matúš Peteja
- The Clinic of Surgery, University Hospital Ostrava, Ostrava, Czech Republic
| | - Petr Reimer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic
| | - Ondřej Jor
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic
| | - Věra Šeděnková
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic
| | - Lucie Panáčková
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic
| | - Peter Ihnát
- The Clinic of Surgery, University Hospital Ostrava, Ostrava, Czech Republic
| | - Michal Burda
- Institute for Research and Applications of Fuzzy Modeling, Centre of Excellence IT4Innovations, University of Ostrava, Ostrava, Czech Republic
| | - Pavel Ševčík
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic
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The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. J Thorac Cardiovasc Surg 2018; 155:1843-1852. [DOI: 10.1016/j.jtcvs.2017.10.151] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 10/12/2017] [Accepted: 10/24/2017] [Indexed: 02/07/2023]
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Muñoz JL, Alvarez MO, Cuquerella V, Miranda E, Picó C, Flores R, Resalt-Pereira M, Moya P, Pérez A, Arroyo A. Procalcitonin and C-reactive protein as early markers of anastomotic leak after laparoscopic colorectal surgery within an enhanced recovery after surgery (ERAS) program. Surg Endosc 2018. [PMID: 29520440 DOI: 10.1007/s00464-018-6144-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND C-reactive protein (CRP) and procalcitonin (PCT) have been described as good predictors of anastomotic leak after colorectal surgery, obtaining the highest diagnostic accuracy on the 5th postoperative day. However, if an enhanced recovery after surgery (ERAS) program is performed, early predictors are needed in order to ensure a safe and early discharge. The aim of this study was to investigate the efficacy of CRP, PCT, and white blood cell (WBC) count determined on first postoperative days, in predicting septic complications, especially anastomotic leak, after laparoscopic colorectal surgery performed within an ERAS program. METHODS We conducted a prospective study including 134 patients who underwent laparoscopic colorectal surgery within an ERAS program between 2015 and 2017. The primary endpoint investigated was anastomotic leak. CRP, PCT, and WBC count were determined in the blood sample extracted on postoperative day 1 (POD 1), POD 2 and POD 3. RESULTS Anastomotic leak (AL) was detected in 6 patients (4.5%). Serum levels of CRP and PCT, but not WBC, determined on POD 1, POD 2, and POD 3 were significantly higher in patients who had AL in the postoperative course. Using ROC analysis, the best AUC of the CRP and PCT levels was on POD 3 (0.837 and 0.947, respectively). A CRP cutoff level at 163 mg/l yielded 85% sensitivity, 80% specificity, and 99% negative predictive value (NPV). A PCT cutoff level at 2.5 ng/ml achieved 85% sensitivity, 95% specificity, 44% positive predictive value, and 99% NPV. CONCLUSIONS CRP and PCT are relevant markers for detecting postoperative AL after laparoscopic colorectal surgery. Furthermore, they can ensure an early discharge with a low probability of AL when an ERAS program is performed.
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Affiliation(s)
- José Luis Muñoz
- Department of Anaesthesia, General University Hospital Elche, Camí de l´Almazara 11, CP 03203, Elche, Alicante, Spain.
| | | | - Vicent Cuquerella
- Department of Anaesthesia, General University Hospital Elche, Camí de l´Almazara 11, CP 03203, Elche, Alicante, Spain
| | - Elena Miranda
- Department of Anaesthesia, General University Hospital Elche, Camí de l´Almazara 11, CP 03203, Elche, Alicante, Spain
| | - Carlos Picó
- Department of Anaesthesia, General University Hospital Elche, Camí de l´Almazara 11, CP 03203, Elche, Alicante, Spain
| | - Raquel Flores
- Department of Anaesthesia, General University Hospital Elche, Camí de l´Almazara 11, CP 03203, Elche, Alicante, Spain
| | - Marta Resalt-Pereira
- Department of Anaesthesia, General University Hospital Elche, Camí de l´Almazara 11, CP 03203, Elche, Alicante, Spain
| | - Pedro Moya
- Department of Surgery, General University Hospital Elche, Alicante, Spain
| | - Ana Pérez
- Department of Anaesthesia, General University Hospital Elche, Camí de l´Almazara 11, CP 03203, Elche, Alicante, Spain
| | - Antonio Arroyo
- Department of Surgery, General University Hospital Elche, Alicante, Spain
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The Impact of an Enhanced Recovery After Surgery Program on Patients Treated for Gynecologic Cancer in the Community Hospital Setting. Int J Gynecol Cancer 2018; 28:581-585. [DOI: 10.1097/igc.0000000000001198] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
ObjectivesThe purpose of this study was to compare the outcomes of gynecologic oncology patients treated in the community hospital setting either under the auspices of an enhanced recovery after surgery (ERAS) protocol or in accordance with physician discretion.MethodsWe retrospectively evaluated a series of consecutive gynecologic oncology patients who were managed via open surgery in coincident with an ERAS pathway from January 2015 to December 2016. They were compared with a historical open surgery cohort who was treated from November 2013 to December 2014. The primary clinical end points encompassed hospital length of stay, hospital costs, and patient readmission rates.ResultsThere were 86 subjects accrued in the ERAS group and 91 patients in the historical cohort. The implementation of ERAS occasioned a greater than 3-day mean reduction in hospital stay (8.04 days for the historical group vs 4.88 days for the ERAS subjects; P = 0.001) and correspondingly diminished hospital costs ($11,877.47/patient vs $9305.26/patient; P = 0.04). Moreover, there were 2 readmissions (2.3%) in the ERAS group compared with 4 (4.4%) in the historical cohort (P = 0.282).ConclusionsThe results from our investigation suggest that adhering to an ERAS protocol confers beneficial hospital length of stay and hospital cost outcomes, without compromising patient readmission rates. Additional investigation scrutinizing the impact of ERAS enactment with more defined study variables in a larger, randomized setting is warranted.
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Nerup N, Rosenstock S, Bulut O. Comparison of single-port and conventional laparoscopic abdominoperineal resection. J Minim Access Surg 2018; 14:27-32. [PMID: 28782746 PMCID: PMC5749194 DOI: 10.4103/jmas.jmas_38_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Within the last two decades, surgical treatment of colorectal cancer has changed dramatically from large abdominal incisions to minimal access surgery. In the recent years, single port (SP) surgery has spawned from conventional laparoscopic surgery. The purpose of this study was to compare conventional with SP laparoscopic abdominoperineal resection (LAPR) for rectal cancer. Patients and Methods: This was a single-center non-randomised retrospective comparative study of prospectively collected data on 53 patients who underwent abdominoperineal resection for low rectal cancer; 41 with conventional laparoscopy and 12 with SP surgery. Results: Patients’ characteristics were in general comparable, but patients in the conventional laparoscopy-group had a significantly higher American Society of Anesthesiologists-score. The operative time was slightly shorter in the conventional laparoscopy-group, but no differences were found in oncological margins of the resected specimen, in length of stay or readmission rate. Conclusions: SP LAPR appeared to be safe and feasible in selected patients. Adequate oncologic resections can be performed with acceptable morbidity and mortality. Larger randomised controlled trials with longer follow-up are needed to determine the beneficial role of this new procedure.
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Affiliation(s)
- Nikolaj Nerup
- Department of Surgical Gastroenterology, Copenhagen University Hospital Hvidovre, Kettegaards allé 30, DK-2650 Hvidovre, Denmark
| | - Steffen Rosenstock
- Department of Surgical Gastroenterology, Copenhagen University Hospital Hvidovre, Kettegaards allé 30, DK-2650 Hvidovre, Denmark
| | - Orhan Bulut
- Department of Surgical Gastroenterology, Copenhagen University Hospital Hvidovre, Kettegaards allé 30, DK-2650 Hvidovre, Denmark
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Impact of complications on length of stay in elective laparoscopic colectomies. J Surg Res 2017; 219:180-187. [DOI: 10.1016/j.jss.2017.05.113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/23/2017] [Accepted: 05/25/2017] [Indexed: 12/23/2022]
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Emmanuel A, Chohda E, Botfield C, Ellul J. Accelerated discharge within 72 hours of colorectal cancer resection using simple discharge criteria. Ann R Coll Surg Engl 2017; 100:52-56. [PMID: 29022790 DOI: 10.1308/rcsann.2017.0149] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Introduction Short hospital stays and accelerated discharge within 72 hours following colorectal cancer resections have not been widely achieved. Series reporting on accelerated discharge involve heterogeneous patient populations and exclude important groups. Strict adherence to some discharge requirements may lead to delays in discharge. The aim of this study was to evaluate the safety and feasibility of accelerated discharge within 72 hours of all elective colorectal cancer resections using simple discharge criteria. Methods Elective colorectal cancer resections performed between August 2009 and December 2015 by a single surgeon were reviewed. Perioperative care was based on an enhanced recovery programme. A set of simplified discharge criteria were used. Outcomes including postoperative complications, readmissions and reoperations were compared between patients discharged within 72 hours and those with a longer postoperative stay. Results Overall, 256 colorectal cancer resections (90% laparoscopic) were performed. The mean patient age was 70.8 years. The median length of stay was 3 days. Fifty-eight per cent of all patients and sixty-three per cent of patients undergoing laparoscopic surgery were discharged within 72 hours. Accelerated discharge was not associated with adverse outcomes compared with delayed discharge. Patients discharged within 72 hours had significantly fewer postoperative complications, readmissions and reoperations. Open surgery and stoma formation were associated with discharge after 72 hours but not age, co-morbidities, neoadjuvant chemoradiation or surgical procedure. Conclusions Accelerated discharge within 72 hours of elective colorectal resection for cancer is safely achievable for the majority of patients without compromising short-term outcomes.
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Affiliation(s)
- A Emmanuel
- King's College Hospital NHS Foundation Trust , UK
| | - E Chohda
- King's College Hospital NHS Foundation Trust , UK
| | - C Botfield
- King's College Hospital NHS Foundation Trust , UK
| | - J Ellul
- King's College Hospital NHS Foundation Trust , UK
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Ban KA, Gibbons MM, Ko CY, Wick EC. Surgical Technical Evidence Review for Colorectal Surgery Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery. J Am Coll Surg 2017; 225:548-557.e3. [PMID: 28797562 DOI: 10.1016/j.jamcollsurg.2017.06.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 06/24/2017] [Accepted: 06/26/2017] [Indexed: 01/01/2023]
Affiliation(s)
- Kristen A Ban
- American College of Surgeons, Chicago, IL; Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Melinda M Gibbons
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Clifford Y Ko
- American College of Surgeons, Chicago, IL; Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD.
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Curtis NJ, Noble E, Salib E, Hipkiss R, Meachim E, Dalton R, Allison A, Ockrim J, Francis NK. Does hospital readmission following colorectal cancer resection and enhanced recovery after surgery affect long term survival? Colorectal Dis 2017; 19:723-730. [PMID: 28093901 DOI: 10.1111/codi.13603] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 11/28/2016] [Indexed: 02/08/2023]
Abstract
AIM Hospital readmission is undesirable for patients and care providers as this can affect short-term recovery and carries financial consequences. It is unknown if readmission has long-term implications. We aimed to investigate the impact of 30-day readmission on long-term overall survival (OS) following colorectal cancer resection within enhanced recovery after surgery (ERAS) care and explore the reasons for and the severity and details of readmission episodes. METHOD A dedicated, prospectively populated database was reviewed. All patients were managed within an established ERAS programme. Five-year OS was calculated using the Kaplan-Meier method. The number, reason for and severity of 30-day readmissions were classified according to the Clavien-Dindo (CD) system, along with total (initial and readmission) length of stay (LoS). Multivariate analysis was used to identify factors predicting readmission. RESULTS A total of 1023 consecutive patients underwent colorectal cancer resection between 2002 and 2015. Of these, 166 (16%) were readmitted. Readmission alone did not have a significant impact on 5-year OS (59% vs 70%, P = 0.092), but OS was worse in patients with longer total LoS (20 vs 14 days, P = 0.04). Of the readmissions, 121 (73%) were minor (CD I-II) and 27 (16%) required an intervention of which 16 (10%) were returned to theatre. Gut dysfunction 32 (19%) and wound complications 23 (14%) were the most frequent reasons for readmission. Prolonged initial LoS, rectal cancer and younger age predicted for hospital readmission. CONCLUSION Readmission does not have a significant impact on 5-year OS. A broad range of conditions led to readmission, with the majority representing minor complications.
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Affiliation(s)
- N J Curtis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - E Noble
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - E Salib
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - R Hipkiss
- Information Management Team, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - E Meachim
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - R Dalton
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - A Allison
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - J Ockrim
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - N K Francis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK.,Faculty of Science, University of Bath, Bath, UK
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Randomized Trial on Fast Track Care in Colorectal Surgery for Deep Infiltrating Endometriosis. J Minim Invasive Gynecol 2017; 24:815-821. [DOI: 10.1016/j.jmig.2017.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 03/26/2017] [Accepted: 04/07/2017] [Indexed: 02/06/2023]
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Enhanced recovery pathway versus standard care in patients undergoing video-assisted thoracoscopic lobectomy. J Thorac Cardiovasc Surg 2017; 154:2084-2090. [PMID: 28728783 DOI: 10.1016/j.jtcvs.2017.06.037] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/09/2017] [Accepted: 06/16/2017] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The objective of this study was to compare outcomes after video-assisted thoracoscopic lobectomy or segmentectomy before and after introduction of an enhanced recovery program. METHODS Data from 600 patients undergoing video-assisted lobectomy or segmentectomy between April 2014 and January 2017 were analyzed. A comparative analysis was performed between patients undergoing operation before (365 patients) and after (235 patients) the start of the enhanced recovery program. The incidence of cardiopulmonary complications and 30-day and 90-day mortality, postoperative length of stay, and 30-day and 90-day hospital readmission rates were evaluated. Risk-adjusted cardiopulmonary morbidity and 30-day mortality were calculated for each group and compared. RESULTS The 2 groups had a similar postoperative length of stay (enhanced recovery pathway median 5 days vs pre-enhanced recovery pathway 4, P = .44), cardiopulmonary complication rates (enhanced recovery pathway 22.6% vs pre-enhanced recovery pathway 22.4%, P = .98), 30-day mortality rates (enhanced recovery pathway 3.8% vs pre-enhanced recovery pathway 2.2%, P = .31), and 90-day mortality rates (enhanced recovery pathway 4.7% vs pre-enhanced recovery pathway 3.0%, P = .37). No differences were noted in terms of 30-day (enhanced recovery pathway 7.2% vs pre-enhanced recovery pathway 7.4%, P = .94) or 90-day readmission rates (enhanced recovery pathway 9.8% vs pre-enhanced recovery pathway 12.3%, P = .34). The risk-adjusted cardiopulmonary morbidity rates were similar in the 2 periods (P = .76), whereas the risk-adjusted 30-day mortality was higher in the enhanced recovery pathway period compared with the pre-enhanced recovery pathway mortality (P = .0004). CONCLUSIONS We found no benefit conferred by the enhanced recovery program on outcomes such as cardiopulmonary complications, 30- and 90-day mortality, length of stay, and readmissions. Enhanced recovery program elements may be insufficiently different than previous standards of perioperative care to confer detectable benefits in our settings.
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Lassiter RL, Talukder A, Abrams MM, Adam BL, Albo D, White CQ. Racial disparities in the use of laparoscopic surgery to treat colonic diverticulitis Are not fully explained by socioeconomics or disease complexity. Am J Surg 2017; 213:673-677. [DOI: 10.1016/j.amjsurg.2016.11.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 11/09/2016] [Accepted: 11/16/2016] [Indexed: 11/17/2022]
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Pisarska M, Pędziwiatr M, Major P, Kisielewski M, Migaczewski M, Rubinkiewicz M, Budzyński P, Przęczek K, Zub-Pokrowiecka A, Budzyński A. Laparoscopic Gastrectomy with Enhanced Recovery After Surgery Protocol: Single-Center Experience. Med Sci Monit 2017; 23:1421-1427. [PMID: 28331173 PMCID: PMC5375176 DOI: 10.12659/msm.898848] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Surgery remains the mainstay of gastric cancer treatment. It is, however, associated with a relatively high risk of perioperative complications. The use of laparoscopy and the Enhanced Recovery After Surgery (ERAS) protocol allows clinicians to limit surgically induced trauma, thus improving recovery and reducing the number of complications. The aim of the study is to present clinical outcomes of patients with gastric cancer undergoing laparoscopic gastrectomy combined with the ERAS protocol. Material/Methods Fifty-three (21 female/32 male) patients who underwent elective laparoscopic total gastrectomy due to cancer were prospectively analyzed. Demographic and surgical parameters were assessed, as well as the compliance with ERAS protocol elements, length of hospital stay, number of complications, and readmissions. Results Mean operative time was 296.4±98.9 min, and mean blood loss was 293.3±213.8 mL. In 3 (5.7%) cases, conversion was required. Median length of hospital stay was 5 days. Compliance with ERAS protocol was 79.6±14.5%. Thirty (56.6%) patients tolerated an early oral diet well within 24 h postoperatively; in 48 (90.6%) patients, mobilization in the first 24 hours was successful. In 17 (32.1%) patients, postoperative complications occurred, with 7 of them (13.2%) being serious (Clavien-Dindo 3-5). The 30-day readmission rate was 9.4%. Conclusions The combination of laparoscopy and the ERAS protocol in patients with gastric cancer is feasible and allows achieving good clinical outcomes.
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Affiliation(s)
- Magdalena Pisarska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Michał Kisielewski
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Marcin Migaczewski
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Mateusz Rubinkiewicz
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Krzysztof Przęczek
- Jagiellonian University Medical College, 2nd Department of General Surgery, Cracow, Poland
| | - Anna Zub-Pokrowiecka
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
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Braga M, Borghi F, Scatizzi M, Missana G, Guicciardi MA, Bona S, Ficari F, Maspero M, Pecorelli N. Impact of laparoscopy on adherence to an enhanced recovery pathway and readiness for discharge in elective colorectal surgery: Results from the PeriOperative Italian Society registry. Surg Endosc 2017; 31:4393-4399. [PMID: 28289972 DOI: 10.1007/s00464-017-5486-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/20/2017] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Previous studies reported that laparoscopic surgery (LPS) improved postoperative outcomes in patients undergoing colorectal surgery within an enhanced recovery program (ERP). However, the effect of minimally invasive surgery on each ERP item has not been clarified, yet. The aim of this study is to assess the impact of LPS on adherence to ERP items and recovery as measured by time to readiness for discharge (TRD). METHODS Prospectively collected data entered in an electronic Italian registry specifically designed for ERP were reviewed. Patients undergoing elective colorectal surgery were divided into three groups: successful laparoscopy, conversion to open surgery, primary open surgery. Adherence to 19 ERP elements and postoperative outcomes were compared among groups. Multivariate regression analysis was used to identify whether LPS had an independent role to improve ERP adherence and postoperative outcomes. RESULTS 714 patients (successful LPS 531, converted 42, open 141) underwent elective colorectal surgery within an ERP. Epidural analgesia was used in the 75.1% of open group patients versus 49.9% of LPS group patients (p = 0.012). After surgery, oral feeding recovery, i.v. fluids suspension, removal of both urinary and epidural catheters occurred earlier in the LPS group both in the overall series and in uneventful patients only. Mean TRD and length of hospital stay were significantly shorter in the LPS group (p < 0.001 for both). Overall morbidity rate was 18.7% in the LPS group versus 32.6% in the open group (p = 0.001). At multivariate analysis, LPS was significantly associated to an increased adherence to postoperative ERP items, a shorter TRD, and a reduced overall morbidity, whereas rectal surgery and new stoma formation impaired postoperative recovery. CONCLUSIONS The present study showed that a successful laparoscopic procedure had an independent role to increase the adherence to postoperative ERP and to improve short-term postoperative outcome.
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Affiliation(s)
- Marco Braga
- Department of Surgery, Vita-Salute University, San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy.
| | | | | | | | | | - Stefano Bona
- Department of Surgery, Humanitas Hospital IRCCS, Rozzano, Italy
| | - Ferdinando Ficari
- Department of Surgery, Careggi Hospital, University of Florence, Florence, Italy
| | - Marianna Maspero
- Department of Surgery, Vita-Salute University, San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Nicolò Pecorelli
- Department of Surgery, Vita-Salute University, San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
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Currie AC, Malietzis G, Jenkins JT, Yamada T, Ashrafian H, Athanasiou T, Okabayashi K, Kennedy RH. Network meta-analysis of protocol-driven care and laparoscopic surgery for colorectal cancer. Br J Surg 2016; 103:1783-1794. [PMID: 27762436 DOI: 10.1002/bjs.10306] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 06/28/2016] [Accepted: 07/25/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Laparoscopic approaches and standardized recovery protocols have reduced morbidity following colorectal cancer surgery. As the optimal regimen remains inconclusive, a network meta-analysis was undertaken of treatments for the development of postoperative complications and mortality. METHODS MEDLINE, Embase, trial registries and related reviews were searched for randomized trials comparing laparoscopic and open surgery within protocol-driven or conventional perioperative care for colorectal cancer resection, with complications as a defined endpoint. Relative odds ratios (ORs) for postoperative complications and mortality were estimated for aggregated data. RESULTS Forty trials reporting on 11 516 randomized patients were included with the network. Open surgery within conventional perioperative care was the index for comparison. The OR relating to complications was 0·77 (95 per cent c.i. 0·65 to 0·91) for laparoscopic surgery within conventional care, 0·69 (0·48 to 0·99) for open surgery within protocol-driven care, and 0·43 (0·28 to 0·67) for laparoscopic surgery within protocol-driven care. Sensitivity analyses excluding trials of low rectal cancer and those with a high risk of bias did not affect the treatment estimates. Meta-analyses demonstrated that mortality risk was unaffected by perioperative strategy. CONCLUSION Laparoscopic surgery combined with protocol-driven care reduces colorectal cancer surgery complications, but not mortality. The reduction in complications with protocol-driven care is greater for open surgery than for laparoscopic approaches. Registration number: CRD42015017850 (https://www.crd.york.ac.uk/PROSPERO).
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Affiliation(s)
- A C Currie
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, UK
| | - G Malietzis
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, UK
| | - J T Jenkins
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, UK
| | - T Yamada
- Department of Surgery, School of Medicine, Keio University, Shinjuku, Tokyo, Japan
| | - H Ashrafian
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - T Athanasiou
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - K Okabayashi
- Department of Surgery, School of Medicine, Keio University, Shinjuku, Tokyo, Japan
| | - R H Kennedy
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, UK
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Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach. Surg Res Pract 2016; 2016:3561249. [PMID: 27504486 PMCID: PMC4967675 DOI: 10.1155/2016/3561249] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 06/14/2016] [Indexed: 02/07/2023] Open
Abstract
ERAS approach (Enhanced Recovery After Surgery) is a multimodal, perioperative pathway designed to achieve early recovery after surgery. ERAS has shown documented efficacy in elective surgery, and the concept of "multimodal" and "multidisciplinary" approach seems still to be of higher importance than each single item within ERAS protocols. New perspectives include the use of ERAS in emergency surgery, where efficacy and safety on outcome have been documented, and flexibility of traditional items may add benefits for traditionally high-risk patients. Obstetric surgery, as well, may open wide horizons for future research, since extremely poor data are currently available, and ERAS benefits may translate even on the baby. Finally, the concept of "outcome" may be extended when considering the specific setting of cancer surgery, in which variables like cancer recurrence, early access to adjuvant therapies, and, finally, long-term survival are as important as the reduced perioperative complications. In this perspective, different items within ERAS protocols should be reinterpreted and eventually integrated towards "protective" techniques, to develop cancer-specific ERAS approaches keeping pace with the specific aims of oncologic surgery.
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Casans Francés R, Ripollés Melchor J, Abad-Gurumeta A, Longás Valién J, Calvo Vecino JM. The role of the anaesthesiologist in enhanced recovery programs. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:273-288. [PMID: 26775121 DOI: 10.1016/j.redar.2015.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 11/04/2015] [Accepted: 11/09/2015] [Indexed: 06/05/2023]
Affiliation(s)
- R Casans Francés
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Clínico Universitario «Lozano Blesa», Zaragoza, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España.
| | - J Ripollés Melchor
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario «Infanta Leonor», Madrid, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España
| | - A Abad-Gurumeta
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario La Paz, Madrid, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España
| | - J Longás Valién
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Clínico Universitario «Lozano Blesa», Zaragoza, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España
| | - J M Calvo Vecino
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario «Infanta Leonor», Madrid, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España
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