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Detection of Anastomotic Leakage Following Elective Colonic Surgery: Results of the Prospective Biomarkers and Anastomotic Leakage (BALL) Study. J Surg Res 2022; 273:85-92. [PMID: 35033821 DOI: 10.1016/j.jss.2021.12.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 10/28/2021] [Accepted: 12/15/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Anastomotic leakage (AL) is an infrequent but life-threatening surgical complication following colorectal surgery. Early diagnosis remains clinically difficult but is a necessity to reduce associated morbidity and mortality. Clinical review and radiological modalities for the diagnosis of leakage remain non-specific and often only detect AL once it is well developed. Inflammatory biomarkers however have shown promise in early pre-clinical detection of leakage following colorectal surgery. METHODS A multi-center, prospective observational study was conducted across four public hospitals in Auckland and Christchurch, New Zealand. Consecutive adults undergoing elective colectomy were initially recruited over a 3-y period. Perioperative blood samples were collected to measure interleukin (IL)-6, IL-1β, tumor necrosis factor α, IL-10, C-reactive protein (CRP), leukocyte and neutrophil counts. Statistical analysis was performed to compare patients with an uncomplicated recovery with patients with AL. RESULTS Sixteen patients developed AL (5.7%), diagnosed at a median post-operative (POD) day 7. CRP and IL-6 were consistently elevated in the early post-operative period in patients with AL, and had the best diagnostic accuracy on POD 3 (area under the curve 0.70; P = 0.02) and POD 1 (area under the curve 0.69; P = 0.02), respectively. IL-10, once adjusted for body mass index and surgical approach, was the sole biomarker significantly elevated in patients with AL on POD 4. CONCLUSIONS Early post-operative elevations of CRP and IL-6 provide utility for early detection of AL after elective colectomy. Application of these inflammatory biomarkers and their combinations in daily practice warrants further investigation.
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Biondi A, Mele MC, Agnes A, Lorenzon L, Cintoni M, Rinninella E, Marincola G, D’Ugo D, Gasbarrini A, Persiani R. OUP accepted manuscript. BJS Open 2022; 6:6530619. [PMID: 35179186 PMCID: PMC8855525 DOI: 10.1093/bjsopen/zrac002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/15/2021] [Accepted: 01/09/2022] [Indexed: 11/14/2022] Open
Abstract
Background Early postoperative discharge after colorectal surgery within the enhanced recovery after surgery (ERAS) guidelines has been demonstrated to be safe, although its applicability has not been universal. The primary aim of this study was to identify the predictors of early discharge and readiness for discharge in a study population. Methods Early discharge was defined as discharge occurring in 72 h or less after surgery. The characteristics and clinical outcomes of the patients in the early and non-early discharge groups were compared, and variables associated with early discharge were identified. Additionally, independent variables associated with the readiness for discharge within 48 h were evaluated. Results Of 965 patients who underwent colorectal surgery between January 2015 and July 2020, 788 were included in this study. No differences in readmission, reoperation, or 30-day mortality were observed between the early and non-early discharge groups. Both early discharge and readiness for discharge had a positive association with adherence to 80 per cent or more of the ERAS items and a negative association with the female sex, duration of surgery, drain positioning, and postoperative complications. Conclusion Early discharge after colorectal surgery is safe and feasible, and is not associated with a high risk of readmission or reoperation. Discharge at 48 h can be reliably predicted in a subset of patients. Future studies should collect prospective data on early discharge related to safety, as well as patients’ expectations, possible organizational issues, and effective costs reduction in Italian clinical practice.
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Affiliation(s)
- Alberto Biondi
- Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Maria Cristina Mele
- Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Annamaria Agnes
- Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Correspondence to: Annamaria Agnes, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy (e-mail: )
| | - Laura Lorenzon
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marco Cintoni
- Scuola di Specializzazione in Scienza dell’Alimentazione, Università di Roma Tor Vergata, Rome, Italy
| | - Emanuele Rinninella
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Domenico D’Ugo
- Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Roberto Persiani
- Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Surgical rectus sheath block combined with multimodal pain management reduces postoperative pain and analgesic requirement after single-incision laparoscopic appendectomy: a retrospective study. Int J Colorectal Dis 2021; 36:75-82. [PMID: 32875376 DOI: 10.1007/s00384-020-03725-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aimed to evaluate the impact of multimodal postoperative pain management, performing a surgical rectus sheath (RS) block via ropivacaine injection into the surgical field after single-incision laparoscopic appendectomy (SILA). METHODS Patients who underwent single-incision laparoscopic appendectomy (SILA) for acute appendicitis were divided into three groups and compared: group 1 (multimodal pain management that included intraoperative application of a surgical RS block), group 2 (conventional pain management with intravenous opioids), or group 3 (multimodal pain management without RS block). Forty, 53, and 42 patients were registered, respectively (Table 1). RESULTS Time to start a liquid (1.2 ± 0.4 h) in group 1 was statistically significantly shorter than that in group 2 (16.3 ± 8.4 h; p < 0.001) and group 3 (4.93 ± 2.3 h; p < 0.001). The median and max postoperative VAS scores in group 1 (1.6 ± 1.2 and 2.2 ± 1.8, respectively) were statistically significantly lower than that in group 2 (3.0 ± 1.2 and 4.2 ± 1.9, respectively; p < 0.001 on both accounts) and group 3 (2.9 ± 0.6 and 3.4 ± 1.2, respectively; p < 0.001 on both accounts). The postoperative hospital stay for group 1 (17.0 ± 9.4 h) was shorter than that for group 2 (44.7 ± 27.9 h; p < 0.001) and group 3 (35.4 ± 20.9 h; p < 0.001). RS block was a significant factor for reducing length of hospital stay and postoperative pain in 24 h. CONCLUSIONS A surgical RS block combined with multimodal pain management after SILA is a safe and effective method that results in reduced postoperative pain and shorter hospitalization.
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Catarci M, Benedetti M, Maurizi A, Spinelli F, Bernacconi T, Guercioni G, Campagnacci R. ERAS pathway in colorectal surgery: structured implementation program and high adherence for improved outcomes. Updates Surg 2020; 73:123-137. [PMID: 33094366 DOI: 10.1007/s13304-020-00885-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 09/03/2020] [Indexed: 01/30/2023]
Abstract
Although there is clear evidence that an Enhanced Recovery After Surgery (ERAS) program in colorectal surgery leads to significantly reduced morbidity rates and length of hospital stay (LOS), it is still unclear what modalities and levels of implementation of the program are necessary to achieve these results. The purpose of this study is to analyze the methods and results of the first year of structured implementation of a colorectal ERAS program in two surgical units of the Azienda Sanitaria Unica Regionale (ASUR) Marche in Italy. A two-center observational study on a prospectively maintained database was performed on 196 consecutive colorectal resections (excluding emergencies and American Society of Anesthesiologists class > III cases) over a 1-year period. More than 50 variables including adherence to the individual items of the ERAS program were considered. Primary outcomes were overall morbidity, major morbidity, mortality and anastomotic leakage rates; secondary outcomes were LOS, re-admission and re-operation. The results were evaluated by univariate and multivariate analyses through logistic regression. After a median follow-up of 39.5 days, we recorded complications in 72 patients (overall morbidity 36.7%), major complications in 14 patients (major morbidity 7.1%), 6 deaths (mortality 3.1%), anastomotic dehiscence in 9 cases (4.9%), mean overall LOS of 6.6 days, 10 readmissions (5.1%) and 13 reoperations (6.7%). The mean adherence rate to the items of the ERAS program was 85.4%, showing a significant dose-effect curve for overall and major morbidity rates, anastomotic leakage rates and LOS. The implementation methods of a colorectal ERAS program in this study led to a high adherence (> 80%) to the program items. High adherence had significant effects also on major morbidity and anastomotic leakage rates.
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Affiliation(s)
- Marco Catarci
- General Surgery Unit, Ospedale C.G. Mazzoni Ascoli Piceno, AV 5, Azienda Sanitaria Unica Regionale (ASUR), Marche, Italy. .,Direttore UOC Chirurgia Generale, Ospedale "C. e G. Mazzoni"-AV5-ASUR Marche, Via degli Iris snc, 63100, Ascoli Piceno, Italy.
| | - Michele Benedetti
- General Surgery Unit, Ospedale C.G. Mazzoni Ascoli Piceno, AV 5, Azienda Sanitaria Unica Regionale (ASUR), Marche, Italy
| | - Angela Maurizi
- General Surgery Unit, Ospedale C. Urbani Jesi (AN), AV 2, Azienda Sanitaria Unica Regionale (ASUR), Marche, Italy
| | - Francesco Spinelli
- Anesthesiology Unit, Ospedale C.G. Mazzoni Ascoli Piceno, AV 5, Azienda Sanitaria Unica Regionale (ASUR), Marche, Italy
| | - Tonino Bernacconi
- Anesthesiology Unit, Ospedale C. Urbani Jesi (AN), AV 2, Azienda Sanitaria Unica Regionale (ASUR), Marche, Italy
| | - Gianluca Guercioni
- General Surgery Unit, Ospedale C.G. Mazzoni Ascoli Piceno, AV 5, Azienda Sanitaria Unica Regionale (ASUR), Marche, Italy
| | - Roberto Campagnacci
- General Surgery Unit, Ospedale C. Urbani Jesi (AN), AV 2, Azienda Sanitaria Unica Regionale (ASUR), Marche, Italy
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Kim WJ, Jin HY, Lee H, Bae JH, Koh W, Mun JY, Kim HJ, Lee IK, Lee YS, Lee CS. Comparing the Postoperative Outcomes of Single-Incision Laparoscopic Appendectomy and Three Port Appendectomy With Enhanced Recovery After Surgery Protocol for Acute Appendicitis: A Propensity Score Matching Analysis. Ann Coloproctol 2020; 37:232-238. [PMID: 34167189 PMCID: PMC8391045 DOI: 10.3393/ac.2020.09.15] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/15/2020] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The objective of this study was to compare the perioperative outcomes between single-incision laparoscopic appendectomy (SILA) and 3-port conventional laparoscopic appendectomy (CLA) in enhanced recovery after surgery (ERAS) protocol. METHODS Of 101 laparoscopic appendectomy with ERAS protocol cases for appendicitis from March 2019 to April 2020, 54 patients underwent SILA with multimodal analgesic approach (group 1) while 47 patients received CLA with multimodal analgesic approach (group 2). SILA and CLA were compared with the single institution's ERAS protocol. To adjust for baseline differences and selection bias, operative outcomes and complications were compared after propensity score matching (PSM). RESULTS After 1:1 PSM, well-matched 35 patients in each group were evaluated. Postoperative hospital stays for patients in group 1 (1.2 ± 0.8 vs. 1.6 ± 0.8 days, P = 0.037) were significantly lesser than those for patients in group 2. However, opioid consumption (2.0 mg vs. 1.4 mg, P=0.1) and the postoperative scores of visual analogue scale for pain at 6 hours (2.4±1.9 vs. 2.8 ± 1.4, P = 0.260) and 12 hours (2.4 ± 2.0 vs. 2.9 ± 1.5, P = 0.257) did not show significant difference between the 2 groups. CONCLUSION SILA resulted in shortening the length of hospitalization without increase in complications or readmission rates compared to CLA with ERAS protocol.
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Affiliation(s)
- Won Jong Kim
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyeong Yong Jin
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyojin Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Hoon Bae
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Wooree Koh
- Department of Surgery, Hansol Hospital, Seoul, Korea
| | - Ji Yeon Mun
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee Ju Kim
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Kyu Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoon Suk Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chul Seung Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Dudi‐Venkata NN, Kroon HM, Bedrikovetski S, Moore JW, Sammour T. Systematic scoping review of enhanced recovery protocol recommendations targeting return of gastrointestinal function after colorectal surgery. ANZ J Surg 2019; 90:41-47. [DOI: 10.1111/ans.15319] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/23/2019] [Accepted: 05/12/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Nagendra N. Dudi‐Venkata
- Colorectal Unit, Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
- Faculty of Health and Medical Science, School of MedicineThe University of Adelaide Adelaide South Australia Australia
| | - Hidde M. Kroon
- Colorectal Unit, Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
| | - Sergei Bedrikovetski
- Faculty of Health and Medical Science, School of MedicineThe University of Adelaide Adelaide South Australia Australia
| | - James W. Moore
- Colorectal Unit, Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
- Faculty of Health and Medical Science, School of MedicineThe University of Adelaide Adelaide South Australia Australia
| | - Tarik Sammour
- Colorectal Unit, Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
- Faculty of Health and Medical Science, School of MedicineThe University of Adelaide Adelaide South Australia Australia
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Enhanced recovery after surgery protocol allows ambulatory laparoscopic appendectomy in uncomplicated acute appendicitis: a prospective, randomized trial. Surg Endosc 2018; 33:429-436. [PMID: 29987566 DOI: 10.1007/s00464-018-6315-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 06/29/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Previous observational studies have demonstrated the safety of discharging patients after laparoscopic appendectomy within the same day without hospitalization. The application of Enhanced Recovery After Surgery (ERAS) guidelines has resulted in shorter length of stay, fewer complications, and reduction in medical costs. The aim of this study was to investigate if ERAS protocol implementation in patients with acute uncomplicated appendicitis decreases the length of stay enough to allow for ambulatory laparoscopic appendectomy. METHODS In this prospective, randomized controlled clinical trial, 108 patients were randomized into two groups: laparoscopic appendectomy with ERAS (LA-E) or laparoscopic appendectomy with conventional care (LA-C). The primary endpoint was postoperative length of stay. The secondary end points were time to resume diet, postoperative pain, postoperative complications, re-admission rate, and reoperation rate. RESULTS From January 2016 through May 2017, 50 patients in the LA-E group and 58 in the LA-C were analyzed. There were no significant differences in preoperative data. Regarding the primary end point of the study, the ERAS protocol significantly reduced the postoperative length of stay with a mean of 9.7 h (SD: 3.1) versus 23.2 h (SD: 6.8) in the conventional group (p < 0.001). The ERAS protocol allowed ambulatory management in 90% of the patients included in this group. There was a significant reduction in time to resume diet (110 vs. 360 min, p < 0.001) and less moderate-severe postoperative pain (28 vs. 62.1%, p < 0.001) in the LA-E versus LA-C group. The rate of complications, readmissions, and reoperations were comparable in both groups (p = 0.772). CONCLUSIONS ERAS implementation was associated with a significantly shorter length of stay, allowing for the ambulatory management of this group of patients. Ambulatory laparoscopic appendectomy is safe and feasible with similar rates of morbidity and readmissions compared with conventional care.
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Pricolo VE, Fei P, Crowley S, Camisa V, Bonvini M. A novel enhanced recovery protocol, combining multimodal analgesia with liposomal bupivacaine and pharmacologic intervention, reduces parenteral opioid use and hospital length of stay after colectomy – A cohort study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2018. [DOI: 10.1016/j.ijso.2018.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Senturk JC, Kristo G, Gold J, Bleday R, Whang E. The Development of Enhanced Recovery After Surgery Across Surgical Specialties. J Laparoendosc Adv Surg Tech A 2017; 27:863-870. [PMID: 28795911 DOI: 10.1089/lap.2017.0317] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS®) principles have gained traction in variety of surgical disciplines. The promise of a reduced length of stay without compromising patient safety or increasing readmission rates has produced a body of literature examining the implementation of ERAS in the care of general, thoracic, urologic, and gynecologic surgery patients. METHODS We performed a review of the literature pertaining to studies of ERAS implementation across colorectal surgery, general surgery, thoracic surgery, urology, and gynecology. The extent of ERAS implementation and reported outcomes across key studies as well as systematic reviews and meta-analyses in each field were summarized. RESULTS The implementation of ERAS protocols has not been uniform across surgical specialties. Despite this, ERAS has produced improvements in patient outcomes. The most commonly described benefit of ERAS application has been reduced length of stay; complication and readmission rates are most consistently decreased in the colorectal literature. Studies have started to measure more nuanced measures of postoperative patient well-being. Efforts are growing to standardize ERAS protocols across diverse fields and call attention to the need for quality control. CONCLUSIONS Challenges remain in the study and execution of ERAS. Controlling for adherence to ERAS components and implementing uniform ERAS protocols across studies are burgeoning topics that have significant implications for study design. The practice of ERAS and its benefits to patients are expected to evolve. Assessing improvements in postdischarge quality of life, timing of return to work and independent living, and adherence to scheduled delivery of adjuvant treatments will strengthen future ERAS investigations.
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Affiliation(s)
- James C Senturk
- 1 Department of Surgery, Brigham and Women's Hospital/Harvard Medical School , Boston, Massachusetts
| | - Gentian Kristo
- 2 Department of Surgery, VA Boston Healthcare System , West Roxbury, Massachusetts
| | - Jason Gold
- 1 Department of Surgery, Brigham and Women's Hospital/Harvard Medical School , Boston, Massachusetts.,2 Department of Surgery, VA Boston Healthcare System , West Roxbury, Massachusetts
| | - Ronald Bleday
- 1 Department of Surgery, Brigham and Women's Hospital/Harvard Medical School , Boston, Massachusetts
| | - Edward Whang
- 1 Department of Surgery, Brigham and Women's Hospital/Harvard Medical School , Boston, Massachusetts.,2 Department of Surgery, VA Boston Healthcare System , West Roxbury, Massachusetts
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