Implementation of enhanced recovery after surgery (ERAS) protocol for anterior cervical discectomy and fusion: a propensity score-matched analysis

Impact of fast-track rehabilitation nursing on pressure ulcers and postoperative complications in patients with inter-trochanteric fractures: A meta-analysis

We sought to investigate the effects of fast-track rehabilitation nursing on pressure ulcers, length of hospital stay and postoperative complications in patients with inter-trochanteric fractures (ITF). The PubMed, Web of Science, Embase, Cochrane Library, China National Knowledge Infrastructure and WanFang databases were searched for randomised controlled trials (RCTs) published from inception to September 2023 on the application of fast-track rehabilitative nursing to ITF. Two investigators independently screened the literature and performed data extraction and quality assessments using the Cochrane Risk of Bias Assessment Tool. The meta-analysis was performed using RevMan 5.4. Overall, 22 RCTs involving 1904 patients were included. Meta-analysis revealed that after fast-track rehabilitation nursing intervention in patients with ITF, the occurrence of pressure ulcers (odds ratio [OR]: 0.29; 95% confidence interval [CI]: 0.18-0.47; p < 0.001) and postoperative complications (OR: 0.19; 95% CI: 0.14-0.26; p < 0.001) were significantly reduced and hospital stay was significantly shorter (standardised mean difference: -3.10; 95% CI: -3.82 to -2.38; p < 0.001). Nursing care for patients with ITF based on the concept of fast-track rehabilitation is conducive to reducing the occurrence of pressure ulcers, lowering the occurrence of complications, shortening the length of hospitalisation and promoting postoperative rehabilitation.

Effects of nurses-led multidisciplinary-based psychological management in spinal surgery: a retrospective, propensity-score-matching comparative study

BACKGROUND

Patients in spine surgery often have emotional disorders which is caused by multi-factors. Therefore, a multidisciplinary and multimodal intervention program is required to improve emotional disorders during the perioperative period. However, related studies were rare. This study aimed to confirm that the multidisciplinary-based psychological management leading by nurses was effective in treating emotional disorders and show the assignments of the members of the multidisciplinary team with the orientations of nurses.

DESIGN

A retrospective, comparative study.

METHOD

This study was a retrospective cohort research and compared the results between the intervention group and control group using the Huaxi Emotional Distress Index (HEI) which was used to evaluate emotional disorders. The intervention group consisted of patients who underwent surgery between January 2018 and December 2020 after psychological management was implemented. The control group consisted of patients with regular care who underwent surgery between January 2015 and December 2017. To improve comparability between the two groups, baseline data from the recruited patients were analyzed using propensity-score-matching (PSM) based on age, sex, marital status, education, and disease region.

RESULTS

A total of 539 (11.5%) people developed emotional disorders, of which 319 (6.8%), 151 (3.2%) and 69 (1.5%) had mild, moderate mood and severe emotional disorders, respectively. 2107 pairs of patients were matched after PSM. Scores of HEI in the intervention group were heightened compared with those in the control group (P<0.001) after matching. Moreover, the incidence of emotional disorders in patients decreased after implementing psychological management (P = 0.001). The severity of emotional disorders was alleviated with statistical significance as well (P = 0.010).

CONCLUSIONS

Nurses-led Multidisciplinary-Based psychological management was able to reduce the incidence of emotional disorders and improve the severity of these in spine surgery patients.

A meta-analysis of the implementation of enhanced recovery after surgery pathways in anterior cervical spine surgery for degenerative cervical spine diseases

OBJECTIVE

To systematically evaluate the perioperative effects of enhanced recovery after surgery (ERAS) protocol on anterior cervical spine surgery by means of meta-analysis.

METHODS

According to the PRISMA guidelines, the article's search on the China National Knowledge Infrastructure (CNKI), Wanfang data resource system, VIP, PubMed database and Cochrane library was conducted to identify clinical studies investigating the effects of ERAS protocols on anterior cervical spine surgery. A quantitative meta-analysis was performed for the clinical outcomes extracted from the studies that met inclusion criteria.

RESULTS

Of the 21 studies identified from the article search, 10 studies met inclusion criteria. The meta-analysis showed shorter length of stay (LOS) (MD = -2.16, 95% CI (-2.57, -1.75), P < 0.00001) and higher patient satisfaction for the ERAS protocols (OR = 3.13, 95% CI (1.97, 4.98), P < 0.00001). Furthermore, ERAS programs led to significant decreases in cost (MD = -0.81, 95% CI (-1.08, -0.53), P < 0.00001) and complication rates (OR = 0.15, 95% CI (0.08, 0.27), P < 0.00001), but no difference in 90-day readmission (OR = 0.63, 95% CI (0.30, 1.35), P = 0.24).

CONCLUSIONS

The data of this study suggest that the implementation of ERAS protocol decreases LOS, cost and complications rates and improve satisfaction for the patients undergoing anterior cervical spine surgery. To support the practice use of ERAS in anterior cervical spine surgery further, controlled trials will be indispensable.

Racial/Ethnic Disparities Among Patients Undergoing Anterior Cervical Discectomy and Fusion or Posterior Cervical Decompression and Fusion for Cervical Spondylotic Myelopathy: A National Administrative Database Analysis

INTRODUCTION

The aim of this study was to investigate the impact of racial disparities on surgical outcomes for cervical spondylotic myelopathy (CSM).

METHODS

Adult patients undergoing anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF) for CSM were identified from the 2016 to 019 National Inpatient Sample Database using the International Classification of Diseases codes. Patients were categorized based on approach (ACDF or PCDF) and race/ethnicity (White, Black, Hispanic). Patient demographics, comorbidities, operative characteristics, adverse events, and health care resource utilization were assessed. Multivariate logistic regression analyses were used to identify independent predictors of extended length of stay (LOS), nonroutine discharge (NRD), and exorbitant costs.

RESULTS

A total of 46,500 patients were identified, of which 36,015 (77.5%) were White, 7465 (16.0%) were Black, and 3020 (6.5%) were Hispanic. Black and Hispanic patients had a greater comorbidity burden compared to White patients (P = 0.001) and a greater incidence of any postoperative complication (P = 0.001). Healthcare resource utilization were greater in the PCDF cohort than the ACDF cohort and greater in Black and Hispanic patients compared to White patients (P < 0.001). Black and Hispanic patient race were significantly associated with extended hospital LOS ([Black] odds ratio [OR]: 2.24, P < 0.001; [Hispanic] OR: 1.64, P < 0.001) and NRD ([Black] OR: 2.33, P < 0.001; [Hispanic] OR: 1.49, P = 0.016). Among patients who underwent PCDF, Black race was independently associated with extended hospital LOS ([Black] OR: 1.77, P < 0.001; [Hispanic] OR: 1.47, P = 0.167) and NRD ([Black] OR: 1.82, P < 0.001; [Hispanic] OR: 1.38, P = 0.052).

CONCLUSIONS

Our study suggests that patient race may influence patient outcomes and healthcare resource utilization following ACDF or PCDF for CSM.

Frailty Influence on Postoperative Surgical Site Infections After Surgery for Degenerative Spine Disease and Adult Spine Deformity. Can a Frailty Index be a Valuable Summary Risk Indicator? A Systematic Review and Metanalysis of the Current Literature

STUDY DESIGN

Metanalysis.

OBJECTIVE

Surgical site infections (SSI) is one of the commonest postoperative adverse events after spine surgery. Frailty has been described as a valuable summary risk indicator for SSI in spine surgery. The aim of this metanalysis is to evaluate the influence of frailty on postoperative SSI in this cohort and provide hints on which index can predict the risk of SSI.

METHODS

Papers describing the postoperative SSI rate in adult degenerative spine disease or adult spine deformity patients with varying degrees of frailty were included in the analysis. The SSI rate in different grades of frailty was considered for outcome measure. Meta-analysis was performed on studies in whom data regarding patients with different levels of frailty and occurrence of postoperative SSI could be pooled. P < .05 was considered significant.

RESULTS

16 studies were included. The frailty prevalence measured using mFI-11 ranged from 3% to 17.9%, these values were inferior to those measured with mFI-5. Significant difference was found between frail and non-frail patients in postoperative SSI rate at metanalysis (z = 5.9547, P < .0001 for mFI-5 and z = 3.8334, P = .0001 for mFI-11).

CONCLUSION

This is the first meta-analysis to specifically investigate the impact of frailty, on occurrence of SSI. We found a relevant statistical difference between frail and non-frail patients in SSI occurrence rate. This is a relevant finding, as the ageing of population increases alongside with spine surgery procedures, a better understanding of risk factors may advance our ability to treat patients while minimizing the occurrence of SSI.

Transforming Outcomes of Spine Surgery-Exploring the Power of Enhanced Recovery After Surgery Protocol: A Systematic Review and Meta-Analyses of 15 198 Patients

BACKGROUND AND OBJECTIVES

Enhanced recovery after surgery (ERAS) protocols aim to optimize patient outcomes by reducing the surgical stress response, expediting recovery, and reducing care costs. We aimed to evaluate the impact of implementing ERAS protocols on the perioperative surgical outcomes and financial implications associated with spine surgeries.

METHODS

A systematic review and meta-analysis of peer-reviewed studies directly comparing outcome differences between spine surgeries performed with and without utilization of ERAS pathways was conducted along Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Of 676 unique articles identified, 59 with 15 198 aggregate patients (7748 ERAS; 7450 non-ERAS) were included. ERAS-treated patients had shorter operative times (mean difference [MD]: 10.2 mins; P < .01), shorter hospitalizations (MD: 1.41 days, P < .01), fewer perioperative complications (relative risk [RR] = 0.64, P < .01), lower postoperative opioid use (MD of morphine equivalent dose: 164.36 mg; P < .01), and more rapid mobilization/time to first out-of-bed ambulation (MD: 0.92 days; P < .01). Spine surgeries employing ERAS were also associated with lower total costs (MD: $1140.26/patient; P < .01), especially in the United States (MD: $2869.11/patient, P < .01) and lower postoperative visual analog pain scores (MD = 0.56, P < .01), without any change in odds of 30-day readmission (RR: 0.80, P = .13) or reoperation (RR: 0.88, P = .60). Subanalyses based on the region of spine showed significantly lower length of stay in both cervical and lumbar surgeries implementing ERAS. Type of procedure showed a significantly lesser time-to-initiate mobilization in fusion surgeries using ERAS protocols compared with decompression.

CONCLUSION

The present meta-analysis indicates that current literature supports ERAS implementation as a means of reducing care costs and safely accelerating hospital discharge for patients undergoing spine surgery.

Association Between Age-stratified Cohorts and Perioperative Complications and 30-day and 90-day Readmission in Patients Undergoing Single-level Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

To assess perioperative complication rates and readmission rates after ACDF in a patient population of advanced age.

SUMMARY OF BACKGROUND DATA

Readmission rates after ACDF are important markers of surgical quality and, with recent shifts in reimbursement schedules, they are rapidly gaining weight in the determination of surgeon and hospital reimbursement.

METHODS

Patients 18 years of age and older who underwent elective single-level ACDF were identified in the National Readmissions Database (NRD) and stratified into 4 cohorts: 18-39 ("young"), 40-64 ("middle"), 65-74 ("senior"), and 75+ ("elderly") years of age. For each cohort, the perioperative complications, frequency of those complications, and number of patients with at least 1 readmission within 30 and 90 days of discharge were analyzed. χ 2 tests were used to calculate likelihood of complications and readmissions.

RESULTS

There were 1174 "elderly" patients in 2016, 1072 in 2017, and 1010 in 2018 who underwent ACDF. Their rate of any complication was 8.95%, 11.00%, and 13.47%, respectively ( P <0.0001), with dysphagia and acute posthemorrhagic anemia being the most common across all 3 years. They experienced complications at a greater frequency than their younger counterparts (15.80%, P <0.0001; 16.98%, P <0.0001; 21.68%, P <0.0001). They also required 30-day and 90-day readmission more frequently ( P <0.0001).

CONCLUSION

It has been well-established that advanced patient age brings greater risk of perioperative complications in ACDF surgery. What remains unsettled is the characterization of this age-complication relationship within specific age cohorts and how these complications inform patient hospital course. Our study provides an updated analysis of age-specific complications and readmission rates in ACDF patients. Orthopedic surgeons may account for the rise in complication and readmission rates in this population with the corresponding reduction in length and stay and consider this relationship before discharging elderly ACDF patients.

Enhanced recovery after surgery (ERAS) in sacral tumour surgery and comprehensive description of a multidisciplinary program: a prospective study in a specialized hospital in China

PURPOSE

There were fewer data to guide the application of enhanced recovery after surgery (ERAS) theory into sacral tumour surgery. In the present study, we were aiming to describe a multidisciplinary program of ERAS and evaluate the availability in sacral tumour surgery.

METHODS

This was a prospective study of patients with sacral tumour between March 2021 and September 2021 at a single centre. We proposed a multidisciplinary program of ERAS for pre-admission, preoperative, intraoperative, postoperative, and post-discharge clinical care which positively influenced outcomes of patients with sacral tumour. All patients were prospectively assigned into two groups, ERAS group in which patients received ERAS protocols (n = 63), No-ERAS group in which patients had conventional clinical pathways (n = 62). Patient data were collected which included demographics, preoperative preparation, detailed information of surgical procedure, 60-day reoperation rate, 60-day readmission, postoperative length of stay (PLOS), time to first ambulation and flatus after surgery, time to removal of last drainage tube, and visual analogue scale (VAS) score at first ambulation and discharge. Complications referred to ones that occurred within 60 days after surgery. The above parameters were compared between ERAS group and No-ERAS group.

RESULTS

Time to first ambulation after surgery in ERAS group (mean 20.9 h) was significantly shorter than that in No-ERAS group (mean 104.3 ho). Meanwhile, time to first flatus after surgery in ERAS group (mean 26.7 h) was also significantly shorter than that in No-ERAS group (mean 37.3 h). Patients in ERAS group had statistically shorter PLOS (10.7 days) as compared to that in No-ERAS group (13.8 days). In ERAS group, 19 of 63 patients (30.2%) were discharged within seven days after surgery as compared to seven of 62 patients (11.3%) in No-ERAS group. VAS score at first ambulation in ERAS group was not obviously higher than that in No-ERAS group though the time of first ambulation in ERAS group was statistically earlier than one in No-ERAS group. Furthermore, VAS score at discharge in ERAS group was significantly lower than that in No-ERAS group. The rate of postoperative incision necrosis was 6.3% (4/63) in ERAS group and 8.1% (5/62) in No-ERAS group and all of these nine patients underwent reoperation before discharge. The difference was not statistically significant in the wound complication of incision necrosis and 60-day reoperation rate. Only one readmission occurred in No-ERAS group due to the surgical site infection and also there was no significant difference of 60-day readmission rate between these two groups. Furthermore, there was no statistical difference of complications of femoral artery thrombosis and rectal rupture between ERAS group and No-ERAS group.

CONCLUSIONS

Our proposed ERAS pathway for sacral tumour surgery and early walking facilitate safe and prompt discharge. ERAS protocols of sacral tumour surgery could decrease PLOS without significantly increasing postoperative complications, 60-day readmission rate and 60-day reoperation rate. The application of ERAS pathway in the field of sacral tumour surgery should have personalized feature with regard to resection type.

Impact of Preoperative Frailty on Outcomes in Patients with Cervical Spondylotic Myelopathy Undergoing Anterior vs. Posterior Cervical Surgery

Introduction: Frailty has been shown to negatively influence patient outcomes across many disease processes, including in the cervical spondylotic myelopathy (CSM) population. The aim of this study was to assess the impact that frailty has on patients with CSM who undergo anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF). Materials and Methods: A retrospective cohort study was performed using the 2016-2019 national inpatient sample. Adult patients (≥18 years old) undergoing ACDF only or PCDF only for CSM were identified using ICD codes. The patients were categorized based on receipt of ACDF or PCDF and pre-operative frailty status using the 11-item modified frailty index (mFI-11): pre-Frail (mFI = 1), frail (mFI = 2), or severely frail (mFI ≥ 3). Patient demographics, comorbidities, operative characteristics, perioperative adverse events (AEs), and healthcare resource utilization were assessed. Multivariate logistic regression analyses were used to identify independent predictors of extended length of stay (LOS) and non-routine discharge (NRD). Results: A total of 37,990 patients were identified, of which 16,665 (43.9%) were in the pre-frail cohort, 12,985 (34.2%) were in the frail cohort, and 8340 (22.0%) were in the severely frail cohort. The prevalence of many comorbidities varied significantly between frailty cohorts. Across all three frailty cohorts, the incidence of AEs was greater in patients who underwent PCDF, with dysphagia being significantly more common in patients who underwent ACDF. Additionally, the rate of adverse events significantly increased between ACDF and PCDF with respect to increasing frailty (p < 0.001). Regarding healthcare resource utilization, LOS and rate of NRD were significantly greater in patients who underwent PCDF in all three frailty cohorts, with these metrics increasing with frailty in both ACDF and PCDF cohorts (LOS: p < 0.001); NRD: p < 0.001). On a multivariate analysis of patients who underwent ACDF, frailty and severe frailty were found to be independent predictors of extended LOS [(frail) OR: 1.39, p < 0.001; (severely frail) OR: 2.25, p < 0.001] and NRD [(frail) OR: 1.49, p < 0.001; (severely frail) OR: 2.22, p < 0.001]. Similarly, in patients who underwent PCDF, frailty and severe frailty were found to be independent predictors of extended LOS [(frail) OR: 1.58, p < 0.001; (severely frail) OR: 2.45, p < 0.001] and NRD [(frail) OR: 1.55, p < 0.001; (severely frail) OR: 1.63, p < 0.001]. Conclusions: Our study suggests that preoperative frailty may impact outcomes after surgical treatment for CSM, with more frail patients having greater health care utilization and a higher rate of adverse events. The patients undergoing PCDF ensued increased health care utilization, compared to ACDF, whereas severely frail patients undergoing PCDF tended to have the longest length of stay and highest rate of non-routine discharge. Additional prospective studies are necessary to directly compare ACDF and PCDF in frail patients with CSM.

Implementation of the Enhanced Recovery After Surgery (ERAS®) program in neurosurgery

BACKGROUND

Over the past decade, Enhanced Recovery After Surgery (ERAS®) guidelines have been proven to simplify postoperative care and improve recovery in several surgical disciplines. The authors set out to create and launch an ERAS® program for cranial neurosurgery that meets official ERAS® Society standards. The authors summarize the successive steps taken to achieve this goal in two specific neurosurgical conditions and describe the challenges they faced.

METHODS

Pituitary neuroendocrine tumors (Pit-NET) resected by a transsphenoidal approach and craniosynostosis (Cs) repair were selected as appropriate targets for the implementation of ERAS® program in the Department of Neurosurgery. A multidisciplinary team with experience in managing these pathologies was created. A specialized ERAS® nurse coordinator was hired. An ERAS® certification process was performed involving 4 seminars separated by 3 active phases under the supervision of an ERAS® coach.

RESULTS

The ERAS® Pit-NET team included 8 active members. The ERAS® Cs team included 12 active members. Through the ERAS® certification process, areas for improvement were identified, local protocols were written, and the ERAS® program was implemented. Patient-centered strategies were developed to increase compliance with the ERAS® protocols. A prospective database was designed for ongoing program evaluation. Certification was achieved in 18 months. Direct costs and time requirements are reported.

CONCLUSION

Successful ERAS® certification requires a committed multidisciplinary team, an ERAS® coach, and a dedicated nurse coordinator.

Enhanced Recovery After Surgery (ERAS) Program for Anterior Cervical Discectomy and Fusion (ACDF) in Patients Over 60 Years Old

Background

Enhanced recovery after surgery (ERAS) is currently widely used in many surgical specialties, but there is still a lack of concern about the cervical ERAS program for old patients (>60 years old). We aimed to determine whether our ERAS program significantly improved satisfaction and outcomes in old patients (>60 years old) with anterior cervical discectomy and fusion (ACDF).

Methods

This is a retrospective cohort study. The study enrolled patients if they were over the age of 60 years old underwent ACDF from July 2019 and June 2021 (ERAS group) and from January 2018 and June 2019 (non-ERAS group). Data including demographic, comorbidity, and surgical information were collected. We also evaluated ERAS process compliance, primary outcome, surgical complication, and length of stay (LOS).

Results

There were 135 patients in the ERAS group, and 122 patients in the non-ERAS group were included. A comparison of the demographic data revealed that there were no statistically significant intergroup differences observed between the group. Overall, ERAS pathway compliance was 91.9%. There were no significant differences in the fusion levels, operative time, intraoperative blood loss, postoperative VAS score, and complications between the ERAS and non-ERAS groups. In addition, there was no significant difference in readmission and mortality at 30-day follow-up between the two groups. However, we observed a statistically significant decrease in the LOS in the ERAS group (8.68±2.34 of ERAS group versus 10.43±4.05 in non-ERAS group, p=0.013).

Conclusion

This report describes the first ERAS protocol used in old patients with ACDF. Our ERAS program is safe and associated with incremental benefits with respect to LOS in old patients with ACDF.

Enhanced recovery after microdiscectomy: reductions in opioid use, length of stay and cost

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are widely used worldwide. Recently, studies of the ERAS program in spinal surgery subspecialties have been reported. The aim of this study was to evaluate the impacts of ERAS in minimally invasive microdiscectomy (MD) surgery.

METHODS

This was a retrospective cohort study of patients undergoing MD at a single center. From March 2018 to March 2021, 286 patients were in the ERAS group. A total of 140 patients from March 2017 to February 2018 were in the conventional group. The outcomes included length of stay (LOS), the postoperative numeric rating scale (NRS), complications, 30-day readmission rate, 30-day reoperation rate and cost. Moreover, perioperative factors were also evaluated.

RESULTS

Compared with the conventional group, the LOS and cost were reduced in the ERAS group. There were no significant differences in the NRS, complication rate, 30-day readmission or reoperation rates between the groups. Furthermore, postoperative drainage volume, and postoperative opioid use were lower in the ERAS group.

CONCLUSIONS

The ERAS protocol for MD surgery reduces LOS, cost and opioid use and accelerates patient recovery.

Fast-track protocols for patients undergoing spine surgery: a systematic review

BACKGROUND CONTEXT

Fast-track is an evidence-based multidisciplinary strategy for pre-, intra-, and postoperative management of patients during major surgery. To date, fast-track has not been recognized or accepted in all surgical areas, particularly in orthopedic spine surgery where it still represents a relatively new paradigm.

PURPOSE

The aim of this review was provided an evidenced-based assessment of specific interventions, measurement, and associated outcomes linked to enhanced recovery pathways in spine surgery field.

METHODS

We conducted a systematic review in three databases from February 2012 to August 2022 to assess the pre-, intra-, and postoperative key elements and the clinical evidence of fast-track protocols as well as specific interventions and associated outcomes, in patients undergoing to spine surgery.

RESULTS

We included 57 full-text articles of which most were retrospective. Most common fast-track elements included patient's education, multimodal analgesia, thrombo- and antibiotic prophylaxis, tranexamic acid use, urinary catheter and drainage removal within 24 hours after surgery, and early mobilization and nutrition. All studies demonstrated that these interventions were able to reduce patients' length of stay (LOS) and opioid use. Comparative studies between fast-track and non-fast-track protocols also showed improved pain scores without increasing complication or readmission rates, thus improving patient's satisfaction and functional recovery.

CONCLUSIONS

According to the review results, fast-track seems to be a successful tool to reduce LOS, accelerate return of function, minimize postoperative pain, and save costs in spine surgery. However, current studies are mainly on degenerative spine diseases and largely restricted to retrospective studies with non-randomized data, thus multicenter randomized trials comparing fast-track outcomes and implementation are mandatory to confirm its benefit in spine surgery.

The Impact of Frailty on Perioperative Outcomes in Patients Receiving Short-Level Posterior Lumbar Interbody Fusion: A Stepwise Propensity Score Matching Analysis

Background

There are many studies on the impact of frailty on postoperative complications; however, there are few studies focusing on stepwise propensity score matching (PSM) to offset the influence of age.

Methods

We gathered data for patients undergoing short-level posterior lumbar interbody fusion from January to December 2021. According to the Fried frailty phenotype, we categorized patients into non-frail, pre-frail, and frail groups, then, stepwise PSM for age, sex, American Society of Anesthesiologists (ASA) and fusion levels were performed to keep comparable clinical data between groups. Univariate and multivariate logistic regressions were used to determine the impact of clinical demographics on postoperative complications.

Results

A total of 559 consecutive patients with complete medical records were enrolled (237 males and 322 females; mean age 72.55 ± 5.86 years). After PSM, we found that pre-frail patients were more vulnerable to develop urinary retention (p = 0.031) and surgical site infections (p = 0.021) than non-frail patients. Longer length of stay (LOS), delayed ambulation and removal of urinary catheter times were observed in pre-frail patients. However, there was a significant difference only in LOS between pre-frail and frail patients. Binary logistic regression revealed that C-reactive protein (CRP) and frail status were independently associated with postoperative complications between non-frail and pre-frail patients, while only CRP was independently correlated with complications between pre-frail and frail patients.

Conclusion

After PSM, we found higher rates of urinary retention and surgical site infections in pre-frail patients than in non-frail patients. CRP was independently related to postoperative complications, while frail status was only independently associated with postoperative complications between pre-frail and non-frail patients. Pre-frail/frail patients tended to have more severe stress responses than non-frail patients.

Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review

Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.

Enhanced recovery after surgery (ERAS) protocol in spine surgery

Enhanced recovery after surgery (ERAS) protocols are a set of interventions which are carried out in the preoperative and perioperative period. They are aimed to decrease the harmful effects of surgery on the body and help the patient recover better post-surgery. The effectiveness of ERAS has been well established in various other surgical specialities. Earlier spine surgery was thought to be very complex for application of ERAS protocols. However, this has changed over the last decade with (ERAS) protocols gaining widespread popularity in spine surgery. Initial studies involving ERAS in spine surgery were limited to lumbar spine. However, over the years the horizon of ERAS has expanded to include anterior cervical surgeries, spine deformity, spinal tumors and spine surgery in the elderly. ERAS has been shown to reduce the length of hospital stay, overall hospital costs, opioid consumption in perioperative and postoperative period and to lower complication rates in spine surgery. In this narrative review, we discuss various aspects of ERAS in spine surgery including the benefits of ERAS in spine surgery, the various components of preoperative, intraoperative and postoperative measures of ERAS protocol.

An enhanced recovery after surgery pathway: LOS reduction, rapid discharge and minimal complications after anterior cervical spine surgery

BACKGROUND

Enhance recovery after surgery (ERAS) is a new and promising paradigm for spine surgery. The purpose of this study is to investigate the effectiveness and safety of a multimodal and evidence-based ERAS pathway to the patients undergoing anterior cervical discectomy and fusion (ACDF).

METHODS

The patients treated with the ACDF-ERAS pathway were compared with a historical cohort of patients who underwent ACDF before ERAS pathway implementation. Primary outcome was length of stay (LOS). Secondary outcomes included cost, MacNab grading, complication rates and 90-day readmission and reoperation. And perioperative factors and postoperative complications were reviewed.

RESULTS

The ERAS protocol was composed of 21 components. More patients undergoing multi-level surgery (n ≥ 3) were included in the ERAS group. The ERAS group showed a shorter LOS and a lower cost than the conventional group. The postoperative satisfaction of patients in ERAS group was better than that in conventional group. In addition, the rate of overall complications was significantly higher in the conventional group than that in the ERAS group. There were no significant differences in operative time, postoperative drainage, or 90-day readmission and reoperation.

CONCLUSIONS

The ACDF-tailored ERAS pathway can reduce LOS, cost and postoperative complications, and improve patient satisfaction without increasing 90-day readmission and reoperation.

Patients Older Than 75 Years Undergoing Polysegmental Lumbar Fusion Surgery Can also Benefit from Enhanced Recovery After Surgery Program

Purpose

To compare pain scores (visual analog scale) on postoperative days 1–3 and length of stay after implementing enhanced recovery after surgery (ERAS) in elderly patients undergoing multi-segments lumbar fusion surgery.

Methods

We performed a retrospective analysis of prospectively collected data, patients older than 75 years were enrolled in the study. We selected two periods, before (Pre-ERAS, n =54 patients) and after (ERAS, n =46 patients) implementation of ERAS. Data were collected on patient demographics, operative and perioperative details, 30-day readmission. The primary outcome was the length of stay (LOS), and the secondary outcomes were postoperative mean pain scores on postoperative days (POD) 1–3 and 30-day readmission rates.

Results

A total of 100 patients (46 in ERAS and 54 in pre-ERAS) were enrolled in this study. There were no significant differences in age, sex, body mass index (BMI), smoking and comorbidities between the groups. However, there was a significant difference in pain on postoperative day (POD) 1 (5.31 ± 1.98 vs 4.37 ± 0.85, p = 0.002), while there was no difference in postoperative complications. The mean LOS was significantly shorter in the ERAS than in the pre-ERAS group, it reduced from 12.29 ± 3.93 to 9.45 ± 2.72 days (p < 0.001).

Conclusion

To our knowledge, this is the first ERAS protocol used in patients (older than 75 years) undergoing polysegmental lumbar fusion surgery. Pain scores on POD 1 and LOS were significantly lower without increased adverse events after implementation of ERAS. This finding suggests that elderly people (>75 years of age) undergoing polysegmental lumbar fusion surgery could also benefit from ERAS.

The Potential Risk Factors for Prolonged Length of Stay Despite an Enhanced Recovery After Surgery Protocol for Elderly Patients Undergoing Short-Level Lumbar Fusion Surgery

Objective

To identify the risk factors associated with prolonged length of stay (LOS) despite an enhanced recovery after surgery (ERAS) protocol in short-level lumbar fusion surgery.

Methods

We gathered data for all patients undergoing short-level lumbar fusion surgery from January to November 2021. Given the discharge criteria, a threshold was set according to mean LOS, and two groups were spontaneously formed: LOS shorter than the threshold for discharge (control group, n = 114) and LOS longer or equal to the threshold for discharge (delayed group, n = 72). Preoperative metrics were compared to identify risk factors associated with prolonged LOS.

Results

A total consecutive 186 patients with complete medical records were enrolled (77 males and 109 females; mean age 71.08 ± 5.70 years). After dichotomization according to the threshold for discharge, there were 114 patients in control group and 72 in delayed group. Statistical analysis demonstrated that age ≥75 years ( P = .002), female sex ( P < .001), American Society of Anesthesiologists grade ≥ 3 ( P = .035), operation time ( P < .001), anesthesia time ( P < .001), ambulation time >1 day ( P = .027), removal of urinary catheter time >1 day ( P = .019), fusion levels ( P < .001), Clavien-Dindo grade > 1 ( P <.001) and allogeneic transfusion ( P = .009) were significantly related to prolonged LOS. Binary logistic regression revealed that age (odds ratio (OR) 5.149; 95% confidence interval (CI) 2.045-12.966, P = .001), sex (OR 5.185, 95% CI 2.183-12.317, P < .001) and Clavien-Dindo grade > 1(OR 15.936, 95% CI 5.220-48.652, P < .001) were independent risk factors of prolonged LOS.

Conclusions

In this retrospective study, we analyzed the potential risk factors associated with delayed LOS despite implementing ERAS, further, binary logistic regression exhibited that age ≥75 years old, female sex and Clavien-Dindo grade >1 were independently correlated with prolonged LOS.

The influence of frailty on postoperative complications in geriatric patients receiving single-level lumbar fusion surgery

PURPOSE

This study evaluates the influence of patient frailty status on postoperative complications in those receiving single-level lumbar fusion surgery.

METHODS

The nationwide readmission database was retrospectively queried between 2016 and 2017 for all patients receiving single-level lumbar fusion surgery. Readmissions were analyzed at 30, 90, and 180 days from primary discharge. Demographics, frailty status, and relevant complications were queried at index admission and all readmission intervals. Complications of interest included infection, urinary tract infection (UTI), posthemorrhagic anemia, inpatient length of stay (LOS), and adjusted all-payer costs. Nearest-neighbor propensity score matching for demographics was implemented to identify non-frail control patients with similar diagnoses and procedures. The analysis used nonparametric Mann-Whitney U testing and odds ratios.

RESULTS

Comparing propensity-matched cohorts revealed significantly greater LOS and total all-payer inpatient costs in frail patients than non-frail patients with comparable demographics and comorbidities (p < 0.0001 for both). Furthermore, frail patients encountered higher rates of UTI (OR: 3.97, 95%CI: 3.21-4.95, p < 0.0001), infection (OR: 6.87, 95%CI: 4.55-10.86, p < 0.0001), and posthemorrhagic anemia (OR: 1.94, 95%CI: 1.71-2.19, p < 0.0001) immediately following surgery. Frail patients had significantly higher rates of 30-day (OR: 1.24, 95%CI: 1.02-1.51, p = 0.035), 90-day (OR: 1.38, 95%CI: 1.17-1.63, p < 0.001), and 180-day (OR: 1.55, 95%CI: 1.30-1.85, p < 0.0001) readmissions. Lastly, frail patients had higher rates of infection at 30-day (OR: 1.61, 95%CI: 1.05-2.46, p = 0.027) and 90-day (OR: 1.51, 95%CI: 1.07-2.16, p = 0.020) readmission intervals.

CONCLUSIONS

Patient frailty status may serve as an important predictor of postoperative outcomes in patients receiving single-level lumbar fusion surgery.

Implementation of Enhanced Recovery After Surgery (ERAS) protocol for elderly patients receiving surgery for intertrochanteric fracture: a propensity score-matched analysis

Purpose

Enhanced Recovery After Surgery (ERAS) is a multimodal approach to perioperative care that aims to reduce patient perioperative complications, accelerate patient recovery, and improve patient satisfaction by refining and optimizing all perioperative management processes. By comparing two groups of patients before and after the implementation of ERAS for intertrochanteric fracture (ITF) with a matching analysis of propensity score (PS), we aimed to demonstrate that the implementation of ERAS protocol shortens the length of hospital stay (LOS), reduces pain, decreases the incidence of postoperative complications, and promotes functional recovery of the joint.

Methods

We selected 2 periods of 1 year, before (n=98patients) and after ERAS implementation (n=92patients). Data were collected on patient demographics, operative and perioperative details, LOS, VAS score, Harris score, and 30-day complications. ERAS-trained nurses are engaged to support patients at each step of the pre/per/postoperative process, including completing a satisfaction survey, with the help of a mobile app. PS analyses were used for dealing with confounding bias in this retrospective observational study.

Results

After PS matching, the outcomes of 124 well-balanced pairs of patients were compared (conventional vs ERAS). LOS was significantly reduced from 24.3±3.9 to 15.2±2.9 days (P<0.001). With the same preoperative VAS scores, we found that patients in the ERAS group had significantly lower postoperative VAS scores than those in the conventional group at days 3 and 7 (P<0.001), but the difference was not statistically significant at day 14. patients in the ERAS group had higher Harris scores than those in the conventional group at 1 and 3 months, but the difference was not significant at 6 months. In addition, we found that only one patient in the ERAS group developed complications, while nine patients in the conventional group developed different complications. There was no significant difference concerning the satisfaction survey.

Conclusion

The introduction of ERAS for ITF in our institution has resulted in a significant decrease in LOS, alleviated patient pain, promoted early recovery of patient’s hip function while effectively preventing complications, and obtained patient satisfaction.

Impact of Enhanced Recovery After Surgery on Long-Term Outcomes and Postoperative Recovery in Patients Undergoing Hepatectomy: A Retrospective Cohort Study

Background

The aim of this study was to evaluate the effects of implementation of the enhanced recovery after surgery (ERAS) program on postoperative recovery and the long-term prognosis in patients who underwent hepatectomy.

Methods

This retrospective study enrolled patients who underwent hepatectomy from January 2015 to December 2018 in Huadong Hospital Affiliated to Fudan University. Since June 2016, a 24-point ERAS protocol has been implemented for patients who underwent hepatic resection. The primary outcomes were overall survival (OS) and disease-free survival (DFS). The secondary outcomes included length of stay (LOS), and incidence of postoperative complications.

Results

A total of 1143 patients were enrolled in this study. After propensity score matching (PSM), there was no significant difference in patients' demographic characteristics. The DFS at 1., 3 years in ERAS group was higher than in non-ERAS group (96.3% vs 88.9% for 1 year, P=0.012; 58.9% vs 46.7% for 3 years, P=0.007). The OS at 1, 3 years in ERAS group was higher than in non-ERAS group (93.1% vs 89.3% for 1 year, P=0.041; 68.7% vs 61.2% for 3 years, P=0.035). In addition, the patients in ERAS group had lower incidences of postoperative hemorrhage, bile leak, and postoperative deep vein thrombosis/pulmonary embolism (DVT/PE), decreased 30-day readmission rate and total readmission rate, and shorter LOS.

Conclusion

ERAS program could be safely applied to patients who underwent hepatectomy thereby improving their recovery and prolonging OS and DFS.