The enhanced recovery after surgery (ERAS) protocol to promote recovery following esophageal cancer resection

Tongue pressure, respiratory muscle and limb strength and functional exercise capacity in oesophageal cancer

OBJECTIVES

Preoperative management of oesophageal cancer requires effective prehabilitation. This study investigates the relationship between tongue pressure, respiratory muscle, handgrip and lower limb muscle strengths, and functional exercise capacity in patients with oesophageal cancer to develop a novel prehabilitation strategy.

METHODS

This prospective, single-centre, observational study analysed data from 29 pretreatment patients with oesophageal cancer. We evaluated tongue pressure, maximal inspiratory and expiratory pressures, handgrip and lower limb muscle strengths, functional exercise capacity and dysphagia scores before treatment. The relationship between parameters was identified using Spearman's correlation analysis.

RESULTS

Maximal inspiratory and expiratory pressures were significantly associated with handgrip and lower extremity muscle strengths and functional exercise capacity. However, tongue pressure was not associated with maximal inspiratory and expiratory pressures, handgrip and lower extremity muscle strengths and functional exercise capacity. Rather, tongue pressure was significantly associated with clinical T, dysphagia and nutritional status scores.

CONCLUSIONS

Respiratory muscle strength was associated with conventional sarcopenia and functional exercise capacity. Tongue pressure was not associated with respiratory muscle strength, conventional sarcopenia and functional exercise capacity. Rather, tongue pressure was associated with clinical T, dysphagia and nutritional status scores. Preoperative management of oesophageal cancer requires prehabilitation consisting of exercise and nutritional therapy and an additional swallowing programme, such as tongue resistance training, for patients without progress in oral intake, based on tongue pressure evaluation.

Predictive factors for intrathoracic anastomotic leakage and postoperative mortality after esophageal cancer resection

BACKGROUND

Esophageal cancer is currently one of the high-risk malignant tumors worldwide, posing a serious threat to human health. This study aimed to analyse the causes of postoperative mortality and intrathoracic anastomotic leakage(IAL) after esophagectomy.

METHODS

A retrospective analysis was conducted on 172 patients with esophageal cancer resection and focused on the preoperative and postoperative indicators. Cox regression analysis was performed to identify factors affected IAL and evaluated the potential factors on postoperative mortality. The Kaplan-Meier curve was applied to evaluate the effect of leakage on postoperative mortality after propensity score matching.

RESULTS

Univariable and multivariable Cox regression analysis showed that infection and high BMI were significant risk factors for IAL, patients with BMI over 24 kg/m2 in IAL group was two times higher than that of the group without IAL (95% CI = 1.01-6.38; P = 0.048). When patients were infected, the hazard ratios(HRs) of anastomotic leakage was twice that of patients without infection (95% CI = 1.22-4.70; P = 0.011). On the other hand, IAL was a significant cause of postoperative mortality, the 40-day postoperative mortality rate in the leakage group was significantly higher than the non leakage group (28.95% in leakage group vs. 7.46% in non leakage group, P<0.01). After propensity score matching, IAL still significantly affected postoperative mortality. The total length of hospital stay of the leakage group was inevitably longer than that of the non leakage group (22.19 ± 10.79 vs. 15.27 ± 8.59).

CONCLUSION

IAL was a significant cause of death in patients underwent esophageal cancer resection. Patients with high BMI over 24 kg/m2 and infection may be more prone to developing IAL after esophagectomy. IAL inevitably prolonged the length of hospital stay and increased postoperative mortality.

Research Progress on Patients of Esophageal Cancer Complicated with Sarcopenia

Aims/Background The application of immunochemotherapy has significantly enhanced the quality of life and overall survival of patients with esophageal cancer. Sarcopenia, which is increasingly prevalent in these patients, markedly affects prognosis, but can be reversed by appropriate and effective treatment. Methods The narrative review was conducted on PubMed using the keywords ("esophageal" or "esophagus" and "sarcopenia"). Results This article reviews the measurement, timing, and intervention strategies for sarcopenia in patients with esophageal cancer. It summarizes the evaluation indicators of skeletal muscle loss in these patients, analyzes the barriers to intervention for frailty among esophageal cancer patients, and proposes corresponding countermeasures. Conclusion Patients with esophageal cancer often suffer from severe sarcopenia. Clinical intervention is crucial in addressing this issue.

Textbook outcome after esophagectomy: A retrospective study from a high-volume center

BACKGROUND

Textbook outcome is a composite quality measurement in esophageal cancer surgery. This study aimed to estimate the rate of textbook outcome esophagectomies at a high-volume center and investigate associations between textbook outcome and overall and recurrence-free survival.

METHODS

A retrospective single-center study was conducted at Copenhagen University Hospital, Rigshospitalet, Denmark, analyzing esophagectomies performed from November 1, 2016, to December 31, 2021. Patients with primary carcinoma of the gastroesophageal junction who underwent elective and curative esophagectomy were included. The rate of textbook outcome esophagectomies was calculated, and the impact of textbook outcome on overall and recurrence-free survival was analyzed using Kaplan-Meier and Cox regression.

RESULTS

A total of 433 patients were included in the study. Textbook outcome was achieved in 195 patients (45%). Achieving textbook outcome was independently associated with improved overall survival (HR 0.67; P = .011) and with a median overall survival of 57 months and 32 months for patients with or without textbook outcome, respectively. A trend for improved recurrence-free survival was observed for patients with textbook outcome (HR 0.74; P = .064).

CONCLUSION

The present study found a consensus-based textbook outcome rate of 45%. Textbook outcome was found to be directly associated with improved overall survival. These results emphasize the association between improved short-term outcomes and long-term survival.

Application of enhanced recovery after surgery for oral dryness prevention after endoscopic sinus surgery

OBJECTIVE

To investigate the efficacy of cluster nursing intervention based on Enhanced Recovery After Surgery (ERAS) for xerostomia in chronic rhinosinusitis after nasal endoscopic surgery.

METHODS

A total of 80 patients with chronic rhinosinusitis who underwent functional nasal endoscopic surgery between January 2020 and December 2021 were selected and randomly divided into a control group (n = 40) and an experimental group (n = 40). Patients in the control group were treated with general nursing, while ERAS-based cluster nursing intervention was adopted for the experimental group, in addition to general nursing. Xerostomia stage and comfort level were observed at 2 h, 6 h, 24 h and 48 h after surgery; negative emotions before and after nursing were also observed.

RESULTS

After the intervention, the xerostomia stage and comfort level at 6, 24 and 48 after surgery were higher in the experimental group (p < 0.05). Negative emotions in the experimental group were lower after nursing (p < 0.001). The self-rating depression scale and self-rating anxiety scale scores increased after nursing in both two groups (p < 0.05).

CONCLUSION

Enhanced recovery after surgery-based cluster nursing intervention can alleviate xerostomia, improve patients' comfort levels, reduce their negative emotions and accelerate postoperative recovery.

LEVEL OF EVIDENCE: 2

Usefulness of Perioperative Nutritional Therapy with the Glutamine/Arginine/Calcium β-Hydroxy-β-Methylbutyrate Product in Esophageal Cancer Surgery: A Single-Center Retrospective Study

A useful perioperative nutritional therapy for highly invasive esophageal cancer surgical cases needs to be developed. We clarified the usefulness of amino-acid-enriched nutritional therapy using glutamine (Gln)/arginine (Arg)/calcium β-hydroxy-β-methylbutyrate (HMB) products on the short-term postoperative outcomes of minimally invasive esophagectomy for esophageal cancer. Altogether, 114 patients (Gln/Arg/HMB group) received perioperative nutritional therapy with Gln/Arg/HMB products, and we retrospectively investigated the change in nutritional parameters including skeletal muscle mass, occurrence of postoperative complications, and short-term postoperative outcomes in this group. The results were compared between the Gln/Arg/HMB and control groups (79 patients not receiving the Gln/Arg/HMB products). The incidence of all postoperative complications, sputum expectoration disorder, and pleural effusion of grade ≥ III was significantly lower in the Gln/Arg/HMB group (62.0% vs. 38.6%, p = 0.001; 44.3% vs. 28.1%, p = 0.020; 27.8% vs. 13.2%, p = 0.011, respectively). The psoas muscle area and postoperative body weight were significantly higher at 1 month and 1 year after surgery in the Gln/Arg/HMB group than in the control group (93.5% vs. 99.9%, p < 0.001; 92.0% vs. 95.4%, p = 0.006). Perioperative amino-acid-enriched nutritional therapy may improve the short-term postoperative outcomes, nutritional status, and skeletal muscle mass of esophageal cancer surgical patients.

Does Prehabilitation Reduce Postoperative Length of Hospital Stay after Esophageal Cancer Surgery?

Objectives

At our hospital, prehabilitation has been provided to patients undergoing esophageal cancer surgery since October 2019. This study explored the effects of prehabilitation based on the accumulated database of these patients.

Methods

This retrospective cohort study included 621 patients who underwent thoracoscopic subtotal esophagectomy. Multiple linear regression analysis was performed using postoperative hospital stay as the objective variable and age, sex, body mass index (BMI), preoperative ventilatory impairment, left ventricular ejection fraction, preoperative hemoglobin A1c, clinical stage, histological type, operative time, surgical blood loss, postoperative complications, and prehabilitation as explanatory variables. We also performed a multivariate analysis in the subgroup of patients who developed postoperative complications and adjusted for possible confounding factors. Postoperative complications and postoperative hospital stay were compared between patients without (n=416) and with (n=205) prehabilitation.

Results

Postoperative complications, age, blood loss, BMI, and ventilatory impairment influenced the overall length of hospital stay. When the analysis was restricted to patients with complications, prehabilitation was added to that list of factors as a substitute for BMI. The rate of postoperative complications was not affected by prehabilitation (P=0.1675). The number of hospital days did not change with or without prehabilitation in the overall population, but when restricted to patients with complications, the number of hospital days was significantly decreased in the prehabilitation group (P=0.0328).

Conclusions

Prehabilitation as a perioperative approach has the potential to reduce the postoperative length of hospital stay in patients undergoing esophageal cancer surgery, and active intervention is recommended.

Short-term outcomes of enhanced recovery after surgery protocol in minimally invasive oesophagectomy: A prospective study

BACKGROUND

Although fast-track treatment pathways are well established in colorectal surgeries, their role in oesophageal resections has not been well studied. This study aims to prospectively evaluate the short-term outcomes of enhanced recovery after surgery (ERAS) protocol in patients undergoing minimally invasive oesophagectomy (MIE) for oesophageal malignancy.

PATIENTS AND METHODS

We studied a prospective cohort of 46 consecutive patients from January 2019 to June 2022 who underwent MIE for oesophageal malignancy. The ERAS protocol mainly consists of pre-operative counselling, pre-operative carbohydrate loading, multimodal analgesia, early mobilisation, enteral nutrition and initiation oral feed. Principal outcome measures were the length of post-operative hospital stay, complication rate, mortality rate and 30-day readmission rate.

RESULTS

The median (interquartile range [IQR]) age of patients was 49.5 (42, 62) years, and 52.2% were female. The median (IQR) post-operative day of intercoastal drain removal and initiation of oral feed was 4 (3, 4) and 4 (4, 6) days, respectively. The median (IQR) length of hospital stay was 6 (6.0, 7.25) days, with a 30-day readmission rate of 6.5%. The overall complication rate was 45.6%, with a major complication (Clavien-Dindo ≥3) rate of 10.9%. Compliance with the ERAS protocol was 86.9%, and the incidence of major complications was associated with failure to follow the protocol ( P = 0.000).

CONCLUSIONS

ERAS protocol in minimally invasive oesophagectomy is feasible and safe. This may result in early recovery with shortened length of hospital stay without an increase in complication and readmission rates.

Esophagectomy Enhanced Recovery After Surgery Initiative Results in Improved Outcomes

BACKGROUND

Esophagectomy for esophageal cancer is a procedure with high morbidity and mortality. This study developed a Multidisciplinary Esophagectomy Enhanced Recovery Initiative (MERIT) pathway and analyzed implementation outcomes in a single institution.

METHODS

The MERIT pathway was developed as a practice optimization and quality improvement initiative. Patients were studied from November 1, 2021 to June 20, 2022 and were compared with historical control subjects. The Wilcoxon rank sum test and the Fisher exact test were used for statistical analysis.

RESULTS

The study compared 238 historical patients (January 17, 2017 to December 30, 2020) with 58 consecutive MERIT patients. There were no significant differences between patient characteristics in the 2 groups. In the MERIT group, 49 (85%) of the patients were male, and their mean age was 65 years (range, 59-71 years). Most cases were performed for esophageal cancer after neoadjuvant therapy. Length of stay improved by 27% from 11 to 8 days (P = .27). There was a 12% (P = .05) atrial arrhythmia rate reduction, as well as a 9% (P = .01) decrease in postoperative ileus. Overall complications were reduced from 54% to 35% (-19%; P = .01).

CONCLUSIONS

This study successfully developed and implemented an enhanced recovery after surgery pathway for esophagectomy. In the first year, study investigators were able to reduce overall complications, specifically atrial arrhythmias, and postoperative ileus.

Risk Factor Analysis for Developing Major Complications Following Esophageal Surgery-A Two-Center Study

BACKGROUND

Esophagectomy carries a high risk of morbidity and mortality compared to other major surgeries. With the aim of creating an easy-to-use clinical preoperative risk assessment tool and to validate previously described risk factors for major complications following surgery, esophagectomies at two tertiary medical centers were analyzed.

METHODS

A total of 450 patients who underwent esophagectomy for esophageal carcinoma at the University Medical Centre, Hamburg, or at the Medical Center University Duisburg-Essen, Germany (January 2008 to January 2020) were retrospectively analyzed. Epidemiological and perioperative data were analyzed to identify the risk factors that impact major complication rates. The primary endpoint of this study was to determine the incidence of major complications.

RESULTS

The mean age of the patients was 63 years with a bimodal distribution. There was a male predominance across the cohort (81% vs. 19%, respectively). Alcohol abuse (p = 0.0341), chronic obstructive pulmonary disease (p = 0.0264), and cardiac comorbidity (p = 0.0367) were associated with a significantly higher risk of major complications in the multivariate analysis. Neoadjuvant chemotherapy significantly reduced the risk of major postoperative complications (p < 0.0001).

CONCLUSIONS

Various patient-related risk factors increased the rate of major complications following esophagectomy. Patient-tailored prehabilitation programs before esophagectomy that focus on minimizing these risk factors may lead to better surgical outcomes and should be analyzed in further studies.

Day Admission Surgery Program in a Prospective Payment System: What Are the Financial Incentives?

Background

Day admission surgery (DAS) is meant to provide a better in-hospital experience for patients and to save costs by reducing the length of stay. However, in a prospective payment system, it may also reduce the reimbursement amount, leading to unintended incentives for hospitals.

Methods

Over a 4-month period in 2021 and based on predefined clinical and logistic criteria, patients from different surgical sub-specialties were identified to follow the institutional DAS program. Revenue-analysis was performed, considering the Swiss diagnosis-related group (SwissDRG) prospective payment policy. Revenue with DAS program was compared to revenue if patients were admitted the day prior surgery (No DAS) using nonparametric pooled bootstrap t-test. All other costs considered identical, an estimation of the average cost spared due to the avoidance of pre-operative hospitalization in the DAS setting was carried out using a micro-costing approach.

Results

Overall, 105 inpatients underwent DAS over the study period, totaling a revenue of CHF 1 209 840. Among them, 25 patients (24%) were low outliers due to the day spared from the DAS program and triggering a mean (SD) financial discount of Swiss Francs (CHF) 4192 (2835), yielding a total amount of CHF 105 435. DAS revealed a mean revenue of CHF 7320 (656), compared to CHF 11 510 (1108) if patients were admitted the day before surgery (No DAS, P = .007).

Conclusion

In a PPS, anticipation of financial penalties when implementing a DAS for all-comers is key to prevent an imbalance of the hospital equation if no financial criteria are used to select eligible patients. Promptly revising workflow to maintain constant fixed costs for a greater number of patients may be a valuable hedging strategy.

Reduced length of intensive care unit stay and early mechanical ventilator weaning with enhanced recovery after surgery (ERAS) in free fibula flap surgery

This study aimed to evaluate the effects of the enhanced recovery after surgery (ERAS) program on postoperative recovery of patients who underwent free fibula flap surgery for mandibular reconstruction. This retrospective study included 188 patients who underwent free fibula flap surgery for complex mandibular and soft tissue defects between January 2011 and December 2022. We divided them into two groups: the ERAS group, consisting of 36 patients who were treated according to the ERAS program introduced from 2021 to 2022. Propensity score matching was used for the non-ERAS group, which comprised 36 cases selected from 152 patients between 2011 and 2020, based on age, sex, and smoking history. After propensity score matching, the ERAS and non-ERAS groups included 36 patients each. The primary outcome was the length of intensive care unit (ICU) stay; the secondary outcomes were flap complications, unplanned reoperation, 30-day readmission, postoperative ventilator use length, surgical site infections, incidence of delirium within ICU, lower-limb comorbidities, and morbidity parameters. There were no significant differences in the demographic characteristics of the patients. However, the ERAS group showed the lower length of intensive care unit stay (ERAS vs non-ERAS: 8.66 ± 3.90 days vs. 11.64 ± 5.42 days, P = 0.003) and post-operative ventilator use days (ERAS vs non-ERAS: 1.08 ± 0.28 days vs. 2.03 ± 1.05 days, P < 0.001). Other secondary outcomes were not significantly different between the two groups. Additionally, patients in the ERAS group had lower postoperative morbidity parameters, such as postoperative nausea, vomiting, urinary tract infections, and pulmonary complications (P = 0.042). The ERAS program could be beneficial and safe for patients undergoing free fibula flap surgery for mandibular reconstruction, thereby improving their recovery and not increasing flap complications and 30-day readmission.

Meta analysis of the second course of radiotherapy for recurrent esophageal cancer1

BACKGROUND

How to improve efficacy and reduce side effects in treating recurrent esophageal cancer by applying the second course of radiotherapy alone and its combination with chemotherapy has been attracting broad research interest.

OBJECTIVE

This review paper aims to systematically evaluate efficacy and side effects of applying the second course of anterograde radiotherapy alone and its combination with chemotherapy in treating recurrent esophageal cancer.

METHODS

First, the relevant research papers are retrieved from PubMed, CNKI and Wanfang databases. Next, Redman 5.3 software is used to calculate the relative risk and 95% confidence interval to evaluate the efficacy and adverse reactions of applying the single-stage radiotherapy with and without combining single/multi dose chemotherapy to treat recurrent esophageal cancer. Then, a meta data analysis is applied to examine the effectiveness and side effects of radiation alone and re-course radiotherapy plus chemotherapy in treating esophageal cancer recurrence after the first radiotherapy.

RESULTS

Fifteen papers are retrieved, which included 956 patients. Among them, 476 patients received radiotherapy combined with single drug/multi drug chemotherapy (observation) and others received only radiotherapy (control). Data analysis results show that the incidence of radiation induced lung injury and bone marrow suppression is high in the observation group. Subgroup analysis also shows the higher effective rate or one-year overall survival rate of patients treated with the second course radiotherapy combined with single drug chemotherapy.

CONCLUSION

The meta-analysis result demonstrates that combining the second course of radiotherapy with single-drug chemotherapy has advantages in treating recurrent esophageal cancer with the manageable side effects. However, due to insufficient data, it is not possible to conduct the further subgroup analysis comparing the side effects of restorative radiation with the combined chemotherapy using between a single drug and multiple drugs.

A successful repair of esophageal atresia (EA) with distal tracheoesophageal fistula (TEF) to a 6-day-old child in a low-resource setting. Case report

INTRODUCTION

Congenital tracheoesophageal fistula (TEF) is a rare and life-threatening anomaly that requires prompt surgical intervention. The case report highlights a successful TEF repair in setting with significant observed cases and low survival rate.

CASE PRESENTATION

We present a Type C Tracheoesophageal fistula successfully repaired by a conventional Open Surgical approach. An infant of 3 days born at term with Birth weight of 3 kg, presenting with postprandial regurgitation, choking and abdominal distension followed by early features of pneumonia. Initial chest X-ray with nasogastric (NS) tube catheter revealed features of esophageal atresia (EA) with distal TEF. An echocardiogram (ECHO) was performed, which revealed moderate patent ductus arteriosus (PDA) and small left to right shunt. A successful delayed primary repair was performed on the sixth day of life in the division of pediatric surgery center.

CONCLUSION

The successful outcome in this case serves as a testament to the dedication and resourcefulness of the healthcare team. It underscores the importance of high suspicious index, collaboration, adaptability, and skill in providing quality care in low-resource settings, reaffirming the possibility of saving lives even in challenging circumstances.

Impact of Enhanced Recovery Protocols on Short-Term Outcomes in Esophagectomy: A Retrospective Cohort Study from Cancer Research Institute, Uttarakhand, India

OBJECTIVE

Surgery for esophageal cancer is associated with high mortality and morbidity, especially in low and middle-income countries. The recent enhanced recovery after surgery guidelines for esophagectomy (2018) which attempt to reduce complications and length of stay (LOS) have rarely been validated in these settings. This study aimed to analyse the effect of this protocol on short-term outcomes in our subset of patients.

METHODS

A retrospective review was conducted to investigate the outcomes of enhanced recovery protocol (ERP) compared to standard pre-protocol care (PP) in patients who underwent esophagectomy for cancer (31 in ERP vs 61 in PP group) at Cancer Research Institute, Uttarakhand, India. The main outcomes measured were 30-day mortality, morbidity and LOS. Risk assessment was stratified as per Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) systems while complications were classified as per the Clavien-Dindo scale.

RESULTS

Preoperative clinical characteristics were similar between groups. Though the predicted POSSUM mortality and morbidity were significantly higher in the ERP group (p = 0.007), 30-day morbidity (19.35% vs 42.62%, p = 0.027) as well as median LOS (12 vs 15 days, p < 0.001) was significantly lower in ERP group. The PP group reported 4 deaths within 30 days as compared to none in the ERP group (p = 0.296). Furthermore, the ERP group reported lower occurrence of pulmonary complications (6.4%vs24.6%,p = 0.046), hemodynamic instability (0%vs14.75%,p = 0.026) as well as need for prolonged postoperative ventilation (> 24 h; 0% vs 11.48%, p = 0.004). Both minor and major complications as assessed by the Clavien-Dindo scale were lower in the group ERP though these differences were not statistically significant (0.059).

CONCLUSIONS

Implementation of ERP improved short-term outcomes; hence can be strongly recommended in patients undergoing esophagectomy.

Epidemiology of Postoperative Complications After Esophagectomy: Implications for Management

BACKGROUND

Despite advances in operative techniques and postoperative care, esophagectomy remains a morbid operation. Leveraging complication epidemiology and the correlation of these complications may improve rescue and refine early recovery pathways.

METHODS

This study retrospectively reviewed all esophagectomies performed at a tertiary academic center from 2014 to 2021 and quantified the timing of the most common complications. Daily incidence values for index complications were calculated, and a covariance matrix was created to examine the correlation of the complications with each other. Study investigators performed a Cox proportional hazards analysis to clarify the association between early diagnosis of postoperative atrial fibrillation and pneumonia with subsequent anastomotic leak.

RESULTS

The study analyzed 621 esophagectomies, with 580 (93.4%) cervical anastomoses and 474 (76%) patients experiencing complications. A total of 159 (25.6%) patients had postoperative atrial fibrillation, and 155 (25.0%) had an anastomotic leak. The median (interquartile range [IQR]) postoperative day of these complications was day 2 (IQR, days 2-3) and day 8 (IQR, days 7-11), respectively. Our covariance matrix found significant associations in the variance of the most common postoperative complications, including pneumonia, atrial fibrillation, anastomotic leak, and readmissions. Early postoperative atrial fibrillation (hazard ratio, 8.1; 95% CI, 5.65-11.65) and postoperative pneumonia (hazard ratio, 3.8; 95% CI, 1.98-7.38) were associated with anastomotic leak.

CONCLUSIONS

Maintaining a high index of suspicion for early postoperative complications is crucial for rescuing patients after esophagectomy. Early postoperative pneumonia and atrial fibrillation may be sentinel complications for an anastomotic leak, and their occurrence may be used to prompt further clinical investigation. Early recovery protocols should consider the development of early complications into postoperative feeding and imaging algorithms.

Enhanced Recovery after Surgery Protocol Decreases Length of Stay and Postoperative Narcotic Use in Microvascular Breast Reconstruction

Background

Enhanced recovery after surgery (ERAS) protocols have demonstrated efficacy following microvascular breast reconstruction. This study assesses the impact of an ERAS protocol following microvascular breast reconstruction at a high-volume center.

Methods

The ERAS protocol introduced preoperative counseling, multimodal analgesia, early diet resumption, and early mobilization to our microvascular breast reconstruction procedures. Data, including length of stay, body mass index, inpatient narcotic use, outpatient narcotic prescriptions, inpatient pain scores, and complications, were prospectively collected for all patients undergoing microvascular breast reconstruction between April 2019 and July 2021. Traditional pathway patients who underwent reconstruction immediately before ERAS implementation were retrospectively reviewed as controls.

Results

The study included 200 patients, 99 in traditional versus 101 in ERAS. Groups were similar in body mass index, age (median age: traditional, 54.0 versus ERAS, 50.0) and bilateral reconstruction rates (59.6% versus 61.4%). ERAS patients had significantly shorter lengths of stay, with 96.0% being discharged by postoperative day (POD) 3, and 88.9% of the traditional cohort were discharged on POD 4 (P < 0.0001). Inpatient milligram morphine equivalents (MMEs) were smaller by 54.3% in the ERAS cohort (median MME: 154.2 versus 70.4, P < 0.0001). Additionally, ERAS patients were prescribed significantly fewer narcotics upon discharge (median MME: 337.5 versus 150.0, P < 0.0001). ERAS had a lower pain average on POD 0-3; however, this finding was not statistically significant.

Conclusion

Implementing an ERAS protocol at a high-volume microvascular breast reconstruction center reduced length of stay and postoperative narcotic usage, without increasing pain or perioperative complications.

Enhanced Recovery After Surgery: Exploring the Advances and Strategies

Enhanced recovery after surgery (ERAS) has emerged as a paradigm-shifting approach in perioperative care, aimed at optimizing patient outcomes, accelerating recovery, and minimizing hospital stays. This review delves into the latest advances and strategies within the field of ERAS, encompassing a comprehensive examination of preoperative, intraoperative, and postoperative interventions. By analyzing an array of clinical studies, meta-analyses, and implementation experiences, this review highlights the multifaceted elements contributing to the success of ERAS programs. Key components such as preoperative patient education, minimally invasive surgical techniques, tailored anesthesia protocols, judicious fluid management, optimized pain control, early ambulation, and structured nutritional support are thoroughly explored. Furthermore, the review delves into the intricacies of ERAS implementation across diverse surgical specialties, emphasizing the significance of multidisciplinary collaboration, protocol customization, and sustained quality improvement initiatives. The analysis not only showcases the tangible benefits of ERAS, including reduced complication rates, shortened hospital stays, and enhanced patient satisfaction, but also underscores the challenges and barriers that medical professionals encounter during program adoption. By synthesizing the current state of ERAS research and practice, this review provides clinicians, administrators, and researchers with valuable insights into the evolving landscape of perioperative care, fostering a deeper understanding of ERAS as a holistic approach that transcends traditional surgical pathways.

Application of multidisciplinary collaborative nursing with family care for enhanced recovery after surgery in children with inguinal hernia

BACKGROUND

Perioperative nursing can reduce the stress reaction and improve the prognosis of children.

AIM

To elucidate the influence of multidisciplinary collaborative nursing for enhanced recovery after surgery (ERAS) with family care in perioperative nursing children with an inguinal hernia and its impact on the prognosis.

METHODS

The data of 100 children with inguinal hernia were retrospectively analyzed. The participants were divided into three groups according to different nursing methods: Groups A (n = 38), B (n = 32), and C (n = 30). Group A received multidisciplinary collaborative ERAS nursing combined with family care nursing; Group B received multidisciplinary collaborative nursing for ERAS; and Group C received routine nursing. The postoperative recovery results of the three groups were compared, including intraoperative blood loss and postoperative feeding time, time of getting out of bed, hospitalization time, and defecation time. Furthermore, the incidence of common complications was also compared between the three groups.

RESULTS

There was less intraoperative blood loss in Groups A and B than in Group C (P < 0.05), and the time of getting out of bed and postoperative hospitalization and defecation times were also decreased in Group C (P < 0.05). There was no significant difference in postoperative feeding time among the three groups (P > 0.05). Each index had no statistical significance between Groups A and B (P > 0.05). The incidence of urinary retention, infection, hematoma, and hernia recurrence in Group A was less than that in Group C (P < 0.05). No significant difference was observed in the overall complication rate between Groups A and B and between Groups B and C (P > 0.05).

CONCLUSION

The application of multidisciplinary collaborative nursing combined with family care in the perioperative care of children with an inguinal hernia for ERAS may promote postoperative rehabilitation for children and reduce the incidence of complications.

The "Weekday Effect"-Does It Impact Esophageal Cancer Surgery Outcomes?

BACKGROUND

Increased 30-day mortality rates have been reported in patients undergoing elective surgery later compared with earlier in the week. However, these reports have been conflicting for esophageal surgery. We conducted a study to assess the differences in outcomes of patients undergoing surgery for esophageal cancer earlier in the week (Tuesday) versus later (Friday).

METHODS

This retrospective analysis of a prospectively maintained database included patients with esophageal cancer who underwent esophageal resection in a tertiary cancer center between 1 January 2005 and 31 December 2017. We compared patients operated on Tuesdays versus Fridays. The primary outcome was a composite of major morbidity (defined as Clavien-Dindo grade 3 or more) and/or mortality. Secondary outcomes included duration of post-operative ventilation, and length of ICU and hospital stay.

RESULTS

Among 1300 patients included, 733 were operated on a Tuesday and 567 on a Friday. Patient and surgery characteristics were similar in the two groups. The primary outcome (composite of major morbidity and mortality) was 23.6% in the Tuesday group versus 26.3% in the Friday group. Mortality was similar in the two groups (6.0%). Multivariable logistic regression analysis showed that the day of surgery was not a predictor of major morbidity or mortality.

CONCLUSIONS

In patients undergoing esophagectomy at tertiary care high volume cancer center, there was no difference in major morbidity and mortality whether the surgery was performed early in the week (Tuesday) or closer to the weekend (Friday).

Minimally invasive versus open esophagectomy after neoadjuvant therapy for esophageal cancer: a meta-analysis

OBJECTIVES

Neoadjuvant therapy and minimally invasive esophagectomy (MIE) are widely used in the comprehensive treatment of esophageal cancer. This study aimed to investigate the advantages of MIE for esophageal cancer after neoadjuvant therapy.

METHODS

Published clinical studies were reviewed and survival data and safety data were extracted. We compared the long-term survival and safety of MIE versus open esophagectomy after neoadjuvant surgery in a series of meta-analyses.

RESULTS

6 retrospective studies were included. Overall, MIE could significantly improve the overall survival of patients with esophageal cancer after neoadjuvant therapy compared with open esophagectomy [hazard ratio (HR) = 0.86, 95% confidence interval (CI) (0.75, 0.98)]. Compared with open esophagectomy, MIE could significantly reduce intraoperative blood loss and operative time [mean difference (MD) = -40.28.78, 95% CI (- 62.98, - 17.58); MD = -28.78, 95% CI (- 42.48, - 15.07), respectively]. There was no significant difference in 30-day and 90-day mortality between MIE and open esophagectomy [odds ratio (OR) = 0.42, 95% CI (0.09, 2.01); OR 0.80, 95% CI (0.25, 2.60), respectively]. MIE could not significantly reduce the incidence of anastomotic leakage, recurrent laryngeal nerve palsy and chylothorax [OR 0.70, 95% CI (0.37, 1.32); OR 1.43, 95% CI (0.33, 6.25); HR = 1.79, 95% CI (0.67, 4.75), respectively], but the incidence of pneumonia was significantly reduced [HR = 0.43, 95% CI (0.22, 0.82)]. In addition, the length of hospital stay and the incidence of total complications were significantly reduced after MIE [MD = -2.61, 95% CI (- 3.10, - 2.12); HR = 0.66, 95% CI (0.45, 0.98), respectively].

CONCLUSION

MIE after neoadjuvant therapy is effective and safe. Compared with open esophagectomy, MIE can improve the long-term survival and reduce the incidence of postoperative complications of esophageal cancer patients.

Identifying the role of preoperative oral/dental health care in post-esophagectomy pulmonary complications: a systematic review and meta-analysis

Esophageal surgery has traditionally been associated with high morbidity rates. Despite the recent advances in the field of minimally invasive surgery and the introduction of enhanced recovery after surgery (ERAS) protocols, post-esophagectomy morbidity, especially that attributed to the respiratory system, remains a concern. In that respect, preoperative intensification of oral care or introduction of structured oral/dental hygiene regimens may lead to tangible postoperative benefits associated with reduced morbidity (respiratory or otherwise) and length of hospital stay. A systematic literature search of the Medline, Embase, Web of Knowledge and clinicaltrials.gov databases was undertaken for studies reporting use of preoperative oral/dental hygiene improvement regimens in patients scheduled to undergo esophagectomy for esophageal cancer. Meta-analysis was performed using a random-effects model. After screening 796 unique studies, seven were deemed eligible for inclusion in the meta-analysis. Pooled results indicated equivalent postoperative pneumonia rates in the oral pretreatment group and control groups (8.7 vs. 8.5%, respectively); however, the odds for developing pneumonia were reduced by 50% in the pretreatment group (odds ratio 0.5, 95% C.I. 0.37 to 0.69, P < 0.001). No statistically significant difference was detected in the anastomotic leak (odds ratio 0.93, 95% C.I. 0.38 to 2.24, P = 0.87) and length of stay outcomes (mean difference 0.63, 95% C.I. -3.22 to 4.47, P = 0.75). Oral/dental pretreatment reduces the odds for developing post-esophagectomy pneumonia. This finding should be cautiously interpreted given the significant limitations inherent in this meta-analysis. Further investigation via well-designed clinical trials is thus warranted before implementation in routine practice can be recommended.

Effect of integrated perioperative rehabilitation intervention under the fast-track surgery concept on stress and complications in patients undergoing craniocerebral injury surgery

Objective

To observe the intervention effect of perioperative rehabilitation intervention of integrated medical care the concept of FTS on stress response and postoperative complications in patients undergoing craniocerebral injury surgery.

Methods

70 patients with Traumatic brain injury (TBI) admitted to the Department of Neurosurgery of our Hospital from January 2019 to December 2021 were as the research objects and were divided into general group and FTS group according to the random number table method, with 35 cases in each group. The general group was intervened with perioperative basic nursing measures for TBI, and the FTS group was intervened with perioperative rehabilitation model of integrated medical care under the concept of FTS on the basis of the general group. The two groups of patients were compared in hemodynamic indexes (heart rate, mean arterial pressure), stress hormone levels (CORT, GLU, E), changes in motor neurological function (GCS score, NHISS score, FMA score), occurrence of postoperative complications (infection, pressure sores, rebleeding, central hyperthermia), short-term quality of life (SF-36) before and after the intervention.

Results

After intervention, the levels of HR, MAP, COR, GLU, and E were significantly lower in FTS group than in the general group (all P < 0.05). After intervention, the Fugl-Meyer score and Barthel index score of upper and lower extremities in both groups were significantly higher than those before intervention, and the FTS group was higher than the general group, and the difference was statistically significant (P < 0.05). After the intervention, the NIHSS scores were significantly lower in both groups than before the intervention, and the FTS group was lower than the general group, and the differences were statistically significant (P < 0.05). Short-term physical function, somatic pain, physical function, general health status, social function, energy, mental health, and emotional function scores were significantly higher in the FTS group than in thegeneral group, and all differences were statistically significant (P < 0.05). The total incidence of infection, pressure ulcers, rebleeding, central high fever and other complications in the FTS group was significantly lower than that in the general group (P < 0.05).

Conclusion

The implementation of integrated perioperative rehabilitation interventions under the concept of FTS for patients with TBI can significantly alleviate patients' stress, promote recovery, reduce the incidence of complications, and improve short-term quality of life, which is worthy of clinical promotion.

Long noncoding RNA CDKN2B-AS1 silencing protects against esophageal cancer cell invasion and migration by inactivating the TFAP2A/FSCN1 axis

Esophageal cancer (EC) is the most aggressive malignancy in the gastrointestinal tract. Long noncoding RNA cyclin-dependent kinase inhibitor 2 B antisense RNA 1 (CDKN2B-AS1) is implicated in EC development. However, the specific mechanisms involved remain poorly defined. Therefore, this research aimed to explore the mechanism of action of CDKN2B-AS1 in EC. Quantitative real-time polymerase chain reaction was conducted to measure CDKN2B-AS1 expression in EC cells and western blotting was utilized to evaluate transcription factor AP-2 alpha (TFAP2A) and fascin actin-bundling protein 1 (FSCN1) expression. After gain-of-function and loss-of-function assays, cell proliferation, migration, invasion, apoptosis, and apoptosis-related protein expression were assessed using cell counting kit-8, scratch tests, Transwell assays, flow cytometry, and western blotting, respectively. The binding relationship between CDKN2B-AS1 and TFAP2A was assessed by RNA immunoprecipitation and RNA pull-down assays. The binding relationship between TFAP2A and FSCN1 was evaluated using dual-luciferase reporter and chromatin immunoprecipitation assays. Tumor xenografts from nude mice were used for in vivo verification. CDKN2B-AS1, TFAP2A, and FSCN1 were upregulated in EC cells. Mechanistically, CDKN2B-AS1 transcriptionally activated FSCN1 by recruiting TFAP2A to the FSCN1 promoter. Silencing CDKN2B-AS1 or TFAP2A suppressed EC cell proliferative, migrating, and invasive properties and augmented apoptosis. TFAP2A was bound to CDKN2B-AS1 and the FSCN1 promoter. Overexpression of TFAP2A or FSCN1 abolished the effects of CDKN2B-AS1-silencing on EC cell function. CDKN2B-AS1 silencing curtailed tumorigenesis in nude mice, which was nullified by the upregulation of TFAP2A or FSCN1. Our findings demonstrated the antioncogenic effects of silencing CDKN2B-AS1 in EC through inactivation of the TFAP2A/FSCN1 axis.

C-reactive protein and drain amylase: their utility in ruling out anastomotic leakage after minimally invasive Ivor-Lewis esophagectomy

INTRODUCTION

Anastomotic leakage (AL) is one of the most feared complications after esophagectomy for esophageal cancer. We investigated the role of serum C-reactive protein (CRP) and drain amylase levels in the early detection of AL.

METHODS

This is a retrospective study of 193 patients who underwent a minimally invasive Ivor-Lewis procedure between January 2017 and October 2021. Mean CRP and median drain amylase levels between patients with and without AL were compared during the first five postoperative days (POD). ROC curves on POD 3, 4 and 5 were plotted to calculate cut-off values for CRP.

RESULTS

In 30 of the 193 patients (16%), AL was diagnosed with a median time to diagnosis of 9 days. Mean CRP was significantly higher in patients with AL on POD 3, 4 and 5. Cut-off values of 59, 110 and 106 mg/L had a high sensitivity of 93%, 90% and 90% on POD 3, 4 and 5. No difference in median drain amylase levels was observed.

CONCLUSIONS

CRP levels with a cut-off point of 110 mg/L on POD 4 do not improve earlier detection of AL, but have a high sensitivity for excluding AL. The value of drain amylase in the first 5 days after surgery is limited.

Interventions targeting postoperative pulmonary complications (PPCs) in patients undergoing esophageal cancer surgery: a systematic review of randomized clinical trials and narrative discussion

Postoperative pulmonary complications (PPCs) represent the most common complications after esophageal cancer surgery. The lack of a uniform reporting nomenclature and a severity classification has hampered consistency of research in this area, including the study of interventions targeting prevention and treatment of PPCs. This systematic review focused on RCTs of clinical interventions used to minimize the impact of PPCs. Searches were conducted up to 08/02/2021 on MEDLINE (OVID), CINAHL, Embase, Web of Science, and the COCHRANE library for RCTs and reported in accordance with PRISMA guidelines. A total of 339 citations, with a pooled dataset of 1,369 patients and 14 RCTs, were included. Heterogeneity of study design and outcomes prevented meta-analysis. PPCs are multi-faceted and not fully understood with respect to etiology. The review highlights the paucity of high-quality evidence for best practice in the management of PPCs. Further research in the area of intraoperative interventions and early postoperative ERAS standards is required. A consistent uniform for definition of pneumonia after esophagectomy and the development of a severity scale appears warranted to inform further RCTs and guidelines.

Malnutrition management in oncology: An expert view on controversial issues and future perspectives

Cancer and anticancer treatments can lead to several negative side effects, including malnutrition. Despite the recognized need for adequate nutritional support in cancer patients, in daily clinical practice, nutrition is still not considered one of the first aspects to be considered. Malnutrition negatively affects the clinical outcomes, treatment response, and overall survival of cancer patients. In this study, three of the most controversial issues related to malnutrition, which emerged during an Italian Consensus Conference, were addressed specifically for patients with head and neck as well as gastrointestinal cancer. The timing of nutritional evaluation and intervention, extension of the Enhanced Recovery after Surgery (ERAS^®) protocols, and cost-effectiveness of nutritional interventions have been considered. This study aimed to illustrate the state-of-the art of each issue and hypothesize future perspectives and actions to be taken, trying to suggest a new nutritional management model for cancer patients in Italy that overcomes the critical issues encountered. Of note, the timely diagnosis of nutritional issue appears to be essential to ensure the correct management of malnourished cancer patients as well as those who are at high risk of malnutrition. Standardized protocols, screening tests, and the inclusion of nutritional parameters in patient medical records would help to achieve good clinical outcomes. Finally, appropriate nutritional support is also associated with cost savings, and it seems necessary to promote its clinical and economic value to obtain improvements in both outcomes and management costs.

Evaluation of the use of inflammatory biomarkers in the early detection of anastomotic leakage after esophagectomy: A retrospective analysis

Background

Postoperative anastomotic leakage remains a major complication of esophagectomy. The development of a reliable method of early detection of anastomotic leakage can revolutionize the management of esophageal carcinoma.

Materials and Methods

This is a retrospective data analysis of 147 patients who underwent Ivor-Lewis esophagectomy as a curative attempt to treat distal esophageal carcinoma in our surgery department between 2010 and 2021. C-reactive protein and white blood cell count in postoperative days 1, 3, 5, and 8 were compared in patients with and without anastomotic leakage. The diagnostic accuracy of these tests was challenged against the clinical reference standard represented by computed tomography or upper gastrointestinal endoscopy.

Results

Twenty-eight patients (19%) developed anastomotic leakage. C-reactive protein values in postoperative day 8 were the only parameter to qualify as a potential clinically helpful test with an area under the receiver operating curve of 0.85 and a P value of less than .01. We calculated the cutoff value for C-reactive protein during postoperative day 8 to be 10.85 mg/dL with specificity and sensitivity of 73.1% and 89.3%, respectively. C-reactive protein showed a positive predictive value of 43.9% and a negative predictive value of 96.7% at this cutoff value.

Conclusion

An absolute diagnostic value of postoperative estimation of serum inflammatory biomarkers to detect anastomotic leakage could not be proved. Serum C-reactive protein on postoperative day 8 with a cutoff value of 10.85 mg/dL could be used to exclude anastomotic leakage after esophagectomy to serve as one of the discharge criteria of the patients.

The Use of Enhanced Recovery After Surgery Protocols and Sugammadex in a Friedreich Ataxia Patient Who Underwent Robotic Surgery: A Case Report of a Patient Who Required No Postoperative Opioids and Was Discharged Home Earlier Than Anticipated

Robotic surgery has shown to have numerous benefits over traditional and laparoscopic surgery, namely, superior precision and improved recovery with shorter hospital stays. However, robotic surgery also presents several issues, including hemodynamic changes related to positioning and the use of pneumoperitoneum. These matters can be problematic in patients with neuromuscular conditions such as Friedreich ataxia (FRDA). Due to a baseline weakened musculature and a higher prevalence of cardiac disease and scoliosis, patients with FRDA may not be as likely to tolerate the cardiopulmonary physiologic changes associated with robotic surgery. Additionally, positioning for robotic surgery can be challenging in FRDA patients who have progressed to spasticity and contractures. To the best of our knowledge, there are no case reports of approaches specifically discussing anesthesia management for robotic surgery in the FRDA patient population.

Anesthesia in general must be carefully planned in FRDA patients to allow for the best possible recovery and minimize complications. Due to the underlying neuromuscular compromise seen in these patients, their ability to recover from the pharmacologic and physiologic changes associated with anesthesia can be more difficult. They are prone to sensitivity to opioids, sedatives, and neuromuscular blocking agents (NMBAs) and are less likely to tolerate hemodynamic changes. Our review revealed no literature to suggest the routine use of Enhanced Recovery After Surgery (ERAS) protocols in FRDA patients or in patients with neuromuscular disease in general.

The use of sugammadex has also been shown to be safe, and literature suggests superiority in both the general population and those with neuromuscular conditions. Our understanding is that there is very limited literature in regard to the safe use of sugammadex in FRDA patients.

Prevalence, nature and trajectory of dysphagia postoesophageal cancer surgery: a prospective longitudinal study protocol

INTRODUCTION

Dysphagia is a common problem following oesophagectomy, and is associated with aspiration pneumonia, malnutrition, weight loss, prolonged enteral feeding tube dependence, in addition to an extended in-hospital stay and compromised quality of life (QOL). To date, the prevalence, nature and trajectory of post-oesophagectomy dysphagia has not been systematically studied in a prospective longitudinal design. The study aims (1) to evaluate the prevalence, nature and trajectory of dysphagia for participants undergoing an oesophagectomy as part of curative treatment, (2) to determine the risk factors for, and post-operative complications of dysphagia in this population and (3) to examine the impact of oropharyngeal dysphagia on health-related QOL across time points.

METHODS AND ANALYSIS

A videofluoroscopy will be completed and analysed on both post-operative day (POD) 4 or 5 and at 6-months post-surgery. Other swallow evaluations will be completed preoperatively, POD 4 or 5, 1-month and 6-month time points will include a swallowing screening test, tongue pressure measurement, cough reflex testing and an oral hygiene evaluation. Nutritional measurements will include the Functional Oral Intake Scale to measure feeding tube reliance, Malnutrition Screening Tool and the Strength, Assistance With Walking, Rise From a Chair, Climb Stairs and Falls questionnaire. The Reflux Symptom Index will be administered to investigate aerodigestive symptoms commonly experienced by adults post-oesophagectomy. Swallowing-related QOL outcome measures will be determined using the European Organisation for Research and Treatment of Cancer QLQ-18, MD Anderson Dysphagia Inventory and the Swallowing Quality of Life Questionnaire.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Tallaght University Hospital/St. James' Hospital Research Ethics Committee (JREC), Dublin, Ireland (Ref. No. 2021-Jul-310). The study results will be published in peer-reviewed journals and presented at national and international scientific conferences.

Study on the Application Value of Concurrent Chemoradiotherapy and Clinical Nursing Pathway for Postoperative Patients with Esophageal Cancer

Backgrounds

To observe the value of concurrent chemoradiotherapy and clinical nursing pathway for postoperative patients with esophageal cancer (EC).

Methods

A total of 88 postoperative EC patients were divided into the radiotherapy group (RG group, 44 cases) and the chemoradiotherapy group (CRG group, 44 cases). The RG group received single three-dimensional conformal radiotherapy+clinical nursing pathway, and the CRG group was combined with chemotherapy on this basis. The 5-year overall survival rate, progression-free survival rate, pathological remission and survival rate, lymph node metastasis and survival rate, quality of life analysis, tumor-related factor level, and incidence of adverse reactions were compared between the two groups.

Results

The overall survival rates at 1, 3, and 5 years were 93.18%, 56.82%, and 50.0% in the CRG group and 86.36%, 52.27%, and 43.18% in the RG group, respectively. The 5-year progression-free survival rate of the CRG group was 60.87%, which was clearly higher than that of the RG group (33.33%). The 1-, 3-, and 5-year overall survival rates of pCR and NpCR patients were 90.48%, 80.95%, and 61.90% and 89.55%, 44.78%, and 38.81%, respectively. The overall 1-year, 3-year, and 5-year survival rates were 81.08%, 37.84, and 24.32% and 96.08%, 66.67%, and 62.75% in patients with lymph node metastasis and nonlymph node metastasis, respectively, with statistical significant differences. The emotional function, physical function, cough, pain, and eating difficulty in the CRG group were better than those in the RG group. After treatment, serum CEA, SCC, CYFRA21-1, and CA199 levels in the CRG group were obviously downregulated compared with those in the RG group. There was no obvious difference in the incidence of adverse reactions between the CRG group and the RG group.

Conclusion

Single radiotherapy and concurrent chemoradiotherapy can be used as effective means in the treatment of EC. Moreover, the quality of life and survival time of the concurrent chemoradiotherapy group were dramatically better than those of the single radiotherapy group, and the antitumor ability of the concurrent chemoradiotherapy group was stronger.

Comparison of sitting and prone positions for real-time ultrasound-guided thoracic epidural catheter placement: a randomized controlled trial

Introduction

Real-time ultrasound-guided thoracic epidural catheter placement (US-TECP) has been recently introduced. Patient’s position is associated with the success of spine interventions; however, the effects of position on the outcome of the procedure remain unknown. We aimed to assess the clinical usefulness of patient positioning during real-time US-TECP.

Methods

Patients were randomly assigned to the prone position group (group P) and sitting position group (group S). The primary outcome was needling time during the procedure. The secondary outcomes were time to mark space, total number of needle passes, number of skin punctures, first-pass success, final success, crossover success, and visibility of ultrasound (US) views. Global Rating Scale (GRS) score, Patient Comfort Scale score, procedural pain intensity, patient satisfaction, and procedure-related complications were also determined.

Results

Sixty-four patients were included in this study. The needling time was significantly shorter in group P than in group S (36.5 (26.5–51.0) vs 59.5 (34.5–152.0) s, p<0.01). The numbers of needle passes and skin punctures were significantly lesser in group P than in group S. First-pass success was higher in group P than in group S. Group P had higher GRS compared with group S. The time to mark space, final success, US visibility score, Patient Comfort Scale score, procedural pain intensity, and patient satisfaction did not differ between the groups. One patient in group S developed a vasovagal reaction.

Discussion

This study shows that prone position may be preferred for real-time US-TECP, considering its better clinical usefulness.

Trial registration number

KCT0005757.

A steady stream of knowledge: decreased urinary retention after implementation of ERAS protocols in ambulatory minimally invasive inguinal hernia repair

BACKGROUND

Potential complications after inguinal hernia repair include uncontrolled post-operative pain and post-operative urinary retention (POUR). Enhanced Recovery After Surgery (ERAS) protocols aim to mitigate post-operative morbidity. We study the impact of ERAS measures alongside discharge without a narcotic prescription on post-operative pain and POUR after minimally invasive inguinal hernia repair.

METHODS

A retrospective review of a prospectively maintained database identified patients that underwent minimally invasive inguinal hernia repair at a single institution. Intra-operative data included operative time, narcotic usage, non-narcotic adjunct medication, and fluid administration. Primary outcomes included rates of POUR and uncontrolled post-operative pain. Operations performed after 2018 were included in the ERAS cohort. Uncontrolled post-operative pain was defined as needing additional narcotic prescriptions, admission, or ER visits for post-operative pain. POUR was defined as requiring an indwelling urethral catheter at discharge, admission for retention, or returning to the ER for urinary retention.

RESULTS

Between January 2008 and March 2021, 1097 patients who underwent minimally invasive inguinal hernia repair were identified. 91.3% of these procedures were laparoscopic and 8.7% were robotic. Average patient age was 57.4 years, 93% were male. Patients receiving care after initiation of the ERAS protocol were significantly less likely to experience POUR when compared to their prior counterparts (1.4% vs. 4.2% p = 0.01); there was no difference in post-operative pain complications (1.4% vs. 2.9% p = 0.15). Patients who were discharged without a narcotic prescription had 0% incidence of POUR. Significant differences were found between the ERAS and non-ERAS cohort regarding narcotic usage and fluid administration. Age, higher fluid volume, and higher narcotic usage were found to be risk factors for POUR while ERAS, sugammadex, and dexamethasone were found to be protective.

CONCLUSION

Implementation of an ambulatory ERAS protocol can significantly decrease urinary retention and narcotic usage rates after minimally invasive inguinal hernia repair.

Effect of Ultrasound Image-Guided Nerve Block on the Postoperative Recovery Quality of Patients with Tibial Fractures Using the Concept of Enhanced Recovery after Surgery

This study was aimed at investigating the clinical effect of ultrasound-guided nerve block based on the concept of enhanced recovery after surgery (ERAS) for postoperative anesthesia in patients with tibial fractures. The noise-reduction processing was introduced in ultrasound images to adjust the ultrasound clarity of the patient. A total of 177 patients with tibial fractures in our hospital were retrospectively analyzed and divided into OG group (general anesthesia combined with nerve block, 78 cases), C1 group (simple general anesthesia, 27 cases), C2 group (ultrasound-guided nerve block combined with general anesthesia, 10 cases), and C3 group (62 cases of spinal-epidural anesthesia). The effect of anesthesia and postoperative recovery time of patients in each group were analyzed. The wake-up time of the OG group was significantly shorter than that of the other three groups (P < 0.05). The doses of propofol and remifentanil in the OG group were much lower than those in the other groups (P < 0.05). After the ultrasound image was processed with noise reduction, the image showed the lesion more clearly. The excellent and good rates of OG group, C1 group, C2 group, and C3 group were 89.86%, 62.73%, 75.37%, and 61.07%, respectively. The Ramsay sedation score and anesthesia satisfaction in the OG group were obviously higher than those in the other groups, but there was no significant difference (P > 0.05). The visual analogue scale (VAS) scores of the OG group at 12 h, 24 h, and 36 h after the surgery were 4.52 ± 0.41, 4.72 ± 0.24, and 4.81 ± 0.74, respectively, which were significantly higher than those of the other three groups (P < 0.05). On the basis of ERAS, ultrasound-guided nerve block combined with general anesthesia can improve the perioperative pain in patients with tibial fractures and significantly shorten the time for the wake-up time. In addition, it was safe and reliable, so it was worthy of clinical promotion.

Immunotherapy Mechanism of Esophageal Squamous Cell Carcinoma with the Effect of STK11/AMPK Signaling Pathway

This study was aimed at exploring the mechanism of serine threonine protein kinase 11 (STK11)/Adenosine 5′-monophosphate-activated protein kinase (AMPK) signaling pathway after immunotherapy for esophageal squamous cell carcinoma (ESCC), providing basic information for the clinical treatment of ESCC. In this study, tissue specimens from 100 patients with ESCC who underwent surgical treatment in Taizhou People's Hospital (group A) and 20 patients with recurrent or metastatic ESCC who received second-line immunotherapy (group B) were collected. The real-time fluorescent quantitative polymerase chain reaction (PCR) (RT-qPCR) technology was used to detect the expression levels of STK11, interferon-γ (IFN-γ), interleukin 6 (IL-6), and vascular endothelial growth factor (VEGF) in the tissues. The immunohistochemical staining was used to detect the positive expression levels (PELs) of STK11 and AMPKα in the tissues, and immunofluorescence staining was used to detect the PELs Teff cells (CD3 and CD8), Treg cells (CD4 and FOXP3), and neutrophils (CD68 and CD163). RT-qPCR results showed that the expression levels of STK11 and IFN-γ in group A were obviously lower, and those of IL-6 and VEGF were much higher in contrast to group B (P < 0.05). The results of immunohistochemical staining showed that the number of STK11- and AMPKα-positive staining cells in group A was dramatically less than that in group B (P <0.05). The results of immunofluorescence staining revealed that the number of positive staining cells for Teff cells, Treg cells, and neutrophils in group A was also less dramatically than that in group B (P <0.05). In summary, immunotherapy can play a therapeutic effect on ESCC by regulating STK11/AMPK pathway and immune cell infiltration.

Effect of Patient-Controlled Epidural Analgesia (PCEA) Based on ERAS on Postoperative Recovery of Patients Undergoing Gynecological Laparoscopic Surgery

Objective

To explore the effect of patient-controlled epidural analgesia (PCEA) based on enhanced recovery after surgery (ERAS) on the postoperative recovery of patients undergoing gynecological laparoscopic surgery.

Methods

Between January 2019 and December 2020, 90 patients scheduled for gynecological laparoscopic surgery and assessed for eligibility were recruited and randomly assigned at a ratio of 1 : 1 to receive either conventional analgesic management (regular group) or PCEA based on ERAS (ERAS group). Comparisons of postoperative rehabilitation indicators, visual analogue scale (VAS) score, self-care ability, complications, and nursing satisfaction were conducted between the two groups.

Results

The ERAS group had significantly shorter first exhaust time (FET), first defecation time (FDT), out-of-bed activity time (OAT), and length of stay (LOS) versus the regular group (P < 0.05). The VAS scores were significantly decreased after treatment, with lower results observed in the ERAS group (P < 0.05). The level of self-responsibility, self-concept, self-care skills, and health knowledge increased significantly in both groups after the intervention, and the ERAS group showed significantly higher results than the regular group (P < 0.05). The total incidence of complications in the ERAS group was significantly lower than that in the regular group (P < 0.05). Eligible patients given PCEA based on ERAS were associated with a higher nursing satisfaction (97.78%) versus conventional analgesic management (82.22%) (P < 0.05).

Conclusion

The application of ERAS for postoperative PCEA management in gynecological laparoscopy provides promising results by effectively enhancing the quality of surgery and promoting rapid postoperative recovery, with a good safety profile.

Video-Assisted Thoracic Surgery vs. Thoracotomy for the Treatment in Patients With Esophageal Leiomyoma: A Systematic Review and Meta-Analysis

Background: Surgical treatment is usually suitable for patients with esophageal leiomyoma. Video-assisted thoracic surgery (VATS) offers a minimally invasive approach to thoracotomy. However, there is no clear conclusion on whether VATS can achieve an equal or even better surgical effect when compared with the traditional open approach in the treatment of esophageal leiomyoma. We performed this meta-analysis to explore and compare the outcomes of VATS vs. thoracotomy for patients with esophageal leiomyoma.

Methods: PubMed, Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), Medline, and Web of Science databases were searched for full-text literature citations. The quality of the articles was evaluated using the Newcastle–Ottawa Scale and the data were analyzed using the Review Manager 5.3 software. Fixed or random effect models were applied according to heterogeneity.

Results: A total of 8 studies with 290 patients, of whom 141 patients were in the VATS group and 149 in the thoracotomy group, were involved in the analysis. Compared with thoracotomy, VATS was associated with shorter operative time, less blood loss in operation, and shorter postoperative hospital stay. There is no significant difference in postoperative pleural drainage day and postoperative complications between the two groups.

Conclusions: VATS has more advantages over thoracotomy, indicating that VATS is better than thoracotomy in terms of postoperative recovery. We look forward to more large-sample, high-quality studies published in the future.

Peri-operative approach to esophagectomy: a narrative review from the anesthesiological standpoint

Objective

This review summarizes the peri-operative anesthesiological approaches to esophagectomy considering the best up-to-date, evidence-based medicine, discussed from the anesthesiologist’s standpoint.

Background

Esophagectomy is the only curative therapy for esophageal cancer. Despite the many advancements made in the surgical treatment of this tumour, esophagectomy still carries a morbidity rate reaching 60%. Patients undergoing esophagectomy should be referred to high volume centres where they can receive a multidisciplinary approach to treatment, associated with better outcomes. The anesthesiologist is the key figure who should guide the peri-operative phase, from diagnosis through to post-surgery rehabilitation. We performed an updated narrative review devoted to the study of anesthesia management for esophagectomy in cancer patients.

Methods

We searched MEDLINE, Scopus and Google Scholar databases from inception to May 2021. We used the following terms: “esophagectomy”, “esophagectomy AND pre-operative evaluation”, “esophagectomy AND protective lung ventilation”, “esophagectomy AND hemodynamic monitoring” and “esophagectomy AND analgesia”. We considered only articles with abstract written in English and available to the reader. We excluded single case-reports.

Conclusions

Pre-operative anesthesiological evaluation is mandatory in order to stratify and optimize any medical condition. During surgery, protective ventilation and judicious fluid management are the cornerstones of intraoperative “protective anesthesia”. Post-operative care should be provided by an intensive care unit or high-dependency unit depending on the patient’s condition, the type of surgery endured and the availability of local resources. The provision of adequate post-operative analgesia favours early mobilization and rapid recovery. Anesthesiologist has an important role during the peri-operative care for esophagectomy. However, there are still some topics that need to be further studied to improve the outcome of these patients.

Effectiveness and safety of a newly introduced multidisciplinary perioperative enhanced recovery after surgery protocol for thoracic esophageal cancer surgery

OBJECTIVE

Data are sparse regarding the multidisciplinary perioperative enhanced recovery after surgery protocol (E-P) for thoracic esophageal cancer surgery that was newly used at another institution. Therefore, this study aimed to retrospectively evaluate the effectiveness and safety of the protocol.

METHODS

We enrolled 101 patients who underwent transthoracic esophagectomy for E-P at the Shizuoka Cancer Center Hospital (SCC). The outcomes obtained at the SCC were compared with the outcomes of 140 patients treated with E-P at the Saitama Medical University International Medical Center (SMU). At the SMU, we compared the results before and after the introduction of E-P.

RESULTS

The rates of morbidity, pulmonary complications, and postoperative pneumonia were 44%, 31%, and 6.9% at the SCC and 44%, 27%, and 6.5% at the SMU (P = 0.91, 0.55, and 0.88, respectively). The mean time to walk was 1.1 and 1.5 days at the SCC and SMU, respectively (P < 0.001). The median length of hospital stay was longer at the SMU than at the SCC (24.0 versus 20.8 days; P = 0.004). In the comparative study before and after the introduction of E-P, the rate of postoperative pneumonia was 16% in the conventional management group and 6.5% in the E-P group (P = 0.02).

CONCLUSION

Postoperative pneumonia was reduced before and after introduction of E-P. As similar short-term postoperative outcomes were promising (except for the time to walk and postoperative hospital stay), the same E-P that was safely performed at the SMU can be implemented as a standard practice.

Patient-Related Prognostic Factors for Anastomotic Leakage, Major Complications, and Short-Term Mortality Following Esophagectomy for Cancer: A Systematic Review and Meta-Analyses

OBJECTIVE

The aim of this study is to identify preoperative patient-related prognostic factors for anastomotic leakage, mortality, and major complications in patients undergoing oncological esophagectomy.

BACKGROUND

Esophagectomy is a high-risk procedure with an incidence of major complications around 25% and short-term mortality around 4%.

METHODS

We systematically searched the Medline and Embase databases for studies investigating the associations between patient-related prognostic factors and anastomotic leakage, major postoperative complications (Clavien-Dindo ≥ IIIa), and/or 30-day/in-hospital mortality after esophagectomy for cancer.

RESULTS

Thirty-nine eligible studies identifying 37 prognostic factors were included. Cardiac comorbidity was associated with anastomotic leakage, major complications, and mortality. Male sex and diabetes were prognostic factors for anastomotic leakage and major complications. Additionally, American Society of Anesthesiologists (ASA) score > III and renal disease were associated with anastomotic leakage and mortality. Pulmonary comorbidity, vascular comorbidity, hypertension, and adenocarcinoma tumor histology were identified as prognostic factors for anastomotic leakage. Age > 70 years, habitual alcohol usage, and body mass index (BMI) 18.5-25 kg/m² were associated with increased risk for mortality.

CONCLUSIONS

Various patient-related prognostic factors are associated with anastomotic leakage, major postoperative complications, and postoperative mortality following oncological esophagectomy. This knowledge may define case-mix adjustment models used in benchmarking or auditing and may assist in selection of patients eligible for surgery or tailored perioperative care.

Recent advances in early esophageal cancer: diagnosis and treatment based on endoscopy

Esophageal cancer (EC) often cannot be discovered in time because of its asymptomatic or symptom-atypical characteristics in early stage. The risk and probability of lymph node metastasis and distant metastasis increase correspondingly as the cancer aggressively invades deeper layers. Treatment regimens may be shifted to surgery and chemoradiotherapy (CRT) from endoscopic eradication therapy (EET) with poor quality of life and prognosis. It is imperative to identify dysplasia and EC early and enable early curative endoscopic treatments. Newer methods have been attempted in the clinical setting to achieve early detection at a more microscopic and precise level. Newer imaging techniques and artificial intelligence (AI) technology have been involved in targeted biopsies and will gradually unveil the visualization of pathology in the future. Early detection and diagnosis are the prerequisite to choose personal and precise treatment regimens. EET has also been undergoing development and improvement to benefit more patients as the first option or the firstly chosen alternative therapy, when compared with esophagectomy. More clinical studies are needed to provide more possibilities for EET.

Clinical TNM staging for esophageal, gastric, and colorectal cancers in the era of neoadjuvant therapy: A systematic review of the literature

AIM

Clinical staging is vital for selecting appropriate candidates and designing neoadjuvant treatment strategies for advanced tumors. The aim of this review was to evaluate diagnostic abilities of clinical TNM staging for gastrointestinal, gastrointestinal cancers.

METHODS

We conducted a systematic review of recent publications to evaluate the accuracy of diagnostic modalities on gastrointestinal cancers. A systematic literature search was performed in PubMed/MEDLINE using the keywords "TNM staging," "T4 staging," "distant metastases," "esophageal cancer," "gastric cancer," and "colorectal cancer," and the search terms used in Cochrane Reviews between January 2005 to July 2020. Articles focusing on preoperative diagnosis of: (a) depth of invasion; (b) lymph node metastases; and (c) distant metastases were selected.

RESULTS

After a full-text search, a final set of 55 studies (17 esophageal cancer studies, 26 gastric cancer studies, and 12 colorectal cancer studies) were used to evaluate the accuracy of clinical TNM staging. Positron emission tomography-computed tomography (PET-CT) and/or magnetic resonance imaging (MRI) were the best modalities to assess distant metastases. Fat and fiber mode of CT may be useful for T4 staging of esophageal cancer, CT was a partially reliable modality for lymph node staging in gastric cancer, and CT combined with MRI was the most reliable modality for liver metastases from colorectal cancer.

CONCLUSION

The most reliable diagnostic modality differed among gastrointestinal cancers depending on the type of cancer. Therefore, we propose diagnostic algorithms for clinical staging for each type of cancer.