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Bär AK, Werkmeister R, Dort JC, Al-Nawas B. Perioperative care in orthognathic surgery - A systematic review and meta-analysis for enhanced recovery after surgery. J Craniomaxillofac Surg 2024:S1010-5182(24)00242-7. [PMID: 39183122 DOI: 10.1016/j.jcms.2024.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 05/30/2024] [Accepted: 08/19/2024] [Indexed: 08/27/2024] Open
Abstract
The aim of this study was to determine whether implementing ERAS (Enhanced Recovery After Surgery) elements/protocols improves outcomes in orthognathic surgery (OGS) compared to conventional care. To achieve this, ERAS-specific perioperative elements were identified and literature on ERAS for OGS was systematically reviewed. Using PRISMA methodology and GRADE approach, 44 studies with 49 perioperative care elements (13 pre-, 15 intra-, 21 postoperative) were analyzed. While 39 studies focused on single elements, only five presented multimodal protocols, with three related to ERAS. Preoperative elements included antimicrobial and steroid prophylaxis and prevention of postoperative nausea and vomiting. Intraoperative aspects, especially anesthesiological, showed high evidence. Outcome parameters were heterogeneous: complications and postoperative pain were well-investigated with high evidence, while length of stay (LOS) and patient satisfaction received low to medium evidence. ICU LOS, healthcare costs, and readmission rates were underreported. The meta-analysis revealed significant results for pain reduction and trends towards fewer complications and shorter LOS in the ERAS group. Overall, ERAS protocols are not established in OMFS, particularly OGS. Further research is needed in pre- and postoperative care and standardized multimodal analgesia. The next step should be developing a comprehensive OGS protocol through a consensus conference and implementing it in clinical practice.
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Affiliation(s)
- Anne-Kathrin Bär
- Department of Oral and Maxillofacial Surgery, Federal Armed Forces Hospital, Rübenacher Str. 170, 56072, Koblenz, Germany; Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany.
| | - Richard Werkmeister
- Department of Oral and Maxillofacial Surgery, Federal Armed Forces Hospital, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - Joseph C Dort
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, Departments of Community Health Sciences and Oncology, Ohlson Research Initiative, Arnie Charbonneau Cancer Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Bilal Al-Nawas
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
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2
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Li YQ, Liu Y, Peng ZQ, Fang R, Xu HY. Enhanced recovery after surgery-based nursing in older patients with postoperative intestinal obstruction after gastric cancer surgery: A retrospective study. World J Clin Cases 2024; 12:4983-4991. [DOI: 10.12998/wjcc.v12.i22.4983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 05/19/2024] [Accepted: 05/28/2024] [Indexed: 06/30/2024] Open
Abstract
BACKGROUND Gastric cancer-related morbidity and mortality rates are high in China. Patients who have undergone gastric cancer surgery should receive six cycles of chemotherapy according to their condition. During this period, intestinal obstruction is likely to occur. Electrolyte balance disorders, peritonitis, intestinal necrosis, and even hypovolemic shock and septic shock can seriously affect the physical and mental recovery of patients and threaten their health and quality of life (QoL).
AIM To quantitatively explore the effects of enhanced recovery after surgery (ERAS)–based nursing on anxiety, depression, and QoL of elderly patients with postoperative intestinal obstruction after gastric cancer.
METHODS The clinical data of 129 older patients with intestinal obstruction after gastric cancer surgery who were treated and cared for in our hospital between January 2019 and December 2021 were examined retrospectively. Nine patients dropped out because of transfer, relocation, or death. According to the order of admissions, the patients were categorized into either a comparison group or an observation group according to the random number table, with 60 cases in each group.
RESULTS After nursing care, the observation group required significantly less time to eat for the first time, recover bowel sounds, pass gas, and defecate than the comparison group (P < 0.05). No significant difference was noted in nutrition-related indicators between the two groups before care. Before care, the Symptom Check List-90 scores between the two groups were comparable, whereas anxiety, depression, paranoia, fear, hostility, obsession, somatization, interpersonal sensitivity, and psychotic scores were significantly lower in the observation group after care (P < 0.05). The QoL scores between the two groups before care did not differ significantly. After care, the physical, social, physiological, and emotional function scores; mental health score; vitality score; and general health score were significantly higher in the observation group, whereas the somatic pain score was significantly lower in the observation group (P < 0.05).
CONCLUSION ERAS-based nursing combined with conventional nursing interventions can effectively improve patient’s QoL, negative emotions, and nutritional status; accelerate the time to first ventilation; and promote intestinal function recovery in elderly patients with postoperative intestinal obstruction after gastric cancer surgery.
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Affiliation(s)
- Yu-Qin Li
- Department of Gastroenterology, Wuhan Fourth Hospital, Wuhan 430033, Hubei Province, China
| | - Ying Liu
- Department of Thoracic Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430079, Hubei Province, China
| | - Zhu-Qing Peng
- Department of Gastroenterology, Wuhan Fourth Hospital, Wuhan 430033, Hubei Province, China
| | - Rong Fang
- Department of Gastroenterology, Wuhan Fourth Hospital, Wuhan 430033, Hubei Province, China
| | - Hai-Yan Xu
- Department of Gastroenterology, Wuhan Fourth Hospital, Wuhan 430033, Hubei Province, China
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3
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Kara S, Ozturk G, Demir Yetis Z, Korkut E, Aksungur N, Altundas N, Dogan N, Ozden K. The Effect of Enhanced Recovery After Surgery Protocol on Surgical Site Infections in Liver Transplantation. Surg Infect (Larchmt) 2024. [PMID: 38959241 DOI: 10.1089/sur.2024.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024] Open
Abstract
Background: Liver surgeries are treatment modalities that require careful pre- and postoperative follow-up for both the surgeon and the patient. Infections are the leading causes of morbidity and mortality after liver transplantation. Infections are the most frequent cause of death between 30 and 180 days after liver transplantation. We aimed to investigate the effect of the Enhanced Recovery After Surgery (ERAS) protocol on the prevention of infections in liver transplant patients. Patients and Methods: The study included patients who underwent liver transplantation in Ataturk University Organ Transplantation Center between 2017 and 2022. Two patient groups with and without ERAS were formed. Blood and urine cultures were collected retrospectively, and those with positive blood cultures for bacteremia were recorded as infection development. The development of infection between the two groups was statistically compared. Also, all patients' length of intensive care stay, length of hospital stay, and duration of antibiotic use were recorded. These parameters were compared between both groups. Results: There was a statistically significant difference between the two groups in terms of infection development (p: 0.01). There was a statistically significant difference between the two groups in terms of duration of antibiotic use and length of hospital stay (Mann-Whitney U test; p: 0.00, p: 0.04, respectively). There was no statistically significant difference between the two groups in terms of length of intensive care stay. Conclusion: We concluded that the introduction of an ERAS protocol was associated with fewer infections, thus shortening the duration of antibiotic therapy and length of hospital stay, although the standardization of the protocols is difficult, especially in liver transplants.
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Affiliation(s)
- S Kara
- Faculty of Medicine, Department of Transplantation Center, Ataturk University, Erzurum, Turkey
| | - G Ozturk
- Faculty of Medicine, Department of Transplantation Center, Ataturk University, Erzurum, Turkey
| | - Z Demir Yetis
- Faculty of Medicine, Department of Transplantation Center, Ataturk University, Erzurum, Turkey
| | - E Korkut
- Faculty of Medicine, Department of Transplantation Center, Ataturk University, Erzurum, Turkey
| | - N Aksungur
- Faculty of Medicine, Department of Transplantation Center, Ataturk University, Erzurum, Turkey
| | - N Altundas
- Faculty of Medicine, Department of Transplantation Center, Ataturk University, Erzurum, Turkey
| | - N Dogan
- Faculty of Medicine, Department of Anesthesiology, Ataturk University, Erzurum, Turkey
| | - K Ozden
- Faculty of Medicine, Department of Infectious Diseases, Ataturk University, Erzurum, Turkey
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4
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Park JO, Lafaro K, Hagendoorn J, Melstrom L, Gerhards MF, Görgec B, Marsman HA, Thornblade LW, Pilz da Cunha G, Yang FF, Labadie KP, Sham JG, Swijnenburg RJ, He J, Fong Y. Outpatient and Ambulatory Extended Recovery Robotic Hepatectomy: Multinational Study of 307 Cases. J Am Coll Surg 2024; 239:61-67. [PMID: 38770933 DOI: 10.1097/xcs.0000000000001107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND For open minor hepatectomy, morbidity and recovery are dominated by the incision. The robotic approach may transform this "incision dominant procedure" into a safe outpatient procedure. STUDY DESIGN We audited outpatient (less than 2 midnights) robotic hepatectomy at 6 hepatobiliary centers in 2 nations to test the hypothesis that the robotic approach can be a safe and effective short-stay procedure. Establishing early recovery after surgery programs were active at all sites, and home digital monitoring was available at 1 of the institutions. RESULTS A total of 307 outpatient (26 same-day and 281 next-day discharge) robotic hepatectomies were identified (2013 to 2023). Most were minor hepatectomies (194 single segments, 90 bi-segmentectomies, 14 three segments, and 8 four segments). Thirty-nine (13%) were for benign histology, whereas 268 were for cancer (33 hepatocellular carcinoma, 27 biliary, and 208 metastatic disease). Patient characteristics were a median age of 60 years (18 to 93 years), 55% male, and a median BMI of 26 kg/m 2 (14 to 63 kg/m 2 ). Thirty (10%) patients had cirrhosis. One hundred eighty-seven (61%) had previous abdominal operation. Median operative time was 163 minutes (30 to 433 minutes), with a median blood loss of 50 mL (10 to 900 mL). There were no deaths and 6 complications (2%): 2 wound infections, 1 failure to thrive, and 3 perihepatic abscesses. Readmission was required in 5 (1.6%) patients. Of the 268 malignancy cases, 25 (9%) were R1 resections. Of the 128 with superior segment resections (segments 7, 8, 4A, 2, and 1), there were 12 positive margins (9%) and 2 readmissions for abscess. CONCLUSIONS Outpatient robotic hepatectomy in well-selected cases is safe (0 mortality, 2% complication, and 1.6% readmission), including resection in the superior or posterior portions of the liver that is challenging with nonarticulating laparoscopic instruments.
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Affiliation(s)
- James O Park
- From the Division of General Surgery, University of Washington, Seattle, WA (Park, Yang, Labadie, Sham)
| | - Kelly Lafaro
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Lafaro, He)
| | - Jeroen Hagendoorn
- Department of Surgical Oncology, University Medical Center, Utrecht, The Netherlands (Hagendoorn)
| | - Laleh Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, CA (Melstrom, Fong)
| | - Michael F Gerhards
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands (Gerhards, Marsman)
| | - Burak Görgec
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands (Görgec, Pilz da Cunha, Swijnenburg)
| | - Hendrik A Marsman
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands (Gerhards, Marsman)
| | - Lucas W Thornblade
- Department of Surgical Oncology, University of California San Fransisco, San Fransisco, CA (Thornblade)
| | - Gabriela Pilz da Cunha
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands (Görgec, Pilz da Cunha, Swijnenburg)
| | - Frank F Yang
- From the Division of General Surgery, University of Washington, Seattle, WA (Park, Yang, Labadie, Sham)
| | - Kevin P Labadie
- From the Division of General Surgery, University of Washington, Seattle, WA (Park, Yang, Labadie, Sham)
| | - Jonathan G Sham
- From the Division of General Surgery, University of Washington, Seattle, WA (Park, Yang, Labadie, Sham)
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands (Görgec, Pilz da Cunha, Swijnenburg)
| | - Jin He
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Lafaro, He)
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, CA (Melstrom, Fong)
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5
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Berikashvili LB, Yadgarov MY, Kuzovlev AN, Smirnova AV, Kadantseva KK, Kuznetsov IV, Polyakov PA, Likhvantsev VV. Adductor Canal Block Versus Femoral Nerve Block in Total Knee Arthroplasty: Network Meta-Analysis. Clin J Pain 2024; 40:447-457. [PMID: 38561898 DOI: 10.1097/ajp.0000000000001214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/19/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES The quality of postoperative analgesia in total knee arthroplasty is crucial for patient recovery, rehabilitation, and hospital stay duration. In line with the above, а single-shot adductor canal block has been considered as an improved method over continuous femoral nerve block. However, continuous adductor canal block and single-shot femoral nerve block have been not adequately addressed in the discussion. This study aimed to compare the effectiveness of various types of adductor and femoral nerve blocks on clinically relevant outcomes in patients following total knee arthroplasty. METHODS A systematic review and network meta-analysis were conducted following "PRISMA-NMA" and Cochrane Handbook guidelines. The eligibility criteria included randomized trials and, where these were lacking for a comparison, nonrandomized studies involving adults undergoing primary total knee arthroplasty, comparing single-shot adductor canal block, continuous adductor canal block, single-shot femoral nerve block, and continuous femoral nerve block. RESULTS A total of 36 studies involving 3308 patients were included. Single-shot adductor canal block showed higher pain scores and opioid consumption but better functional recovery at 24 h compared with continuous femoral nerve block. However, this trend vanishes by the 48 h assessment postsurgery. Continuous adductor canal block required higher opioid consumption but better functional recovery and shorter hospital stay compared with continuous femoral nerve block. Single-shot adductor canal block showed higher pain scores but comparable opioid consumption and functional recovery to continuous adductor canal block. DISCUSSION The shift from continuous femoral nerve block to single-shot adductor canal block as the preferred method for pain relief after total knee arthroplasty may be premature. While the latter improves mobility, it falls short in pain control and does not shorten hospital stays. Continuous adductor canal block shows promise but is currently underappreciated, and single-shot femoral nerve block is often overshadowed by other techniques in regional anesthesia. Further high-quality, multicenter randomized controlled trials are needed to validate these findings.
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Affiliation(s)
- Levan B Berikashvili
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology
- Vladimirsky Moscow Regional Research and Clinical Institute
| | - Mikhail Ya Yadgarov
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology
| | - Artem N Kuzovlev
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology
| | - Anastasia V Smirnova
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology
- City Clinical Oncological Hospital No. 1
| | - Kristina K Kadantseva
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology
- A. Loginov Moscow Clinical Scientific Centre
| | - Ivan V Kuznetsov
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology
| | - Petr A Polyakov
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology
| | - Valery V Likhvantsev
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology
- First Moscow State Medical University, Moscow, Russia
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6
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Bezu L, Akçal Öksüz D, Bell M, Buggy D, Diaz-Cambronero O, Enlund M, Forget P, Gupta A, Hollmann MW, Ionescu D, Kirac I, Ma D, Mokini Z, Piegeler T, Pranzitelli G, Smith L, The EuroPeriscope Group. Perioperative Immunosuppressive Factors during Cancer Surgery: An Updated Review. Cancers (Basel) 2024; 16:2304. [PMID: 39001366 PMCID: PMC11240822 DOI: 10.3390/cancers16132304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 06/19/2024] [Accepted: 06/20/2024] [Indexed: 07/16/2024] Open
Abstract
Surgical excision of the primary tumor represents the most frequent and curative procedure for solid malignancies. Compelling evidence suggests that, despite its beneficial effects, surgery may impair immunosurveillance by triggering an immunosuppressive inflammatory stress response and favor recurrence by stimulating minimal residual disease. In addition, many factors interfere with the immune effectors before and after cancer procedures, such as malnutrition, anemia, or subsequent transfusion. Thus, the perioperative period plays a key role in determining oncological outcomes and represents a short phase to circumvent anesthetic and surgical deleterious factors by supporting the immune system through the use of synergistic pharmacological and non-pharmacological approaches. In line with this, accumulating studies indicate that anesthetic agents could drive both protumor or antitumor signaling pathways during or after cancer surgery. While preclinical investigations focusing on anesthetics' impact on the behavior of cancer cells are quite convincing, limited clinical trials studying the consequences on survival and recurrences remain inconclusive. Herein, we highlight the main factors occurring during the perioperative period of cancer surgery and their potential impact on immunomodulation and cancer progression. We also discuss patient management prior to and during surgery, taking into consideration the latest advances in the literature.
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Affiliation(s)
- Lucillia Bezu
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Département d'Anesthésie, Chirurgie et Interventionnel, Gustave Roussy, 94805 Villejuif, France
- U1138 Metabolism, Cancer and Immunity, Gustave Roussy, 94805 Villejuif, France
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA 94305, USA
| | - Dilara Akçal Öksüz
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Clinic for Anesthesiology, Intensive Care, Emergency Medicine, Pain Therapy and Palliative Medicine, Marienhaus Klinikum Hetzelstift, 67434 Neustadt an der Weinstrasse, Germany
- ESAIC Mentorship Program, BE-1000 Brussels, Belgium
| | - Max Bell
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Solna, 17176 Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institute, 17176 Stockholm, Sweden
| | - Donal Buggy
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Division of Anaesthesiology, Mater Misericordiae University Hospital, D07 WKW8 Dublin, Ireland
- School of Medicine, University College, D04 V1W8 Dublin, Ireland
| | - Oscar Diaz-Cambronero
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Department of Anesthesiology, Hospital Universitario y Politécnico la Fe, 46026 Valencia, Spain
- Perioperative Medicine Research, Health Research Institute Hospital la Fe, 46026 Valencia, Spain
- Faculty of Medicine, Department of Surgery, University of Valencia, 46010 Valencia, Spain
| | - Mats Enlund
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Center for Clinical Research, Uppsala University, SE-72189 Västerås, Sweden
- Department of Anesthesia & Intensive Care, Västmanland Hospital, SE-72189 Västerås, Sweden
| | - Patrice Forget
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), Institute of Applied Health Sciences, Epidemiology Group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZN, UK
- Department of Anaesthesia, NHS Grampian, University of Aberdeen, Aberdeen AB25 2ZN, UK
- Pain and Opioids after Surgery (PANDOS) ESAIC Research Group, European Society of Anaesthesiology and Intensive Care, 1000 Brussels, Belgium
- IMAGINE UR UM 103, Anesthesia Critical Care, Emergency and Pain Medicine Division, Nîmes University Hospital, Montpellier University, 30900 Nîmes, France
| | - Anil Gupta
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Department of Physiology and Pharmacology, Karolinska Institute, 17176 Stockholm, Sweden
| | - Markus W Hollmann
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Department of Anesthesiology, Amsterdam UMC, 1100 DD Amsterdam, The Netherlands
| | - Daniela Ionescu
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Department of Anesthesia and Intensive Care, University of Medicine and Pharmacy "Iuliu Hatieganu", 400012 Cluj-Napoca, Romania
- Outcome Research Consortium, Cleveland, OH 44195, USA
| | - Iva Kirac
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Genetic Counselling Unit, University Hospital for Tumors, Sestre Milosrdnice University Hospital Centre, 10000 Zagreb, Croatia
| | - Daqing Ma
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London SW10 9NH, UK
- Department of Anesthesiology, Perioperative and Systems Medicine Laboratory, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Zhirajr Mokini
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- ESAIC Mentorship Program, BE-1000 Brussels, Belgium
- Clinique du Pays de Seine, 77590 Bois le Roi, France
| | - Tobias Piegeler
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Department of Anesthesiology and Intensive Care, University of Leipzig Medical Center, 04275 Leipzig, Germany
| | - Giuseppe Pranzitelli
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Department of Anesthesiology and Intensive Care, San Timoteo Hospital, 86039 Termoli, Italy
| | - Laura Smith
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Department of Anaesthesia, NHS Grampian, University of Aberdeen, Aberdeen AB25 2ZN, UK
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZN, UK
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7
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Robella M, Vaira M, Ansaloni L, Asero S, Bacchetti S, Borghi F, Casella F, Coccolini F, De Cian F, di Giorgio A, Framarini M, Gelmini R, Graziosi L, Kusamura S, Lippolis P, Lo Dico R, Macrì A, Marrelli D, Sammartino P, Sassaroli C, Scaringi S, Tonello M, Valle M, Sommariva A. Enhanced recovery after surgery (ERAS) implementation in cytoreductive surgery (CRS) and hyperthermic IntraPEritoneal chemotherapy (HIPEC): Insights from Italian peritoneal surface malignancies expert centers. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108486. [PMID: 38971013 DOI: 10.1016/j.ejso.2024.108486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 05/12/2024] [Accepted: 06/12/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND Cytoreductive surgery (CRS) combined with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is a complex procedure that involves extensive peritoneal and visceral resections followed by intraperitoneal chemotherapy. The Enhanced Recovery After Surgery (ERAS) program aims to achieve faster recovery by maintaining pre-operative organ function and reducing the stress response following surgery. A recent publication introduced dedicated ERAS guidelines for CRS and HIPEC with the aim of extending the benefits to patients with peritoneal surface malignancies. METHODS A survey was conducted among 21 Italian centers specializing in peritoneal surface malignancies (PSM) treatment to assess adherence to ERAS guidelines. The survey covered pre/intraoperative and postoperative ERAS items and explored attitudes towards ERAS implementation. RESULTS All centers completed the survey, demonstrating expertise in PSM treatment. However, less than 30 % of centers adopted ERAS protocols despite being aware of dedicated guidelines. Preoperative optimization was common, with variations in bowel preparation methods and fasting periods. Intraoperative normothermia control was consistent, but fluid management practices varied. Postoperative practices, including routine abdominal drain placement and NGT management, varied greatly among centers. The majority of respondents expressed an intention to implement ERAS, citing concerns about feasibility and organizational challenges. CONCLUSIONS The study concludes that Italian centers specialized in PSM treatment have limited adoption of ERAS protocols for CRS ± HIPEC, despite being aware of guidelines. The variability in practice highlights the need for standardized approaches and further evaluation of ERAS applicability in this complex surgical setting to optimize patient care.
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Affiliation(s)
- Manuela Robella
- Surgical Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Candiolo (TO), Italy.
| | - Marco Vaira
- Surgical Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Candiolo (TO), Italy
| | - Luca Ansaloni
- General Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Salvatore Asero
- Soft Tissue U.O. Surgical Oncology-Soft Tissue Tumors, Dipartimento di Oncologia, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specializzazione Garibaldi Catania, 95123 Catania, Italy
| | - Stefano Bacchetti
- Advanced Surgical Oncology Center, ASUFC, DAME, University of Udine, 33100 Udine, Italy
| | - Felice Borghi
- Surgical Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Candiolo (TO), Italy
| | - Francesco Casella
- Upper GI Surgery Division, University of Verona, 37129 Verona, Italy
| | - Federico Coccolini
- General Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | | | - Andrea di Giorgio
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Framarini
- General and Oncologic Department of Surgery, Morgagni - Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Roberta Gelmini
- General and Oncological Surgery Unit, AOU of Modena University of Modena and Reggio Emilia, Italy
| | - Luigina Graziosi
- University of Perugia, General and Emergency Surgery Department, Santa Maria Della Misericordia Hospital, Perugia, Italy
| | - Shigeki Kusamura
- Peritoneal Surface Malignancy Unit, Dept. of Surgery, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Piero Lippolis
- General and Peritoneal Surgery, Department of Surgery, Hospital University Pisa (AOUP), Pisa, Italy
| | - Rea Lo Dico
- Department of General and Emergency Surgery, S.Camillo-Forlanini Hospital, Rome, Italy
| | - Antonio Macrì
- Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi", University of Messina, Messina, Italy
| | - Daniele Marrelli
- Department of Medicine, Surgery, and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, 53100 Siena, Italy
| | - Paolo Sammartino
- CRS and HIPEC Unit, Pietro Valdoni, Umberto I Policlinico di Roma, 00161 Roma, Italy
| | - Cinzia Sassaroli
- UOSD Ricerca Integrata Medico Chirurgica nelle Neoplasie del Peritoneo, "Fondazione Giovanni Pascale" IRCCS, Naples, Italy
| | - Stefano Scaringi
- AOU Careggi, IBD Unit-Chirurgia Dell'Apparato Digerente, 50100 Firenze, Italy
| | - Marco Tonello
- Unit of Surgical Oncology of the Esophagus and Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Mario Valle
- Peritoneal Tumours Unit, IRCCS, Regina Elena Cancer Institute, 00144 Rome, Italy
| | - Antonio Sommariva
- Unit of Surgical Oncology of the Esophagus and Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
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Weigle CA, Beetz O, Wiemann BA, Tessmer P, Störzer S, Cammann S, Vondran FWR, Oldhafer F, Schmelzle M, Richter N. Resection of intrahepatic cholangiocarcinoma in octogenarians: a single-center analysis. Discov Oncol 2024; 15:224. [PMID: 38865024 PMCID: PMC11169410 DOI: 10.1007/s12672-024-01065-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/27/2024] [Indexed: 06/13/2024] Open
Abstract
The rapidly aging population in industrialized countries comes with an increased incidence of intrahepatic cholangiocarcinoma (iCC) which presents new challenges for oncological treatments especially in elderly patients. Thus, the question arises to what extent the benefit of surgical resections, as the only curative treatment option, outweighs possible perioperative risks in patients ≥ 80 years of age (octogenarians). We therefore retrospectively analyzed 311 patients who underwent resection for iCC at Hannover Medical School between January 1996 and December 2022. In total, there were 11 patients older than 80 years in our collective. Despite similar tumor size, octogenarians underwent comparatively less extensive surgery (54.5% major resections in octogenarians vs. 82.7% in all other patients; p = 0.033) with comparable rates of lymphadenectomy and tumor-free resection margins. Furthermore, we did not observe increased major postoperative morbidity (Clavien-Dindo ≥ IIIa complications: 27.3% vs. 34.3% in all other patients; p = 0.754) or mortality (estimated 1-year OS of 70.7% vs. 72.5% in all other patients, p = 0.099). The length of intensive care unit (ICU) or intermediate care unit (IMC) stay was significantly longer in octogenarians, however, with a comparable length in total hospital stay. The estimated overall survival (OS) did also not differ significantly, although a trend towards reduced long-term survival was observed (14.5 months vs. 28.03 months in all other patients; p = 0.099). In conclusion, primary resection is a justifiable and safe therapeutic option even in octogenarians but requires an even more thorough preoperative patient selection.
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Affiliation(s)
- Clara A Weigle
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Oliver Beetz
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Bengt A Wiemann
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Philipp Tessmer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Simon Störzer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Sebastian Cammann
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Florian W R Vondran
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Felix Oldhafer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Moritz Schmelzle
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Nicolas Richter
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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9
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De Gasperi A, Petrò L, Amici O, Scaffidi I, Molinari P, Barbaglio C, Cibelli E, Penzo B, Roselli E, Brunetti A, Neganov M, Giacomoni A, Aseni P, Guffanti E. Major liver resections, perioperative issues and posthepatectomy liver failure: A comprehensive update for the anesthesiologist. World J Crit Care Med 2024; 13:92751. [PMID: 38855273 PMCID: PMC11155507 DOI: 10.5492/wjccm.v13.i2.92751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/15/2024] [Accepted: 05/07/2024] [Indexed: 06/03/2024] Open
Abstract
Significant advances in surgical techniques and relevant medium- and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections. To support these outstanding results and to reduce perioperative complications, anesthesiologists must address and master key perioperative issues (preoperative assessment, proactive intraoperative anesthesia strategies, and implementation of the Enhanced Recovery After Surgery approach). Intensive care unit monitoring immediately following liver surgery remains a subject of active and often unresolved debate. Among postoperative complications, posthepatectomy liver failure (PHLF) occurs in different grades of severity (A-C) and frequency (9%-30%), and it is the main cause of 90-d postoperative mortality. PHLF, recently redefined with pragmatic clinical criteria and perioperative scores, can be predicted, prevented, or anticipated. This review highlights: (1) The systemic consequences of surgical manipulations anesthesiologists must respond to or prevent, to positively impact PHLF (a proactive approach); and (2) the maximal intensive treatment of PHLF, including artificial options, mainly based, so far, on Acute Liver Failure treatment(s), to buy time waiting for the recovery of the native liver or, when appropriate and in very selected cases, toward liver transplant. Such a clinical context requires a strong commitment to surgeons, anesthesiologists, and intensivists to work together, for a fruitful collaboration in a mandatory clinical continuum.
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Affiliation(s)
- Andrea De Gasperi
- Former Head, Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda ASST GOM Niguarda, Milan 20163, Italy
| | - Laura Petrò
- AR1, Ospedale Papa Giovanni 23, Bergamo 24100, Italy
| | - Ombretta Amici
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Ilenia Scaffidi
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Pietro Molinari
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Caterina Barbaglio
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Eva Cibelli
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Beatrice Penzo
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Elena Roselli
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Andrea Brunetti
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Maxim Neganov
- Anestesia e Terapia Intensiva Generale, Istituto Clinico Humanitas, Rozzano 20089, Italy
| | - Alessandro Giacomoni
- Chirurgia Oncologica Miniinvasiva, Grande Ospedale Metropolitano Niguarda ASST GOM Niguarda, Milan 20163, Italy
| | - Paolo Aseni
- Dipartimento di Medicina d’Urgenza ed Emergenza, Grande Ospedale Metropolitano Niguarda ASST GOM Niguarda, Milano 20163, MI, Italy
| | - Elena Guffanti
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
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10
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Dyas AR, Stuart CM, Bronsert MR, Kelleher AD, Bata KE, Cumbler EU, Erickson CJ, Blum MG, Vizena AS, Barker AR, Funk L, Sack K, Abrams BA, Randhawa SK, David EA, Mitchell JD, Weyant MJ, Scott CD, Meguid RA. Anatomic Lung Resection Outcomes After Implementation of a Universal Thoracic ERAS Protocol Across a Diverse Health Care System. Ann Surg 2024; 279:1062-1069. [PMID: 38385282 PMCID: PMC11087203 DOI: 10.1097/sla.0000000000006243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
OBJECTIVE We sought to evaluate how implementing a thoracic enhanced recovery after surgery (ERAS) protocol impacted surgical outcomes after elective anatomic lung resection. BACKGROUND The effect of implementing the ERAS Society/European Society of Thoracic Surgery thoracic ERAS protocol on postoperative outcomes throughout an entire health care system has not yet been reported. METHODS This was a prospective cohort study within one health care system (January 2019-March, 2023). A thoracic ERAS protocol was implemented on May 1, 2021 for elective anatomic lung resections, and postoperative outcomes were tracked using the electronic health record and Vizient data. The primary outcome was overall morbidity; secondary outcomes included individual complications, length of stay, opioid use, chest tube duration, and total cost. Patients were grouped into pre-ERAS and post-ERAS cohorts. Bivariable comparisons were performed using independent t -test, χ 2 , or Fisher exact tests, and multivariable logistic regression was performed to control for confounders. RESULTS There were 1007 patients in the cohort; 450 (44.7%) were in the post-ERAS group. Mean age was 66.2 years; most patients were female (65.1%), white (83.8%), had a body mass index between 18.5 and 29.9 (69.7%), and were ASA class 3 (80.6%). Patients in the postimplementation group had lower risk-adjusted rates of any morbidity, respiratory complication, pneumonia, surgical site infection, arrhythmias, infections, opioid usage, ICU use, and shorter postoperative length of stay (all P <0.05). CONCLUSIONS Postoperative outcomes were improved after the implementation of an evidence-based thoracic ERAS protocol throughout the health care system. This study validates the ERAS Society/European Society of Thoracic Surgery guidelines and demonstrates that simultaneous multihospital implementation can be feasible and effective.
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Affiliation(s)
- Adam R. Dyas
- Surgical Outcomes and Applied Research, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Christina M. Stuart
- Surgical Outcomes and Applied Research, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Michael R. Bronsert
- Surgical Outcomes and Applied Research, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alyson D. Kelleher
- Department of Quality and Safety, University of Colorado School of Medicine, Aurora, CO
| | - Kyle E. Bata
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Ethan U. Cumbler
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | | | - Matthew G. Blum
- Department of Surgery, UCHealth Memorial Hospital, Colorado Springs, CO
| | - Annette S. Vizena
- Department of Anesthesiology, UCHealth Poudre Valley Hospital. Fort Collins, CO
| | - Alison R. Barker
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Lauren Funk
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Karishma Sack
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Benjamin A. Abrams
- Department of Anesthesiology and Critical Care, University of Colorado School of Medicine, Aurora, CO
| | - Simran K. Randhawa
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Elizabeth A. David
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - John D. Mitchell
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | | | - Christopher D. Scott
- Department of Surgery, University of Virginia Medical Center, Charlottesville, VA
| | - Robert A. Meguid
- Surgical Outcomes and Applied Research, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
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11
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Fichtinger RS, Aldrighetti LA, Abu Hilal M, Troisi RI, Sutcliffe RP, Besselink MG, Aroori S, Menon KV, Edwin B, D'Hondt M, Lucidi V, Ulmer TF, Díaz-Nieto R, Soonawalla Z, White S, Sergeant G, Olij B, Ratti F, Kuemmerli C, Scuderi V, Berrevoet F, Vanlander A, Marudanayagam R, Tanis P, Dewulf MJ, Dejong CH, Eminton Z, Kimman ML, Brandts L, Neumann UP, Fretland ÅA, Pugh SA, van Breukelen GJ, Primrose JN, van Dam RM. Laparoscopic Versus Open Hemihepatectomy: The ORANGE II PLUS Multicenter Randomized Controlled Trial. J Clin Oncol 2024; 42:1799-1809. [PMID: 38640453 PMCID: PMC11107897 DOI: 10.1200/jco.23.01019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 11/13/2023] [Accepted: 01/17/2024] [Indexed: 04/21/2024] Open
Abstract
PURPOSE To compare outcomes after laparoscopic versus open major liver resection (hemihepatectomy) mainly for primary or metastatic cancer. The primary outcome measure was time to functional recovery. Secondary outcomes included morbidity, quality of life (QoL), and for those with cancer, resection margin status and time to adjuvant systemic therapy. PATIENTS AND METHODS This was a multicenter, randomized controlled, patient-blinded, superiority trial on adult patients undergoing hemihepatectomy. Patients were recruited from 16 hospitals in Europe between November 2013 and December 2018. RESULTS Of the 352 randomly assigned patients, 332 patients (94.3%) underwent surgery (laparoscopic, n = 166 and open, n = 166) and comprised the analysis population. The median time to functional recovery was 4 days (IQR, 3-5; range, 1-30) for laparoscopic hemihepatectomy versus 5 days (IQR, 4-6; range, 1-33) for open hemihepatectomy (difference, -17.5% [96% CI, -25.6 to -8.4]; P < .001). There was no difference in major complications (laparoscopic 24/166 [14.5%] v open 28/166 [16.9%]; odds ratio [OR], 0.84; P = .58). Regarding QoL, both global health status (difference, 3.2 points; P < .001) and body image (difference, 0.9 points; P < .001) scored significantly higher in the laparoscopic group. For the 281 (84.6%) patients with cancer, R0 resection margin status was similar (laparoscopic 106 [77.9%] v open 122 patients [84.1%], OR, 0.60; P = .14) with a shorter time to adjuvant systemic therapy in the laparoscopic group (46.5 days v 62.8 days, hazard ratio, 2.20; P = .009). CONCLUSION Among patients undergoing hemihepatectomy, the laparoscopic approach resulted in a shorter time to functional recovery compared with open surgery. In addition, it was associated with a better QoL, and in patients with cancer, a shorter time to adjuvant systemic therapy with no adverse impact on cancer outcomes observed.
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Affiliation(s)
- Robert S. Fichtinger
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | | | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, United Kingdom
- Department of Surgery, Poliambulanza Hospital, Brescia, Italy
| | - Roberto I. Troisi
- Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Transplantation Service, Federico II University, Naples, Italy
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital, Ghent, Belgium
| | - Robert P. Sutcliffe
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Somaiah Aroori
- Department of Surgery, Plymouth Hospitals NHS Trust, Plymouth, United Kingdom
| | - Krishna V. Menon
- Department of Surgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Bjørn Edwin
- Intervention Center and Department of Hepatic, Pancreatic and Biliary Surgery, Oslo University Hospital and Institute of Medicine, University of Oslo, Oslo, Norway
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, AZ Groeninge, Kortrijk, Belgium
| | - Valerio Lucidi
- Department of Digestive Surgery, Unit of Hepatobiliary Surgery and Transplantation, Hôpitaux Universitaires de Bruxelles, Hôpital Erasme, Brussels, Belgium
| | - Tom F. Ulmer
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Rafael Díaz-Nieto
- Department of Hepato-Biliary Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Zahir Soonawalla
- Department of Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Steve White
- Department of Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Gregory Sergeant
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Jessa Hospital, Hasselt, Belgium
| | - Bram Olij
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- GROW—School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Christoph Kuemmerli
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, United Kingdom
| | - Vincenzo Scuderi
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital, Ghent, Belgium
| | - Frederik Berrevoet
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital, Ghent, Belgium
| | - Aude Vanlander
- Department of Surgery, Free University Hospital, AZ Jette Hospital, Brussels, Belgium
| | - Ravi Marudanayagam
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Pieter Tanis
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Maxime J.L. Dewulf
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Cornelis H.C. Dejong
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Deceased
| | - Zina Eminton
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Merel L. Kimman
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Lloyd Brandts
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Ulf P. Neumann
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Department of Surgery, University Hospital Essen, Essen, Germany
| | - Åsmund A. Fretland
- Intervention Center and Department of Hepatic, Pancreatic and Biliary Surgery, Oslo University Hospital and Institute of Medicine, University of Oslo, Oslo, Norway
| | - Siân A. Pugh
- Department of Oncology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Gerard J.P. van Breukelen
- Department of Methodology and Statistics, CAPHRI Care and Public Health Research Institute Maastricht University, Maastricht, the Netherlands
| | - John N. Primrose
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, United Kingdom
| | - Ronald M. van Dam
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- GROW—School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
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12
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Moosburner S, Dahlke PM, Neudecker J, Hillebrandt KH, Koch PF, Knitter S, Ludwig K, Kamali C, Gül-Klein S, Raschzok N, Schöning W, Sauer IM, Pratschke J, Krenzien F. From morbidity reduction to cost-effectiveness: Enhanced recovery after surgery (ERAS) society recommendations in minimal invasive liver surgery. Langenbecks Arch Surg 2024; 409:137. [PMID: 38653917 PMCID: PMC11039530 DOI: 10.1007/s00423-024-03329-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/19/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Minimal-invasive liver surgery (MILS) reduces surgical trauma and is associated with fewer postoperative complications. To amplify these benefits, perioperative multimodal concepts like Enhanced Recovery after Surgery (ERAS), can play a crucial role. We aimed to evaluate the cost-effectiveness for MILS in an ERAS program, considering the necessary additional workforce and associated expenses. METHODS A prospective observational study comparing surgical approach in patients within an ERAS program compared to standard care from 2018-2022 at the Charité - Universitätsmedizin Berlin. Cost data were provided by the medical controlling office. ERAS items were applied according to the ERAS society recommendations. RESULTS 537 patients underwent liver surgery (46% laparoscopic, 26% robotic assisted, 28% open surgery) and 487 were managed by the ERAS protocol. Implementation of ERAS reduced overall postoperative complications in the MILS group (18% vs. 32%, p = 0.048). Complications greater than Clavien-Dindo grade II incurred the highest costs (€ 31,093) compared to minor (€ 17,510) and no complications (€13,893; p < 0.001). In the event of major complications, profit margins were reduced by a median of € 6,640. CONCLUSIONS Embracing the ERAS society recommendations in liver surgery leads to a significant reduction of complications. This outcome justifies the higher cost associated with a well-structured ERAS protocol, as it effectively offsets the expenses of complications.
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Affiliation(s)
- Simon Moosburner
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany
| | - Paul M Dahlke
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jens Neudecker
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Karl H Hillebrandt
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany
| | - Pia F Koch
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Sebastian Knitter
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Kristina Ludwig
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Can Kamali
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Safak Gül-Klein
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Nathanael Raschzok
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany
| | - Wenzel Schöning
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Igor M Sauer
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Felix Krenzien
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany.
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13
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Muetterties CE, Taylor JM, Kaeding DE, Rosales Morales R, Nguyen AV, Kwan L, Tseng CY, Delong MR, Festekjian JH. Impact of Gabapentin on Postoperative Hypotension in Enhanced Recovery after Surgery Protocols for Microvascular Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5732. [PMID: 38623445 PMCID: PMC11018206 DOI: 10.1097/gox.0000000000005732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/20/2024] [Indexed: 04/17/2024]
Abstract
Background Enhanced recovery after surgery (ERAS) protocols have been associated with hypotensive episodes after autologous breast reconstruction. Gabapentin (Gaba), a nonopioid analgesic used in ERAS, has been shown to attenuate postoperative hemodynamic responses. This study assesses ERAS's impact, with and without Gaba, on postoperative hypotension after microvascular breast reconstruction. Methods Three cohorts were studied: traditional pathway, ERAS + Gaba, and ERAS no-Gaba. We evaluated length of stay, inpatient narcotic use [morphine milligram equivalents (MME)], mean systolic blood pressure, hypotension incidence, and complications. The traditional cohort was retrospectively reviewed, whereas the ERAS groups were enrolled prospectively after the initiation of the protocol in April 2019 (inclusive of Gaba until October 2022). Results In total, 441 patients were analyzed. The three cohorts, in the order mentioned above, were similar in age and bilateral reconstruction rates (57% versus 61% versus 60%). The ERAS cohorts, both with and without Gaba, had shorter stays (P < 0.01). Inpatient MME was significantly less in the ERAS + Gaba cohort than the traditional or ERAS no-Gaba cohorts (medians: 112 versus 178 versus 158 MME, P < 0.01). ERAS + Gaba significantly increased postoperative hypotensive events on postoperative day (POD) 1 and 2, with notable reduction after Gaba removal (P < 0.05). Across PODs 0-2, mean systolic blood pressure was highest in the traditional cohort, followed by ERAS no-Gaba, then the ERAS + Gaba cohort (P < 0.05). Complication rates were similar across all cohorts. Conclusions Postmicrovascular breast reconstruction, ERAS + Gaba reduced overall inpatient narcotic usage, but increased hypotension incidence. Gaba removal from the ERAS protocol reduced postoperative hypotension incidence while maintaining similar stay lengths and complication rates.
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Affiliation(s)
- Corbin E. Muetterties
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Jeremiah M. Taylor
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Diana E. Kaeding
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Ricardo Rosales Morales
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Anissa V. Nguyen
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
- Department of Urology, University of California Los Angeles, Los Angeles, Calif
| | - Lorna Kwan
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
- Department of Urology, University of California Los Angeles, Los Angeles, Calif
| | - Charles Y. Tseng
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Michael R. Delong
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Jaco H. Festekjian
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
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14
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Delabays C, Demartines N, Joliat GR, Melloul E. Enhanced recovery after liver surgery in cirrhotic patients: a systematic review and meta-analysis. Perioper Med (Lond) 2024; 13:24. [PMID: 38561792 PMCID: PMC10983761 DOI: 10.1186/s13741-024-00375-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 03/04/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Few studies have assessed enhanced recovery after surgery (ERAS) in liver surgery for cirrhotic patients. The present meta-analysis assessed the impact of ERAS pathways on outcomes after liver surgery in cirrhotic patients compared to standard care. METHODS A literature search was performed on PubMed/MEDLINE, Embase, and the Cochrane Library. Studies comparing ERAS protocols versus standard care in cirrhotic patients undergoing liver surgery were included. The primary outcome was post-operative complications, while secondary outcomes were mortality rates, length of stay (LoS), readmissions, reoperations, and liver failure rates. RESULTS After evaluating 41 full-text manuscripts, 5 articles totaling 646 patients were included (327 patients in the ERAS group and 319 in the non-ERAS group). Compared to non-ERAS care, ERAS patients had less risk of developing overall complications (OR 0.43, 95% CI 0.31-0.61, p < 0.001). Hospitalization was on average 2 days shorter for the ERAS group (mean difference - 2.04, 95% CI - 3.19 to - 0.89, p < 0.001). Finally, no difference was found between both groups concerning 90-day post-operative mortality and rates of reoperations, readmissions, and liver failure. CONCLUSION In cirrhotic patients, ERAS protocol for liver surgery is safe and decreases post-operative complications and LoS. More randomized controlled trials are needed to confirm the results of the present analysis.
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Affiliation(s)
- Constant Delabays
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland.
| | - Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Emmanuel Melloul
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
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Wu R, Robayo V, Nguyen DT, Chan EY, Chihara R, Huang HJ, Graviss EA, Kim MP. Enhanced recovery after surgery may mitigate the risks associated with robotic-assisted fundoplication in lung transplant patients. Surg Endosc 2024; 38:2134-2141. [PMID: 38443500 DOI: 10.1007/s00464-024-10719-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/28/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION A history of lung transplantation is a risk factor for poor outcomes in patients undergoing laparoscopic fundoplication. We wanted to determine whether enhanced recovery after a robotic-assisted surgery program would mitigate these risks. METHODS We performed a single-center retrospective analysis of the Society of Thoracic Surgery database for patients who underwent elective antireflux procedures from 1/2018 to 2/2021 under the enhanced recovery after surgery program using robotic assistance. We identified the patient and surgical characteristics, morbidity, length of stay, and 30-day readmission rates. RESULTS Among 386 patients who underwent barrier creation, 41 had previously undergone a lung transplant, either bilateral (n = 28) or single (n = 13). There were no significant differences in postoperative complications (9.8% vs. 5.2%, p = 0.27), median hospital length of stay (1 d vs. 1 d, p = 0.28), or 30-day readmission (7.3% vs. 4.9%, p = 0.46). Bivariate analysis showed that older age (p = 0.03), history of DVT/PE (p < 0.001), history of cerebrovascular events (p = 0.03), opioid dependence (p = 0.02), neurocognitive dysfunction (p < 0.001), and dependent functional status (p = 0.02) were associated with postoperative complications. However, lung transplantation was not associated with an increased risk of postoperative complications (p = 0.28). DISCUSSION The risk of surgical complications in patients with a history of lung transplantation may be mitigated by the combination of ERAS and minimally invasive surgery such as robot-assisted surgery.
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Affiliation(s)
- Rebecca Wu
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | | | - Duc T Nguyen
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Edward Y Chan
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
- Division of Thoracic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Ray Chihara
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
- Division of Thoracic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Howard J Huang
- Division of Pulmonary Critical Care, and Sleep Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Edward A Graviss
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, FACS. 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA
| | - Min P Kim
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA.
- Division of Thoracic Surgery, Houston Methodist Hospital, Houston, TX, USA.
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16
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Schmoke N, Nemeh C, Gennell T, Schapiro D, Hiep-Catarino A, Alexander M, Chalphin AV, Crum RW, Holynskyj L, Kubacki T, Schechter WS, Zitsman J. Enhanced recovery after surgery improves clinical outcomes in adolescent bariatric surgery. Surg Obes Relat Dis 2024:S1550-7289(24)00123-0. [PMID: 38653653 DOI: 10.1016/j.soard.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 02/10/2024] [Accepted: 03/09/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols are evidence-based, multimodal approaches to optimize patient recovery and minimize complications. OBJECTIVES Our team evaluated clinical outcomes following the implementation of an ERAS protocol for adolescents undergoing metabolic and bariatric surgery. SETTING Academic hospital, New York, NY, USA. METHODS We performed a single-institution longitudinal assessment of adolescents who underwent laparoscopic vertical sleeve gastrectomy (VSG) between August 2021 and November 2022. Unpaired t-tests and Fisher's exact test were used to compare means between groups and categorical factors. RESULTS Forty-three patients were included in the study, 21 who participated in the ERAS protocol and 22 control patients. ERAS cohort was 52% females, with a median age of 17.5 years and a median body mass index (BMI) of 46.3 kg/m2. The non-ERAS cohort was 59% females, with a median age of 16.7 years and a median BMI of 44.0 kg/m2. There were no significant differences between baseline characteristics. Patients in the ERAS group had a shorter time to oral intake (10.7 hours versus 21.5 hours, P < .01), lower morphine milligram equivalents (18.2 versus 97.0, P < .01), and shorter length of stay (1.5 days versus 2.0 days, P = .01). There were no significant differences between return visits to the emergency department (ED) within 30 days (3 versus 2, P = .66) or readmissions (0 versus 1, P = 1.0). CONCLUSIONS The described ERAS protocol is safe and effective in adolescents undergoing laparoscopic VSG and is associated with shorter time to oral intake, reduced opioid requirements, and shorter hospital lengths of stay with no increase in return ED visits or readmissions.
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Affiliation(s)
- Nicholas Schmoke
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Christopher Nemeh
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Tania Gennell
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Dana Schapiro
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Ashley Hiep-Catarino
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Matthew Alexander
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Alexander V Chalphin
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Robert W Crum
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Leign Holynskyj
- Deparment of Nursing/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Tatiana Kubacki
- Division of Pediatric Anesthesia, Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - William S Schechter
- Division of Pediatric Anesthesia, Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York; Division of Pediatric Pain Medicine and Advanced Care Medicine, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York; Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Jeffrey Zitsman
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York.
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17
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Voigt KR, de Graaff MR, Verhoef C, Kazemier G, Swijneburg RJ, Mieog JSD, Derksen WJM, Buis CI, Gobardhan PD, Dulk MD, van Dam RM, Liem MSL, Leclercq WKG, Bosscha K, Belt EJT, Vermaas M, Kok NFM, Patijn GA, Marsman HM, van den Boezem PB, Klaase JM, Grünhagen DJ. Association of modified textbook outcome and overall survival after surgery for colorectal liver metastases: A nationwide analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107972. [PMID: 38278128 DOI: 10.1016/j.ejso.2024.107972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/16/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Textbook outcome (TO) represents a multidimensional quality measurement, encompassing the desirable short-term outcomes following surgery. This study aimed to investigate whether achieving TO after resection of colorectal liver metastases (CRLM) surgery is related to better overall survival (OS) in a national cohort. METHOD Data was retrieved from the Dutch Hepato Biliary Audit. A modified definition of TO (mTO) was used because readmissions were only recorded from 2019. mTO was achieved when no severe postoperative complications, mortality, prolonged length of hospital stay, occurred and when adequate surgical resection margins were obtained. To compare outcomes of patients with and without mTO and reduce baseline differences between both groups propensity score matching (PSM) was used for patients operated on between 2014 and 2018. RESULTS Out of 6525 eligible patients, 81 % achieved mTO. For the cohort between 2014 and 2018, those achieving mTO had a 5-year OS of 46.7 % (CI 44.8-48.6) while non-mTO patients had a 5-year OS of 33.7 % (CI 29.8-38.2), p < 0.001. Not achieving mTO was associated with a worse OS (aHR 1.34 (95 % CI 1.17-1.53), p < 0.001. Median follow-up was 76 months., PSM assigned 519 patients to each group. In the PSM cohort patients achieving mTO, 5-year OS was 43.6 % (95 % CI 39.2-48.5) compared to 36.4 % (95 % CI 31.9-41.2) in patients who did not achieve mTO, p = 0.006. CONCLUSION Achieving mTO is associated with improved long-term survival. This emphasizes the importance of optimising perioperative care and reducing postoperative complications in surgical treatment of CRLM.
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Affiliation(s)
- Kelly R Voigt
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Michelle R de Graaff
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, the Netherlands; Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.
| | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Rutger J Swijneburg
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Wouter J M Derksen
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Carlijn I Buis
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, the Netherlands
| | - Paul D Gobardhan
- Department of Surgery, Amphia Medical Centre, Breda, the Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Nutrim - School of Nutrition and Translational Research in Metabolism, Maastricht University, the Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Mike S L Liem
- Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | | | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's, Hertogenbosch, the Netherlands
| | - Eric J T Belt
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Maarten Vermaas
- Department of Surgery, IJsselland Hospital, Capelle Aan de Ijssel, the Netherlands
| | - Niels F M Kok
- Department of Surgery, Antoni van Leeuwenhoek - Dutch Cancer Institute, Amsterdam, the Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala, Zwolle, the Netherlands
| | - H M Marsman
- Department of Surgery, Onze Lieve Vrouwen Hospital, Amsterdam, the Netherlands
| | | | - Joost M Klaase
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, the Netherlands
| | - Dirk J Grünhagen
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
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18
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Çetin B, Çilesiz NC, Ozkan A, Onuk Ö, Kır G, Balci MBC, Özdemir E. Enhanced Recovery After Surgery (ERAS) Reduces Hospital Costs and Length of Hospital Stay in Radical Cystectomy: A Prospective Randomized Controlled Study. Cureus 2024; 16:e55460. [PMID: 38571847 PMCID: PMC10988186 DOI: 10.7759/cureus.55460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2024] [Indexed: 04/05/2024] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols challenge the conventional and rigid methods of surgery and anesthesia and bring about novel changes that are quite drastic. The core principle of the protocol is to minimize the metabolic disturbance caused by surgical injury, facilitate the restoration of functions in a brief period, and promote the resumption of normal activity at the earliest. To compare the outcomes of ERAS and standard protocol for patients who have undergone radical cystectomy (RC) with ileal conduit urinary diversion. This prospective randomized controlled study was performed between 2015 and 2023. The 77 patients were divided into two groups ERAS (n=39) and Standard (n=38) by sequential randomization. These two groups are divided according to protocols of bowel preparation, anesthesia, and postoperative nutrition. The clinical and demographic characteristics of the patients, and the American Society of Anesthesiologists (ASA) and Eastern Cooperative Oncology Group (ECOG) scores were recorded. Perioperative findings, the degree of complications according to the Clavien-Dindo classification, and the total cost of treatment were recorded and analyzed. Length of hospital stay (18.82±9.25 day vs 27.34±15.05 day), and cost of treatment (2168,2±933$ 2879±1806$) were higher in the standard group. The rate of nausea and vomiting and the use of antiemetics were higher in the ERAS group compared to the standard group. In patients undergoing RC, the ERAS protocol was found to shorten the duration of hospitalization and reduce the total cost of hospital stay.
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Affiliation(s)
- Buğra Çetin
- Urology, Altınbaş University Medicalpark Bahçelievler Hospital, Istanbul, TUR
| | | | | | - Özkan Onuk
- Urology, Biruni University Hospital, Istanbul, TUR
| | - Gülay Kır
- Anesthesiology and Reanimation, Koç University, Istanbul, TUR
| | - M B Can Balci
- Urology, Taksim Training and Research Hospital, Istanbul, TUR
| | - Enver Özdemir
- Urology, Gaziosmanpaşa Training and Research Hospital, Istanbul, TUR
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19
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Davey MG, Donlon NE, Fearon NM, Heneghan HM, Conneely JB. Evaluating the Impact of Enhanced Recovery After Surgery Protocols on Surgical Outcomes Following Bariatric Surgery-A Systematic Review and Meta-analysis of Randomised Clinical Trials. Obes Surg 2024; 34:778-789. [PMID: 38273146 PMCID: PMC10899423 DOI: 10.1007/s11695-024-07072-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/08/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programmes are evidence-based care improvement processes for surgical patients, which are designed to decrease the impact the anticipated negative physiological cascades following surgery. AIM To perform a systematic review and meta-analysis of randomised clinical trials (RCTs) to evaluate the impact of ERAS protocols on outcomes following bariatric surgery compared to standard care (SC). METHODS A systematic review was performed in accordance with PRISMA guidelines. Meta-analysis was performed using Review Manager version 5.4 RESULTS: Six RCTs including 740 patients were included. The mean age was 40.2 years, and mean body mass index was 44.1 kg/m2. Overall, 54.1% underwent Roux-en-Y gastric bypass surgery (400/740) and 45.9% sleeve gastrectomy (340/700). Overall, patients randomised to ERAS programmes had a significant reduction in nausea and vomiting (odds ratio (OR): 0.42, 95% confidence interval (CI): 0.19-0.95, P = 0.040), intraoperative time (mean difference (MD): 5.40, 95% CI: 3.05-7.77, P < 0.001), time to mobilisation (MD: - 7.78, 95% CI: - 5.46 to - 2.10, P < 0.001), intensive care unit stay (ICUS) (MD: 0.70, 95% CI: 0.13-1.27, P = 0.020), total hospital stay (THS) (MD: - 0.42, 95% CI: - 0.69 to - 0.16, P = 0.002), and functional hospital stay (FHS) (MD: - 0.60, 95% CI: - 0.98 to - 0.22, P = 0.002) compared to those who received SC. CONCLUSION ERAS programmes reduce postoperative nausea and vomiting, intraoperative time, time to mobilisation, ICUS, THS, and FHS compared to those who received SC. Accordingly, ERAS should be implemented, where feasible, for patients indicated to undergo bariatric surgery. Trial registration International Prospective Register of Systematic Reviews (PROSPERO - CRD42023434492.
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Affiliation(s)
- Matthew G Davey
- Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland.
- Department of Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.
| | - Noel E Donlon
- Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland
- Department of Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
| | - Naomi M Fearon
- Surgical Professorial Unit, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Helen M Heneghan
- Surgical Professorial Unit, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - John B Conneely
- Department of Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
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20
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Sánchez-Pérez B, Ramia JM. Does enhanced recovery after surgery programs improve clinical outcomes in liver cancer surgery? World J Gastrointest Oncol 2024; 16:255-258. [PMID: 38425397 PMCID: PMC10900164 DOI: 10.4251/wjgo.v16.i2.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/11/2023] [Accepted: 01/09/2024] [Indexed: 02/02/2024] Open
Abstract
Enhanced recovery after surgery (ERAS) programs have been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016 and the new recommendations in 2022. Liver surgery is usually performed in oncological patients (liver metastasis, hepatocellular carcinoma, cholangiocarcinoma, etc.), but the real impact of liver surgery ERAS programs in oncological outcomes is not clearly defined. Theoretical advantages of ERAS programs are: ERAS decreases postoperative complication rates and has been demonstrated a clear relationship between complications and oncological outcomes; a better and faster postoperative recovery should let oncologic teams begin chemotherapeutic regimens on time; prehabilitation and nutrition actions before surgery should also improve the performance status of the patients receiving chemotherapy. So, ERAS could be another way to improve our oncological results. We will discuss the literature about liver surgery ERAS focusing on its oncological implications and future investigations projects.
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Affiliation(s)
- Belinda Sánchez-Pérez
- Department of General, Digestive and Transplantation Surgery, University Regional Hospital, Málaga 29010, Málaga, Spain
| | - José M Ramia
- Department of Surgery, Hospital General Universitario Dr. Balmis, Alicante 03010, Spain
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21
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Zhang M, Cai P. Application on perioperative ERAS concept in elderly lung cancer patients undergoing surgery. Medicine (Baltimore) 2024; 103:e36929. [PMID: 38335409 PMCID: PMC10860964 DOI: 10.1097/md.0000000000036929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 11/19/2023] [Accepted: 12/20/2023] [Indexed: 02/12/2024] Open
Abstract
Investigating the applying effects of the enhanced recovery after surgery (ERAS) in the perioperative period of elderly lung cancer patients undergoing the surgery. We randomly selected 98 elderly patients with lung cancer who were admitted to our hospital and underwent surgery from January 2022 to September 2023 as study subjects. The control group received conventional care during the perioperative period, and the intervention group received ERAS-guided care measures. The differences in perioperative-related indices, pulmonary function, pain level, inflammatory factors, and postoperative complication rates between these 2 groups were compared. The postoperative extubation time, the activity time since getting out of bad and hospital stay were lower in the observation group than those in the control group (P < .05). At 3 days postoperatively, the FEV1, forced vital capacity and maximum ventilation volume of these 2 groups were lower than those of their same groups before surgery, and those of the observation group were higher than those of the control group (P < .05). At 3 days postoperatively, the numerical rating scale in both groups were lower than those of their same groups at 6 hours postoperatively, and the numerical rating scale of the observation group was lower than that of the control group (P < .05). At 3 days postoperatively, tumor necrosis factor-α, IL-6, and CRP in both groups were higher than those in their same groups before surgery, and those of the observation group was lower than those of the control group (P < .05). The incidence of postoperative complications in the observation group was lower than that in the control group (P < .05). ERAS applied in the perioperative period of elderly lung cancer patients undergoing surgery can shorten the hospital stay, promote the postoperative recovery on pulmonary function, alleviate inflammation, and reduce the risk of postoperative complications.
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Affiliation(s)
- Ming Zhang
- Department of Thoracic Surgery, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China
| | - Ping Cai
- Department of Thoracic Surgery, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China
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22
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Clet A, Guy M, Muir JF, Cuvelier A, Gravier FE, Bonnevie T. Enhanced Recovery after Surgery (ERAS) Implementation and Barriers among Healthcare Providers in France: A Cross-Sectional Study. Healthcare (Basel) 2024; 12:436. [PMID: 38391811 PMCID: PMC10887527 DOI: 10.3390/healthcare12040436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/16/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
The implementation of Enhanced Recovery After Surgery (ERAS) is a challenge for healthcare systems, especially in case of patients undergoing major surgery. Despite a proven significant reduction in postoperative complications and hospital lengths of stay, ERAS protocols are inconsistently used in real-world practice, and barriers have been poorly described in a cohort comprising medical and paramedical professionals. This study aims to assess the proportion of French healthcare providers who practiced ERAS and to identify barriers to its implementation amongst those surveyed. We conducted a prospective cross-sectional study to survey healthcare providers about their practice of ERAS using an online questionnaire. Healthcare providers were contacted through hospital requests, private hospital group requests, professional corporation requests, social networks, and personal contacts. The questionnaire was also designed to explore barriers to ERAS implementation. Identified barriers were allocated by two independent assessors to one of the fourteen domains of the Theoretical Domains Framework (TDF), which is an integrative framework based on behavior change theories that can be used to identify issues relating to evidence on the implementation of best practice in healthcare settings. One hundred and fifty-three French healthcare providers answered the online questionnaire (76% female, median age 35 years (IQR: 29 to 48)). Physiotherapists, nurses, and dieticians were the most represented professions (31.4%, 24.2%, and, 14.4%, respectively). Amongst those surveyed, thirty-one practiced ERAS (20.3%, 95%CI: 13.9 to 26.63). Major barriers to ERAS practice were related to the "Environmental context and resources" domain (57.6%, 95%CI: 49.5-65.4), e.g., lack of professionals, funding, and coordination, and the "Knowledge" domain (52.8%, 95%CI: 44.7-60.8), e.g., ERAS unawareness. ERAS in major surgery is seldom practiced in France due to the unfavorable environment (i.e., logistics issues, and lack of professionals and funding) and a low rate of procedure awareness. Future studies should focus on devising and assessing strategies (e.g., education and training, collaboration, institutional support, the development of healthcare networks, and leveraging telehealth and technology) to overcome these barriers, thereby promoting the wider implementation of ERAS.
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Affiliation(s)
- Augustin Clet
- Université Rouen Normandie, Normandie Univ, GRHVN UR 3830, F-76000 Rouen, France
- ADIR Association, Rouen University Hospital, F-76000 Rouen, France
| | - Marin Guy
- Centre Aquitain Du Dos, Hôpital Privé Saint-Martin, F-33600 Pessac, France
| | - Jean-François Muir
- Université Rouen Normandie, Normandie Univ, GRHVN UR 3830, F-76000 Rouen, France
- ADIR Association, Rouen University Hospital, F-76000 Rouen, France
- Pulmonary, Thoracic Oncology and Respiratory Intensive Care Department, Rouen University Hospital, F-76000 Rouen, France
| | - Antoine Cuvelier
- ADIR Association, Rouen University Hospital, F-76000 Rouen, France
- Pulmonary, Thoracic Oncology and Respiratory Intensive Care Department, Rouen University Hospital, F-76000 Rouen, France
| | - Francis-Edouard Gravier
- Université Rouen Normandie, Normandie Univ, GRHVN UR 3830, F-76000 Rouen, France
- ADIR Association, Rouen University Hospital, F-76000 Rouen, France
| | - Tristan Bonnevie
- Université Rouen Normandie, Normandie Univ, GRHVN UR 3830, F-76000 Rouen, France
- ADIR Association, Rouen University Hospital, F-76000 Rouen, France
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Schwenk W, Flemming S, Girona-Johannkämper M, Wendt W, Darwich I, Strey C. [Structured implementation of fast-track pathways to enhance recovery after elective colorectal resection : First results from five German hospitals]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:148-156. [PMID: 37947802 DOI: 10.1007/s00104-023-01986-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/13/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Multimodal optimized perioperative management (mPOM, fast-track, enhanced recovery after surgery, ERAS) leads to a significantly accelerated recovery of patients with elective colorectal resections. Nevertheless, fast-track surgery has not yet become established in everyday clinical practice in Germany. We present the results of a structured fast-track implementation in five German hospitals. METHODS Prospective data collection in the context of a 13-month structured fast-track implementation. All patients ≥ 18 years undergoing elective colorectal resection and who gave informed consent were included. After 3 months of preparation (pre-FAST), fast-track treatment was initiated and continued for 10 months (FAST). Outcome criteria were adherence to internationally recommended fast-track elements, postoperative complications, functional recovery, and postoperative hospital stay. RESULTS Data from 192 pre-FAST and 529 FAST patients were analyzed. Age, sex, patient risk, location, and type of disease were not different between both groups. The FAST patients were more likely to have undergone minimally invasive surgery (82% vs. 69%). Fast-track adherence increased from 52% (35-65%) under traditional treatment to 83% (65-96%) under fast-track treatment (p < 0.01). The duration until the end of infusion treatment, removal of the bladder catheter, first bowel movement, oral solid food, regaining autonomy, suitability for discharge and postoperative length of stay were significantly lower in the FAST group. Complications, reoperations, and readmission rates did not differ. CONCLUSION Fast-track adherence rates > 75% can also be achieved in German hospitals through structured fast-track implementation and the recovery of patients can be significantly accelerated.
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Affiliation(s)
- Wolfgang Schwenk
- Gesellschaft für Optimiertes perioperatives Management, GOPOM GmbH, Düsseldorf, Deutschland.
- Gesellschaft für Optimiertes Perioperatives Management GOPOPM GmbH, Oberlörickerstr. 390b, 40547, Düsseldorf, Deutschland.
| | - Sven Flemming
- Universitätsklinik für Allgemein‑, Viszeral‑, Gefäß- und Transplantationschirurgie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | | | - Wolfgang Wendt
- Viszeralchirurgie / Proktologie, Diakonissenkrankenhaus Dresden, Dresden, Deutschland
| | - Ibrahim Darwich
- Klinik für Allgemein- und Viszeralchirurgie, St. Marien Krankenhaus Siegen, Siegen, Deutschland
| | - Christoph Strey
- Klinik für Allgemein- und Viszeralchirurgie, DRK Krankenhaus Clementinenhaus, Hannover, Deutschland
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24
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Pang TS, Cao LP. Estimation of Physiologic Ability and Surgical Stress scoring system for predicting complications following abdominal surgery: A meta-analysis spanning 2004 to 2022. World J Gastrointest Surg 2024; 16:215-227. [PMID: 38328319 PMCID: PMC10845291 DOI: 10.4240/wjgs.v16.i1.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/24/2023] [Accepted: 12/19/2023] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Postoperative complications remain a paramount concern for surgeons and healthcare practitioners. AIM To present a comprehensive analysis of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system's efficacy in predicting postoperative complications following abdominal surgery. METHODS A systematic search of published studies was conducted, yielding 17 studies with pertinent data. Parameters such as preoperative risk score (PRS), surgical stress score (SSS), comprehensive risk score (CRS), postoperative complications, postoperative mortality, and other clinical data were collected for meta-analysis. Forest plots were employed for continuous and binary variables, with χ2 tests assessing heterogeneity (P value). RESULTS Patients experiencing complications after abdominal surgery exhibited significantly higher E-PASS scores compared to those without complications [mean difference and 95% confidence interval (CI) of PRS: 0.10 (0.05-0.15); SSS: 0.04 (0.001-0.08); CRS: 0.19 (0.07-0.31)]. Following the exclusion of low-quality studies, results remained valid with no discernible heterogeneity. Subgroup analysis indicated that variations in sample size and age may contribute to heterogeneity in CRS analysis. Binary variable meta-analysis demonstrated a correlation between high CRS and increased postoperative complication rates [odds ratio (OR) (95%CI): 3.01 (1.83-4.95)], with a significant association observed between high CRS and postoperative mortality [OR (95%CI): 15.49 (3.75-64.01)]. CONCLUSION In summary, postoperative complications in abdominal surgery, as assessed by the E-PASS scoring system, are consistently linked to elevated PRS, SSS, and CRS scores. High CRS scores emerge as risk factors for heightened morbidity and mortality. This study establishes the accuracy of the E-PASS scoring system in predicting postoperative morbidity and mortality in abdominal surgery, underscoring its potential for widespread adoption in effective risk assessment.
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Affiliation(s)
- Tian-Shu Pang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - Li-Ping Cao
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
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Grass F, Roth-Kleiner M, Demartines N, Agri F. Day Admission Surgery Program in a Prospective Payment System: What Are the Financial Incentives? Health Serv Insights 2024; 17:11786329231222970. [PMID: 38250650 PMCID: PMC10798120 DOI: 10.1177/11786329231222970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/07/2023] [Indexed: 01/23/2024] Open
Abstract
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.
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Affiliation(s)
- Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Matthias Roth-Kleiner
- Medical Direction, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
- Lausanne University Hospital, Lausanne, Switzerland
| | - Fabio Agri
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
- Department of Administration and Finance. Lausanne University Hospital, Lausanne, Switzerland
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Pi S, Masterson J, Ma SP, Corbin CK, Milstein A, Chen JH. Using Case Mix Index within Diagnosis-Related Groups to Evaluate Variation in Hospitalization Costs at a Large Academic Medical Center. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2024; 2023:1201-1208. [PMID: 38222372 PMCID: PMC10785921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
In analyzing direct hospitalization cost and clinical data from an academic medical center, commonly used metrics such as diagnosis-related group (DRG) weight explain approximately 37% of cost variability, but a substantial amount of variation remains unaccounted for by case mix index (CMI) alone. Using CMI as a benchmark, we isolate and target individual DRGs with higher than expected average costs for specific quality improvement efforts. While DRGs summarize hospitalization care after discharge, a predictive model using only information known before admission explained up to 60% of cost variability for two DRGs with a high excess cost burden. This level of variability likely reflects underlying patient factors that are not modifiable (e.g., age and prior comorbidities) and therefore less useful for health systems to target for intervention. However, the remaining unexplained variation can be inspected in further studies to discover operational factors that health systems can target to improve quality and value for their patients. Since DRG weights represent the expected resource consumption for a specific hospitalization type relative to the average hospitalization, the data-driven approach we demonstrate can be utilized by any health institution to quantify excess costs and potential savings among DRGs.
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Affiliation(s)
- Selina Pi
- Department of Biomedical Data Science, Stanford, California, USA
| | | | - Stephen P Ma
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Conor K Corbin
- Department of Biomedical Data Science, Stanford, California, USA
| | - Arnold Milstein
- Clinical Excellence Research Center, Stanford University, Stanford, CA, USA
| | - Jonathan H Chen
- Stanford Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California, USA
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27
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Hsiao WL, Wu YC, Tai HC. Reduced length of intensive care unit stay and early mechanical ventilator weaning with enhanced recovery after surgery (ERAS) in free fibula flap surgery. Sci Rep 2024; 14:302. [PMID: 38167861 PMCID: PMC10762210 DOI: 10.1038/s41598-023-50881-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 12/27/2023] [Indexed: 01/05/2024] Open
Abstract
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.
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Affiliation(s)
- Wei-Ling Hsiao
- School of Nursing, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-Cheng Wu
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, 7 Zhong-Shan South Road, Taipei, 10002, Taiwan
| | - Hao-Chih Tai
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, 7 Zhong-Shan South Road, Taipei, 10002, Taiwan.
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28
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Dahlke PM, Benzing C, Lurje G, Malinka T, Raschzok N, Kamali C, Gül-Klein S, Schöning W, Hillebrandt KH, Pratschke J, Neudecker J, Krenzien F. Impact of complexity in minimally invasive liver surgery on enhanced recovery measures: prospective study. BJS Open 2024; 8:zrad147. [PMID: 38242574 PMCID: PMC10799324 DOI: 10.1093/bjsopen/zrad147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/30/2023] [Accepted: 10/31/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Adherence to enhanced recovery after surgery (ERAS) protocols is crucial for successful liver surgery. The aim of this study was to assess the impact of minimally invasive liver surgery complexity on adherence after implementing an ERAS protocol. METHODS Between July 2018 and August 2021, a prospective observational study involving minimally invasive liver surgery patients was conducted. Perioperative treatment followed ERAS guidelines and was recorded in the ERAS interactive audit system. Kruskal-Wallis and ANOVA tests were used for analysis, and pairwise comparisons utilized Wilcoxon rank sum and Welch's t-tests, adjusted using Bonferroni correction. RESULTS A total of 243 patients were enrolled and categorized into four groups based on the Iwate criteria: low (n = 17), intermediate (n = 81), advanced (n = 74) and expert difficulty (n = 71). Complexity correlated with increased overall and major morbidity rate, as well as longer length of stay (all P < 0.001; standardized mean difference = 0.036, 0.451, 0.543 respectively). Adherence to ERAS measures decreased with higher complexity (P < 0.001). Overall adherence was 65.4%. Medical staff-centred adherence was 79.9%, while patient-centred adherence was 38.9% (P < 0.001). Complexity significantly affected patient-centred adherence (P < 0.001; standardized mean difference (SMD) = 0.420), but not medical staff-centred adherence (P = 0.098; SMD = 0.315). Postoperative phase adherence showed major differences among complexity groups (P < 0.001, SMD = 0.376), with mobilization measures adhered to less in higher complexity cases. CONCLUSION The complexity of minimally invasive liver surgery procedures impacts ERAS protocol adherence for each patient. This can be addressed using complexity-adjusted cut-offs and 'gradual adherence' based on the relative proportion of cut-off values achieved.
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Affiliation(s)
- Paul M Dahlke
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Christian Benzing
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Georg Lurje
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Thomas Malinka
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Nathanael Raschzok
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178, Berlin, Germany
| | - Can Kamali
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Safak Gül-Klein
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Wenzel Schöning
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Karl H Hillebrandt
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Jens Neudecker
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Felix Krenzien
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178, Berlin, Germany
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Nigam A, Hawksworth JS, Winslow ER. Minimally Invasive Robotic Techniques for Hepatocellular Carcinoma Resection: How I Do It. Surg Oncol Clin N Am 2024; 33:111-132. [PMID: 37945137 DOI: 10.1016/j.soc.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
The adoption of minimally invasive techniques for hepatocellular resection has progressively increased in North America. Cumulative evidence has demonstrated improved surgical outcomes in patients who undergo minimally invasive hepatectomy. In this review, the authors' approach and methodology to minimally invasive robotic liver resection for hepatocellular carcinoma is discussed.
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Affiliation(s)
- Aradhya Nigam
- Department of Surgery, Medstar Georgetown University Hospital, 3800 Reservoir Road, NW, 4PHC, Washington, DC 20007, USA
| | - Jason S Hawksworth
- Division of Abdominal Organ Transplantation, Columbia University Irving Medical Center, 622 West 168th Street, PH14-105, New York, NY 20032, USA.
| | - Emily R Winslow
- Department of Transplant Surgery, Medstar Georgetown University Hospital, 3800 Reservoir Road, NW, 2PHC, Washington, DC 20007, USA
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30
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Anika NN, Mohammed M, Shehryar A, Rehman A, Oliveira Souza Lima SR, Hamid YH, Mimms CS, Abdallah S, Kumar YS, Ibrahim M. Transforming Bariatric Surgery Outcomes: The Pivotal Role of Enhanced Recovery After Surgery (ERAS) Protocols in Patient-Centered Care. Cureus 2024; 16:e52648. [PMID: 38380206 PMCID: PMC10877221 DOI: 10.7759/cureus.52648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2024] [Indexed: 02/22/2024] Open
Abstract
Bariatric surgery is a critical strategy in managing morbid obesity. Enhanced recovery after surgery (ERAS) protocols have revolutionized perioperative care in this field. This systematic review aims to synthesize current evidence on the impact of ERAS protocols on patient-centered outcomes in bariatric surgery. A comprehensive search across multiple databases was conducted, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies involving adult patients undergoing bariatric surgery and focusing on the implementation and outcomes of ERAS protocols were included. Data extraction and analysis emphasized patient recovery, well-being, and satisfaction. Eleven studies met the inclusion criteria. The review revealed that ERAS protocols are associated with reduced postoperative recovery times, decreased hospital stays, and enhanced patient satisfaction. Notably, ERAS protocols effectively reduced complications and optimized resource utilization in bariatric surgery. Comparative insights from non-bariatric surgeries highlighted the versatility and adaptability of ERAS protocols across different surgical disciplines. ERAS protocols significantly improve patient-centered outcomes in bariatric surgery. Their adoption facilitates a patient-focused approach, accelerating recovery and enhancing overall patient well-being. The findings advocate for the broader implementation of ERAS protocols in surgical care, emphasizing the need for continuous refinement to meet evolving healthcare demands. This review supports the paradigm shift toward integrating ERAS protocols in bariatric surgery and potentially other surgical fields.
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Affiliation(s)
- Nabila N Anika
- Medicine and Surgery, Holy Family Red Crescent Medical College and Hospital, Dhaka, BGD
| | | | | | | | | | - Yusra H Hamid
- Community Medicine, University of Khartoum, Khartoum, SDN
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31
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Zhao R, Hou X, Niu Y, Wang J. Effect of the Home to Hospital to Home nutrition management program on postoperative liver cancer patients: A single-center randomized controlled study. Medicine (Baltimore) 2023; 102:e36648. [PMID: 38065853 PMCID: PMC10713131 DOI: 10.1097/md.0000000000036648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/22/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Malnutrition is the most common complication in postoperative liver cancer patients. This study aimed to investigate the effects of the Home to Hospital to Home nutrition management program on postoperative liver cancer patients. METHODS A total of 184 liver cancer patients were randomly assigned to either an intervention group (treated under the Home to Hospital to Home nutrition management program) or a control group (treated with the general nutritional method). Nutrition-related indicators, such as prealbumin (PA) and albumin, were assessed before and after treatment in both groups. The incidence of complications (e.g., nausea or vomiting, bloating, difficulty defecating, ascites), length of hospital stay, first time to anal exhaust and out-of-bed activity, and patient satisfaction were recorded. RESULTS A total of 184 liver cancer patients were randomly assigned to either an intervention group (treated under the Home to Hospital to Home nutrition management program) or a control group (treated with the general nutritional method). Nutrition-related indicators, such as prealbumin (PA) and albumin, were assessed before and after treatment in both groups. The incidence of complications (e.g., nausea or vomiting, bloating, difficulty defecating, ascites), length of hospital stay, first time to anal exhaust and out-of-bed activity, and patient satisfaction were recorded. CONCLUSION The Home to Hospital to Home nutrition management program improves the nutritional status of postoperative liver cancer patients, lowers the incidence of complications, shortens hospital stays, increases patient satisfaction, and promotes the early recovery of patients.
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Affiliation(s)
- Runan Zhao
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, China
| | - Xiaohong Hou
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, China
| | - Yushuo Niu
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, China
| | - Jianlu Wang
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, China
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32
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Ke Y, Ng RRG, Elangovan S, Leong YH, Goh ZH, Graves N, Shannon NB, Abdullah HR. Prehabilitation programs - a systematic review of the economic evidence. Front Med (Lausanne) 2023; 10:1281843. [PMID: 38105890 PMCID: PMC10722222 DOI: 10.3389/fmed.2023.1281843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/17/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction Prehabilitation, which involves improving a patient's physical and psychological condition before surgery, has shown potential benefits but has yet to be extensively studied from an economic perspective. To address this gap, a systematic review was conducted to summarize existing economic evaluations of prehabilitation interventions. Methods The PRISMA Protocols 2015 checklist was followed. Over 16,000 manuscripts were reviewed, and 99 reports on preoperative interventions and screening tests were identified, of which 12 studies were included in this analysis. The costs are expressed in Pounds (GBP, £) and adjusted for inflation to December 2022. Results The studies were conducted in Western countries, focusing on specific surgical subspecialties. While the interventions and study designs varied, most studies demonstrated cost savings in the intervention group compared to the control group. Additionally, all cost-effectiveness analysis studies favored the intervention group. However, the review also identified several limitations. Many studies had a moderate or high risk of bias, and critical information such as time horizons and discount rates were often missing. Important components like heterogeneity, distributional effects, and uncertainty were frequently lacking as well. The misclassification of economic evaluation types highlighted a lack of knowledge among physicians in prehabilitation research. Conclusion This review reveals a lack of robust evidence regarding the economics of prehabilitation programs for surgical patients. This suggests a need for further research with rigorous methods and accurate definitions.
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Affiliation(s)
- Yuhe Ke
- Department of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, Singapore
| | - Roderica Rui Ge Ng
- Department of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, Singapore
| | - Shalini Elangovan
- Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Yun Hao Leong
- Department of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, Singapore
| | - Zhao Han Goh
- Department of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, Singapore
| | - Nicholas Graves
- Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Nicholas B. Shannon
- Duke-NUS Medical School, Singapore, Singapore
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Hairil Rizal Abdullah
- Department of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, Singapore
- Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
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Kimura C, Liu Y, Crowder SE, Arbaugh C, Mai U, Shankar K, Shelton A, Visser B, Kin C. Barriers and Facilitators of Surgical Prehabilitation Adherence from the Patient Perspective: a Mixed Method Study. J Gastrointest Surg 2023; 27:2547-2556. [PMID: 37848690 DOI: 10.1007/s11605-023-05857-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 09/27/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Adherence to prehabilitation is crucial for optimal benefit, but reasons for low adherence to home-based programs remain unexplored. Our aim was to identify and explore barriers and facilitators to prehabilitation adherence among patients undergoing abdominal surgery. METHODS Nested in a single-center randomized controlled trial on prehabilitation (Perioperative Optimization With Enhanced Recovery (POWER)), this study had an explanatory sequential design with a connect integration. Patients randomized to the intervention arm were included in the quantitative analysis, and a subset of them was invited for a semi-structured interview. The exposure was the frequency of barriers to physical activity and healthy eating, and the outcome was adherence to those components of prehabilitation. Logistic or linear regression was used as appropriate. RESULTS Among 133 participants in the intervention arm, 116 (87.2%) completed the initial survey ((56.9% women, median age 61 years old (IQR 49.0; 69.4)). The most frequent barriers to exercise and healthy eating were medical issues (59%) and lack of motivation (31%), respectively. There was no significant association between the barriers to physical activity score and adherence to this component of the program (OR 0.89, 95% CI 0.78-1.02, p=0.09). Higher barriers to healthy eating scores were associated with lower Mediterranean diet scores pre- and post-intervention (coef.: -0.32, 95% CI: -0.49; -0.15, p<0.001; and coef.: -0.27, 95% CI: -0.47; -0.07, p=0.01, respectively). Interviews with 15 participants revealed that participating in prehabilitation was a motivator for healthy eating and exercising through goal setting, time-efficient workouts, and promoting self-efficacy. CONCLUSIONS We identified key barriers to be addressed and facilitators to be leveraged in future prehabilitation programs. TRIAL REGISTRATION NCT04504266.
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Affiliation(s)
- Cintia Kimura
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, H3680K, Stanford, CA, 94305, USA.
| | - Yuning Liu
- Stanford Prevention Research Center, Stanford, CA, USA
| | - Sarah E Crowder
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, H3680K, Stanford, CA, 94305, USA
- Brigham Young University, Provo, UT, USA
| | - Carlie Arbaugh
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, H3680K, Stanford, CA, 94305, USA
| | - Uyen Mai
- S-SPIRE Center, Stanford University, Stanford, CA, USA
| | - Kreeti Shankar
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, H3680K, Stanford, CA, 94305, USA
| | - Andrew Shelton
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, H3680K, Stanford, CA, 94305, USA
| | - Brendan Visser
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, H3680K, Stanford, CA, 94305, USA
| | - Cindy Kin
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, H3680K, Stanford, CA, 94305, USA
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Gu YX, Wang XY, Chen Y, Shao JX, Ni SX, Zhang XM, Shao SY, Zhang Y, Hu WJ, Ma YY, Liu MY, Yu H. Optimizing surgical outcomes for elderly gallstone patients with a high body mass index using enhanced recovery after surgery protocol. World J Gastrointest Surg 2023; 15:2191-2200. [PMID: 37969721 PMCID: PMC10642464 DOI: 10.4240/wjgs.v15.i10.2191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 06/23/2023] [Accepted: 08/17/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Rehabilitation of elderly patients with a high body mass index (BMI) after cholecystectomy carries risks and requires the adoption of effective perioperative management strategies. The enhanced recovery after surgery (ERAS) protocol is a comprehensive treatment approach that facilitates early patient recovery and reduces postoperative complications. AIM To compare the effectiveness of traditional perioperative management methods with the ERAS protocol in elderly patients with gallbladder stones and a high BMI. METHODS This retrospective cohort study examined data from 198 elderly patients with a high BMI who underwent cholecystectomy at the Shanghai Fourth People's Hospital from August 2019 to August 2022. Among them, 99 patients were managed using the traditional perioperative care approach (non-ERAS protocol), while the remaining 99 patients were managed using the ERAS protocol. Relevant indicator data were collected for patients preoperatively, intraoperatively, and postoperatively, and surgical outcomes were compared between the two groups. RESULTS The comparison results between the two groups of patients in terms of age, sex, BMI, underlying diseases, surgical type, and preoperative hospital stay showed no statistically significant differences. However, the ERAS group had a significantly shorter preoperative fasting time than the non-ERAS group (4.0 ± 0.9 h vs 7.6 ± 0.9 h). Regarding intraoperative indicators, there were no significant differences between the two groups of patients. However, in terms of postoperative recovery, the ERAS protocol group exhibited significant advantages over the non-ERAS group, including a shorter hospital stay, lower postoperative pain scores and postoperative hunger scores, and higher satisfaction levels. The readmission rate was lower in the ERAS protocol group than in the non-ERAS group (3.0% vs 8.1%), although the difference was not significant. Furthermore, there were significant differences between the two groups in terms of postoperative nausea and vomiting severity, postoperative abdominal distention at 24 h, and daily life ability scores. CONCLUSION The findings of this study demonstrate that the ERAS protocol confers significant advantages in postoperative outcomes following cholecystectomy, including reduced readmission rates, decreased postoperative nausea and vomiting, alleviated abdominal distension, and enhanced functional capacity. While the protocol may not exhibit significant improvement in early postoperative symptoms, it does exhibit advantages in long-term postoperative symptoms and recovery. These findings underscore the importance of implementing the ERAS protocol in the postoperative management of cholecystectomy patients, as it contributes to improving patients' recovery and quality of life while reducing health care resource utilization.
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Affiliation(s)
- Yue-Xia Gu
- Department of Nursing, Shanghai Fourth People’s Hospital Affiliated to Tongji University School of Medicine, Shanghai 200434, China
| | - Xin-Yu Wang
- Department of General Surgery, Shanghai Fourth People’s Hospital School of Medicine Tongji University, Shanghai 200434, China
| | - Yang Chen
- Department of General Surgery, Shanghai Fourth People’s Hospital School of Medicine Tongji University, Shanghai 200434, China
| | - Jun-Xiu Shao
- Department of Nursing, Shanghai Xuhui Central Hospital, Shanghai 200031, China
| | - Shen-Xian Ni
- Department of Nursing, Shanghai Fourth People’s Hospital Affiliated to Tongji University School of Medicine, Shanghai 200434, China
| | - Xiu-Mei Zhang
- Department of Nursing, Shanghai Fourth People’s Hospital Affiliated to Tongji University School of Medicine, Shanghai 200434, China
| | - Si-Yu Shao
- Department of Nursing, Shanghai Fourth People’s Hospital Affiliated to Tongji University School of Medicine, Shanghai 200434, China
| | - Yu Zhang
- Department of Nursing, Shanghai Fourth People’s Hospital Affiliated to Tongji University School of Medicine, Shanghai 200434, China
| | - Wen-Jing Hu
- Department of Nursing, Shanghai Fourth People’s Hospital Affiliated to Tongji University School of Medicine, Shanghai 200434, China
| | - Ying-Ying Ma
- Department of Nursing, Shanghai Xuhui Central Hospital, Shanghai 200031, China
| | - Meng-Yao Liu
- Department of Nursing, Shanghai Xuhui Central Hospital, Shanghai 200031, China
| | - Hua Yu
- Department of General Surgery, Shanghai Fourth People’s Hospital School of Medicine Tongji University, Shanghai 200434, China
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Asadourian PA, Lu Wang M, Demetres MR, Imahiyerobo TA, Otterburn DM. Closing the Gap: A Systematic Review and Meta-Analysis of Enhanced Recovery After Surgery Protocols in Primary Cleft Palate Repair. Cleft Palate Craniofac J 2023; 60:1230-1240. [PMID: 35582828 DOI: 10.1177/10556656221096631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Assess the evidence for Enhanced Recovery After Surgery (ERAS) protocols in the cleft palate population. DESIGN A systematic review of MEDLINE, Embase, Cochrane, and CINAHL databases for articles detailing the use of ERAS protocols in patients undergoing primary palatoplasty. SETTING New York-Presbyterian Hospital. PATIENTS/PARTICIPANTS Patients with cleft palate undergoing primary palatoplasty. INTERVENTIONS Meta-analysis of reported patient outcomes in ERAS and control cohorts. MAIN OUTCOME MEASURE(S) Methodological quality of included studies, opioid use, postoperative length of stay (LOS), rate of return to emergency department (ED)/readmission, and postoperative complications. RESULTS Following screening, 6 original articles were included; all were of Modified Downs & Black (MD&B) good or fair quality. A total of 354 and 366 were in ERAS and control cohorts, respectively. Meta-analysis of comparable ERAS studies showed a difference in LOS of 0.78 days for ERAS cohorts when compared to controls (P < .05). Additionally, ERAS patients utilized significantly less postoperative opioids than control patients (P < .05). Meta-analysis of the rate of readmission/return to ED shows no difference between ERAS and control groups (P = .59). However, the lack of standardized reporting across studies limited the power of meta-analyses. CONCLUSIONS ERAS protocols for cleft palate repair offer many advantages for patients, including a significant decrease in the LOS and postoperative opioid use without elevating readmission and return to ED rates. However, this analysis was limited by the paucity of literature on the topic. Better standardization of data reporting in ERAS protocols is needed to facilitate pooled meta-analysis to analyze their effectiveness.
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Yu C, Liu Y, Tang Z, Zhang H. Enhanced recovery after surgery in patients undergoing craniotomy: A meta-analysis. Brain Res 2023; 1816:148467. [PMID: 37348748 DOI: 10.1016/j.brainres.2023.148467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND AND OBJECTIVE Enhanced recovery after surgery (ERAS) is a multidisciplinary,and evidence-based perioperative care method. It is effective in shortening hospital stays and improving clinical outcomes. However, the application of ERAS in craniotomy lacks reliable evidence. The purpose of this study is to investigate the efficacy and safety of ERAS in craniotomy. METHODS Studies of ERAS in craniotomy were systematically searched in PubMed, Embase, Cochrane, and Web of Science. Primary outcomes (total hospital stay and postoperative hospital stay, hospitalization cost, percent of patients with moderate to severe pain) and secondary outcomes (readmission rate and incidence of complication) were compared between ERAS and traditional perioperative care. RESULT Of the 10 studies included in this meta-analysis, 6 were randomized-controlled trials (RCTs), 3 were cohort studies, and 1 was non-RCT. A total of 1275 patients were included, with 648 in the ERAS group and 627 in the control group. Compared with the control group, the ERAS group had a significantly shortened total length of stay (LOS) (MD = -2.437, 95% CI: -3.616, -1.077, P = 0.001) and postoperative LOS, reduced hospitalization cost (SMD = -0.631, 95% CI: -0.893, -0.369, P = 0.001), and lower percent of patients with moderate to severe pain. There was no significant difference in readmission rate between the two groups. Though, the ERAS group had a significantly lower risk of pneumonia than the control group. CONCLUSION ERAS is safe and effective for craniotomy as it shortens total and postoperative LOS, reduces hospitalization costs, decreases the percent of patients with moderate to severe pain.
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Affiliation(s)
- Chunyang Yu
- Beijing Tiantan Hospital, Capital Medical University, China
| | - Yuqing Liu
- Department of Rehabilitation Medicine, Peking University Third Hospital, China
| | - Zhiqing Tang
- School of Rehabilitation, Capital Medical University, China; Beijing Bo'ai Hospital, China Rehabilitation Research Center, China
| | - Hao Zhang
- School of Rehabilitation, Capital Medical University, China; Beijing Bo'ai Hospital, China Rehabilitation Research Center, China; University of Health and Rehabilitation Sciences, China; Cheeloo College of Medicine, Shandong University, China.
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Koch F, Dietrich M, Green M, Moikow L, Schmidt M, Ristig M, Meier-Hellmann A, Ritz JP. [The Usefulness of ERAS Concepts for Colorectal Resections - an Economic Analysis under DRG Conditions]. Zentralbl Chir 2023; 148:454-459. [PMID: 36063840 DOI: 10.1055/a-1880-1309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND ERAS (Enhanced Recovery After Surgery) describes a multimodal, interdisciplinary and interprofessional treatment concept that optimizes the postoperative convalescence of the patient through the use of evidence-based measures. GOAL OF THE WORK The aim of this article is to examine the economic feasibility of the concept in the German DRG system. MATERIAL AND METHODS Since August 2019, patients have been treated in our clinic according to the later certified ERAS concept. The last 20 patients before ERAS implementation are compared below with 20 patients after ERAS implementation, who were identified using a matched pair analysis. In addition to the comparison of costs and revenues, the clinical outcome of the patients is also presented. RESULTS The cases of the patients in the pre-ERAS cohort caused median costs of € 7432.83. BWR of 3.38 were billable. The resulting DRG revenue for the patients in this group amounted to € 11325.78. The proceeds generated in the end amounted to € 4575.14. The cases of patients in the ERAS cohort resulted in costs of € 5582.96. BWR of 2.84 could be billed. The DRG proceeds for the patients in this group therefore amounted to € 10014.18. The profit generated was thus € 4993.84. DISCUSSION The cost reduction generated by ERAS was comparable to the "loss" caused by the BWR decrease. ERAS is therefore also possible to cover costs in the German DRG system.
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Affiliation(s)
- Franziska Koch
- Klinik für Allgemein- und Viszeralchirurgie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Melanie Dietrich
- Klinik für Allgemein- und Viszeralchirurgie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Martina Green
- Klinik für Allgemein- und Viszeralchirurgie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Lutz Moikow
- Klinik für Anästhesiologie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Mareike Schmidt
- Geschäftsführung, HELIOS Klinikum Uelzen, Uelzen, Deutschland
| | - Matthias Ristig
- Klinik für Allgemein- und Viszeralchirurgie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | | | - Jörg-Peter Ritz
- Klinik für Allgemein- und Viszeralchirurgie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
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Wu Y, Fu Y, He Y, Gong X, Han Z, Fan H, Zhu T, Li H. The application of enhanced recovery after surgery (ERAS) in chronic rhinosinusitis patients undergoing endoscopic sinus surgery: A systematic review and meta-analysis. PLoS One 2023; 18:e0291835. [PMID: 37733792 PMCID: PMC10513253 DOI: 10.1371/journal.pone.0291835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/06/2023] [Indexed: 09/23/2023] Open
Abstract
OBJECTIVES Enhanced recovery after surgery (ERAS) has become extensively practiced and has shown encouraging benefits. Within recent years, ERAS has also been increasingly performed in chronic rhinosinusitis (CRS) patients undergoing endoscopic sinus surgery (ESS). However, the actual efficacy of ERAS in CRS patients undergoing ESS is not completely clear, and the related evidence remains weak. This systematic review and meta-analysis aimed to evaluate the effectiveness and safety of ERAS in the perioperative management of CRS patients receiving ESS. METHODS We searched randomized controlled trials in PubMed, Web of Science, EMBASE, Cochrane CENTRAL, Ovid, China National Knowledge Infrastructure, Chinese BioMedical Literature Database, Wanfang, and VIP Database up to February 2023, to analyze the effectiveness and safety of ERAS in ESS perioperative management of CRS patients. We appraised the methodological quality in the included RCTs using the Cochrane Collaboration tool and assessed the quality of evidence with the Recommendations Assessment, Development and Evaluation (GRADE) tool. Meta-analysis, subgroup analysis, and sensitivity analysis were carried out with the the software Review Manager 5.3 and Stata 12.0. In addition, potential publication bias was detected by Begg's test, Egger's test, and funnel plot test. RESULTS Twenty-eight studies involving 2636 patients were included within this study. In comparison with the standard care (SC) group, the ERAS group had the advantages in the following aspects: length of stay (MD = -2.50, 95%CI: -3.04 to -1.97), pain scores (MD = -1.07, 95%CI: -1.46 to -0.67), anxiety score (SMD = -2.13, 95%CI: -2.83 to -1.44), depression score (SMD = -2.42, 95%CI: -3.13 to -1.71), hospitalization expenses, and quality of life. At the same time, the ERAS group presented a markedly lower incidence of adverse events in comparison to the SC group, such as overall complications (RR = 0.28, 95%CI:0.20 to 0.41), postoperative nausea and vomiting (RR = 0.33, 95%CI:0.21 to 0.50), facial edema (RR = 0.20, 95%CI:0.11 to 0.38), low back pain (RR = 0.28, 95%CI:0.16 to 0.49), urinary retention (RR = 0.12, 95%CI:0.05 to 0.30) and haemorrhage (RR = 0.19, 95%CI:0.07 to 0.55). CONCLUSIONS The results showed that the ERAS protocol is effective and safe in CRS patients who undergo ESS. However, Due to the limited overall methodological quality included studies, caution should be exercised in the interpretation of the results. More high-quality, multiple-centre, and large-sample studies are in demand in the future to further validate its clinical efficacy.
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Affiliation(s)
- Yuqi Wu
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yijie Fu
- School of Preclinical Medicine, Chengdu University, Chengdu, China
| | - Yuanqiong He
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xinru Gong
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Zhoutong Han
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Hongli Fan
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Tianmin Zhu
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Hui Li
- School of Preclinical Medicine, Chengdu University, Chengdu, China
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Latka K, Kołodziej W, Rajski R, Pawuś D, Chowaniec J, Latka D. Outpatient Spine Surgery in Poland: A Survey on Popularity, Challenges, and Future Perspectives. Risk Manag Healthc Policy 2023; 16:1839-1848. [PMID: 37719687 PMCID: PMC10505014 DOI: 10.2147/rmhp.s425465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/31/2023] [Indexed: 09/19/2023] Open
Abstract
Objective This study aimed to investigate the popularity of outpatient spine surgery in Poland, identify factors influencing its adoption, and assess its benefits, challenges, and impact on patient outcomes and healthcare costs. Additionally, the study proposes strategies to improve outpatient spine surgery adoption and ensure its safe implementation in Poland. Materials and Methods An electronic survey was distributed to members of the Polish Spine Surgery Society and the Polish Neurosurgery Society. Data were analyzed using Matlab R2020b statistical software, employing descriptive statistics to summarize the responses. Results The survey indicated that 67% of respondents provide spinal procedures commercially, with 58% performing them on an outpatient basis, showing the growing role of the private sector in providing spinal surgery services in Poland. Root nerve blocks and joint blocks were the most common outpatient procedures, followed by microdiscectomy, endoscopic discectomy, and L-S spinal fusion. The public NHF was the most common payer for outpatient procedures. Conclusion Outpatient spine surgery in Poland is not yet widespread, but improvements can be made to reduce hospital stays and enhance recovery. Changes in reimbursement systems to cover outpatient procedures and addressing physicians' liability concerns, particularly by emphasizing the NO-fault system, are essential. With proper support, outpatient spine surgery could become a valuable addition to Poland's healthcare system.
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Affiliation(s)
- Kajetan Latka
- Department of Neurosurgery, The St. Hedwig’s Regional Specialist Hospital, Opole, Poland
- Center for Minimally Invasive Spine and Peripheral Nerve Surgery neurochirurg.opole.pl, Opole, Poland
| | - Waldemar Kołodziej
- Center for Minimally Invasive Spine and Peripheral Nerve Surgery neurochirurg.opole.pl, Opole, Poland
- Department of Neurosurgery, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Rafal Rajski
- Department of Neurosurgery, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Dawid Pawuś
- Faculty of Electrical Engineering, Automatic Control and Informatics, Opole University of Technology, Opole, Poland
| | - Jacek Chowaniec
- Department of Neurosurgery, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Dariusz Latka
- Center for Minimally Invasive Spine and Peripheral Nerve Surgery neurochirurg.opole.pl, Opole, Poland
- Department of Neurosurgery, Institute of Medical Sciences, University of Opole, Opole, Poland
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Scherman P, Syk I, Holmberg E, Naredi P, Rizell M. Risk Factors for Postoperative Complications Following Resection of Colorectal Liver Metastases and the Impact on Long-Term Survival: A Population-Based National Cohort Study. World J Surg 2023; 47:2230-2240. [PMID: 37210422 PMCID: PMC10387456 DOI: 10.1007/s00268-023-07043-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Postoperative complications (POCs) following resection of colorectal liver metastases (CRLM) are common. The objective of this study was to evaluate risk factors for developing complications and their impact on survival considering prognostic factors of the primary tumor, metastatic pattern and treatment in a well-defined national cohort. METHODS Patients treated with resection for CRLM that was also radically resected for their primary colorectal cancer (diagnosed in 2009-2013) were identified in Swedish national registers. Liver resections were categorized according to extent of surgery (Category I-IV). Risk factors for developing POCs as well as prognostic impact of POCs were evaluated in multivariable analyses. A subgroup analysis of minor resections was performed to evaluate POCs after laparoscopic surgery. RESULTS POCs were registered for 24% (276/1144) of all patients after CRLM resection. Major resection was a risk factor for POCs in multivariable analysis (IRR 1.76; P = 0.001). Comparing laparoscopic and open resections in the subgroup analysis of small resections, 6% (4/68) in the laparoscopic group developed POCs compared to 18% (51/289) after open resection (IRR 0.32; P = 0.024). POCs were associated with a 27% increased excess mortality rate (EMRR 1.27; P = 0.044). However, primary tumor characteristics, tumor burden in the liver, extrahepatic spread, extent of liver resection and radicality had higher impact on survival. CONCLUSION Minimal invasive resections were associated with a decreased risk of POCs following resection of CRLM which should be considered in surgical strategy. Postoperative complications were associated with a moderate risk for inferior survival.
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Affiliation(s)
- Peter Scherman
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Surgery, Helsingborg Hospital, Charlotte Yhlens gata 10, 254 37, Helsingborg, Sweden.
| | - Ingvar Syk
- Department of Surgery, Clinical Sciences Malmö, Lund University, Lund, Sweden
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Naredi
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Rizell
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Transplantation, Sahlgrenska University Hospital, Gothenburg, Sweden
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Lyu Y, Yu H, Jia K, Chen G, He X, Muir R. Emergency nurse and physician perceptions of barriers and facilitators to optimal nutrition in the emergency department: A national cross-sectional survey. Int Emerg Nurs 2023; 70:101327. [PMID: 37597279 DOI: 10.1016/j.ienj.2023.101327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 05/12/2023] [Accepted: 07/07/2023] [Indexed: 08/21/2023]
Abstract
INTRODUCTION Optimal nutritional support is becoming increasingly important in Emergency Departments (EDs) as over half of patients presenting to ED are reported to be malnourished or at risk of malnutrition. Few studies have examined the barriers and facilitators to nutritional support in ED. AIM To identify barriers and facilitators to providing optimal nutritional support in the ED from nurse and physician perspectives. METHODS A cross-sectional 31-item electronic survey was developed, validated, and distributed nationally in August 2021 in China. RESULTS A total of 1766 eligible respondents completed the survey, including 846 ED nurses and 920 ED physicians from 155 hospitals. Barriers to optimal nutrition were moderate (2.72/5 ± 0.88); the most common barrier was lack of multidisciplinary team-work support. Facilitators to support optimal nutrition were moderately high (3.58/5 ± 1.08); the most common facilitator was technical/professional support and organizational management. Respondents who received recent nutrition training and those with higher levels of nutrition knowledge (self-rated) perceived fewer barriers overall to optimal nutrition in ED (P < 0.01). CONCLUSION Context specific barriers and facilitators both hinder and support optimal nutrition in ED. Further research is required to develop tailored interventions to address specific barriers to optimal nutrition and enhance facilitators in the ED context.
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Affiliation(s)
- Yang Lyu
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Han Yu
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Beijing, China
| | - Kai Jia
- Department of Nutrition, Beijing Chao-Yang Hospital, Beijing, China
| | - Gang Chen
- Department of Pharmacy, Beijing Chao-Yang Hospital, Beijing, China
| | - Xinhua He
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Beijing, China
| | - Rachel Muir
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia; Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia; Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
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Jin B, Gu Y, Xi S, Liu X, Wu X, Li G. Application of enhanced recovery after surgery following liver transplantation. World J Surg Oncol 2023; 21:248. [PMID: 37587507 PMCID: PMC10433670 DOI: 10.1186/s12957-023-03139-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/08/2023] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVE To investigate the effect of an enhanced recovery after surgery (ERAS) programme following liver transplantation and to further clarify the safety and clinical application value of an ERAS programme. METHODS A retrospective analysis of 250 patients who underwent liver transplant at Beijing You'an Hospital affiliated to Capital Medical University between March 2019 and December 2021 was conducted. According to different perioperative management methods, patients were divided into a control group (120 cases) and an ERAS group (130 cases). Postoperative safety indicators, efficacy indicators and economic indicators were compared between the two groups. RESULTS There was no significant difference in the safety indicators between the two groups. The ERAS group showed significantly lower results compared with the control group in terms of ventilator-associated pneumonia, urinary tract infection, pressure injury of oral and nasal mucosa, postoperative pain score 5 days after surgery and the incidence of delirium, whereas the Barthel score 10 days after surgery was significantly higher. There was no significant difference between the two groups in skin pressure injury or the Subjective Global Assessment grade 10 days after surgery. The length of intensive care unit stay, the total length of stay after surgery and the 10-day medical expenses after surgery were significantly lower in the ERAS group than in the control group. CONCLUSION The application of an ERAS programme after liver transplantation can effectively promote the postoperative recovery of patients and reduce medical costs. Studies have shown that the ERAS programme has important application value in improving the postoperative quality of life and reducing the economic burden of patients after liver transplantation. This programme provides a new concept for related clinical improvement and application.
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Affiliation(s)
- Boxun Jin
- Department of Intensive Care Unit, Beijing Youan Hospital, Capital Medical University, No. 8 Yoanmenwai Xitoutiao, Beijing, 100069, China
| | - Yanmei Gu
- Department of Intensive Care Unit, Beijing Youan Hospital, Capital Medical University, No. 8 Yoanmenwai Xitoutiao, Beijing, 100069, China
| | - Shuangmei Xi
- Department of Intensive Care Unit, Beijing Youan Hospital, Capital Medical University, No. 8 Yoanmenwai Xitoutiao, Beijing, 100069, China
| | - Xin Liu
- Department of Intensive Care Unit, Beijing Youan Hospital, Capital Medical University, No. 8 Yoanmenwai Xitoutiao, Beijing, 100069, China
| | - Xiulian Wu
- Department of Intensive Care Unit, Beijing Youan Hospital, Capital Medical University, No. 8 Yoanmenwai Xitoutiao, Beijing, 100069, China
| | - Guangming Li
- Department of Intensive Care Unit, Beijing Youan Hospital, Capital Medical University, No. 8 Yoanmenwai Xitoutiao, Beijing, 100069, China.
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El Tahan MR, Pahade A, Gómez-Ríos MÁ. Enhanced recovery after surgery: comes out to the Sun. BMC Anesthesiol 2023; 23:274. [PMID: 37580649 PMCID: PMC10424371 DOI: 10.1186/s12871-023-02236-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 08/07/2023] [Indexed: 08/16/2023] Open
Abstract
ERAS programs aim to reduce the length of hospital stays and lower costs, and minimize the risk of postoperative complications and readmissions while enhancing the overall patient experience. BMC Anesthesiology has initiated a new collection on ERAS, urging investigators to conduct large-scale, high-quality studies that address the existing knowledge gap.
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Affiliation(s)
- Mohamed R El Tahan
- Cardiothoracic Anaesthesia Unit, Department of Anaesthesia, Intensive Care, and Pain Management, College of Medicine, Mansoura University, Mansoura, Egypt
- Anesthesiology Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | | | - Manuel Ángel Gómez-Ríos
- Anesthesiology and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, A Coruña, Galicia, Spain.
- Departmento de Anestesiología, Complejo Hospitalario Universitario de A Coruña, Xubias de Arriba, 84, A Coruña, 15006, Spain.
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Bloc S, Alfonsi P, Belbachir A, Beaussier M, Bouvet L, Campard S, Campion S, Cazenave L, Diemunsch P, Di Maria S, Dufour G, Fabri S, Fletcher D, Garnier M, Godier A, Grillo P, Huet O, Joosten A, Lasocki S, Le Guen M, Le Saché F, Macquer I, Marquis C, de Montblanc J, Maurice-Szamburski A, Nguyen YL, Ruscio L, Zieleskiewicz L, Caillard A, Weiss E. Guidelines on perioperative optimization protocol for the adult patient 2023. Anaesth Crit Care Pain Med 2023; 42:101264. [PMID: 37295649 DOI: 10.1016/j.accpm.2023.101264] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs. DESIGN A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. METHODS Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format. RESULTS The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations. CONCLUSIONS Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.
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Affiliation(s)
- Sébastien Bloc
- Clinical Research Department, Ambroise Pare Hospital Group, Neuilly-sur-Seine, France; Department of Anesthesiology, Clinique Drouot Sport, Paris, France.
| | - Pascal Alfonsi
- Department of Anesthesia, University of Paris Descartes, Groupe Hospitalier Paris Saint-Joseph, 185 rue Raymond Losserand, F-75674 Paris Cedex 14, France
| | - Anissa Belbachir
- Service d'Anesthésie Réanimation, UF Douleur, Assistance Publique Hôpitaux de Paris, APHP.Centre, Site Cochin, Paris, France
| | - Marc Beaussier
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, 42 Boulevard Jourdan, 75014, Paris, France
| | - Lionel Bouvet
- Department of Anaesthesia and Intensive Care, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Lyon, France
| | | | - Sébastien Campion
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département d'Anesthésie-Réanimation, F-75013 Paris, France; Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
| | - Laure Cazenave
- Department of Anaesthesia and Critical Care, Hospices Civils de Lyon, Lyon, France; Groupe Jeunes, French Society of Anaesthesia and Intensive Care Medicine (SFAR), 75016 Paris, France
| | - Pierre Diemunsch
- Unité de Réanimation Chirurgicale, Service d'Anesthésie-réanimation Chirurgicale, Pôle Anesthésie-Réanimations Chirurgicales, Samu-Smur, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1, Avenue Molière, 67098 Strasbourg Cedex, France
| | - Sophie Di Maria
- Department of Anaesthesiology and Critical Care, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Guillaume Dufour
- Service d'Anesthésie-Réanimation, CHU de Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75013 Paris, France
| | - Stéphanie Fabri
- Faculty of Economics, Management & Accountancy, University of Malta, Malta
| | - Dominique Fletcher
- Université de Versailles-Saint-Quentin-en-Yvelines, Assistance Publique-Hôpitaux de Paris, Hôpital Ambroise-Paré, Service d'Anesthésie, 9, Avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
| | - Marc Garnier
- Sorbonne Université, GRC 29, DMU DREAM, Service d'Anesthésie-Réanimation et Médecine Périopératoire Rive Droite, Paris, France
| | - Anne Godier
- Department of Anaesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris, France
| | | | - Olivier Huet
- CHU de Brest, Anesthesia and Intensive Care Unit, Brest, France
| | - Alexandre Joosten
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium; Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Villejuif, France
| | | | - Morgan Le Guen
- Paris Saclay University, Department of Anaesthesia and Pain Medicine, Foch Hospital, 92150 Suresnes, France
| | - Frédéric Le Saché
- Department of Anesthesiology, Clinique Drouot Sport, Paris, France; DMU DREAM Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Isabelle Macquer
- Bordeaux University Hospitals, Bordeaux, Anaesthesia and Intensive Care Medicine Department, Bordeaux, France
| | - Constance Marquis
- Clinique du Sport, Département d'Anesthésie et Réanimation, Médipole Garonne, 45 rue de Gironis - CS 13 624, 31036 Toulouse Cedex 1, France
| | - Jacques de Montblanc
- Departments of Anesthesiology and Intensive Care Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | | | - Yên-Lan Nguyen
- Anesthesiology and Critical Care Medicine Department, Cochin Academic Hospital, APHP, Université de Paris, 75014 Paris, France
| | - Laura Ruscio
- Departments of Anesthesiology and Intensive Care Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France; INSERM U 1195, Université Paris-Saclay, Saint-Aubin, Île-de-France, France
| | - Laurent Zieleskiewicz
- Service d'Anesthésie Réanimation, Hôpital Nord, AP-HM, Marseille, Aix Marseille Université, C2VN, France
| | - Anaîs Caillard
- Centre Hospitalier Universitaire La Cavale Blanche Université de Bretagne Ouest, Anaesthesiology, Critical Care and Perioperative Medicine Department, Brest, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP, Nord, Clichy, France; University of Paris, Paris, France; Inserm UMR_S1149, Centre for Research on Inflammation, Paris, France
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Wendel SK, Bookman K, Holmes M, Wiler JL. Successful Implementation of Workflow-Embedded Clinical Pathways During the COVID 19 Pandemic. Qual Manag Health Care 2023; 32:205-210. [PMID: 36913774 PMCID: PMC10289068 DOI: 10.1097/qmh.0000000000000408] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND AND OBJECTIVES Clinical pathways have been found effective for improving adherence to evidence-based guidelines, thus providing better patient outcomes. As coronavirus disease-2019 (COVID-19) clinical guidance changed rapidly and evolved, a large hospital system in Colorado established clinical pathways within the electronic health record to guide clinical practice and provide the most up-to-date information to frontline providers. METHODS On March 12, 2020, a system-wide multidisciplinary committee of specialists in emergency medicine, hospital medicine, surgery, intensive care, infectious disease, pharmacy, care management, virtual health, informatics, and primary care was recruited to develop clinical guidelines for COVID-19 patient care based on the limited available evidence and consensus. These guidelines were organized into novel noninterruptive digitally embedded pathways in the electronic health record (Epic Systems, Verona, Wisconsin) and made available to nurses and providers at all sites of care. Pathway utilization data were analyzed from March 14 to December 31, 2020. Retrospective pathway utilization was stratified by each care setting and compared with Colorado hospitalization rates. This project was designated as a quality improvement initiative. RESULTS Nine unique pathways were developed, including emergency medicine, ambulatory, inpatient, and surgical care guidelines. Pathway data were analyzed from March 14 to December 31, 2020, and showed that COVID-19 clinical pathways were used 21 099 times. Eighty-one percent of pathway utilization occurred in the emergency department setting, and 92.4% applied embedded testing recommendations. A total of 3474 distinct providers employed these pathways for patient care. CONCLUSIONS Noninterruptive digitally embedded clinical care pathways were broadly utilized during the early part of the COVID-19 pandemic in Colorado and influenced care across many care settings. This clinical guidance was most highly utilized in the emergency department setting. This shows an opportunity to leverage noninterruptive technology at the point of care to guide clinical decision-making and practice.
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Affiliation(s)
- Sarah K. Wendel
- Department of Emergency Medicine, University of Virginia, Charlottesville (Dr Wendel); Department of Emergency Medicine, University of Colorado, Aurora (Drs Bookman and Wiler); and Clinical Quality Department, University of Colorado Hospital, Aurora (Ms Holmes and Dr Wiler)
| | - Kelly Bookman
- Department of Emergency Medicine, University of Virginia, Charlottesville (Dr Wendel); Department of Emergency Medicine, University of Colorado, Aurora (Drs Bookman and Wiler); and Clinical Quality Department, University of Colorado Hospital, Aurora (Ms Holmes and Dr Wiler)
| | - Molly Holmes
- Department of Emergency Medicine, University of Virginia, Charlottesville (Dr Wendel); Department of Emergency Medicine, University of Colorado, Aurora (Drs Bookman and Wiler); and Clinical Quality Department, University of Colorado Hospital, Aurora (Ms Holmes and Dr Wiler)
| | - Jennifer L. Wiler
- Department of Emergency Medicine, University of Virginia, Charlottesville (Dr Wendel); Department of Emergency Medicine, University of Colorado, Aurora (Drs Bookman and Wiler); and Clinical Quality Department, University of Colorado Hospital, Aurora (Ms Holmes and Dr Wiler)
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Ioannidis O, Ramirez JM, Ubieto JM, Feo CV, Arroyo A, Kocián P, Sánchez-Guillén L, Bellosta AP, Whitley A, Enguita AB, Teresa M, Anestiadou E. The EUPEMEN (EUropean PErioperative MEdical Networking) Protocol for Bowel Obstruction: Recommendations for Perioperative Care. J Clin Med 2023; 12:4185. [PMID: 37445224 DOI: 10.3390/jcm12134185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 07/15/2023] Open
Abstract
Mechanical bowel obstruction is a common symptom for admission to emergency services, diagnosed annually in more than 300,000 patients in the States, from whom 51% will undergo emergency laparotomy. This condition is associated with serious morbidity and mortality, but it also causes a high financial burden due to long hospital stay. The EUPEMEN project aims to incorporate the expertise and clinical experience of national clinical specialists into development of perioperative rehabilitation protocols. Providing special recommendations for all aspects of patient perioperative care and the participation of diverse specialists, the EUPEMEN protocol for bowel obstruction, as presented in the current paper, aims to provide faster postoperative recovery and reduce length of hospital stay, postoperative morbidity and mortality rate.
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Affiliation(s)
- Orestis Ioannidis
- Fourth Department of Surgery, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital "George Papanikolaou", 57010 Thessaloniki, Greece
| | - Jose M Ramirez
- Institute for Health Research Aragón, 50009 Zaragoza, Spain
- Department of Surgery, Faculty of Medicine, University of Zaragoza, 50009 Zaragoza, Spain
| | - Javier Martínez Ubieto
- Institute for Health Research Aragón, 50009 Zaragoza, Spain
- Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, 50009 Zaragoza, Spain
| | - Carlo V Feo
- Department of Surgery, Azienda Unità Sanitaria Locale Ferrara-University of Ferrara, 44121 Ferrara, Italy
| | - Antonio Arroyo
- Department of Surgery, Universidad Miguel Hernández Elche, Hospital General Universitario Elche, 03203 Elche, Spain
| | - Petr Kocián
- Department of Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, 150 06 Prague, Czech Republic
| | - Luis Sánchez-Guillén
- Department of Surgery, Universidad Miguel Hernández Elche, Hospital General Universitario Elche, 03203 Elche, Spain
| | - Ana Pascual Bellosta
- Institute for Health Research Aragón, 50009 Zaragoza, Spain
- Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, 50009 Zaragoza, Spain
| | - Adam Whitley
- Department of Surgery, University Hospital Kralovske Vinohrady, 100 34 Prague, Czech Republic
| | | | - Marta Teresa
- Institute for Health Research Aragón, 50009 Zaragoza, Spain
| | - Elissavet Anestiadou
- Fourth Department of Surgery, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital "George Papanikolaou", 57010 Thessaloniki, Greece
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Lambert J, Mair T, Arujunan K, Shugaba A, Uwadiae H, Livesey A, Ahmad R, Sgourakis G, Gaffney C, Subar D. The effect of the enhanced recovery programme on long-term survival following liver resection for colorectal liver metastases. Langenbecks Arch Surg 2023; 408:239. [PMID: 37337084 PMCID: PMC10279559 DOI: 10.1007/s00423-023-02968-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Enhanced recovery programmes are associated with improved short-term outcomes following liver surgery. The impact of enhanced recovery programmes on medium- and long-term outcomes is incompletely understood. This study aimed to assess the impact of an enhanced recovery programme on long-term survival in patients undergoing surgery for colorectal liver metastases. METHODS At a tertiary hepatobiliary centre, we analysed short-, medium- and long-term outcomes in consecutive patients undergoing liver resection for colorectal liver metastases. A five-year retrospective review was carried out comparing the enhanced recovery programme to standard care. RESULTS A total of 172 patients were included in the analysis: 87 on standard care and 85 on an enhanced recovery programme. Open surgery was performed in 122 patients: 74 (85.1%) and 48 (56.5%) patients in the standard care and enhanced recovery programme, respectively (p < 0.001). There was a significant reduction in the median (IQR) length of hospital stay in the enhanced recovery programme compared with standard care (7 (5) days vs. 8 (3) days, p = 0.0009). There was no significant difference in survival between standard care and the Enhanced Recovery Programme at one (p = 0.818), three (p = 0.203), and five years (p = 0.247). CONCLUSION An enhanced recovery programme was associated with a reduced length of hospital stay. There was no effect on the one-, three- and five-year survival.
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Affiliation(s)
- Joel Lambert
- BRIDGES Research Group, Department of General and Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, BB2 3HH, UK
- Lancaster Medical School, Health Innovation One, Sir John Fisher Drive, Lancaster University, Lancaster, LA1 4AT, UK
| | - Thomas Mair
- BRIDGES Research Group, Department of General and Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, BB2 3HH, UK
| | - Kalaiyarasi Arujunan
- BRIDGES Research Group, Department of General and Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, BB2 3HH, UK
| | - Abdulwarith Shugaba
- BRIDGES Research Group, Department of General and Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, BB2 3HH, UK
- Lancaster Medical School, Health Innovation One, Sir John Fisher Drive, Lancaster University, Lancaster, LA1 4AT, UK
| | - Harmony Uwadiae
- BRIDGES Research Group, Department of General and Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, BB2 3HH, UK
| | - Anne Livesey
- BRIDGES Research Group, Department of General and Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, BB2 3HH, UK
| | - Rami Ahmad
- BRIDGES Research Group, Department of General and Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, BB2 3HH, UK
| | - Georgios Sgourakis
- BRIDGES Research Group, Department of General and Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, BB2 3HH, UK
| | - Christopher Gaffney
- Lancaster Medical School, Health Innovation One, Sir John Fisher Drive, Lancaster University, Lancaster, LA1 4AT, UK.
| | - Daren Subar
- BRIDGES Research Group, Department of General and Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, BB2 3HH, UK
- Lancaster Medical School, Health Innovation One, Sir John Fisher Drive, Lancaster University, Lancaster, LA1 4AT, UK
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Xie F, Wang D, Ge J, Liao W, Li E, Wu L, Lei J. Robotic approach together with an enhanced recovery programme improve the perioperative outcomes for complex hepatectomy. Front Surg 2023; 10:1135505. [PMID: 37334205 PMCID: PMC10272522 DOI: 10.3389/fsurg.2023.1135505] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 05/04/2023] [Indexed: 06/20/2023] Open
Abstract
Objective Robotic surgery has more advantages than traditional surgical approaches to complex liver resection; however, the robotic approach is invariably associated with increased cost. Enhanced recovery after surgery (ERAS) protocols are beneficial in conventional surgeries. Methods The present study investigated the effects of robotic surgery combined with an ERAS protocol on perioperative outcomes and hospitalization costs of patients undergoing complex hepatectomy. Clinical data from consecutive robotic and open liver resections (RLR and OLR, respectively) performed in our unit in the pre-ERAS (January 2019-June 2020) and ERAS (July 2020-December 2021) periods were collected. Multivariate logistic regression analysis was performed to determine the impact of ERAS and surgical approaches-alone or in combination-on LOS and costs. Results A total of 171 consecutive complex liver resections were analyzed. ERAS patients had a shorter median LOS and decreased total hospitalization cost, without a significant difference in the complication rate compared with the pre-ERAS cohort. RLR patients had a shorter median LOS and decreased major complications, but with increased total hospitalization cost, compared with OLR patients. Comparing the four combinations of perioperative management and surgical approaches, ERAS + RLR had the shortest LOS and the fewest major complications, whereas pre-ERAS + RLR had the highest hospitalization costs. Multivariate analysis found that the robotic approach was protective against prolonged LOS, whereas the ERAS pathway was protective against high costs. Conclusions The ERAS + RLR approach optimized postoperative complex liver resection outcomes and hospitalization costs compared with other combinations. The robotic approach combined with ERAS synergistically optimized outcome and overall cost compared with other strategies, and may be the best combination for optimizing perioperative outcomes for complex RLR.
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Affiliation(s)
- Fei Xie
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Dongdong Wang
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jin Ge
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wenjun Liao
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Enliang Li
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Linquan Wu
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Province Engineering Research Center of Hepatobiliary Disease, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jun Lei
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Province Engineering Research Center of Hepatobiliary Disease, Second Affiliated Hospital of Nanchang University, Nanchang, China
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Mesnard T, Dubosq M, Pruvot L, Azzaoui R, Patterson BO, Sobocinski J. Benefits of Prehabilitation before Complex Aortic Surgery. J Clin Med 2023; 12:jcm12113691. [PMID: 37297886 DOI: 10.3390/jcm12113691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/14/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
The purpose of this narrative review was to detail and discuss the underlying principles and benefits of preoperative interventions addressing risk factors for perioperative adverse events in open aortic surgery (OAS). The term "complex aortic disease" encompasses juxta/pararenal aortic and thoraco-abdominal aneurysms, chronic aortic dissection and occlusive aorto-iliac pathology. Although endovascular surgery has been increasingly favored, OAS remains a durable option, but by necessity involves extensive surgical approaches and aortic cross-clamping and requires a trained multidisciplinary team. The physiological stress of OAS in a fragile and comorbid patient group mandates thoughtful preoperative risk assessment and the implementation of measures dedicated to improving outcomes. Cardiac and pulmonary complications are one of the most frequent adverse events following major OAS and their incidences are correlated to the patient's functional status and previous comorbidities. Prehabilitation should be considered in patients with risk factors for pulmonary complications including advanced age, previous chronic obstructive pulmonary disease, and congestive heart failure with the aid of pulmonary function tests. It should also be combined with other measures to improve postoperative course and be included in the more general concept of enhanced recovery after surgery (ERAS). Although the current level of evidence regarding the effectiveness of ERAS in the setting of OAS remains low, an increasing body of literature has promoted its implementation in other specialties. Consequently, vascular teams should commit to improving the current evidence through studies to make ERAS the standard of care for OAS.
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Affiliation(s)
- Thomas Mesnard
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
- Univ. Lille, INSERM U1008-Advanced Drug Delivery Systems and Biomaterials, 59000 Lille, France
| | - Maxime Dubosq
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
| | - Louis Pruvot
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
| | - Richard Azzaoui
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
| | - Benjamin O Patterson
- Department of Vascular Surgery, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Jonathan Sobocinski
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
- Univ. Lille, INSERM U1008-Advanced Drug Delivery Systems and Biomaterials, 59000 Lille, France
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Martynov I, Scholz S, Perger L, Lacher M. Implementation of Enhanced Recovery Protocols After Minimally Invasive Surgery in Children: A Multinational Survey Study Among International Pediatric Endosurgery Group and European Paediatric Surgeons' Association Members. J Laparoendosc Adv Surg Tech A 2023; 33:503-511. [PMID: 37062759 DOI: 10.1089/lap.2022.0537] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
Aim: The aim of this multinational survey was to provide insights into individual surgeon's experience with implementation of enhanced recovery after surgery (ERAS) programs centered on minimally invasive surgery (misERAS) and to identify perceived barriers to utilization of these protocols. Methods: An online survey was conducted between July 2021 and March 2022 on behalf of the International Pediatric Endosurgery Group (IPEG) and European Paediatric Surgeons' Association (EUPSA) Research Committees. All IPEG and EUPSA members were contacted by e-mail and asked to complete an anonymous questionnaire that included 20 items. Results: Of an estimated 890 IPEG and 800 EUPSA members, 248 completed the survey (14.7%). A minority of respondents (n = 45, 18.1%) stated that misERAS protocols were followed as "utilizing specific ERAS guidelines," whereas 67.3% (n = 167) replied that they were trying to adhere to the basic ERAS principles in their practice. Almost half (n = 117, 47.2%) of the respondents stated that there was an increase in implementation of specific misERAS guidelines over the last 5 years. A lack of education and standardized protocols, lack of support and collaboration, and the existing culture leading to moderate to extreme barriers to misERAS implementation were reported by 25%-40% of respondents. Conclusions: This survey demonstrates that pediatric surgeons from the IPEG and EUPSA communities try to adhere to basic ERAS principles when performing MIS. The major barrier to misERAS implementation is profound lack of education. The fact that only 18% of respondents utilize specific institutional misERAS protocols suggests that at present, ERAS has not found its way into MIS in the broad landscape.
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Affiliation(s)
- Illya Martynov
- Department of Pediatric Surgery, University of Leipzig, Leipzig, Germany
| | - Stefan Scholz
- Division of Pediatric General and Thoracic Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lena Perger
- Division of Pediatric Surgery, Department of General Surgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Martin Lacher
- Department of Pediatric Surgery, University of Leipzig, Leipzig, Germany
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